Sequential thulium laser vaporization and catheter-guided 5-aminolevulinic acid photodynamic therapy for long-segment...

Long-segment intraurethral condyloma acuminatum (CA) is difficult to treat because the urethral lumen limits visual access, instrument maneuverability, and uniform contact between a topical agent and the mucosa. Treatment must balance immediate removal of visible disease against cumulative mucosal injury: repeated or deep destructive procedures can cause bleeding, ulceration, pain, scarring/fibrosis, stenosis, and urethral stricture [1,2]. Electrocautery can rapidly destroy discrete accessible lesions but may produce thermal injury when applied deeply or circumferentially. Cryotherapy is useful for selected superficial distal lesions, although controlled, uniform application over a long intraluminal field is technically difficult. Cold-knife excision preserves tissue for histology but would require repeated mucosal incisions for diffuse disease and may increase bleeding and scar formation. Laser vaporization offers endoscopic precision, hemostasis, and efficient debulking, but excessive depth or circumferential coagulation can also promote fibrosis. Conversely, 5-aminolevulinic acid photodynamic therapy (ALA-PDT) provides a field-directed treatment for residual or subclinical HPV-infected epithelium but is less efficient as the sole treatment for bulky obstructing lesions and may cause illumination-associated pain and local inflammation [2]. We therefore used thulium laser vaporization for controlled removal of the visible tumor burden, followed by catheter-guided ALA-PDT for the long residual mucosal field. This rationale is consistent with a previous report combining visible-lesion removal with PDT [3], but this single case does not establish superiority over electrocautery, cryotherapy, excision, laser monotherapy, or other combined approaches.