Laparoscopic resection of a recurrent etroperitoneal schwannoma (case report and review of the literature)

actas urol esp. 2010;34(5):477–488

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Laparoscopic resection of a recurrent etroperitoneal schwannoma (case report and review of the literature) Resección laparoscópica de schwannoma retroperitoneal recurrente (reporte de un caso y revisión de la literatura médica)

Dear Editor, We report the case of a 39-year-old female patient with no significant history of her current condition. She initially experienced moderately severe right lumbar pain six years before. Extension studies revealed a right retroperitoneal tumor, which was resected by conventional open surgery. The histopathological laboratory reported a completely resected benign retroperitoneal schwannoma. Four years later, a follow-up tomographic scan showed a 3×3 cm right retroperitoneal tumor adjacent to psoas and spine (Figure 1). Lumboscopic resection was decided because of prior reports of recurrent schwannoma with malignant transformation. Retroperitoneal space was created using a 12-mm subcostal incision. Access was obtained to the retroperitoneal space by blunt dissection, and 300 mL of water for injection were introduced for 5 min into a no. 8 glove finger adjusted with a 0 silk to a no. 16 Levin catheter. A 10-mm trocar was introduced through this opening. Another 10-mm trocar was inserted under direct vision at Petit triangle level, and an additional 5-mm trocar was inserted at the level of the anterior axillary line for triangulation1. Dissection of pararenal space was performed, and a 3×3 cm tumor adjacent to the psoas, spine, and kidney was found and could be completely resected. The

Figure 1 – Retroperitoneal schwannoma.

final histopathological report was of a benign retroperitoneal schwannoma (neurilemoma). Primary retroperitoneal schwannomas are rare tumors in the absence of von Recklinghausen disease2. Approximately 50 cases have been reported in international medical literature, and their prevalence in this location ranges from 0.5%-1.2% according to an Indian review3. It is a well encapsulated tumor arising in the peripheral nerve sheath mainly in young adults. While they are more common in peripheral nerves or cranial nerves, they have also been reported in locations such as retroperitoneum4,5. Preoperative diagnosis is difficult, as there are no pathognomonic signs. Tumors are usually found incidentally based on compression data of adjacent organs or work-up studies. Their origin cannot be determined even with use of ultrasound, tomography, or MRI. The latter two imaging tests help define the spinal origin of such tumors and their frequent cystic degeneration. Angiography or angio-MRI has been considered to be of some help in some vascularized tumors, but is not very useful in most cases6. Guided biopsy is usually inadequate or inconclusive, and surgery thus represents the best curative or palliative alternative, although recurrence is common even within 6 months. Radiation therapy has been partially successful in benign schwannomas, but provides no benefit in cases of malignant disease7. If a significant growth from the spinal cord is documented, a combined approach with the neurosurgery department is most adequate to guarantee total tumor resection8. Pathological diagnosis is achieved when fusiform bundles of Schwann cells are demonstrated with hematoxylin and eosin, and by immunohistochemical enhancement through the S-100 protein. In the case reported, the retroperitoneoscopic procedure conventionally performed at our institution, a variant of those previously described by Gaur, Gill, and Santinelli, was used. We think this is an adequate and safe approach to these smaller recurrences, achieving a wide resection and a histopathological result that indicates the nature of the tumor. Retroperitoneum is a rare location of schwannoma. The few symptoms and the usually benign nature of the lesion cause that in most cases the finding corresponds to a big tumor, and open surgery is therefore the procedure of choice. However, for recurrent or incidentally found tumors, lumboscopic resection is an effective management alternative9,10.

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  1. Gaur D. Laparoscopic operative retroperitoneoscopy: Use of a new device. J Urol. 1992;148:1137.   2. Takatera H, Takaha M. Retroperitoneal schwannoma. Urology. 1986;28:529-31.   3. Arshad S, Girish D. Retroperitoneal schwannoma. BHJ. 2002.   4. White HR. Survival in malignant schwannoma. Cancer. 1971;27:720-9.   5. Regan JF, Juler GL, Scmutzer KJ. Retroperitoneal neurilemmoma. Am J Surg. 1977;134:140-5.   6. Goh B, Tan Y, Chung Y, Chow P, Ooi L, Wong W, et-al. Retroperitoneal schwannoma. Am J Surg. 2006;192:14-8.   7. Heaton ND, Howard ER. Malignant retroperitoneal schwannoma. J R Soc Med. 1991;84:308-10.   8. Pollo C, Richard A, De Preux J. Résection d’un schwannome retroperitoneal en sablier par abord combiné Neurochirurgie. 2004;50:53-6.   9. De Diego Rodríguez E, Roca Edreira A, Martín García B, Hernández Rodríguez R, Portillo Martín JA, Gutiérrez Baños JL,

et al. Retroperitoneal benign schwannoma. Report of a new case. Actas Urol Esp. 2000;24:685-8. 10. Mir Maresma C, Raventós CX, Celma A, Bestard Vallejo J, Orsola de los Santos A, Morote Robles J, et al. Schwanoma retroperitoneal benigno, exéresis por laparoscopia. Actas Urol Esp. 2008;32:455-7.

P. Ávila Herreraa,*, M. González Domínguezb, O.F. Hernández Ordóñezb, and J. Gutiérrez Acevesa,b aDepartment

of Urology, Nuevo Hospital Civil, Guadalajara, Jalisco, Mexico bCentro Médico Nacional La Raza, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico *Author for correspondence. E-mail: [email protected] (P. Ávila Herrera).

Urethral duplication: case report and review of the literature Duplicación uretral: presentación de un caso clínico y revisión de la literatura médica

Dear Editor, We report the case of a 7-year-old male patient with a history of recurrent urinary tract infections who was seen at our office due to the presence of two openings in the glans, one in an orthotopic position and the other in a more dorsal location. The patient reported voiding through both openings, with a stronger flow from the orthotopic opening, as well as continuous dribbling. There was no history of urethral instrumentation. Ultrasound examination of the kidney was normal, and a serial voiding cystourethrography showed a complete dorsal accessory urethra up to the bladder neck (figure 1). The main tract corresponded to the orthotopic urethra. Both urethral meatus were explored by inserting a 10 Fr probe. A good passage of the probe through both meatus was seen. The accessory dorsal urethra was resected. Postoperative course was uneventful, and no urinary tract infections occurred. Urethral duplication is an abnormality mainly occurring in males and whose incidence is unknown. It may be associated to other changes in the genitourinary tract (posterior urethral valves, vesicoureteral reflux, renal dysplasia or agenesia, exstrophy of the bladder), heart, bowel (imperforate anus, esophageal atresia), bones, etc.2,3. Embryological development of urethra starts at about the third week of pregnancy with migration of mesenchymal cells from the primordial line to

the cloacal membrane, originating the so-called cloacal folds from which urethral folds will derive. Approximately at the end of the third month, urethral folds close as a tube over the urethral plate to form the penile urethra. This process is completed at about the fourth month with the formation of glandular urethra. A noxa in this sequence would be the

Figure 1 – Voiding cystourethrography showing a complete dorsal accessory urethra up to the bladder neck.