Retrovesical leiomyoma

UROPA HOLOC

RETROVESICAL LEIOMYOMA NELSON G . ORDONEZ, M .D . ALBERTO G . AYALA, M .D . O. LAWRENCE JOHNSTON, M .D . DOUGLAS E . JOHNSON, M .D . From the Departments of Pathology and Urology, The University of Texas M . D . Anderson Hospital and Tumor Institute at Houston, Texas, and Allegan, Michigan

ABSTRACT-Primary tumors arising in the retrovesical area are rare . We recently treated by primary excision a large retrovesical leiomyoma in a forty-five-year-old man . The smooth muscle nature of the tumor was confirmed by electron microscopy . Recognizing this entity is important, since treatment consists only of surgical removal, and the prognosis should be excellent .

Leiomyomas are benign tumors that can originate in any part of the body where smoothmuscle cells are present . The most common sites for these tumors are the skin, uterus, retroperitoneal region, gastrointestinal tract, and geni. In the genitourinary systourinary system tem, leiomyomas have been reported as arising in the renal parenchyma and the kidney capsule, 34 renal pelvis," ureter,0 ' 7 bladder wall,"-' urethra, 10 prostate," , " epididymis, 13 '4 spermatic cord and vas deferens, 3.14-' 5 penis,3 scrotum, 1 e testis,',"," and seminal vesicles . 1 s .19 Leiomyomas originating in the seminal vesicles and retrovesical area are rare, and only a few cases have been reported .'""' We report on a patient with a leiomyoma originating in the retrovesical area and briefly review other, similar cases reported in the literature . Case Report A forty-five-year-old white man presented with an eighteen-month history of hesitancy and nocturia . Significant in his medical history were adult-onset diabetes and type I V hyperlipidemia . He was afebrile, and his blood pressure

UROLOGY

JANUARY 1986

!

was 140/90 in the right arm when he was seated . The results of a physical examination were normal, except that the rectal examination revealed a large, smooth, nontender mass above and continuous with the prostate . Laboratory study results included normal levels of creatinine and blood urea nitrogen and a normal complete blood count . His serum glucose level was 189 . Urinalysis showed 1 + glucose and 5 to 10 white blood cells per high-power field . A urine culture produced no growth . Chest x-ray film, bone scan, barium enema, and bilateral pedal lymphangiograms were all within normal limits . Scattered flocculent calcifications, confined to the pelvis, were seen on a plain film of the abdomen (Fig . IA) . The cystogram phase of an intravenous pyelogram showed a large retrovesical mass elevating the bladder and displacing it forward (Fig . 1B) . Pelvic ultrasound revealed a rounded, solid mass . Cystoscopy was unsuccessfully attempted ; however, urethroscopic evaluation showed a normal verumontanum and marked elongation and elevation of an intrinsically normal prostatic urethra.

VOLUME XXVII, NUMBER 1

67



(A) Abdominal roentgenogram showing calcifications in soft tissue of pelvis . (B) Intravenous pyelogram showing elevation and displacement of bladder (arrow) . FIGURE 1 .

On bimanual palpation under anesthesia, a spherical, freely-movable mass was felt in the midline above and continuous with the prostate . After a transrectal needle biopsy was performed, the diagnosis was a smooth-muscle tumor that had no evidence of mitotic activity or anaplasia . However, low-grade leiomyosarcoma could not be histologically ruled out . Surgical enucleation and removal of a large retrovesical mass attached to and appearing to arise from the right seminal vesicle was accomplished through a midline lower abdominal incision . After an uneventful postoperative course, the patient was discharged from the hospital. Five years after surgery the patient has had no evidence of recurrence of his tumor and appears clinically asymptomatic .

FIGURE 2 .

Gross appearance of tumor .

Pathologic findings

The lobulated, firm tumor measured 13 x 13 x 11 cm and weighed 615 Gm . The right seminal vesicle was incorporated into the mass . A 10.5-cm segment of the right distal vas deferens was attached to the specimen . Cut surfaces of the tumor were lobulated, light tan, and had focal areas of hemorrhage and necrosis (Fig . 2) . Light microscopy showed the tumor to be comprised of interlacing bundles of spindleshaped cells with eosinophilic cytoplasma and regular, oval nuclei . No mitoses were present (Fig . 3) . Electron microscopy confirmed the smooth-muscle nature of the tumor. The tumor cells contained numerous intracytoplasmic myofilaments with dense bodies and attachment plaques (Fig . 4) . 68

FIGURE 3 .

Light microscopy shows interlacing bundles of tumor cells that have appearance of welldifferentiated smooth-muscle cells .

UROLOGY

/

JANUARY 1986 / VOLUME XXVII, NUMBER I

4. Electron micrograph demonstrating intracytoplasmic myofilaments with dense bodies (long arrows) . Insert shows greater detail of myofilaments with dense bodies and attachment plaques (short arrow) (original magnification x 6,200 and insert x 20,000) . FIGURE

Comment Although the seminal vesicles can be affected by direct extension of prostatic carcinomas and the retrovesical pouch is not an uncommon site for transcelomic metastases, primary tumors originating in this region are rare . Those few that develop can be benign or malignant and can be of either epithelial or mesenchymal origin ." 11 A leiomyoma arising in the seminal vesicle or retrovesical area is rare; a review of the literature disclosed only 6 . Table I summarizes the most important clinical features of the tumors in these 6 patients and in our patient . The 7 patients' ages have ranged from forty-two to seventy-two years, averaging 56 .4 years . Four of the patients had clinical symptoms related to the tumor; in the other 3,

TABLE I .

Case No . 1 2 3 4 5 6 7

Series Emmerich (1910) 15 Voelcker (1912)' Ceelen (1912) Pana (1930) * Plant and Standard (1944) 18 Buck and Shaw (1972)'B Ordonez et al .

the tumor was an incidental finding at autopsy . The tumors ranged from 5 cm to 13 em in greatest dimension ." The exact site of origin of the tumor has been difficult or impossible to establish in most reported cases . We believe that the tumor herein reported probably originated in the capsule of the seminal vesicle . We base this conclusion primarily on its location and close attachment to that structure . However, the possibility that the tumor arose from smooth-muscle fibers of the adjacent pelvic soft tissue or bladder cannot be totally excluded . The histologic distinction between leiomyoma and well-differentiated leiomyosarcoma can be extremely difficult, especially if the specimen is small . In certain organs such as the uterus and the gastrointestinal tract, the degree of mitotic activity has been established as an

Reported cases of retrovesical tumors

Age (Yrs) 74 56 67 59 66 42 45

Signs and Symptoms Incidental autopsy findings Perineal pain Incidental autopsy findings Incidental autopsy findings Palpable abdominal mass Diurnal urinary frequency Urinary hesitancy and nocturia

Location Ampulla left vas deferens Capsule of seminal vesicle Right seminal vesicle Left seminal vesicle Left seminal vesicle and ampulla vas deferens Right seminal vesicle Right seminal vesicle

"Cited be Plant and Standard .'"

UROLOGY

;

JANUARY 1986 / VOLUME XXVII, NUMBER 1

69

important parameter for establishing the diagnosis of malignancy. In our patient the absence of mitoses and the fact that the patient remains free of tumor five years after surgical resection indicates that the tumor was benign . 6723 Bertner Avenue Houston, Texas 77030 (DR . ORDONEZ) ACKNOWLEDGMENT. To Dr. Francis X . Worthington and Dr. Jerome Rain, Miami, Florida, for referring the patient to our institution . References 1 . Hajdu SI : Pathology of Soft Tissue Tumors, Philadelphia, Lea & Febiger, 1979, pp 308-310 . 2 . Enzinger FM, and Weiss SW : Soft Tissue Tumors, St . Louis, C . V. Mosby, 1983, pp 281-297 . 3 . Belis JA, Post GJ, Rochman SC, and Milam DR : Genitourinary leiomyomas, Urology 13 : 424 (1979) . 4 . Fishbone G, and Davidson AJ : Leiomyoma of the renal capsule, Radiology 92 : 1006 (1969) . 5 . Litzky GM, Seidel RE and O'Brien JE : Leiomyoma of the renal pelvis, J Urol 105 : 171 (1971) . 6 . Kao VCY, Graff PW, and Rappaport H : Leiomyoma of the ureter, Cancer 24 : 535 (1969) . 7 . Mondschein LJ, Sutton AP, and Rothfeld SA : Leiomyoma of the ureter in child : first reported case, J Urol 116 : 516 (1976) . 8 . O'Connell K, and Edson M : Leiomyoma of bladder, Urol-

70

ogy 6 : 14 (1975) . 9 . Mutchler RW and Gorder JL : Leiomyoma of the bladder in a child, Br J Radiol 45 : 538 (1972) . 10 . Shield DE, and Weiss RM : Leiomyoma of the female urethra, J Urol 109 : 430 (1973) . 11 . Kaufman JJ, and Berneike RB : Leiomyoma of the prostate, ibid 65 ; 297 (1951) . 12 . Vassilakis GB : Pure leiomyoma of the prostate, Urology 11 : 93 (1978) . 13 . Spark RP : Leiomyoma of the epididymis, Arch Pathol 93 : 18 (1972) . 14 . Thompson GJ : Tumors of the spermatic cord, epididymis and testicular tunica . Surg Cynecol Obstet 62 : 712 (1936) . 15 . Emmerich E : Enorm Cystenbildung der Vas deferens, Zentralbl All ; Pathol 21 : 673 (1910) . 16, Iloreta AT, Bekisov H, and Newman HR : Leiomyoma of the scrotum, Urology 10 : 48 (1977) . 17 . Honore LH, and Sullivan LD : Intratesticular leiomyoma, j Urol 114 : 631 (1935) . 18 . Plant A, and Standard S : Cystomyoma of seminal vesicle, Ann Surg 199 : 253 (1944) . 19 . Buck AC, and Shaw RE : Primary tumours of the retrovesical region with special reference to mesenchymal tumours of the seminal vesicles, Br J Urol 44 : 47 (1972) . 20 . Mostofi KF, and Price EB Jr: Tumours of the male genital system : Atlas of Tumor Pathology, fase 8, Washington, D .C ., Armed Forces Institute of Pathology, 1973, pp 259-261 . 21, Damajanov I, and Apic R : Cystadenoma of the seminal vesicles, J Urol 111 : 808 (1974) . 22 . Williamson RCN : Seminal vesicle tumors, J R Soc Med 71 : 286 (1978) . 23 . Islam M : Benign mesenchymoma of the seminal vesicles, Urology 13 : 203 (1979) .

UROLOGY

/

JANUARY 1986 / VOLUME XXVII, NUMBER 1