Leiomyoma of the Prostate

Leiomyoma of the Prostate

THE JOURNAL OF UROLOGY Vol. 65, No. 2, February, 1951 Printed in U.S.A. LEIOMYOMA OF THE PROSTATE JOSEPH J. KAUFMAN AND ROBERT R. BERNEIKE From t...

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THE JOURNAL OF UROLOGY

Vol. 65, No. 2, February, 1951 Printed in U.S.A.

LEIOMYOMA OF THE PROSTATE JOSEPH J. KAUFMAN

AND

ROBERT R. BERNEIKE

From the Surgical Service, Veterans Administration Hospital, Newington, Connecticut and the Department of Urology, Yale University School of Medicine, New Haven, Conn.

While leiomyoma arising in the uterus constitutes the commonest tumor of the body, its occurrence is rare in other organs. Although minute leiomyomatous nodules are rather common, true leiomyomas of the prostate are rare. It is apparent from the variation in the specimens reported as leiomyoma that there is no strict definition. This is understandable because often the origin of the lesion cannot be proved unequivocally, and secondly, the differentiation of hyperplasia from neoplasm is sometimes impossible even by the experienced pathologist. For the sake of convenience we have arbitrarily defined leiomyoma of the prostate as follows: A circumscribed or encapsulated mass of smooth muscle, 1 cm. or more in diameter, containing varying amounts of fibrous tissue but devoid of glandular elements, and which is either obviously prostatic or juxtaprostatic in origin and position. By this definition we eliminate most cases of fibromuscular hyperplasia, bladder neck tumors and clinically insignificant nodules which create discrepancies in the literature. Patch and Rhea state that minute leiomyomatous nodules occur commonly in benign hyperplasia of the prostate. In a comprehensive study they made large or whole sections of surgically removed glands and were able to demonstrate nodules varying in size from 0.5 to 3.0 mm. in 25.4 per cent of 181 consecutive cases. They agree, however, that larger smooth muscle tumors of the prostate are rare. Using the definition above, we have found 35 cases previously reported (table 1), and we are adding 3 additional cases. CASE REPORTS

Case 1. M. R., No. 21387, an 80 year old white man of Russian descent, was admitted to the ward urological service of the New Haven Hospital on September 2, 1939. He complained of gradually increasing frequency and hesitancy, culminating in complete retention 5 days prior to admission. He had been catheterized twice daily since that time. There were no other significant facts in the past history and the family history was noncontributory. Physical examination revealed a well developed man whose temperature was 99.6F and whose blood pressure was 145/70. He had large bilateral inguinal hernias. On rectal examination the prostate was found to be 3 or 4 times normal size and elastic in consistency. Urinalysis revealed albumin 1 plus, 3-5 white blood cells, 1-2 red blood cells per high power field and staphylococci and B. coli on stained smear and culture. The serological test for syphilis was negative. The nonprotein nitrogen was 29. On the phenolsulfonphthalein test there was 60 per cent excretion in 1 hour and Sponsored by the VA and published with the approval of the Chief Medical Director. The statements and conclusions published by the authors are a result of their own study and do not necessarily reflect the opinion or policy of the Veterans Administration. 297

TABLE AUTHOR

DATE ~~

AGE

SYMPTOMS

OPERATION

1

POSITION

SIZE

PATHOLOGIC DESCRIPTION

RESULT

Lebec

1876

76

Urinary

None. Autopsy

Middle lobe

3 cm. diam.

Encapsulated tumor of smooth muscle fibers similar to smooth muscle tumor of uterus.

Died; pneumania

Vignola

1922

63

Rectal

Perineal

Posterior (perineal)

250 gm.

Fibromyoma with no trace of glandular elements

Recovery

Tandler & Zuckerkandl

1922

65

Urinary, Complete retention

Supra pubic

Lat. lobe

100 gm.

One lobe smooth muscle hyperplasia without glands; one lobe glandular hyperplasia.

Recovery

Rectal

Perineal

Posterior (perineal)

180 gm.

Composed entirely of interlacing smooth muscle fibers

Recovery

Urinary, Complete retention

Perineal

Intraprostatic

360 gm.

Composed entirely of smooth muscle cells. Infrequent mitoses.? malignant

Recovery X-ray treatment

Damski

1924

Bugbee

Hl26

62

Rubritius

1927

70

~

P'i

Hinman & Sullivan

1931

1931

7:3

36

39

:,.

q

~

:,.

Urinary

Supra pubic

Mass protruding into bladder

Estimated 7 cm. diam.

Encapsulated smooth muscle tumor without glandular elements.

Recovery

z :,. z l:;;I fd fd to M ;rj

z

M

--

Wolman

00

~

--

49

t,J ~

~~

Urinary, Complete retention

None. Autopsy

Ant. to urethra

Rectal

Perineal

Posterior pedunculated

2.5

Posterior

3x2x2 cm. 5 gm.

Rectal

Perineal & autopsy

1.9

1.8 1.2 cm. X

X

3.5 4.5 cm. X

X

Encapsulated smooth muscle tumor with scanty conn. tiss. stroma and no glandular elements.

Died Pneumonia

Discrete tumor of interlacing strands of smooth muscle with no glandular elements

Recovery

Discrete tumor of irregular bundles of smooth muscle cells with no glandular elements.

Died 24 hours.

~

Neupert

1931

I

Urinary

67

Laparotomy

Retro peritoneal mass arising from prostatic area

3600 gm.

Intraprostatic globular n1asses

Estim. 10 cm. diam.

Intraprostatic

2 cm. diam.

I Fibromyoma of the prostate (no

Died 24 hours.

glandular elements)

----~---- -------

Deuticke

rn32 I 65

Dial and Halpert

193:3

Perinea!

Rectal

_______ I I Urinary I Suprapuhic

I 59

Recovery

Composed of smooth muscle ,,·ith no epithelial elements. -----

I I

I

Composed of smooth muscle with no epithelial elements. Other parts of prostate, glandular hyperplasia.

,I Recoven; "

I t" t,j

--------

65

H

Urinary, complete retention

Perinea!

Urinary

1.2 cm.

diam.

Typical smooth muscle tumor devoid of glandular elements.

>"1

;:!:;

_______ I

:,.-

\

i Suprapubic

Intraprostatic; median lobe

I

I

2 cm. diam.

I I

Typical circumscribed smooth muscle tumor devoid of glantlular elements.

Recovery

19:33

I 62

Urinary, complete rete11tion

Composed of smooth muscle fibers devoid of glandular elements.

Recovery

,__· - - - - - - Powell

rn:n I 76

Patch and Rhea

rn35 I so

Uriuar,,

--------

>,j

~

>,:j

I

Mitchell & Blaisdell

0

t,j

(-------

1---1--

0 ~ 0

I

- - - - - - - -I

67

Intraprostatie II

Recovery

I Suprapubic

4.5 cm. dimn. ;35 gm.

Intraprostatic

II I

II Intraprostatic

0

IP

8

:,.>-3

: Supra pubic

i:li

t,j

Estimated 2 X 1.5 X l cm.

Encapsulatetl smooth muscle tumor with adenomatous l1_rperplasia in other parts of the prostate.

--------!

Recovery

-~-

I

i Kornitzer

I

Urinar_\·, None. AuI Intraprostatic I rn.5 cm. complete tops)I projecting in- i diam. to bladder I n;tent10n "--------- ________ ! I

I~;:1,;-I--;;;-,

Encapsulated smooth muscle tumor without glandular elemen ts.

Dead

Recovery

ty

co

rt:)

cham.

-

-

·-

8

Table I-Continued AUTHOR

DATE

AGE

SYMPTOMS

OPERATION

POSITION

PATHOLOGIC DESCRIPTION

SIZE

RESULT

- - -KornitzerContinued

Akin

Baretz

Pratt

1936

1936

1936

73

Urinary, complete retention

Suprapubic

Projecting at bladder neck.

48

Urinary, priapism

TUR

Pedunculated extending into urethra

76

73

Urinary, complete retention

Supra pubic

Urinary, complete retention

Supra pubic

Intraprostatic

Intraprostatic. Lat. lobes

Estimated 5 cm. diam.

Pure circumscribed smooth muscle tumor

Recovery

Smooth muscle tumor with no glandular elements. Lymphocytic infiltration.

Recovery

Estimated 2xlx 1 cm.

Circumscribed and encapsulated areas of interlacing bundles of smooth muscle. Other areas show glandular hyperplasia and prosta ti tis.

Recovery

3.5 X 5 cm.

Two distinct leiomyomata. Encapsulated smooth muscle tumors without glandular elements.

Recovery

Encapsulated smooth muscle tumor without glandular elements. Delicate conn. tiss. stroma.

Recovery

!""' ~

5

!z

§ ~ ~ tc

t,l

Koenig

1936

24

Rectal

Perinea! Rt. posterior biopsy Suprapubic

181 gm. 12 X 8 6 cm.

X

~ ~

Mimpriss

1936

60

Urinary, comylete retention

Supra pubic

Intraprostatic.

570 gm.

Circumscribed smooth muscle tumor with no epithelial elements.

Died 20 hours

Heggie

1936

69

Urinary, complete retention

Suprapubic

Intraprostatic middle lobe.

1.5 cm. diam.

Circumscribed fibromyoma

Recovery

33

Urinary

Suprapubic

Intraprostatic.

95 gm.

Fibromuscular hypertrophy with no glandular elements and with small areas (2-5 mm.) of pure smooth muscle masses.

Died Pneumonia Hemorrhage ! ·

71

Urinary, complete retention

Supra pubic

Middle lobe in traprostatic

98 gm.

Circumscribed, almost pure leiomyoma with no glandular elements.

Recovery

7

Sharply demarcated tumor of smooth muscle fibers with no epithelial elements.

Recovery

Circumscribed tumor of interlacing bundles of smooth muscle with no glandular tissue.

Recovery

Mass arising from 1450 gm. base of bladder, replacing prostate.

Smooth muscle tumor devoid of epithelial elements.

Dead

--Wyler

1939

37

Urinary

Perinea!

Intraprostatic

Keen

1939

62

Urinary, complete retention

Supra pubic

Intraprostatic

Urinary & rectal

None. Autopsy

4.5 cm.

X

4.5 X 3 cm.

t<

....0t;:I

~

~ 0

>;!.

>-3

Magoun

1939

Neuswanger

1939

Pelkonen

1946

McIntyre

1948

60

73

t;:I

>,:I ~

0

Supra pubic

Intraprostatic

3 x 5 cm.

Smooth muscle tumor circumscribed and without glandular elements.

Recovery

Rectal

Supra pubic

Lat. lobes, pointing posteriorly

350 gm.

Circumscribed tumor of interlacing smooth muscle bundles without acini.

Recovery

Urinary & rectal

Suprapubic cystotomy &TUR

Intraprostatic, pointing anteriorly.

Nodular mass composed of smooth muscle fibers with no glandular elements.

Recovery

Urinary

ll:1

~

t;:I

-- ------69

-71

c,-, 0

.....

<:,:)

Table l-Contin1ted

0

t-:i

AUTHOR

DATE

AGE

SYMPTOMS

OPERATION

--- --

Carson

1950

65

I

POSITIO:N'

SIZE

PATHOLOGIC DESCRIPTION

RESULT

Urinary, complete retention

Perinea!

Intraprostatic arising from region of veru montanum

112 gm. 7.2 X 5.5 x 3.9 cm.

Pure leiomyoma with foci of hyalinization

Recovery

Urinary

TUR

Middle lobe intravesical enlargement

148 gm.

Degenerating leiomyoma with degeneration giant cells.

Recovery

--- -Gray & Thompson

1950

59

I

'-< <-,

~

q

~p,-

z p,zl:;I :,:i :,:i

b:I t?i

:,:I

zt?i ~

t?i

LEIOMYOMA OF THE PROSTATE

303

20 per cent during the second hour. An x-ray of the chest showed slight enlarge~ ment of the left ventricle with widening, lengthening and caclification of the aorta.

Fm. l. Whole sectio11 of prostate X 2. Lciomyoma has displaced hyperplastic glandular tissue to nAriphery.

Fw. 2. Photomicrograph of leiom,1·oma X 200. Note interlacing smooth muscle fibers q,nd sµarne lymphoc:l"tic infiltration.

Cystoscopy revealed a bladder capacity of 300 cc. The bladder wall was trabeculated and inflamed, but otherwise normaL There was intra-urethral intrusion of both enlarged lateral prostatic lobes. On September 15, 1939, under general anesthesia, perineal prostatectomy was

304

r

J. J. KAUFMAN AND R. R. BERNEIKE

performed. The specimen weighed 85 gm. On cut section the specimen presented a whorled appearance with a watered-silk luster. On microscopic examination the tissue was found to consist chiefly of dense fibromuscular stroma, the major portion of which was devoid of glandular elements. The tissue was cellular and arranged in whorls. There was a diffuse sparse infiltration by lymphocytes. The few glandular elements of the specimen were displaced to the periphery by the leiomyoma and consisted of nests of acini lined by tall columnar epithelium. There were some areas of cystic dilatation seen and in these the epithelium was flattened (figs. 1 and 2). The pathologic diagnosis was leiomyoma of the prostate associated with benign hyperplasia. The patient had an uneventful postoperative course. Case 2. W. L., No. 46379, was a 63 year old white man who entered the Veterans Administration Hospital, Newington, Conn. on October 18, 1948, for re-evaluation of skin tumors of the face. The patient had been admitted on 4 previous occasions. Diagnoses on these entries included hydrocele, varicocele, hemorrhoids, inguinal hernias and basal cell tumors of the face. His last admission was 5 months previously at which time rectal examination was allegedly negative. On his present admission rectal examination revealed a rubbery, firm mass about 2 by 2 cm. in size at the apex of the prostate. This was nontender, had a fixed base and did not invade the rectal mucosa. It was clearly defined and seemed pedunculated. On review of the patient's history, he stated that for about 6 months prior to the present admission he had had mild rectal tenesmus. There was no history of constipation, melena, diarrhea or other changes in the bowel habits. He denied urinary symptoms. Urinalysis revealed a specific gravity of 1.025, albumin 1 plus, and a normal microscopic examination. Urine smear and culture were negative. The nonprotein nitrogen was 29 mg. per cent. The blood count was normal. Acid phosphatase was 2.5 King-Armstrong units and alkaline phosphatase was 7.45 KingArmstror.g units. Cystoscopy revealed no bladder residual and a bladder capacity of 400 cc. The bladder wall and trigone appeared normal. On the surface of the verumontanum there was an irregular opening representing a patulous orifice of the sinus pocularis. The position of the nodule at the apex of the prostate was confirmed by recto-urethral palpation with the cystoscope in place. The differential diagnoses were miillerian duct cyst, carcinoma of the prostate and adenoma. On November 10, 1948, under spinal anesthesia, perineal exposure of the prostate was done. A well encapsulated ovoid mass, 2 by 3 cm. in size, was found at the apex of the prostate. This was enucleated with ease and a frozen section was reported as leiomyoma. The remainder of the prostate was left in situ. Postoperative course was uneventful. Pathological report of the tumor removed was as follows: "Specimen consists of a rubbery yellow-pink ovoid piece of tissue 2.5 by 2 by 1.5 cm. in size. Cross section reveals glistening homogenous gray-yellow cut surface with whorled appearance. Microscopic examination reveals interlacing whorls of smooth muscle cells with rich acidophilic cytoplasm and long cylindrical sausage-shaped vesicular nuclei with rounded ends. There

LEIOMYOMA OF THE PROSTATE

305

is no evidence of glandular elements, nor is there evidence of cellular anaplasia.. Diagnosis: Leiomyoma of the prostate." While the patient was in the hospital, multiple basal cell tumors of the face were removed. This patient has been followed for 6 months following the myomectomy. His preoperative rectal complaints were allayed by the operation and rectal examinations during the postoperative period to date have revealed a prostate of normal contour, consistency and size.

Frn. 3. Case 2. A, photomicrograph of leiomyoma X 100. Tumor consists of smooth muscle bundles and is devoid of glandular elements. B, X 500 . .i'i" ote whorls of smooth muscle fibers.

Case 3. W. B., Ro. 51,543, a 62 year old white man, entered the Veterans Administration Hospital, Newington, Conn. on October 31, 1949 complaining of abdominal pain and weight loss of 5 months' duration. The symptoms began insidiously with right lower quadrant pain radiating to the left lower quadrant, occurring once or twice a week and lasting 30 minutes. This symptom was superseded by episodes of right upper quadrant pain radiating across the upper abdomen, occurring 30 minutes after meals and accompanied by transient nausea. The patient had lost 20 pounds in the preceding 5 months. He also stated that he had been subject to chronic constipation for the past 10 years, but that there had been no change in the character of the stools. He denied melena and dyschezia. During the 4 months prior to his admission he had noted nocturia I to 3 times, slight hesitancy and slight reduction in the force of the urinary stream. Physical examination revealed a liver edge palpable three fingerbreadths below the right costal margin, a reducible left inguinal hernia, and an unusual prostate. The latter was described as being twice normal size, with a firm, discrete pedunculated, cherry-sized nodule on the left lobe. Laboratory data included normal hematological findings, clear urine which

306

J. J, KAUFMAN AND R. R. BERNEIKE

contained no albumin or significant sediment on repeated examinations, normal liver function tests, negative stool examinations, and a serum acid phosphatase value of 2.7 King-Armstrong units. Additional diagnostic studies included electrocardiograms, a gallbladder series, metastatic series, and sigmoidoscopy, all of which were indeterminate. A barium enema revealed slight narrowing in the mid transverse colon.

Fm. 4. Case 3. Surgical specimen showing pedunculated leiomyoma

Fm. 5. High power photomicrograph showing interlacing smooth muscle bundles and absence of glandular elements.

Prior to re-examination of the bowel, urological evaluation was deemed advisable because several observers agreed that the prostatic nodule deserved investigation to rule out carcinoma. On November 7, 1949, cystoscopy disclosed residual urine 15 cc; the bladder capacity was 200 cc. There was moderate trabeculation and cellule formation, and the lateral lobes of the prostate met in the midline. Recto-urethral palpation of the prostate confirmed the presence of

LEIOMYOMA OF THE PROSTATE

307

a firm nodule, approximately 2 cm. in diameter, arising posteriorly from the left lobe. The bladder urine showed 10 white blood cells per high power field and no bacteriuria. On December 2, under spinal anesthesia, perinea! exposure of the prostate revealed a pedunculated nodule on the left lobe which was biopsied, and which, on frozen section, proved to contain no carcinoma. Enucleation of the prostate was then carried out. Description of the gross specimen was as follows: "The specimen consists of a prostate which is of pink-gray color, firm consistency and nodular outline, and measures 6 by 3 by 3 cm. Attached to the main portion of the specimen is a pedunculated nodule of firm consistency which measures 2 by 1.5 by 1.5 cm. On cut section, the surface of the main portion of the prostate shows islands of grayish-tan glandular tissue, measuring an average of one cm. in diameter, and surrounded by white fibromuscular stroma. The pedunculated nodule presents a uniform appearance and the cut surface is of glistening, homogeneous character and white color." The microscopic appearance of the leiomyoma was similar to that described in the first two cases, showing interlacing bundles of smooth muscle in a collagenous stroma, frequent whorl formations, and no acinar elements. The main portion of the prostate showed hyperplastic acini regularly disposed throughout the fibromuscular matrix. The leiomyoma was sharply demarcated from the adenomatous prostate and was surrounded by a collagenous capsule. The patient had an uneventful course, and at discharge, on the seventeenth postoperative day, he was voiding without difficulty and had no evidence of urinary tract infection. He was to return to the hospital after a brief period of convalescence for further evaluation of the gastro-intestinal tract. DISCUSSION

In the 35 cases heretofore reported, the ages of the patients ranged from 24 to 80 years with an average of 61.4 years. Symptomatology was urinary in 26 cases, rectal in 7 and both rectal and urinary in 2. The average age of patients presenting urinary complaints was 64, the average age of patients with rectal' complaints was 54. In most patients with urinary symptoms, the complaints werf' indistinguishable from those of prostatism. Complete urinary retention occurred in 40 per cent of the cases. The rectal symptoms usually consisted of progressive constipation, obstipation or tenesmus. Of the previously reported cases, 18 were treated by suprapubic prostatectomy, 9 by perinea! resection, 3 by transurethral resection and 5 were found at autopsy. Description of the size of the tumors is difficult to summarize because of variation in methods of estimation and because of the lack of exact information in some reports. The largest reported case is that of Neupert in which the specimen weighed 3.6 kg. Of the 13 cases in which specimens were described by weight (aside from the 2 massive tumors described by Neupert and Magoun in which the growths weighed 3.6 kg. and 1.45 kg. respectively) the average weight was 191 gm. Measurements were recorded in only 22 cases and the average was 4.8 by 4.1 by 3.8 cm. In all cases the diagnosis of leiomyoma was confirmed by the microscopic picture of a circumscribed

308

J. J. KAUFMAN AND R. R. BERNEIKE

smooth muscle tumor with or without glandular elements in other parts of the specimen. Lateral, median, posterior and combinations of lobes have been involved. It has been shown that the tumors may be either intra- or extraprostatic. In the former group they usually displace the normal or hyperplastic glandular tissue to the periphery and in the latter group they are often pedunculated and produce pressure on neighboring organs such as the rectum. The intraprostatic leiomyomas with intravesical or intra-urethral extension are usually clinically indistinguishable from symptomatic benign prostatic hyperplasia. There are numerous theories regarding the pathogenesis of leiomyomas of the prostate. Tandler and Zuckerkandl expressed the belief that infection and inflammation transform adenomatous masses of the prostate into smooth muscle with the formation of myomas. Ewing also believed that in chronic prostatitis there may be "hyperplasia" of smooth muscle tissue which at times simulates neoplasm. He also stated, however, that isolated or pedunculated myomas arise in the prostate and that the histology of these is different from that of the "hyperplastic" fibromuscular tissue seen in ordinary hypertrophy and in chronic inflammation. Adrion believed that arteriosclerosis or infection may produce dedgenration of hyperplastic tubular nodules so that only scar tissue and smooth muscle stroma remain. Blum and Rubritius believed that leiomyomas represent fibromuscular "hypertrophy" in an organ in which there is glandular, muscular, and connective tissue and in which any one may predominate in the picture of hyperplasia of the prostate, although the adenomatous hyperplasia is by far the most common. Jacoby contended that pure leiomyomas never occur and that in all cases epithelial elements are found. Patch and Rhea, on the other hand, think that leiomyomas represent bona fide tumors and that they originate from embryological anlagen. They state that true leiomyomas are to be differentiated from the small fibromuscular nodules which are seen frequently in "leiomyomatous forms of prostatic enlargement." Deming believes that prostatic hypertrophy begins as a fibromuscular nodule in the prostatic urethra and that this nodule is invaded by ductal epithelium which in turn may become adenomatous and replace the fibromuscular tissue. He also believes that when there are no adjacent suburethral ducts to invade the primary tumor, the nodule may develop into a large myomatous mass without glandular elements. He supports this contention with the statement that often numerous smooth muscle tumors can be demonstrated in the muscular wall of the posterior urethra. He concurs with Patch and Rhea in their belief that these tumors actually arise from embryologic anlagen. Although Ewing states that an analogy between the etiology of uterine and prostatic myomas cannot be drawn because the two organs are not homologues, Lowsley points out that the lower miillerian duct fibers which form the veru pierce the posterior urethra where they are mixed with the musculature of the urethral wall. Deming believes that the leiomyomas arise from these anlagen situated in the posterior urethra. (Hinman's first case, Carson's case and the authors' second case showed midline tumors posteriorly opposite the verumontanum and support the theory that such growth originated from midline structures, most probably miillerian duct anlagen).

LEIOMYOMA OF THE PROSTATE

309

While it is true that leiomyoma of the prostate occurs infrequently enough to consider it a curiosity, it still should be included in the differential diagnosis of prostatic and bladder neck tumors. The preoperative diagnosis can rarely be made in cases where the tumor is intraprostatic and produces bladder neck obstruction unless it is discovered on transurethral biopsy. The disease occurs in the age group in which glandular hyperplasia of the prostate is most common and frequently may be masked by co 1comitant adenomatous enlargement. \J\There the tumor is mainly extraprostatic and points posteriorly (as in our case 2 and in 7 other reported cases) it may be confused with carcinoma of the prostate, mullerian duct cyst, prostatic adenoma or prostatic cyst. It should be suspected in cases where there is an extramural anterior rectal mass of elastic or firm consistency. ·where the tumors are intraprostatic, they ,Yill be amenable to the standard methods of prostatectomy. If they are extraprostatic they usually can be enucleated with ease. Extirpation of the tumors will result in cure unless sarcomatous change has occurred. No case of recurrence following prostatectomy or myomectomy has been reported. Morbidity and survival following surgery are comparable to those associated ·with other benign prostatic growths. CONCL"GSIONS

Thirty-eight cases of true leiomyoma of the prostate, including the 3 cases presented in this paper, have been reported. True leiomyomas of the prostate must be differentiated from the small fibromuscular nodules which are frequently associated with hyperplasia of the prostate. Leiomyomas of the prostate may be extra- or intraprostatic and may produce either rectal or urinary symptoms. Various theories as to the pathogenesis of this entity have been presented. Leiomyoma of the prostate should be suspected when a firm or elastic mass is felt anteriorly on rectal examination. Prostatectomy or myomectomy (depending on the position of the usually results in cure.

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