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Leiomyoma of the Prostate: Report of Case
THE JOURNAL OF UROLOGY
Vol. 64, No. 3, September 1950 Printed in U.S.A.
LEIOMYOMA OF THE PROSTATE: REPORT OF CASE CARY P. GRAY Fellow in Urology, Mayo Foundation AND
GERSHOM J. THOMPSO~ Section on Urology, !Ylayo Clinic, Rochester, Minn.
The most common form of prostatic enlargement is that due to an increase in the epithelial elements. Both smooth muscle and fibrous connective tissue are present but it is unusual for one of these to be the cause of prostatic enlargement. Small myomatous nodules in the midst of glandular or adenomatous areas have been observed by both Young and Ewing. According to Young, Tandler and Zuckerkandl maintained that areas of leiomyomatous tissue have been produced by inflammation which has in turn resulted in the transformation of adenomatous tissue into muscular tissue. Patch and Rhea and most other authors do not believe in this theory, however. It has been suggested by Keen that endocrine influences may be related to the growth of the smooth muscle but that, however, embryonic disturbances must be considered. Keen stated that these growths are usually benign and that sarcomatous changes are infrequent. Leiomyomas of the prostate which are of sufficient size to cause distortion in the configuration of the prostate and surrounding structures are in reality rare lesions. Patch and Rhea in 1935 could find reports of only 10 cases in the literature and added 1 of their own. Keen in 1939 reviewed the data on the 20 cases reported up to that time and reported a case that he had encountered. No additional cases were reported until 1948, when McIntyre reported a case, making a total of 22. Keen stated that lVfoCallum found 8 prostatic leiomyomas in 14,000 necropsies, and that Alcock, in 700 prostatectomies, found an incidence of 1 per cent. Hinman and Sullivan, Bugbee, and Wolman have all reported interesting cases. The symptoms, Keen stated, parallel the direction of the growth and are as follows: (1) urinary difficulty, (2) rectal difficulty due to occlusion, (3) perineal bulging and tension and (4) abdominal distress. Vve are reporting another unusual case of leiomyoma of the prostate, the growth being confined to the median lobe and producing only mild obstructive symptoms but giving rise to a persistent hematuria which is not listed above as being one of the prevalent symptoms. REPORT OF CASE
A 59 year old man entered the Mayo Clinic on June 28, 1948, complaining of recurrent painless hematuria of 6 weeks' duration. The past history was noncontributory. In mid-May, 1948, he experienced an episode of painless hema511
512
CARY P. GRAY AND GERSHOM J. THOMPSON
turia, mostly terminal in type. During this attack, he had a cystoscopic examination but was not aware of the findings. The hematuria continued intermittently after the examination, the urine at times being practically all blood, and there was accompanying mild urinary frequency, nocturia, and slight terminal dribbling. Physical examination revealed a stocky, medium-sized man in no acute distress. No masses were palpated in the abdomen. The heart and lungs were normal. Grade 2 enlargement of the prostate (graded on a basis of 1 to 4) was noted; the condition was thought to be benign. Laboratory examination of the urine revealed a specific gravity of 1.027; acid reaction; absence of sugar; albuminuria, grade 2; erythruria, grade 1 (on a basis of 1 to 5, grade 5 representing gross blood); and pyuria, grade 2 (50 cells per high-power field). The hemoglobin content of the blood was 13.4 gm. per 100 cc., the erythrocytes numbered 4,620,000 and leukocytes 10,800 per cubic millimeter of blood. The flocculation reaction for syphilis was negative. The concentration of urea was 38 mg. per 100 cc. of blood. The sedimentation rate was 30 mm. in 1 hour (Westergren). The blood group was B, Rh negative. An excretory urogram showed a normal upper urinary tract but the excretory cystogram revealed a huge, round, smooth, filling defect which arose from the floor of the bladder and which appeared to occupy most of the intravesical space. This defect was thought to be due to prostatic enlargement. On July 2, 1948, a cystoscopic examination was done using metycaine hydrochloride (benzoyl-gamma-[2-methylpiperidino]-propyl hydrochloride) spinal anesthesia. There was no evidence of a tumor of the bladder. The median lobe projected intravesically to a great extent and was also subtrigonal. With the No. 27 Thompson resectoscope, tissue weighing 148 gm. was removed (fig. 1). This included the entire median lobe. There was no lateral lobe tissue which required removal. Because of excessive loss of blood due to the extreme vascularity of the gland, 500 cc. of blood was given by transfusion during the sixtyfive-minute operative procedure. The pathologist reported degenerating leiomyoma with degeneration giant cells (fig. 2). The postoperative course was quite smooth. A mixture of penicillin and streptomycin was given the first 3½ days as a prophylactic measure because of the thinness of the capsule as a result of the extensive resection of the tissue posteriorly. The temperature reached 101.5 F. the first day but gradually subsided to normal levels, and the use of antibiotics was discontinued on the fourth postoperative day. The urethral catheter was removed July 8, 1948, and the patient was able to urinate without the slightest difficulty. He was dismissed from our care on July 13, 1948, the eleventh postoperative day, at which time he was voiding normally. There was no hematuria and no residual urine. A letter from the patient's family physician received more than a year after the operation revealed no evidence of the recurrence of the growth, as determined by rectal examination. There has been no frequency, nocturia, or hematuria and there was no residual urine at the time of the last report.
LEIOMYOMA OF THE PROSTATE
513
FIG. I. Leiomyoma of prostate. One hundred and forty-eight grams of tissue were removed.
FIG. 2. Leiomyoma of prostate. Smooth-muscle cells and degeneration giant cells are present throughout. There is absence of prostatic acini. Sections were stained with hematoxylin and eosin (a, X90; b, X300).
The occurrence of small focal areas of leiomyomatous tissue in prostatic tissue is not unusual. We have reported another case of an unusually large leiomyoma of the prostate which was operated on successfully by transurethral methods.
514
CARY P. GRAY AND GERSHOM J. THOMPSON
That this is a comparatively rare cause of prostatic enlargement is evident from a review of the literature. However, probably many more cases are existent but unreported. REFERENCES BUGBEE, H. G.: Leiomyoma of the prostate; report of a case. J. Urol., 16: 67-71, 1926. EWING, J.: Neoplastic Diseases, a Treatise on Tumors. Ed. 4, Philadelphia: W. B. Saunders Co., 1940, pp. 224-239. HINMAN, F. AND SULLIVAN, J. J.: Two cases of leiomyoma of the prostate. J. Urol., 26: 475-483, 1931. KEEN, M. R.: The leiomyomatous prostate. J. Urol., 42: 158-169, 1939. McINTYRE, D. W.: Massive leiomyoma of the prostate: Case report. J. Urol., 59: 11981202, 1948. PATCH, F. S. AND RHEA, L. J.: Leiomyoma of the prostate gland. Brit. J. Urol., 7: 213-228, 1935. WoLMAN, I. J.: A case of leiomyoma of the prostate. J. Urol., 25: 93-97, 1931. YouNG, H. H.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926, vol. l,p.427.
Vol. 64, No. 3, September 1950 Printed in U.S.A.
LEIOMYOMA OF THE PROSTATE: REPORT OF CASE CARY P. GRAY Fellow in Urology, Mayo Foundation AND
GERSHOM J. THOMPSO~ Section on Urology, !Ylayo Clinic, Rochester, Minn.
The most common form of prostatic enlargement is that due to an increase in the epithelial elements. Both smooth muscle and fibrous connective tissue are present but it is unusual for one of these to be the cause of prostatic enlargement. Small myomatous nodules in the midst of glandular or adenomatous areas have been observed by both Young and Ewing. According to Young, Tandler and Zuckerkandl maintained that areas of leiomyomatous tissue have been produced by inflammation which has in turn resulted in the transformation of adenomatous tissue into muscular tissue. Patch and Rhea and most other authors do not believe in this theory, however. It has been suggested by Keen that endocrine influences may be related to the growth of the smooth muscle but that, however, embryonic disturbances must be considered. Keen stated that these growths are usually benign and that sarcomatous changes are infrequent. Leiomyomas of the prostate which are of sufficient size to cause distortion in the configuration of the prostate and surrounding structures are in reality rare lesions. Patch and Rhea in 1935 could find reports of only 10 cases in the literature and added 1 of their own. Keen in 1939 reviewed the data on the 20 cases reported up to that time and reported a case that he had encountered. No additional cases were reported until 1948, when McIntyre reported a case, making a total of 22. Keen stated that lVfoCallum found 8 prostatic leiomyomas in 14,000 necropsies, and that Alcock, in 700 prostatectomies, found an incidence of 1 per cent. Hinman and Sullivan, Bugbee, and Wolman have all reported interesting cases. The symptoms, Keen stated, parallel the direction of the growth and are as follows: (1) urinary difficulty, (2) rectal difficulty due to occlusion, (3) perineal bulging and tension and (4) abdominal distress. Vve are reporting another unusual case of leiomyoma of the prostate, the growth being confined to the median lobe and producing only mild obstructive symptoms but giving rise to a persistent hematuria which is not listed above as being one of the prevalent symptoms. REPORT OF CASE
A 59 year old man entered the Mayo Clinic on June 28, 1948, complaining of recurrent painless hematuria of 6 weeks' duration. The past history was noncontributory. In mid-May, 1948, he experienced an episode of painless hema511
512
CARY P. GRAY AND GERSHOM J. THOMPSON
turia, mostly terminal in type. During this attack, he had a cystoscopic examination but was not aware of the findings. The hematuria continued intermittently after the examination, the urine at times being practically all blood, and there was accompanying mild urinary frequency, nocturia, and slight terminal dribbling. Physical examination revealed a stocky, medium-sized man in no acute distress. No masses were palpated in the abdomen. The heart and lungs were normal. Grade 2 enlargement of the prostate (graded on a basis of 1 to 4) was noted; the condition was thought to be benign. Laboratory examination of the urine revealed a specific gravity of 1.027; acid reaction; absence of sugar; albuminuria, grade 2; erythruria, grade 1 (on a basis of 1 to 5, grade 5 representing gross blood); and pyuria, grade 2 (50 cells per high-power field). The hemoglobin content of the blood was 13.4 gm. per 100 cc., the erythrocytes numbered 4,620,000 and leukocytes 10,800 per cubic millimeter of blood. The flocculation reaction for syphilis was negative. The concentration of urea was 38 mg. per 100 cc. of blood. The sedimentation rate was 30 mm. in 1 hour (Westergren). The blood group was B, Rh negative. An excretory urogram showed a normal upper urinary tract but the excretory cystogram revealed a huge, round, smooth, filling defect which arose from the floor of the bladder and which appeared to occupy most of the intravesical space. This defect was thought to be due to prostatic enlargement. On July 2, 1948, a cystoscopic examination was done using metycaine hydrochloride (benzoyl-gamma-[2-methylpiperidino]-propyl hydrochloride) spinal anesthesia. There was no evidence of a tumor of the bladder. The median lobe projected intravesically to a great extent and was also subtrigonal. With the No. 27 Thompson resectoscope, tissue weighing 148 gm. was removed (fig. 1). This included the entire median lobe. There was no lateral lobe tissue which required removal. Because of excessive loss of blood due to the extreme vascularity of the gland, 500 cc. of blood was given by transfusion during the sixtyfive-minute operative procedure. The pathologist reported degenerating leiomyoma with degeneration giant cells (fig. 2). The postoperative course was quite smooth. A mixture of penicillin and streptomycin was given the first 3½ days as a prophylactic measure because of the thinness of the capsule as a result of the extensive resection of the tissue posteriorly. The temperature reached 101.5 F. the first day but gradually subsided to normal levels, and the use of antibiotics was discontinued on the fourth postoperative day. The urethral catheter was removed July 8, 1948, and the patient was able to urinate without the slightest difficulty. He was dismissed from our care on July 13, 1948, the eleventh postoperative day, at which time he was voiding normally. There was no hematuria and no residual urine. A letter from the patient's family physician received more than a year after the operation revealed no evidence of the recurrence of the growth, as determined by rectal examination. There has been no frequency, nocturia, or hematuria and there was no residual urine at the time of the last report.
LEIOMYOMA OF THE PROSTATE
513
FIG. I. Leiomyoma of prostate. One hundred and forty-eight grams of tissue were removed.
FIG. 2. Leiomyoma of prostate. Smooth-muscle cells and degeneration giant cells are present throughout. There is absence of prostatic acini. Sections were stained with hematoxylin and eosin (a, X90; b, X300).
The occurrence of small focal areas of leiomyomatous tissue in prostatic tissue is not unusual. We have reported another case of an unusually large leiomyoma of the prostate which was operated on successfully by transurethral methods.
514
CARY P. GRAY AND GERSHOM J. THOMPSON
That this is a comparatively rare cause of prostatic enlargement is evident from a review of the literature. However, probably many more cases are existent but unreported. REFERENCES BUGBEE, H. G.: Leiomyoma of the prostate; report of a case. J. Urol., 16: 67-71, 1926. EWING, J.: Neoplastic Diseases, a Treatise on Tumors. Ed. 4, Philadelphia: W. B. Saunders Co., 1940, pp. 224-239. HINMAN, F. AND SULLIVAN, J. J.: Two cases of leiomyoma of the prostate. J. Urol., 26: 475-483, 1931. KEEN, M. R.: The leiomyomatous prostate. J. Urol., 42: 158-169, 1939. McINTYRE, D. W.: Massive leiomyoma of the prostate: Case report. J. Urol., 59: 11981202, 1948. PATCH, F. S. AND RHEA, L. J.: Leiomyoma of the prostate gland. Brit. J. Urol., 7: 213-228, 1935. WoLMAN, I. J.: A case of leiomyoma of the prostate. J. Urol., 25: 93-97, 1931. YouNG, H. H.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926, vol. l,p.427.