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Urethral Hemangioma
0022-534 7/87 /1371-0116$02.00/0 Vol. 137, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
URETHRAL HEMANGIOMA GEORGE STEINHARDT*
AND
ALAN PERLMUTTER
From the Department of Urology, Wayne State University School of Medicine and Department of Pediatric Urology, Children's Hospital of Michigan, Detroit, Michigan
ABSTRACT
Urethral hemangiomas are uncommon lesions that can cause significant hemorrhagic morbidity. Since the lesions tend to recur complete urethral excision and subsequent urethral reconstruction have been advocated in the past as the preferred method of treatment. We present an alternative method of management of urethral hemangioma. Urethral hemangiomas are rare benign lesions that cause significant hemorrhagic morbidity. Histologically, these lesions ~re composed of thin endothelial-lined spaces. 1 The delicate nature of the vascular channels makes it difficult to fulgurate the lesions endoscopically. Although benign in nature, these lesions tend to recur unless completely eradicated. 2 For these reasons, most recent authors recommend complete urethral excision and subsequent urethral reconstruction to treat these troublesome lesions. 3 • 4 We report a case of extensive urethral hemangiomas that were poorly controlled with transurethral fulguration. We obtained an excellent surgical result without resorting to radical urethral excision. CASE REPORT
D.R., a 16-year-old boy, presented to a local urologist 2 years previously with a lifelong history of gross hematuria. A bluish, polypoid lesion was visible just within the urethral meatus.
On evaluation at our hospital the patient was anemic. Retrograde urethrography demonstrated urethral lesions throughout the pendulous urethra (fig. 1, B). Endoscopy showed scattered extension of the lesion into the distal bulbous urethra. Treatment consisted of urethral marsupialization from the subcoronal area to the penoscrotal junction, followed by periodic interval ambulatory surgical fulguration of the exposed lesions plus endoscopic fulguration of the scattered more proximal lesions. Fulguration was performed on 3 different occasions, resulting in excellent urethral preservation and complete eradication of the lesion (fig. 2). Subsequent urethral closure in the manner of Johanson5 was accomplished without difficulty 10 months after marsupialization. In the 2 years 4 months since urethral closure the patient has required urethroscopy with fulguration 3 times for small hemangiomas. Most of the hemangiomas were in the fossa navicularis, a location not previously exteriorized.
FIG. 1. Retrograde urethrograms. A, normal pendulous urethra. B, progression of hemangiomas
After it was determined radiographically that the lesion was confined to the distal 2 cm. of the urethra (fig. l,A), endoscopic biopsy and fulguration of the lesion were performed. The biopsy specimen was confirmed to be a cavernous hemangioma with focal capillary areas. The patient was seen again 3 months later with urethral bleeding. Endoscopic examination showed extension of the lesion throughout the entire pendulous urethra. Transurethral fulguration provided only temporary remission, and 1 year later the patient again had significant urethral hemorrhage.
Accepted for publication July 30, 1986. * Current address: Department of Pediatric Urology, St. Louis University Medical Center, 1325 S. Grand Blvd., St. Louis, Missouri 63104.
DISCUSSION
The history and presentation of our patient are representative of patients with urethral hemangiomas. Some authors state that patients with these lesions present most commonly in the third decade 6 but others report either a childhood presentation 2 • 4 or a history of hematuria in childhood. 3 Since the lesion is believed to be congenital early presentation should be expected. The diagnosis of urethral hemangiomas most often is made endoscopically but transurethral control of the lesion usually is inadequate. The lesions tend to recur and extend unless completely eradicated. Total excision of the involved urethra has been recommended3 and certainly could be expected to cure the patient. However, we were unwilling to accept the deformity or complications of such surgery. Our approach of urethral 116
117
URETHP4L HEMANGH)MA
marsupialization with direct vrn1on interval has afforded gradual but complete control of the lesion. patient has incurred no penile deformity or anatomical urethral distortion as a result of our efforts. We believe that total urethral excision is not necessary in patients with urethral hernangiomas. Dr. George Farrow, Mayo Clinic, confirmed the biopsy specimen findings. REFERENCES
1. Stout, A. P. and Latter, R.: Tumors of soft tissue. In: Atlas of
2. 3. 4. 5. 6. FIG. 2. Exteriorized urethra
Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 5, pp. 67-72, 1967. Manuel, E. S., Seery, W. H. and Cole, A. T.: Capillary hemangioma of the male urethra: case report with literature revie,v. J. Urol., 117: 804, 1977. Roberts, J. W. and Devine, C. J., Jr.: Urethral hemangioma: treatment by total excision and grafting. J. Urol., 129: 1053, 1983. Tilak, G. H.: Multiple hemangiomas of the male urethra-treatment by Denis Browne-Swinney-Johanson urethroplasty. J. Urol., 97: 96, 1967. Johanson, B.: Reconstruction of the male urethra in strictures. Acta Chir. Scand., suppl. 176, p. 1, 1953. Sharma, S. K., Reddy, M. J., Joshi, V. V. and Bapna, B. C.: Capillary haemangioma of male urethra. Brit. J. Urol., 53: 277, 1981.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
URETHRAL HEMANGIOMA GEORGE STEINHARDT*
AND
ALAN PERLMUTTER
From the Department of Urology, Wayne State University School of Medicine and Department of Pediatric Urology, Children's Hospital of Michigan, Detroit, Michigan
ABSTRACT
Urethral hemangiomas are uncommon lesions that can cause significant hemorrhagic morbidity. Since the lesions tend to recur complete urethral excision and subsequent urethral reconstruction have been advocated in the past as the preferred method of treatment. We present an alternative method of management of urethral hemangioma. Urethral hemangiomas are rare benign lesions that cause significant hemorrhagic morbidity. Histologically, these lesions ~re composed of thin endothelial-lined spaces. 1 The delicate nature of the vascular channels makes it difficult to fulgurate the lesions endoscopically. Although benign in nature, these lesions tend to recur unless completely eradicated. 2 For these reasons, most recent authors recommend complete urethral excision and subsequent urethral reconstruction to treat these troublesome lesions. 3 • 4 We report a case of extensive urethral hemangiomas that were poorly controlled with transurethral fulguration. We obtained an excellent surgical result without resorting to radical urethral excision. CASE REPORT
D.R., a 16-year-old boy, presented to a local urologist 2 years previously with a lifelong history of gross hematuria. A bluish, polypoid lesion was visible just within the urethral meatus.
On evaluation at our hospital the patient was anemic. Retrograde urethrography demonstrated urethral lesions throughout the pendulous urethra (fig. 1, B). Endoscopy showed scattered extension of the lesion into the distal bulbous urethra. Treatment consisted of urethral marsupialization from the subcoronal area to the penoscrotal junction, followed by periodic interval ambulatory surgical fulguration of the exposed lesions plus endoscopic fulguration of the scattered more proximal lesions. Fulguration was performed on 3 different occasions, resulting in excellent urethral preservation and complete eradication of the lesion (fig. 2). Subsequent urethral closure in the manner of Johanson5 was accomplished without difficulty 10 months after marsupialization. In the 2 years 4 months since urethral closure the patient has required urethroscopy with fulguration 3 times for small hemangiomas. Most of the hemangiomas were in the fossa navicularis, a location not previously exteriorized.
FIG. 1. Retrograde urethrograms. A, normal pendulous urethra. B, progression of hemangiomas
After it was determined radiographically that the lesion was confined to the distal 2 cm. of the urethra (fig. l,A), endoscopic biopsy and fulguration of the lesion were performed. The biopsy specimen was confirmed to be a cavernous hemangioma with focal capillary areas. The patient was seen again 3 months later with urethral bleeding. Endoscopic examination showed extension of the lesion throughout the entire pendulous urethra. Transurethral fulguration provided only temporary remission, and 1 year later the patient again had significant urethral hemorrhage.
Accepted for publication July 30, 1986. * Current address: Department of Pediatric Urology, St. Louis University Medical Center, 1325 S. Grand Blvd., St. Louis, Missouri 63104.
DISCUSSION
The history and presentation of our patient are representative of patients with urethral hemangiomas. Some authors state that patients with these lesions present most commonly in the third decade 6 but others report either a childhood presentation 2 • 4 or a history of hematuria in childhood. 3 Since the lesion is believed to be congenital early presentation should be expected. The diagnosis of urethral hemangiomas most often is made endoscopically but transurethral control of the lesion usually is inadequate. The lesions tend to recur and extend unless completely eradicated. Total excision of the involved urethra has been recommended3 and certainly could be expected to cure the patient. However, we were unwilling to accept the deformity or complications of such surgery. Our approach of urethral 116
117
URETHP4L HEMANGH)MA
marsupialization with direct vrn1on interval has afforded gradual but complete control of the lesion. patient has incurred no penile deformity or anatomical urethral distortion as a result of our efforts. We believe that total urethral excision is not necessary in patients with urethral hernangiomas. Dr. George Farrow, Mayo Clinic, confirmed the biopsy specimen findings. REFERENCES
1. Stout, A. P. and Latter, R.: Tumors of soft tissue. In: Atlas of
2. 3. 4. 5. 6. FIG. 2. Exteriorized urethra
Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, 2nd series, fasc. 5, pp. 67-72, 1967. Manuel, E. S., Seery, W. H. and Cole, A. T.: Capillary hemangioma of the male urethra: case report with literature revie,v. J. Urol., 117: 804, 1977. Roberts, J. W. and Devine, C. J., Jr.: Urethral hemangioma: treatment by total excision and grafting. J. Urol., 129: 1053, 1983. Tilak, G. H.: Multiple hemangiomas of the male urethra-treatment by Denis Browne-Swinney-Johanson urethroplasty. J. Urol., 97: 96, 1967. Johanson, B.: Reconstruction of the male urethra in strictures. Acta Chir. Scand., suppl. 176, p. 1, 1953. Sharma, S. K., Reddy, M. J., Joshi, V. V. and Bapna, B. C.: Capillary haemangioma of male urethra. Brit. J. Urol., 53: 277, 1981.