Difficulty in the intravesical morcellation procedure for leiomyoma of the prostate enucleated by HoLEP

Abstract

Leiomyoma of prostate are rare benign neoplasms that are usually diagnosed incidentally through postoperative pathological examination. A 70-year-old man is presented with severe symptoms of lower urinary tract obstruction. Although a digital rectal examination and the prostate-specific antigen level did not suggest malignancy, transrectal ultrasonography showed an unusual homogenous echoic mass measuring 45×37 mm in size in the prostate. A needle biopsy was performed and pathological diagnosis was prostatic leiomyoma. Holmium laser enucleation of prostate (HoLEP) was chosen and performed to resect the tumour. Although the enucleation step presented no problems, the morcellation procedure using a conventional transurethral mechanical morcellator was very difficult owing to the firmness of the tissue. By using a bipolar erectrosurgical loop, fragmentation and removal of tissue was accomplished. This is the first case reported of these rare neoplasms in which HoLEP was offered as a less invasive surgical approach. We emphasise the firmness of the leiomyomatous tissue, which would lead to morcellation failure.

Figure 1

Transverse (left panel) and sagittal (right panel) images of transrectal ultrasonography show homogeneous isoechoic mass in the right* lobe of the prostate. *This transverse image was captured with left and right reversed.

Figure 2

Needle biopsy of the tumour demonstrates a fascicular pattern of abundant smooth muscle cells with no mitotic activity and minimal nuclear atypia. No normal glands were seen in all biopsy samples obtained from the tumour.

Figure 3

Axial T1-weighted image (left panel) shows a mass with homogeneous isointense relative to muscle. T2-weighted image (right panel) demonstrates the mass is well circumscribed and slightly high intensity relative to muscle.

Figure 4

Increase in the size of tumour is relatively small on CT images. Left panel: CT taken 4 years before. Right panel: preoperative CT.

Figure 5

Complete resection of tumour is demonstrated on postoperative MRI-T2-weighted images (lower panels). Upper panels are images taken preoperatively.