The role of partial cystectomy in benign bladder conditions

Introduction

Cystectomy most commonly used procedure for malignant bladder disorders since late 19^th century. Partial cystectomy became surgical option for selected cases of bladder cancer and for benign conditions like neurogenic bladder, intertetialcystitis, radiation cystitis.1 Partial cystectomy can be an option for rare conditions like endometriosis of bladder, leiomyoma and pheochromocytoma.2 Very few studies available regarding the role of partial cystectomy for rare benign diseases. We report the role of cystectomy for 3 rare cases of benign diseases of bladder.

Case-I. Endometriosis of bladder

A 26 years old female patient presented to urology outpatient department with hematuria, suprapubic pain and dysuria of 3 months duration. She had history of Frequency, Urgency, burning urination and suprapubic pain when bladder was full. Her first child was delivered by cesarian section. Her second child was died due to uterine rupture for which she had undergone emergency hysterectomy after which she developed all these symptoms. On further evaluation her urine examination showed grossheamaturia. Ultrasongraphy showed a mass lesion in the bladder. CECT abdomen showed an enhancing mass lesion of size of 5x4 cm in the dome of bladder which was deeply infiltrating (Figure 1). cystoscopy was done and a nodular lesion seen over the dome (Figure 2).

With the provisional diagnosis of endometriosis of bladder andmedical management was given to the patient. Gonadotropin releasing hormone (GnRH) analogues given initially to control pain and hematuria for 6 weeks. But mass did not regress. Then patient had undergone partial cystectomy (Figure 3). Post operative period was uneventful. Patient was symptomatically improved. Patient has been coming for follow up since 2 years with nocomplaints.

Endometriosis of bladder is the presence of endometrial tissue outside the uterine cavity. Most commonly affected site for endometriosis are the bladder (85%), ureter (9%), kidneys (4%), and urethra (2%).3 Partial cystectomy can be the treatment of choice for endometriosis based on severity of symptoms and extent of disease.4

Figure 1

Figure 2

Figure 3

Case-II. Pheochrmocytoma of bladder

Pheochromocytoma of bladder are exceedingly rare tumors accounting for less than 0.05% of all bladder tumors and less than 1% of all pheochromocytomas.In the genitourinary tract, urinary bladder is the most common site for pheochromocytomas (79.2%), followed by the urethra (12.7%), pelvis (4.9%), and ureter (3.2%).5

A 13yr old male child presented to the urology out patientwith recurrent attacks of severe headache, palpitations, sweating after the act of micturition since 3 months. He also had Micturition Syncope (fainting at the end of the act of micturition). BP was 130/90. Past and perinatal history was insignificant. Investigations revealed-a negative VMA, 24 hours urinary metanephrins were normal (129.72 microgms/day) and 24hours urinary normetanephrins were elevated (1200mgms/day).

Ultrasonography showed a 2.4x1.1 cm sized hypoechoic well defined lesion with peripheral vascularity seen in the superior aspect of wall of urinary bladder. CECT abdomen showed crescentic shaped intensely enhancing hyperdense lesion closely abutting the anterosuperior aspect of the bladder, slightly towards right side of midline size of 1.2cmsx2.2cms x2.8cms (Figure 4). PET-CT done with 68Ga dotatate which is a specific tracer for neuroendocrine lesions showed tracer localization in the bladder wall lesion (Figure 5).

   Cystoscopy showed nodular lesion in the bladder. Patient underwent partial cystectomy with provisional diagnosis of pheochromocytoma. Biopsy and immunohistochemistry markers (IHC and Chromogranin) confirmed the diagnosis (Figure 6). Post op period was uneventful. Patient has been in follow up since 5 years and doing well without any complications.

Figure 4

Figure 5

Figure 6

Case-III. Ovarian dermoid eroding into bladder

A 21 years old female patient came to urology department with suprapubic pain, frequency, dysuria and urgency since 6 moths. She had history of passing hair in the urine, occasionally since 6 months. On further evaluation, urine culture showed E.coliand treated for UTI. Ultrasonography showed right ovarian mass with vesical caliculus. CECT Abdomen showed a 6*5 cm ovarian dermoid eroding into the bladder (Figure 7). On surgical exploration a dermoid cyst arising from right ovary adherent and eroding the bladder dome was noticed and partial cystectomy was done (Figure 8). The ovarian dermoid cyst showed a tuft of hair and a calculus adherent. The same was confirmed on histopathology.Post-operative period was uneventful. She was in follow up without any complaints last 3 years.

Ovarian dermoid cysts are germ cell tumours of ovary with malignant potential of 1-3%. Majority of them are asymptomatic and discovered incidentally. Due to complications like torsion, spontaneous rupture and chemical peritonitis, surgical removal of ovarian dermoid cyst is adivised.6

Figure 7

Figure 8

Conclusion

All the benign conditions reported in this manuscript had distinct clinical features from which a proper diagnosis can be made-micturition syncope in pheochromacytoma, history of hysterectomy and hematuria in endometriosis and passing hair in urine dermoid eroding the bladder.

Partial cystectomy resulted in complete cure and so is eminently suitable in the managementof these benign conditions.We observed no complications of this procedure either early or late.

Acknowledgment

The author thankful to Department of Urology for providing all the facilities to carry out this work.

Source of Funding

No financial support was received for the work within this manuscript.

Conflict of Interest

The authors declare they have no conflict of interest.