Hemangioma of the Prostate: A Case Report and Literature Review

Hemangioma of the Prostate: A Case Report and Literature Review

Article Information

Hsu Fu-Kai¹, Hung Siu-Wan², Wu Chih-Ying³, Chiang Heng-Chieh⁴ and Chiu Kun-Yuan^5*

¹Taichung Veterans General Hospital, Taichung, Taiwan
²Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
³Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
⁴Division of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
⁵Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan

^*Corresponding Author: Chiu Kun-Yuan, Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan

Received: 01 September 2017; Accepted: 18 September 2017; Published: 22 September 2017

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Abstract

Hemangioma of the prostate is extremely rare. Here we described a 69-year-old man who had lower urinary tract symptoms (LUTS) for 5 years, treated as benign prostate hyperplasia (BPH) by Diode laser enucleation. Massive bleeding developed during the procedure with subsequently recurrent urine retention due to blood clot accumulation off and on for the following 3 years. Selective arterial embolization and repeated bladder irrigation failed to control the continuous bleeding, which finally caused obstructive uropathy. Cystoprostatectomy was then performed and the pathological result proved cavernous hemangioma of the prostate.

Keywords

Hemangioma, Laser therapy, Lower urinary tract symptoms, Prostate

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Article Details

Abbreviations:

BPH: Benign Prostate Hyperplasia; CT: Computed Tomography; LUTS: Lower Urinary Tract Symptoms; PSA: Prostate Specific Antigen; TURP: Transurethral Resection of the Prostate

1. Introduction

LUTS is the symptoms related to storage, voiding, or post micturition. It is primarily attributed to BPH in elderly men [1]. Hemangioma, a vascular malformation, is an extremely rare etiology of LUTS. When hemangioma was large enough, it can lead to LUTS. Gross hematuria is the cardinal symptom of urinary tract hemangioma, but it is difficult to confirm the diagnosis by conventional radiographic examination [2]. If prostatic hemangioma presents with LUTS rather than hematuria, we may easily confuse it with BPH. Transurethral resection of the prostate (TURP) had been used to treat the prostatic hemangioma with transient complication of a slow stream and initial voiding difficulty [3]. Selective arterial embolization had been applied on prostatic hemangioma treatment with only one episode of hematuria after the procedure [4]. The perineal intracapsular prostatectomy was performed in a reported case, but the patient was dead due to uncontrollable bleeding during the operation [5]. Thus, misdiagnosis of prostatic hemangioma can lead to a tragedy. We present a case of prostatic hemangioma treated with Diode laser enucleation complicated with repeated bleeding and obstructive uropathy for 3 years.

2. Case Report

A 69-year-old man had LUTS since 5 years ago. The rectal examination showed a huge prostate with multiple nodularity. Serum prostate specific antigen (PSA) level was 8.74 ng/ml. Transrectal ultrasound disclosed the prostate was 89 × 71 × 76mm with an internal 45 × 24mm cystic lesion (Figure 1). Abdominal computed tomography (CT) revealed an enlarged prostate with a well-enhanced glandular hyperplasia structure and peripheral enhancement similar to "ring of fire" in the delay phase (Figure 2). Although prostate cancer cannot be ruled out, the patient decided to receive Diode laser enucleation of the prostate. Massive intraoperative bleeding was noted and Foley’s catheter traction was performed. After the procedure, LUTS was improved but intermittent hematuria with recurrent urine retention bothered him in the following 3 years. Bladder irrigation by cystoscopy and even cystoscopic evacuation of hematoma were performed for several times. This patient also received selective arterial embolization for twice but in vain. He had obstructive uropathy with acute renal failure (serum creatinine level 12.0 mg/dl) developed 4 years later. Bilateral percutaneous nephrostomy were introduced and the renal function recovered (serum creatinine level 2.5 mg/dl). The serum PSA increased to 12.49 ng/ml and non-contrast CT revealed marked enlargement of the prostate gland due to hemorrhage. Laparoscopic radical cystoprostatectomy with ileal conduit reconstruction was performed. The pathology proved cavernous hemangioma with hematoma of the prostate (Figure 3) and incidental adenocarcinoma of the prostate (Gleason's score: 3+3=6).

Figure 1: Ultrasonography demonstrated a huge prostate with a 45 mm x 24 mm multiloculated cystic lesion.

Figure 2: Delay-contrasted CT revealed a hypoattenuated lesion in left lobe with peripheral enhancement (P) similar to "ring of fire". Note that the well-enhanced glandular hyperplasia structure (G) on the right lobe.

Figure 3: Irregular dilated and anastomosing vascular channels accompanied with fibrosis in prostate (H&E, 100X) were noted under microscopic evaluation. Cavernous hemangioma with hematoma in prostate is impressed.

3. Discussion

Case	Authors	Age	Symptom	Pre-operative image finding	Treatment	Complication
1	Rivoir et al (1953) (5)	65	LUTS	Cystoscopy: bladder trabeculation and injected mucosa	Prostatectomy	Death
2	Fiorelli et al (1991) (4)	30	Hematuria and hematospermia	Cystoscopy: bluish-red vascular area	Selective arterial embolism	Hematuria once
3	Ristau et al (2011) (6)	69	Asymptom	No remarkable finding	Prostatectomy	No
4	Serizawa et al (2011) (3)	84	LUTS	No remarkable finding	TURP	Slow stream and initial micturation difficulty for 6 months

4. Conflicts of Interest

The researcher claims no conflicts of interests.

References

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