European Journal of Cardiovascular Medicine

Bladder leiomyomas are smooth muscle tumours, predominantly found in women of childbearing age.[1] Mesenchymal tumours of the urinary bladder are rare, accounting for approximately 1–5% of all bladder tumours, with leiomyomas constituting less than 0.43% of all cases. The etiology remains unclear, with chronic detrusor irritation and hormonal imbalances being proposed mechanisms.[2] Bladder leiomyomas may present asymptomatically or with obstructive and irritative voiding symptoms, haematuria, and pelvic pain. Morphologically, they may exhibit an endovesical (63–86%), intramural (3–7%), or extravesical (11–30%) growth pattern.[3]

The pathophysiology of bladder leiomyomas has been hypothesized to involve: [3]

1. Hormonal influences.
2. Dysontogenesis.
3. Perivascular inflammation leading to metaplastic transformation.
4. Inflammatory-mediated tumorigenesis secondary to bladder infections.

We report three cases of symptomatic bladder leiomyoma managed at our centre.

Study Design: A retrospective case series including three patients diagnosed with bladder leiomyoma.

Setting: Department of Urology, SPMC, Bikaner.

Inclusion Criteria: Patients diagnosed with bladder leiomyoma based on imaging, cystoscopy, and histopathology.

Data Collection: Patient demographics, clinical presentation, imaging findings, surgical management, histopathological diagnosis, and post-operative outcomes were reviewed.

Case 1: A 63-year-old male presented with right renal pain, mixed lower urinary tract symptoms, intermittent fever, and a bladder mass. The patient had a history of substance abuse (opium) for 15 years. There was no history of haematuria, urinary retention, or surgical interventions. Ultrasound KUB (USG KUB) revealed a large (90mm × 98mm) hypoechoic mass in the right postero-lateral bladder wall with associated right hydroureteronephrosis. Plain & Contrast enhanced MRI of abdomen with pelvis (figure 1) showed: A lobulated homogenously enhancing supra-prostatic lesion (108x87x80 mm) in right side of pelvis appearing hyper intense on T2W & STIR images while hypointense on T1W images. Mass was compressing right ureter causing right proximal HUN, likely soft tissue tumour. Cystoscopy confirmed a mass protruding from the right-lateral bladder wall with normal overlying mucosa. Transrectal tru-cut biopsy suggested a spindle cell lesion of smooth muscle origin. Intraoperatively we found a well encapsulated, smooth, multilobulated tumour on right side of urinary bladder (figure 2). The tumour was surgically enucleated via a lower midline extraperitoneal approach (figure 3 & 4). A small rent (2.5 × 3 cm) was repaired intraoperatively, and a suprapubic catheter was placed. The postoperative period was uneventful.

Case 2: A 65-year-old male presented with mixed lower urinary tract symptoms and a single episode of haematuria. Ultrasound KUB and CT-IVU identified a solid mass (5 × 5.5 cm) along the right bladder wall. Cystoscopy revealed intact bladder mucosa, and the tumour was resected transurethrally (TURBT). Histopathology confirmed a diagnosis of bladder leiomyoma.

Case 3: A 30-year-old female presented with irritative lower urinary tract symptoms without haematuria. Ultrasonography detected a bladder dome mass (3 × 4 cm), but CT-IVU did not reveal the lesion due to inadequate bladder distension. Intraoperative cystoscopy identified an extravesical mass with intact bladder mucosa. The tumour was enucleated via an open extravesical approach.

• All three patients had successful tumour resection.
• Postoperative histopathological examination confirmed the diagnosis of bladder leiomyoma.
• No malignant transformation was observed.
• No recurrence or complications were reported during follow-up.

Figure.1

T2-W MRI of abdomen and pelvis

 A lobulated homogenously enhancing huge supra- prostatic lesion (108x87x80 mm) in right side of pelvis appearing hyper intense on T2W & STIR images while hypointense on T1W images.

Figure [2]:

Intra-operative picture of a huge intramural bladder leiomyoma

FIGURE 3:  Enucleated specimen of bladder leiomyoma

FIGURE 4: Cut section of enucleated specimen of bladder leiomyoma

Bladder leiomyomas are rare but the most common benign bladder neoplasms.[4] They predominantly affect females, with a female-to-male ratio of 3:1, and have a mean age of presentation around 45 years.[5] Symptoms depend on tumour size and location, with intravesical tumours typically presenting with urinary urgency, frequency, haematuria, and, in some cases, bladder outlet obstruction leading to hydronephrosis.[5]

Diagnostic Imaging:

• Ultrasound typically shows a smooth, homogeneous, solid mass.[6]
• CT/MRI provides detailed information on size, location, and tissue characteristics.
• MRI is preferred for assessing composition and bladder wall involvement. It typically shows an intermediate signal intensity on T1-weighted images and an intermediate to low signal intensity on T2-weighted images. Following contrast administration, tumour shows variable pattern of enhancement, with some enhancing homogenously and others showing little enhancement.[7]
• Cystoscopy is essential for evaluating intravesical tumours.

Histopathology differentiates bladder leiomyomas from malignant neoplasms such as leiomyosarcoma and muscle-invasive urothelial carcinoma. The bladder mucosa often appears normal on cystoscopy, complicating diagnosis.

Management:

• Conservative management is an option for asymptomatic cases, as malignant transformation is rare.
• Symptomatic tumours require resection based on size and location.[8]
• Transurethral resection (TURBT) is preferred for small, intravesical tumours.
• Open, laparoscopic, or robotic-assisted surgery is required for larger or extravesical tumours.
• Partial cystectomy may be considered for extensive tumours.

In our case series, two tumours were managed via open extra-peritoneal extravesical enucleation due to their intramural/extravesical locations and large sizes. One tumour was resected transurethrally. The postoperative period was uneventful in all cases, with no evidence of recurrence.

Strengths and Limitations

Strengths:

• Detailed clinical and imaging data.
• Histopathological confirmation.
• Description of different surgical approaches.

Limitations:

• Small sample size.
• Single-centre experience.
• Short follow-up duration.

Bladder leiomyomas are rare but clinically significant benign tumours. Diagnosis requires a combination of imaging, cystoscopy, and histopathology. Surgical resection is the treatment of choice for symptomatic patients, with TURBT being preferred for smaller tumours and open/laparoscopic approaches for larger ones. Further studies are needed to establish long-term outcomes and optimal management strategies.

Conflicts of Interest

None.

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