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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 131-134
Ultrasonographic diagnosis of an unusual vesical hemangioma presenting as hydroureteronephrosis


Yash Diagnostic Center, Yash Hospital and Research Center, Civil Lines, Kanth Road, Moradabad (UP), India

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Date of Web Publication8-Jan-2010
 

   Abstract 

Vesical hemangiomas are rare and benign tumors of mesenchymal origin. They usually present with multiple episodes of hematuria and the diagnosis is usually achieved patho­logically. We present a rare case of vesical hemangioma at vesicoureteric junction that presented with abdominal pain secondary to hydroureteronephrosis and the diagnosis was suspected on ultrasonography and confirmed later by pathology.

How to cite this article:
Rastogi R, Bhargava S, Sachdeva IS, Rastogi V. Ultrasonographic diagnosis of an unusual vesical hemangioma presenting as hydroureteronephrosis. Saudi J Kidney Dis Transpl 2010;21:131-4

How to cite this URL:
Rastogi R, Bhargava S, Sachdeva IS, Rastogi V. Ultrasonographic diagnosis of an unusual vesical hemangioma presenting as hydroureteronephrosis. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2014 Oct 24];21:131-4. Available from: http://www.sjkdt.org/text.asp?2010/21/1/131/58788

   Case Report Top


A 15-year-old girl with a recent onset of dull aching pain on the left side of abdomen was referred for evaluation at our hospital. Her cli­nical and laboratory examinations were unre­markable including any recent episode of he­maturia.

Ultrasound scan of the abdomen revealed bor­derline enlargement of the left kidney with mild dilatation of the pelvicaliceal system and upper ureter [Figure 1]; it measured approximately 11.2 Χ 4.9 cm with parenchymal thickness of 19.2 mm in the midpolar region. In addition, there was a focal, solid, sessile, hypoechoic mass located at the left vesicoureteric junction with partial ureteric obstruction [Figure 2]. The mass had a large intravesical component and small distal ureteric component. The mass measured 4.21 Χ 3.76 Χ 3.39 cm maximally with a volume of approximately 28.1 mL. No evidence of any calcification or necrosis was detected within the mass. There was thickening of the vesical mucosa overlying the mass. Color Doppler ima­ging of the mass revealed numerous vascular channels both peripherally and within the tumor matrix with arterial and venous pattern of blood flow [Figure 3]. The arterial flow was of mode­rate velocity with low RI and good diastolic flow (PSV: 23.1 cm/sec, EDV: 10 cm/sec, RI: 0.54). 3D color Doppler ultrasound imaging [Figure 4] and 3D ultrasound angiography [Figure 5] well delineated the vascular nature of the vesical mass.

Based on the ultrasound imaging, we diag­nosed a vascular mass of the urinary bladder with high probability of submucosal vesical he­mangioma causing partial obstruction at the left vesicoureteric junction with secondary hy­droureteronephrosis (Grade I).

The patient was advised for subsequent con­trast enhanced CT scan or MRI of lower abdo­men followed by cystoscopy and biopsy. How­ever, due to financial constraints, the patient un­derwent only cystoscopy, which revealed a se­ssile, bluish soft tissue mass at the left vesi­coureteric junction appearing as hemangioma with urine dripping from the ureteric orifice. The biopsy obtained during cystoscopy re­vealed proliferating vascular channels [Figure 6] with no evidence of any inflammatory cells, cellular dysplasia, or muscular involvement.

The tumor was subsequently resected through a transurethral route and stent was placed to maintain the patency of vesicoureteric junction, and it was removed after 8 weeks. Immediate and three months postoperative follow-up was uneventful.


   Discussion Top


The urinary bladder is a rare site for heman­giomas, benign mesenchymal tumors that re­present 0.6 percent of vesical tumors. [1],[2] The cavernous type is the commonest variety, ac­counting for more than three fourth of these tumors; the rest are capillary and arteriovenous types, and most of them develop in childhood. [3] There is predilection for males in adult age group with M:F = 3.7:1. [1]

Most of the hemangiomas are solitary, smaller than 3 cm and have a predilection for dome, trigone and posterior walls of the urinary bladder; [1],[2],[4] in our case, the tumor was larger than 3 cm. The presenting symptom of a hemangioma is usually macroscopic hematuria followed by irritable voiding, abdominal pain and some­times urinary retention. [5] To our knowledge, si­milar cases with the location of tumor at the vesicoureteric junction with subsequent hydro­ureteronephrosis and abdominal pain have not been reported in literature before.

Vesical hemangiomas may occur in isolation or may be associated with syndromes such as Klippel-Trenaunay- Weber syndrome More Details, Rendu­Weber-Osler syndrome and Sturge-Weber Syn­drome.

Vesical hemangiomas usually appear as solid, focal, hypervascular, sessile, intramural masses on ultrasonography, CT scan, and MR imaging. On intravenous pyelography, they may be de­tected as filling defects, while they appear on MRI as low to intermediate intensity lesions on T1WI and markedly hyperintense on T2WI. [6] In addition, scintigraphy in blood pool phase usually shows increased activity in case of hemangiomas. [7]

Cystoscopic appearance of a sessile, bluish mass is highly suggestive of hemangioma. Small hemangioma may be detected on ima­ging, but may be occasionally missed on cys­toscopy; [8] hence, thorough evaluation is needed.

The usual differential diagnosis includes en­dometriosis, melanomas, rhabdomyosarcomas and angiosarcomas. Vesical endometrioma may manifest as hemorrhage that can be detected on imaging and usually present with cyclical blee­ding. Melanotic melanoma is usually hyper­intense on T1WI. Rhabdomyosarcomas are not usually hyperintense on MR imaging. Absence of cellular atypia differentiates hemangiomas from angiosarcomas.

Biopsy is conclusive and post-biopsy bleeding is not an usual complication. [3] The origin of tu­mor is submucosal with more than three fourth involving the muscular layer as well.

Small tumors are usually treated by transure­thral resection or prior Neodymium-Yag laser to reduce the size of the lesion and to control postoperative bleeding.[2],[9] Larger tumors or those with high suspicion of malignancy are treated with partial cystectomy[10] Patients treated for vesical hemangiomas have a favorable outcome but follow-up is advised to detect relapses.[5]

In conclusion, vesical hemangiomas can oc­cur rarely at the vesicoureteric junction and may present with abdominal pain instead of hematuria due to consequent hydroureterone­phrosis. Though the diagnosis of vesical he­mangioma can be suspected on imaging stu­dies including US with color doppler, CT and MRI, definitive diagnosis requires cystoscopy and biopsy.

 
   References Top

1.Cheng L, Nascimento AG, Neumann RM, et al. Hemangioma of the urinary bladder. Cancer 1999;86:498-504.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Garcia RJ, Fernandez GJ, Jalon MA, et al. Treatment of a cavernous hemangioma of the bladder by endoscopical resection. Arch Esp Urol 2004;57:731-3.  Back to cited text no. 2      
3.Wong-You-Cheong JJ, Woodward PJ, Man­ning MA, Sesterhenn IA. Neoplasms of the urinary bladder: Radiologic-pathologic correla­tion. RadioGraphics 2006;26:553-80.  Back to cited text no. 3      
4.Vazquez BS, Vazquez NS, Pinzon BJ, et al. Vesical cavernous hemangioma. Actas Urol Esp 2001;25(8):586-8.  Back to cited text no. 4      
5.Martin MS, Muller AC, Gonzalo RV, et al. He­mangioma of the urinary bladder. Actas Urol Esp 2007;31:1172-4.  Back to cited text no. 5      
6.Chen M, Lipson SA, Hricak H. MR imaging evaluation of benign mesenchymal tumors of the urinary bladder. AJR Am J Roentgenol 1997;168:399-403.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Ishikawa K, Saitoh M, Chida S. Detection of bladder hemangioma in a child by blood-pool scintigraphy. Pediatr Radiol 2003;33:433-5.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Szynaka P, Zoch-Zwierz WM, Owsiejczuk P. Cavernous hemangioma of the bladder in an 8­year-old girl. Urologia Polska 2006;59:1.  Back to cited text no. 8      
9.Smith JA Jr. Laser treatment of bladder hemangioma. J Urol 1990;143:282-4.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Ikeda T, Shimamoto K, Tanji N, et al. Caver­nous hemangioma of the urinary bladder in an 8-year-old child. Int J Urol 2004;11:429-31.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Rajul Rastogi
131/132, 2nd Floor, H-1 Block, Sector 11, Rohini 110085, Delhi
India
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PMID: 20061708

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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