Congenital vascular tumors and malformations involving urinary tract: diagnosis and surgical management

Hemangioma of the Urinary Bladder: A Brief Narrative Review of Their Diagnosis, Histology, and Treatment Options

BACKGROUND

Hemangioma of the urinary bladder is a rare benign tumor. Although benign, their presenting symptoms are alarming for both patients and doctors, and their rarity makes them challenging to correctly diagnosis and treat. This review paper summarizes current knowledge about hemangioma of the urinary bladder, treatment options, and follow-up modalities.

SUMMARY

After the kidney, the bladder is the second most common location of hemangiomas in the urinary tract. There is painless gross hematuria on clinical presentation once the lesion has eroded the urothelium. Magnetic resonance imaging (MRI) has been reported to be valuable in diagnosing soft-tissue hemangiomas. Cystoscopic findings of a sessile, blue, multilocular mass suggest hemangioma. Most tumors are solitary, smaller than 3 cm, and have smooth or irregular surfaces. Histologically, lesions comprise numerous proliferative capillaries with thin-walled, dilated, blood-filled vessels lined with flattened endothelium. The treatment of patients with hemangioma has been controversial. It depends on the tumor size and the degree of penetration. The prognosis of these tumors is excellent.

KEY MESSAGES

Despite the widespread use of MRI, CT, and endoscopy in evaluating hematuria, hemangioma remains one of the rarest bladder tumors. Moreover, only a histological examination can confirm the diagnosis. Transurethral resection, fulguration, and YAG laser ablation are standard treatments for small tumors. In terms of follow-up, cystoscopy after 6 months of treatment helps assess recurrence. In addition, MRI is a practical, noninvasive technique for follow-up of small hemangiomas.

Klippel-Trenaunay Syndrome Associated With Urinary Tract Hemangiomas: A Case Report

The association between Klippel-Trenauney syndrome (KTS) and bladder hemangiomas is rare. The most common clinical manifestation is hematuria. The diagnosis is made from the characteristic cystoscopic appearance of the tumor. We report the case of a patient presenting recurrent macroscopic hematuria in the context of KTS. A cystoscopic evaluation revealed bladder hemangiomas. A conservative approach consisting of bladder irrigation and close follow-up was chosen as therapy. Conservative treatment of bladder irrigation and close follow-up is the recommended initial treatment of moderate and infrequent episodes of hematuria in this context. The more invasive therapeutic options have to be considered especially for frequent or life-threatening episodes of hematuria. This case suggests that conservative treatment may be effective in treating moderate and infrequent episodes of hematuria due to bladder hemangioma in the context of KTS. Further studies are required to adequately establish the effectiveness, limitations, and complications of each approach.

A series of vascular tumors and tumorlike lesions of the bladder

Vascular tumors of the bladder are rare and a subject of small series and case reports. We retrospectively identified vascular tumors of the urinary bladder from the consultation files from one of the authors. We identified 13 lesions that included 3 hemangiomas, 3 intravascular papillary endothelial hyperplasias (Masson vegetant hemangioendotheliomas), 2 arteriovenous malformations (AVMs), 1 epithelioid hemangioendothelioma (EHE), and 4 angiosarcomas. One of the angiosarcomas was associated with conventional high-grade urothelial carcinoma (sarcomatoid carcinoma). All patients were adults with a range in age from 18 to 85 years old (mean 63.3). There was no statistical difference among the various lesions in terms of age, although angiosarcomas tended to arise in older patients (mean 71 y vs. 60 y of the remainder). Hematuria was the most common presentation of both benign and malignant lesions. Other symptoms included voiding irritation, pelvic pain, and obstruction. Histologically, benign and malignant lesions were similar to their counterparts in other organ systems. Two hemangiomas were of the capillary type and a third one of the cavernous subtype. They measured 1.1, 2.4, and 3.2 cm. Both AVMs were clinically large broad-based masses measuring 5.5 and 5.8 cm in greatest diameter. One of the AVMs was associated with pseudoepitheliomatous hyperplasia of the urothelium. All 3 patients with Masson lesion had history of radiation therapy for other causes. These presented as raised lesions and were all <1.0 cm. Patients with hemangiomas, papillary endothelial hyperplasias, and AVM had an invariably benign prognosis and needed no further therapy. These benign lesions had consistent involvement of the submucosa and spared the muscularis propria of the organ. All cases of angiosarcoma and EHE involved the muscularis propria. Two of four patients with angiosarcoma had a history of prior radiation therapy and all 4 were dead of disease at 6 months. Angiosarcomas measured 3, 4.5, 5, and 5.8 cm in greatest diameter at cystoscopy. The patient with EHE had a single nodule treated by transurethral resection of the bladder and no evidence of disease at 4 years of follow-up. None of the patients experienced marked gross hematuria that resulted in morbidity or mortality. A wide spectrum of benign, intermediate malignant, and malignant vascular lesions primarily involved the bladder. Despite the potential for marked hemorrhage, none of the tumors resulted in marked hematuria. Papillary endothelial hyperplasia occurs in the bladder and must be differentiated from angiosarcoma, which has a rapidly fatal outcome.

Urogenital involvement in the Klippel-Trenaunay-Weber syndrome. Treatment options and results

OBJECTIVE

Klippel-Trenaunay-Weber syndrome (KTWS) is a congenital condition characterized by vascular malformations of the capillary, venous and lymphatic systems associated to soft tissue and bone hypertrophy in the affected areas. This syndrome may involve bladder, kidney, urethra, ureter and genitals. We report the treatment of 7 KTWS patients with urogenital involvement.

MATERIALS AND METHODS

From 1995 to 2005, 7 patients with KTWS were evaluated and the charts of these patients were reviewed.

RESULTS

Patients' median age was 19-years (range 4 to 46-years) and only 1 was female. The clinical presentation included genital deformities in 3 cases, hematuria in 2 and urethrorragia in 2, one of which associated with cryptorchidism and phimosis. Three patients had an association of pelvic and genital malformations, including 2 patients with hematuria due to vesical lesions and 1 patient with left ureterohydronephrosis due to a pelvic mass. Two patients had urethral lesions. Treatment included endoscopic laser coagulation for 1 patient with recurrent hematuria and 1 patient with urethrorrhagia, pelvic radiotherapy for 1 patient with hematuria and circumcision in 2 patients with genital deformities. One patient required placement of a double-J catheter to relieve obstruction. Hematuria and urethrorragia were safely and effectively controlled with laser applications. Circumcision was also effective. The patient treated with radiotherapy developed a contracted bladder and required a continent urinary diversion.

CONCLUSIONS

Urogenital involvement in patients with KTWS is not rare and must be suspected in the presence of hematuria or significant cutaneous deformity of the external genitalia. Surgical treatment may be warranted in selected cases.

Klippel-Trenaunay Syndrome: Incidence and Treatment of Genitourinary Sequelae

PURPOSE

Prior reviews regarding genitourinary manifestations of Klippel-Trenaunay syndrome used data acquired from diverse specialty specific articles to define the incidence and sequelae of its genitourinary manifestations. We believe that this resulted in erroneous conclusions regarding the urological complications of Klippel-Trenaunay syndrome.

MATERIALS AND METHODS

Data on genitourinary manifestations in patients with Klippel-Trenaunay syndrome treated at 1 institution from 1970 through 2005 were acquired.

RESULTS

Of 218 patients with Klippel-Trenaunay syndrome 30% (66 of 218) had genitourinary involvement, including 7% (15) with cutaneous genital abnormalities, 7% (15) with visceral genitourinary involvement and 16% (36) with each type. Intermittent bleeding from cutaneous genital abnormalities developed in 65% of patients (33 of 51). Conservative treatment with compression and/or cauterization was attempted in all 33 patients and it was successful in 64% (21 of 33). Intractable hemorrhage resulted in excision of the cutaneous bleeding site in 36% of cases (12 of 33). A total of 39 hospitalizations for gross hematuria occurred in 9% of the patients (19 of 218). Hematuria developed from the bladder in 11 cases, the urethra in 4 and the kidney in 4. Conservative therapy resolved gross hematuria in 21% of the patients (4 of 19). Refractory hematuria was successfully treated with cauterization in 37% of the patients (7 of 19) and by angiographic embolization in 10% (2 of 19). Intractable gross hematuria resulted in open surgical excision of the bleeding site in 32% of the patients (6 of 19).

CONCLUSIONS

The incidence of genitourinary manifestations of Klippel-Trenaunay syndrome is 30%, which is triple the previously reported incidence of 9%. Unlike prior reports stating that the genitourinary abnormalities rarely caused problems, 52% of the patients (34 of 66) with Klippel-Trenaunay syndrome who had urological manifestations eventually required interventional therapy for genitourinary complications.

Klippel-Trénaunay syndrome: 2 case reports and a review of genitourinary manifestations

PURPOSE

We summarize the literature and present our experience with genitourinary manifestations of the Klippel-Trénaunay syndrome, which can lead to challenging management problems.

MATERIALS AND METHODS

We report on 2 patients with genitourinary manifestations of the Klippel-Trénaunay syndrome and performed a MEDLINE review of the literature using the key words "Klippel-Trénaunay," "vascular malformation" and "genitourinary."

RESULTS

Genitourinary manifestations were cited in 18 articles, including 1,174 cases of the Klippel-Trénaunay syndrome, detailing the presentation and management of bladder, external genitalia and retroperitoneal involvement in the Klippel-Trénaunay syndrome. The overall genitourinary symptoms in patients with the Klippel-Trénaunay syndrome seem to occur in the more severe cases and usually involve cutaneous vascular malformations of the trunk, pelvis and genitalia.

CONCLUSIONS

Intra-abdominal and intrapelvic extension of the vascular malformations of the Klippel-Trénaunay syndrome frequently occurs concurrently with the lower abdominal, pelvic cutaneous involvement of the external genitalia, as in our 2 cases and in our review of the literature. These data provide a better understanding of the spectrum of genitourinary manifestations in the Klippel-Trénaunay syndrome and provide insight for the clinician to formulate individual therapies for these patients.

Endoscopic neodymium:yttrium aluminium garnet (Nd:YAG) laser irradiation of a bladder hemangioma associated with Klippel-Weber syndrome

A case of endoscopic neodymium:yttrium aluminium garnet (Nd:YAG) laser coagulation of a bladder hemangioma associated with Klippel-Weber syndrome is presented. The patient presented with extensive nevus and swelling of the left lower limb since birth. She was diagnosed with Klippel-Weber syndrome by angiography at the age of 1 year. Gross hematuria had been observed since she was 1 year old and, in addition, endoscopic examination revealed diffuse bladder hemangiomas. At 8 years of age, gross hematuria became worse and gait disturbance also appeared. She was referred to the Department of Urology at Tohoku University School of Medicine for endoscopic treatment in June 1998. Under general anesthesia, the bladder was inflated with CO2 gas and the hemangiomas were coagulated by Nd:YAG laser photonic irradiation endoscopically. Gross hematuria was markedly improved immediately following this treatment. Klippel-Weber syndrome is a rather uncommon disease which shows various types of vascular anomaly and hypertrophy of the lower extremities. Three to 6% of the patients have associated bladder hemangiomas. Although Nd:YAG laser irradiation provides results superior to alternative therapy and is the preferred treatment for most patients with bladder hemangioma, in this case, hemangiomas are multiple and present the possibility of re-bleeding, therefore long-term and close follow up is important.

Hemangioma of the urinary bladder

BACKGROUND

Hemangioma of the urinary bladder is rare and the long term outcome of patients is unknown.

METHODS

The authors evaluated the clinical and pathologic findings in 19 patients with a vesical hemangioma. All patients were treated at the Mayo Clinic between 1932-1998 and had histologic confirmation of the diagnosis. Hemangioma was classified into cavernous, capillary, or arteriovenous types based on conventional criteria from other sites. Clinical information was obtained from chart review. The mean follow-up of the patients was 6.9 years (range, 0.3-25 years).

RESULTS

The mean patient age at the time of diagnosis was 58 years (range, 19-76 years) and the male-to-female ratio was 3.7:1. Patients typically presented with macroscopic hematuria and endoscopic findings usually were nonspecific. The diagnosis of hemangioma was suspected in 3 patients (16%) prior to biopsy. There was a predilection for the posterior and lateral walls and the tumor usually was small (range, 0.2-3 cm; median, 0.7 cm) and solitary. The histologic types of hemangioma were cavernous (15 cases), capillary (2 cases), and arteriovenous (2 cases). All patients were treated with biopsy with or without fulguration, except for one patient who was treated with a partial cystectomy. No patients developed a recurrence during a mean follow-up of 6.9 years.

CONCLUSIONS

Patients with hemangioma of the urinary bladder have a favorable outcome. Biopsy and fulguration are effective for hemangioma of the bladder when the lesion is small.

Bladder hemangioma as a cause of massive hematuria in a child. A case report and literature review

A 12-year-old girl with bladder hemangioma presenting with massive hematuria is described. The patient was previously operated for removal of cystic hygroma from the chest wall. The association of those two pathological entities suggests possible common etiology and pathogenesis and the various therapeutic options are reviewed.

Hematuria in a newborn infant caused by bladder hemangioma

A newborn boy had gross hematuria caused by hemangiomas of the bladder. The sonographic examination and the voiding cystourethrogram showed an irregular and thick bladder wall with a lesion extending into the vesical lumen. Cystoscopic examination and biopsy of the lesions were diagnostic of hemangioma. Immediately after lesion fulguration, the hematuria disappeared, and 3 weeks later the follow-up ultrasound examination showed resolution of the lesion. At 1 year, the patient's urinalysis and ultrasound scan were normal. To our knowledge, this is the first reported case of hematuria in a newborn caused by a bleeding hemangioma of the bladder.

Bladder hemangioma. Case report and review of the literature

The Authors report a case of vesical hemangioma; it was typical for site and clinical presentation whereas the age of onset and gross appearance were atypical. A TUR biopsy was performed without complications, but did not confirm diagnosis. A partial cystectomy was performed. A one-year follow-up, negative for recurrence, confirmed this procedure as the definitive treatment of choice.

Potassium thiophosphate laser treatment of genitourinary hemangioma in the pediatric population

Multiple hemangiomas of the urogenital system are uncommon lesions that usually recur and can cause significant morbidity. Three pediatric patients with urethral, bladder, penile, scrotal and vaginal hemangiomas underwent treatment of these lesions with the potassium thiophosphate laser. All patients had multiple lesions and suffered from recurrent bleeding before treatment. Potassium thiophosphate photocoagulation was delivered to the surface, urethral and vaginal lesions. Treatment-associated bleeding did not occur in any case. Followup urogenital and cystoscopic examinations revealed complete obliteration or marked diminution in the size of the treated hemangiomas. All patients had a decrease in the frequency and intensity of bleeding episodes and 2 were subsequently without further episodes of bleeding. Potassium thiophosphate laser photoablation provides excellent results in the pediatric population and is preferred to more extensive surgical intervention.

Neodymium:YAG laser treatment of bladder hemangiomas

We present 3 cases of bladder hemangiomas, one single and two multiple, with a long-term history of recurrent hematuria, treated with endoscopic neodymium:YAG (yttrium, aluminum, garnet) laser photocoagulation, and obtaining good results.

Laser treatment of bladder hemangioma

Bladder hemangiomas may occur singly or in association with systemic arteriovenous malformations. A total of 13 patients with bladder hemangiomas underwent treatment at this university. All patients had recurrent bleeding and neodymium:YAG laser energy was delivered endoscopically to the hemangioma. No treatment-related bleeding occurred in any patient, and all had a significant decrease in the frequency and intensity of bleeding episodes. Followup cystoscopic examinations have shown either complete eradication of the hemangioma or a marked decrease in size. Neodymium:YAG laser irradiation provides results superior to alternative therapy and is the preferred treatment for most patients with bladder hemangioma.

Congenital genitourinary hemangiomas in a patient with the Klippel-Trenaunay syndrome: management with the neodymium:YAG laser

The Klippel-Trenaunay syndrome is an unusual congenital anomaly characterized by cutaneous hemangiomas, multiple varicosities, soft tissue hypertrophy and, rarely, gastrointestinal or genitourinary hemangiomas. The large bladder as well as multiple penile hemangiomas in our patient were treated successfully with the neodymium:YAG laser with minimal morbidity.

Cavernous hemangiomas of the bladder in the pediatric age group

We describe 2 children with bladder hemangiomas. The diagnosis, pathology and treatment of these lesions in children are reviewed.

Hemangiolymphangioma of the urinary bladder in a child

A rare case of hemangiolymphangioma of the urinary bladder with associated cutaneous hemangiomas of the shaft and glans penis and the scrotum is presented. Unusual features of clinical presentation, noninvasive diagnosis, and the surgical management are discussed.

Neodymium:YAG laser irradiation of bladder hemangioma

Bladder hemangiomas may occur singly or in association with systemic arteriovenous malformations. Previously open surgical removal of these lesions has been necessary and endoscopic resection or biopsy strongly discouraged. We report a case of the Klippel-Trenaunay-Weber syndrome and a massive bladder hemangioma. Hemorrhagic complications were controlled by endoscopic application of neodymium:YAG laser photo-irradiation.

Vesical haemangioma. Report of two cases

Two cases of vesical haemangioma and a review of the literature are presented. In one of the cases association with cutaneous "Blue Rubber Bleb Nevus" has been found. Vesical haemangioma is a benign tumour, probably of congenital origin, that occurs in young patients. The first symptom is generally haematuria, and diagnosis is confirmed by cystoscopy. The treatment of choice is partial cystectomy, and the most common histologic form is cavernous haemangioma.

Assessment of cavernous hemangioma of bladder by technetium-99-tagged albumin scan

A case of cavernous hemangioma of the bladder is presented and its endoscopic appearance is illustrated. A scan utilizing technetium-99-labeled albumin has been found valuable in determining the extent of the lesion.

Klippel-Trenaunay syndrome associated with urinary tract hemangiomas

Genitourinary hemangiomas in 2 children with Klippel-Trenaunay syndrome are reported. The presence of cutaneous hemangiomas should alert urologists to the possibility of urinary tract hemangiomas inpatients with gross hematuria. Transurethral manipulation of bladder hemangiomas should be avoided because of the danger of excessive hemorrhage, the treatment of choice being partial cystectomy.