|Year : 2019 | Volume
| Issue : 3 | Page : 203-205
Transurethral En bloc excision of pediatric bladder tumor using holmium laser
Pankaj N Maheshwari1, Anant P Pore1, Saurabh R Patil1, Nick Okwi2
1 Department of Urology, Fortis Hospital Mulund, Mumbai, Maharashtra, India
2 Department of Urology, Fortis Hospital Mulund, Mumbai, Maharashtra, India; Department of Surgery, Busitema University of Health Sciences, Mbale, Uganda
|Date of Web Publication||6-Jun-2019|
Dr. Pankaj N Maheshwari
Fortis Hospital Mulund, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A 12-year-old male child, during evaluation of chronic constipation, was incidentally diagnosed to have a fronded bladder growth. Transurethral en bloc excision of the tumor was achieved using holmium laser. Histopathology confirmed it to be an inflammatory pseudotumor. This case is reported for its unusual presentation and management by holmium laser.
Keywords: Bladder tumor, en bloc excision, holmium laser, technique
|How to cite this article:|
Maheshwari PN, Pore AP, Patil SR, Okwi N. Transurethral En bloc excision of pediatric bladder tumor using holmium laser. J Indian Assoc Pediatr Surg 2019;24:203-5
|How to cite this URL:|
Maheshwari PN, Pore AP, Patil SR, Okwi N. Transurethral En bloc excision of pediatric bladder tumor using holmium laser. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2019 Sep 15];24:203-5. Available from: http://www.jiaps.com/text.asp?2019/24/3/203/259759
| Introduction|| |
Bladder tumors are not uncommon in adults but very rare in children. The histologic types of tumors seen in the pediatric population differ from those seen in adults. Many benign, malignant, and reactive bladder lesions are encountered in childhood.
Standard treatment in children is transurethral resection of the tumor. Usually, no postoperative intravesical chemotherapy or immunotherapy is needed in children.
| Case Report|| |
A 12-year-old male child was evaluated for vague abdominal pain with constipation of 2-month duration. An 18 mm × 15 mm fronded lesion was incidentally detected in the bladder on abdominal ultrasonography. He had neither lower urinary tract symptoms, dysuria, nor hematuria.
Blood parameters were normal. Urine did not show microscopic hematuria or abnormal cells on cytology. Computerized tomogram (CT) scan confirmed the lesion while rest of the urinary system was normal.
With a clinical suspicion of a fronded neoplastic mass in the bladder, the child underwent a cystoscopy with a pediatric 15-Fr sheath. The solitary papillary growth was confirmed above and lateral to the left ureteric orifice [Figure 1]a. En bloc excision of the tumor along with a 2-mm normal bladder–mucosal margin was performed with holmium laser. A 550-μm laser fiber could be easily inserted through the pediatric sheath. Tumor excision was done with the energy at 1.5 J and 40 Hz (60 W). Complete tumor excision was achieved, and tumor base biopsies were taken [Figure 1]b.
|Figure 1: (a) Cystoscopy image showing the fronded bladder tumor; (b) tumor base after complete excision of the tumor|
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The child had a smooth postoperative course. Urine was clear at the end of the procedure; hence, a 12-Fr Foley catheter was placed without the need for bladder irrigation. The catheter was removed after 24 h, and the child was discharged from the hospital within 36 h of the procedure.
Histopathology confirmed the tumor to be a pseudotumor with chronic inflammatory cystitis. At a follow-up of 1 year, no recurrences or complications were documented.
| Discussion|| |
Bladder tumor in children is an extremely rare condition. It differs from adults in a way that nonepithelial tumors are more common in children than transitional cell carcinomas. Rhabdomyosarcoma is the most common pediatric bladder tumor. Other lesions such as malignant rhabdoid tumor, inflammatory myofibroblastic tumor, and neuroblastoma may be found. Urothelial carcinomas are very unusual.
The usual presentation is with hematuria, dysuria, or abdominal pain. Interestingly, our patient had an incidental diagnosis during evaluation of constipation. He did not have any prior history of urological symptoms, disease, or urinary infection. The usual evaluation is by a CT or a contrast-enhanced magnetic resonance imaging. Even on these investigations, it is difficult to differentiate benign from malignant tumors.
The standard treatment of the bladder tumor in children would be transurethral resection of the tumor or open tumor excision. The problem with transurethral resection procedure is that not all centers would be equipped with pediatric resectoscope. Transurethral resection carries a risk of bleeding, bladder perforation, and obturator spasms. The risk of recurrence may also be high in view of the piece-meal removal of the tumor.
En bloc excision has an advantage of adequate tumor resection and the ability to collect good-quality tumor specimens for pathological diagnosis and staging when compared to conventional transurethral resection of bladder tumor. The recurrence may also be less with en bloc excision.
In this child, because we used holmium laser, the procedure could be performed through the standard pediatric cystoscopy sheath. The laser fiber is 550 m (1.5 Fr); hence, it can be placed through the working channel standard sheath.
Holmium laser has been used effectively and safely to treat bladder tumor in adults. With its precise cutting ability and excellent hemostatic properties, holmium laser can help adequate resection while providing sufficient tissue for histopathological examination. As there is no electrical current stimulation occurring while resection, obturator reflex and spasms do not happen during holmium laser resection of bladder tumor. An additional advantage of holmium laser is that the fiber can be inserted through a routine cystoscopy sheath, making the availability of pediatric resectoscope redundant.
As the procedure is bloodless, a small 12-Fr Foley catheter can be placed without the need for postoperative bladder irrigation. Postoperative pain is less, and the catheter is needed for a period of 24 h only. This helps reduce the hospital stay and the patient can be discharged from hospital without catheter in 1–2 days.
Histopathology proved it to be a pseudotumor with chronic inflammatory cystitis. Inflammatory pseudotumor of the bladder is a benign proliferative lesion of the submucosal stroma that cannot be distinguished from malignant tumors of the bladder either endoscopically or radiographically. Although benign, the proliferative nature has led to recommend open surgical removal or complete transurethral resection for definitive treatment.
Inflammatory pseudotumors are often secondary to lower urinary tract obstruction or cystitis. This child did not have any history of infection, trauma, or instrumentation to predispose him to chronic cystitis or pseudotumor.
To the best of our knowledge, this is the first case report of the use of holmium laser en bloc excision in the management of bladder tumor in children.
| Conclusion|| |
Bladder tumor in children is a rare problem. This case report establishes the feasibility and safety of holmium laser for en bloc resection of bladder tumor in the pediatric age group.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Huppmann AR, Pawel BR. Polyps and masses of the pediatric urinary bladder: A 21-year pathology review. Pediatr Dev Pathol 2011;14:438-44.
Zangari A, Zaini J, Gulìa C. Genetics of bladder malignant tumors in childhood. Curr Genomics 2016;17:14-32.
Bansal A, Sankhwar S, Goel A, Kumar M, Purkait B, Aeron R, et al.
Grading of complications of transurethral resection of bladder tumor using Clavien-Dindo classification system. Indian J Urol 2016;32:232-7.
] [Full text]
Sureka SK, Agarwal V, Agnihotri S, Kapoor R, Srivastava A, Mandhani A, et al.
Is en-bloc transurethral resection of bladder tumor for non-muscle invasive bladder carcinoma better than conventional technique in terms of recurrence and progression? A prospective study. Indian J Urol 2014;30:144-9.
] [Full text]
D'souza N, Verma A. Holmium laser transurethral resection of bladder tumor: Our experience. Urol Ann 2016;8:439-43.
Fletcher SG, Galgano MT, Michalsky MP, Roth JA. Regression of inflammatory pseudotumor of the bladder in a child with medical management. Urology 2007;69:982.e11-2.