Inflammatory Myofibroblastic Tumor of the Urinary Bladder Managed by Laparoscopic Partial Cystectomy
A 17-year-old unmarried nonsmoking female presented with burning micturition, increasing urinary frequency, suprapubic pain, and occasional hematuria for the past 1 year. The patient had no history of fever, pyuria, or flank pain. The results of general and systemic physical examinations were unremarkable. The results of routine hemogram and blood chemistry profiles were within normal limits. Ultrasonography of the abdomen and pelvis revealed a large heteroechoic mass arising from the dome and anterior wall of the urinary bladder. Contrast-enhanced computerized tomographic scans revealed a large, eccentric lobulated heterogeneously enhancing mass sized 8 cm×5 cm×5 cm and arising in the midline from the dome and anterior wall of the urinary bladder (). Cystoscopy showed a broad-based, lobulated growth arising from the dome and anterior bladder wall. Biopsy of the lesion revealed oval to spindle-shaped cells accompanied by lymphocytes, neutrophils, and plasma cells on a myxoid stroma. The spindle cells had a high nuclear: cytoplasm ratio, a scant to moderate amount of eosinophilic cytoplasm, and oval to elongated hyperchromatic nuclei with frequent mitoses. Immunohistochemistry was positive for vimentin, smooth muscle actin, muscle-specific actin, cytokeratin, and anaplastic lymphoma kinase-1 (ALK-1) and negative for desmin (). A diagnosis of IMT was made and LPC was planned.\nThe bowel was prepared 1 day before surgery. A standard transperitoneal four-port technique was used with the patient in a modified lithotomy and 20-degree Trendelenburg position. First, a 12-mm camera port was placed 3 cm above the umbilicus. Two working ports 10 mm on the right side and 5 mm on the left side were placed at the midclavicular line 2 cm below the level of the umbilicus. Another 5-mm port was placed midway between the umbilicus and the symphysis pubis. The bladder was mobilized starting from just above the peritoneal reflection on the anterior abdominal wall and was extended down on both sides in an inverted-V shaped manner. Dissection was carried down to Retzius' space with mobilization of the bladder from all sides. With simultaneous cystoscopic guidance and transillumination, the tumor outline was defined (). Cystotomy was done about 2 cm away from the tumor margin and was carried circumferentially around the tumor leaving a 2-cm healthy margin (). The bladder was closed in two layers with 2-0 polyglactin suture and the specimen was retrieved in an EndoCatch bag (USCC, Norwalk, CT, USA). A Foley catheter and tube drain were placed in the bladder and Retzius' space, respectively. Operative time was 130 minutes and blood loss was 200 mL with no intraoperative complications. The drain was removed on the second postoperative day and the patient was discharged on the fourth day. The catheter was removed on the 10th postoperative day after a cystogram revealed no leaks.\nOwing to the uncertain malignant potential of the IMT, the patient was kept on 3 monthly cystoscopic surveillance and has been free from any recurrence after 22 months of surgery.