Indian Journal of Urology
UROLOGICAL IMAGES
Year
: 2018  |  Volume : 34  |  Issue : 3  |  Page : 229--230

Exophytic benign prostatic hyperplasia presenting with refractory retention: A rare entity


Ashish Khanna1, Girdhar Singh Bora1, Ujjwal Gorsi2, Aditya Prakash Sharma1, Ravimohan S Mavuduru1,  
1 Department of Urology, PGIMER, Chandigarh, India
2 Department of Radiodiagnosis, PGIMER, Chandigarh, India

Correspondence Address:
Ravimohan S Mavuduru
Department of Urology, PGIMER, Chandigarh
India

Abstract

The transitional zone is the most common site of benign prostatic hyperplasia (BPH). Exophytic BPH is an exceedingly rare entity with only one case described in the English literature. We herein describe a case of exophytic BPH in a 48-year-old man presenting as a large pelvic mass with refractory retention managed successfully with robot assistance. To the best of our knowledge, this is the first case of exophytic benign prostatic enlargement managed by surgical excision.



How to cite this article:
Khanna A, Bora GS, Gorsi U, Sharma AP, Mavuduru RS. Exophytic benign prostatic hyperplasia presenting with refractory retention: A rare entity.Indian J Urol 2018;34:229-230


How to cite this URL:
Khanna A, Bora GS, Gorsi U, Sharma AP, Mavuduru RS. Exophytic benign prostatic hyperplasia presenting with refractory retention: A rare entity. Indian J Urol [serial online] 2018 [cited 2022 Jan 29 ];34:229-230
Available from: https://www.indianjurol.com/text.asp?2018/34/3/229/235538


Full Text

 Case Report



A 48-year-old male presented with history of urinary retention associated with mild suprapubic discomfort. He had a history of lower urinary tract symptoms (LUTS), predominantly voiding, for 10 months. Digital rectal examination revealed a large mass, and the prostate was not separately felt. Serum prostate-specific antigen (PSA) was 141 ng/ml. He underwent a finger-guided, transrectal prostate biopsy, which revealed benign prostatic hyperplasia (BPH). A magnetic resonance imaging scan 6 weeks after biopsy showed a 9.8 cm × 8 cm × 8 cm well-defined pelvic mass abutting the prostate with positive claw sign (indicating prostatic origin). The mass was hypointense on T1 images and heterogeneously hyperintense on T2-weighted images [Figure 1]. A 12 core Transrectal Ultrasound (TRUS)-guided biopsy was performed. The histopathology again revealed BPH. He underwent robot-assisted excision of the mass using 4-robotic arms and pelvic docking. Intraoperatively, a well-defined mass was seen impinging the bladder neck. Dissection was started with peritoneal incision in the rectovesical pouch, identifying both the vas and seminal vesicles which were lifted with the mass. The dissection was then carried out between the bladder and the mass identifying both the ureters which were pushed laterally by the mass [Figure 2]a. The mass seemed to arise from the left lobe of the prostate; therefore, a partial prostatectomy was performed [Figure 2]b. The specimen weighed 90 gm. On cut section, multiple nodules ranging from 1.5 cm to 4.5 cm in size were seen to occupy the whole specimen [Figure 2]c. The final histopathology was consistent with BPH. Postoperative course was uneventful, and the patient voided well. Four weeks postoperatively, PSA was 1.98 ng/dl. Ultrasound showed a 21 cc prostate, and cystoscopy revealed Grade I prostate [Figure 2]d.{Figure 1}{Figure 2}

 Discussion



Embryonic and fetal descriptions of prostatic anatomy by Lowsley [1] followed by more detailed work of Franks [2] identified the inner gland as the exclusive site of BPH. However, the most widely used description of zonal anatomy by McNeal [3] states that the periurethral and the transitional zone are the exclusive seat of BPH.

Egawa et al.[4] reported the presence of nodular hyperplasia in the peripheral zone (PZ) at an autopsy. He opined exophytic growth of the transitional zone glands into the PZ or hyperplasia of the ectopic transitional zone tissue as the possible explanation.

Blascko et al.[5] described the only case of a multilobulated mass posterior to the urinary bladder detected incidentally in a 60-year-old male. In contrast to our patient, the serum PSA value of their patient was 1.87 ng/ml and TRUS guided and a separate computed tomography-guided biopsy revealed benign prostatic epithelium. The authors opined that although hyperplastic prostatic nodules most commonly protrude into the bladder, rarely, they can grow outside the prostate and present as pelvic mass.

Our patient presented with chronic urinary retention with background LUTS and significantly elevated serum PSA values. It is plausible that compression of the bladder neck by the mass caused his symtoms. Robot-assisted excision of the mass relieved the LUTS and also provided definitive exclusion of a malignant pathology.

 Conclusion



Exophytic BPH is a rare entity. A differential diagnosis of this entity should be considered in elderly male presenting with a retrovesical mass.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

References

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2Franks LM. Benign nodular hyperplasia of the prostate; a review. Ann R Coll Surg Engl 1953;14:92-106.
3McNeal JE. Anatomy of the prostate: An historical survey of divergent views. Prostate 1980;1:3-13.
4Egawa S, Ohori M, Uchida T, Mashimo S, Kuwao S. Nodular hyperplasia in the peripheral zone of the prostate gland. Br J Urol 1994;74:520-1.
5Blaschko SD, Eisenberg ML. Exophytic benign prostatic hyperplasia. Urology 2011;78:322.