LAUSR

Periurethral masses including urethral leiomyoma are rare [1, 2] and pose a significant challenge for diagnosis and management. A 43-year-old woman presented with dysuria, urge incontinence and a “bulge” for 3 months. On physical examination, she had a firm left anterior periurethral mass. Pelvic MRI demonstrated a T2 isointense, peripherally enhancing and central hypoenhancing 2.5 cm × 1.9 cm × 2.4 cm mass consistent with adenocarcinoma (Fig. 1). The mass was thought to arise from a urethral diverticulum, primary urethral malignancy or urethral leiomyoma. Cystoscopy revealed no involvement of the urethral lumen. However, physical examination suggested involvement of the urethral wall as gentle external compression of the mass during cystoscopy easily collapsed the urethra and biopsy revealed a benign leiomyoma. The patient underwent transvaginal removal of the mass (Fig. 2a). An inverted U-shaped incision was made, and the mass was dissected circumferentially. It was seen to arise from a stalk on the lateral posterior urethra (Fig. 2b). The lateral edges of the incision were mobilized to make flaps, and the periurethral fascia overlying the diverticular sac was then incised vertically, with both blunt and sharp dissection using peanuts and Metzenbaum scissors. The sac overlying the mass was dissected circumferentially, and the mass, grasped with a towel clamp, was dissected to a stalk arising from the urethral wall and excised in its entirety (Fig. 2c). The urethra was repaired in a multilayer watertight closure. We then overlapped our flaps, raised in the beginning of surgery, with interrupted mattress sutures with 3-0 absorbable polyglactin braided suture. This was done to ensure that there were no overlapping suture lines and the flap completely covered the urethra, creating four layers of closure. The vaginal epithelial incision was then closed with 2-0 absorbable polyglactin braided suture (Fig. 2d). The patient tolerated the procedure well and was discharged on postoperative day 0 with a Foley in place which remained for 5 days, at which time she successfully passed her void trial. She was then evaluated postoperatively with a 6-week postoperative visit as well as 3and 4-month follow-up visits. She initially had dysuria postoperatively with work-up negative for infection. Her symptoms ultimately resolved by her 4-month follow visit, and no recurrent vaginal bulges were observed on examination. Final pathology confirmed urethral leiomyoma. We believe this approach was safe and effective with complete removal of the mass, resolution of symptoms and no perioperative complications through 4-month follow-up.