Lateral Bladder Wall Research Articles

Transvesical Blockade of the Obturator Nerve to Prevent Adductor Contraction in Transurethral Bladder Surgery

To evaluate the efficacy of transvesical obturator nerve block (ONB) in the prevention of obturator nerve reflex and leg jerking during transurethral resection of bladder tumors (TURBT). A total of 60 patients were studied, in whom the transurethral resection of tumors on the posterolateral bladder wall were performed under spinal anesthesia (SA). The patients were randomly divided into two groups. In the first group, we performed transvesical ONB and SA together, while the second group received only SA. The patients underwent TURBT using monopolar cautery. Incidence of leg jerking was registered and compared in these two groups. We used a nerve stimulator to detect the obturator nerve next to the lateral bladder wall. The obturator nerve was identified by its response to nerve stimulation. Then, 10 mL of 1% lidocaine was slowly injected through the working channel of a cystoscope. In the intervention group, 34 ONBs (4 bilateral and 26 unilateral) were tried. We could not detect the obturator nerve by nerve stimulation in six patients, and lidocaine injection was carried out blindly in these cases. One patient in the intervention group experienced adductor contraction. Among 30 patients in the control group, 5 patients had leg jerking, and in 2 patients, the procedure ended incompletely because of muscle spasm. Comparing these two groups, transvesical ONB effectively decreased leg jerking during TURBT (16.5% vs 3%; P < 0.05). Local blockade of the obturator nerve during cystoscopy is an effective method to avoid its stimulation in TURBT. It can be performed easily, and we did not experience any serious complication.

Association of Intravesical Tumor Location With Metastases to the Pelvic Lymph Nodes in Transitional Cell Cancer of the Bladder

IntroductionIn this study, we aimed to determine those clinical and pathologic features that are associated with pelvic lymph node metastasis in patients with transitional cell cancer of the bladder. Unlike previous studies, we particularly focused on intravesical tumor location. MethodsWe included 173 patients who underwent radical cystectomy and bilateral pelvic lymphadenectomy for muscle-invasive or high-risk superficial bladder cancer. Fifty patients (28.9%) presented with lymph node metastases. Tumor-related and personal characteristics were analyzed. ResultsLymph node positive disease occurred in association with an increasing pathologic tumor stage (P<10−6) and with a decreasing differentiation status (P=0.008). The rate of pelvic lymph node metastasis differed in primary tumors growing on different intravesical locations. Cancers located exclusively on the lateral bladder walls (P<10−5) and tumors involving the lateral walls (P=0.042) were highly correlated with lymph node positive disease. Posterior wall tumors were least associated with lymph node metastases compared with other tumor locations (P=0.015). Focal tumor growths located on the lateral bladder wall and an increasing pathologic tumor stage and decreasing differentiation-status were identified as independent risk factors for the pelvic lymph node status. ConclusionsFor the first time we present the association of intravesical tumor location and the rate of lymph node metastasis in transitional cell cancer of the bladder. Our findings may ultimately contribute to a more individualized patient management.

Mesh erosion into the urinary bladder following laparoscopic inguinal hernia repair; is this the tip of the iceberg?

A 67-year-old man presented with recurrent sepsis, groin swelling, and lower urinary tract symptoms 12 years after bilateral TEP inguinal hernia repair. Diagnosis of mesh migration and erosion into the urinary bladder was made by cystoscopy. Exploration of the groin confirmed Prolene mesh erosion into the lateral wall of the urinary bladder. This is the second reported case following TEP repair. A review of the literature reveals eight reported cases following laparoscopic repair since 1994. The factors contributing to mesh migration and erosion are discussed. With large case series of mesh non-fixation being reported in world literature, it may be that the incidence of this complication will increase in the future. A lower diagnostic threshold and reporting of this complication should be encouraged.

Bipolar Transurethral Resection in Saline (TURis®): Outcome and Complication Rates After the First 1000 Cases

TURis((R)) is an emerging technique that shows the same efficacy of monopolar resection. However, there is currently little available data on the safety of bipolar devices. We assessed outcome and safety of TURis on a large cohort of patients with at least 6 months' follow-up. Between January 2006 and October 2007, 1000 consecutive transurethral resection (TUR), 376 transurethral resection of prostate, 480 transurethral resection of bladder neoplasm, and 144 transurethral incision of prostate were performed. All procedures were carried out with a bipolar device in physiologic saline (TURis). The resectoscope used was an Olympus 26F in continuous flow-type Iglesias with continuous aspiration. The loops were all disposable/single use. The incidence of unwanted stimulation of the obturator reflex, TUR syndrome, thermal skin lesion, blood transfusion, urethral strictures, and bladder neck contractures were recorded. None of the patients operated experienced a TUR syndrome or a thermal skin lesion. The median follow-up of the entire cohort was 12 months (range, 6-24 months); 663 patients had at least 1-year follow-up (66.3%). Urethral stricture occurred in 27 patients (2.7%). Four patients developed a bladder neck contracture after transurethral resection of prostate (1%). Early postoperative clot retention occurred in 21 patients (2.1%), and 11 patients needed one or more transfusion (1.1%). Only six patients (2%) submitted to TUR of a neoplastic lesions at the lateral bladder wall experienced an unwanted trigger of the obturator reflex. TURis offers the patient the same results as monopolar technology guaranteeing maximum safety without increasing the incidence of urethral strictures.

MRI anatomical study of the outside‐in transobturator suburethral tape procedure

This study aims to clarify the relationship between the outside-in transobturator suburethral tape and the anatomical structures at the blind passage of the obturator foramen, and to detail the tape position, shape, and the factors on which they are dependent. MRI scans were performed on 30 patients operated on with a dermal porcine collagen suburethral tape, indicated for urodynamically proven stress incontinence. The lateral bladder wall was the closest structure to the tape at the passage of the obturator foramen, whereas vascular injuries appeared to be minimal using the outside-in technique. The distance from tape to bladder neck was correlated with the distance from tape to pubococcygeal line (PCL) (p=0.001), and with urethral length (p=0.049). From the obturator foramen to its passage under the urethra, the tape was U-shaped with a cranio-caudal and antero-posterior orientation. The cranio-caudal tape shape was correlated with the distance between the tape and the PCL (p=0.002), and to the patient's anatomical characteristics: distance between the bladder neck and the pubis (p=0.01), and the urethral length (p=0.01). The antero-posterior shape was correlated with the urethral length (p=0.02). The lateral bladder wall is the structure most at risk during the outside-in transobturator suburethral tape procedure. The distance from tape to bladder neck is dependent on the vertical position of the tape. The tape shape is dependent on both tape position under the urethra and the patient's anatomical characteristics.

Bladder leiomyoma: case report

Leiomyoma is a benign lesion which represents 0.04-0.5% of bladder tumors. It is more common in females and its peak incidence is between 4th and 5th decades. Surgery is the treatment of choice and adequate results have been previously reported. 38 years old male patient who consulted for chronic pelvic pain syndrome. CT scan showed a 2 cm diameter exophitic lesion at the anterior left lateral bladder wall, which protruded into the perivesical fat. We performed a laparoscopic partial cistectomy locating the tumor and resecting it with simultaneous cystoscopic control, obtaining negative margins. The operative time was 70 minutes with an intraoperative blood loss of 50 ml. Postoperative period was uneventful. Final pathology reported: Bladder wall leiomyoma, without mitosis or atypia. Immunohistochemistry was positive for Actine and Vimentine stablishing diagnosis. Cd 1 17 (c-kit) was negative and ruled out a Gastrointestinal Stromal Tumor. Leiomyoma is bladder's most common benign non epithelial tumor. It represents 35-46% of these lesions with a 2:5 male/female ratio. It origins from the smooth muscle bundles and at the urinary tract the most common localizations are kidney and bladder. Clinical presentation depends on tumor size and localization. Ultrasound is the most useful diagnostic tool and the pathological diagnosis is mandatory. Surgery is the treatment of choice and technique depends on tumor size and localization. The laparoscopic approach seems to be an effective alternative in this group of tumors. Prognosis is good and recurrence is rare.

Leiomyosarcoma at the Ureterovesical Junction

Non-urothelial neoplasms of the bladder account for less than 5% of all bladder tumors. Leiomyosarcoma is the most common malignant mesenchymal tumor that arises in the adult bladder. Leiomyosarcomas of the bladder are considered to be highly aggressive tumors. Most patients present at an advanced stage, with less than 30% of patients presenting with stage T1 disease. Surgical resection still remains the cornerstone of treatment with the status of the surgical margin being a strong predictor of the outcome. A 59-year-old man presented to our institution with urinary urgency, and cystoscopic examination revealed a huge submucosal mass on the lateral bladder wall. A radical cystoprostatectomy and ileal neobladder procedure was performed. The patient was diagnosed with a primary leiomyosarcoma of the bladder. After 1 year of follow-up, there has been no recurrence or metastasis. (Korean J Urol 2008;49:855-859)

Bladder Wall Thickness in Healthy School-Aged Children

To evaluate the effectiveness of transabdominal ultrasonography for bladder volume and detrusor muscle thickness and to research the relationship of these measurements with age, height, and body mass index. We reviewed the records of 244 healthy, school-aged children from February to May 2003. After a complete urologic examination, the weight and height of all children were measured, and their body mass index was determined. Transabdominal ultrasonography with a high-frequency probe was performed to obtain the anterior, posterior, and lateral bladder wall thicknesses. The mean age of the children was 10.7 +/- 3.6 years (range 7 to 15), and the mean bladder volume was 256 cm3 (range 78 to 790). The relationship between bladder volume and age was significant (P = 0.0001, r = 0.568). The mean anterior, posterior, and lateral detrusor thickness was 1.42 mm (range 0.8 to 2.8), 1.57 mm (range 0.7 to 3.1), and 1.49 mm (range 0.6 to 2.6), respectively. The relationships between increasing age and the anterior and posterior wall thicknesses were significant (P <0.05), but the relationship between age and the lateral wall thickness was not (P >0.05). The relationship between bladder volume and body mass index was significant (P = 0.0001, r = 0.2959). A strong positive and significant correlation was found between the anterior (P = 0.0001) and posterior (P = 0.001) wall thicknesses and body mass index, but the correlation between the lateral wall thickness and body mass index was not significant (P = 0.079, r = 0.113). Strong, positive correlations were found between the anterior and posterior wall detrusor thicknesses and increased age and body mass index, but the same correlations for lateral wall detrusor thickness were not found.

Inadvertent Breakage of the Spinal Needle during the Obturator Nerve Block for the Transurethral Resection of Bladder Tumor - A case report -

Obturator nerve block is occasionally performed during transurethral resection of lateral bladder wall tumors to prevent the violent contraction of the adductor muscle of the thigh. Rare complications including intravascular injection of the local anesthetics and hematoma formation may occur during the obturator nerve block. We report a case of the unintentional breakage of the spinal needle during the obturator nerve block with successful removal of the broken spinal needle by an orthopedic surgeon. (Korean J Anesthesiol 2007; 53: 250~3)

Malignant paraganglioma of the urinary bladder

Paragangliomas of the urinary bladder is one of the rare tumors and accounts for 0.06% of all bladder tumors. Malignancy is uncommon, occuring in 10–15% of the bladder paragangliomas with less than 20 cases previously reported and determined by its clinical behaviour rather than the histological features. Herein, we describe a case of urinary bladder paraganglioma in a 33-year-old male patient who exhibited with macroscopic painless hematuria. On ultrasonographic examination, a 6 cm × 4 cm mass along the left lateral wall of the urinary bladder was detected. The patient underwent CT examination, which revealed a hyperdense mass with some calcification in it. Also bilateral obturator and iliac lymph nodes measuring up to 2 cm were detected. MR imaging was also performed and again an intense enhancing mass in the left lateral wall of the bladder with bilateral lymph nodes and possible invasion to the seminal vesicles and sigmoid colon was shown. In the laboratory analysis, the 24 h urine vanillylmandelic acid (VMA) level was significantly elevated. During transurethral cystoscopy (TUR) and biopsy a hypertension crisis occured which was controlled by medical therapy. Following histopathologic analysis the diagnosis was established as paraganglioma. The patient has undergone radiation therapy for 2 months and only minimal regression of the tumoral size was observed. Due to the fact that long term follow-up is mandatory for these tumors, the patient is closely being monitored by the urology clinic.

Interstitial cells and cholinergic signalling in the outer muscle layers of the guinea‐pig bladder

To explore the relationship between cholinergic mechanisms and interstitial cells (ICs) in the outer muscle layer of the bladder. In bladder tissue from male guinea-pigs, ICs were identified by their response to nitric oxide (NO) with a rise in cGMP. Sections of the lateral bladder wall were incubated in Krebs' solution containing 1 mm of the nonspecific phosphodiesterase inhibitor isobutyl-methyl-xanthene. Tissues were then exposed to 100 microm of the NO donor NONOate for 10 min, control tissues remained in Krebs' solution. Tissues were then processed for immunohistochemistry for cGMP, choline acetyltransferase (ChAT), neurofilament protein, and the nonspecific neuronal marker protein gene product (PGP) 9.5. cGMP-positive ICs were found mainly in the outer muscle layers of the bladder wall. Three types were identified based on location; on the outer surface of the bladder wall, on the surface of the muscle bundles, and within the muscle bundles. Some of the intramuscular ICs stained for ChAT, but they did not stain with PGP 9.5. Nerve fibres were seen in close contact with the ChAT-positive intramuscular ICs, and these nerves expressed ChAT and neurofilament protein. A subpopulation of intramuscular ICs can synthesise acetylcholine, and might release acetylcholine onto the underlying muscle. These cells are in close contact with nerves, suggesting that they might be activated by neural inputs. Thus there may be a system in the detrusor involving cholinergic nerves acting on ICs which can activate the smooth muscle via a complex cholinergic input.

Prognostic Value of Inverted Papilloma of the Urinary Tract

Purpose: This study aimed to evaluate the tumor biologic behavior and prognostic value of inverted papilloma (IP) of the urinary tract. Materials and Methods: Thirty-one cases (27 males and 4 females, mean age 55.2 years) of urinary IP that were treated at a single center were retrospectively reviewed. There were 21 cases with bladder IP only (group 1), 8 cases with bladder IP and transitional cell carcinoma (TCC) within a single neoplasm (group 2), and 2 cases with IP and TCC in a different location (group 3). The patient and tumor characteristics were analyzed. Results: There was a male predominance with hematuria being the main presenting symptom in all groups. The most common macroscopic feature of IP was a polypoid lesion in group 1. The most common location of IP was bladder neck (57.1%) in group 1 and lateral bladder wall (75%) in group 2. The most common associated urologic disease was benign prostatic hyperplasia in group 1. Transurethral resection was performed in 30 cases (96.8%). There were no recurrences at a mean follow-up of 19.4 (3-68) months after surgery in 27 cases followed for 3 months or longer. Conclusions: One-third of urinary IP were associated with TCC within a single neoplasm or in a different location, and this suggests that IP has a malignant potential. However, because there was no recurrence in IP of the urinary tract, a surveillance protocol as frequent as the one suggested for urothelial cancer does not seem to be necessary. (Korean J Urol 2006;47:1103-1106) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Bladder wall lipoma in patient with irritative voiding symptoms

A 48-year-old man presented with urinary frequency and nocturia. He reported minimal improvement of his symptoms despite treatment with alpha-antagonists. Concurrently, during an evaluation for hip pain, the patient’s family physician obtained a magnetic resonance imaging scanthat incidentally revealed two polypoid lesions within the bladder wall, with properties consistent with adipose tissue (Fig. 1). Cystoscopy demonstrated smooth, yellow, well-circumscribed masses at the anteroinferior and left lateral bladder wall (Fig.

Vergleich der Motorblockade zwischen Ropivacain 0,75 % und Prilocain 1 % bei der direkten Obturatoriusblockade zur transurethralen Blasentumorresektion - ein neuer Ansatz zur Bewertung des Motorblocks mit der MRC-Skala

Obturator nerve block is used for transurethral resection of lateral bladder wall tumors to prevent adductor muscle spasm and associated complications. Therefore, the local anesthetic applied should provide an adequate motor blockade. Ropivacaine 0.75 % was compared to prilocaine 1 % and motor blockade assessment performed by the Medical Research Council (MRC)-scale. 40 patients (20 per group) scheduled for transurethral resection were randomized to either receiving 10 ml ropivacaine 0.75 % or prilocaine 1 % for direct obturator nerve block in a controlled user-blinded study. Motor block was assessed with the MRC-scale 5 and 10 minutes after local anesthetic injection followed by an assessment 120 and 180 minutes after surgery. Surgery was performed in equally distributed spinal or general anesthesia, intraoperative adductor spasm intensity was evaluated by surgeon's ranking. Motor blockade intensity was significantly higher with ropivacaine 0.75 % at all time points of assessment. Intraoperatively, severe spasm only occurred in the prilocaine 1 %-group. Ropivacaine 0.75 % is a more appropriate agent for direct obturator nerve block than prilocaine 1 %, providing a faster onset and a more intense and longer-lasting motor blockade. This may reduce surgical complications and facilitate early surgical re-intervention. In this study, MRC-scale was appropriate for motor blockade assessment in a peripheral nerve block.

Endoscopic Cross-Trigonal Ureteral Reimplantation Under Carbon Dioxide Bladder Insufflation: A Novel Technique

To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children. Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively. Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%. This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.

Tecnica alternativa para prevenir la estimulación del nervio obturador durante la RTU vesical de neoformaciones en cara lateral

ObjetivesWe presents an alternative to prevent the obturator nerve stimulation during TUBR. Material and MethodWe revise 400 bladder tumours corresponding to 218 patients, 46,8% of them localized in lateral bladder wall. An alternative technique is used for that blockade. ResultsThere have been no adductor contractions in more than 95% of TUBR. ConclusionsThe alternative technique may reduce the stimulation of the obturador nerve and the risk of bladder perforation.

VESICOLYMPHOCELE FISTULA FOLLOWING SCLEROTHERAPY FOR LYMPHOCELE

A 54-year-old female underwent radical hysterectomy with pelvic lymph node dissection for uterine cervical carcinoma. Pathological examination demonstrated a stage Ib1 squamous cell carcinoma. Three weeks postoperatively the patient suffered right lower extremity edema and a mild intermittent fever (37.5C). She complained of 2-hour urinary frequency. Physical examination revealed mild tenderness of the right lower quadrant area. Excretory urography showed marked extrinsic compression of the right side of the urinary bladder. Computerized tomography (CT) demonstrated a huge round cystic pelvic mass 7 11 cm in diameter compressing the bladder and suggestive of a lymphocele (fig. 1). Percutaneous drainage of 500 ml clear yellow fluid was performed using an 8.5Fr pigtail catheter placed under fluoroscopic guidance. Subsequently, 40 ml 95% ethanol was instilled into the lymphocele cavity. Ethanol was exposed for 15 minutes and was then completely removed by aspiration. With sclerotherapy 4 times daily the amount of drainage progressively decreased. However, a gradual increase in the drainage amount and an abrupt high fever (39.0C) developed. Assuming that the fever may have been caused by an infection of the septated lymphocele cavity, the tube was removed. Blood culture revealed no growth, but urinalysis showed pyuria (leukocytes greater than 100 per high power field) with the growth of Staphylococcus aureus (greater than 10/ml). The mild intermittent fever persisted and the patient complained of painful urination with the intermittent passage of white greasy material. Cystoscopic examination demonstrated profuse aggregated chylousmaterials floating in the lumen of the bladder (fig. 2,A). A deep ulcerative cavity in the right lateral wall of the bladder was found, suggesting a fistula between the lymphocele cavity and the bladder lumen. Pelvic CT revealed that the right lateral bladder wall had thickened irregularly and that the lymphocele cavity had collapsed (fig. 2, B). The body temperature then normalized. Three weeks later symptoms were improved and followup cystoscopy showed that the ulcerative bladder wall was markedly healed. Eight weeks later the lesion had almost healed and the symptoms had resolved completely.

CORRELATION BETWEEN DETRUSOR COLLAGEN CONTENT AND URINARY SYMPTOMS IN PATIENTS WITH PROSTATIC OBSTRUCTION

We used computerized imaging analysis to compare the collagen content of detrusor specimens between patients affected with symptomatic obstructive benign prostatic hyperplasia (BPH) and asymptomatic controls. In our study we enrolled 36 patients with symptomatic urodynamically obstructed BPH undergoing transurethral resection of the prostate. We also enrolled 28 men (mean age 61.3, range 55 to 70) undergoing transurethral resection of the bladder for primitive, singular Ta bladder cancer, with no significant urinary symptoms, as the control group. During the transurethral surgical procedure in controls and in patients with BPH, a biopsy was performed deep through the muscular layer from either of the lateral bladder walls. Computerized morphometric analysis of the stained sections was performed with an image analysis system, and a percentage of collagen fibers was extracted through morphological filtering and expressed as a mean percentage of the total bioptic area. Collagen content in bladder detrusor specimens was significantly higher in patients with BPH compared to controls (48% and 17% of bioptic area, respectively, p <0.001). Mean detrusor collagen content was clearly higher in patients with severe symptoms than in patients with moderate symptoms (50.45 +/- 8.22% and 43.09% +/- 7.05%, respectively). Our study supports the important role of detrusor collagen neo-deposition in determining lower urinary tract symptoms in obstructive BPH. Detrusor collagen content correlates with urodynamic obstruction, the presence and severity of symptoms and, given that collagen neoformation is irreversible could probably have a role in the postoperative persistence of lower urinary tract symptoms in patients undergoing surgery for BPH.

Paraganglioma of the Urinary Bladder: A Case Report

Paragangliomas of the urinary bladder are very rare. To date, there are no reliable methods for predicting their clinical behavior, so long-term follow-up is required. We describe a paraganglioma of the urinary bladder in a 32-year-old male who presented with painless gross hematuria. Abdominal ultrasonography revealed a protruding mass with hematoma over the right lateral wall of the urinary bladder. The tumor was not completely resected by transurethral resection of bladder tumor (TURBT) due to intermingling with the bladder wall. Follow-up I131-metaiodobenzylguanidine was performed 3 weeks after surgery and suspected incomplete resection lesions were noted. Histologic examination of the tumor indicated paraganglioma of the urinary bladder. We also provide a brief review of the literature for comparison.

Primary Rhabdomyosarcoma of the Seminal Vesicle

CASE REPORT A 50-year-old man was evaluated for transient tetraplegia. Digital rectal examination revealed a hard palpable mass not directly in contact with the prostate. Sonography showed the right seminal vesicle as the tissue of origin of the spherical tumor (fig. 1). Computerized tomography demonstrated a round 8 8 cm. contrast enhancing solid mass situated between the rectum and bladder without evidence of metastasis (fig. 2). Prostate specific antigen was 0.3 ng./ml. The tumor of the right seminal vesicle was resected, and because of infiltration of the lateral bladder wall, partial resection of the bladder was performed. However, tumor resection was complete. Frozen section revealed a histopathological diagnosis of sarcoma, but the pathologist could not make a definitive diagnosis. Therefore, intraoperative radiation (12 Gy.) was performed. The final histopathological evaluation, including immunohistochemistry, showed a high grade embryonic rhabdomyosarcoma with noticeable nuclear polymorphisms and expression of myoglobin, actin, myosin and desmin. Postoperatively external beam radiation therapy was performed with an overall dose of 50.4 Gy. (28 times 1.8 Gy. single dose). While on radiation therapy, the patient also received chemotherapy consisting of 2,820 mg. ifosfamide and 94 mg. doxorubicin. Followup comprising magnetic resonance imaging and physical examination was performed quarterly during the first year and semiannually from the second year onward. At 19 months postoperatively the patient presented with painless gross hematuria, but cystoscopy and biopsy demonstrated no malignancy. At 35 months postoperatively the patient was disease-free. Twenty months after completion of radiation therapy hydronephrosis developed as a long-term sequela on the right side.