Submucosal cystic neurofibroma of the bladder- A case report

50 year old male, farmer by occupation presented with dysuria and urinary incontinence 3months duration, hematuria 2 episodes, only in the initial stream, painless, no passage of clots or tissue bits. Abdominal examination was normal with no organs or mass palpable. Digital rectal examination revealed grade 1 prostatic enlargement and above prostate,there was large boggy mass , superior extent could not be felt . Routine biochemical and hematological investigation revealed raised renal parameters. Urine routine examination was normal. Urine culture revealed - no growth. Urine cytology - negative for malignancy. Chest x ray is normal. USG study, showed multiloculated mixed echogenic mass appearing within bladder. Both kidneys showed hydroureteronephrosis. Suprapubically usg guided trucut biopsies from the mass done twice- were negative for malignancy. Plain CT abdomen and pelvis done previously showed heterodense lesions inside the bladder both anterior and posteriorly, with peri vesical extension posteriorly. Antegrade study showed multiple filling defects inside the bladder. MRI pelvis showed hetero intense mass lesion, soft tissue component predominantly in posterior aspect, and multiple cystic components filling rest of the bladder, both ureteric orifices encroached by the mass. Initially right percutaneous nephrostomy (pcn) was done, left pcn done subsequently because of persistently elevated renal parameters. Cystoscopy revealed normal bladder mucosa , with indendations seen - (right) lateral wall, (right) anterior wall, and in the posterior wall midline above trigone, (right) ureteric orifice could not be visualised. Trans urethral resection biopsy - possibility of benign leiomyoma. Surgery through lower abdominal, extraperitoneal approach. Bladder was opened. Tumour found to be intramucosal, pedunculated arising from the base of the bladder, mostly from the right side, involving right ureteric orifice also. Entire tumour was resected and right ureteric reimplantation done . Post operative histopathology - sub mucosal cystic neurofibroma. The case is presented for its rarity.