Mucosa-Sparing Trans-Vestibular Surgical Approach for Excision of an Anterior Urethral Leiomyoma: A Case Report and Review of the Literature

INTRODUCTION AND HYPOTHESIS: Urethral leiomyomas are rare benign smooth-muscle tumors. Approximately 40 well-documented cases have been reported, most arising from the posterior urethral wall where exposure is relatively straightforward. Anterior wall lesions pose surgical difficulty because of proximity to the external urinary sphincter, periurethral fascia, and vestibular mucosa, all of which must be preserved to avoid urethrovaginal fistula and stress urinary incontinence. We hypothesized that a mucosa-sparing trans-vestibular approach would allow safe excision with preservation of urethral integrity and continence. METHODS: A 39-year-old para-1 woman presented with a 6-month history of a tender peri-meatal urethral mass and intermittent post-coital spotting. Examination revealed a 3 cm anterior urethral mass distorting the external urethral meatus. Pelvic MRI demonstrated a 2.7 cm well-circumscribed anterior distal urethral mass with apparent urethral wall involvement. Examination under anesthesia, cystourethroscopy, and core biopsy confirmed leiomyoma. The lesion was excised via a mucosa-sparing trans-vestibular approach with intraoperative catheter palpation, capsular dissection, layered urethral reconstruction, and mid-urethral sphincter re-approximation. RESULTS: A 3 cm anterior urethral leiomyoma with focal urethral communication was excised. Blood loss was minimal; there were no intraoperative complications. A transurethral catheter was maintained for 21 days. Micturating cystourethrogram confirmed an intact urethra without fistula; the patient was continent. Histopathology confirmed benign leiomyoma (SMA-positive, desmin-positive, MIB-1 < 1%). CONCLUSIONS: Anterior urethral leiomyomas are an important differential in women with a peri-meatal mass. The mucosa-sparing trans-vestibular technique provides excellent anterior urethral exposure while preserving vestibular mucosa and periurethral fascia, thereby reducing the risk of urethrovaginal fistula and postoperative incontinence.