Treatment for Bladder Haemangioma
For bladder hemangiomas, treatment should be conservative observation for asymptomatic lesions, while symptomatic cases require endoscopic management (transurethral resection, fulguration, or Nd:YAG laser ablation) for small tumors, with open surgical excision reserved for larger lesions with significant extravesical extension. 1, 2
Initial Assessment and Diagnosis
- Bladder hemangiomas are rare benign vascular tumors that typically present with painless gross hematuria once the lesion erodes through the urothelium 1, 2
- Cystoscopic findings characteristically show a sessile, blue, multilocular mass with smooth or irregular surfaces, most commonly smaller than 3 cm and solitary 2
- MRI is the most valuable imaging modality for diagnosing soft-tissue hemangiomas and assessing the extent of disease, particularly extravesical extension 2
- Histological confirmation is essential, showing numerous proliferative capillaries with thin-walled, dilated, blood-filled vessels lined with flattened endothelium 2
Treatment Algorithm Based on Tumor Characteristics
Asymptomatic Lesions
- No treatment is required for asymptomatic hemangiomas, as these benign vascular tumors can regress spontaneously through fibrosclerosis 1
- Conservative observation with periodic monitoring is the appropriate management strategy 1
Small Symptomatic Tumors (<3 cm)
- Endoscopic management is the standard treatment for small bladder hemangiomas 1, 2
- Transurethral resection, fulguration, or Nd:YAG laser ablation are equally acceptable first-line endoscopic approaches 2, 3
- Nd:YAG laser coagulation provides superior results to alternative therapies and is the preferred endoscopic treatment for most patients 3
- The bladder should be inflated with CO2 gas during laser treatment to optimize visualization and safety 3
Large or Extensive Lesions
- Open surgical excision is preferred for larger hemangiomas due to the "iceberg" phenomenon where considerable extravesical extension exists beyond what is visible endoscopically 1
- Many bladder hemangiomas extend significantly beyond their apparent cystoscopic appearance, making endoscopic management unsuitable due to risk of massive hemorrhage or recurrence 1
- Local excision via open surgery is recommended when tumors are not amenable to endoscopic resection because of size 1, 4
- Patients undergoing endoscopic treatment must be prepared for conversion to open surgery in case of complications or inadequate resection 1
Pediatric Considerations
- Propranolol should be considered as first-line medical therapy for infantile bladder hemangiomas, particularly in children with multiple lesions or associated cutaneous/internal hemangiomas 5
- Propranolol has demonstrated significant improvement in bladder lesions at 6-week follow-up cystoscopy and MRI, offering a non-invasive alternative to surgery 5
- This medical approach is especially valuable for avoiding invasive surgical techniques in the pediatric population 5
Critical Pitfalls and Caveats
- Do not attempt endoscopic resection of large lesions without preparation for open conversion, as the risk of massive hemorrhage is substantial given the frequent extravesical extension 1
- The extent of hemangiomas often extends further than immediately apparent on cystoscopy, requiring careful preoperative imaging assessment 1
- Multiple or diffuse bladder hemangiomas (as seen in Klippel-Weber syndrome) carry risk of re-bleeding even after successful treatment, necessitating long-term close follow-up 3
Follow-Up Protocol
- Cystoscopy at 6 months after treatment is essential to assess for recurrence 2
- MRI is a practical, noninvasive technique for follow-up of small hemangiomas and monitoring for regrowth 2
- Long-term surveillance is particularly important for patients with multiple lesions or syndromic associations due to higher recurrence risk 3