Leiomyomas are benign tumors of smooth muscle cells, and occur frequently in the uterus. Extrauterine leiomyomas are unusual, and even more rare in the female urethra. The differential diagnosis includes  leiomyosarcomas. Computer Tomography (CT), Magnetic Resonance Imaging (MRI), 2D and 4D perineal ultrasound as well as 3D vaginal ultrasound are the imaging techniques used to aid diagnosis. Out of the given modalities, the ultrasound was perceived the most accurate in diagnosis and mapping of possible invasion of tumor into the urethral tissue. This video film shows the excision of the leiomyoma from urethra and preoperative diagnosis and postoperative followup with 2D perineal and 3D vaginal ultrasound.

Case report: A 48 year old healthy primipara presented with a six week history with a protruding tumor from the vaginal introitus, she had dysuria and incomplete voiding but no hematuria or pain. CT showed a 50X65 mm tumor compressing the urethra, and recommended MRI. The patient failed to come to MRI control for a year. MRI after a year showed a growth of tumor to 70x60 mm.   From the cranial edge of the tumor a 20mm long triangular offshoot was seen hence, an ingrowth to the urethra could not be excluded. The radiologist recommended ultrasonography. 2D perineal ultrasond showed that the tumor deviated away from the urethra cranially and respected the urethral wall integrity. Color doppler imaging showed rich vascularity; multiple ultrasound guided biopsies showed leiomyoma cells however, due to the size of the tumor malignancy could not be excluded. Cystourethroscopy showed no invasion in the urethral lumen. The tumor was completely removed vaginally without inflicting further damage to the urethra. Peroperative urethroscopy showed an intact urethral wall. Postoperatively an indwelling caterer was kept for 14 days and the patient was able to void without any difficulties.

Histopathological examination showed a well circumscribed mass measuring 70x50x60 mm. Microscopically it showed interlacing fibers of smooth muscle cells, no increased mitosis was seen. Follow up with physical examination and 2D perineal and 3D vaginal ultrasound showed no recurrence of the tumor. The patient had no urinary incontinence or bladder emptying problems.

Urethral leiomyomas are difficult to diagnos and MRI can be helpful. However, 2D perineal ultrasound as well as 3D vaginal ultrasound are superior in comparison to MRI and CT imaging techniques in diagnosis of urethral leiomyomas. Complete surgical removal is recommended.