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Bilateral Leukoplakia of the Renal Pelvis
THE JOURNAL OF UROLOGY
Vol. 65, No. 4, April 1951
Printed in U.S.A.
BILATERAL LEUKOPLAKIA OF THE RENAL PELVIS FEDOR L. SENGER, JOHN J. BOTTONE
AND
JAMES H. KELLEHER
From the Department of Urology, The Long Island College Hospital, Long Island College of Medicine, Brooklyn, N. Y.
Leukoplakia of the urinary tract is probably more prevalent than a survey of the literature would indicate. Leukoplakia of the renal pelvis, however, while not so prevalent as that of the urinary bladder, is seen more frequently than leukoplakia of the ureter. Kutzmann, in 1929, collected 67 cases from the literature, and Patch, in a review of 152 cases of leukoplakia of the urinary tract, found it to be present in the renal pelvis and calyces in 36 cases, in the ureter in 6 cases, and in the urinary bladder in 110 cases. It is reasonable to assume that the paucity of cases presenting this lesion in the ureter is, perhaps, because it is not as readily demonstrated at this site by the present means at our disposal. Leukoplakia of the renal pelvis has been reported, among others, by Beer, Kretschmer, Patch, Low and Coakley, Armstrong et al., Hinman et al., Taylor and Kutzmann. The basic pathology is a squamous metaplasia of the epithelium of the renal pelvis and calyces with keratinization. There is cellular infiltration of the submucosa with varying amounts of edema and fibrosis, depending upon the duration of the infective process with which it is usually associated. The etiology of the condition is assumed to be chronic infection. Vitamin A deficiency, as demonstrated by Wohlbach and Howe in rats, is a theory which has been promulgated in the past; this, however, has not received as strong support from most investigators. Leukoplakia of the renal pelvis is assumed by most writers to be a pre-cancerous lesion, as is leukoplakia anywhere else in the body. The symptoms are usually those of chronic urinary tract infection with or without renal colic, and the passage of "gritty flakes" in the urine. It is the passage of these "gritty flakes" in the urine which should lead one to suspect the diagnosis, together with the history of chronic urinary infection and the pyelographic findings. CASE REPORT
E. P. (L.I.C.H.) 5556, a 47 year old white male radio operator, was admitted to The Long Island College Hospital on June 19, 1949, complaining of passing "gritty flakes" in his urine. Past history revealed two previous hospital admissions for the same complaint. On the last admission, February 1, 1949, retrograde pyelograms revealed a marked, mottled appearing pyelogram on the right side for which a right renal exploratory was advised and which was refused. The patient was then given a course of aureomycin which seemed to benefit him somewhat. Just prior to discharge from the hospital, the patient passed a rather copious amount of gritty material per urethram; this specimen was sent to the pathology laboratory for microscopic examination and reported to be "cornified 528
r
BILATERAL LEUKOPLAKIA OF RENAL PELVIS
529
epithelium." The patient had undergone an epididymectomy at another hospital 7 years previously, the reason for which was unknown to him. He had been treated for prostatitis at various intervals and also stated that he had been passing "gritty flakes" in his urine for 7 years, during some of which time he had served in the Army and had been worked up urologically, the result of this investigation disclosing a small left renal calculus which patient still had on admission. Physical examination was essentially negative except for absence of the left epididymis. Blood pressure 134/84. The blood chemistry was within normal
FIG. l
limits. Hemoglobin 14 gm. White blood cells 14,250, neutrophils 86, lymphocytes 14. Kahn and Mazzini tests negative. Urinalysis negative except for moderate numbers of squamous epithelial cells per high power field. Vitamin A oral tolerance test: fasting 15 u., 3 hrs. 65 u., 5 hrs., 200 u., 7 hrs., 130 u. 10 hrs. 60 u. Bladder and right and left kidney urine cultures revealed Staphlococcus aureus. Retrograde pyelograms on June 20, 1949 revealed marked mottling of the pelvis and calyces of the right kidney, together with beginning pyelographic changes of mottling in the left renal pelvis and calyces (fig. 1). The pyelographic findings in the right kidney appeared not to have progressed since previous admission on February 1, 1949. However, the changes apparent in the left pyelogram were not present on previous admission. A diagnosis of bilateral leukoplakia of the renal pelvis with possible neoplasm on the right was made.
530
FEDOR L. SENGER, JOHN J. BOTTONE AND JAMES H. KELLEHER
Surgical exploration of the right kidney was again advised because it was believed that a neoplasm could not definitely be ruled out. A right renal exploratory was performed on June 21, 1949. The right renal pelvis and calyces were explored and the mucosa appeared thickened, glistening and wrinkled throughout but no gross evidence of neoplasm was present. A biopsy of the pelvis was taken and a frozen section confirmed the diagnosis of leukoplakia. :!:\" ephrectomy was not done. The pathological diagnosis was "chronic pyelitis ,vith squamous metaplasia and hyperkeratosis" (fig. 2). The postoperative course was uneventful; a lmY grade fever returned to normal on the fourth postoperative day and remained there for the duration of the patient's hospital stay. The wound healed per primam and the patient was discharged from the hospital on the twelfth postoperative day, July 3, 1949. The patient has been seen at periodic intervals since discharge and has been more or less asymptomatic, except for one episode of microscopic hematuria and
FIG.
2
right renal colic associated with the passage of a larger than usual plaque of tissue. His pyuria has improved considerably and, while he still occasionally passes "gritty flakes" in his urine, he does so at less frequent intervals and in much smaller amounts. He has been kept empirically on daily doses of vitamin A, 200,000 u. at first and after 2 months this was reduced to 100,000 u. daily. He is also receiving an acid ash diet and urinary antiseptics. The patient was last seen on January 24, 1950, at which time he was feeling well and working every day, and had been free of symptoms for over a month at that time. The general picture of the patient's condition, however, we know is unimproved even though he feels well at present. The pyelographic findings remain approximately as they were 6 months ago. SUMMARY
A case of leukoplakia of the renal pelvis is presented. It is presumed that the condition is bilateral because of the history and the pyelographic changes in both renal pelves. Confirmation of the diagnosis was obtained only on the right side, however.
BILATERc\L LEl:KOPLAKIA OF RENAL PELVIS
531
Right nephrectomy was not done because of the presumed bilaterality of the condition. Surgical exploration -was performed only to definitely exclude a neoplasm. The "gritty flakes" passed in the urine should be examined by the pathologist for microscopic characteristics of leukoplakia. Chronic urinary infection, with the passage of "gritty flakes" in the with or without renal colic and retrograde pyelographic changes consistent with this lesion, should lead one to suspect the diagnosis. The normal vitamin A curve ,vould seem to preclude vitamin A deficiency as a cause of this condition. We believe the diagnosis can be made preoperatively. REFERENCES ARMSTRONG, C. I-L-1.RLIN, H. C. AND FORT, C. A.: J. UroL, 63: 208, Hl50. BEER, E. · Am. J. Sc., 147: 244, Hl14. Hrn:vIAN, F., KUTZ:\lANN, A. A. AND GrnsoN, T. E.: Surg., Gynec. & Obst., 39: 472, KRETSCHMER, H. L.: Surg., & Obst., 31: 325, 1920. KuTZMANN, A. A.: Arch. Surg., 19: 871, 1929. Low, H. T. AND H. E.: J. Urol., 60: 712, 1948. PATCH, F. S.: Xew Eng. Mecl., 200: 423, 1929; also J. A. l\I. A., 136: 824, 1948. TAYLOR, W. N.: Am. J. Surg., 32: 335, 1936. WoHLBACH, S. B ..-\.ND HmvE, P.R.: J. Exp. Mecl., 42: 753, 1925.
1924.
Vol. 65, No. 4, April 1951
Printed in U.S.A.
BILATERAL LEUKOPLAKIA OF THE RENAL PELVIS FEDOR L. SENGER, JOHN J. BOTTONE
AND
JAMES H. KELLEHER
From the Department of Urology, The Long Island College Hospital, Long Island College of Medicine, Brooklyn, N. Y.
Leukoplakia of the urinary tract is probably more prevalent than a survey of the literature would indicate. Leukoplakia of the renal pelvis, however, while not so prevalent as that of the urinary bladder, is seen more frequently than leukoplakia of the ureter. Kutzmann, in 1929, collected 67 cases from the literature, and Patch, in a review of 152 cases of leukoplakia of the urinary tract, found it to be present in the renal pelvis and calyces in 36 cases, in the ureter in 6 cases, and in the urinary bladder in 110 cases. It is reasonable to assume that the paucity of cases presenting this lesion in the ureter is, perhaps, because it is not as readily demonstrated at this site by the present means at our disposal. Leukoplakia of the renal pelvis has been reported, among others, by Beer, Kretschmer, Patch, Low and Coakley, Armstrong et al., Hinman et al., Taylor and Kutzmann. The basic pathology is a squamous metaplasia of the epithelium of the renal pelvis and calyces with keratinization. There is cellular infiltration of the submucosa with varying amounts of edema and fibrosis, depending upon the duration of the infective process with which it is usually associated. The etiology of the condition is assumed to be chronic infection. Vitamin A deficiency, as demonstrated by Wohlbach and Howe in rats, is a theory which has been promulgated in the past; this, however, has not received as strong support from most investigators. Leukoplakia of the renal pelvis is assumed by most writers to be a pre-cancerous lesion, as is leukoplakia anywhere else in the body. The symptoms are usually those of chronic urinary tract infection with or without renal colic, and the passage of "gritty flakes" in the urine. It is the passage of these "gritty flakes" in the urine which should lead one to suspect the diagnosis, together with the history of chronic urinary infection and the pyelographic findings. CASE REPORT
E. P. (L.I.C.H.) 5556, a 47 year old white male radio operator, was admitted to The Long Island College Hospital on June 19, 1949, complaining of passing "gritty flakes" in his urine. Past history revealed two previous hospital admissions for the same complaint. On the last admission, February 1, 1949, retrograde pyelograms revealed a marked, mottled appearing pyelogram on the right side for which a right renal exploratory was advised and which was refused. The patient was then given a course of aureomycin which seemed to benefit him somewhat. Just prior to discharge from the hospital, the patient passed a rather copious amount of gritty material per urethram; this specimen was sent to the pathology laboratory for microscopic examination and reported to be "cornified 528
r
BILATERAL LEUKOPLAKIA OF RENAL PELVIS
529
epithelium." The patient had undergone an epididymectomy at another hospital 7 years previously, the reason for which was unknown to him. He had been treated for prostatitis at various intervals and also stated that he had been passing "gritty flakes" in his urine for 7 years, during some of which time he had served in the Army and had been worked up urologically, the result of this investigation disclosing a small left renal calculus which patient still had on admission. Physical examination was essentially negative except for absence of the left epididymis. Blood pressure 134/84. The blood chemistry was within normal
FIG. l
limits. Hemoglobin 14 gm. White blood cells 14,250, neutrophils 86, lymphocytes 14. Kahn and Mazzini tests negative. Urinalysis negative except for moderate numbers of squamous epithelial cells per high power field. Vitamin A oral tolerance test: fasting 15 u., 3 hrs. 65 u., 5 hrs., 200 u., 7 hrs., 130 u. 10 hrs. 60 u. Bladder and right and left kidney urine cultures revealed Staphlococcus aureus. Retrograde pyelograms on June 20, 1949 revealed marked mottling of the pelvis and calyces of the right kidney, together with beginning pyelographic changes of mottling in the left renal pelvis and calyces (fig. 1). The pyelographic findings in the right kidney appeared not to have progressed since previous admission on February 1, 1949. However, the changes apparent in the left pyelogram were not present on previous admission. A diagnosis of bilateral leukoplakia of the renal pelvis with possible neoplasm on the right was made.
530
FEDOR L. SENGER, JOHN J. BOTTONE AND JAMES H. KELLEHER
Surgical exploration of the right kidney was again advised because it was believed that a neoplasm could not definitely be ruled out. A right renal exploratory was performed on June 21, 1949. The right renal pelvis and calyces were explored and the mucosa appeared thickened, glistening and wrinkled throughout but no gross evidence of neoplasm was present. A biopsy of the pelvis was taken and a frozen section confirmed the diagnosis of leukoplakia. :!:\" ephrectomy was not done. The pathological diagnosis was "chronic pyelitis ,vith squamous metaplasia and hyperkeratosis" (fig. 2). The postoperative course was uneventful; a lmY grade fever returned to normal on the fourth postoperative day and remained there for the duration of the patient's hospital stay. The wound healed per primam and the patient was discharged from the hospital on the twelfth postoperative day, July 3, 1949. The patient has been seen at periodic intervals since discharge and has been more or less asymptomatic, except for one episode of microscopic hematuria and
FIG.
2
right renal colic associated with the passage of a larger than usual plaque of tissue. His pyuria has improved considerably and, while he still occasionally passes "gritty flakes" in his urine, he does so at less frequent intervals and in much smaller amounts. He has been kept empirically on daily doses of vitamin A, 200,000 u. at first and after 2 months this was reduced to 100,000 u. daily. He is also receiving an acid ash diet and urinary antiseptics. The patient was last seen on January 24, 1950, at which time he was feeling well and working every day, and had been free of symptoms for over a month at that time. The general picture of the patient's condition, however, we know is unimproved even though he feels well at present. The pyelographic findings remain approximately as they were 6 months ago. SUMMARY
A case of leukoplakia of the renal pelvis is presented. It is presumed that the condition is bilateral because of the history and the pyelographic changes in both renal pelves. Confirmation of the diagnosis was obtained only on the right side, however.
BILATERc\L LEl:KOPLAKIA OF RENAL PELVIS
531
Right nephrectomy was not done because of the presumed bilaterality of the condition. Surgical exploration -was performed only to definitely exclude a neoplasm. The "gritty flakes" passed in the urine should be examined by the pathologist for microscopic characteristics of leukoplakia. Chronic urinary infection, with the passage of "gritty flakes" in the with or without renal colic and retrograde pyelographic changes consistent with this lesion, should lead one to suspect the diagnosis. The normal vitamin A curve ,vould seem to preclude vitamin A deficiency as a cause of this condition. We believe the diagnosis can be made preoperatively. REFERENCES ARMSTRONG, C. I-L-1.RLIN, H. C. AND FORT, C. A.: J. UroL, 63: 208, Hl50. BEER, E. · Am. J. Sc., 147: 244, Hl14. Hrn:vIAN, F., KUTZ:\lANN, A. A. AND GrnsoN, T. E.: Surg., Gynec. & Obst., 39: 472, KRETSCHMER, H. L.: Surg., & Obst., 31: 325, 1920. KuTZMANN, A. A.: Arch. Surg., 19: 871, 1929. Low, H. T. AND H. E.: J. Urol., 60: 712, 1948. PATCH, F. S.: Xew Eng. Mecl., 200: 423, 1929; also J. A. l\I. A., 136: 824, 1948. TAYLOR, W. N.: Am. J. Surg., 32: 335, 1936. WoHLBACH, S. B ..-\.ND HmvE, P.R.: J. Exp. Mecl., 42: 753, 1925.
1924.