Multiple fibrous polyps of ureter

Multiple fibrous polyps of ureter

MULTIPLE FIBROUS MUAYAD AL HUSSAINI, HAROLD E. MARDEN, MARVIN W. WOODRUFF, POLYPS OF URETER M.D. JR.,M.D. M.D. From the Department of Surger...

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MULTIPLE

FIBROUS

MUAYAD

AL HUSSAINI,

HAROLD

E. MARDEN,

MARVIN

W. WOODRUFF,

POLYPS OF URETER

M.D. JR.,M.D. M.D.

From the Department of Surgery, Section of Urology, Albany Medical College of Union University, Albany, New York

ABSTRACT-A

case is presented of multiple fibrous polyps of the upper ureter associated with ureterovesical obstruction in an eleven-year-old girl. Local excision of the polyps was done with reimplantation of the ureter in the bladder. Follow-up for forty-four months showed a good functional result with no evidence of recurrent disease.

Tumors of the ureter are relatively rare. Benign mesenchymal tumors of the ureter are rarer. Scott in 1963l found 144 benign ureteral tumors reported in the literature up to that time. The majority of these were epithelial in origin, while 32 were probably similar to our case, being described as fibromata, polyps, or vascular fibromata. Since then, Parker2 reported 1 case in a tenyear-old-boy and Crum et a1.3 reported 4 cases of fibrous polyps in patients aged twenty-five, twenty, eleven, and forty, for a total of 37 cases. No apparent association has been found with similar lesions elsewhere in the body or with congenital urinary tract malformations. The cause of fibrous ureteral polyps is not known. Because of the paucity of such cases, the prognosis and potential for malignancy and recurrence or persistence are not known. There has been insufficient data for standardization of treatment. We present a case of multiple fibrous polyps of the upper ureter in an eleven-year-old girl with associated lower ureteral obstruction from a stricture. Case Report An eleven-year-old white girl was admitted to the Albany Medical Center Hospital on December 14, 1969, with a history of persistent urinary tract infection for six months and two episodes of gross painless hematuria occurring six months and two weeks prior to admission. An

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excretory urogram at another institution on November 15, 1969, revealed multiple filling defects in the upper left ureter with dilatation of the lower left ureter down to the ureterovesical junction. Physical examination showed a normal, healthy young girl with no positive findings. Pertinent laboratory data included: hematocrit 39, white blood cells 7,700, blood urea nitrogen 13 mg. per 100 ml. Cytologic examination of urine from the left ureter showed class 1-2, and was negative for malignant cells. Microscopically the urine contained only an occasional hyaline cast and no sugar and albumin. A stained smear revealed bacteria, and urine culture grew enterococci. On cystoscopy the bladder was not remarkable. A left retrograde pyelogram again revealed the filling defects in the upper ureter as well as dilatation of the lower ureter due to a ureterovesical stricture (Fig. 1A). No reflux could be demonstrated on cystogram. On December 16, 1969, the left ureter was explored through a flank incision. The ureter was opened and found to contain six polypoid lesions in its upper third, each measuring about 1.5 cm. in diameter (Fig. 1B). Each had a stalk measuring about 0.5 cm. in length. These were excised at their bases and the upper ureter closed, The lower end of the left ureter was then exposed and transected about 3 cm. above the bladder. The upper end was reimplanted in the bladder using the Politano-Leadbetter technique. Frozen

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FIGURE 1. (A) Preoperative retrograde pyelogram showing j3ling defects in upper left ureter. (B) Six polypoid lesions in upper third of left ureter. (C) Microscopic view of jibrous polyps with loose fibrous stroma with areas of myxoid degeneration. (D) Postoperative intravenous pyelogram showing marked reduction of left hydroureter and no recurrence of PObPS.

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as well as permanent sections showed fibrous polyps with a loose fibrous stroma with areas of myxoid degeneration. The overlying epithelium was intact and normal (Fig. 1C). A urethral catheter was left indwelling for ten days, but no ureteral catheter was used. No significant urinary leakage from the wound occurred. Her vital signs remained normal, and she was discharged on the ninth postoperative day. She was seen four months later at which time the urine was clear microscopically. An intravenous pyelogram showed marked reduction in the left hydroureter with no evidence of recurrence of the polyps (Fig. 1D). The most recent intravenous pyelogram, on August 22, 1973, showed a normal-appearing upper left urinary tract with no evidence of filling defects or irregularity. Comment The treatment of benign ureteral lesions has included nephro-ureterectomy, segmental resection of the ureter, and local excision. Because of the pedunculated nature of the polyps in our patient, and the necessity of correcting an obstruction of the lower end of the ureter, local excision was carried out. Whether or not this will prove to be adequate treatment remains to be seen. If there is recurrence, at least a partial resection of the ureter

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will be necessary. No reports of cases with recurrence have been found in the literature, but most patients have been treated by nephroureterectomy because a malignant tumor was suspected. The possibility of a benign lesion, especially in younger patients, should be borne in mind. The opportunity for preservation of a normally functioning kidney with a benign lesion must be balanced against possible spread of a malignant tumor from opening the ureter. In younger persons ureteral tumors are more apt to be benign than in the older age group. Our patient sought medical attention because of persistent infection with two episodes of hematuria, again demonstrating the value of investigation of these complaints. After forty-four months the patient has sterile urine with no evidence of recurrence. 23 Hackett Boulevard Albany, New York 12208 (DR. MARDEN) References

SCOTT, W. W.: Tumors of the ureter, in CAMPBELL, M. F., and HARRISON, J. H.: Urology, 2nd ed., Philadelphia, W. B. Saunders Company, 1963. PARKER, D. J.: A fibrous polyp of the ureter in childhood, Br. J. Ural. 40: 418 (1968). CRUM, P. M., SAYEGH, H. S., SACHER, H. C., and WEST-

COTT, J. W.: Benign ureteral polyps,J.Ural.102:678 (1969).

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