A Case of Ureteral Intussusception Associated with Ureteral Polyp

A Case of Ureteral Intussusception Associated with Ureteral Polyp

0022-534 7/83/1295-1043$02.00/0 Vol.129, May Printed in U.S.A. THE JOURNAL OF UROLOGY Copyright© 1983 by The Williams & Wilkins Co. A CASE OF URETE...

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0022-534 7/83/1295-1043$02.00/0 Vol.129, May Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1983 by The Williams & Wilkins Co.

A CASE OF URETERAL INTUSSUSCEPTION ASSOCIATED WITH URETERAL POLYP YASUO FUKUSHI, SEIICHI ORIKASA AND MUTSUO TAKEUCHI From the Department of Urology, Tohoku University School of Medicine, Sendai and Iwaki Kyoritsu Hospital, Iwaki, Japan

ABSTRACT

We report a case of left ureteral intussusception associated with a ureteral polyp. At operation a 7 cm. long polyp was seen originating from the tip of the inside of the proximal ureter, causing 1.7 cm. of antegrade invagination. The polyp was resected and the invaginated region was rep;l.ired since pathological examination revealed a benign tumor. At followup an excretory urogram demonstrated prompt improvement of left hydronephrosis. Intussusception of the ureter associated with a ureteral tumor is rare, with only 12 cases reported in the literature, including 3 from J apan. 1- 12 Herein we report a case of ureteral intussusceptimi associated with an inflammatory polyp and discuss its etiology.

"claw of crab", which usually is observed in an invaginated region of the intestinal canal, was seen in the border region and a thin filling defect that was suspected to be a tumor was noted at the tip of the stenotic region (part A of figure). Ureteral intussusception caused by a left ureteral tumor was suspected.

C

A, drip infusion pyelography shows "claw of crab" -shaped radiographic sign between proximal stenotic ureter and distal dilated ureter. B, antegrade intussusception of ureter. C, schematic diagram of ureter and polyp. D, ureterotomy demonstrates long polyp pedunculated to ureter. Pinhole-like proximal ureteral lumen can be seen just beside tumor stalk. CASE REPORT

A 59-year-old woman was referred to us for gross hematuria and flank pain. Urinalysis revealed hematuria but systemic findings were normal. Drip infusion pyelography revealed mild left hydronephrosis and a large filling defect in the middle part of the left ureter. The ureter was dilated at the area of the filling defect and its proximal side was stenotic. The image, Accepted for publication June 25, 1982.

Surgical exploration revealed a 1. 7 cm. ureteral intussusception and the ureter immediately below was markedly dilated (parts Band C of figure). When the dilated ureter was opened a 7 cm. long polyp extruded. The pedicle of the polyp originated from the tip of the inside of the proximal ureter that was invaginated (part D of figure). Pathological examination during operation revealed a benign tumor, which was resected. After lysis of the external adhesion of the invaginated region, intussusception was repaired. Microscopic examination showed an inflammatory polyp.

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DISCUSSION

ADDENDUM

Ureteral intussusception associated with a ureteral tumor is rare. To the best of our knowledge there have been only 12 cases reported in the literature, including 3 from Japan. In only 3 cases was ureteral intussusception diagnosed preoperatively by an excretory urogram. 6 -B In our case intussusception was diagnosed by drip infusion pyelography. The relationship between intussusception and the tumor can be explained as follows: 1) accidental combination, 2) ureteral invagination develops first and inflammatory change causes tumor formation or 3) ureteral invagination occurs secondary to tumor. Cases in groups 1 and 2 cannot be considered, since no case of ureteral intussusception without a tumor has been reported, and the complicated tumor has not always been an inflammatory polyp. Mazer and associates, who reported a case of ureteral intussusception associated with low grade noninvasive transitional cell carcinoma, described that if the tumor had been invasive intussusception could not occur because of adhesion to the surroundings and thickening of the ureteral wall. 8 This idea is substantiated by the fact that the remaining 11 reported cases and our case were all associated with a benign polyp. In our case the pedicle of the polyp originating from the tip of the inside of the ureter invaginated, the tumor was long and little changes were noted in the kidney and upper ureter. These findings suggested that ureteral intussusception occurred secondary to the polyp. We believe that the tumor developed first, and then it was pulled into the downstream by almost normal urinary flow and peristalsis. The ureteral wall then was pulled downward into the distal ureteral lumen. Mazer and associates indicated that thickness of the ureteral wall prevented the onset of ureteral intussusception. We wish to point out that a small ratio between thickness of the wall and lumen caliber of the ureter, limited range of mobility of the ureter itself, decrease in urinary flow due to severe disorders of passage and dilatation 'Of the ureter proximal to the tumor also are factors that prevent ureteral intussusception.

Soon after this case was reported a 50-year-old woman presented with right ureteral intussusception by an inflammatory ureteral polyp that was 7 cm. long. Diagnosis was made by drip infusion pyelography and the clinical symptoms were much the same as the case reported herein. The tumor was removed and the invagination was reconstructed. REFERENCES

1. Runner, G. L.: Intussusception of the ureter due to a large papilloma-like polypus. J. Urol., 40: 752, 1938. 2. Bumpus, H. C., Jr.: Intussusception of the ureter. Trans. Amer. Ass. Genito-Urin. Surg., 32: 127, 1939. 3. Fagerstrom, D. P.: Proliferative tumors of the ureter and renal pelvis, with further observations on the significance of "epithelial cell nests": six case reports. J. Urol., 59: 333, 1948. 4. Biedermann, G.: Beitrag zur Kenntnis der gutartigen Harnleitergeschwiilste. Z. Urol., 44: 680, 1951. 5. Morley, H. V., Shumaker, E. J. and Gardner, L. W.: Intussusception of the ureter associated with a benign polyp. J. Urol., 67: 266, 1952. 6. Bonomini, B.: Invaginazione dell'uretere da polipo benigno diagnosticata preoperatoriamente con urografia endovenosa. Rad. Medica, 48: 929, 1962. 7. Gerdes, G. and Nordqvist, L.: Intussusception of the ureter caused by a primary benign tumour. Acta Chir. Scand., 132: 397, 1966. 8. Mazer, M. J., Lacy, S. S. and Kao, L.: "Bell-shaped ureter;" a radiographic sign of antegrade intussusception. Urol. Rad., 1: 63, 1979. 9. Fiorelli, C., Durval, A., Cello, V. D., Rizzo, M. and Nicita, G.: Ureteral intussusception by a fibroepithelial polyp. J. Urol., 126: 110, 1981. 10. Furumoto, H., Nakamura, T. and Wada, I.: Polyp of the ureter causing urinary retention. Dermatol. Urol., 17: 9, 1963. 11. Sai, T., Kohata, K. and Yamauchi, T.: A case of the ureteral polyp. Jap. J. Urol., 62: 270, 1971. 12. Hayashida, S., Koganemaru, T., Kiriyama, T. and Yamamoto, N.: Ureteral polyp: a review of the Japanese literature and report of two cases. Jap. J. Clin. Urol., 27: 61, 1973.