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An unusual case of pelviureteric junction obstruction
An Unusual
Case of Pelviureteric
Junction
Obstruction
By J.D. Greig and A.F. Azmy Glasgow,
Scotland
l We describe an unusual case of pelviureteric junction obstruction in a child due to a benign ureteric polyp. Benign neoplasms of the ureter are uncommon in adults and extremely rare in children. Copyright Q 1992 by W.B. Saunders Company INDEX WORDS: Ureteric polyp; tion.
B
pelviureteric junction obstruo
ENIGN neoplasms of the ureter are uncommon in adults and extremely rare in children. CASE REPORT
A 7-year-old boy bad a l-year history of intermittent left-sided flank pain. Urine analysis demonstrated microscopic haematuria though urine culture was negative. Renal ultrasound demonstrated a moderate left hydronephrosis, and an intravenous urogram (IVU) showed a dilated pelvicalyceal system and obstruction at the level of the pelviureteric junction (PUJ), which itself appeared to be lower than expected. A subsequent prone radiograph demonstrated a filling defect and was thought to represent a radiotranslucent calculus (Fig 1). Micturating cystogram showed no reflux; cystoscopy and retrograde pyelogram were not performed.
Fig 2.
Resected specimen showing polyp.
The left kidney was explored and showed marked dilatation of an extrarenal pelvis with good renal cortex. A soft mobile pedunculated ureteric lesion at the PUJ was palpated. The polyp, together with the corresponding segment of ureter, was excised (Fig 2). Due to the dilatation of the extrarenal pelvis, a reduction pyeloplasty was performed. Follow-up after 1 year showed adequate drainage on 99Tc DTPA study. Histological examination of the polyp showed it to be a fibroepethelial polyp covered by transitional epithelium. There was no evidence of malignancy. DISCUSSION
Abeshouse’ described 592 primary ureteric neoplasms, 139 of which were benign. Compere et al2 were the first to report benign ureteric polyps present-
Fig 1.
IVU with arrow indicting polyp causing hydronephrosis.
Journalof Pediatric Surgery, Vol27, No 4 (April), 1992: pp 525-526
From the Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, Scotland. Address reprint requests to A.F. Azrny, MD, Department of Paediatric Surgery, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 SSJ, Scotland. Copyright o 1992 by W B. Saunders Company 0022-3468/92/2704-0029$03.00/O
525
GREIGAND
526
ing in children. Only 16 cases of benign ureteric polyps in children have been reported.’ The age at presentation ranged from birth to 15 years of age. Males and the left side were more commonly affected.’ Duration of symptoms varied from less than 1 month to 10 years. Presentation with intermittent flank or abdominal pain is common. However, 4 children presented acutely with urinary tract infection or haematuria. Delay in diagnosis was common with a mean delay of 5.5 years.“ The IVU appearance in the case reported had been mistaken for a congenital PUJ obstruction and additional radiographs in the prone position demonstrated the filling defect. Most of the published cases often commented on the quite marked
AZMY
cortical atrophy due to long-standing back pressure. In the reported case, the renal cortex has been preserved, perhaps due to intervention early in childhood. The commoner histological type is the fibroepitheha1 polyp in which there are multiple layers of transitional epithelial cells sharply delineated from the underlying connective tissue. The other type is a stromal polyp, in which the connective tissue predominates with a normal or minimal epithelial metaplasia. Multiple polyps occurred in about half of the patients reported and they were always localized to one segment of the ureter. The etiology of these lesions remains obscure but their benign nature and the need for conservative surgery should be emphasized.
REFERENCES 1. Abeshouse BS: Primary benign and malignant tumors of the ureter. A review of the literature and a report on 1 benign and 12 malignant tumors. Am J Surg 91:237-271, 1956 2. Compere DE, Begley GF, Isaacks HE, et al: Ureteral polyps. J Urol79:209-214,195s 3. Macksood MJ, Roth DR, Chang CH, et al: Benign fibroepithe-
ha1 polyps as a cause of intermittent uretero-pelvic junction obstruction in a child: A case report and review of the literature. .I Urol 134:951-952,1985 4. Williams PR, Fegetter J, Miller RA, et al: The diagnosis and management of benign fibrous ureteric polyps. Br J Urol 52:253256,198O
Case of Pelviureteric
Junction
Obstruction
By J.D. Greig and A.F. Azmy Glasgow,
Scotland
l We describe an unusual case of pelviureteric junction obstruction in a child due to a benign ureteric polyp. Benign neoplasms of the ureter are uncommon in adults and extremely rare in children. Copyright Q 1992 by W.B. Saunders Company INDEX WORDS: Ureteric polyp; tion.
B
pelviureteric junction obstruo
ENIGN neoplasms of the ureter are uncommon in adults and extremely rare in children. CASE REPORT
A 7-year-old boy bad a l-year history of intermittent left-sided flank pain. Urine analysis demonstrated microscopic haematuria though urine culture was negative. Renal ultrasound demonstrated a moderate left hydronephrosis, and an intravenous urogram (IVU) showed a dilated pelvicalyceal system and obstruction at the level of the pelviureteric junction (PUJ), which itself appeared to be lower than expected. A subsequent prone radiograph demonstrated a filling defect and was thought to represent a radiotranslucent calculus (Fig 1). Micturating cystogram showed no reflux; cystoscopy and retrograde pyelogram were not performed.
Fig 2.
Resected specimen showing polyp.
The left kidney was explored and showed marked dilatation of an extrarenal pelvis with good renal cortex. A soft mobile pedunculated ureteric lesion at the PUJ was palpated. The polyp, together with the corresponding segment of ureter, was excised (Fig 2). Due to the dilatation of the extrarenal pelvis, a reduction pyeloplasty was performed. Follow-up after 1 year showed adequate drainage on 99Tc DTPA study. Histological examination of the polyp showed it to be a fibroepethelial polyp covered by transitional epithelium. There was no evidence of malignancy. DISCUSSION
Abeshouse’ described 592 primary ureteric neoplasms, 139 of which were benign. Compere et al2 were the first to report benign ureteric polyps present-
Fig 1.
IVU with arrow indicting polyp causing hydronephrosis.
Journalof Pediatric Surgery, Vol27, No 4 (April), 1992: pp 525-526
From the Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, Scotland. Address reprint requests to A.F. Azrny, MD, Department of Paediatric Surgery, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 SSJ, Scotland. Copyright o 1992 by W B. Saunders Company 0022-3468/92/2704-0029$03.00/O
525
GREIGAND
526
ing in children. Only 16 cases of benign ureteric polyps in children have been reported.’ The age at presentation ranged from birth to 15 years of age. Males and the left side were more commonly affected.’ Duration of symptoms varied from less than 1 month to 10 years. Presentation with intermittent flank or abdominal pain is common. However, 4 children presented acutely with urinary tract infection or haematuria. Delay in diagnosis was common with a mean delay of 5.5 years.“ The IVU appearance in the case reported had been mistaken for a congenital PUJ obstruction and additional radiographs in the prone position demonstrated the filling defect. Most of the published cases often commented on the quite marked
AZMY
cortical atrophy due to long-standing back pressure. In the reported case, the renal cortex has been preserved, perhaps due to intervention early in childhood. The commoner histological type is the fibroepitheha1 polyp in which there are multiple layers of transitional epithelial cells sharply delineated from the underlying connective tissue. The other type is a stromal polyp, in which the connective tissue predominates with a normal or minimal epithelial metaplasia. Multiple polyps occurred in about half of the patients reported and they were always localized to one segment of the ureter. The etiology of these lesions remains obscure but their benign nature and the need for conservative surgery should be emphasized.
REFERENCES 1. Abeshouse BS: Primary benign and malignant tumors of the ureter. A review of the literature and a report on 1 benign and 12 malignant tumors. Am J Surg 91:237-271, 1956 2. Compere DE, Begley GF, Isaacks HE, et al: Ureteral polyps. J Urol79:209-214,195s 3. Macksood MJ, Roth DR, Chang CH, et al: Benign fibroepithe-
ha1 polyps as a cause of intermittent uretero-pelvic junction obstruction in a child: A case report and review of the literature. .I Urol 134:951-952,1985 4. Williams PR, Fegetter J, Miller RA, et al: The diagnosis and management of benign fibrous ureteric polyps. Br J Urol 52:253256,198O