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Benign fibrous ureteral polyps
BENIGN FIBROUS URETERAL POLYPS HAU H. CHANG, M .D . PAUL RAY, D .O . EDWARD OCKULY, M .D . PATRICK GUINAN, M .D. From the Divisions of Urology, the University of Illinois and Cook County Hospital, Chicago, Illinois ; the Medical College of Ohio at Toledo, Ohio; and the San Joaquin Community Hospital, Bakersfield, California
ABSTRACT-Benign fibrous polyps of the ureter are rare . A review of the English literature since 1930 revealed that 71 cases had been described . Three additional cases of fibrous ureteral polyps, one in a ureter with ureteritis cystica, are reported with a discussion of both the histologic findings and proposed treatment plan .
Primary benign tumors of the ureter are rare . Benign ureteral polyps are even rarer, with only 71 cases previously reported . We report 3 additional cases as well as review of the 71 cases from the literature . With the advances in diagnostic radiologic techniques, as well as ureteroscopy, the diagnosis of benign ureteral tumors has been increasing, with nearly twothirds diagnosed since 1960 (Table I) . Case Reports Case 1
A thirty-nine-year-old printer was hospitalized in 1966 with a chief complaint of left flank pain . Eighteen years previously the patient had had a similar episode of pain associated with gross hematuria . An intravenous pyelogram (IVP) at that time demonstrated no significant pathologic condition . One year prior to his present admission he again experienced mild intermittent pain in the left flank . The pain was nonradiating and not associated with frequency, urgency, or hematuria, The patient drank six to eight cans of beer per day and smoked one to two cigars per day. Physical examination revealed a muscular male with normal vital signs . His abdomen was soft, flat, nontender, and without any palpable
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masses . Urinalysis, blood urea nitrogen (BUN), and uric acid were within normal limits . Urine culture showed no growth, and cytology findings were class I . IVP revealed a left hydroureter with multiple radiolucent filling defects up to 3 cm in length in the distal half of the ureter . A left retrograde pyelogram confirmed the dilation and the multiple filling defects distally (Fig . IA) . A left nephroureterectomy with excision of a bladder cuff was performed . The tumor, on gross examination, was a polypoid translucent mass measuring 9 by 2 .5 by 2 cm (Fig . 1B) . The cut surface was myxomatous and partly cystic ; the cysts contained clear fluid . There were focal areas of hemorrhage . Microscopically, the polypoid tumor was composed of loosely arranged connective tissue covered by transitional epithelium which was focally hyperplastic . Submucosal epithelial cell TABLE I .
Decade
Occurrence by decade
Number of Cases
1930-1939
3
1940-1949
4
1950-1959
18
1960-1969
17
1970-present
32
74
TOTAL
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(A and B, Case 1) Left retrograde pyelogram with distal obstruction (A) ; left nephroureterectomy specimen (B) with distal ureteral polypoid mass (arrow) . (C and D, Case 2) Left retrograde pyelogram with serpentine filling defect (C) ; left nephroureterotomy specimen (D) with ureteral polyps (arrow) . (E and F, Case 3) Left retrograde pyelogram revealing left ureteropelvic juncture filling defect (E) ; microscopic sections of polyps (F) revealing gland-like structures extending to surface (arrow) . FIGURE 1 .
nests, the so-called von Brunn nests, were also Case 2 present, with tubular and crypt-like formations . These tubules branched distally and A twenty-nine-year-old man was admitted to the hospital in 1971 complaining of intermittent opened onto the surface of the polyp . A postoperative WVP showed a normal right upper vague generalized abdominal pain for two years . Eight years prior to this admission the urinary tract . The patient remains without evipatient had had one episode of gross, painless dence of recurrent urinary tract disease .
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TABLE II .
Age distribution
Years 0-10 11-20
Number of Cases 7 17
21-30 31-40 41-50 51-60 61-70 71-80
14 17 9 6 2 2
hematuria . Cystoscopy at that time revealed urethritis, and a retrograde pyelogram was normal . One year later, the patient experienced severe intermittent lower back and abdominal pain. The pain lasted for several hours ; it recurred one year later associated with gross hematuria . On admission physical examination revealed a muscular white man, with normal vital signs . His abdomen was soft and nontender, and no masses were palpable . There was no costovertebral tenderness . Complete blood count and routine electrolytes were within normal limits . Findings on urine cytology were class I . IVP revealed grade II hydronephrosis and hydroureter of the left upper tract . There were multiple filling defects at the junction of the upper and middle thirds of the left ureter. A left retrograde pyelogram confirmed multiple serpentine filling defects at the level of L2 to L4 (Fig . IC) . Ureterotomy demonstrated a large papillary tumorous mass . A nephroureterectomy was performed, and the patient had an uneventful recovery. Gross examination revealed three soft, light pink, filiform polyps measuring between 0 .7 and 3 cm in length and 0 .1 cm in greatest diameter, and one multifilamentous polyp, 4 cm in length and 1 .1 cm in greatest diameter (Fig . 1D) . There were several smaller polyps adjacent and distal to the large lesion . Microscopically the polyps were covered by a benignappearing transitional cell epithelium supported by a loose vascular connective tissue infiltrated by plasma cells . Serial sections of the polyps revealed occasional gland-like structures of transitional epithelium buried in the stroma with openings extending to the surface epithelium . Case 3 A twenty-six-year-old Mexican-American man was admitted to the hospital in 1983 because of intermittent pain radiating to the left thigh for two years . There was no history of
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dysuria or hematuria . Findings on urinalysis were normal . Intravenous urogram revealed left ureteropelvic junction obstruction with hydronephrosis . A left retrograde pyelogram showed no other filling defects except at the left ureteropelvic junction (Fig . 1E) . A dismembered pyeloplasty was performed, excising the area of the polyp . Two 1-cm calculi were also removed from the renal pelvis . Histologic examination confirmed the mass to be a benign fibrous polyp of the ureter with ureteritis cystica and numerous submucosal epithelial cell nests with openings extending to the surface of the polyp (Fig . 1F) . Review of Literature A review of the literature suggests that primary tumors of the ureter, benign or malignant, are rare .'-' Benign lesions constitute approximately one fourth of all tumors of the ureter. Primary benign ureteral tumors can be classified into two main groups : papillomas with transitional epithelium predominating, and mesodermal tumors with stromal tissue predominating. Benign fibrous polyps of the ureter account for 61 per cent of the mesodermal tumors and 28 per cent of all benign ureteral tumors . Only 71 cases of histologically proved benign fibrous polyps of the ureter have been described previously in the English literature."' The patients ranged in age from newborn to seventy-three years, with the highest incidence in the second, third, and fourth decades (Table II) . Possible etiologic factors that have been suggested include obstruction, trauma, irritation, infection, specific exogenous or endogenous carcinogens, hormonal imbalance, and allergy. The majority of the patients presented with pain in the flank or lower quadrant of the abdomen, or hematuria . Urinary frequency, dysuria, and/or pyuria were less common findings . Most of the patients had roentgenologic evidence of moderate to severe hydronephrosis . Complete nonvisualization of the kidney on excretory urogram was unusual . Interestingly, the left ureter was involved more often than the right, with a ratio of about 2 to 1 . The onset of clinical symptoms ranged from a few hours to forty-five years prior to diagnosis ; two fifths of the patients had symptoms for longer than two years . The ureteropelvic junction and the upper third of the ureter were frequent sites of involvement, accounting for approximately 60 per cent
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TABLE III .
of the cases (Table III) . There was one instance of bilateral involvement ." Five patients had intussusception of the ureter.',13 .31 Six patients also had polyps, associated with concomitant stones . In 1 patient, the distal aspect of the polyp had a well-differentiated transitional cell carcinoma . 50 Most of the lesions were solitary with slender stalks . Forty-eight of the 74 patients had single lesions with a slender stalk . Ten had a few or a cluster of polyps in the same area which could be treated by segmental resection of the ureter with anastomosis or excision of the polyps alone. Two instances of ureteral polyposis involving the entire ureter were reported . The first patient with hamartomatous ureteral polyposis had an associated Peutz-Jeghers syndrome . 35 The second patient was an eleven-year-old boy with left upper segment ureteral polyposis . 52 The stroma of most polyps consisted of edematous fibrous connective tissue with dilated capillaries, minimal cellular infiltration, and occasional epithelial cell nests . The various polyps had varying amounts of collagen fibers and epithelial cell nests . The polyps were covered with transitional epithelium with occasional cellular hyperplasia . Occasionally they were focally covered by one or two layers of cuboidal cells, presumably the result of thinnedout epithelium due to stromal edema and enlargement . Most of the polyps were described as having an edematous smooth surface with a thin, pedunculated base . Some larger polyps had villous polypoid projections emanating from a broad base . The treatment of benign polyps was dictated by the degree of obstruction, the involvement of the ureter, and the intraoperative impression of a carcinoma . Therefore, procedures varying from segmental resection to nephroureterectomy have been performed . It was not until 1945, when Vest' advocated either local excision or segmental resection of the ureter for benign tumor of the ureter, that less radical therapy was considered . Since then more articles have appeared favoring conservative management . The 74 cases reviewed in this series revealed that 15 patients had excision of the polyp with or without fulguration of the base . Fourteen had segmental resection of the ureter with endto-end anastomosis . Five had pyeloplasties . Twelve patients had nephroureterectomy for either advanced hydronephrosis with pyelo-
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AUGUST 1987 / VOLUME XXX, NUMBER 2
Location of
Location Ureteropelvic junction Upper one third Upper one third and mid Mid one third Mid and lower one third Lower one third Bilateral
benign ureteral polyps Rt . Side Lt. Side 7 7
16 11
1 4 1 8
2 7 2 7 1
nephritis or inability to restore ureteral continuity. Twenty-six underwent nephroureterectomy without ureterotomy and frozen section because it was feared that the lesion was malignant . One of these latter patients underwent nephroureterectomy because frozen section suggested the possibility of malignancy ; there was a small focus of carcinoma on permanent section . 50 A right nephroureterectomy was done on a pregnant woman because of misleading decidual cell nests in a biopsy specimen obtained from a polypoid extrusion from the right ureteral orifice simulating a cluster of malignant cells in a lymphatic channel of a benign polyp . 10 One patient underwent autotransplantation .48 Three recurrences are reported . The first was a forty-year-old man with multiple polyps in the right and left ureters . Two years later, additional benign stromal polyps were removed from an area previously uninvolved . 34 The second patient with recurrence was a thirteenyear-old black female with excision of a short pedunculated polyp who experienced gross hematuria and urinary retention one and one-half years later. At surgery, a 1-cm firm pink polypoid mass at the ureteropelvic junction was removed . Microscopic examination of the ureteral tumor showed groups of migratory epithelial cells consistent with the diagnosis of polypoid hamartoma and epithelial cell nests in the ureter and renal pelvis? The third patient with a recurrence was a twenty-two-year-old woman who had undergone two previous resections for recurrent ureteral polyps in a portion of the ureteral wall of the same ureter ; she underwent autotransplantation after a third recurrence .4B In 36 of 74 patients ureteral salvage was attempted . Recurrences developed in the same ureter in 3 of the remaining 110 ureters at risk (38 patients with one ureter removed and 36 patients with both ureters remaining), a recurrence rate of less than 3 per cent . None of the
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reported polyps recurred at the same site . Among the 74 patients only 7 patients (10%), including the patient with two recurrences, had involvement of the ureter which would have precluded restoration of ureteral continuity by resection and reanastomosis . In summary, the management of benign fibrous ureteral polyps includes a careful workup leading to a preoperative impression of a ureteral filling defect . If this assessment indicates ureteral polyps, a ureteral exploration, open or closed, could be considered . If exploration and pathologic examination confirms a benign fibrous ureteral polyp, local excision is a viable option and could save the involved renal unit . Chicago, Illinois 60612 (DR . GUINAN) References 1 . Moore T : Tumors of the ureter, Br j Surg 29: 371 (1941) . 2, Abeshouse BS : Primary benign and malignant tumors of the ureter, Am I Surg 91 : 237 (1956) . 3 . Gittes RF : Thmors of ureter and renal pelvis, in Harrison JH (Ed) : Urology, 4th ed, Philadelphia, WB Saunders, 1979, vol 2, pp 1029-1030, 4 . Melicow MM, and Findlay HV : Primary benign tumors of ureter, review of literature and report of a case, Surg Gynecol Obstet 54 : 680 (1932) . 5 . Argue HS : Primary benign tumor of the ureter, Urol Cutan Rev 38 : 232 (1934) . 6 . Harmer GL : Intussusception of the ureter due to a large papilloma like polypus, j Urol 40 : 752 (1938) . 7 . Johnson CM, and Smith DR : Benign polyps of the ureter, ibid 47 : 448 (1942) . 8 . Vest SA : Conservative surgery in certain benign tumors of ureter, ibid 53 : 97 (1945) . 9 . Palmer JK, and Greene LF : Benign fibromucous polyp of the ureter, Surgery 22 : 562 (1947) . 10 . Hamm FC, and Lavalle LL : Emor of the ureter, j Ural 61 : 493 (1949) . 11 . Douglas HL : Ureteral tumors, Ann Surg 131 : 755 (1950) . 12 . McCusky jF, Randolph BE, and Fisher H : Benign tumor of the ureter, W Va Med j 47 : 154 (1951) . 13 . Morley HU, Shumaker EJ, and Gardner CW: Intussusception of the ureter associated with a benign polyp, j Urol 67 : 266 (1952) . 14 . Pierce WV and Miner WR : Benign tumors of the ureter, South Med j 45: 485 (1952) . 15 . Baker WJ, and Graf EC : Tumors of the ureter, j Urol 70 : 390 (1953) . 16 . Oppenheimer GD, and Narins L : Benign tumor of the ureter, j Mount Sinai Hosp 21 : 213 (1954) . 17 . Compere DE, et al : Ureteral polyps, j Urol 79: 209 (1958) . 18 . Wood LC, and Howe GE : Primary tumors of the ureter, ibid 79 : 418 (1958) . 19 . Howard TL : Giant polyp of the ureter, ibid 79 : 397 (1958) . 20 . Schneiderman C, Simon M, and Sedlezky 1 : Benign polyp of ureter, Br I Urol 31 : 168 (1959) . 21 . Brock DR : Benign polyp of ureter, j Ural 83 : 572 (1960) . 22 . MacDougall JA : Primary tumors of the ureter, Br J Urol 33 : 160 (1961) . 23 . Ardulno J : Conservative surgery for ureteral polyps, j Urol 85 : 925 (1961) . 24 . Evans AT, and Stevens RK : Fibroepithelial polyps, of ureter and renal pelvis, ibid 86 : 313 (1961) .
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25 . Wogalter H : Ureteral polyp : 19 year history, ibid 87 : 528 (1961) 26 . Breckenridge RL, Lynch PV, and Holfelner ED : Fibrous polyp of ureter, ibid 90: 160 (1963) . 27 . Robards VL, Thompson IM, and Ross G Jr : Primary tumors of the ureter, )AMA 187 : 778 (1964) . 28 . Deklotz RI, and Young BW : Conservative surgery in the management of benign ureteral polyps, Br J Urol 36 : 375 (1964) . 29 . Auerbach S, Lewis HY, and McDonald JR : Recurrent pelypoid hamartoma and epithelial cell nests in the ureter and renal pelvis of an adolescent, j Urol 95 : 691 (1966) . 30 . Roen PR, and Kandalaft S : Primary benign mesodermal ureteral tumor, ibid 96 : 890 (1966) . 31 . Cerdes G, and Nordquist L : Intussusception of the ureter caused by a benign tumor, Acta Chir Scand 132 : 397 (1966) . 32 . Paker DJ : A fibrous polyp of the ureter in childhood, Br J Urol 40 : 418 (1968) . 33 . Soderdahl DW and Schuster SR : Benign ureteral polyp newborn, )AMA 207 : 1714 (1969) . 34 . Crum PM, Sayegh ES, Sacher EG, and Wescott JW : Benign ureteral polyps, j Urol 102 : 678 (1969) . 35 . Sommerhaug RG, and Mason T : Peutz-Jeghers syndrome and ureteral polyposis, JAMA 211 : 120 (1970) . 36 . Bose B, and Williams JP : Benign polyoidal tumor of ureter, Br J Surg 58 : 149 (1971) . 37 . Knackstedt J, Pirozynski W, and Oliver JA : Benign fibroepithelial polyps of ureter, Br J Ural 43 : 284 (1971) . 38 . Hudson HC, and Howland RI : Primary benign ureter tumor of mesodermal origin, J Urol 105 : 794 (1971) . 39 . Vastola 3W, Hajdu SL and Grabstald H : Benign ureteral polyps, NY State J Med 71 : 2679 (1971) . 40 . Cavalio T, and Cracker DW: Benign turner of ureter, j Natl Mod Assoc 64 : 421 (1972) . 41 . Neal JM, and Arbuckle LD : Benign fibrous polyp of the ureter, j Urol 109 : 308 (1973) . 42 . Colgan JR, Skaist LE, and Morrow JW : Benign ureteral tumors in childhood, ibid 109 : 308 (1973) . 43, Hussaini M, Marden H, and Woodruff M : Multiple fibrous polyps of the ureter, Urology 2 : 563 (1973) . 44 . Kretkowski RC, and Derrick FC Jr: Primary ureteral tumors, ibid 1 : 36 (1973) . 45 . Pinto RS, and Fauver E : Benign £ibroepithelioma of ureter, ibid 3 : 747 (1974) . 46 . Elsen EC, and McLaughlin AP : Xanthomatous ureteral polyp, ibid 4: 214 (1974) . 47 . Stuppler SA, and Kandzari SJ : Fibroepithelial polyps of ureter, a benign ureteral tumor ibid 5 : 553 (1975) . 48 . Saltzstein EC, and Fine SW: Renal autotransplantation and partial resection of the ureter for recurrent benign ureteral tumor, Surgery 77 : 607 (1975) . 49 . Cup A : Benign mesodermal polyp in childhood . J Urol 114 : 619 (1975) . 50 . Davides KC, and King LM : Fibrous polyps of the ureter, ibid 115 : 651 (1976) . 51 . Hughes FA, and Davis CS : Multiple benign ureteral fibrous polyp, AJR 126 : 723 (1976) . 52 . Eilenborg J, Serry W, and Cole A : Multiple fibroepithelial polyps in the pediatric age group, j Urol 117 : 793 (1977) . 53 . Abrams HJ, Bachbinder ML and Sutton AP : Benign ureteral lesions ; rare causes of hydronephros£s in children, Urology 9 : 517 (1977) . 54. Clements JC, McLeod DC, Green WR, and Star RE : A case report : duplicated vena cava with right retrocaval ureter and ureteral tumor, j Urol 119 :284 (1978) . 55. Schulman CC : Ureteric polyp as a cause of hydronephrosis in childhood, j Pediat Surg 13 : 537 (1978) . 56. Vandendris M : Fibrous polyp of the ureter, Br J Urol 56 : 233 (1979) . 57 . Debruyre FM, Moonen WA, Daenekindt AA, and Delaere KPJ : Fibroepithelial polyp of ureter, Urology 16 : 355 (1980) . 58 . Fagerstrom DP : Proliferative tumors of the ureter and renal pelvis, with further observations of the significance "epithelial cell nests,") Urol 59: 333 (1948) .
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ABSTRACT-Benign fibrous polyps of the ureter are rare . A review of the English literature since 1930 revealed that 71 cases had been described . Three additional cases of fibrous ureteral polyps, one in a ureter with ureteritis cystica, are reported with a discussion of both the histologic findings and proposed treatment plan .
Primary benign tumors of the ureter are rare . Benign ureteral polyps are even rarer, with only 71 cases previously reported . We report 3 additional cases as well as review of the 71 cases from the literature . With the advances in diagnostic radiologic techniques, as well as ureteroscopy, the diagnosis of benign ureteral tumors has been increasing, with nearly twothirds diagnosed since 1960 (Table I) . Case Reports Case 1
A thirty-nine-year-old printer was hospitalized in 1966 with a chief complaint of left flank pain . Eighteen years previously the patient had had a similar episode of pain associated with gross hematuria . An intravenous pyelogram (IVP) at that time demonstrated no significant pathologic condition . One year prior to his present admission he again experienced mild intermittent pain in the left flank . The pain was nonradiating and not associated with frequency, urgency, or hematuria, The patient drank six to eight cans of beer per day and smoked one to two cigars per day. Physical examination revealed a muscular male with normal vital signs . His abdomen was soft, flat, nontender, and without any palpable
114
masses . Urinalysis, blood urea nitrogen (BUN), and uric acid were within normal limits . Urine culture showed no growth, and cytology findings were class I . IVP revealed a left hydroureter with multiple radiolucent filling defects up to 3 cm in length in the distal half of the ureter . A left retrograde pyelogram confirmed the dilation and the multiple filling defects distally (Fig . IA) . A left nephroureterectomy with excision of a bladder cuff was performed . The tumor, on gross examination, was a polypoid translucent mass measuring 9 by 2 .5 by 2 cm (Fig . 1B) . The cut surface was myxomatous and partly cystic ; the cysts contained clear fluid . There were focal areas of hemorrhage . Microscopically, the polypoid tumor was composed of loosely arranged connective tissue covered by transitional epithelium which was focally hyperplastic . Submucosal epithelial cell TABLE I .
Decade
Occurrence by decade
Number of Cases
1930-1939
3
1940-1949
4
1950-1959
18
1960-1969
17
1970-present
32
74
TOTAL
UROLOGY
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AUGUST 1987 / VOLUME XXX, NUMBER 2
(A and B, Case 1) Left retrograde pyelogram with distal obstruction (A) ; left nephroureterectomy specimen (B) with distal ureteral polypoid mass (arrow) . (C and D, Case 2) Left retrograde pyelogram with serpentine filling defect (C) ; left nephroureterotomy specimen (D) with ureteral polyps (arrow) . (E and F, Case 3) Left retrograde pyelogram revealing left ureteropelvic juncture filling defect (E) ; microscopic sections of polyps (F) revealing gland-like structures extending to surface (arrow) . FIGURE 1 .
nests, the so-called von Brunn nests, were also Case 2 present, with tubular and crypt-like formations . These tubules branched distally and A twenty-nine-year-old man was admitted to the hospital in 1971 complaining of intermittent opened onto the surface of the polyp . A postoperative WVP showed a normal right upper vague generalized abdominal pain for two years . Eight years prior to this admission the urinary tract . The patient remains without evipatient had had one episode of gross, painless dence of recurrent urinary tract disease .
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TABLE II .
Age distribution
Years 0-10 11-20
Number of Cases 7 17
21-30 31-40 41-50 51-60 61-70 71-80
14 17 9 6 2 2
hematuria . Cystoscopy at that time revealed urethritis, and a retrograde pyelogram was normal . One year later, the patient experienced severe intermittent lower back and abdominal pain. The pain lasted for several hours ; it recurred one year later associated with gross hematuria . On admission physical examination revealed a muscular white man, with normal vital signs . His abdomen was soft and nontender, and no masses were palpable . There was no costovertebral tenderness . Complete blood count and routine electrolytes were within normal limits . Findings on urine cytology were class I . IVP revealed grade II hydronephrosis and hydroureter of the left upper tract . There were multiple filling defects at the junction of the upper and middle thirds of the left ureter. A left retrograde pyelogram confirmed multiple serpentine filling defects at the level of L2 to L4 (Fig . IC) . Ureterotomy demonstrated a large papillary tumorous mass . A nephroureterectomy was performed, and the patient had an uneventful recovery. Gross examination revealed three soft, light pink, filiform polyps measuring between 0 .7 and 3 cm in length and 0 .1 cm in greatest diameter, and one multifilamentous polyp, 4 cm in length and 1 .1 cm in greatest diameter (Fig . 1D) . There were several smaller polyps adjacent and distal to the large lesion . Microscopically the polyps were covered by a benignappearing transitional cell epithelium supported by a loose vascular connective tissue infiltrated by plasma cells . Serial sections of the polyps revealed occasional gland-like structures of transitional epithelium buried in the stroma with openings extending to the surface epithelium . Case 3 A twenty-six-year-old Mexican-American man was admitted to the hospital in 1983 because of intermittent pain radiating to the left thigh for two years . There was no history of
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dysuria or hematuria . Findings on urinalysis were normal . Intravenous urogram revealed left ureteropelvic junction obstruction with hydronephrosis . A left retrograde pyelogram showed no other filling defects except at the left ureteropelvic junction (Fig . 1E) . A dismembered pyeloplasty was performed, excising the area of the polyp . Two 1-cm calculi were also removed from the renal pelvis . Histologic examination confirmed the mass to be a benign fibrous polyp of the ureter with ureteritis cystica and numerous submucosal epithelial cell nests with openings extending to the surface of the polyp (Fig . 1F) . Review of Literature A review of the literature suggests that primary tumors of the ureter, benign or malignant, are rare .'-' Benign lesions constitute approximately one fourth of all tumors of the ureter. Primary benign ureteral tumors can be classified into two main groups : papillomas with transitional epithelium predominating, and mesodermal tumors with stromal tissue predominating. Benign fibrous polyps of the ureter account for 61 per cent of the mesodermal tumors and 28 per cent of all benign ureteral tumors . Only 71 cases of histologically proved benign fibrous polyps of the ureter have been described previously in the English literature."' The patients ranged in age from newborn to seventy-three years, with the highest incidence in the second, third, and fourth decades (Table II) . Possible etiologic factors that have been suggested include obstruction, trauma, irritation, infection, specific exogenous or endogenous carcinogens, hormonal imbalance, and allergy. The majority of the patients presented with pain in the flank or lower quadrant of the abdomen, or hematuria . Urinary frequency, dysuria, and/or pyuria were less common findings . Most of the patients had roentgenologic evidence of moderate to severe hydronephrosis . Complete nonvisualization of the kidney on excretory urogram was unusual . Interestingly, the left ureter was involved more often than the right, with a ratio of about 2 to 1 . The onset of clinical symptoms ranged from a few hours to forty-five years prior to diagnosis ; two fifths of the patients had symptoms for longer than two years . The ureteropelvic junction and the upper third of the ureter were frequent sites of involvement, accounting for approximately 60 per cent
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TABLE III .
of the cases (Table III) . There was one instance of bilateral involvement ." Five patients had intussusception of the ureter.',13 .31 Six patients also had polyps, associated with concomitant stones . In 1 patient, the distal aspect of the polyp had a well-differentiated transitional cell carcinoma . 50 Most of the lesions were solitary with slender stalks . Forty-eight of the 74 patients had single lesions with a slender stalk . Ten had a few or a cluster of polyps in the same area which could be treated by segmental resection of the ureter with anastomosis or excision of the polyps alone. Two instances of ureteral polyposis involving the entire ureter were reported . The first patient with hamartomatous ureteral polyposis had an associated Peutz-Jeghers syndrome . 35 The second patient was an eleven-year-old boy with left upper segment ureteral polyposis . 52 The stroma of most polyps consisted of edematous fibrous connective tissue with dilated capillaries, minimal cellular infiltration, and occasional epithelial cell nests . The various polyps had varying amounts of collagen fibers and epithelial cell nests . The polyps were covered with transitional epithelium with occasional cellular hyperplasia . Occasionally they were focally covered by one or two layers of cuboidal cells, presumably the result of thinnedout epithelium due to stromal edema and enlargement . Most of the polyps were described as having an edematous smooth surface with a thin, pedunculated base . Some larger polyps had villous polypoid projections emanating from a broad base . The treatment of benign polyps was dictated by the degree of obstruction, the involvement of the ureter, and the intraoperative impression of a carcinoma . Therefore, procedures varying from segmental resection to nephroureterectomy have been performed . It was not until 1945, when Vest' advocated either local excision or segmental resection of the ureter for benign tumor of the ureter, that less radical therapy was considered . Since then more articles have appeared favoring conservative management . The 74 cases reviewed in this series revealed that 15 patients had excision of the polyp with or without fulguration of the base . Fourteen had segmental resection of the ureter with endto-end anastomosis . Five had pyeloplasties . Twelve patients had nephroureterectomy for either advanced hydronephrosis with pyelo-
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AUGUST 1987 / VOLUME XXX, NUMBER 2
Location of
Location Ureteropelvic junction Upper one third Upper one third and mid Mid one third Mid and lower one third Lower one third Bilateral
benign ureteral polyps Rt . Side Lt. Side 7 7
16 11
1 4 1 8
2 7 2 7 1
nephritis or inability to restore ureteral continuity. Twenty-six underwent nephroureterectomy without ureterotomy and frozen section because it was feared that the lesion was malignant . One of these latter patients underwent nephroureterectomy because frozen section suggested the possibility of malignancy ; there was a small focus of carcinoma on permanent section . 50 A right nephroureterectomy was done on a pregnant woman because of misleading decidual cell nests in a biopsy specimen obtained from a polypoid extrusion from the right ureteral orifice simulating a cluster of malignant cells in a lymphatic channel of a benign polyp . 10 One patient underwent autotransplantation .48 Three recurrences are reported . The first was a forty-year-old man with multiple polyps in the right and left ureters . Two years later, additional benign stromal polyps were removed from an area previously uninvolved . 34 The second patient with recurrence was a thirteenyear-old black female with excision of a short pedunculated polyp who experienced gross hematuria and urinary retention one and one-half years later. At surgery, a 1-cm firm pink polypoid mass at the ureteropelvic junction was removed . Microscopic examination of the ureteral tumor showed groups of migratory epithelial cells consistent with the diagnosis of polypoid hamartoma and epithelial cell nests in the ureter and renal pelvis? The third patient with a recurrence was a twenty-two-year-old woman who had undergone two previous resections for recurrent ureteral polyps in a portion of the ureteral wall of the same ureter ; she underwent autotransplantation after a third recurrence .4B In 36 of 74 patients ureteral salvage was attempted . Recurrences developed in the same ureter in 3 of the remaining 110 ureters at risk (38 patients with one ureter removed and 36 patients with both ureters remaining), a recurrence rate of less than 3 per cent . None of the
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reported polyps recurred at the same site . Among the 74 patients only 7 patients (10%), including the patient with two recurrences, had involvement of the ureter which would have precluded restoration of ureteral continuity by resection and reanastomosis . In summary, the management of benign fibrous ureteral polyps includes a careful workup leading to a preoperative impression of a ureteral filling defect . If this assessment indicates ureteral polyps, a ureteral exploration, open or closed, could be considered . If exploration and pathologic examination confirms a benign fibrous ureteral polyp, local excision is a viable option and could save the involved renal unit . Chicago, Illinois 60612 (DR . GUINAN) References 1 . Moore T : Tumors of the ureter, Br j Surg 29: 371 (1941) . 2, Abeshouse BS : Primary benign and malignant tumors of the ureter, Am I Surg 91 : 237 (1956) . 3 . Gittes RF : Thmors of ureter and renal pelvis, in Harrison JH (Ed) : Urology, 4th ed, Philadelphia, WB Saunders, 1979, vol 2, pp 1029-1030, 4 . Melicow MM, and Findlay HV : Primary benign tumors of ureter, review of literature and report of a case, Surg Gynecol Obstet 54 : 680 (1932) . 5 . Argue HS : Primary benign tumor of the ureter, Urol Cutan Rev 38 : 232 (1934) . 6 . Harmer GL : Intussusception of the ureter due to a large papilloma like polypus, j Urol 40 : 752 (1938) . 7 . Johnson CM, and Smith DR : Benign polyps of the ureter, ibid 47 : 448 (1942) . 8 . Vest SA : Conservative surgery in certain benign tumors of ureter, ibid 53 : 97 (1945) . 9 . Palmer JK, and Greene LF : Benign fibromucous polyp of the ureter, Surgery 22 : 562 (1947) . 10 . Hamm FC, and Lavalle LL : Emor of the ureter, j Ural 61 : 493 (1949) . 11 . Douglas HL : Ureteral tumors, Ann Surg 131 : 755 (1950) . 12 . McCusky jF, Randolph BE, and Fisher H : Benign tumor of the ureter, W Va Med j 47 : 154 (1951) . 13 . Morley HU, Shumaker EJ, and Gardner CW: Intussusception of the ureter associated with a benign polyp, j Urol 67 : 266 (1952) . 14 . Pierce WV and Miner WR : Benign tumors of the ureter, South Med j 45: 485 (1952) . 15 . Baker WJ, and Graf EC : Tumors of the ureter, j Urol 70 : 390 (1953) . 16 . Oppenheimer GD, and Narins L : Benign tumor of the ureter, j Mount Sinai Hosp 21 : 213 (1954) . 17 . Compere DE, et al : Ureteral polyps, j Urol 79: 209 (1958) . 18 . Wood LC, and Howe GE : Primary tumors of the ureter, ibid 79 : 418 (1958) . 19 . Howard TL : Giant polyp of the ureter, ibid 79 : 397 (1958) . 20 . Schneiderman C, Simon M, and Sedlezky 1 : Benign polyp of ureter, Br I Urol 31 : 168 (1959) . 21 . Brock DR : Benign polyp of ureter, j Ural 83 : 572 (1960) . 22 . MacDougall JA : Primary tumors of the ureter, Br J Urol 33 : 160 (1961) . 23 . Ardulno J : Conservative surgery for ureteral polyps, j Urol 85 : 925 (1961) . 24 . Evans AT, and Stevens RK : Fibroepithelial polyps, of ureter and renal pelvis, ibid 86 : 313 (1961) .
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25 . Wogalter H : Ureteral polyp : 19 year history, ibid 87 : 528 (1961) 26 . Breckenridge RL, Lynch PV, and Holfelner ED : Fibrous polyp of ureter, ibid 90: 160 (1963) . 27 . Robards VL, Thompson IM, and Ross G Jr : Primary tumors of the ureter, )AMA 187 : 778 (1964) . 28 . Deklotz RI, and Young BW : Conservative surgery in the management of benign ureteral polyps, Br J Urol 36 : 375 (1964) . 29 . Auerbach S, Lewis HY, and McDonald JR : Recurrent pelypoid hamartoma and epithelial cell nests in the ureter and renal pelvis of an adolescent, j Urol 95 : 691 (1966) . 30 . Roen PR, and Kandalaft S : Primary benign mesodermal ureteral tumor, ibid 96 : 890 (1966) . 31 . Cerdes G, and Nordquist L : Intussusception of the ureter caused by a benign tumor, Acta Chir Scand 132 : 397 (1966) . 32 . Paker DJ : A fibrous polyp of the ureter in childhood, Br J Urol 40 : 418 (1968) . 33 . Soderdahl DW and Schuster SR : Benign ureteral polyp newborn, )AMA 207 : 1714 (1969) . 34 . Crum PM, Sayegh ES, Sacher EG, and Wescott JW : Benign ureteral polyps, j Urol 102 : 678 (1969) . 35 . Sommerhaug RG, and Mason T : Peutz-Jeghers syndrome and ureteral polyposis, JAMA 211 : 120 (1970) . 36 . Bose B, and Williams JP : Benign polyoidal tumor of ureter, Br J Surg 58 : 149 (1971) . 37 . Knackstedt J, Pirozynski W, and Oliver JA : Benign fibroepithelial polyps of ureter, Br J Ural 43 : 284 (1971) . 38 . Hudson HC, and Howland RI : Primary benign ureter tumor of mesodermal origin, J Urol 105 : 794 (1971) . 39 . Vastola 3W, Hajdu SL and Grabstald H : Benign ureteral polyps, NY State J Med 71 : 2679 (1971) . 40 . Cavalio T, and Cracker DW: Benign turner of ureter, j Natl Mod Assoc 64 : 421 (1972) . 41 . Neal JM, and Arbuckle LD : Benign fibrous polyp of the ureter, j Urol 109 : 308 (1973) . 42 . Colgan JR, Skaist LE, and Morrow JW : Benign ureteral tumors in childhood, ibid 109 : 308 (1973) . 43, Hussaini M, Marden H, and Woodruff M : Multiple fibrous polyps of the ureter, Urology 2 : 563 (1973) . 44 . Kretkowski RC, and Derrick FC Jr: Primary ureteral tumors, ibid 1 : 36 (1973) . 45 . Pinto RS, and Fauver E : Benign £ibroepithelioma of ureter, ibid 3 : 747 (1974) . 46 . Elsen EC, and McLaughlin AP : Xanthomatous ureteral polyp, ibid 4: 214 (1974) . 47 . Stuppler SA, and Kandzari SJ : Fibroepithelial polyps of ureter, a benign ureteral tumor ibid 5 : 553 (1975) . 48 . Saltzstein EC, and Fine SW: Renal autotransplantation and partial resection of the ureter for recurrent benign ureteral tumor, Surgery 77 : 607 (1975) . 49 . Cup A : Benign mesodermal polyp in childhood . J Urol 114 : 619 (1975) . 50 . Davides KC, and King LM : Fibrous polyps of the ureter, ibid 115 : 651 (1976) . 51 . Hughes FA, and Davis CS : Multiple benign ureteral fibrous polyp, AJR 126 : 723 (1976) . 52 . Eilenborg J, Serry W, and Cole A : Multiple fibroepithelial polyps in the pediatric age group, j Urol 117 : 793 (1977) . 53 . Abrams HJ, Bachbinder ML and Sutton AP : Benign ureteral lesions ; rare causes of hydronephros£s in children, Urology 9 : 517 (1977) . 54. Clements JC, McLeod DC, Green WR, and Star RE : A case report : duplicated vena cava with right retrocaval ureter and ureteral tumor, j Urol 119 :284 (1978) . 55. Schulman CC : Ureteric polyp as a cause of hydronephrosis in childhood, j Pediat Surg 13 : 537 (1978) . 56. Vandendris M : Fibrous polyp of the ureter, Br J Urol 56 : 233 (1979) . 57 . Debruyre FM, Moonen WA, Daenekindt AA, and Delaere KPJ : Fibroepithelial polyp of ureter, Urology 16 : 355 (1980) . 58 . Fagerstrom DP : Proliferative tumors of the ureter and renal pelvis, with further observations of the significance "epithelial cell nests,") Urol 59: 333 (1948) .
UROLOGY
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VOLUME XXX, NUMBER 2