Benign papilloma of the renal pelvis

BENIGN PAPILLOMA FEDOR

L.

SENGER

OF THE RENAL PELVIS* AND

BROOKLYN,

JOHN

NEW

RIMARY tumors of the renal peIvis are of rare occurrence. The majority of them are papiIlomatous, far outnumbering the squamous ceII type. WhiIe it is usuaIIy beIieved that the true papiIloma is the most frequentIy found, nevertheless series of cases are reported in which the maIignant tumors are much more numerous. Hugh Young agrees with this, stating “benign neopIasms of the renaI peIvis are exceptionaIIy infrequent, maIignant changes being usuaIIy found upon close and carefu1 pathoIogica1 examination.” It is this rarity that prompts us to report this case, the onIy one in the records of the Long IsIand CoIIege HospitaI as far as we are able to ascertain by diligent search. We quote from a paper published by us in the American Journal of Surgery in 1937 on primary epitheIia1 tumors of the renal peIvis : “The benign papilloma usuaIIy arises in the renaI peIvis and metastasizes to the ureter and bladder by direct extension and implantation. These tumors are as a ruIe muItipIe and may be extremeIy numerous, covering the entire mucosa with fine vegetations. OccasionaIIy there is seen one Iarge tumor with severa smaI1 polyps scattered over the peIvis and calyces. The tumors are viIIous or wart-Iike, attached by a narrow pedicle and expand in a fanlike shape. Their greater vascularity is a source of hemorrhage which is the chief symptom. Incrustations with saIts and calcui are frequently seen. Various grades of hydronephrosis often result from partial occIusion, chiefly by uretera transplants. The microscopic structure is typica and consists of eIongated bIood vesseIs covered by muItipIe Iayers of transitional epithelium. The tumor cells are cubica1, cyIindrica1 or elongated and spindIe-shaped, but

J. BOTTONE

YORK

the arrangement is orderIy and the growth is confined to the mucous membrane. Round ceI1 infiItration is found at the base of the tumor. The course of these tumors is usuaIIy benign but they may become malignant by invasion of the submucous layers, so that they aIways shouId be considered potentiaIIy maIignant. Recurrences after removal or from impIantation in the wound, have occurred in a maIignant form.” This disease is one of aduIt Iife; most cases occur in individuaIs between the ages of forty and seventy years. Its origin is stiI1 a matter of conjecture, yet one cannot lose sight of the prominent part pIayed by chronic irritation and infection over a Iong period of time. The importance of congenita1 abnormalities in the production of these growths is probIematica1. The symptomatoIogy of pelvic papiIIomas is that of any renaI neopIasm. In their order of frequency of occurrence, and chronologically the symptoms are hematuria, pain and tumor mass. Hematuria occurs in seventy out of ninety cases and is often intermittent and painIess, but occasionaIIy may be coIicky due to the passage of clots. The pain may be a duI1, persistent ache in the renaI area or a true coIic and may resuIt from uretera obstruction caused by bIood clots or uretera tumor transpIant. The tumor mass is most often a hydronephrotic enlargement of the kidney. For the diagnosis of renaI pelvic neoplasm, one must depend IargeIy upon cystoscopic and pyeIographic findings. A picture of a more or Iess diIated peIvis within which one visuaIizes a fiIIing defect is fairly characteristic. The presence of a tumor transpIant about the uretera orifice or the adjacent bIadder waI1 asso-

P

* From the UroIogicaI Departments of the Long Island ColIege of Medicine and the Long Island College IIospitaI. 125

126

Amcric:m

Journal

01 Surgery

Senger,

JULY.1011

Bottone-PapiIloma

ciated with these findings points strongIy to a neopIasm of the peIvis. However, considering everything the diagnosis is made

pIasm to progress by extension aIong the mucous membrane of the ureter and into the bIadder, along with their high incidence of recurrence in mahgnant form, makes it imperative that the surgery be of a radica1 nature. Therefore, compIete nephro-ureterectomy incIuding the resection of a portion of the bIadder waI1 immediatery adjacent to and surrounding the isoIatera1 uretera orifice is recommended. OccasionaIIy where indicated, because of the patient’s poor condition, it may be advisabIe to perform the operation in two stages, the nephrectomy first and the ureterectomy Iater. SimpIe nephrectomy is justifiabIe only as a Roentgentherapy ofpaIIiative measure. fers us very Iittle hope. CASE

showing deformity.

FIG. I. Pyelogram

characteristic

with diffIcuIty preoperatively. One must consider in the differentia1 diagnosis defects due to incompIete fiIIing of the peIvis with pyeIographic medium and defects due to

The following is the report of a sixty-three year oId CzechosIovakian machinist who was admitted to the uroIogica1 service of the Long Island CoIIege HospitaI on August 16, 1939. He had never had any urinary symptoms prior to the evening before admission when he noted a moderate amount of bIood mixed with his urine. That night he voided three more times, very unusua1 for him, and each time the urine was pink in color. He had no pain what-

FIG. 2. Low power photomicrograph growth.

bIood cIot. It wouId aIso be diffIcuIt to excIude a parenchyma1 tumor that had secondariIy invaded the peIvis. As regards the treatment of tumors of the renaI peIvis, whatever the nature of the The we11 growth, surgery is indicated. known tendency of the papiIIomatous neo-

REPORT

soever,

of the papillomatous

aIthough

he did have sIight soreness in

the Ieft flank. The past history

incIuded

maIaria

in 1907

and psoriasis in 1932. Venereal disease was denied by name and symptoms. He had a right hydroceIe

for years.

Ieast a quart

He admitted

of whiskey

drinking

at

each week for years.

NEW SERIES

VOL.

1.111, No.

Senger,

I

Bottone-Papilloma

PhysicaI examination reveaIed the patient to be a stoIid, we11 deveIoped flabby Iooking, co-operative white male, who looked his stated

FIG.

3.

Gross

specimen,

iIIustrating

age. The onIy positive findings were many carious teeth, a left nontender, paIpabIe kidney which did not feel enlarged and a large right hydrocele of the tunica vaginalis. The bIadder urine was bIoody but not a11 bIood. The capacity was IO ounces. The mucose, trigone and bladder neck were normal. Urethroscopy revealed no abnorma1 findings. Number 6 F catheters were introduced without obstruction to 25 cm. The left kidney urine was hazy amber and contained very many red blood cells. Phenolsulfonphthalein excretions Urine cultures produced no were normal. growth. Retrograde pyelography reveaIed a fiIling defect in the pelvis of the Ieft kidney producing a smooth compression of the left peIvis and calyces. The left ureter was moderately diIated in its entire extent. The right side was normaI. Confirmatory intravenous urography revealed the same fiIIing defect. A tentative diagnosis of papiIIary tumor of the Ieft renaI pelvis was made and on August 24 a nephrectomy and partia1 ureterectomy were performed. Further operative procedure was deemed inadvisable at this time because of the patient’s poor genera1 condition. ConvaIescence was rapid and uneventful. The wound heaIed by primary intention and the patient was discharged to the cIinic on the thirteenth postoperative day. Three months later the patient was readmitted to the hospital for an

American Journnl of Surgery

127

eIective ureterectomy. His general condition had, in the mean time, improved considerably. Cystoscopy now revealed a normal hIadder.

tumor

in

the

kidney

pelvis.

Most interesting of a11 was the apparent compIete occIusion of the left ureteral stump. Because of this and since there was no evidence of recurrence, it was decided not to perform this surgical procedure. The patient since has been very cooperative and has revisited the Out-patient Department on many occasions. As far as we are abIe to teI1 he is entireIy weI1. 12 by 6 by 4.5 cm. The kidney measured The capsuIe stripped with ease. Fetal Iobulations are present. The pelvis showed only a minima1 amount of diIatation. Liquid purulent material was present and in the widest portion of the pelvis, almost directIy in the center, there was a filamentous, friable mass measuring 2 by 2 by I cm. Its base was attached to one side of the peIvis while the apex partiaIIy obstructed the ureter. thickened.

The

ureter

was markedly

Microscopically, the section through the tumor mass and peIvic membrane consisted of multipIe axes of connective tissue covered by severa Iayers of transitional epithelium which was uniform in size, shape and staining characteristics. There was no infiltration, bizarre-shaped celIs or mitotic figures. The pelvic membrane was somewhat thickened and fibrosed and there was a minima1 amount of round ceI1 infiltration. Diagnosis: PapiIIoma of the renaI peIvis.

I28

Am~,ic;,nJwrnal of Surgcl-,v

Senger,

Ijottone-

CONCLUSION

REFERENCES

A case of papiIIoma of the renal peIvis is herein reported. The only symptom noted was one episode of siIent hematuria. Nephrectomy and partia1 ureterectomy have apparentIy produced a satisfactory resuIt aIthough it is stiI1 too earlv to determine the subsequent events in &is case.

1. BOTHE, A. E. J. Uroi., 22: 46, 1929. CAULK, J. R. Ann. Surg., 1o6: 68, 1937. 1: EISENDRATH and ROLNICK. Urology, ed. 4, 1938. *. MACKENZIE, D. W. and RATNER, M. J. Ud., 28:

A MAJOR revolution way, and it is believed knowledge as well as well-being. From-“The March (Columbia University

i’ 7:

405, ‘932. SHUPE, T. P. Tr. Am. Ass. C.-U. Surg., 27: 161, 1934. YOUNG, H. H. Practice of Urology. 1926. SENGER, F. L. md BOTTONE, J. J. Am. J. Surg., 37:

57. 1937.

regarding many theories in the virus field is under that the upheaval will produce advances in general an improvement in man’s physical and economic of Medicine”-New Press).

York

Academy

of Medicine