BE~IGN POLYPS OF THE URETER CLARK M. JOHNSON
DONALD R. SMITH
From the Department of Surgery, Division of Urology, University of California Medical School, San Francisco
Primary tumors of the ureter are rare. Up to 1937, 136 cases were recorded in the literature and of these only 40 were benign. The diagnosis of ureteral neoplasm is but occasionally made by urological investigation and only rarely by ureteropyelography. In the case reported below a preoperative diagnosis of benign tumor of the ureter was made on radiographic evidence alone. CASE REPORT
A medical student 24 years of age was first seen in October 1939 complaining of constant dull pain in the left flank, radiating to the left lower quadrant of the abdomen and the penis. Since the age of 6 years the patient had suffered from attacks of left renal pain every month, each bout lasting a day or so. At the age of 17 years, he noted cloudy red urine with 2 attacks of the pain. A diagnosis of left renal lithiasis was made at this time. At operation no stone was found, but a nephropexy was performed. The patient was free from symptoms for 2 years, when the pain recurred in the left side of the back, similar in all respects to his previous discomfort. When first seen by us, the patient was suffering from his most persistent attack of pain which was associated with malaise for the first time. He never had had chills, fever, burning on urination, frequency or gross pyuria. N octuria was rare. Renal pain was never experienced at night. On occasion he was conscious of suprapubic pain radiating to the penis after urination. Nausea or vomiting were never brought on by the pain. Physical examination was entirely negative except for the prostate which was swollen and tender. Prostatic secretion obtained by massage contained 80 per cent pus. Urinalysis showed 50 red blood cells and 10 white blood cells per high dry field as well as a few rods. In the test of kidney function, 65 per cent of the phthalein was recovered in 1 hour. Complete urological examination was then carried out. The bladder was normal but the posterior urethra was inflamed. :Number 6 F. catheters were passed to both renal pelves with ease. Both kidneys were free from infection. The phthalein test showed 17 per cent function from the right kidney in ½hour but only 5 per cent from the left. Pyelograms demonstrated hydronephrosis on the left (fig. 1), but the ureter was inadequately filled. The prostatitis was treated, but the attacks of pain continued. Dilatations of the left ureter were instituted without benefit. Urinalyses always showed a few red cells. Tn March 1941 intravenous urograms revealed a more advanced hydronephrosis on the left side with delayed renal secretion and poor emptying of the pelvis 448
BE:\IGN POLYPS OF THE 1-::RETEH
of the kidney. The upper part of the ureter waR not visualized. A diagnosis of stricture of the left nreteropelvic junction was made and 10 days later retrograde pyelograms were made. The bladder was normal and neither kidney ,ms in-
Fie;. 1 Frc. 2 Fie. 1 Retrograde pyelogram shmdng left hydronephrosis, the etiology of which was not recognized beca.use the possibility of ureteral tumor was not considered. Fw. 2. Retrograde pyelogram 18 months later. The degree of hydroncphrosis has not clrnngcd. In the upper portion of the left ureter is a tear-shaped negative shaclmc The diagnosis of uretcral ))o]yp was obvious.
Fm. Retrograde pye]ogram (left oblique) again demonstrating n uretern! polyp as the cause of the hydrnnephrnsis.
fccted. The phtha!(1in tec-t shmYed 17 per cent function from the right and 13 per cent from the left kidney in½ hour. There ·was no transvesical leakage. The right pycloureterogram ,ms normal. The" left pyelogram showed a large
FIG. 4. Surgical specimen with the ureter opened showing the ureteral polyps
FIG. 5. Photomicrograph of polyp. The mucosa is of the transitional type, typical of the ureter. There are no mitotic figures or invasion of the submucosa. The deeper tissue iS:made up of loose bundles of smooth muscle and connective tissue. 450
BENIG:\' POLYPS OF THE URETER
nephrosis and a filling defect in the upper portion of the ureter (fig. 2). A diagnosis of polyp of the ureter was made because of the smooth pedunculated appearance of the negative shadow. Comparison with the original film" demonstrated that a similar defect had been overlooked at onr first examination (fig. 1). In June 1941 the patient re-entered the hospital for surgery. At this time he recalled that his father had often been able to terminate the pain by innrting and then shaking him by the ankles. This maneuver undoubtedly relieved the un·kral obstruction changing the position of the polyp. The left pyelogram was repeated and a meteral defect was again demonstrated (fig. 3). 1~nder avertin, nitrous oxide and oxygen anesthesia and through a lumbar incision, the kidney was freed with difficulty because of the previous nephropcxy. The ureter was greatly dilated and on palpation two small polyps could be felt below the ureteropelvic junction. They were freely movable. N ephrectomy and partial ureterectomy were carried out. Figure 4 shows the gross specimen. The hydronephrosis was well developecl. The appearance of the polyps at the ureteropelvic junction immediately ,mggested their resemblance to those seen in the nasopharynx. They measured 10 and 12 mm. in length respeetiYely and were 4 mm. in diameter. They ,,,ere smooth, pale and soft. Section of the polyps (fig. 5) showed them to be lined with mucosa typical of the ureter. In a few areas these cells were piled up in little papillary projections. X o mitotic figures ,vere seen and there was no invasion of the submucosa. 1'he underlying tis,rne was made up of loose bundles of smooth muscle and connectiv(: tissue. There was a mild infiltration of small round cells in the suhmucosa. number of eapillaries were noted. The pathological diagnosis was hydronephrosis resulting from obstruction caused hy ureteral polyps. In our opinion they ,vere probably congenital in ongm. DISCUSSIOX
In 1932, l\folirow and Findlay 1Yere able to collect 28 cases of benign ureteral tumor from the literature, to which they added 1 case. Rusche and Bacon, in Hl38, found 10 additional reports and added another, making 40 in all. Since their summary, we have found 9 other published cases in addition to our own, bringing the total to 50. Reports of ;3 other examples appeared in journals not available to nB. Benign ureteral tumon, may manifest themselves at any age but are nsuall_v seen in the fifth and sixth decades. Men are more commonly afflicted. The incidence i:c; equal in either ureter, but the lower portion of the ureter is more often affected than the upper part. The neoplasm is usually papillomatouB; tumors are umrnuaL The :3 common signs and symptoms are hematuria, renal tumor and renal pain, none of which, bowever, is pathognomonic of ureteral growth. \VhiJe the hematuria eomes from the tnmor itself, the renal mass and pain are secondary to obstnwtion of the upper tract. Colic may occur as a result of blood clots. Pre-
CLARK iVI. JOHNSON AND DONALD R. SMITH
sumptive evidence of ureteral growth may be obtained by the urcteral catheter which meets an obstruction in its ascent followed by undue bleeding from that ureter. Except for those cases in which a papilloma is seen at cystoscopy, protruding from the ureteral orifice, the only pathognomonic sign of ureteral tumor is the demonstration of a filling defect in the ureterogram. This, however, has been accomplished in less than 15 per cent of the cases. Rusche and Bacon were able to demonstrate the papilloma in their patient only after serial pyeloureterograms taken during gradual withdrawal of the catheter. Most cases of ureteral tumor have been diagnosed at the operating table or by the pathologist. Seven patients underwent nephrectomy for hydronephrosis only to have continuation of hematuria which led to the ultimate diagnosis of ureteral neoplasm, necessitating secondary ureterectomy. If pyeloureterograms fail to demonstrate a ureteral defect, the proper diagnosis may be suggested by excluding other causes of renal pain, hematuria and hydronephrosis. A careful history, physical examination and urinalysis correlated with cystoscopy and pyelography should rule out stone, renal tumor, injury, tuberculosis, and infarction. Failure to make the proper diagnosis often occurs because the possibility of ureteral growth is not considered. Since it is usually impossible before operation to differentiate between benign papillomata and malignant tumors of the ureter, total nephroureterectomy is indicated. In our case, however, the ureterogram demonstrated so clearly the pedunculated polypoid character of the tumor that only partial ureterectomy and nephrectomy were deemed necessary. REFERENCES HosEL, MAX: Zur Diagnose und Behandlung der Harnleitertumoren. Ztschr. f. Urol., 30: 481-487, 1936. HuNNER, GuY L.: Intussusception of the ureter due to a large papilloma-like tumor. J. Urol., 40: 752-765, 1938. MELrcow, M. JVI. AND FINDLAY, H. V.: Primary benign tumors of the ureter. Surg., Gynec. & Obst., 54: 680-689, 1932. MICHON, L.: Uretfaectomie totale pour papillomatose diffuse de l'uretcre droit. Soc. frarn;. d'Urol., June 15, 1936. IN: ,J. d'Urol., 42: 360-363, 1936. MULLER, ACHILLES: Bemerkungen zur Pathogenesc der Anilintumoren. Schwriz. med. Wchnschr., 21: 232-233, 1940. PARKER, GoEFFREY: Un papillome primitif dP l'uretcre. J. d'urol., 45: 38-44, 1938. PATCH, F. S.: Primary tumors of the ureter. "Crol. & Cu tan. Rev., 42: 625-629, 1938. RAMSEY, E. M.: Asymptomatic hydronephrosis resulting from papilloma of ureter. J. -Crol., 42: 341-346, 1939. RusCHE, CARL AND BACON, S. K.: Primary ureteral neoplasms. J. Urol., 39: 319-340, 1938. SCHNEIDER, HERMANN: Ein seltsames Papillom des Ureters. Ztschr. f. Urol., 31: 130-131, 1937.