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Carcinoma of the Bladder Presenting as Simple Adult Ureterocele
THE JOURNAL OF UROLOGY
Vol. 111, January
Copyright© 1974 by The Williams & Wilkins Co.
Printed in U.S.A.
CARCINOMA OF THE BLADDER PRESENTING AS SIMPLE ADULT URETEROCELE FRANK P. MORSE, III, BERNARD SEARS
AND
HATHORN P. BROWN
From the Departments of Surgery (Urology), Peter Bent Brigham Hospital and the Beth Israel Hospital, Boston, Massachusetts
of Waldeyer's sheath at the ureterovesical junction together with stenosis of the ureteral meatus. Although this stenosis is usually considered to be of congenital origin, there are certain acquired causes of ureteral meatal stenosis which may give rise to the radiographic appearance of simple ureterocele. Those most commonly mentioned are calculus disease of the lower ureter, recent passage of a ureteral calculus or instrumentation with edema. 3 Carcinoma of the bladder should be added to this list.
The cobra-head deformity occasionally found on excretory urography (IVP) has been stated to be a pathognomonic sign of adult simple ureterocele. 1 Recently, 2 cases of invasive carcinoma of the bladder demonstrated this radiologic sign. Since this sign may occasionally be an indication of vesical malignancy further study of patients is indicated. CASE REPORTS
Case 1. H. K., a 51-year-old man, was initially seen with complaints of dysuria, frequency and nocturia. Examination of the urine revealed a urinary infection and the patient was treated with sulfa medication. The symptoms were unrelieved by treatment and an IVP at that time showed an ovoid configuration of the left lower ureter with a surrounding lucent area resembling a ureterocele (fig. 1). On cystoscopic examination a tumor was found over the left ureteral orifice, which on biopsy was an infiltrating, high grade transitional cell carcinoma. The patient subsequently underwent segmental resection of the bladder and reimplantat.ion of the left ureter. Case 2. M. G., a 63-year-old man, was seen for the complaint of burning on urination. Urinalysis revealed microscopic hematuria and an IVP showed an ovoid configuration of the right lower ureter with a lucent shadow around it. The radiologist reported a ureterocele (fig. 2). Cystoscopic examination showed a tumor involving the right ureteral orifice which on biopsy was a poorly differentiated, infiltrating transitional cell carcinoma. The patient underwent urinary diversion and total cystectomy. DISCUSSION
The clinical differentiation between ectopic and simple ureterocele was first made by Ericsson. 2 The ectopic forms are seen more commonly in children, tend to be larger, are usually symptomatic and frequently cause renal damage. Simple ureteroceles are most frequently seen in adults, may be asymptomatic and may cause little or no obstruction. 2 The etiology of simple ureterocele has been generally considered to be a congenital defect
FIG. 1. IVP shows dilatation of terminal portion ofleft ureter resembling simple ureterocele. In 1969 Sherwood and Stevenson reported 2 cases of carcinoma of the bladder mimicking simple ureterocele. • Our 2 cases are the third and fourth to be reported. Diagnosis was confirmed in all cases by cystoscopic examination.
Accepted for publication July 20, 1973. 'Thompson, G. J. and Kelalis, P. P.: Ureterocele: a cli~ica_l appraisal of 176 cases. J. Urol., 91: 488, 1964. Ericsson, N. 0.: Ectopic ureterocele in infants and children; a clinical study. Acta Chir. Scand., suppl., 197, pp. 1-92, 1954.
3 Wershub, L. P. and Kirwin, T. J.: Ureterocele, its etiology, pathogenesis and diagnosis. Amer. J. Surg., 88: 317, 1954. • Sherwood, T. and Stevenson, J. J.: Ureteroceles in disguise. Brit. J. Radio!., 42: 899, 1969.
36
CARCINOMA OF BLADDER PRESENTING AS URETEROCELE
3'7
FIG, 2. A, IVP shows dilatation of terminal right ureter. '.\lote lucent area surrounding ureterocele suggests thick wall. B, post-voiding film shows typical cobra-head deformity of right lower ureter.
It has been stated that the cobra-head sign is pathognomonic of simple ureterocele and that some small, asymptomatic ureteroceles may be followed conservatively. 5 · 6 This would not seem to be true in view of the findings reported in these 2 cases. Cystoscopic examination should be performed on all patients with this radiographic sign to rule out significant The tumors in our cases were high grade, infiltrating lesions. In order to create the radiographic appearance of a ureterocele there must be stenosis of the orifice. Whereas a non-infiltrating papilloma may cause obstruction, one may postulate that a 5 Aas, T. N.: Ureterocele: a clinical study of sixty-eight cases in fifty-two adults. Brit. J. Urol., 32: 133, 1960. 6 Raper, F. P.: Ureterocele in adults. Proc. Roy. Soc. Med., 51: 781, 1958.
tumor must infiltrate the lamina fixation and stenosis of the orifice appearance of ureterocele. This true, may be able to predict a serious lesion in presence of this sign. Although the stage and are not reported in Sherwood's cases, both were treated by cystectomy which would also suggest invasive tumors. SUMMARY
Two cases are reported of carcinoma of bladder simulating adult simple ureterocele on IVP. The importance is stressed of a full study and the possibility is raised that this sign may specifically indicate an noma.
Vol. 111, January
Copyright© 1974 by The Williams & Wilkins Co.
Printed in U.S.A.
CARCINOMA OF THE BLADDER PRESENTING AS SIMPLE ADULT URETEROCELE FRANK P. MORSE, III, BERNARD SEARS
AND
HATHORN P. BROWN
From the Departments of Surgery (Urology), Peter Bent Brigham Hospital and the Beth Israel Hospital, Boston, Massachusetts
of Waldeyer's sheath at the ureterovesical junction together with stenosis of the ureteral meatus. Although this stenosis is usually considered to be of congenital origin, there are certain acquired causes of ureteral meatal stenosis which may give rise to the radiographic appearance of simple ureterocele. Those most commonly mentioned are calculus disease of the lower ureter, recent passage of a ureteral calculus or instrumentation with edema. 3 Carcinoma of the bladder should be added to this list.
The cobra-head deformity occasionally found on excretory urography (IVP) has been stated to be a pathognomonic sign of adult simple ureterocele. 1 Recently, 2 cases of invasive carcinoma of the bladder demonstrated this radiologic sign. Since this sign may occasionally be an indication of vesical malignancy further study of patients is indicated. CASE REPORTS
Case 1. H. K., a 51-year-old man, was initially seen with complaints of dysuria, frequency and nocturia. Examination of the urine revealed a urinary infection and the patient was treated with sulfa medication. The symptoms were unrelieved by treatment and an IVP at that time showed an ovoid configuration of the left lower ureter with a surrounding lucent area resembling a ureterocele (fig. 1). On cystoscopic examination a tumor was found over the left ureteral orifice, which on biopsy was an infiltrating, high grade transitional cell carcinoma. The patient subsequently underwent segmental resection of the bladder and reimplantat.ion of the left ureter. Case 2. M. G., a 63-year-old man, was seen for the complaint of burning on urination. Urinalysis revealed microscopic hematuria and an IVP showed an ovoid configuration of the right lower ureter with a lucent shadow around it. The radiologist reported a ureterocele (fig. 2). Cystoscopic examination showed a tumor involving the right ureteral orifice which on biopsy was a poorly differentiated, infiltrating transitional cell carcinoma. The patient underwent urinary diversion and total cystectomy. DISCUSSION
The clinical differentiation between ectopic and simple ureterocele was first made by Ericsson. 2 The ectopic forms are seen more commonly in children, tend to be larger, are usually symptomatic and frequently cause renal damage. Simple ureteroceles are most frequently seen in adults, may be asymptomatic and may cause little or no obstruction. 2 The etiology of simple ureterocele has been generally considered to be a congenital defect
FIG. 1. IVP shows dilatation of terminal portion ofleft ureter resembling simple ureterocele. In 1969 Sherwood and Stevenson reported 2 cases of carcinoma of the bladder mimicking simple ureterocele. • Our 2 cases are the third and fourth to be reported. Diagnosis was confirmed in all cases by cystoscopic examination.
Accepted for publication July 20, 1973. 'Thompson, G. J. and Kelalis, P. P.: Ureterocele: a cli~ica_l appraisal of 176 cases. J. Urol., 91: 488, 1964. Ericsson, N. 0.: Ectopic ureterocele in infants and children; a clinical study. Acta Chir. Scand., suppl., 197, pp. 1-92, 1954.
3 Wershub, L. P. and Kirwin, T. J.: Ureterocele, its etiology, pathogenesis and diagnosis. Amer. J. Surg., 88: 317, 1954. • Sherwood, T. and Stevenson, J. J.: Ureteroceles in disguise. Brit. J. Radio!., 42: 899, 1969.
36
CARCINOMA OF BLADDER PRESENTING AS URETEROCELE
3'7
FIG, 2. A, IVP shows dilatation of terminal right ureter. '.\lote lucent area surrounding ureterocele suggests thick wall. B, post-voiding film shows typical cobra-head deformity of right lower ureter.
It has been stated that the cobra-head sign is pathognomonic of simple ureterocele and that some small, asymptomatic ureteroceles may be followed conservatively. 5 · 6 This would not seem to be true in view of the findings reported in these 2 cases. Cystoscopic examination should be performed on all patients with this radiographic sign to rule out significant The tumors in our cases were high grade, infiltrating lesions. In order to create the radiographic appearance of a ureterocele there must be stenosis of the orifice. Whereas a non-infiltrating papilloma may cause obstruction, one may postulate that a 5 Aas, T. N.: Ureterocele: a clinical study of sixty-eight cases in fifty-two adults. Brit. J. Urol., 32: 133, 1960. 6 Raper, F. P.: Ureterocele in adults. Proc. Roy. Soc. Med., 51: 781, 1958.
tumor must infiltrate the lamina fixation and stenosis of the orifice appearance of ureterocele. This true, may be able to predict a serious lesion in presence of this sign. Although the stage and are not reported in Sherwood's cases, both were treated by cystectomy which would also suggest invasive tumors. SUMMARY
Two cases are reported of carcinoma of bladder simulating adult simple ureterocele on IVP. The importance is stressed of a full study and the possibility is raised that this sign may specifically indicate an noma.