Fibroepithelial ureteral polypsand urolithiasis

Fibroepithelial ureteral polypsand urolithiasis


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FIBROEPITHELIAL URETERAL POLYPS AND UROLITHIASIS DAMIEN BOLTON, M.D. MARSHALL L. STOLLER, M.D. PIERCE IRBY, IlL M.D. From the Department of Urology; University of California School of Medicine, San Francisco, California

ABSTRACT--Fibroepithelial polyps are the most common benign tumor of the ureter. Most of the literature regarding their cause ascribes it to chronic infection. These publications, however, show that the majority of such cases never were associated with a documented urinary tract infection. Fibroepithelial polyps appear with equal frequency in male and female subjects and are found in all age groups including children, in contrast to what would have been expected with an infectious cause. Four histologically confirmed cases of fibroepithelial polyps were associated with chronic inflammation of the upper urinary tract related to the presence of calculi and/or Double J ureteral stents. All patients were managed successfully by endoscopic means, preserving renal function. Fibroepithelial ureteral polyps may be associated with urolithiasis, which serves as a source of chronic inflammation. A review of the literature is presented and supports these observations.

The ureteral fibroepithelial polyp has puzzled urologists since its initial description in 1932.1 Although now recognized as the most c o m m o n benign neoplasm of the ureter, 2 its pathologic basis remains uncertain. Consensus exists that it arises from elements of mesodermal origin within the uretera] wall. However, the inducing and promoting agents of this tumor remain to be conclusively identified. Previously suggested causative factors have included chronic infection 3 and a congenital basis. 4 Our experience with 4 patients who presented with ureteral fibroepithelial polyps in association with u r i n a r y calculi appears to support a causative theory based u p o n chronic irritation. This m a y be a c o m m o n e l e m e n t in this condition and is supported by m a n y previous reports. MATERIAL AND METHODS Between March and June 1993, 4 patients with histologically confirmed fibroepithetial polyps of the ureter were treated at our institution, all of whom had radiographic evidence of urinary calculi within the ipsilateral ureter prior to diagnosis.

Submitted: April 13, 1994, accepted: May 13, 1994



A 50-year-old Chinese woman w of bilateral anatrophic nephrolith{ years previously, presented with a bilateral extracorporeal shock v (ESWL) with bilateral Double J prior to presentation. The Double~ removed 3 months postlithotrips plication. She presented with sym t with renal colic. An intravenous l strated bilateral ureteral calculi v m o d e r a t e o b s t r u c t i o n . Uneven1 ureteroscopic stone extraction w; retrograde urogram and ureteros ureter found a normal-appearing However, a web of multiple ureter~ parent in the proximal ureter cau (Fig. 1). The polyps were remow wall of the ureter without difficult forceps and sent for histologic ex~ mal hemorrhage was controlled wi diathermy electrode. A 7 x 8 m m identified proximal to the fibroepil removed with a basket w i t h o u t , DoubleJ ureteral stent was placed of the procedure and removed 4 v tively without complication. Histol, UROLOGY~ / OcIoBER1994 / V

FIGURE 2. HistologJc study of polyp demonstrates marked inflammatory infiltrate (original magnification x I00).


t}etrograde urogram demonstrates upper ~t filling defects, found at ureteroscopy to ~oepithelial ureteral polyps.

rmed the diagnosis of a fibroepithelial ureteral ~, associated with inflammation (Fig. 2). Stone isis revealed 70% calcium oxalate and 30% calphosphate. Urine culture performed prior to :roscoDv s h o w e d no evidence of bacterial


33-year-old black woman presented with a 3history of intermittent right-sided lower abiinal pain Abdominal ultrasound examination ionstrated mild right-sided hydronephrosis. An ivenous urogram confirmed the above findings revealed a 5 x 6 m m obstructing radio-opaque eral calculus at the $2 level. The distal ureter not visualized. Urine culture was negative for erial growth. Rigid ureteroscopy was undern to remove the calculus. A 14 m m long red:d polyp was visible upon entry into the distal er. The polyp was bypassed with difficulty, and culus identified just proximal to the base of the p was removed. The polyp then was excised by ping the base with forceps. Hemostasis was / OCTO~aR1994 / VOLUME44, N u M ~ 4

FIGURE 3. Low-power view of polyp removed from patient 2 also shows evidence of submucosal inflammatory changes (original magnification x40).

successfully obtained using coagulation diathermy. Histologic analysis confirmed the diagnosis of a fibroepithelial polyp (Fig. 3). Stone analysis revealed 70% calcium oxalate and 30% calcium phosphate. Cast 3

A 46-year--old Vietnamese man presented with left-sided renal colic. Ten years prior to presentation he u n d e r w e n t bilateral anatrophic nephrotithotomies. An intravenous urogram demonstrated the presence of right renal and left upper ureteral calculi. A left-sided Double J stent was placed to relieve the renal colic. The left ureteral calculus advanced into the lower ureter prior to the scheduled bilateral ESWL (3 weeks later). Ureteroscopic stone extraction was undertaken to remove the 7 x 6 mm calculus without incident. In the proximal ureter a 5 m m long polypoid lesion was noted, protruding into the lumen of the upper third of the ureter.


This was removed using endoscopic grasping forceps and sent for histologic analysis. The lesion was found to be a fibroepithelial polyp with submucosal i n f l a m m a t o r y infiltrate. Stone analysis demonstrated 65% calcium oxalate and 35% calcium phosphate. CASE 4

A 47-year-old w h i t e w o m a n p r e s e n t e d w i t h gross painless hematuria. Past medical history included ESWL on two occasions for an inferior caliceal calculus, left ureteroscopy, and left percutan e o u s n e p h r o l i t h o t o m y for m u l t i p l e c a l c i u m oxalate calculi. An i n t r a v e n o u s u r o g r a m performed on presentation identified mild left-sided hydronephrosis with incomplete visualization of the ureter. A s u b s e q u e n t r e t r o g r a d e u r o g r a m demonstrated a proximal left ureteral stricture at the L4 level in association with a lucent filling defect. Ureteroscopy of this lesion revealed a multil o b e d p o l y p o i d p r o l a p s i n g u r e t e r a l lesion; a biopsy of which was done and the remainder of the tissue fulgurated. Pathologic examination of the tissue specimen confirmed a fibroepithelial polyp with inflammation. COMMENT Since the initial description, approximately 140 cases of fibroepithelial polyps have been reported in the English language literature. Initial reports described this lesion as a lucent filling defect within the ureter treated by nephroureterectomy with a presumptive diagnosis of transitional cell carcinoma. Recently similar radiologic abnormalities have regularly been investigated by ureteroscopy and biopsy, leading to a diagnosis being made early enough to permit renal conservation using treatment with endourologic techniques. Many anecdotal suggestions have been proposed regarding the prevalence and cause of this condition. Fibroepithelial polyps of the ureter have been stated to be more c o m m o n in the upper than the lower ureter, 5 more c o m m o n in males than females by a 3:2 ratio, 6 and to occur as a result of urinary tract infection. 3 A review of these p u b l i s h e d cases (Table I) demonstrates a wide clinical spectrum in the patient population with fibroepitheliat polyps, correlating poorly with previously stated causative theories. The data from these series do, however, permit comparison with established theories of the origin of similar polypoid lesions elsewhere in the body. A more plausible explanation for this condition, consistent with the marked clinical variability identified, can be suggested. 584

One hundred sixteen, published cases of fibt ithelial polyps contain sufficient data for as: m e n t of patient demographics. Two distinct grl of patients appear to be affected: an adult grou I patients: 47 m e n and 39 w o m e n , mean ag years) and a less frequently alluded to pediatri hort less than 16 years of age (30 patients: 24 and 6 girls, mean age 9 years). Hematuria wa most c o m m o n presenting symptom, accountin nearly 50% of patients in both age groups. The near equal ratio of m e n to women ir adult group of patients is in contrast to what w be expected if the cause was upper urinary tra~ fection. A significant n u m b e r of female subjec the younger age group would have been exp! if urinary infection was a causative factor; i ever, only 10 female patients (26%) were iden within the 12- to 30-year age group, among vv upper urinary tract infections are more corn1 Also, only 6 of the 116 patients in the total g have bacteriologic evidence of a urinary trac fection in the period prior to the diagnosis fibroepithelial ureteral polyp, Calculi and other inflammation-inducing le of the urina W tract have previously been assoc with fibroepithelial p o l y p s This association is sistent with accepted pathologic theories on t growth. The n a t u r a l h i s t o r y of fibroepitk ureteral polyps may be similar to that of p, elsewhere in the body. However, these basic ries as to cause have not previously been appli fibroepithelial ureteral polyps. Polyps throughout the body are defined as m scopically visible tubelike projections, origin from a m u c o u s m e m b r a n e and projecting il lumen, and with varying degrees of malignar tential depending u p o n their site, time of o rence, and the histologic characteristics of tl dividual lesion, s A congenital group of pol} identified, evolving from hamartomatous tl These may present at any time from birth thr adulthood depending u p o n the size and locati the lesion (eg, upper intestinal polyps in con tal polyposis s y n d r o m e s ) . Nonhamartom~ polypoid lesions are considered to represer nign tumors, usually arising from the meso& tissues of the organ of origin, and occurr*: response to the same p a t t e r n of initiatior promotion agents propose d for the more con tumors of epithelial origin. Such agents of t development may be genetic (as displayed m ditions such as familial polyposis coli) or ext: (demonstrated in the majority of cases of polyps that occur as a response to repeated, c~ attacks of inflammation).

U R O L O G Y ~ / OC~;OBER1994 / VOLUME44,


Review of published

No. of Pts. Age 1t. ~aL al. ]raf

1 1 1 1 1 I 3

Polleck 12


~en Iilliams ,,e et al. Crocker :al.


1 2

1 1 1 1 7 1 1 1 3


King t al.


M Calculus M M Hematuria F Hematuria F M Hematuria F Hematuria F Hematuria F Hematuria F M Hematuria F Calculus M Hematuria M F Hematuria M Hematuria F Hematuria F M Hematuria F F Hematuria M Bilateral polyps M M M Hematuria M M Hematuria M Hematuria

1 15


15 6 12 35 25 20 11 40 45



1 1 1 1 2



Nordquist 1




1 1 1 1

44 10 34 60


[ Davis

1 2

q5 31



1 t

42 33 11


t a/.


43 11 36 36 13 20 35 36 37 36 15 55 27 19 35 21 61 14 11 4O 62 12 6 9 66 30 26 13

24 45 47 36 11 4 59 25 40 29 59

~al. ~tevens



cases of ureteral fibroepithelial



Pyuria Hematuria Hematuria Hematuria TCC on polyp Hematuria Hematuria

No. of Pts. Age

Ikegami etal.


46 47

Johnson and Smith Knackstedt et al.

1 2


Ledor etal.



Lee etal.


50 51 52 1 53 54

Liddell et al. MacDougall McCusky etat. Melicow and Findlay Morley etal. Musselman and Kay

1 1 1 1 1 2

55 56

Mydto eta/. Naucler et al.

t 3

57 58 59 60

Neal and Arbuckle Neyetal. Qesterling et aL Qppenheimerand Narins Palmer and Greene Arker Pierce and Miner

1 1 1

Psihramis and Hartwick Robards et al. Roen and Kandalaft Roodhooft et al. Salas etaL


61 62 63 64

Hematuria Retrocaval ureter


65 66 67 68 69 70 71 72

5 9 7 43 59 21 19 8 8 13 25 28 25 69 21 61


1 1 1 2

25 34 10 18 44


t t 1 1 2

26 43 57 11 28 35


1 1 1

46 7 37


Stuppterand Kandzari Tafja eta/.

1 2

77 Thorupeta/. 5 Van Poppel eta~.

1 4


Lower UTI 75 76 Hematuria Hematuria Hematuria Intussuscepting 78

Vogelzang et al.


6 Williams et aL 79 Wood and Howe 80 Yongand Rajamani 81 Deklotzand Young 82 Zungri etaL

t2 1 1 1 6


Hematuria Calculus Hematuria Hematuria

CTOB~R 199~- / "VOLUME4q, NUMBER ~

Hematuria Hematuria Hematuria Multiple polyps Microhematuria Microhematuria

Intussuscepting Hematuria Microhematuria

Calculus Hematuria

Hematuria Hematuria Hematuria Calculus Multiple polyps Microhematuria



20 29 33



2t 21 33 6 23 43 76 4O 27


19 17 31 44 54 43 40 26 27


Hematuria Hematuria Hematuria

Association Calculi iri upper tract


1 2



24 72 51 32

Schiotz Schulman Schneiderman etal. Soderdahland Schuster Sommerhaug and Mason Stukart et al.



Hematuria Hematuria Microhematuria Hematuria Hematuria Intussuscepting ureter Hematuria Hematuria Hematuria Hematuria ktematuria Hematuria


Based upon our review of the literature, fibroepithelial ureteral polyps may fit adequately into such a classification scheme, providing a basis for a new understanding of their cause. Lesions in the pediatric age group may be accounted for by the hamartomatous growth of ureteral mesenchymal tissue. The precise histologic features of these tumors in adults are poorly documented. Typically they are covered by a normal layer of urothelium and are composed largely of a fibromyxoid stroma deri{ed from the submucosa of the ureteral wall, and do not include any muscular elements. The demonstration of significant inflammation in association with polyp growth in our series is consistent with extrinsic promoting agents. Such agents may include urinary crystals, calculi, and/or Double J stents. Double J stents have been shown to induce an inflammatory response resulting in ureteral damage in the canine and porcine ureter models. 9,1° The potential for malignant transformation, consistent with the features of current tumor theory, is rare but has been documented with the demonstration of a transitional cell carcinoma arising from the tip of a fibroepithelial polyp. H Review of the literature and our own experience with 4 recent cases leads us to offer new suggestions on the growth of fibroepithelial ureteral polyps. We consider that this tumor may occur as a pediatric lesion induced by congenital genetic factors. In the adult, fibroepithelial polyps may occur ad-ditionally as a result of long-term or repeated inflammation of ureteral tissue. Such inflammation may result from urinary crystals, calculi, stents, infection, or other undocumented factors. In most instances these factors will be insufficient to initiate polyp growth. Less commonly a symptomatic fibroepithelial polyp may result, usually presenting with hematuria. Marshall Stoller, M.D.

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