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Fibrous Polyp of Ureter
THE JOURNAL OF UROLOGY
Vol. 90, No. 2 August 1963 Copyright © 1963 by The Williams & Wilkins Co. Printed in U.S.A.
FIBROUS POLYP OF URETER ROBERT L. BRECKENRIDGE, PHILIP V. LYNCH
AND
EDWARD D. HOLFELNER
Frain Our Lady of Laureles Hospital, Camden, N. J.
Primary tumors of the ureter, particularly benign tumors, are rare. Although the first benign tumor was described as early as 1861,1 few have since been recorded. In 1950, Mortensen and Murphy collected 77 cases. 2 Six years later, Abeshouse found an additional 60 cases and added one of his own, bringing the total number of benign tumors to 138. 3 By 1960 Brock added one and found 16 others in the literature. 4 Only a few have since appeared. 5 · 6 The majority of the benign tumors are epithelial in origin and are classified as papillomas or adenomas. Those of mesodermal origin are extremely rare and are either fibrous polyps or vascular tumors (hemangiomas, angiomas or lymphangiomas). Other so-called primary tumors have been described as granulomas and endometriomas. The fibrous polyps have also been called fibromas, fibromyomas and myomas. In 1958 Compere and associates collected 18 cases of fibrous polyps and added three of their own. 7 Only a few have been described since. 4 • 8 The fibrous polyp is composed of either single or multiple finger-like projections of a relatively loose connective tissue with varying degrees of vascularity. Each is covered by a continuation of the mucous membrane that lines the ureter. Both grossly and microscopically, their resemblance to the common nasal polyps is striking. Like the nasal polyps,8 they are definitely benign tumors. No case has ever been described as being malignant. Therefore, it is best treated by lr:cal excision. Accepted for publication March 6, 1963. 1 Lebert: Anat. Path., 1: 269 and 2: 372, 1861. 2 Mortensen, H. and Murphy, L.: Brit. J. Urol., 22: 103, 1950. 3 Abeshouse, B. S.: Amer. J. Surg., 91: 237, 1956. 4 Brock, D.R.: J. Urol., 83: 572-574, 1960. 5 Cilento, A. and D'Alessandro, A.: Arch. Ital Urol., 33: 316-338, 1960. 6 Macdougall, J. A.: Brit. J. Urol., 33: 160-166, 1961. 7 Compere, D. E., Begley, G. F., Isaacks, H. E., Frazier, T. H. and Dryden, C. B.: J. Urol., 79: 209-214, 1958. 8 Wood, L. G. and Howe, G. E.: J. Urol., 79: 418-430, 1958. 160
Characteristically the tumor causes the ureter to assume a fusiform or sausage shape and produces almost complete obstruction with eventual hydronephrosis. It may arise from any part of the ureter, but is most often located in the upper portion. In one instance7 the polyp presented itself as a tumor projecting through the ureterovesical orifice into the bladder. In other instances portions of the tumor partly filled the dilated pelvis of the kidney when it arose near the ureteropelvic junction. Intussusception of the ureter has also occurred as a complication of the large polyps. 9 This complication undoubtedly produces acute symptoms of pain, with or without hematuria. Actually these are the two most common symptoms of this benign neoplasm. Nausea, vomiting, chills· and fever, particularly in the younger patient, have also been described. 7 Pyuria is uncommon. Hematuria, with or without colic type flank or low abdominal pain that may radiate to the labia or scrotum, is the characteristic sign. In rare instances there may be no symptoms or signs referable to the genitourinary system. 4 ' 10 Although Abeshouse 3 states that the majority of all benign tumors occur in patients during their fourth and fifth decades, apparently the fibrous polyps occur more frequently in the earlier decades. The earliest reported case was that in a 6-year-old boy who had had repeated episodes of nausea, vomiting, chills and fever with flank pain for 3}2 years. 7 It is most likely, therefore, that his neoplasm had been present at least at the age of two. The other reported cases have been mainly in teenagers. 3 , 4 CASE REPORT
A 26-year-old white male machine operator was admitted to Our Lady of Lourdes Hospital on August 13, 1962, complaining of dysuria and a sense of urgency a few weeks in duration. On the day of admission he also complained of gross hematuria. Physical examination revealed severe 9 Morley, H. V., Shumaker, E. F. and Gardner, L. W.: J. Urol., 67: 266-271, 1952. 10 Howard, T. L.: J. Urol., 79: 397-402, 1958.
FIG. 1. A, retrograde pyelogram shows tumor producing hydronephrosis and hydroureter of proximal portion of ureter. B, hemi-section of kidney and ureter. Note smooth, multiple finger-like projections of tumor.
FIG. 2. A, low power magnification of base of tumor shows its contiguous multicentric origin. X35 B, microphotograph of one of stalks of polyp shows loose, vascular core covered with nornial transitional epithelium. XlOO. 161
162
BRECKENRIDGE, LYNCH AND HOLFELNER
tenderness over the left kidney. The prostate was small, rubbery in consistency and non-tender. The urine had a specific gravity of 1.027 and a pH of 5.5. It contained 1 plus albumin and a trace of acetone. There were innumerable red blood cells and 20 to 25 white blood cells present. The blood urea nitrogen was 15 mg./ml. An excretory urogram revealed left hydronephrosis. A retrograde pyelogram revealed. two areas of radiolucency in the region of the left ureteropelvic junction. A second retrograde pyelogram revealed dilatation of the left renal pelvis and blunting and cuffing of the calyces (fig. 1, A). The areas of radiotranslucency were again visualized. Exploration of the left kidney and ureter revealed hydronephrosis of the extrarenal type. The proximal portion of the ureter was dilated. Marked hydronephrosis was present and an aberrant artery and vein crossed the ureteropelvic junction to the lower pole of the kidney. It was felt that a stricture of the ureter was present secondary to these vessels. A left nephrectomy and partial ureterectomy were performed. The excised kidney revealed that the calyces, pelvis and attached portion of the ureter were dilated (fig. 1, B). The dilatation was due to the presence of a papillary tumor which filled the lumen of the distal portion of the attached segment of ureter. The tumor was located 1.8 cm. from the ureteropelvic junction. The tumor was composed of multiple pink, rubbery, smooth, finger-like projections of papillary tissue, which arose from an area of the wall within the lumen. These projections were freely movable but were firmly adherent at their bases. Ristologically the finger-like projections were composed of a pale-staining, loose, vascular connective tissue, not unlike that seen in nasal polyps (fig. 2, A). They had a multicentric origin, arising from the submucosa of the ureter. The projections were covered with transitional cell epithelium (fig. 2, B).
DISCUSSION
Although very few cases of fibrous polyps of the ureter have been carefully recorded with x-ray studies and surgical descriptions, it now seems likely that the diagnosis of such a neoplasm may be suspected by either the roentgenologist or the surgeon. In the case of roentgenographic findings, using excretory urography and retrograde pyelography, the unmmally large size of the tumor, the fusiform or sausage-shape swelling of the affected ureter and the obliteration of the lumen with production of hydronephrosis and hydroureter are characteristic. At the operating table the surgeon may recognize this tumor as a polypoid or wart-like mass that bulges forth, as if under tension, when the ureter is split. He may recognize its multiple, smooth, finger-like projections extending up and down the ureter. He will also see the small area of attachment, which is surprising for the size of this tumor. He will be aware of the absence of any infiltration. From experience he can differentiate it from the more common papillomas. These are delicate, soft, lacy projections that break readily. They are frequently multiple and of small size. Most investigators believe that the fibrous polyp of the ureter, like the nasal polyp, is a benign lesion and can be treated successfully by local excision. The papilloma, on the other hand, is either malignant or potentially malignant and must be treated radically by nephroureterectomy. Therefore, recognition of the type of tumor, either by the roentgenologist or the surgeon, will define the extent of surgery. SUMMARY
A patient with a fibrous polyp of the ureter is reported. Although this is an extremely rare tumor, enough evidence is now available to differentiate it from the papilloma, both by roentgenography and gross examination. It is a benign tumor and may be adequately treated by local excision.
Vol. 90, No. 2 August 1963 Copyright © 1963 by The Williams & Wilkins Co. Printed in U.S.A.
FIBROUS POLYP OF URETER ROBERT L. BRECKENRIDGE, PHILIP V. LYNCH
AND
EDWARD D. HOLFELNER
Frain Our Lady of Laureles Hospital, Camden, N. J.
Primary tumors of the ureter, particularly benign tumors, are rare. Although the first benign tumor was described as early as 1861,1 few have since been recorded. In 1950, Mortensen and Murphy collected 77 cases. 2 Six years later, Abeshouse found an additional 60 cases and added one of his own, bringing the total number of benign tumors to 138. 3 By 1960 Brock added one and found 16 others in the literature. 4 Only a few have since appeared. 5 · 6 The majority of the benign tumors are epithelial in origin and are classified as papillomas or adenomas. Those of mesodermal origin are extremely rare and are either fibrous polyps or vascular tumors (hemangiomas, angiomas or lymphangiomas). Other so-called primary tumors have been described as granulomas and endometriomas. The fibrous polyps have also been called fibromas, fibromyomas and myomas. In 1958 Compere and associates collected 18 cases of fibrous polyps and added three of their own. 7 Only a few have been described since. 4 • 8 The fibrous polyp is composed of either single or multiple finger-like projections of a relatively loose connective tissue with varying degrees of vascularity. Each is covered by a continuation of the mucous membrane that lines the ureter. Both grossly and microscopically, their resemblance to the common nasal polyps is striking. Like the nasal polyps,8 they are definitely benign tumors. No case has ever been described as being malignant. Therefore, it is best treated by lr:cal excision. Accepted for publication March 6, 1963. 1 Lebert: Anat. Path., 1: 269 and 2: 372, 1861. 2 Mortensen, H. and Murphy, L.: Brit. J. Urol., 22: 103, 1950. 3 Abeshouse, B. S.: Amer. J. Surg., 91: 237, 1956. 4 Brock, D.R.: J. Urol., 83: 572-574, 1960. 5 Cilento, A. and D'Alessandro, A.: Arch. Ital Urol., 33: 316-338, 1960. 6 Macdougall, J. A.: Brit. J. Urol., 33: 160-166, 1961. 7 Compere, D. E., Begley, G. F., Isaacks, H. E., Frazier, T. H. and Dryden, C. B.: J. Urol., 79: 209-214, 1958. 8 Wood, L. G. and Howe, G. E.: J. Urol., 79: 418-430, 1958. 160
Characteristically the tumor causes the ureter to assume a fusiform or sausage shape and produces almost complete obstruction with eventual hydronephrosis. It may arise from any part of the ureter, but is most often located in the upper portion. In one instance7 the polyp presented itself as a tumor projecting through the ureterovesical orifice into the bladder. In other instances portions of the tumor partly filled the dilated pelvis of the kidney when it arose near the ureteropelvic junction. Intussusception of the ureter has also occurred as a complication of the large polyps. 9 This complication undoubtedly produces acute symptoms of pain, with or without hematuria. Actually these are the two most common symptoms of this benign neoplasm. Nausea, vomiting, chills· and fever, particularly in the younger patient, have also been described. 7 Pyuria is uncommon. Hematuria, with or without colic type flank or low abdominal pain that may radiate to the labia or scrotum, is the characteristic sign. In rare instances there may be no symptoms or signs referable to the genitourinary system. 4 ' 10 Although Abeshouse 3 states that the majority of all benign tumors occur in patients during their fourth and fifth decades, apparently the fibrous polyps occur more frequently in the earlier decades. The earliest reported case was that in a 6-year-old boy who had had repeated episodes of nausea, vomiting, chills and fever with flank pain for 3}2 years. 7 It is most likely, therefore, that his neoplasm had been present at least at the age of two. The other reported cases have been mainly in teenagers. 3 , 4 CASE REPORT
A 26-year-old white male machine operator was admitted to Our Lady of Lourdes Hospital on August 13, 1962, complaining of dysuria and a sense of urgency a few weeks in duration. On the day of admission he also complained of gross hematuria. Physical examination revealed severe 9 Morley, H. V., Shumaker, E. F. and Gardner, L. W.: J. Urol., 67: 266-271, 1952. 10 Howard, T. L.: J. Urol., 79: 397-402, 1958.
FIG. 1. A, retrograde pyelogram shows tumor producing hydronephrosis and hydroureter of proximal portion of ureter. B, hemi-section of kidney and ureter. Note smooth, multiple finger-like projections of tumor.
FIG. 2. A, low power magnification of base of tumor shows its contiguous multicentric origin. X35 B, microphotograph of one of stalks of polyp shows loose, vascular core covered with nornial transitional epithelium. XlOO. 161
162
BRECKENRIDGE, LYNCH AND HOLFELNER
tenderness over the left kidney. The prostate was small, rubbery in consistency and non-tender. The urine had a specific gravity of 1.027 and a pH of 5.5. It contained 1 plus albumin and a trace of acetone. There were innumerable red blood cells and 20 to 25 white blood cells present. The blood urea nitrogen was 15 mg./ml. An excretory urogram revealed left hydronephrosis. A retrograde pyelogram revealed. two areas of radiolucency in the region of the left ureteropelvic junction. A second retrograde pyelogram revealed dilatation of the left renal pelvis and blunting and cuffing of the calyces (fig. 1, A). The areas of radiotranslucency were again visualized. Exploration of the left kidney and ureter revealed hydronephrosis of the extrarenal type. The proximal portion of the ureter was dilated. Marked hydronephrosis was present and an aberrant artery and vein crossed the ureteropelvic junction to the lower pole of the kidney. It was felt that a stricture of the ureter was present secondary to these vessels. A left nephrectomy and partial ureterectomy were performed. The excised kidney revealed that the calyces, pelvis and attached portion of the ureter were dilated (fig. 1, B). The dilatation was due to the presence of a papillary tumor which filled the lumen of the distal portion of the attached segment of ureter. The tumor was located 1.8 cm. from the ureteropelvic junction. The tumor was composed of multiple pink, rubbery, smooth, finger-like projections of papillary tissue, which arose from an area of the wall within the lumen. These projections were freely movable but were firmly adherent at their bases. Ristologically the finger-like projections were composed of a pale-staining, loose, vascular connective tissue, not unlike that seen in nasal polyps (fig. 2, A). They had a multicentric origin, arising from the submucosa of the ureter. The projections were covered with transitional cell epithelium (fig. 2, B).
DISCUSSION
Although very few cases of fibrous polyps of the ureter have been carefully recorded with x-ray studies and surgical descriptions, it now seems likely that the diagnosis of such a neoplasm may be suspected by either the roentgenologist or the surgeon. In the case of roentgenographic findings, using excretory urography and retrograde pyelography, the unmmally large size of the tumor, the fusiform or sausage-shape swelling of the affected ureter and the obliteration of the lumen with production of hydronephrosis and hydroureter are characteristic. At the operating table the surgeon may recognize this tumor as a polypoid or wart-like mass that bulges forth, as if under tension, when the ureter is split. He may recognize its multiple, smooth, finger-like projections extending up and down the ureter. He will also see the small area of attachment, which is surprising for the size of this tumor. He will be aware of the absence of any infiltration. From experience he can differentiate it from the more common papillomas. These are delicate, soft, lacy projections that break readily. They are frequently multiple and of small size. Most investigators believe that the fibrous polyp of the ureter, like the nasal polyp, is a benign lesion and can be treated successfully by local excision. The papilloma, on the other hand, is either malignant or potentially malignant and must be treated radically by nephroureterectomy. Therefore, recognition of the type of tumor, either by the roentgenologist or the surgeon, will define the extent of surgery. SUMMARY
A patient with a fibrous polyp of the ureter is reported. Although this is an extremely rare tumor, enough evidence is now available to differentiate it from the papilloma, both by roentgenography and gross examination. It is a benign tumor and may be adequately treated by local excision.