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Genitourinary polyps in children
PEDIATRIC UROLOGY
GENITOURINARY POLYPS IN CHILDREN PHILIP E. GLEASON, M.D. STEPHEN A. KRAMER, M.D. From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT--Objectives. This study was undertaken to review the presenting complaints, diagnostic evaluation, treatment, and natural history of children with genitourinary polyps seen at the Mayo Clinic during the past 35 years. Methods. We retrospectively reviewed the charts of all children less than 16 years of age with symptomatic genitourinary polyps who were seen at the Mayo Clinic between ] 957 and 1992. The age of each patient, clinical presentation, anatomic location of the polyp, diagnostic evaluation, and treatment were reviewed. Long-term follow-up data, including complications, were recorded, and the literature was reviewed. Results. The most common presenting symptoms were hematuria in 9 patients (gross 7, microscopic 2) and urinary tract obstruction in 9 patients {upper tract 5, lower tract 6). Four children had ureteral polyps. Excretory urography showed hydronephrosis and filling defects in 5 patients and a filling defect without hydronephrosis in 1 child. Two patients underwent segmental ureterectomy, 1 had open excision of the polyp, and 1 had ureteroscopic exdsion. Urethral polyps were identified in 12 children, most often as a filling defect of the posterior urethra on voiding cystourethrography (5 patients) or during cystourethroscopy [7 patients). All 12 patients were managed successfully by transurethral resection. Conclusions. Genitourinary polyps in children require a high degree of alertness and can be diagnosed with excretory urography, with voiding cystourethrography, or endoscopically. The biologic activity of these polyps is uniformly benign, and there have been no recurrences following complete excision.
Fibroepithelial genitourinary polyps are an uncommon cause of hematuria and obstructive urinary symptoms in the pediatric age group. 1-5 The widespread use of high-quality excretory urography and voiding cystourethrography with fluoroscopy has led to an increased recognition of these benign lesions. This study was undertaken to review the presenting complaints, diagnostic evaluation, treatment, and natural history of children with genitourinary polyps seen at the Mayo Clinic during the past 35 years. MATERIAL AND METHODS We retrospectively reviewed the charts of all children less than 16 years of age with symptomatic genitourinary polyps who were seen at the Mayo Clinic between 1957 and 1992. The age of each patient, clinical presentation, anatomic location of Submitted: December 23, 1993, accepted (with revisions): February 25, 1994
I 06
the polyp, diagnostic evaluation, and t r e a t ~ were reviewed. Long-term follow-up data, inc!~ ing complications, were recorded, and the l i [ ~ ture was reviewed. RESULTS The ages of the 16 children with fibroepithelial genitourinary polyps 1 year to 14 years, with a mean of 8.9 were 15 boys and 1 girl. Follow-up r~ months to 19 years, with a mean of 3 Twelve patients had urethral polyf were located at the verumontanum posterior urethra. Presenting symptc hematuria in 5 (gross 3 and microscc mittent obstructive voiding complai] urinary retention in 2 patients. In the urethral polyp was visualized defect within the posterior urethra dt cystourethrography (Fig. 1). Recen bladder u l t r a s o n o g r a p h y has bern . . . . 11PFhl (~V
/
T. . . . .
irma
/ ~7 . . . . . . .
,44
K/'I,/M~
jRg:1. Filling defect in posterior urethra consistent ~ure*hrol polyp.
~mation of a mobile, stalk-based mass. Seven He!urethral polyps were diagnosed by means of ~urethroscopy. ~[hrhl polyps were managed successfully by ~c6pic transurethral resection in each patient. i~e patient transurethral resection of the polyp isomplicated by the polyps floating into the l*der, and the patient required a suprapubic i~gesical approach for polyp retrieval. :iur patients had ureteral polyps. Each polyp t6cated in the upper third of the ureter just disi0 tile:, ureteropelvic junction. Three presented ~intermittent flank pain and 2 had gross hema~i Three polyps were located on the left and 1 !he :~ight. Excretory urography showed a filling i~t in'the-upper ureter in all 4 patients, and 3 !h}dronephrosis Retrograde pyelography and i~roscopy were used to confirm the presence of ~k bdsed, mobile filling defect (Fig 2) :]iihe 4 patients with ureteral polyps, 2 underii!?egmental ureterectomy of the polyp and disi~ibe~edpyeloplasty. One patient was seen elseiie With : left flank pain and underwent flank ~f0ration for presumed obstruction of the !{ropelvic junction. There was no evidence of !!:nsicnarrowing of the ureter, and the patient ;{reated by nephropexy alone. He was referred iur institution i year postoperatively with re= ,~ent intermittent flank pain. Excretory urograi demonstrated filling defects in the upper !~r consistent with ureteral polyps (Fig. 3). The O'underwent left flank exploration with exciiof the polyps and ureteroureterostomy. The i{h patient underwent ureteroscopy with exci~ L Q G Y / ]vLY 1994 / Vocv~,la 4q, NVMB~R 1
FIGURE 2. Retrograde ureteropyelogram shows a stalk-based filling defect in the upper ureter.
FIGURE 3. Excretory urogram demonstrates filling defects in the upper ureter consistent with ureteral polyps.
sion of the polyps and fulguration of the ureteral base. His postoperative course was complicated by passage of blood clots requiring a percutaneous nephrostomy. He had persistent left hydronephrosis 3 months postoperatively and underwent flank 107
exploration. Despite successful ureteroscopic excision of the polyp, intraoperative findings demonstrated ureteral tortuosity and periureteral adhesions, and the patient u n d e r w e n t segmental ureterectomy and ureteropyelostomy. His postoperative course remains uneventful, and excretory urography at 6 months shows resolution of the hydronephrosis. Histopathologic examination of each polyp showed a core composed of connective tissue and smooth muscle covered by normal transitional epithelium. In e.ach patient, the polyp was resected or excised completely, and there have been no recurrences after a mean follow-up of 3.4 years. COMMENT Genitourinary polyps are an uncommon source of upper and lower urinary tract obstruction and hematuria in children. Urinary polyps have been described from the middle calix of the kidney to the anterior urethra; however, the most common sites include: the ureteropelvic junction and the verumontanum. 6 Literature reviews for cases of both upper ~,5 and lower 3'4 genitourinary tract polyps as late as the mid 1980s revealed relatively few reports. '.However, with increased evaluation of the genitourinary tract by radiographic contrast studies, ultrasonography, and endoscopy, polyps of the urethra and ureter are increasingly being recognized as sources of obstruction and hematuria. 2 The mean age at presentation in our series (8.9 years) is similar to that in previous reports. 2 Genitourinary polyps may also be seen in young adults, presumably having been asymptomatic in childhood or having gone undiagnosed for other reasons. 2,3,5 Interestingly, concomitant posterior urethral polyps and obstruction of the ureteropelvic junction have been reported in two patients with Beckwith-Wiedemann syndrome, r,s Both ureteral and urethral[ polyps are more common in males, and ureteral polyps occur predominantly on the left side.1 Obstruction is the most common source of both upper and lower urinary tract symptoms3 ,4 Upper urinary tract complaints such as renal colic or vague abdominal and flank pain were observed in 3 of our 4 patients (75%) with ureteral polyps. Fifty percent of our patients with urethral polyps presented with obstructive lower urinary tract voiding complaints, including hesitancy, diminished urinary stream, incomplete emptying, and urinary retention. Whereas posterior urethral and bladder neck polyps have been associated with upper tract ,dilation in 20% to 58% of previous reports, 3,4 none of our patients had upper tract dila1N~
tion. Hematuria occurred in 9 of our patients (56%), an incidence similar to the reported 50% tO 65% for upper tract polyps and 13% to 33% fo~ urethral polyps. 1,4 Less common presentation~ have i n c l u d e d n o n s p e c i f i c d e t e c t i o n of hy dronephrosis (including detection in utero), 9 irri, tative voiding symptoms, and bladder calculi) ,e Evaluation of upper tract symptoms by excre; tory urography characteristically shows hydro~ nephrosis or filling defects (or both) in the upper ureter. Radiographic differentiation from intrinsic stenosis of the ureteropelvic junction is most ofte~ based on a fusiform dilation of the ureter sur~ rounding the polyp with contrast highlighting ~ filling defect. Stenosis of the ureteropelvic junc: tion typically demonstrates only the stenotic junf tion and nonvisualization of the proximal ureter: Presence of a polyp is confirmed by mobility of the stalk-based lesion on retrograde pyelography and ureteroscopy. Earlier in our series, urethral polyps were ofte] missed on voiding cystourethrography without flu oroscopy and required cystoscopy for diagnosl] More recently, urethral polyps have been show] accurately on voiding cystourethrography in fi~ patients, presumably because of improved radio graphic imaging and fluoroscopy. Polyps are typi cally mobile, stalk-based lesions of the posterf~i urethra that tend to float into the bladder durin} filling and storage of urine and then are expelie/t into the prostatic urethra during voiding, wher~ they produce variable degrees of bladder outlet ob struction. In older children, whose polyps have thin stai~ with surrounding ureteral dilation, the aPpro~c] may be by either retrograde ureteroscopy or ante grade pyeloscopy. In children in whom endosc0pi~ access is limited or in those with more sessile le! sions, we prefer a flank exploration throueh an ~ni terior subcostal muscle-s Plittin g incisionOUret~Ni • polyps may be managed by open polypectomy W!!l~ fulguration of the base. The ureter is visualiz~ and the segment containing the polyp is exciSe{i and ureteral continuity is reestablished by eitMi ureteroureterostomy or a ureteropyelostomy. Lower urinary tract polyps have traditiona{ been approached suprapubically. However, w! the development of pediatric resectoscopes, tt1¢ lesions can n o w m o s t often be manag! •
Fibroepithelial polyps are a benign mesoderm~ tumor, presumably congenital in nature, arising {~ a protrusion from the ureteral or urethral N~!!~ [IR('3I OCV
/ lr*iv 1c)c)4 / VOTZIMF44. NU~vI~
t t i o n d e m o n s t r a t e s a core tissue a n d s m o o t h m u s c l e t i o n a l e p i t h e l i u m . 10 T h e i r ormly benign, and there currences when they have Radiographic assessment tness will establish t h e dibe p e r f o r m e d w i t h c o n Stephen A. Kramer, M.D. Department of Urology Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 REFERENCES
~ :i: Macksood MJ, Roth DR, Chang cn, and Perlmutter AD: ~e~f~n fibroepithelial polyps as a cause of intermittent ~r~f~l~elvic junction obstruction in a child: a case report ~{;~]tevi'ew of the literature . J Urol 1985 ~ . 134" . 951-952 .
IDJ~C'N
~
L va~ ~TMF4A._Nrz~nFR 1
2. Foster RS, and Garrett RA: Congenital posterior urethral polyps. J Urol 136: 670-672, 1986. 3. Kimche D, and Lask D: Congenital polyp of the prostatic urethra. J Urol 127: 134, 1982. 4. Downs RA: Congenital polyps of the prostatic urethra: a review of the literature and report of two cases. Br J Urol 42: 76-85, 1970. 5. Williams PR, Feggetter J, Miller RA, and Wickham JEA: The diagnosis and management of benign fibrous ureteric polyps. BrJ Urol 52: 253-256, 1980. 6. Banner ME and Pollack HM: Fibrous ureteral polyps. Radiology 130: 73-76, 1979. 7. Crankson S, and Ahmed S: Benign bladder neck polyp and ureteropelvic obstruction in Beckwith-Wiedemann syndrome. Aust N ZJ Surg 61: 955-957, 1991. 8. Bockrath JM, Maizels M, and Firlit CF: Benign bladder neck polyp causing tandem obstruction of the urinary tract in a patient with Beckwith-Wiedemann syndrome. J Urol 128: 1309-1312, 1982. 9. Caro PA, Rosenberg HK, and Snyder HM III: Congenital urethral polyp. AJR 147: 1041-1042, 1986. 10. Youssif M: Posterior urethral polyps in inthnts and children. Eur Urol 11: 69-70, 1985.
109
GENITOURINARY POLYPS IN CHILDREN PHILIP E. GLEASON, M.D. STEPHEN A. KRAMER, M.D. From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT--Objectives. This study was undertaken to review the presenting complaints, diagnostic evaluation, treatment, and natural history of children with genitourinary polyps seen at the Mayo Clinic during the past 35 years. Methods. We retrospectively reviewed the charts of all children less than 16 years of age with symptomatic genitourinary polyps who were seen at the Mayo Clinic between ] 957 and 1992. The age of each patient, clinical presentation, anatomic location of the polyp, diagnostic evaluation, and treatment were reviewed. Long-term follow-up data, including complications, were recorded, and the literature was reviewed. Results. The most common presenting symptoms were hematuria in 9 patients (gross 7, microscopic 2) and urinary tract obstruction in 9 patients {upper tract 5, lower tract 6). Four children had ureteral polyps. Excretory urography showed hydronephrosis and filling defects in 5 patients and a filling defect without hydronephrosis in 1 child. Two patients underwent segmental ureterectomy, 1 had open excision of the polyp, and 1 had ureteroscopic exdsion. Urethral polyps were identified in 12 children, most often as a filling defect of the posterior urethra on voiding cystourethrography (5 patients) or during cystourethroscopy [7 patients). All 12 patients were managed successfully by transurethral resection. Conclusions. Genitourinary polyps in children require a high degree of alertness and can be diagnosed with excretory urography, with voiding cystourethrography, or endoscopically. The biologic activity of these polyps is uniformly benign, and there have been no recurrences following complete excision.
Fibroepithelial genitourinary polyps are an uncommon cause of hematuria and obstructive urinary symptoms in the pediatric age group. 1-5 The widespread use of high-quality excretory urography and voiding cystourethrography with fluoroscopy has led to an increased recognition of these benign lesions. This study was undertaken to review the presenting complaints, diagnostic evaluation, treatment, and natural history of children with genitourinary polyps seen at the Mayo Clinic during the past 35 years. MATERIAL AND METHODS We retrospectively reviewed the charts of all children less than 16 years of age with symptomatic genitourinary polyps who were seen at the Mayo Clinic between 1957 and 1992. The age of each patient, clinical presentation, anatomic location of Submitted: December 23, 1993, accepted (with revisions): February 25, 1994
I 06
the polyp, diagnostic evaluation, and t r e a t ~ were reviewed. Long-term follow-up data, inc!~ ing complications, were recorded, and the l i [ ~ ture was reviewed. RESULTS The ages of the 16 children with fibroepithelial genitourinary polyps 1 year to 14 years, with a mean of 8.9 were 15 boys and 1 girl. Follow-up r~ months to 19 years, with a mean of 3 Twelve patients had urethral polyf were located at the verumontanum posterior urethra. Presenting symptc hematuria in 5 (gross 3 and microscc mittent obstructive voiding complai] urinary retention in 2 patients. In the urethral polyp was visualized defect within the posterior urethra dt cystourethrography (Fig. 1). Recen bladder u l t r a s o n o g r a p h y has bern . . . . 11PFhl (~V
/
T. . . . .
irma
/ ~7 . . . . . . .
,44
K/'I,/M~
jRg:1. Filling defect in posterior urethra consistent ~ure*hrol polyp.
~mation of a mobile, stalk-based mass. Seven He!urethral polyps were diagnosed by means of ~urethroscopy. ~[hrhl polyps were managed successfully by ~c6pic transurethral resection in each patient. i~e patient transurethral resection of the polyp isomplicated by the polyps floating into the l*der, and the patient required a suprapubic i~gesical approach for polyp retrieval. :iur patients had ureteral polyps. Each polyp t6cated in the upper third of the ureter just disi0 tile:, ureteropelvic junction. Three presented ~intermittent flank pain and 2 had gross hema~i Three polyps were located on the left and 1 !he :~ight. Excretory urography showed a filling i~t in'the-upper ureter in all 4 patients, and 3 !h}dronephrosis Retrograde pyelography and i~roscopy were used to confirm the presence of ~k bdsed, mobile filling defect (Fig 2) :]iihe 4 patients with ureteral polyps, 2 underii!?egmental ureterectomy of the polyp and disi~ibe~edpyeloplasty. One patient was seen elseiie With : left flank pain and underwent flank ~f0ration for presumed obstruction of the !{ropelvic junction. There was no evidence of !!:nsicnarrowing of the ureter, and the patient ;{reated by nephropexy alone. He was referred iur institution i year postoperatively with re= ,~ent intermittent flank pain. Excretory urograi demonstrated filling defects in the upper !~r consistent with ureteral polyps (Fig. 3). The O'underwent left flank exploration with exciiof the polyps and ureteroureterostomy. The i{h patient underwent ureteroscopy with exci~ L Q G Y / ]vLY 1994 / Vocv~,la 4q, NVMB~R 1
FIGURE 2. Retrograde ureteropyelogram shows a stalk-based filling defect in the upper ureter.
FIGURE 3. Excretory urogram demonstrates filling defects in the upper ureter consistent with ureteral polyps.
sion of the polyps and fulguration of the ureteral base. His postoperative course was complicated by passage of blood clots requiring a percutaneous nephrostomy. He had persistent left hydronephrosis 3 months postoperatively and underwent flank 107
exploration. Despite successful ureteroscopic excision of the polyp, intraoperative findings demonstrated ureteral tortuosity and periureteral adhesions, and the patient u n d e r w e n t segmental ureterectomy and ureteropyelostomy. His postoperative course remains uneventful, and excretory urography at 6 months shows resolution of the hydronephrosis. Histopathologic examination of each polyp showed a core composed of connective tissue and smooth muscle covered by normal transitional epithelium. In e.ach patient, the polyp was resected or excised completely, and there have been no recurrences after a mean follow-up of 3.4 years. COMMENT Genitourinary polyps are an uncommon source of upper and lower urinary tract obstruction and hematuria in children. Urinary polyps have been described from the middle calix of the kidney to the anterior urethra; however, the most common sites include: the ureteropelvic junction and the verumontanum. 6 Literature reviews for cases of both upper ~,5 and lower 3'4 genitourinary tract polyps as late as the mid 1980s revealed relatively few reports. '.However, with increased evaluation of the genitourinary tract by radiographic contrast studies, ultrasonography, and endoscopy, polyps of the urethra and ureter are increasingly being recognized as sources of obstruction and hematuria. 2 The mean age at presentation in our series (8.9 years) is similar to that in previous reports. 2 Genitourinary polyps may also be seen in young adults, presumably having been asymptomatic in childhood or having gone undiagnosed for other reasons. 2,3,5 Interestingly, concomitant posterior urethral polyps and obstruction of the ureteropelvic junction have been reported in two patients with Beckwith-Wiedemann syndrome, r,s Both ureteral and urethral[ polyps are more common in males, and ureteral polyps occur predominantly on the left side.1 Obstruction is the most common source of both upper and lower urinary tract symptoms3 ,4 Upper urinary tract complaints such as renal colic or vague abdominal and flank pain were observed in 3 of our 4 patients (75%) with ureteral polyps. Fifty percent of our patients with urethral polyps presented with obstructive lower urinary tract voiding complaints, including hesitancy, diminished urinary stream, incomplete emptying, and urinary retention. Whereas posterior urethral and bladder neck polyps have been associated with upper tract ,dilation in 20% to 58% of previous reports, 3,4 none of our patients had upper tract dila1N~
tion. Hematuria occurred in 9 of our patients (56%), an incidence similar to the reported 50% tO 65% for upper tract polyps and 13% to 33% fo~ urethral polyps. 1,4 Less common presentation~ have i n c l u d e d n o n s p e c i f i c d e t e c t i o n of hy dronephrosis (including detection in utero), 9 irri, tative voiding symptoms, and bladder calculi) ,e Evaluation of upper tract symptoms by excre; tory urography characteristically shows hydro~ nephrosis or filling defects (or both) in the upper ureter. Radiographic differentiation from intrinsic stenosis of the ureteropelvic junction is most ofte~ based on a fusiform dilation of the ureter sur~ rounding the polyp with contrast highlighting ~ filling defect. Stenosis of the ureteropelvic junc: tion typically demonstrates only the stenotic junf tion and nonvisualization of the proximal ureter: Presence of a polyp is confirmed by mobility of the stalk-based lesion on retrograde pyelography and ureteroscopy. Earlier in our series, urethral polyps were ofte] missed on voiding cystourethrography without flu oroscopy and required cystoscopy for diagnosl] More recently, urethral polyps have been show] accurately on voiding cystourethrography in fi~ patients, presumably because of improved radio graphic imaging and fluoroscopy. Polyps are typi cally mobile, stalk-based lesions of the posterf~i urethra that tend to float into the bladder durin} filling and storage of urine and then are expelie/t into the prostatic urethra during voiding, wher~ they produce variable degrees of bladder outlet ob struction. In older children, whose polyps have thin stai~ with surrounding ureteral dilation, the aPpro~c] may be by either retrograde ureteroscopy or ante grade pyeloscopy. In children in whom endosc0pi~ access is limited or in those with more sessile le! sions, we prefer a flank exploration throueh an ~ni terior subcostal muscle-s Plittin g incisionOUret~Ni • polyps may be managed by open polypectomy W!!l~ fulguration of the base. The ureter is visualiz~ and the segment containing the polyp is exciSe{i and ureteral continuity is reestablished by eitMi ureteroureterostomy or a ureteropyelostomy. Lower urinary tract polyps have traditiona{ been approached suprapubically. However, w! the development of pediatric resectoscopes, tt1¢ lesions can n o w m o s t often be manag! •
Fibroepithelial polyps are a benign mesoderm~ tumor, presumably congenital in nature, arising {~ a protrusion from the ureteral or urethral N~!!~ [IR('3I OCV
/ lr*iv 1c)c)4 / VOTZIMF44. NU~vI~
t t i o n d e m o n s t r a t e s a core tissue a n d s m o o t h m u s c l e t i o n a l e p i t h e l i u m . 10 T h e i r ormly benign, and there currences when they have Radiographic assessment tness will establish t h e dibe p e r f o r m e d w i t h c o n Stephen A. Kramer, M.D. Department of Urology Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 REFERENCES
~ :i: Macksood MJ, Roth DR, Chang cn, and Perlmutter AD: ~e~f~n fibroepithelial polyps as a cause of intermittent ~r~f~l~elvic junction obstruction in a child: a case report ~{;~]tevi'ew of the literature . J Urol 1985 ~ . 134" . 951-952 .
IDJ~C'N
~
L va~ ~TMF4A._Nrz~nFR 1
2. Foster RS, and Garrett RA: Congenital posterior urethral polyps. J Urol 136: 670-672, 1986. 3. Kimche D, and Lask D: Congenital polyp of the prostatic urethra. J Urol 127: 134, 1982. 4. Downs RA: Congenital polyps of the prostatic urethra: a review of the literature and report of two cases. Br J Urol 42: 76-85, 1970. 5. Williams PR, Feggetter J, Miller RA, and Wickham JEA: The diagnosis and management of benign fibrous ureteric polyps. BrJ Urol 52: 253-256, 1980. 6. Banner ME and Pollack HM: Fibrous ureteral polyps. Radiology 130: 73-76, 1979. 7. Crankson S, and Ahmed S: Benign bladder neck polyp and ureteropelvic obstruction in Beckwith-Wiedemann syndrome. Aust N ZJ Surg 61: 955-957, 1991. 8. Bockrath JM, Maizels M, and Firlit CF: Benign bladder neck polyp causing tandem obstruction of the urinary tract in a patient with Beckwith-Wiedemann syndrome. J Urol 128: 1309-1312, 1982. 9. Caro PA, Rosenberg HK, and Snyder HM III: Congenital urethral polyp. AJR 147: 1041-1042, 1986. 10. Youssif M: Posterior urethral polyps in inthnts and children. Eur Urol 11: 69-70, 1985.
109