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Painless Hematuria, Unilateral Hydroureteronephrosis and Bladder Distortion
0022-5347 /79/1225-0687$02.00/0 Vol. 122, November
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1979 by The Williams & Wilkins Co.
Clinicopathologi cal Conference p AINLESS HEMATURIA, UNILATERAL HYDROURETERONEPHROSIS AND BLADDER DISTORTION G. ROGER JOHNSON,* CARL M. SANDLERt
AND
JOSEPH N. CORRIERE, JR.:j:
From the Division of Urology, Department of Surgery and Department of Radiology, The University of Texas Medical School at Houston, Houston, Texas
PRESENTATION OF CASE§
Dr. G. Roger Johnson. A 57-year-old white woman was referred for evaluation of recent intermittent episodes of gross, painless hematuria, which had occurred during the last 8 months. About 20 months earlier the woman first began to experience intermittent episodes of total gross, painless hematuria. A month later she underwent cystoscopy at another institution and the examination revealed a small superficial lesion on the left wall of the bladder that had been reported to resemble a classical papillary transitional cell carcinoma. The lesion was fulgurated but no tissue was removed for microscopic examination. The endoscopist noted marked trigonal distortion, which prevented him from accurately identifying the ureteral orifices. On pelvic examination no masses were palpated. Cystoscopy was repeated 3 months later and no mucosal lesions were present. The patient remained asymptomatic for the next 8 months and, therefore, sought no further medical attention. Then, the intermittent hematuria returned, again without associated symptomatology, and persisted for the most recent 8 months, at which time the woman requested re-evaluation. An excretory urogram (IVP) was performed and the woman was then referred to our institution for further study because of the history and the radiologic abnormalities. At the time of our evaluation she denied flank pain, fever, chills, dysuria, frequency, urgency or nocturia. Her weight had remained stable during the last few years, her appetite was good and she appeared to be in excellent general health. She recalled having had several urinary tract infections during pregnancies, all occurring >20 years ago. An appendectomy had been performed when she was a child. She had had an abdominal hysterectomy and vesicourethral suspension for menometrorrhagia and mild stress incontinence 6 years before we saw her. She denied any family history of genitourinary disease and she had never traveled outside of the United States. Physical examination revealed a well developed, well nourished white woman, who appeared to be her stated age and was in no distress. The vital signs were normal. Examination of the head and neck, chest and extremities was within normal limits. The abdomen was flat, soft and non-tender with no masses or organs palpable. A well healed Pfannenstiel incision was noted. Ascultation revealed no bruits. Bowel sounds were normal. External genitalia were normal and no pelvic masses were present. The uterus and adnexal structures were absent. No • Chief Resident in Urology, The Hermann Hospital. t Assistant Professor of Radiology, The University of Texas Medical School at Houston. t Professor and_ Director, Divisi
tenderness was noted on examination. A hemogram was normal with a hematocrit of 43 per cent. Urinalysis showed 10 to 15 white and many red blood cells per high power field but was otherwise normal. A urine culture was sterile. The results of the serum chemistry and blood coagulation studies were normal except for a slightly elevated serum glucose (114 mg./dl.) and alkaline phosphatase (119 µ./1.). S~rum creatinine was 1.4 mg./dl. A chest x-ray and electrocardiogram were within normal limits. A skin test with purified protein derivative was negative at 48 hours. DISCUSSION OF IVP
Dr. Carl M. Sandler. The preliminary radiograph demonstrated multiple calcifications in the pelvis, which had the appearance of phleboliths. Additionally, there was . a small density just to the left of L5, which on subsequent ra~10gra1;>hs was shown to be outside the urinary tract. On the 5-mmute film there was mild delay in excretion from the right kidney and early filling of the collecting syst~m and renal_ pelvis, both of which appear dilated. The left kidney, collectmg system and ureter appeared normal. By 10 minutes there was_ excellent opacification of the right collecting system and pelvis, ~oth of which again were noted to be moderately hydronephrotic. T~e 15-minute radiograph demonstrated dilatation of the entrre right ureter to the level of the bladder (fig. 1). . X-rays of the bladder revealed a rel~tiv~ly smo?th defect m the right inferior aspect. In some pro1ect1ons this defect appeared to be extrinsic. On the left anterior oblique vie_w of the bladder the dilated ureter was projected through this defect (fig. 2, A). This fmding also was demonstrated on the erect view of the bladder (fig. 2, B). . . . The radiologic findings suggested several d1fferen~ial d1a~nostic possibilities. The first to be considered was an mtraves1cular neoplasm causing obstruction of the right ureter. ~ecause the defect is relatively smooth-walled one could consider the possibility of a benign neoplasm, s_uch as a leiomyoma, a neurofibroma or, perhaps, a paraganghoma. These neoplasms generally tend to have smooth margins and_ t_e:1d to be l~cated adjacent to the trigone. Certainly, the possibility of a malignant bladder tumor, despite its relatively smooth appearance, cannot be excluded. If the defect is truly extrinsic to the bladder an extravesicular neoplasm, either benign or malignant, is a possibility. Endometriosis has been reported to have this app_ea:ance and postoperative defects in the bladder also can mrm1c these changes. The appearance of the dilated ureter projected throu~h t~e defect in the bladder is suggestive of ureterocele, which is perhaps best appreciated on the post-_voiding_ radiograph (fi~. 3). A simple ureterocele presented rad10graph1cally as a cyst!c dilatation of the distal ureter typically surrounded by a thm radiolucent halo. However, the radiographic appearance of this
688
CLINICOPATHOLOGICAL CONFERENCE
case is more in keeping with a pseudoureterocele, in that there is asymmetry of the dilated ureteral lumen and the dilatation extends into the upper urinary tract. In their series of 5 pseudoureteroceles Thornbury and associates found that they commonly were associated with acquired obstruction of the urinary tract, usually related to a bladder malignancy. 1 In summary, the findings are in keeping with relatively low
Fm. 1. Radiograph 15 minutes after injection of contrast medium. Note dilatation of right ureter to level of bladder and radiolucent filling defect in bladder.
grade obstruction of the right ureter, with an appearance of the distal ureter suggesting a pseudoureterocele. This is most likely related to a neoplasm, possibly benign, of the bladder. DIFFERENTIAL DIAGNOSIS
Dr. Joseph N. Corriere, Jr. Before describing the findings at cystoscopy, which will eliminate many possible pathologic processes suggested by the IVP, let us consider the history and the studies already performed. Without doubt hematuria and bladder distortion must be considered first to be caused by a bladder tumor when they occur in a 57-year-old patient who has had a prior bladder tumor. Because of the hydroureteronephrosis and the apparent large filling defect on the radiograph I was concerned that the lesion may be quite large but it seems that such a lesion could be palpated on pelvic examination. It also is hard to believe that such a large bladder tumor, if that is what this is, had not caused more irritative symptoms but we all know it may not. Doctor Sandler suggested that we consider a ureterocele or pseudoureterocele as the cause of the filling defect, which also could account for the ureteral obstruction. Dilated urinary tract structures, such as bladder diverticula, hydronephrosis and ureteroceles, can bleed intermittently. This diagnosis also could explain the bladder distortion and difficulty in finding the
Fm. 3. Post-evacuation radiograph of bladder. Dilated ureter appears to terminate as ureterocele. Asymmetry of dilated ureteral lumen and extension of dilatation into upper urinary tract suggest pseudoureterocele.
Fm. 2. Radiograph of bladder. A, left anterior oblique view demonstrates bladder filling defect. B, erect x-ray demonstrates dilated ureter projected through this defect.
PAINLESS HEMATURIA, UNILATERAL HYDROURETERONEPHROSIS AND BLADDER DISTORTION
ureteral orifices described 19 months earlier. However, the ureteral obstruction appears to be of short duration and I just do not believe that a simple ureterocele is satisfactorily consistent with the available information. Could the entire process be extrinsic? Certainly, bladder distortion and the acute nature of the obstruction are compatible with this possibility. Unfortunately, such a mass should be palpable on examination if this were the case and none was described. This patient could have a ureteral lesion at the level of the ureterovesical junction. A ureteral tumor is a good possibility because of the history. There are calcifications in the pelvic area, which suggests that one of them may be a ureteral calculus, a well known cause of hematuria and hydroureteronephrosis. However, one would expect some prior episode of pain with a stone and one would have to explain the apparent filling defect as mucosa! edema. The defect seems a bit too large to be edema from an intramural calculus or ureteral tumor, for that matter. Finally, we must consider inflammatory disease as the etiologic agent. Tuberculosis does cause ureteral obstruction at this level, as does schistosomiasis. Since the chest radiograph and skin test are negative and the patient has never left the country, I will rule these out. Inflammation also can occur after an operation and lead to ureteral obstruction but even though the prior resectionist had difficulty recognizing the ureteral orifices, the previous lesion was said to be on the left side of the bladder and at present the patient has a right ureteral obstruction. I believe that it is appropriate to perform diagnostic cystoscopy and then proceed with definitive therapy. CLINICAL DIAGNOSIS
Bladder tumor with obstruction of the right ureterovesical junction. DISCUSSION OF SURGERY
Doctor Johnson. Cystoscopy revealed both ureteral orifices displaced laterally. The right orifice also was elevated as if by an extrinsic mass and was virtually on the lateral wall of the bladder. Cystitis cystica was present on the distorted trigone in the area of the right orifice. No other mucosal lesions were present. Blood was seen effluxing from the right ureteral orifice and clear urine effluxed from the left ureter. Pelvic examination again revealed no masses. The right extraperitoneal paravesical area was explored through a Pfannenstiel incision. The right dilated ureter was followed down to the level of the bladder. No masses could be palpated, although the entire right side of the bladder was fixed to the symphysis pubis. The ureter was transected as low as possible and the cut end was sent for frozen section examination. Clear urine effluxed from the upper tract and the histology of the ureter showed moderate inflammation with no evidence of tumor. The bladder was opened and the ureteral orifice was circumscribed. The entire intramural ureter then was dissected from its bed and sent for frozen section evaluation. During this
689
dissection permanent braided sutures, obviously used in the previous vesicourethral suspension, were cut across and appeared to be responsible for the bladder and ureteral orifice distortion. When the ureter was opened no mucosa! lesions were present but a 5 x 4 mm. calculus was impacted in the lumen adjacent to the sutures. Only chronic inflammation was present on histology. Ureteroneocystostomy was performed. Postoperatively, the patient did well and left the hospital after 10 days. Permanent sections of the intramural ureter confirmed the frozen section findings of chronic inflammation. The calculus was composed of 40 per cent calcium oxalate monohydrate, 50 per cent calcium oxalate dihydrate and 10 per cent calcium apatite. DISCUSSION OF FINDINGS
Doctor Corriere. A reconstruction of the possible history in this case is conjectural at best but it seems that the initial urinary tract problem occurred at the time of the vesicourethral suspension 6 years earlier. At that time permanent suture material used in the repair partially obstructed the right ureter. Sometime in the last 20 months a small calculus in the right kidney traveled down the ureter and lodged at the point of obstruction, which acutely increased whatever hydroureteronephrosis was present and initiated the intermittent hematuria. How all of this occurred without some evidence of flank or abdominal pain and what the subsequent bladder tumor has to do with it all I am not at all sure! This is the third case of ureteral obstruction after vesicourethral suspension that I have seen personally. The other 2 patients had postoperative anuria because of bilateral ureteral involvement and this was corrected by removal of the sutures. There is little in the literature concerning this surgical misadventure but it appears to be the consequence of inadvertent suture placement through the intramural ureter with subsequent distortion of the trigone (which is evident on radiograph), when this area of the bladder is fixed to the symphysis pubis. 2•3 During suture placement some surgeons also have an assistant elevate the base of the bladder by placing a hand in the vagina. This maneuver could distort the bladder and lead to a deeper bite of bladder than is intended. By inflating the indwelling urethral catheter balloon with at least 20 cc fluid it is likely that the base of the bladder can be kept away from the area to be sutured and this complication can be avoided. FINAL DIAGNOSIS
Ureteral obstruction secondary to previous vesicourethropexy; ureteral calculus. REFERENCES
1. Thornbury, J. R., Silver, T. M. and Vinson, R. K.: Ureteroceles vs.
pseudoureteroceles in adults. Urographic diagnosis. Radiology, 122: 81, 1977. 2. Bright, T. C., III and Peters, P. C.: Ureteral injuries secondary to operative procedures. Urology, 9: 22, 1977. 3. Persky, L. and Guerriere, K.: Complications ofMarshall-MarchettiKrantz urethropexy. Urology, 8: 469, 1976.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1979 by The Williams & Wilkins Co.
Clinicopathologi cal Conference p AINLESS HEMATURIA, UNILATERAL HYDROURETERONEPHROSIS AND BLADDER DISTORTION G. ROGER JOHNSON,* CARL M. SANDLERt
AND
JOSEPH N. CORRIERE, JR.:j:
From the Division of Urology, Department of Surgery and Department of Radiology, The University of Texas Medical School at Houston, Houston, Texas
PRESENTATION OF CASE§
Dr. G. Roger Johnson. A 57-year-old white woman was referred for evaluation of recent intermittent episodes of gross, painless hematuria, which had occurred during the last 8 months. About 20 months earlier the woman first began to experience intermittent episodes of total gross, painless hematuria. A month later she underwent cystoscopy at another institution and the examination revealed a small superficial lesion on the left wall of the bladder that had been reported to resemble a classical papillary transitional cell carcinoma. The lesion was fulgurated but no tissue was removed for microscopic examination. The endoscopist noted marked trigonal distortion, which prevented him from accurately identifying the ureteral orifices. On pelvic examination no masses were palpated. Cystoscopy was repeated 3 months later and no mucosal lesions were present. The patient remained asymptomatic for the next 8 months and, therefore, sought no further medical attention. Then, the intermittent hematuria returned, again without associated symptomatology, and persisted for the most recent 8 months, at which time the woman requested re-evaluation. An excretory urogram (IVP) was performed and the woman was then referred to our institution for further study because of the history and the radiologic abnormalities. At the time of our evaluation she denied flank pain, fever, chills, dysuria, frequency, urgency or nocturia. Her weight had remained stable during the last few years, her appetite was good and she appeared to be in excellent general health. She recalled having had several urinary tract infections during pregnancies, all occurring >20 years ago. An appendectomy had been performed when she was a child. She had had an abdominal hysterectomy and vesicourethral suspension for menometrorrhagia and mild stress incontinence 6 years before we saw her. She denied any family history of genitourinary disease and she had never traveled outside of the United States. Physical examination revealed a well developed, well nourished white woman, who appeared to be her stated age and was in no distress. The vital signs were normal. Examination of the head and neck, chest and extremities was within normal limits. The abdomen was flat, soft and non-tender with no masses or organs palpable. A well healed Pfannenstiel incision was noted. Ascultation revealed no bruits. Bowel sounds were normal. External genitalia were normal and no pelvic masses were present. The uterus and adnexal structures were absent. No • Chief Resident in Urology, The Hermann Hospital. t Assistant Professor of Radiology, The University of Texas Medical School at Houston. t Professor and_ Director, Divisi
tenderness was noted on examination. A hemogram was normal with a hematocrit of 43 per cent. Urinalysis showed 10 to 15 white and many red blood cells per high power field but was otherwise normal. A urine culture was sterile. The results of the serum chemistry and blood coagulation studies were normal except for a slightly elevated serum glucose (114 mg./dl.) and alkaline phosphatase (119 µ./1.). S~rum creatinine was 1.4 mg./dl. A chest x-ray and electrocardiogram were within normal limits. A skin test with purified protein derivative was negative at 48 hours. DISCUSSION OF IVP
Dr. Carl M. Sandler. The preliminary radiograph demonstrated multiple calcifications in the pelvis, which had the appearance of phleboliths. Additionally, there was . a small density just to the left of L5, which on subsequent ra~10gra1;>hs was shown to be outside the urinary tract. On the 5-mmute film there was mild delay in excretion from the right kidney and early filling of the collecting syst~m and renal_ pelvis, both of which appear dilated. The left kidney, collectmg system and ureter appeared normal. By 10 minutes there was_ excellent opacification of the right collecting system and pelvis, ~oth of which again were noted to be moderately hydronephrotic. T~e 15-minute radiograph demonstrated dilatation of the entrre right ureter to the level of the bladder (fig. 1). . X-rays of the bladder revealed a rel~tiv~ly smo?th defect m the right inferior aspect. In some pro1ect1ons this defect appeared to be extrinsic. On the left anterior oblique vie_w of the bladder the dilated ureter was projected through this defect (fig. 2, A). This fmding also was demonstrated on the erect view of the bladder (fig. 2, B). . . . The radiologic findings suggested several d1fferen~ial d1a~nostic possibilities. The first to be considered was an mtraves1cular neoplasm causing obstruction of the right ureter. ~ecause the defect is relatively smooth-walled one could consider the possibility of a benign neoplasm, s_uch as a leiomyoma, a neurofibroma or, perhaps, a paraganghoma. These neoplasms generally tend to have smooth margins and_ t_e:1d to be l~cated adjacent to the trigone. Certainly, the possibility of a malignant bladder tumor, despite its relatively smooth appearance, cannot be excluded. If the defect is truly extrinsic to the bladder an extravesicular neoplasm, either benign or malignant, is a possibility. Endometriosis has been reported to have this app_ea:ance and postoperative defects in the bladder also can mrm1c these changes. The appearance of the dilated ureter projected throu~h t~e defect in the bladder is suggestive of ureterocele, which is perhaps best appreciated on the post-_voiding_ radiograph (fi~. 3). A simple ureterocele presented rad10graph1cally as a cyst!c dilatation of the distal ureter typically surrounded by a thm radiolucent halo. However, the radiographic appearance of this
688
CLINICOPATHOLOGICAL CONFERENCE
case is more in keeping with a pseudoureterocele, in that there is asymmetry of the dilated ureteral lumen and the dilatation extends into the upper urinary tract. In their series of 5 pseudoureteroceles Thornbury and associates found that they commonly were associated with acquired obstruction of the urinary tract, usually related to a bladder malignancy. 1 In summary, the findings are in keeping with relatively low
Fm. 1. Radiograph 15 minutes after injection of contrast medium. Note dilatation of right ureter to level of bladder and radiolucent filling defect in bladder.
grade obstruction of the right ureter, with an appearance of the distal ureter suggesting a pseudoureterocele. This is most likely related to a neoplasm, possibly benign, of the bladder. DIFFERENTIAL DIAGNOSIS
Dr. Joseph N. Corriere, Jr. Before describing the findings at cystoscopy, which will eliminate many possible pathologic processes suggested by the IVP, let us consider the history and the studies already performed. Without doubt hematuria and bladder distortion must be considered first to be caused by a bladder tumor when they occur in a 57-year-old patient who has had a prior bladder tumor. Because of the hydroureteronephrosis and the apparent large filling defect on the radiograph I was concerned that the lesion may be quite large but it seems that such a lesion could be palpated on pelvic examination. It also is hard to believe that such a large bladder tumor, if that is what this is, had not caused more irritative symptoms but we all know it may not. Doctor Sandler suggested that we consider a ureterocele or pseudoureterocele as the cause of the filling defect, which also could account for the ureteral obstruction. Dilated urinary tract structures, such as bladder diverticula, hydronephrosis and ureteroceles, can bleed intermittently. This diagnosis also could explain the bladder distortion and difficulty in finding the
Fm. 3. Post-evacuation radiograph of bladder. Dilated ureter appears to terminate as ureterocele. Asymmetry of dilated ureteral lumen and extension of dilatation into upper urinary tract suggest pseudoureterocele.
Fm. 2. Radiograph of bladder. A, left anterior oblique view demonstrates bladder filling defect. B, erect x-ray demonstrates dilated ureter projected through this defect.
PAINLESS HEMATURIA, UNILATERAL HYDROURETERONEPHROSIS AND BLADDER DISTORTION
ureteral orifices described 19 months earlier. However, the ureteral obstruction appears to be of short duration and I just do not believe that a simple ureterocele is satisfactorily consistent with the available information. Could the entire process be extrinsic? Certainly, bladder distortion and the acute nature of the obstruction are compatible with this possibility. Unfortunately, such a mass should be palpable on examination if this were the case and none was described. This patient could have a ureteral lesion at the level of the ureterovesical junction. A ureteral tumor is a good possibility because of the history. There are calcifications in the pelvic area, which suggests that one of them may be a ureteral calculus, a well known cause of hematuria and hydroureteronephrosis. However, one would expect some prior episode of pain with a stone and one would have to explain the apparent filling defect as mucosa! edema. The defect seems a bit too large to be edema from an intramural calculus or ureteral tumor, for that matter. Finally, we must consider inflammatory disease as the etiologic agent. Tuberculosis does cause ureteral obstruction at this level, as does schistosomiasis. Since the chest radiograph and skin test are negative and the patient has never left the country, I will rule these out. Inflammation also can occur after an operation and lead to ureteral obstruction but even though the prior resectionist had difficulty recognizing the ureteral orifices, the previous lesion was said to be on the left side of the bladder and at present the patient has a right ureteral obstruction. I believe that it is appropriate to perform diagnostic cystoscopy and then proceed with definitive therapy. CLINICAL DIAGNOSIS
Bladder tumor with obstruction of the right ureterovesical junction. DISCUSSION OF SURGERY
Doctor Johnson. Cystoscopy revealed both ureteral orifices displaced laterally. The right orifice also was elevated as if by an extrinsic mass and was virtually on the lateral wall of the bladder. Cystitis cystica was present on the distorted trigone in the area of the right orifice. No other mucosal lesions were present. Blood was seen effluxing from the right ureteral orifice and clear urine effluxed from the left ureter. Pelvic examination again revealed no masses. The right extraperitoneal paravesical area was explored through a Pfannenstiel incision. The right dilated ureter was followed down to the level of the bladder. No masses could be palpated, although the entire right side of the bladder was fixed to the symphysis pubis. The ureter was transected as low as possible and the cut end was sent for frozen section examination. Clear urine effluxed from the upper tract and the histology of the ureter showed moderate inflammation with no evidence of tumor. The bladder was opened and the ureteral orifice was circumscribed. The entire intramural ureter then was dissected from its bed and sent for frozen section evaluation. During this
689
dissection permanent braided sutures, obviously used in the previous vesicourethral suspension, were cut across and appeared to be responsible for the bladder and ureteral orifice distortion. When the ureter was opened no mucosa! lesions were present but a 5 x 4 mm. calculus was impacted in the lumen adjacent to the sutures. Only chronic inflammation was present on histology. Ureteroneocystostomy was performed. Postoperatively, the patient did well and left the hospital after 10 days. Permanent sections of the intramural ureter confirmed the frozen section findings of chronic inflammation. The calculus was composed of 40 per cent calcium oxalate monohydrate, 50 per cent calcium oxalate dihydrate and 10 per cent calcium apatite. DISCUSSION OF FINDINGS
Doctor Corriere. A reconstruction of the possible history in this case is conjectural at best but it seems that the initial urinary tract problem occurred at the time of the vesicourethral suspension 6 years earlier. At that time permanent suture material used in the repair partially obstructed the right ureter. Sometime in the last 20 months a small calculus in the right kidney traveled down the ureter and lodged at the point of obstruction, which acutely increased whatever hydroureteronephrosis was present and initiated the intermittent hematuria. How all of this occurred without some evidence of flank or abdominal pain and what the subsequent bladder tumor has to do with it all I am not at all sure! This is the third case of ureteral obstruction after vesicourethral suspension that I have seen personally. The other 2 patients had postoperative anuria because of bilateral ureteral involvement and this was corrected by removal of the sutures. There is little in the literature concerning this surgical misadventure but it appears to be the consequence of inadvertent suture placement through the intramural ureter with subsequent distortion of the trigone (which is evident on radiograph), when this area of the bladder is fixed to the symphysis pubis. 2•3 During suture placement some surgeons also have an assistant elevate the base of the bladder by placing a hand in the vagina. This maneuver could distort the bladder and lead to a deeper bite of bladder than is intended. By inflating the indwelling urethral catheter balloon with at least 20 cc fluid it is likely that the base of the bladder can be kept away from the area to be sutured and this complication can be avoided. FINAL DIAGNOSIS
Ureteral obstruction secondary to previous vesicourethropexy; ureteral calculus. REFERENCES
1. Thornbury, J. R., Silver, T. M. and Vinson, R. K.: Ureteroceles vs.
pseudoureteroceles in adults. Urographic diagnosis. Radiology, 122: 81, 1977. 2. Bright, T. C., III and Peters, P. C.: Ureteral injuries secondary to operative procedures. Urology, 9: 22, 1977. 3. Persky, L. and Guerriere, K.: Complications ofMarshall-MarchettiKrantz urethropexy. Urology, 8: 469, 1976.