THE JOURNAL OF UROLOGY
Vol. 68, No. 5, November 1952 Printed in U.S.A.
PRIMARY BENIGN NEOPLASM OF URETER ASSOCIATED WITH URETERAL CALCULUS THEODORE L. SAXE
Fewer than 40 cases of primary benign neoplasm of the ureter, substantiated by microscopic examination, have been reported in the literature. Of these, only a small percentage have been associated with ureteral calculi. It is the purpose of this paper to report an additional case of primary neoplasm associated with calculus. CASE REPORT
B.lVI., a 47 year old luncheonette counterman and former pugilist, was referred to me by his physician on February 14, 1950, because of microscopic hematuria. He complained of vague, dull abdominal and left loin pain of 1 year's duration. He had chronic, severe low backache for 5 years. One year previously he had received treatment for several months by an orthopedist because of backache, but the pain, nevertheless, persisted. During this period, the patient recalled that he had several episodes of nocturia up to three times, which would last for several nights and then disappear spontaneously. In August 1949, there was an attack of severe left loin colic. He consulted a physician, who found microscopic hematuria. The patient states that he then consulted a urologist in another city, who, after doing physical and cystoscopic examinations and taking a scout film, told him that he had probably passed a small stone. The abdominal and left loin pain and the backache persisted. His family physician examined the urine on several occasions during the next 4 months, and each time found microscopic hematuria. The patient also stated that he had been having episodes of pain in his great toes for several years, and that this had been diagnosed as gout. Physical examination revealed a husky, well developed man in no acute distress. Several small, whitish tumors were noted on the lobe of each ear, and these presumably were uric acid tophi. No abdominal or loin masses were present and no tenderness in the costovertebral angle. The genitalia appeared normal. The prostate was slightly enlarged, smooth, boggy and nontender. The urine was smoky. Acid reaction. Specific gravity 1.018. Albumin, slight trace. Sugar, negative. Microscopic examination: specimen was loaded with red blood cells. Excretory urography disclosed a tiny calcareous shadow in the region of the left ureter at the level of the interspace between the third and fourth lumbar vertebrae. The dye appeared in both kidneys within five minutes. No structural changes were detected in either the left or right kidney. In the 15 and 30 minute films, a filling defect was noted in the middle third of the left ureter. The right ureter appeared normal. Cystoscopy and left retrograde pyelography were done under caudal anesthesia. The bladder appeared normal. A No. 6 ureteral catheter was passed 10 819
THEODORE L. SAXE
cm. up the left ureter, and a gravity pyelogram made (fig. 1). Dye came back into the bladder around the catheter after approximately 5 cc of 40 per cent hippuran, colored blue with indigo carmine, had passed through the catheter. The catheter was then passed to 20 cm. without meeting obstruction or noticeable bleeding. The patient was admitted to the Park East Hospital, New York City, on February 24, 1950 (admission 6098). The preliminary diagnosis was 1) tumor of the left ureter; 2) left ureterolithiasis. Urinalysis revealed 5-8 white blood cells per high power field. No red blood cells. Hemoglobin 5,400,000. White blood cells 10,600. Urea nitrogen 9 mg. per cent. Blood uric acid 3.3 mg. per cent. Serology was negative.
Fm. 1. Retrograde pyelogram done by gravity method
A scout film taken on the day of admission again showed a small calcareous shadow in the region of the left ureter between the third and fourth lumbar vertebrae. Operation was done February 25 under spinal anesthesia. With the patient placed on his side in the usual kidney position, a left loin incision was made exposing the midportion of the ureter. A soft, fusiform enlargement of the inferior portion of the middle third of the ureter was noted. A 1 cm. incision was made through the wall of the ureter at the greatest diameter of the enlargement. As this incision was made, a grape seed sized, tan colored, smooth calculus popped out into the wound. A polypoid mass, which was attached to the wall of the ureter by a pedicle, protruded through the ureterotomy wound. The pathologist was called to the operating room to examine the tumor in situ. It was his opinion that it was benign. The tumor was removed complete with its pedicle and surrounding wall by
NEOPLASM OF URETER AND URETERAL CALCULUS
an elliptical incision. A No. 8 ureteral catheter was passed through the ureterotomy down to the bladder and then up to the pelvis without meeting obstrucc tion. The catheter was then removed, and the ureterotomy closed with 000 plain catgut sutures. A Penrose drain was placed down into the wound and exteriorized posteriorly. The incision was then closed in layers. There was a temperature rise to 101.6F on the first postoperative day. Thereafter, the temperature remained normal. The patient was out of bed on the second day, and the wound was dry by the eighth postoperative day. He was discharged on the tenth day completely asymptomatic. · Pathologist's report (Dr. Arthur Schifrin): The gross specimen was a pea sized polypoid structure measuring 1 cm. in height and 0.6 cm. in width. It was of soft consistency. On section the base measured 0.5 cm. in width. The polyp consisted of gray-pink, soft, homogeneous tissue which was sharply demarcated from the submucosal area. The lesion was resected 0.4 cm. deep to the polyp
Fm. 2. Benign papilloma of ureter. Note sharp demarcation from stroma. (X 200.)
and closest circumferential edge was 0.3 cm. from the polyp. In addition, a fragment of the adjacent ureteral wall and a grape seed sized tan colored calculus were removed. On microscopic examination (fig. 2) the tumor had a polypoid papillary architecture and was lined by regular transitional epithelium with regular nuclei. No frank nuclear atypism, nuclear bizarreness or mitoses were seen. The basal layer of the epithelium was sharply demarcated from the stroma which contained several large dilated congested blood vessels. Study of the adjacent ureter wall showed that the surface of the lumen was lined by regular transitional epithelium with regular nuclei. The basal layer was sharply defined. The submucosa was edematous and congested. The muscular layer was well developed. No infiltration of the wall by tumor tissue was noted. Diagnosis: Benign transitional cell papilloma of ureter; adjacent wall, free of tumor tissue; ureteral calculus, which consisted of uric acid, ammonia and calcium oxalate.
THEODORE L. SAXE
There has been no recurrence of low backache, no microscopic hematuria or vague abdominal and left loin pain since the operation. Excretory urography was done on March 18 and also October 16, 1950. Normal urograms were obtained both times. The patient was last seen on August 11, 1951, at which time he had no symptoms, and the urine was normal. DISCUSSION
The diagnosis of ureteral neoplasm in this case was made on the presence of a large filling defect which could be detected by both excretory and retrograde pyelography. The possibility of nonopaque uric acid calculi in the ureter in this patient, who had a history of gout, was entertained, but the easy passage of a No. 6 ureteral catheter past the large filling defect seemed to preclude such a diagnosis. On the other hand, the lack of profuse bleeding, particularly after instrumentation of the ureter, was unlike the usual ureteral neoplasm. The association of an opaque calculus with the main lesion was proven preoperatively by the excretory urogram with exposures taken in the anteroposterior and oblique positions. The bizarreness and unusual behavior of the lesion to instrumentation prompted me to explore the ureter before proceeding with radical surgery. The benign appearance of the polyp, the softness of the wall and the opinion of the pathologist at the operating table led to conservative surgery. Ureteronephrectomy has been advocated as the procedure of choice for ureteral neoplasm, whether malignant or benign. In the past few years, several dissenting opinions have been voiced. The objection to conservative surgery of benign lesions has been theoretical. It has been said that if a benign lesion were allowed to stay in the ureter long enough, it would become malignant. Perhaps so, but if the lesion is removed while still in the benign stage, does the potentiality to malignancy still remain? Actually, there has been no adequate clinical study of patients who have had conservative surgery. In the operation performed on this patient, an elliptical section of the dilated ureteral wall which contained the pedicle of the polyp was excised, and the opening closed in the usual manner as for any ureterotomy. This simple procedure has appeared to be adequate in this case. SUMMARY
A case of primary benign ureteral neoplasm associated with ureteral calculus is presented. A suggestion is made that conservative surgery may be adequate for the treatment of benign primary tumors of the ureter.
2777 Hudson Blvd., Jersey City 6, N. J. REFERENCES DOUGLASS, H. L.: Ann. Surg., 131: 755, 1950. EDELSTEIN, J.M. AND MARCUS, S. M.: J. Urol., 60: 409, 1948. MELICow, M. M. AND FINDLAY, H. V.: Surg. Gynec. & Obst., 54: 680, 1932. RusCHE, C. AND BACON, S. K.: J. Urol., 39: 319, 1938.