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Radiolucent Seed Calculi in an Orthotopic Ureterocele
0022-5347 /88/1406-1521$2.00/0 'V oL 140, December
THE JOURNAL OF UROLOGY
Copyright© 1988 by The 1Ni!liams & Wilkins Co.
Printed in U.S.A.
RADIOLUCENT SEED CALCULI IN AN ORTHOTOPIC URETEROCELE W. S. WONG AND M. K. LI From the Division of Urology, Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
ABSTRACT
We report a case of radiolucent seed calculi in an orthotopic ureterocele. The diagnosis was based on clinical suspicion and confirmed by ultrasonography. (J. Ural., 140: 1521-1522, 1988)
Milk of calcium is defined as a liquid suspension of calcium particles 1 and seed calculi are defined as a collection of numerous small definable stones. 2 Two cases ofureteroceles with milk of calcium 3 •4 and 1 case of ureterocele with seed calculi 2 have been reported. The diagnoses were not difficult because the milk of calcium and seed calculi presented as radiopaque masses on plain x-ray films. We report a case of radio lucent seed calculi in an orthotopic ureterocele. CASE REPORT
A 40-year-old Chinese woman presented in May 1986 with full stream hematuria for 1 week and mild left loin discomfort. Physical examination showed no abnormalities. Urinalysis revealed microscopic hematuria but no pyuria. Urine pH was 6 and no crystals were found. Urine culture yielded no growth. Plain x-ray films of the abdomen and pelvis showed no radiopaque urinary calculi (fig. 1, A). Serum creatinine was 0.063 mmol/L, and serum calcium, phosphate and uric acid were normal. An excretory urogram (IVP) demonstrated a left orthotopic ureterocele without any obstruction (fig. 1, B), which was confirmed by cystoscopy. No stones, tumor or other mucosa! pathological conditions were found. Clean urine was seen coming from both ureteral orifices.
Fm. 2. Ultrasonography of bladder shows dense echoes caused by stones inside ureteroce!e (arrowheads) and acoustic shadow beneath stones (arrows).
Fm. 1. A, plain x-ray film of pelvis shows no radiopaque urinary calculi. B, IVP reveals left orthotopic ureterocele (arrows)
The patient experienced several attacks of full stream hematuria and left loin discomfort after the IVP. Ultrasonography revealed stones inside the ureterocele (fig. 2). A 24-hour urine for calcium, phosphate and uric acid contents was within normal range. Endoscopic incision of the ureterocele was performed and more than 100 seed calculi were found inside the ureterocele (fig. 3). Stone analysis revealed calcium and uric acid. Convalescence was uneventful. An IVP and voiding cystogram 10 months postoperatively were normal with no evidence of obstruction or reflux. Accepted for publication March 18, 1988.
DISCUSSION
Adult ureteroceles are frequently found to contain calculi and discrete calculi are noted in 17 to 35 per cent of ureteroceles. 5 Ureteroceles with milk of calcium or seed calculi are rare. Most stones in ureteroceles are calcium oxalate alone or they are combined with calcium phosphate but none contains cystine or uric acid. 6 It is unique that the stones in our patient were composed of calcium and uric acid. Uric acid calculi are radiolucent and the diagnosis of such calculi inside a ureterocele is more difficult. The cause for such stone formation is not known. With a normal serum and urinary uric acid, the urinary
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WONG AND LI
recommended treatment for ureteroceles with stones is open ureterocelectomy and reimplantation of the ureter for fear of reflux after endoscopic surgery. 6 It has been shown that reflux may not always be present after endoscopic incision of ureteroceles with or without stones, 7 •8 as demonstrated by our case. However, the treatment for stones in ureteroceles remains controversial.
REFERENCES
FIG. 3. Seed calculi 2 mm. or less in diameter inside and outside ureterocele that had been incised endoscopically.
stasis inside the ureterocele may be the main contributing factor. It is generally believed that ureteroceles are associated with urinary stasis, which is partly responsible for the formation and growth of calculi. 6 Our patient might have remained untreated if ultrasonography of the bladder had not been performed. The diagnosis was based on clinical suspicion and confirmed by ultrasonography, which is not routinely performed for hematuria. The
1. Reynolds, W. F., Goldstein, A. M. B., Williams, E. J. and Fauer, R. B.: Uncommon radiologic observations in renal milk-of-calcium stone. Urology, 11: 419, 1978. 2. Curcio, C. M. and Goldman, S. M.: Seed calculi in an ectopic ureterocele: a case report. J. Urol., 130: 1165, 1983. 3. Becker, J. M. and Pollack, H.: Milk of calcium and ureterocele. Urol. Rad., 3: 31, 1981. 4. Engel, I. A., Brill, P. W. and Winchester, P.: Obstructed ureterocele with milk of calcium. Urol. Rad., 3: 35, 1981. 5. Messing, E. M. and Henry, S. C.: Stones in orthotopic, nonobstructing ureteroceles. J. Urol., 122: 403, 1979. 6. Amar, A. D.: Management of urinary calculous disease in patients with ureterocele. J. Urol., 117: 34, 1977. 7. Rodriguez, J. V.: Endoscopic surgery of calculi in ureteroceles. Eur. Urol., 10: 36, 1984. 8. Tank, E. S.: Experience with endoscopic incision and open unroofing of ureteroceles. J. Urol., 136: 241, 1986.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The 1Ni!liams & Wilkins Co.
Printed in U.S.A.
RADIOLUCENT SEED CALCULI IN AN ORTHOTOPIC URETEROCELE W. S. WONG AND M. K. LI From the Division of Urology, Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
ABSTRACT
We report a case of radiolucent seed calculi in an orthotopic ureterocele. The diagnosis was based on clinical suspicion and confirmed by ultrasonography. (J. Ural., 140: 1521-1522, 1988)
Milk of calcium is defined as a liquid suspension of calcium particles 1 and seed calculi are defined as a collection of numerous small definable stones. 2 Two cases ofureteroceles with milk of calcium 3 •4 and 1 case of ureterocele with seed calculi 2 have been reported. The diagnoses were not difficult because the milk of calcium and seed calculi presented as radiopaque masses on plain x-ray films. We report a case of radio lucent seed calculi in an orthotopic ureterocele. CASE REPORT
A 40-year-old Chinese woman presented in May 1986 with full stream hematuria for 1 week and mild left loin discomfort. Physical examination showed no abnormalities. Urinalysis revealed microscopic hematuria but no pyuria. Urine pH was 6 and no crystals were found. Urine culture yielded no growth. Plain x-ray films of the abdomen and pelvis showed no radiopaque urinary calculi (fig. 1, A). Serum creatinine was 0.063 mmol/L, and serum calcium, phosphate and uric acid were normal. An excretory urogram (IVP) demonstrated a left orthotopic ureterocele without any obstruction (fig. 1, B), which was confirmed by cystoscopy. No stones, tumor or other mucosa! pathological conditions were found. Clean urine was seen coming from both ureteral orifices.
Fm. 2. Ultrasonography of bladder shows dense echoes caused by stones inside ureteroce!e (arrowheads) and acoustic shadow beneath stones (arrows).
Fm. 1. A, plain x-ray film of pelvis shows no radiopaque urinary calculi. B, IVP reveals left orthotopic ureterocele (arrows)
The patient experienced several attacks of full stream hematuria and left loin discomfort after the IVP. Ultrasonography revealed stones inside the ureterocele (fig. 2). A 24-hour urine for calcium, phosphate and uric acid contents was within normal range. Endoscopic incision of the ureterocele was performed and more than 100 seed calculi were found inside the ureterocele (fig. 3). Stone analysis revealed calcium and uric acid. Convalescence was uneventful. An IVP and voiding cystogram 10 months postoperatively were normal with no evidence of obstruction or reflux. Accepted for publication March 18, 1988.
DISCUSSION
Adult ureteroceles are frequently found to contain calculi and discrete calculi are noted in 17 to 35 per cent of ureteroceles. 5 Ureteroceles with milk of calcium or seed calculi are rare. Most stones in ureteroceles are calcium oxalate alone or they are combined with calcium phosphate but none contains cystine or uric acid. 6 It is unique that the stones in our patient were composed of calcium and uric acid. Uric acid calculi are radiolucent and the diagnosis of such calculi inside a ureterocele is more difficult. The cause for such stone formation is not known. With a normal serum and urinary uric acid, the urinary
1521
1522
WONG AND LI
recommended treatment for ureteroceles with stones is open ureterocelectomy and reimplantation of the ureter for fear of reflux after endoscopic surgery. 6 It has been shown that reflux may not always be present after endoscopic incision of ureteroceles with or without stones, 7 •8 as demonstrated by our case. However, the treatment for stones in ureteroceles remains controversial.
REFERENCES
FIG. 3. Seed calculi 2 mm. or less in diameter inside and outside ureterocele that had been incised endoscopically.
stasis inside the ureterocele may be the main contributing factor. It is generally believed that ureteroceles are associated with urinary stasis, which is partly responsible for the formation and growth of calculi. 6 Our patient might have remained untreated if ultrasonography of the bladder had not been performed. The diagnosis was based on clinical suspicion and confirmed by ultrasonography, which is not routinely performed for hematuria. The
1. Reynolds, W. F., Goldstein, A. M. B., Williams, E. J. and Fauer, R. B.: Uncommon radiologic observations in renal milk-of-calcium stone. Urology, 11: 419, 1978. 2. Curcio, C. M. and Goldman, S. M.: Seed calculi in an ectopic ureterocele: a case report. J. Urol., 130: 1165, 1983. 3. Becker, J. M. and Pollack, H.: Milk of calcium and ureterocele. Urol. Rad., 3: 31, 1981. 4. Engel, I. A., Brill, P. W. and Winchester, P.: Obstructed ureterocele with milk of calcium. Urol. Rad., 3: 35, 1981. 5. Messing, E. M. and Henry, S. C.: Stones in orthotopic, nonobstructing ureteroceles. J. Urol., 122: 403, 1979. 6. Amar, A. D.: Management of urinary calculous disease in patients with ureterocele. J. Urol., 117: 34, 1977. 7. Rodriguez, J. V.: Endoscopic surgery of calculi in ureteroceles. Eur. Urol., 10: 36, 1984. 8. Tank, E. S.: Experience with endoscopic incision and open unroofing of ureteroceles. J. Urol., 136: 241, 1986.