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Transitional cell carcinoma in a fused crossed ectopic kidney
CASE REPORT
TRANSITIONAL CELL CARCINOMA IN A FUSED CROSSED ECTOPIC KIDNEY URI GUR, OFER YOSSEPOWITCH,
AND
JACK BANIEL
ABSTRACT Nephroureterectomy is considered the reference standard treatment for invasive transitional cell carcinoma of the ureter. When this malignancy occurs in a patient with renal fusion anomaly, separating the involved kidney from its conjoint mate becomes a challenging task for the surgeon. We report a unique case in which a patient with an L-shaped left-to-right crossed ectopic kidney was diagnosed with invasive ureteral transitional cell carcinoma. The preoperative assessment in these uncommon cases should include renal angiography or computed tomography angiography to provide key information about the renal vasculature, which is essential for planning the surgical dissection and line of separation between the kidneys. UROLOGY 62: 748xvi–748xvii, 2003. © 2003 Elsevier Inc.
C
rossed renal ectopy is a rare condition in which one kidney is ectopic and may be fused with its contralateral mate in various forms. When the relative area of fusion is extensive, nephrectomy becomes a complex procedure and requires a thorough preoperative imaging workup. We report a rare case of transitional cell carcinoma in the ureter of an L-shaped crossed ectopic kidney treated by nephroureterectomy. CASE REPORT A 71-year-old man presented with painless macroscopic hematuria. The physical examination was unremarkable, except for an enlarged prostate. The blood workup indicated normal renal function. An ultrasound study showed an ectopic, horizontally lying, kidney in the left lower abdomen and fused with the right kidney. The left renal pelvis, along with the proximal ureter, was significantly dilated. The cystoscopic examination was normal and revealed both ureteral orifices at their regular position. Computed tomography demonstrated an Lshaped crossed ectopic kidney with moderate left hydronephrosis (Fig. 1). The left mid-ureter was enlarged and contained an irregular intraluminal From the Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva; and Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel Address for correspondence: Jack Baniel, M.D., Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel Submitted: March 14, 2003, accepted (with revisions): May 22, 2003
748xvi
© 2003 ELSEVIER INC. ALL RIGHTS RESERVED
FIGURE 1. Computed tomography scan demonstrating fused renal anomaly. Outlined arrow indicates laterally rotated right renal pelvis; white arrow indicates hydronephrotic left renal pelvis.
mass (Fig. 2). Diagnostic retrograde ureterography and subsequent ureteroscopy revealed a 5-cm-long papillary lesion involving the entire ureteral circumference, consistent with a ureteral tumor. The pathologic examination disclosed high-grade transitional cell carcinoma invading the lamina propria. Before definitive treatment, renal angiography was performed that demonstrated both renal arteries emerging from the aorta at their normal position, supplying each of the kidneys in a completely separate manner. A midline transabdominal incision was performed, and exposure of both kidneys and great vessels was achieved after reflection of the cecum 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00577-6
FIGURE 2. Computed tomography scan showing lesion in dilated left ureter. Outlined arrow indicates normal right ureter; white arrow indicates solid lesion in left ureter.
and ascending colon. By first ligating and dividing the left renal vessels at their origin adjacent to the aorta, a clear line of demarcation between the ischemic left kidney and the laterally rotated right kidney was established. A parenchymal isthmus of approximately 8 cm in size was sharply cut through, and the kidneys were separated. No additional selective ligation of the exposed arteries at the bare surface of the right kidney was required. After an anterior cystotomy, the left kidney, ureter, and a bladder cuff were removed en bloc. The final pathologic examination revealed high-grade transitional cell carcinoma of the ureter, Stage pT1. The postoperative convalescence was uneventful. COMMENT Transitional cell carcinoma in ectopic kidneys is rare.1,2 Some investigators have suggested that urinary stasis in distorted pelvicaliceal systems, often
UROLOGY 62 (4), 2003
associated with this type of anomaly, may be tumorigenic.1 The reference standard management for invasive high-grade ureteral tumor remains nephroureterectomy. Because more than 90% of ectopic kidneys are fused, surgery under these circumstances becomes a challenging task involving complex anatomic relations with aberrant vasculature and entails dissection within the renal parenchyma, similarly to nephron-sparing surgery. To the best of our knowledge, we report the first case of transitional cell carcinoma in a fused, crossed ectopic kidney. This case underscores the importance of performing a preoperative angiographic assessment, in addition to standard imaging techniques, to display the individual renal vasculature, which facilitates planning the surgical approach to avoid significant hemorrhage during parenchymal dissection. Recent data pertaining to donor nephrectomies suggest that computed tomography angiography, which is less invasive than conventional angiography, has excellent ability for illustrating the renal vasculature anatomy.3 Similarly, magnetic resonance angiography has also been reported. Although separation and excision of a fused ectopic kidney may present potential surgical difficulty, the primary goal of cancer control should not be compromised. REFERENCES 1. Miller DC, and Kropp KA: Transitional cell carcinoma associated with crossed renal ectopia and previous cyclophosphamide therapy. J Urol 148: 1244 –1246, 1992. 2. Baniel J, Glezerson G, Tobias M, et al: Crossed renal ectopia: case report. Scand J Urol Nephrol 25: 241–244, 1991. 3. Smith PA, Ratner LE, Lynch FC, et al: Role of CT angiography in the preoperative evaluation for laparoscopic nephrectomy. Radiographics 18: 589 –601, 1998.
748xvii
TRANSITIONAL CELL CARCINOMA IN A FUSED CROSSED ECTOPIC KIDNEY URI GUR, OFER YOSSEPOWITCH,
AND
JACK BANIEL
ABSTRACT Nephroureterectomy is considered the reference standard treatment for invasive transitional cell carcinoma of the ureter. When this malignancy occurs in a patient with renal fusion anomaly, separating the involved kidney from its conjoint mate becomes a challenging task for the surgeon. We report a unique case in which a patient with an L-shaped left-to-right crossed ectopic kidney was diagnosed with invasive ureteral transitional cell carcinoma. The preoperative assessment in these uncommon cases should include renal angiography or computed tomography angiography to provide key information about the renal vasculature, which is essential for planning the surgical dissection and line of separation between the kidneys. UROLOGY 62: 748xvi–748xvii, 2003. © 2003 Elsevier Inc.
C
rossed renal ectopy is a rare condition in which one kidney is ectopic and may be fused with its contralateral mate in various forms. When the relative area of fusion is extensive, nephrectomy becomes a complex procedure and requires a thorough preoperative imaging workup. We report a rare case of transitional cell carcinoma in the ureter of an L-shaped crossed ectopic kidney treated by nephroureterectomy. CASE REPORT A 71-year-old man presented with painless macroscopic hematuria. The physical examination was unremarkable, except for an enlarged prostate. The blood workup indicated normal renal function. An ultrasound study showed an ectopic, horizontally lying, kidney in the left lower abdomen and fused with the right kidney. The left renal pelvis, along with the proximal ureter, was significantly dilated. The cystoscopic examination was normal and revealed both ureteral orifices at their regular position. Computed tomography demonstrated an Lshaped crossed ectopic kidney with moderate left hydronephrosis (Fig. 1). The left mid-ureter was enlarged and contained an irregular intraluminal From the Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva; and Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel Address for correspondence: Jack Baniel, M.D., Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel Submitted: March 14, 2003, accepted (with revisions): May 22, 2003
748xvi
© 2003 ELSEVIER INC. ALL RIGHTS RESERVED
FIGURE 1. Computed tomography scan demonstrating fused renal anomaly. Outlined arrow indicates laterally rotated right renal pelvis; white arrow indicates hydronephrotic left renal pelvis.
mass (Fig. 2). Diagnostic retrograde ureterography and subsequent ureteroscopy revealed a 5-cm-long papillary lesion involving the entire ureteral circumference, consistent with a ureteral tumor. The pathologic examination disclosed high-grade transitional cell carcinoma invading the lamina propria. Before definitive treatment, renal angiography was performed that demonstrated both renal arteries emerging from the aorta at their normal position, supplying each of the kidneys in a completely separate manner. A midline transabdominal incision was performed, and exposure of both kidneys and great vessels was achieved after reflection of the cecum 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00577-6
FIGURE 2. Computed tomography scan showing lesion in dilated left ureter. Outlined arrow indicates normal right ureter; white arrow indicates solid lesion in left ureter.
and ascending colon. By first ligating and dividing the left renal vessels at their origin adjacent to the aorta, a clear line of demarcation between the ischemic left kidney and the laterally rotated right kidney was established. A parenchymal isthmus of approximately 8 cm in size was sharply cut through, and the kidneys were separated. No additional selective ligation of the exposed arteries at the bare surface of the right kidney was required. After an anterior cystotomy, the left kidney, ureter, and a bladder cuff were removed en bloc. The final pathologic examination revealed high-grade transitional cell carcinoma of the ureter, Stage pT1. The postoperative convalescence was uneventful. COMMENT Transitional cell carcinoma in ectopic kidneys is rare.1,2 Some investigators have suggested that urinary stasis in distorted pelvicaliceal systems, often
UROLOGY 62 (4), 2003
associated with this type of anomaly, may be tumorigenic.1 The reference standard management for invasive high-grade ureteral tumor remains nephroureterectomy. Because more than 90% of ectopic kidneys are fused, surgery under these circumstances becomes a challenging task involving complex anatomic relations with aberrant vasculature and entails dissection within the renal parenchyma, similarly to nephron-sparing surgery. To the best of our knowledge, we report the first case of transitional cell carcinoma in a fused, crossed ectopic kidney. This case underscores the importance of performing a preoperative angiographic assessment, in addition to standard imaging techniques, to display the individual renal vasculature, which facilitates planning the surgical approach to avoid significant hemorrhage during parenchymal dissection. Recent data pertaining to donor nephrectomies suggest that computed tomography angiography, which is less invasive than conventional angiography, has excellent ability for illustrating the renal vasculature anatomy.3 Similarly, magnetic resonance angiography has also been reported. Although separation and excision of a fused ectopic kidney may present potential surgical difficulty, the primary goal of cancer control should not be compromised. REFERENCES 1. Miller DC, and Kropp KA: Transitional cell carcinoma associated with crossed renal ectopia and previous cyclophosphamide therapy. J Urol 148: 1244 –1246, 1992. 2. Baniel J, Glezerson G, Tobias M, et al: Crossed renal ectopia: case report. Scand J Urol Nephrol 25: 241–244, 1991. 3. Smith PA, Ratner LE, Lynch FC, et al: Role of CT angiography in the preoperative evaluation for laparoscopic nephrectomy. Radiographics 18: 589 –601, 1998.
748xvii