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Villous adenoma of the renal pelvis: A case report and literature review
Urological Science xxx (2013) 1e3
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Case report
Villous adenoma of the renal pelvis: A case report and literature review Tsung-Yi Huang a, Sheau-Fang Yang b, c, d, Shu-Pin Huang a, c, Hsin-Chih Yeh c, e, Ching-Chia Li c, e, * a
Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Pathology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Department of Urology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan d Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan e Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2013 Received in revised form 14 May 2013 Accepted 20 June 2013 Available online xxx
Villous adenomas are common in the gastrointestinal tract but are rare in the urinary tract. Villous adenomas of the urinary tract are identified mostly in the urinary bladder in the current published literature in English. There are only scattered individual case reports showing villous adenoma in the other parts of the urinary tract such as the urethra, ureter, and renal pelvis. Here, we report a fourth case of villous adenoma in the renal pelvis with manifestation of mucus-filled kidney (muconephrosis). A 54year-old male patient presented with acute urinary retention with mucinuria initially and he finally received nephrectomy. No obvious evidence of recurrence has been noted in the 1-year follow-up. Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: hydronephrosis renal pelvis villous adenoma
1. Introduction Villous adenomas originating in the urinary tract are relatively rare. Villous adenomas are most frequently found in the gastrointestinal tract, seldom in the urinary tract, and even more rarely in the upper urinary tract. They have been identified mostly in the bladder followed by the urethra in the published literature.1 We report an additional case of villous adenoma arising in the renal pelvis (Table 1)2,5,7,9,10 that presented with acute urinary retention. 2. Case report A 54-year-old man had suffered from dysuria for several days. Acute urinary retention attacked and he came to our emergency department for help. A urethral Foley catheter was indwelled and massive mucinous urine flowed out slowly. He also had symptoms including obscure right flank soreness, nocturia, weak stream with abdominal straining, incomplete emptying, and urinary frequency for more than 1 year. He had no other systematic symptoms, such as cardiovascular, respiratory, or gastrointestinal discomfort. He had a * Corresponding author. Department of Urology, Kaohsiung Medical University Hospital, 100 Tzyou 1st Road, Kaohsiung, Taiwan. E-mail address: [email protected] (C.-C. Li).
history of right renal stone more than 10 years previously but did not receive any treatment in the past. On physical examination, a palpable mass in the right abdomen was detected. Digital rectal examination revealed normal prostate size without hard nodules. The urinalysis and urine cytology did not show any abnormal findings. Laboratory data revealed a normal creatinine level and the estimated glomerular filtration rate was acceptable. Enhanced computed tomography (CT) revealed severe right hydronephrosis and atrophic cortex change with a renal stone of lower calyx (Fig. 1). No suspicious soft tissue lesion shadow was noted. Open-method nephrectomy was performed without complications and a significant quantity of yellowish jelly-like mucus fluxed from this split kidney (Fig. 2). Gross examination showed a markedly enlarged kidney with a markedly dilated pelvicaliceal system filled with abundant mucus. There were several elevated nodules measuring up to 2 cm in the greatest diameter on the pelvic mucosa (Fig. 3). Two staghorn stones were also noted. Microscopic examination of the kidney showed multiple villous adenomas exhibiting papillary architectures with central fibrovascular cores, consisting of pointed or blunt finger-like processes lined by pseudostratified columnar epithelium (Fig. 4). Extensive mucin production, diffuse intestinal metaplasia, and urolithiasis of the renal pelvis were present. The patient felt much improved on urination after surgery. The postoperative course was smooth and the patient was discharged
1879-5226/$ e see front matter Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.urols.2013.06.004
Please cite this article in press as: Huang T-Y, et al., Villous adenoma of the renal pelvis: A case report and literature review, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2013.06.004
2
T.-Y. Huang et al. / Urological Science xxx (2013) 1e3
Table 1 Summary of villous adenoma in the renal pelvis in published reports. Reference
Age (y) & sex
Symptom
Past history
Survey
Management
Outcome
Nation
Park et al7 Shih et al2 Bhat et al5 Current case Frickmann et al9 Bos et al10
79 64 52 54 85 d
Fever, flank pain Flank pain Abdominal pain Flank pain, AUR Incidental d
Renal stone Bil. renal stones Ureter stone Renal stone Renal stone d
CT RP, CT CT, MRI CT CT d
Nephrectomy URS biopsy Nephrectomy Nephrectomy Nephrectomy d
Unknown Residual NED NED Unknown d
USA Taiwan India Taiwan Germany Germany
M M M M F
AUR ¼ acute urinary retention; CT ¼ computed tomography; F ¼ female; M ¼ male; MRI ¼ magnetic resonance imaging; NED ¼ no evidence of disease; RP ¼ retrograde pyelography; URS ¼ ureterorenoscopic.
Fig. 1. Right kidney shows severe hydronephrosis with (A) thin renal cortex and (B) renal stones (indicated by arrows).
Fig. 2. Gross specimen: (A) intact appearance and (B: cut) abundant mucus-like material filled the dilated proximal ureter and renal pelvis.
within 5 days. During the 6-month and 12-month follow-ups, the patient did not suffer from any discomfort and had no obvious CT evidence of recurrence. 3. Discussion Except for colonic villous adenoma, villous adenoma seldom occurs in the hepatobiliary and genitourinary tracts.2 Villous adenoma of the urinary tract has been noted most commonly in the urinary bladder, and has also been reported in the urethra, urachus, and prostate.3,4 The presence of villous adenomas in the upper urinary tract is relatively uncommon and they are rarely found in the renal pelvis.2,5 Patients are typically middle-aged and older males who present clinically with microscopic hematuria and lower urinary tract irritative symptoms.6 In some cases, mucinous urine was noted incidentally. Muconephrosis, first termed by Park et al7 in 2002, describes a mucus-filled kidney by renal pelvic villous adenoma. Etiology of villous adenomas of the urinary tract is thought to arise from intestinal metaplasia of transitional
Fig. 3. The pelvis is dilated and filled with mucus. There are several elevated nodules on the pelvic mucosa (arrow).
Please cite this article in press as: Huang T-Y, et al., Villous adenoma of the renal pelvis: A case report and literature review, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2013.06.004
T.-Y. Huang et al. / Urological Science xxx (2013) 1e3
3
producing cells. Nuclear atypia is variable. Immunohistochemically, these two entities are also similar, with positive findings for cytokeratin 20 and carcinoembryonic antigen, and negative findings for epithelial membrane antigen staining in most cases.3,4 In contrast to villous adenomas of the colon and rectum, about 50% of villous adenomas of the urinary tract show positive findings for cytokeratin 7, whereas villous adenomas of the colon and rectum showed negative findings.3 Villous adenomas of the genitourinary tract have a good prognosis and surgical resection is curative. However, it is uncertain whether an untreated lesion might eventually develop into an adenocarcinoma. In our patient, nephrectomy was performed considering the atrophic change of the kidney with poor renal function and en-bloc resection of the kidney may be required for complete pathologic evaluation.7 For these cases of nonfunctioning kidney with marked hydronephrosis, nephrectomy is a choice of treatment. Considering the personal reason and the possibility of positive resection margins, our patient chose to take the openmethod surgery, even though laparoscopic nephrectomy is a suitable alternative to open surgery for these cases and significantly reduces the morbidity of surgery. We should follow-up this patient closely due to the possibility of tumor recurrence or progression to adenocarcinoma.8
References
Fig. 4. (A) Microscopic examination reveals villous adenoma with papillary architecture (hematoxylin and eosin, original magnification 20). (B) Higher magnification of the tumor cells reveal pseudostratified nuclei and mucin-producing cytoplasm (hematoxylin and eosin, original magnification 400).
epithelium after long-term irritation such as stone impaction, chemical injury, or chronic inflammation.3,5 Histologically, villous adenomas of the urinary tract and villous adenomas of the colon and rectum are identical. They both exhibit rounded projections of pseudostratified columnar epithelium with goblet-type mucin-
1. Tamboli P, Ro JY. Villous adenoma of urinary tract: a common tumor in an uncommon location. Adv Anat Pathol 2000;7:79e84. 2. Shih CM, Wu SC, Lee CC, Pan CC. Villous adenoma of the ureter with manifestation of mucus hydroureteronephrosis. J Chin Med Assoc 2007;70:33e5. 3. Cheng L, Montironi R, Bostwick DG. Villous adenoma of the urinary tract: a report of 23 cases, including 8 with coexistent adenocarcinoma. Am J Surg Pathol 1999;23:764e71. 4. Seibel JL, Prasad S, Weiss RE, Bancila E, Epstein JI. Villous adenoma of the urinary tract: a lesion frequently associated with malignancy. Hum Pathol 2002;33:236e41. 5. Bhat S, Chandran V. Villous adenoma of the renal pelvis and ureter. Indian J Urol 2010;26:598e9. 6. Nakamura Y, Orikasa K, Fujishima F, Shibahara Y, Saito R, Ohkubo T, et al. A case of villous adenoma of the urinary bladder with tubulovillous architecture: characterization by immunohistochemical analysis. Pol J Pathol 2011;62: 179e82. 7. Park S, Meng MV, Greenberg MS, Deng DY, Stoller ML. Muconephrosis. Urology 2002;60:344. 8. Shiota M, Tokuda N, Kanou T, Yamasaki H. Villous adenoma of female urethra: an investigation of the mechanism of development regarding glandular neoplasms in the urinary tract. Indian J Urol 2006;22:376e7. 9. Frickmann H, Jungblut S, Bargon J, Willenbrock K, Storkel S, Hanke P. Villous adenoma of the renal pelvis and ureter. Urologe A 2006;45:1435e7 [Article in German]. 10. Bos I, Lichtenauer HP, Frontzeck M. Intestinal type of villous adenoma of the kidney pelvis. Pathologe 1998;9:109e14 [Article in German].
Please cite this article in press as: Huang T-Y, et al., Villous adenoma of the renal pelvis: A case report and literature review, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2013.06.004
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Case report
Villous adenoma of the renal pelvis: A case report and literature review Tsung-Yi Huang a, Sheau-Fang Yang b, c, d, Shu-Pin Huang a, c, Hsin-Chih Yeh c, e, Ching-Chia Li c, e, * a
Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Pathology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan Department of Urology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan d Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan e Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2013 Received in revised form 14 May 2013 Accepted 20 June 2013 Available online xxx
Villous adenomas are common in the gastrointestinal tract but are rare in the urinary tract. Villous adenomas of the urinary tract are identified mostly in the urinary bladder in the current published literature in English. There are only scattered individual case reports showing villous adenoma in the other parts of the urinary tract such as the urethra, ureter, and renal pelvis. Here, we report a fourth case of villous adenoma in the renal pelvis with manifestation of mucus-filled kidney (muconephrosis). A 54year-old male patient presented with acute urinary retention with mucinuria initially and he finally received nephrectomy. No obvious evidence of recurrence has been noted in the 1-year follow-up. Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: hydronephrosis renal pelvis villous adenoma
1. Introduction Villous adenomas originating in the urinary tract are relatively rare. Villous adenomas are most frequently found in the gastrointestinal tract, seldom in the urinary tract, and even more rarely in the upper urinary tract. They have been identified mostly in the bladder followed by the urethra in the published literature.1 We report an additional case of villous adenoma arising in the renal pelvis (Table 1)2,5,7,9,10 that presented with acute urinary retention. 2. Case report A 54-year-old man had suffered from dysuria for several days. Acute urinary retention attacked and he came to our emergency department for help. A urethral Foley catheter was indwelled and massive mucinous urine flowed out slowly. He also had symptoms including obscure right flank soreness, nocturia, weak stream with abdominal straining, incomplete emptying, and urinary frequency for more than 1 year. He had no other systematic symptoms, such as cardiovascular, respiratory, or gastrointestinal discomfort. He had a * Corresponding author. Department of Urology, Kaohsiung Medical University Hospital, 100 Tzyou 1st Road, Kaohsiung, Taiwan. E-mail address: [email protected] (C.-C. Li).
history of right renal stone more than 10 years previously but did not receive any treatment in the past. On physical examination, a palpable mass in the right abdomen was detected. Digital rectal examination revealed normal prostate size without hard nodules. The urinalysis and urine cytology did not show any abnormal findings. Laboratory data revealed a normal creatinine level and the estimated glomerular filtration rate was acceptable. Enhanced computed tomography (CT) revealed severe right hydronephrosis and atrophic cortex change with a renal stone of lower calyx (Fig. 1). No suspicious soft tissue lesion shadow was noted. Open-method nephrectomy was performed without complications and a significant quantity of yellowish jelly-like mucus fluxed from this split kidney (Fig. 2). Gross examination showed a markedly enlarged kidney with a markedly dilated pelvicaliceal system filled with abundant mucus. There were several elevated nodules measuring up to 2 cm in the greatest diameter on the pelvic mucosa (Fig. 3). Two staghorn stones were also noted. Microscopic examination of the kidney showed multiple villous adenomas exhibiting papillary architectures with central fibrovascular cores, consisting of pointed or blunt finger-like processes lined by pseudostratified columnar epithelium (Fig. 4). Extensive mucin production, diffuse intestinal metaplasia, and urolithiasis of the renal pelvis were present. The patient felt much improved on urination after surgery. The postoperative course was smooth and the patient was discharged
1879-5226/$ e see front matter Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.urols.2013.06.004
Please cite this article in press as: Huang T-Y, et al., Villous adenoma of the renal pelvis: A case report and literature review, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2013.06.004
2
T.-Y. Huang et al. / Urological Science xxx (2013) 1e3
Table 1 Summary of villous adenoma in the renal pelvis in published reports. Reference
Age (y) & sex
Symptom
Past history
Survey
Management
Outcome
Nation
Park et al7 Shih et al2 Bhat et al5 Current case Frickmann et al9 Bos et al10
79 64 52 54 85 d
Fever, flank pain Flank pain Abdominal pain Flank pain, AUR Incidental d
Renal stone Bil. renal stones Ureter stone Renal stone Renal stone d
CT RP, CT CT, MRI CT CT d
Nephrectomy URS biopsy Nephrectomy Nephrectomy Nephrectomy d
Unknown Residual NED NED Unknown d
USA Taiwan India Taiwan Germany Germany
M M M M F
AUR ¼ acute urinary retention; CT ¼ computed tomography; F ¼ female; M ¼ male; MRI ¼ magnetic resonance imaging; NED ¼ no evidence of disease; RP ¼ retrograde pyelography; URS ¼ ureterorenoscopic.
Fig. 1. Right kidney shows severe hydronephrosis with (A) thin renal cortex and (B) renal stones (indicated by arrows).
Fig. 2. Gross specimen: (A) intact appearance and (B: cut) abundant mucus-like material filled the dilated proximal ureter and renal pelvis.
within 5 days. During the 6-month and 12-month follow-ups, the patient did not suffer from any discomfort and had no obvious CT evidence of recurrence. 3. Discussion Except for colonic villous adenoma, villous adenoma seldom occurs in the hepatobiliary and genitourinary tracts.2 Villous adenoma of the urinary tract has been noted most commonly in the urinary bladder, and has also been reported in the urethra, urachus, and prostate.3,4 The presence of villous adenomas in the upper urinary tract is relatively uncommon and they are rarely found in the renal pelvis.2,5 Patients are typically middle-aged and older males who present clinically with microscopic hematuria and lower urinary tract irritative symptoms.6 In some cases, mucinous urine was noted incidentally. Muconephrosis, first termed by Park et al7 in 2002, describes a mucus-filled kidney by renal pelvic villous adenoma. Etiology of villous adenomas of the urinary tract is thought to arise from intestinal metaplasia of transitional
Fig. 3. The pelvis is dilated and filled with mucus. There are several elevated nodules on the pelvic mucosa (arrow).
Please cite this article in press as: Huang T-Y, et al., Villous adenoma of the renal pelvis: A case report and literature review, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2013.06.004
T.-Y. Huang et al. / Urological Science xxx (2013) 1e3
3
producing cells. Nuclear atypia is variable. Immunohistochemically, these two entities are also similar, with positive findings for cytokeratin 20 and carcinoembryonic antigen, and negative findings for epithelial membrane antigen staining in most cases.3,4 In contrast to villous adenomas of the colon and rectum, about 50% of villous adenomas of the urinary tract show positive findings for cytokeratin 7, whereas villous adenomas of the colon and rectum showed negative findings.3 Villous adenomas of the genitourinary tract have a good prognosis and surgical resection is curative. However, it is uncertain whether an untreated lesion might eventually develop into an adenocarcinoma. In our patient, nephrectomy was performed considering the atrophic change of the kidney with poor renal function and en-bloc resection of the kidney may be required for complete pathologic evaluation.7 For these cases of nonfunctioning kidney with marked hydronephrosis, nephrectomy is a choice of treatment. Considering the personal reason and the possibility of positive resection margins, our patient chose to take the openmethod surgery, even though laparoscopic nephrectomy is a suitable alternative to open surgery for these cases and significantly reduces the morbidity of surgery. We should follow-up this patient closely due to the possibility of tumor recurrence or progression to adenocarcinoma.8
References
Fig. 4. (A) Microscopic examination reveals villous adenoma with papillary architecture (hematoxylin and eosin, original magnification 20). (B) Higher magnification of the tumor cells reveal pseudostratified nuclei and mucin-producing cytoplasm (hematoxylin and eosin, original magnification 400).
epithelium after long-term irritation such as stone impaction, chemical injury, or chronic inflammation.3,5 Histologically, villous adenomas of the urinary tract and villous adenomas of the colon and rectum are identical. They both exhibit rounded projections of pseudostratified columnar epithelium with goblet-type mucin-
1. Tamboli P, Ro JY. Villous adenoma of urinary tract: a common tumor in an uncommon location. Adv Anat Pathol 2000;7:79e84. 2. Shih CM, Wu SC, Lee CC, Pan CC. Villous adenoma of the ureter with manifestation of mucus hydroureteronephrosis. J Chin Med Assoc 2007;70:33e5. 3. Cheng L, Montironi R, Bostwick DG. Villous adenoma of the urinary tract: a report of 23 cases, including 8 with coexistent adenocarcinoma. Am J Surg Pathol 1999;23:764e71. 4. Seibel JL, Prasad S, Weiss RE, Bancila E, Epstein JI. Villous adenoma of the urinary tract: a lesion frequently associated with malignancy. Hum Pathol 2002;33:236e41. 5. Bhat S, Chandran V. Villous adenoma of the renal pelvis and ureter. Indian J Urol 2010;26:598e9. 6. Nakamura Y, Orikasa K, Fujishima F, Shibahara Y, Saito R, Ohkubo T, et al. A case of villous adenoma of the urinary bladder with tubulovillous architecture: characterization by immunohistochemical analysis. Pol J Pathol 2011;62: 179e82. 7. Park S, Meng MV, Greenberg MS, Deng DY, Stoller ML. Muconephrosis. Urology 2002;60:344. 8. Shiota M, Tokuda N, Kanou T, Yamasaki H. Villous adenoma of female urethra: an investigation of the mechanism of development regarding glandular neoplasms in the urinary tract. Indian J Urol 2006;22:376e7. 9. Frickmann H, Jungblut S, Bargon J, Willenbrock K, Storkel S, Hanke P. Villous adenoma of the renal pelvis and ureter. Urologe A 2006;45:1435e7 [Article in German]. 10. Bos I, Lichtenauer HP, Frontzeck M. Intestinal type of villous adenoma of the kidney pelvis. Pathologe 1998;9:109e14 [Article in German].
Please cite this article in press as: Huang T-Y, et al., Villous adenoma of the renal pelvis: A case report and literature review, Urological Science (2013), http://dx.doi.org/10.1016/j.urols.2013.06.004