0022-5347 /34/l 322-0343$02.00 /00 VoL 132,
THE JOURNAL OF UROLOGY
1984 by The Williams & Wilkins Co.
FIBROEPITHELIAL POLYPS OF THE URETER ROBERT R BAHNSON, MICHAEL D. BLUM
MICHAEL F. CARTER
From the Department of Urology, Northwestern University Medical School, Chicago, Illinois
We report a case of fibroepithelial polyps of the ureter, which are rare, benign mesodermal tumors. The advantage of ureteroscopic confirmation of this benign tumor is emphasized. Primary ureteral neoplasms are infrequent in urological practice and represent 1 per 3,690 urological hospital admissions. 1 Benign ureteral tumors are even more rare, and include epithelial and nonepithelial lesions. Nonepithelial neoplasms originate from mesodermal elements within the ureteral wall and are represented by leiomyomas, fibromas, neurofibromas, endometriomas and fibroepithelial polyps. Fibroepithelial ureteral polyps are the most common of the nonepithelial (benign) tumors and a recent review of the literature revealed 112 reported cases. 2 This review and other reports of similar patients have emphasized the difficulty of establishing a diagnosis preoperatively despite extensive preoperative evaluation. 3 Consequently, fear of potential malignant disease may prompt needless radical surgery. We describe a patient in whom the
Several serpentine, fibrovascular ureteral polyps with a smooth epithelial surface were observed (fig. 2). Despite ureteral dilation with a Gri.i.ntzig balloon-tipped catheter, the larger ll.5F endoscope, which accepts a biopsy forceps and resectoscope loop, could not be passed for attempted biopsy or resection of the lesions. Retrograde brushing was not performed. The postoperative course was uneventful. The diagnosis of fibroepithelial polyps was suspected because of the typical symptoms and clinical findings, and was confirmed by direct visualization of the lesions using ureteroscopy. Careful follovvup was recommended with surgical correction reserved for recurrent symptoms or development of hydronephrosis. During 8 months of followup the patient has remained asymptomatic without hematuria or flank pain.
FIG. l. A, IVP demonstrates nonobstructive, well defined filling defect (arrow). B, retrograde pyelogram shows oblong filling defect in proximal third of right ureter as well as defect in inferior pelvis (arrow).
suspected diagnosis was confirmed endoscopically with the rigid ureteropyeloscope, which permitted recommendation of conservative treatment.
The clinical presentation of hematuria and a ureteral filling defect poses a diagnostic challenge to the urologist. A differential diagnosis includes benign and malignant tumors, nonopaque stones, thrombus, sloughed papillae and inflammatory lesions. The differentiation between malignant epithelial tumors and benign ureteral polyps is particularly important because local resection is the treatment of choice for the latter while radical surgery usually is required for the former. Debruyne and associates reviewed 112 patients operated on for fibroepithelial polyps. 2 Of these patients 41 (37 per cent) underwent potentially unnecessary nephroureterectomy because of an uncertain preoperative diagnosis. Local resection in 63 per cent produced uniformly excellent results with no reported recurrence. Ureteroscopy can differentiate clearly the smooth, regular surface of pedunculated fibroepithelial polyps from the irregular, friable appearance of urothelial carcinoma. This may ob-
A 20-year-old white man presented with complaints of gross hematuria and episodic right flank pain 3 months in duration. Physical examination was normal and urinalysis showed microscopic hematuria. An excretory urogram (IVP) revealed prompt bilateral function from normal collecting systems but within the proximal third of the right ureter a regular, slender, nonobstructing filling defect was noted (fig. 1, A). A repeat IVP 3 weeks later demonstrated no change in the intraluminal lesion. The patient was referred to our institution and a right retrograde ureteropyelogram confirmed the presence of a smooth, pedunculated filling defect (fig. 1, B). Ureteroscopy was performed using a lOF ureteropyeloscope. Accepted for publication March 30, 1984. 343
BAHNSON, BLUM AND CARTER
pelvic filling defects, diagnosis of structural distortions of the renal collecting system, retrieval of foreign bodies, biopsy and fulguration of suspected neoplasms, and extraction of ureteral and renal pelvic calculi using a combination of stone basket, forceps and ultrasonic lithotripsy. 4 - 6 Substantial medical and economic benefit is achieved when experience with ureteropyeloscopy enables the urologist to perform ureteroscopic procedures on patients who formerly required an open surgical technique. ADDENDUM
Eleven months after presentation the patient underwent transurethral ureteroscopic resection of the polyps because of recurrent flank pain and hematuria. Pathological diagnosis was fibroepithelial polyps. Dr. Stephen C. Jacobs provided the followup information. REFERENCES
FIG. 2. Photograph taken from videotape recording of ureteroscopy shows fibroepithelial polyp projecting into lumen of ureter (large arrow). Arrowheads indicate ureteral wall.
viate the need for extirpative surgery and allow a conservative approach to treatment. The addition of ureteroscopy to the endoscopic armamentarium of the urologist permits visual inspection of the entire ureter and renal pelvis. Indications for its use include diagnosis of intraluminal ureteral and renal
1. Abeshouse, B. S.: Primary benign and malignant tumors of the ureter: review of the literature and report of 1 benign and 12 malignant tumors. Amer. J. Surg., 91: 237, 1956. 2. Debruyne, F. M., Moonen, W. A., Daenekindt, A. A. and Delaere, K. P. J.: Fibroepithelial polyp of ureter. Urology, 16: 355, 1980. 3. Stuppler, S. A. and Kandzari, S. J.: Fibroepithelial polyps of ureter. A benign ureteral tumor. Urology, 5: 553, 1975. 4. Bush, I. M., Guinan, P. and Lanners, J.: Ureterorenoscopy. Urol. Clin. N. Amer., 9: 131, 1982. 5. Huffman, J.: Stone basket retrieval. Letter to the Editor. Urology, 18: 325, 1981. 6. Huffman, J. L., Bagley, D. H., Schoenberg, H. W. and Lyon, E. S.: Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy. J. Urol., 130: 31, 1983.