THE JouR::'.\lAL OF UROLOGY
Vol. 79, No. 3, March. 195~ [)r£nted in U.8.A.
GIANT POLYP OF URETER T. LEON HOWARD
In the practice of a urologist who has confined himself to thie:i specialty for the past 50 years, it seems logical that "rare" entities of the ureter should haYc been observed not once, but many times. From the ninth verse of the first chapter of Ecclesiastes is inscribed a very pertinent notation: "There is no new thing under the sun," ·which makes one realize that "the more you think you knoff the more you had better listen." YVith such evident facts before me, I am dubious about presenting thi;, giant polyp of the ureter even as a rarity, much less as one among the first 2fi to he reported. In all the years of viewing unusual renal and uretcral conditiow;;, I have only seen one polypoid growth in the upper urinary tract and that was in October 195G at the meeting of the South Central Section in 1Texico This ease wat, presented by Drs. Herbert E. Isaacks and Dolphus E. Cornpere of Fort Texas. It was so well presa1ted that it merited honorable mention for the second best case of the "Problem Hour." The polyp was located in the right renal was bifid in character, and acted as a valve to obstruct the ureteropelvic outlet with destruction of the kidney. A personal ('.Ommlmication from Capt. "\V. JVI, Silliphant, director of the Institute of Pathology in \Vashington, D. C. to Dr. I'aul K. Hamilton, Jr., pathologist at Mercy Hospital, Denver states: "As far as we can determine there are only two similar cases of reactive metcral m the files at the Armed Forces Institute of Pathology." In UROLOGY, edited Carnpbell, is shown a case of Dr. Francis C. H.egan of Rochester, N. Y. whieh, in many respects, is quite similar to ours. Dr writes that he has never published the history of this patient. Dr. records 7 cases of true ureteral polyps in the chapter on Tumors of the Frogenital In 1D57 Twinern presented a paper 011 Primary Tumors of the Ureter in which no mention of polypoid growths is made. In 1D32, 1folicow and Findlay col-lected 28 proven cases of benign ureteral tumors, four of ,d1ich were fibrous in consistency and the rest papillomatous. Campbell's comment on this series is interesting for he states that Hi pathological terms were m,ed in describing the types of tumor found in the :V[elicow and Findlay colled,ion. I f:>hould like to suggest that perhaps 16 different pathologists passed opinions on these specimens. The lower ureter ,rns the site of the growth in 75 per cent and hematuria was a cardinal ::;ign in 75 per cent of these cases. I wish to empha,;ize the fact that the patient whose case I am reporting did not seek medical aid for urinary symptoms but for persistent jaundice and rapid los::; of weight. CASE TIEPOHT
T. R. of Nebraska, a white gasoline station attendant aged 60 years, entered St. Luke's Hospital, Denver on July 2:3, 1956 and was admitted to the service of Dr. Fred Harper. Both parents had died of cancer. Read at annual meeting of \V cstern Section of American Urological Association, Sen Hie, Wash., l\lay :n~:iO, 19,57.
'I'. LEOX HOWARD
Fm. 1. A, retrograde pyelogram, July 24, 1956. Normal left kidney; bulb catheter in lower right ureter and large filling defect. B, two catheters in right ureter with shadows of calculi and spiral catheter encircling polyp, December 5, 1956.
Only pertinent facts in the history will be cited. In 1952 the patient had an attack of hematuria. Under medication the bleeding ceased until May 20, 1956 when bright red blood appeared in a voided specimen for four days without subjective symptoms. At the same time he became icteric. In order to determine the cause of the hematuria, the family physician made an intravenous urogram which shmved right hydronephrosis and a normal left renal pelvis. In July 1956 the patient entered St. Luke's. Physical examination disclosed an enlarged liver. The laboratory data were suggestive of biliary tract obstruction. Dr. Emerson J. Collier was responsible for the urological conclusions as he was called in consultation by Dr. Harper at this time. On July 24, 1956, Dr. Collier, with the patient under a spinal anesthetic, made a retrograde pyelogram (fig. 1, A) which revealed a normal left kidney, a bulb catheter in the lower right ureter and a large filling defect of the ureter on that side. No stone shadows were seen. When examination of the urinary tract study was completed, Dr. Collier was of the opinion that the illness of the patient was probably caused by ureteral carcinoma and the jaundice secondary to metastatic liver in ,olvement from the tumor. As the patient was steadily losing weight from probable malignant lesion in the liver, it was deemed justifiable to explore the area of the liver first. Dr. Harper performed an exploratory laparotomy on August 5, 1956. Little beyond an occluded common bile duct as it entered the bowel was found. AT tube was placed
GIAN'l' URE'I'ERAL POLYP
m thA duct for The right kidney and the ureter were thAn The kidney felt normal, but a large sausage-shaped mass was followed frmu just below the to the region of the bladder. It was deemed unwise to take sections from the mass. The patient 1vas next seen on our service at Hospital, Denver on De., eember 4, 1056. The bile duct T tube ,vas still draining satisfactorily and a of 25 pounds in ,'H"ight \ms admitted. Jaundice had disappeared and the complaint was burning on urination with, at times, a dark colored voided urine. On December 1956 my partner, Dr. Henry Buchtel, introduced a J ohrrnon basket up the ureter in an atte1npt to snare off a specimen for study. Failing in this he then passed two catheters up the right ureter and the comment was as follows: "A. radiopaque catheter shows tlrn distal end at the upper fold of the right kidney. A second catheter extends to the level of the upper margin of the sacroiliac joint. It is debatable whether these catheters are within the ureter. If the catheters are within the ureter, the diagnosis is mega ureter. There are two calcified one in the region of the kidney area, the other in the lower portion of the right ureter. The intrnhepatic ·was delineated au air contrast study" 1., B shows hrn catheters in the right ureter described by the roentgenologis1, with stone ,;hadows and a catheter encircling the polyp. The was little different from that made Dr. Collier in July oue catheter ascended in a spiraL The stone :c:hadows ,Yere not seen In the 195G but ('.an be outlined in figure 1, B (the December 195G understood the roentgenologist was t·onfused aboll1 the location of the catheters. ·~~uuc,v".M
!c1G. 2. A, third film in series of intravenous urogrmns at end of :30 minutes. Dye in good concentration in 5 minutes. B, l-hour intravenous film. Dye is beginning renal pelvis.
The most interesting of Dr. Collier's July series of intravenous films are reproduced in figure 2. Figure 2, A is the third of the intravenous series at the end of 30 minutes. The dye had appeared in good concentration in 5 minutes. Figure 2, B, a one-hour film, showed the dye beginning to leave the renal pelvis. Another film showed that the dye had reached the pedicle of the polyp at the end of one and a half hours. Evidently the kidney pelvis was in a state of systole. A two-hour upper ureterogram showed the ureter in diastole. The next film, taken immediately afterward, showed a violent systolic contraction of the pelvis and ureter. The lower segment of the ureter, as it neared the bladder, was filled for the first time. Operation was performed by Dr. William Ivers and myself on December 7. No difficulty was encountered in securing exposure of the entire ureterorenal tract through a right lateral rectus incision that extended from the middle of Poupart's ligament to the tip of the twelfth rib, then transversely to insertion of this rib. The ureter felt like a well-filled colon and, through this same incision, the renal pedicle was easily delineated. The ureter was ligated near the bladder where it was of normal size and dissected to the kidney pelvis without difficulty as there were no ureteral adhesions. The renal vessels were differentiated, tied separately, then cut. The entire renoureteral system was removed intact. The patient left the hospital on December 16, nine days after surgery, and all attempts to get him to return have failed. Through correspondence he states that he is in excellent health but still is wearing his common bile duct tube. Description of gross specimen (Dr. Paul K. Hamilton): "The specimen consists of the kidney and ureter. The external surface of the kidney appears normal, and it measures 11 by 6 by 4 cm. The ureteropelvic junction appears relatively normal, measuring L5 cm. in width. At a point 6 cm. distal to the junction, the ureter enlarges into a fusiform mass that has a maximum diameter of 2.5 cm. The wall of the ureter in this enlarged area has a distended appearance and an increased consistency. "\Vithin the lumen of the ureter a greyish-yellow, soft mass is found which is attached to the ureter just below the ureteropelvic junction by a narrow pedicle measuring 7 mm. in diameter. The mass measures 10 by 3 cm. The mass appears to consist of grey, soft, finger-like projections which are fused together in several areas. Two small calculi are found, one distal to the pedicle of the tumor mass and one proximal. The average diameter of these calculi is 5 mm. "A hemisection of the kidney is made and, with the exception of a small, well circumscribed, yellow, necrotic nodule within the cortex of the upper pole, no significant gross lesions are noted. The calyces and the pelvis are slightly dilated. "Sections of the ureteral tumor reveal an irregular papillomatous structure which is covered by a thin layer of transitional epithelium. The stroma of the papillomatous structure consists of a loose fibrous tissue which is moderately edematous in many areas and slightly to moderately vascular. There are numerous irregular, dilated spaces throughout, which are empty. Sections of the ureter reveal slight transitional epithelial hyperplasia with marked smooth muscle hypertrophy of the wall. Sections of the kidney reveal a well circumscribed,
GIAW.r URETERAL POLYP
Fm. 3. A, kidney and ureter intact. 13, kidney and Liroter opened. Note .~mall g;rnrndonrn in kidney center and giant polyp delivered from ureter al cavity.
slightly irregular, granulornatous focus with marked central necrosis by a dense area of hyalinized fibrous tissue. In some areas epithclioid cells are present in a palisading formation. A few ill defined giant cells are rmDcsLrni· One of the mterlobular veins eontains a thrombosi:c;. No evidence of malignancy noted. "Stains for acid fast organisms and periodic acid Schiff stains for fungi renal none to be present. "Diagnosis. U reteral i granulomatous focus, cortex of kidney, hydro· ureter with marked sn10oth muscle hypertrophy. Figure 3, A shows the kidney and ureter intact; figure 3, B, after the and ureter had been Note the small granulomatous focus in the center of the kidney and the giant polyp that was delinffed from the ureteral COMMEN'l'
According to Col. James K Ash, "the development of polyps is largely a matter of vasomotor reaction and 1nechanics, the result of repeated and chronic attach of inflammation of the mucosa." The microscopic findings in the polyps of the nose and those of the urinary tract are quite similar. Arc ,ve in the future going to find an increase in ureteraJ polyp8!' Such i~ possible, for one of the causes of nasal polypoid growths has been ascribed to an allergic background and each year the human race is being exposed to more antigens by the multitude of drugs that we are so indiscriminately prescribing. Consequently, the question should be answered in the affirmative, for mucosa] tissue;.; are changed repeated allergic reactions which are conducive to infection. Thi.~ is confirmatory of Col. Ash's opinion as to the cause of these Had the patient not suffered jaundiee and weight loss but sought relief fron:1 his urinary alone, I am confident his right urinary tract, in all bility, would have been sayed.
T. LEON HOWARD
I wish to thank Drs. Isaacks and Compere, who were so kind in supplying me svith a history of their case as well as slides, and also for assistance I had, not only from my own office, but the roentgenological and pathological departments at Mercy Hospital, Denver. 1224 Republic Bldg., Denver 2, Colo. REFERENCES CAMPBELL, MEREDI'fH: Philadelphia: W. B. Saunders Co., 1954, vol. 2, p. 1035. COMPERE, D. E., BEGLEY, G. F., ISAACKS, H. E., FRAZIER, T. H. A"D DRYDEN, C. B.: Ureteral polpys. J. Urol. 79: 209-214, 1958. lVIELicow, M. M. AND FINDLAY, H. V.: Primary benign tumors of ureter: Review of literature and case report. Surg., Gynec. & Obst., 54: 680-689, 1932. SrLLIPHAN'l', W. M.: Personal communication taken from files of Armed Forces Institute of Pathology, Washington, D. C. Twr"EM, F. P.: Primary tumors of ureter. J.A.M.A., 163: 808-813, 1957