CALCIFIED PAPILLOMA OF URETER

N. ERICK ALBERT, M.D.

JAMES L. MEE, M.D.

Lodi, California

ABSTRACT-A case of calcified benign papilloma of the ureter treated by local excision is pre- sented.

Benign lesions of the ureter are rare and may present a difficult diagnostic problem. With ac- curate preoperative evaluation, however, they can be safely treated by local excision alone. We present an unusual case of a benign calcified ureteral lesion that was associated with recur- rent urinary tract infections and was amenable to local resection.

Case Report

A forty-eight-year-old Mexican-American woman was evaluated because of recurrent

urinary tract infections associated with urea- splitting organisms. Intravenous pyelogram (IVP) showed extensive calcification in the left renal collection system with a left kidney length of 12.2 cm. The right side showed evidence of cortical atrophy with reduction of kidney size to 9.4 cm. The calyceal system was clubbed, al- though the ureter was normal in size and a right mid-ureteral calcified lesion was noted. This le- sion had a central radiolucent area and measured 1.4 by 2.5 cm (Fig. 1). Radiograph of the ureteral lesion suggested either calcification around sloughed renal papillae or possibly a

FIGURE 1. (A) Plain film of abdomen showing extensive left renal collecting system calcification and right mid- ureteral lesion with central radiolucency. (B) Ten-minute film showing right calyceal blunting and cortical atrophy. Proximal right ureter is not di- lated.

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FIGURE 2. Forceps are grasping calcified lesion. Ar- row points to stalk. Pediatric feeding tube is coursing proxi- mally toward renal pelvis and vascular loop is around ureter distal to ureterotomy, which is exposed by stay sutures.

calcified ureteral tumor. Laboratory evaluation included normal serial serum calcium deter- mination of between 9.2 and 10.0 mg/dl and normal serum creatinine. Urine cultures re- mained sterile on a regimen of nitrofurantoin suppression. Because of persistent urinary tract infections, hematuria and intermittent left and right loin pain, the patient was advised to have bilateral collecting system surgery.

She underwent exploration of the right ureter through a transverse mid-abdominal incision. The ureter was opened between stay sutures. A pedunculated calcified lesion was encountered (Fig. 2). The lesion was amputated flush with the ureteral wall, and a frozen section of the stalk revealed benign squamous metaplasia. The base of the lesion was fulgurated and the ureter closed. The patient had an uneventful re- covery.

The lesion was subsequently bisected and de- calcified. Sections of the remaining tissue showed a crystalline matrix and spaces contain- ing loose connective tissue and scattered chronic inflammatory cells. No epithelial elements were identified (Fig. 3). Two months later the pa- tient underwent a left anatrophic nephroli- thotomy and has been stone-free with sterile urine on subsequent examinations.

Comment

Benign lesions of the ureter are rare and gen- erally are difficult to diagnose. Two categories are recognized pathologically: l epithelial le- sions which may be papillary, polyp or adeno- matous and mesodermal tumors, most common

UROLOGY / MAY1986 / VOLUMEXXVII,NUMBER5

FIGURE 3. Lesion decalcified showing cry<Ttal ma- trix and loose connective tissue.

of which are the fibromas. These lesions are of- ten preceded by hematuria, flank pain, or loin mass.’ Malignant lesions of the ureter are three times more common than benign lesions and have a male predominance, unlike the benign tumors which have equal sexual distributions. Also, malignant lesions tend to occur in the lower portion of the ureter while benign lesions tend to be more common proximally.1.2

Radiologically, three types of findings have been noted on IVP: (1) nonvisualization of the ipsilateral side; (2) unilateral hydronephrosis; (3) ureteral defect without hydronephrosis or proximal change of the collecting system.’ Our patient had clubbing of the right renal calyces which is probably due to chronic infection and papillary necrosis rather than proximal hydro- nephrosis.

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These benign lesions are often difficult to diagnose preoperatively because of the prob- lems with radiologic visualization. Retrograde ureterograms may show filling defects, and the differential diagnosis includes malignant le- sions, radiolucent stones, blood clots and extrin- sic compression from retroperitoneal tumors or vascular structures4 The treatment of these benign lesions is almost always local excision if the diagnosis can be made accurately pre- operatively. Although some investigators clas- sify these tumors as grade I transitional cell car- cinomas,4 long-term survival is the rule, and local excision is certainly warranted in those pa- tients in whom the diagnosis can be made prior to surgery.5 The origin of the calcification of our lesions is clear. Certainly chronic infection and inflammation can cause significant urothelial

changes,2 and calcification of these inflamma- tory structures can occur.

830 S. Ham Lane Lodi, California 95240

(DR. ALBERT)

References

1. Arger PH, and Stolz JL: Ureteral tumors, Radiology 116: 812 (1972).

2. Geerdsen J: Tumors of the renal pelvis and ureter, Stand J Urol Nephrol 13: 287 (1979).

3. Pinto RS, Fauver E, and Anderson JK: Benign fibroepithe- lioma of ureter, Urology 3: 747 (1974).

4. Emmett JL, and Witten DM (Eds): Tumors, The renal pelvis and ureter. In: Clinical Urography, Philadelphia, W. B. Saunders Co, 1971, p 1145.

5. Bergman H, and Hotchkiss RS: Ureteral tumors, in Bergman H (Ed): The Ureter, New York, Springer-Verlag, 1981, pp 288-291.

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