RECURRENCE OF PAPILLOMA OF RENAL PELVIS

ON URETERAL STUMP THIRTY YEARS AFTER

NEPHRECTOMY

A. DOUNIS, M.D. D. MITROPOULOS, M.D.

From the Department of Urology, Naval Hospital of Athens, Greece

ABSTRACT-Papillomas of the upper urinary tract may be multiple, developing either simul- taneously or at various times. Recurrence may occur many years after surgical treatment, even after thirty years, as in the case we report.

Epithelial tumors of the upper urinary tract are relatively rare. Many etiologic factors have been postulated, including congenital islets in the submucosa, tobacco, lithiasis, inflamma- tory alterations, and industrial environmental causes.’ The management of these tumors may be either radical (total nephroureterectomy with removal of a periureteral cuff of bladder) or more conservative.

In the case of a tumor of the renal pelvis a recurrent tumor may develop at the ureteral stump after nephrectomy and incomplete ure- terectomy. Recurrence may occur many years after the surgical procedure as in the case we report.

Case Report

A sixty-five-year-old man was referred to our clinic in January, 1984, because of gross painless hematuria of three months’ duration.

The patient had had gross painless hematuria in 1953, and an intravenous pyelogram demon- strated a mild degree of hydronephrosis of the left kidney without any obvious obstruction. He underwent nephrectomy through a left subcos- tal incision. The postoperative diagnosis was “papilloma of the kidney pelvis,” but he refused a second operation for total ureterectomy.

From 1953 until 1983 he was free of any symptoms. Cystoscopy showed a dilated ure- teral orifice with a protruding tumor, and a complete ureterectomy, including a cuff of bladder, was performed. Postoperative course was uneventful, and hematuria stopped,

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Pathologic findings Gross. The ureter measured 15 cm in

length and the lumen was filled by a tumor which showed a delicate papillary pattern upon emersion in fluid (Fig. 1).

FIGURE 1. Entire operative specimen.

UROLOGY / JULY 1988 / VOLUME XxX11, NUMBER 1

FIGURE 2. Microscopic ap- pearance of papillary lesion in ureter: (A) low power; (B) high power.

Microscopic. The numerous sections re- vealed a marked hyperplasia of the urothelium. Large papillary fronds with fibrovascular stalks were prominent. These stalks were covered by thick transitional epithelium (Fig. 2). Final diagnosis was transitional cell carcinoma of the ureter grade I, Stage A.

Comment Total nephrectomy and complete ureterec-

tomy, including a cuff of bladder, has long been the standard treatment for renal pelvis tumors2 However, some authors have suggested that more conservative excisions for low-grade pelvic tumors may be appropriate.3 The re- ported incidence of recurrent tumors in the ure- teral remnant after incomplete ureterectomy varies from 16 percent to 64 percent.4

There are various theories explaining the multiplicity of papillary tumors in the urinary tract: (1) implantation, (2) multicentricity, (3) lymphatic spread, and (4) direct extension. The absence of tumor formation above the primary focus and the rarity of bilateral tumors give support to the theory of cellular implantation. The multicentric theory cannot be rejected es- pecially in the case of the chemical tumors. Careful pathologic studies of the distal ureter and comparisons of renal pelvis and subsequent ureteral stump tumors using chromosomal mapping techniques may help to answer the question. 5

Recurrences occur early after the first ap- pearance and their frequency is due to histology

of the primary tumor (more common after pap- illary than after non-papillary tumors), locali- zation (more frequent after pelvocaliceal than after ureteric tumors), number of primary tu- mors (recurrence increases with multiplicity), and type of operation6

In our case the tumor was papillary and its primary focus was at the renal pelvis, but the patient remained free of symptoms for thirty years, which is the longest time described in the literature,

The possibility of recurrence even so many years after the first appearance, serves to em- phasize the necessity of nephroureterectomy and removal of the bladder cuff as well as fre- quent follow-up cystoscopic examinations.

11521 Athens, Greece (DR. DOUNIS)

References

1. Fourcroy JL, Berger M, and Athari F: Distal ureteral papil- loma associated with extensive proliferative ureteritis, J Ural 126: 819 (1981).

2. Hewitt CB: Nephroureterectomy with bladder cuff in the treatment of transitional cell carcinoma of the upper urinary tract, in Scott R Jr (Ed): Current Controversies in Urologic Management, Philadelphia, WB Saunders Co, 1972, p 69.

3. Petkovic SD: Epidemiology and treatment of renal pelvic and ureteral tumors, J Urol 114: 858 (1975).

4. No&s BN. et al: Transitional cell carcinoma of renal pelvis, Urology 19: 472 (1982).

5. Falor WH, and Ward RM: Prognosis in well-differentiated noninvasive carcinoma of the bladder based on chromosomal analysis, Surg Gynecol Obstet 144: 515 (1977).

6. Mazeman E: Tumors of the upper urinary tract calyces, re- nal pelvis and ureter, Em Urol 2: 120 (1976).

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