Vol. 116, November
THE JOURNAL OF UROLOGY
Frinted in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
ENDOMETRIOSIS OF THE URETER KIMIO FUJITA From the Urological Division, Saku Central Hospital, Minamisaku Usuda, Nagano, Japan
A 43-year-old woman had periodic asymptomatic gross hematuria 1 year in duration. She had undergone a hysterectomy 3 years earlier for myoma uteri and the right ovary was removed with the uterus because of its cystic change. Although
loma-like tumor that was identified as endometriosis on microscopic examination. There are 3 main concepts concerning the pathogenesis of endometriosis: 1) it arises from embryonic rests of mtillerian and wolffian ducts, 2) it is a metaplastic change caused by hormonal or inflammatory stimulation and 3) it is disseminated from t:he endometrium, directly or through lymphatic and vascular channels. 2 Marshall, 3 and Miles and Falconer• suggested that renal endometriosis probably developed from the cells of the miillerian duct attached to the ureteral bud or metanephros. In
FIG. 2. Microscopic view of tumor shows endometriosis
FIG. 1. Right kidney was not seen intravenously. Succeeding retrograde pyelography reveals obliterated ureter and ovoid mass. an endometrial change had not occurred the possibility of ovarian endometriosis remained. An excretory urogram revealed a right non-functioning kidney. On cystoscopic examination the bladder appeared normal. A ureteral catheter was introduced easily but stopped at 8 cm. Injection of contrast medium showed an intraluminal ovoid mass, which was 2 cm. in diameter (fig. 1). A ureteral tumor was suspected and a right nephroureterectomy was performed through the transperitoneal approach. Pelvic endometriosis was not observed. The ureter had been erroneously ligated at the point where the contrast medium stopped. A polypous tumor projected intraluminally. Histological diagnosis was endometriosis (fig. 2). The muscular layer was not involved. DISCUSSION
Endometriosis of the kidney and ureter is rare. The only case reported in Japan involved a woman who had pelvic endometriosis. 1 The right ureter was involved in the mass and about 1 cm. distal to the lesion there was a small intraluminal granuAccepted for publication April 9, 1976.
light of the case reported by Hirota and Origasa, 1 spreading by way of the lymphatics or blood vessels is the most probable genesis of intra-ureteral endometriosis. REFERENCES
1. Hirota, N. and Origasa, S.: Ureteral obstruction from endometriosis. Jap. J. Clin. Ural., 25: 237, 1971.
2. O'Conor, V. J. and Greenhill, J. P.: Endometriosis of the bladder and ureter. Surg., Gynec. & Obst., 80: 113, 1945. 3. Marshall, V. F.: The occurrence of endometrial tissue in the kidney: case report and discussion. J. Urol., 50: 652, 1943. 4. Miles, H. B. and Falconer, K. W.: Renal endometriosis associated with hematuria. J. Ural., 102: 291, 1969. COMMENT Although involvement of the lower ureter with endometriosis is not common, it is not rare among women who have active pelvic endometriosis. I believe that this is a case of direct invasion. I do not believe my former theory, metaplasia, but consider that emboli metastasis or direct invasion explains nearly all cases. Victor F. Marshall New York Hospital New York, New York REPLY BY AUTHOR The proliferative area is isolated and just limited within the lamina propria mucosae of the ureter with intact muscular and submucosal layers. It is a common and natural site of emboli metastasis and common with usual bladder endometriosis.
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THE JOURNAL OF UROLOGY
Frinted in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
ENDOMETRIOSIS OF THE URETER KIMIO FUJITA From the Urological Division, Saku Central Hospital, Minamisaku Usuda, Nagano, Japan
A 43-year-old woman had periodic asymptomatic gross hematuria 1 year in duration. She had undergone a hysterectomy 3 years earlier for myoma uteri and the right ovary was removed with the uterus because of its cystic change. Although
loma-like tumor that was identified as endometriosis on microscopic examination. There are 3 main concepts concerning the pathogenesis of endometriosis: 1) it arises from embryonic rests of mtillerian and wolffian ducts, 2) it is a metaplastic change caused by hormonal or inflammatory stimulation and 3) it is disseminated from t:he endometrium, directly or through lymphatic and vascular channels. 2 Marshall, 3 and Miles and Falconer• suggested that renal endometriosis probably developed from the cells of the miillerian duct attached to the ureteral bud or metanephros. In
FIG. 2. Microscopic view of tumor shows endometriosis
FIG. 1. Right kidney was not seen intravenously. Succeeding retrograde pyelography reveals obliterated ureter and ovoid mass. an endometrial change had not occurred the possibility of ovarian endometriosis remained. An excretory urogram revealed a right non-functioning kidney. On cystoscopic examination the bladder appeared normal. A ureteral catheter was introduced easily but stopped at 8 cm. Injection of contrast medium showed an intraluminal ovoid mass, which was 2 cm. in diameter (fig. 1). A ureteral tumor was suspected and a right nephroureterectomy was performed through the transperitoneal approach. Pelvic endometriosis was not observed. The ureter had been erroneously ligated at the point where the contrast medium stopped. A polypous tumor projected intraluminally. Histological diagnosis was endometriosis (fig. 2). The muscular layer was not involved. DISCUSSION
Endometriosis of the kidney and ureter is rare. The only case reported in Japan involved a woman who had pelvic endometriosis. 1 The right ureter was involved in the mass and about 1 cm. distal to the lesion there was a small intraluminal granuAccepted for publication April 9, 1976.
light of the case reported by Hirota and Origasa, 1 spreading by way of the lymphatics or blood vessels is the most probable genesis of intra-ureteral endometriosis. REFERENCES
1. Hirota, N. and Origasa, S.: Ureteral obstruction from endometriosis. Jap. J. Clin. Ural., 25: 237, 1971.
2. O'Conor, V. J. and Greenhill, J. P.: Endometriosis of the bladder and ureter. Surg., Gynec. & Obst., 80: 113, 1945. 3. Marshall, V. F.: The occurrence of endometrial tissue in the kidney: case report and discussion. J. Urol., 50: 652, 1943. 4. Miles, H. B. and Falconer, K. W.: Renal endometriosis associated with hematuria. J. Ural., 102: 291, 1969. COMMENT Although involvement of the lower ureter with endometriosis is not common, it is not rare among women who have active pelvic endometriosis. I believe that this is a case of direct invasion. I do not believe my former theory, metaplasia, but consider that emboli metastasis or direct invasion explains nearly all cases. Victor F. Marshall New York Hospital New York, New York REPLY BY AUTHOR The proliferative area is isolated and just limited within the lamina propria mucosae of the ureter with intact muscular and submucosal layers. It is a common and natural site of emboli metastasis and common with usual bladder endometriosis.
664
