International Urology and Nephrolooy 11 (3), pp. 169-- 172 (1979)
Incidence and Complications of Ureteral Stump Pathology Tn. BURGRELE, CL. P. IOANID, M. G~LESANU Urological Clinic, Hospital Panduri, Bucharest, Romania (Received February 22, 1978)
The authors report on 58 patients with ureteral stump disease. Therapeutic errors, certain specific conditions, but also nephrectomies done for diseases other than pyelo-caiyceal tumors and tuberculosis may increase the severity of ureteral stump pathology. The clinical symptoms are often vague, and are demonstrated too late. The incidence may be reduced and the outcome improved by removal of the ureter whenever favourable conditions for development exist, and by looking for them by efficient exploration and complete excision, if nephrectomy is followed by even less marked changes.
The ureteral stump diseases following nephrectomy still merit attention despite the fact that for many years nephroureterectomy is being performed in cases of pyelocalyceal tumors and renal tuberculosis, which are the most frequent causes o f ureteral stump pathology. Ureteral stump pathology is still a controversial issue because the above standpoint is not universally adopted yet, it does not apply to some special conditions, and the remnant ureter following nephreetomy may become the seat of various lesions in case o f lithiasis or hydronephrosis [10, 13, 15, 18]. On the other hand, it is also claimed that the existence of stump pathology cannot require nephroureterectomy instead of a simple nephrectomy for any disease. One has to bear in mind that the ureteral stump troubles are not always related to the disease which necessitated nephrectomy. The stump tumors may follow nephrectomies for hydronephrosis or lithiasis. Whenever tuberculosis and lithiasis occur together and only the latter is identified, it is possible to preserve a pathologic ureter with all its consequences [19, 21, 27]. In hydronephrosis following nephrectomy, when an unidentified obstructive distal ureteral stone is left at the origin of the lesion, such a pathology will easily occur; anyway, any dilated remnant ureter may become the seat of some pathologic changes (lithiasis, nonspecific infections, metaplasia). These may appear after various periods o f time, ranging f r o m several months to several years, even in a remnant ureter which has normal qualities. Besides, such a process may occur in the very small remnant part even though, as a precaution towards these diseases, a large but not complete ureterectomy was performed at the time of nephrectomy. 1"
International Urology and
Nephrology 11~ 1979
170
Burghele et al.: Ureteral stump pathology
It should also be emphasized that the clinical manifestations of stump pathology are often latent and even if they arise far from the original site of operation they are seldom taken into consideration. In these conditions, the remnant ureter diseases must be thought o f and should be seriously considered, since their severity sometimes requiresa cautious analysis andproper treatment [1, 3, 8, 1t, 14, 24,
25, 281. Our cases have already been reported [12, 19]. Recently, reconsidering them, we made some new observations which might be worth of mentioning. Thus, while in the period 1947-1965 we had 23 patients with ureteral stump diseases (6 lithiasis, 5 nonspecific infections, 5 tuberculosis, 7 tumors), in 1971 their number rose to 35 (6 lithiasis, 9 nonspecific infections, 7 tuberculosis, 13 tumors), and in 1976 to 58 (7 tuberculosis, 19 nonspecific infections, 8 lithiasis, 24 tumors). As regards the frequency of ureteral stump pathology we are stressing our opinion that its accurate appreciation is still difficult, because some of the cases remain unknown due to a tendency of not reporting them, to diagnostic errors or to the belief that their relatively low incidence makes them unimportant. However, as indicated also by published statistical evidence, it is certain that this matter should be payed attention to by specialists [16, 17, 20, 22, 23, 26]. Some data concerning our cases are presented in Table 1. The proportion of neoplastic lesions, 24 cases including 22 following nephrectomy done for pyelocalyceal tumors and the two others for lithiasis or hydronephrosis, is meaningful. Table 1 Principal features in ureteral stump disease Nephrectomy
No. o f cases
Tuberculosis Pyelo-calyceal papillomatosis Pyonephrosis with stone without stone
15 4
Disease
No, o f cases
8
Tuberculosis Nonspecific infection
27
Tumor Nonspecific infection
22 5 7 I0
19
Lithiasis Nonspecific infection Tumor Tuberculosis
Hydronephrosis
Lithiasis Nonspecific infection Tumor
Hydatic cyst
Nonspecific infection Total
International Urology and Nephrology 11, 1979
No. o f secondary ureterectomies
6 22
1 1
16
58
47
171
Burghele et al. : Ureteral stump' pathology
It should be also pointed out that nonspecific infections (19 patients) were present in one third of the cases. The interval between nephrectomy and the discovery of the ureteral stump disease exceeded one year in 50 ~ of cases, 5 years in 6 cases and 10 years in 6 cases (20 years in one and even 32 years in another ease) [2, 9] (Table 2). Table 2 Time of discovery of ureteral stump disease No. of eases
Disease
Time, years 10
1
(14)
2
1
(16)
5
1
1
(16)
i
1
3
3
(18) (20) (32)
29
17
6
Secondary ureterectomy was carried out in 47 patients (see Table 1); the rest refused to be operated on, or the extent of neoplastic changes made an operation impossible or unfeasible. The above-mentioned informations state the necessity to take practical steps accordingly. First, all the pyelo-calyceal tumors, in tuberculosis, especially when some ureteral pathological disorders are discovered before and during operation, nephroureterectomy should be performed. Secondly, a complete evaluation of the ureter should be carried out before and after operation in all cases requiring nephrectomy. This seems to be justified, because if conditions (such as dilatation, stenosis, chronic inflammation, lithiasis, abnormalities) favouring subsequent pathological changes in the ureteral stump occur, nephroureterectomy (or stone removal) must be performed. In nephrectomized patients any postoperative disorder, however slight, and any persistent urinary infection should call attention to these lesions, and exploration of the remnant stump should be decided upon. As regards treatment of these diseases, except for the few cases in which local or general motivated conditions lead only to a palliative operation, the method of choice is complete exeresis, which is the more efficient the earlier it is done [1, 4, 5, 6, 7]. International
Urology and
Nephrology
11,
1979
172
Burghele et al.: Ureteral stump pathology
References 1. Bianchi, F.: Fr6quence de la pathologie de l'uret6re restant. J. d'Urol, ndphroL, 82, Suppl. 2, 275 (1976). 2. Brongersma, H.: Un cas d'ur6t6rite se manifestant 23 ans apr6s la n6phrectomie. Ass. Franc. Urol., 21, 573 (1921). 3. Bruce, A. N., Aeod, S. A.: Reflux in residual ureter. J. Urol., 92, 278 (1964). 4. Burghele, Th.: La n6phro-ur6t6rectomie totale par voie lombaire et intra-p6ritoneale dans le traitement de la tuberculose r6no-ur6t6rale. J. d'Urol., 61, 517 (1955). 5. Burghele, Th., Albescu, I.: Die totale Nephroureterektomie im Rahmen der gegenw/irtigen Behandlung der Urogenitaltuberkulose bei Mann und Frau. Urol. lnt., 25, 1 (1970). 6. Burghele, Th.: Nephroureterectomy in urinary tuberculosis. Europ. Urol., 2, 1 (1976). 7. Couvelaire, R.: La n6phro-ur6t6rectomie totale par vole mixte: lombaire et vaginale, ou lombaire et p6rin6ale, or. d'Urol., 57, 501 (1951). 8. Deliveliotis, A., Syrmos, C., Saltsos, A.: A p r o p o s de onze cas d'urdt6re restant. J. d' Urol. ndphrol., 82, Suppl. 2, 311 (1976). 9. Davidson, S.: Pyoureter 17 years after nephrectomy. J.A.M.A., 118, 137 (1942). 10. G6tze, F. J. : Erkrankungen des Harnleiters nach Nephrektomie. Z. Urol. Chir., 54, 591 (1961). 11. Hautmann, L., Dekkers, J. L., Lutzeyer, W.: Le mognon ur6t6ral oubli6. J. d'Urol. ndphrol., 82, Suppl. 2, 280 (1976). 12. Ioanid, P., Angelescu, N. : Patologia bontului ureteral r~mas dup~ nefrectomie. Chirurgia (Bucuresti), 14, 425 (1965). 13. Litvak, A.: Le mognon ur6tfral du n6phr~ctomis6: un danger. Urol. Int. (Basel), 14, 129 (1962). 14. Lj~nggren, R.: Complication caused by the stump of the ureter after nephrectomy. J. Urol., 59, 179 (1942). 15. Lutzeyer, W., Teichmann, H. H.: Erkrankungen des Restureters nach Nephrektomie. Z. Urol., 54, 431 (1961). 16. Malek, A. R.." Symptomatic ureteral stump. J. Urol., 106, 521 (1971). 17. Masson, J. T., Coburn, W. A.: Disease of ureteral remnant following nephrectomy. Arch. sur#., 70, 289 (1955). 18. Moore, Th.: Lesion of ureteric stump after nephrectomy. Brit. or. Urol., 29, 208 (1957). 19. Neagu, V., ioanid, C., Angelescu, N. : Disorders of the ureteral stump, lnt. Urol. Nephrol., 5, 363 (1971). 20. Petkovic, S., Mutovdzic, M.: Le probl6me de l'uret6re restant apr~s traitement pour tumeur du bassinet ou de l'uret6re. J. d'Urol, nOphrol., 82, Suppl. 2, 287 (1976). 21. Puigvert, A.: The ureter in renal tuberculosis. Brit. J. Urol., 27, 258 (1955). 22. Pu.scariu, V., Bonachi, R. : Two cases of ureteral stump disease excepting tuberculosis. Urol. Int., 25, 360 (1958). 23. Van Regemoter, G. : La pathologie de l'uret~re restant, or. d" Urol. n~phrol., 82, Suppl. 2, 286 (1976). 24. Risse, G.: Consideration of ureteral stump subsequent to nephrectomy. Urol., 64, 275 (1950). 25. Sauer, H.: ~ b e r Ureterstumpferkrankungen. Z. Urol., 27, 468 (1933). 26. Surraco, N.: Le mognon de l'uret6re apr6s la n6phrectomie, or. d'Urol., 58, 829 (1952). 27. Viollet, G. : L'uret~re du tuberculeux uro-g6nital. Vie todd., 44, 295 (1963). 28. Wetterwald, F.: La pathologie de l'uret6re restant. J. d'Urol, ndphrol., 88, Suppl. 2, 251 (1976).
International Urology and Ncphrology i1, 1979
Incidence and Complications of Ureteral Stump Pathology Tn. BURGRELE, CL. P. IOANID, M. G~LESANU Urological Clinic, Hospital Panduri, Bucharest, Romania (Received February 22, 1978)
The authors report on 58 patients with ureteral stump disease. Therapeutic errors, certain specific conditions, but also nephrectomies done for diseases other than pyelo-caiyceal tumors and tuberculosis may increase the severity of ureteral stump pathology. The clinical symptoms are often vague, and are demonstrated too late. The incidence may be reduced and the outcome improved by removal of the ureter whenever favourable conditions for development exist, and by looking for them by efficient exploration and complete excision, if nephrectomy is followed by even less marked changes.
The ureteral stump diseases following nephrectomy still merit attention despite the fact that for many years nephroureterectomy is being performed in cases of pyelocalyceal tumors and renal tuberculosis, which are the most frequent causes o f ureteral stump pathology. Ureteral stump pathology is still a controversial issue because the above standpoint is not universally adopted yet, it does not apply to some special conditions, and the remnant ureter following nephreetomy may become the seat of various lesions in case o f lithiasis or hydronephrosis [10, 13, 15, 18]. On the other hand, it is also claimed that the existence of stump pathology cannot require nephroureterectomy instead of a simple nephrectomy for any disease. One has to bear in mind that the ureteral stump troubles are not always related to the disease which necessitated nephrectomy. The stump tumors may follow nephrectomies for hydronephrosis or lithiasis. Whenever tuberculosis and lithiasis occur together and only the latter is identified, it is possible to preserve a pathologic ureter with all its consequences [19, 21, 27]. In hydronephrosis following nephrectomy, when an unidentified obstructive distal ureteral stone is left at the origin of the lesion, such a pathology will easily occur; anyway, any dilated remnant ureter may become the seat of some pathologic changes (lithiasis, nonspecific infections, metaplasia). These may appear after various periods o f time, ranging f r o m several months to several years, even in a remnant ureter which has normal qualities. Besides, such a process may occur in the very small remnant part even though, as a precaution towards these diseases, a large but not complete ureterectomy was performed at the time of nephrectomy. 1"
International Urology and
Nephrology 11~ 1979
170
Burghele et al.: Ureteral stump pathology
It should also be emphasized that the clinical manifestations of stump pathology are often latent and even if they arise far from the original site of operation they are seldom taken into consideration. In these conditions, the remnant ureter diseases must be thought o f and should be seriously considered, since their severity sometimes requiresa cautious analysis andproper treatment [1, 3, 8, 1t, 14, 24,
25, 281. Our cases have already been reported [12, 19]. Recently, reconsidering them, we made some new observations which might be worth of mentioning. Thus, while in the period 1947-1965 we had 23 patients with ureteral stump diseases (6 lithiasis, 5 nonspecific infections, 5 tuberculosis, 7 tumors), in 1971 their number rose to 35 (6 lithiasis, 9 nonspecific infections, 7 tuberculosis, 13 tumors), and in 1976 to 58 (7 tuberculosis, 19 nonspecific infections, 8 lithiasis, 24 tumors). As regards the frequency of ureteral stump pathology we are stressing our opinion that its accurate appreciation is still difficult, because some of the cases remain unknown due to a tendency of not reporting them, to diagnostic errors or to the belief that their relatively low incidence makes them unimportant. However, as indicated also by published statistical evidence, it is certain that this matter should be payed attention to by specialists [16, 17, 20, 22, 23, 26]. Some data concerning our cases are presented in Table 1. The proportion of neoplastic lesions, 24 cases including 22 following nephrectomy done for pyelocalyceal tumors and the two others for lithiasis or hydronephrosis, is meaningful. Table 1 Principal features in ureteral stump disease Nephrectomy
No. o f cases
Tuberculosis Pyelo-calyceal papillomatosis Pyonephrosis with stone without stone
15 4
Disease
No, o f cases
8
Tuberculosis Nonspecific infection
27
Tumor Nonspecific infection
22 5 7 I0
19
Lithiasis Nonspecific infection Tumor Tuberculosis
Hydronephrosis
Lithiasis Nonspecific infection Tumor
Hydatic cyst
Nonspecific infection Total
International Urology and Nephrology 11, 1979
No. o f secondary ureterectomies
6 22
1 1
16
58
47
171
Burghele et al. : Ureteral stump' pathology
It should be also pointed out that nonspecific infections (19 patients) were present in one third of the cases. The interval between nephrectomy and the discovery of the ureteral stump disease exceeded one year in 50 ~ of cases, 5 years in 6 cases and 10 years in 6 cases (20 years in one and even 32 years in another ease) [2, 9] (Table 2). Table 2 Time of discovery of ureteral stump disease No. of eases
Disease
Time, years 10
1
(14)
2
1
(16)
5
1
1
(16)
i
1
3
3
(18) (20) (32)
29
17
6
Secondary ureterectomy was carried out in 47 patients (see Table 1); the rest refused to be operated on, or the extent of neoplastic changes made an operation impossible or unfeasible. The above-mentioned informations state the necessity to take practical steps accordingly. First, all the pyelo-calyceal tumors, in tuberculosis, especially when some ureteral pathological disorders are discovered before and during operation, nephroureterectomy should be performed. Secondly, a complete evaluation of the ureter should be carried out before and after operation in all cases requiring nephrectomy. This seems to be justified, because if conditions (such as dilatation, stenosis, chronic inflammation, lithiasis, abnormalities) favouring subsequent pathological changes in the ureteral stump occur, nephroureterectomy (or stone removal) must be performed. In nephrectomized patients any postoperative disorder, however slight, and any persistent urinary infection should call attention to these lesions, and exploration of the remnant stump should be decided upon. As regards treatment of these diseases, except for the few cases in which local or general motivated conditions lead only to a palliative operation, the method of choice is complete exeresis, which is the more efficient the earlier it is done [1, 4, 5, 6, 7]. International
Urology and
Nephrology
11,
1979
172
Burghele et al.: Ureteral stump pathology
References 1. Bianchi, F.: Fr6quence de la pathologie de l'uret6re restant. J. d'Urol, ndphroL, 82, Suppl. 2, 275 (1976). 2. Brongersma, H.: Un cas d'ur6t6rite se manifestant 23 ans apr6s la n6phrectomie. Ass. Franc. Urol., 21, 573 (1921). 3. Bruce, A. N., Aeod, S. A.: Reflux in residual ureter. J. Urol., 92, 278 (1964). 4. Burghele, Th.: La n6phro-ur6t6rectomie totale par voie lombaire et intra-p6ritoneale dans le traitement de la tuberculose r6no-ur6t6rale. J. d'Urol., 61, 517 (1955). 5. Burghele, Th., Albescu, I.: Die totale Nephroureterektomie im Rahmen der gegenw/irtigen Behandlung der Urogenitaltuberkulose bei Mann und Frau. Urol. lnt., 25, 1 (1970). 6. Burghele, Th.: Nephroureterectomy in urinary tuberculosis. Europ. Urol., 2, 1 (1976). 7. Couvelaire, R.: La n6phro-ur6t6rectomie totale par vole mixte: lombaire et vaginale, ou lombaire et p6rin6ale, or. d'Urol., 57, 501 (1951). 8. Deliveliotis, A., Syrmos, C., Saltsos, A.: A p r o p o s de onze cas d'urdt6re restant. J. d' Urol. ndphrol., 82, Suppl. 2, 311 (1976). 9. Davidson, S.: Pyoureter 17 years after nephrectomy. J.A.M.A., 118, 137 (1942). 10. G6tze, F. J. : Erkrankungen des Harnleiters nach Nephrektomie. Z. Urol. Chir., 54, 591 (1961). 11. Hautmann, L., Dekkers, J. L., Lutzeyer, W.: Le mognon ur6t6ral oubli6. J. d'Urol. ndphrol., 82, Suppl. 2, 280 (1976). 12. Ioanid, P., Angelescu, N. : Patologia bontului ureteral r~mas dup~ nefrectomie. Chirurgia (Bucuresti), 14, 425 (1965). 13. Litvak, A.: Le mognon ur6tfral du n6phr~ctomis6: un danger. Urol. Int. (Basel), 14, 129 (1962). 14. Lj~nggren, R.: Complication caused by the stump of the ureter after nephrectomy. J. Urol., 59, 179 (1942). 15. Lutzeyer, W., Teichmann, H. H.: Erkrankungen des Restureters nach Nephrektomie. Z. Urol., 54, 431 (1961). 16. Malek, A. R.." Symptomatic ureteral stump. J. Urol., 106, 521 (1971). 17. Masson, J. T., Coburn, W. A.: Disease of ureteral remnant following nephrectomy. Arch. sur#., 70, 289 (1955). 18. Moore, Th.: Lesion of ureteric stump after nephrectomy. Brit. or. Urol., 29, 208 (1957). 19. Neagu, V., ioanid, C., Angelescu, N. : Disorders of the ureteral stump, lnt. Urol. Nephrol., 5, 363 (1971). 20. Petkovic, S., Mutovdzic, M.: Le probl6me de l'uret6re restant apr~s traitement pour tumeur du bassinet ou de l'uret6re. J. d'Urol, nOphrol., 82, Suppl. 2, 287 (1976). 21. Puigvert, A.: The ureter in renal tuberculosis. Brit. J. Urol., 27, 258 (1955). 22. Pu.scariu, V., Bonachi, R. : Two cases of ureteral stump disease excepting tuberculosis. Urol. Int., 25, 360 (1958). 23. Van Regemoter, G. : La pathologie de l'uret~re restant, or. d" Urol. n~phrol., 82, Suppl. 2, 286 (1976). 24. Risse, G.: Consideration of ureteral stump subsequent to nephrectomy. Urol., 64, 275 (1950). 25. Sauer, H.: ~ b e r Ureterstumpferkrankungen. Z. Urol., 27, 468 (1933). 26. Surraco, N.: Le mognon de l'uret6re apr6s la n6phrectomie, or. d'Urol., 58, 829 (1952). 27. Viollet, G. : L'uret~re du tuberculeux uro-g6nital. Vie todd., 44, 295 (1963). 28. Wetterwald, F.: La pathologie de l'uret6re restant. J. d'Urol, ndphrol., 88, Suppl. 2, 251 (1976).
International Urology and Ncphrology i1, 1979
