331
CASE REPORTS
anaesthesia showed that the urinary leak came from an opening 2 c m above the anal verge, which could be cannulated up to 5 cm. Cystourethroscopy was unremarkable except for an oedematous right ureteric orifice. A fistulogram revealed a wide bifurcated tract up to the stone with filling of the right ureter and bladder (Fig. 2). A micturating cystourethrogram was normal. AI.exploration, the 4-cm bifid fistulous tract containing the !; large stones was completely excised and the dilated proximal ureter was reimplanted into a Boari bladder tube. Post-operative recovery was uneventful. An IVU 3 months later showed complete regression of the right hydroureteronephrosis.
Comment Ureteric fistulas are usually a result of infection, inflammation or stones (Sathaye et al. 1988). Fistulas with the lower gastrointestinal tract are very rare (Kar et al., 1984). To the best of our knowledge, a fistula between the ureter and anal canal has not been previously reported. In our patient the impacted stone had probably created local infection and an abscess which burst perianally. The fistulectomy for the misdiagnosed fistula in ano caused the opening to recede into the anal canal. Because of the calculus the inflammation and fistula persisted. References Kar, A, Angwafo, F. F. and Jhunjhuwala, J. S. (1984). Ureteroarterial and ureterosigmoid fistula associated with polyethylene indwelling ureteral stents. J. Urol., 132,755-757. Sathaye, U. V., Dodia, V. B. and Mehta, J. M. (1988). Ureterovasal fistula with calculi. Indian J . Surg., 50, 373. Requests for reprints to: U. V. Sathaye, Consultant Urologist, Opposite Medical College, Solerium Road, Jamnagar 361 008, India.
L-eiomyomaof the Renal Pelvis A. O'BRIEN, B. S I N N O T , P. McLEAN and G. D. DOYLE, Llepartments of Urology and Histopathology, Beaumont Hospital, Dublin, Ireland
Case Report A 43-year-old lady was referred with a history of left loin pain and intermittent frank haematuria. Clinical examination revealed left renal angle tenderness.
Intravenous urography showed minimal function from an atrophic right kidney. The upper pole calices of the left kidney were distorted and dilated. Ultrasonography confirmed an atrophic right kidney and revealed a cyst, 5 cm in diameter, in the posterolateral aspect of the upper pole of the left kidney. Medial to the cyst was a lobulated area of soft tissue echogenicity, measuring 3.5 x 2 cm, adjacent to the dilated upper pole calices. Retrograde ureterography revealed a filling defect at the infundibulum of the upper pole calices. At ureteroscopy the filling defect was seen to be caused by a rounded, smooth, darkcoloured lesion on the renal pelvic wall, almost completely occluding the infundibulum of the upper pole calices. O n exploration a cyst was found in the upper pole of the kidney. The cyst was readily separable from adjacent renal parenchyma and was found to be contiguous with the solid, firm lesion arising from the pelvic wall at the infundibulum of the upper pole calices. The pelvicaliceal system was otherwise macroscopically normal. The lesion and cyst were resected en bloc by a n upper pole partial nephrectomy (Fig. 1). The patient made a satisfactory recovery. Histological examination showed the cyst to be lined by a low cuboidal epithelium. The solid lesion (Fig. 2) consisted of uniform spindle cells arranged in bundles coursing in various directions and in places exhibiting a palisading pattern. The nuclei of uniform morphology had blunted ends and were surrounded by a distinctly eosinophilic cytoplasm. Mitotic figures were infrequent. Examination of P T A H preparations under oil revealed longitudinal intracytoplasmic filaments. Positivity for tumour markers, including vimentin, desmin and muscle specific actin, was demonstrated. The tumour showed the features of a leiomyoma on electron microscopy.
Comment Renal leiomyomas are uncommon tumours and have been categorised into 3 groups, depending mainly on their site within the kidney, and thereby the location of the smooth muscle cells from which they are likely to have arisen (Belis et al., 1979). In the most common group the leiomyomas are on the cortical surface or in the most superficial cortex and are considered to arise from smooth muscle cells in the renal capsule. They are usually multiple and small, measuring only a few millimetres in diameter. They show no predilection for either gender and do not cause any symptoms, having generally been coincidental findings at autopsy or surgical exploration. In contrast, the second category comprises solitary tumours which have attained large proportions, weighing up to 5 kg. While their large dimensions have not infrequently rendered their exact site of origin difficult to determine, they are
332
Fig. 1 Gross appearance of specimen as seen from the renal pelvis. Lesion outlined by arrows.
BRITISH JOURNAL OF UROLOGY
who presented with either pain or haematuria and were found to have renal pelvic filling defects on intravenous urography. All of the previously reported patients were presumed to have transitional cell tumours which were resected by nephroureterectomy. Our patient is the only one to have presented with both pain and haematuria. Since the contralateral kidney was barely functional, maximal preservation of functioning renal parenchyma was desirable. The ureteroscopic appearance of the renal pelvic lesion was reassuring, as it was considered that the tumour was unlikely to be a transitional cell carcinoma. This is the only reported case of renal pelvic leiomyoma to have been resected by partial nephrectomy. The gross, microscopic and immunohistochemical features were similar to those reported previously. However, it is the only case to have been associated with cyst formation.
References Belis, J. A., Post,G.J., Rochman,S. C. etal. (1979). Genitourinary leiomyomas. J . Urol., 13,424429. Kho, G . T. and Duggan, M. A. (1989). Bizarre leiomyoma of the renal pelvis with ultrastructural and immunohistochemical findings. J . Urol., 141,928-929. Zuckermann, 1. C., Kershner, D., Laytner, B. D. ef al. (1947). Leiomyoma of the kidney. Ann. Surg., 126,220-228. Requests for reprints to: A. O’Brien, Department of Urology, Craigavon Area Hospital, Craigavon, N . Ireland.
Ureterocolic Fistula due to Impacted Ureteric Stone Fig. 2 Section showing uniform spindle cells lying parallel and arranged in bundles which course in various directions. (H and E x 200).
believed to arise from cortical vascular smooth muscle cells. They usually give rise to flank pain or discomfort, though their diagnosis has occasionally followed the finding of an asymptomatic abdominal mass. They occur almost invariably in females, and in all age groups, including the newborn (Zuckerman et a/., 1947). Leiomyomas arising from smooth muscle of the renal pelvic wall are rare, only 5 patients having been previously reported (Kho and Duggan, 1989). All were women, aged between 24 and 50 years,
K. P. PATIL, S. D. SHETW, N. ANANDAN and A. IBRAHIM, Department of Urology, College of Medicine, King Saud University (Abha). and Asir Central Hospital, Abha. Saudi Arabia
Ureteric fistulas are usually ureterovaginal and ureterocutaneous, but ureteroarterial and ureteroarterio-enteric fistulas have been reported following aortoiliac bypass graft surgery (Kar et al., 1984). Ureteroenteric fistulas are very rare. We report a case of ureterocolic fistula caused by an impacted ureteric calculus.
Case Report A 40-year-oldSaudi male was referred with a history of
CASE REPORTS
anaesthesia showed that the urinary leak came from an opening 2 c m above the anal verge, which could be cannulated up to 5 cm. Cystourethroscopy was unremarkable except for an oedematous right ureteric orifice. A fistulogram revealed a wide bifurcated tract up to the stone with filling of the right ureter and bladder (Fig. 2). A micturating cystourethrogram was normal. AI.exploration, the 4-cm bifid fistulous tract containing the !; large stones was completely excised and the dilated proximal ureter was reimplanted into a Boari bladder tube. Post-operative recovery was uneventful. An IVU 3 months later showed complete regression of the right hydroureteronephrosis.
Comment Ureteric fistulas are usually a result of infection, inflammation or stones (Sathaye et al. 1988). Fistulas with the lower gastrointestinal tract are very rare (Kar et al., 1984). To the best of our knowledge, a fistula between the ureter and anal canal has not been previously reported. In our patient the impacted stone had probably created local infection and an abscess which burst perianally. The fistulectomy for the misdiagnosed fistula in ano caused the opening to recede into the anal canal. Because of the calculus the inflammation and fistula persisted. References Kar, A, Angwafo, F. F. and Jhunjhuwala, J. S. (1984). Ureteroarterial and ureterosigmoid fistula associated with polyethylene indwelling ureteral stents. J. Urol., 132,755-757. Sathaye, U. V., Dodia, V. B. and Mehta, J. M. (1988). Ureterovasal fistula with calculi. Indian J . Surg., 50, 373. Requests for reprints to: U. V. Sathaye, Consultant Urologist, Opposite Medical College, Solerium Road, Jamnagar 361 008, India.
L-eiomyomaof the Renal Pelvis A. O'BRIEN, B. S I N N O T , P. McLEAN and G. D. DOYLE, Llepartments of Urology and Histopathology, Beaumont Hospital, Dublin, Ireland
Case Report A 43-year-old lady was referred with a history of left loin pain and intermittent frank haematuria. Clinical examination revealed left renal angle tenderness.
Intravenous urography showed minimal function from an atrophic right kidney. The upper pole calices of the left kidney were distorted and dilated. Ultrasonography confirmed an atrophic right kidney and revealed a cyst, 5 cm in diameter, in the posterolateral aspect of the upper pole of the left kidney. Medial to the cyst was a lobulated area of soft tissue echogenicity, measuring 3.5 x 2 cm, adjacent to the dilated upper pole calices. Retrograde ureterography revealed a filling defect at the infundibulum of the upper pole calices. At ureteroscopy the filling defect was seen to be caused by a rounded, smooth, darkcoloured lesion on the renal pelvic wall, almost completely occluding the infundibulum of the upper pole calices. O n exploration a cyst was found in the upper pole of the kidney. The cyst was readily separable from adjacent renal parenchyma and was found to be contiguous with the solid, firm lesion arising from the pelvic wall at the infundibulum of the upper pole calices. The pelvicaliceal system was otherwise macroscopically normal. The lesion and cyst were resected en bloc by a n upper pole partial nephrectomy (Fig. 1). The patient made a satisfactory recovery. Histological examination showed the cyst to be lined by a low cuboidal epithelium. The solid lesion (Fig. 2) consisted of uniform spindle cells arranged in bundles coursing in various directions and in places exhibiting a palisading pattern. The nuclei of uniform morphology had blunted ends and were surrounded by a distinctly eosinophilic cytoplasm. Mitotic figures were infrequent. Examination of P T A H preparations under oil revealed longitudinal intracytoplasmic filaments. Positivity for tumour markers, including vimentin, desmin and muscle specific actin, was demonstrated. The tumour showed the features of a leiomyoma on electron microscopy.
Comment Renal leiomyomas are uncommon tumours and have been categorised into 3 groups, depending mainly on their site within the kidney, and thereby the location of the smooth muscle cells from which they are likely to have arisen (Belis et al., 1979). In the most common group the leiomyomas are on the cortical surface or in the most superficial cortex and are considered to arise from smooth muscle cells in the renal capsule. They are usually multiple and small, measuring only a few millimetres in diameter. They show no predilection for either gender and do not cause any symptoms, having generally been coincidental findings at autopsy or surgical exploration. In contrast, the second category comprises solitary tumours which have attained large proportions, weighing up to 5 kg. While their large dimensions have not infrequently rendered their exact site of origin difficult to determine, they are
332
Fig. 1 Gross appearance of specimen as seen from the renal pelvis. Lesion outlined by arrows.
BRITISH JOURNAL OF UROLOGY
who presented with either pain or haematuria and were found to have renal pelvic filling defects on intravenous urography. All of the previously reported patients were presumed to have transitional cell tumours which were resected by nephroureterectomy. Our patient is the only one to have presented with both pain and haematuria. Since the contralateral kidney was barely functional, maximal preservation of functioning renal parenchyma was desirable. The ureteroscopic appearance of the renal pelvic lesion was reassuring, as it was considered that the tumour was unlikely to be a transitional cell carcinoma. This is the only reported case of renal pelvic leiomyoma to have been resected by partial nephrectomy. The gross, microscopic and immunohistochemical features were similar to those reported previously. However, it is the only case to have been associated with cyst formation.
References Belis, J. A., Post,G.J., Rochman,S. C. etal. (1979). Genitourinary leiomyomas. J . Urol., 13,424429. Kho, G . T. and Duggan, M. A. (1989). Bizarre leiomyoma of the renal pelvis with ultrastructural and immunohistochemical findings. J . Urol., 141,928-929. Zuckermann, 1. C., Kershner, D., Laytner, B. D. ef al. (1947). Leiomyoma of the kidney. Ann. Surg., 126,220-228. Requests for reprints to: A. O’Brien, Department of Urology, Craigavon Area Hospital, Craigavon, N . Ireland.
Ureterocolic Fistula due to Impacted Ureteric Stone Fig. 2 Section showing uniform spindle cells lying parallel and arranged in bundles which course in various directions. (H and E x 200).
believed to arise from cortical vascular smooth muscle cells. They usually give rise to flank pain or discomfort, though their diagnosis has occasionally followed the finding of an asymptomatic abdominal mass. They occur almost invariably in females, and in all age groups, including the newborn (Zuckerman et a/., 1947). Leiomyomas arising from smooth muscle of the renal pelvic wall are rare, only 5 patients having been previously reported (Kho and Duggan, 1989). All were women, aged between 24 and 50 years,
K. P. PATIL, S. D. SHETW, N. ANANDAN and A. IBRAHIM, Department of Urology, College of Medicine, King Saud University (Abha). and Asir Central Hospital, Abha. Saudi Arabia
Ureteric fistulas are usually ureterovaginal and ureterocutaneous, but ureteroarterial and ureteroarterio-enteric fistulas have been reported following aortoiliac bypass graft surgery (Kar et al., 1984). Ureteroenteric fistulas are very rare. We report a case of ureterocolic fistula caused by an impacted ureteric calculus.
Case Report A 40-year-oldSaudi male was referred with a history of
