IMAGES FOR SURGEONS ANZJSurg.com
Leiomyoma of the ureter A 57-year-old woman was referred following an acute episode of left-sided pyelonephritis associated with Klebsiella spp infection. After antibiotic treatment and resolution of the infection, the left flank pain continued and imaging revealed left hydronephrosis and hydroureter, with apparent obstruction on the left pelvic sidewall associated with the presence of a round lesion approximately 36 mm in diameter (Fig. 1). The left ovary appeared to be in close relation to the obstructing lesion, but separate. The right renal tract was normal. Her serum creatinine level was elevated at 102 μmol/L, but tumour markers were equivocal with normal results for carcinoembryonic antigen and CA-125, but an elevated level of CA19.9 (84 kU/L). The woman had undergone hysterectomy 8 years prior, for menorrhagia associated with a fundal leiomyoma (fibroid), and the uterus had been morcellated to effect delivery. No other abnormality had been observed at the time of hysterectomy, and the ovaries and fallopian tubes had been preserved. The patient had been completely well and asymptomatic in the intervening period. After the diagnosis of ureteric obstruction was made she wished to delay definitive surgery as her daughter was about to get married, so as an interim
measure a left ureteric stent was passed, although the obstruction proved very difficult to negotiate. One month later, after the wedding, a laparotomy was performed that revealed normal intraperitoneal appearances, with a normal left ovary and tube. The retroperitoneum was entered and the left pelvic ureter was dissected free and found to be obstructed by a large round tumour (Fig. 2). The tumour was dissected from the ureter and the stent left in place for later retrieval. The patient recovered uneventfully, and the histology revealed a benign leiomyoma (fibroid). Uterine fibroids are extremely common, with the majority of women having at least one fibroid by the time of menopause.1 Until recently, the presence of fibroids remote from the uterus itself was uncommon, but the increasing use of laparoscopic morcellation techniques for hysterectomy and management of fibroids has been associated with reports of intraperitoneal ‘seeding’ and growth of intraperitoneal ‘daughter’ fibroids.2 Growth of retroperitoneal
Fig. 1. Abdominopelvic computed tomography showing left ureter obstructed by the tumour (arrow).
Fig. 2. Dissection of the left pelvic ureter with the tumour in place. The ureter has been stented.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
fibroids elsewhere in the genitourinary tract is exceedingly rare. Leiomyoma of the kidney has been described, arising from either the renal capsule, or very rarely from the renal vein.3 While there are many reports of renal leiomyomata in the literature, there are fewer than a dozen reported cases of leiomyoma of the ureter since the original report in 1955, with only four in female patients.4–10 Because of the almost universal presentation with ureteric obstruction and hydronephrosis, older case reports generally report removal of the ureter and kidney. The more recent reports describe management like ours, with intraoperative frozen section and preservation of the urinary structures. With the increasing use of laparoscopic treatments for fibroids,1 with either myomectomy and morcellation of the fibroids, or laparoscopic hysterectomy with morcellation, similar cases may become more common in the coming years. The risk of intraperitoneal seeding is now being recognized, and techniques such as morcellation within a bag are being trialled to reduce this risk.11
References 1. Daniels B, Robson S. Uterine fibroids. O&G Mag. 2012; 14: 58–60. 2. Ostrzenski A. Uterine leiomyoma particle growing in an abdominal-wall incision after laparoscopic retrieval. Obstet. Gynecol. 1997; 89: 853–4. 3. Nouralizadeh A, Tabibi A, Mahmoudnejad N, Taheri M, Torbati P. Partial ureterectomy for a huge primary leiomyoma of the ureter. J. Pak. Med. Assoc. 2010; 60: 62–4.
Images for surgeons
4. Yashi M, Hashimoto S, Muraishi O, Tozuka K, Tokue A. Leiomyoma of the ureter. Urol. Int. 2000; 64: 40–2. 5. Leighton KM. Leiomyoma of the ureter. Br. J. Urol. 1955; 27: 256–7. 6. Naruse K, Yamada Y, Aoki S, Taki T, Honda N, Iwafuchi H. A case of primary leiomyoma of the ureter. Int. J. Urol. 2007; 14: 248–50. 7. Kao VC, Graff PW, Rappaport H. Leiomyoma of the ureter. A histologically problematic rare tumour confirmed by immunohistochemical studies. Cancer 1969; 24: 535–42. 8. Sekar N, Nagrani B, Yadav RV. Ureterocele with leiomyoma of ureter. Br. J. Urol. 1980; 52: 400. 9. Zaitoon MM. Leiomyoma of ureter. Urology 1986; 28: 50–1. 10. Igarashi OSH, Nakada J, Nishida A, Shirai T, Mechida T. A case of leiomyoma of the ureter. Jpn. J. Clin. Urol. 1994; 48: 328–30. 11. Kho KA, Anderson TL, Nezhat CH. Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice. Obstet. Gynecol. 2014; 124: 787–93.
Michelle Englund,* FRANZCOG Simon McCredie,† FRACS Steve Robson,‡ FRANZCOG *Gosford Hospital, Gosford, New South Wales, Australia, †Canberra Hospital, Canberra, Australian Capital Territory, Australia and ‡Australian National University, Canberra, Australian Capital Territory, Australia doi: 10.1111/ans.12972
© 2015 Royal Australasian College of Surgeons
Leiomyoma of the ureter A 57-year-old woman was referred following an acute episode of left-sided pyelonephritis associated with Klebsiella spp infection. After antibiotic treatment and resolution of the infection, the left flank pain continued and imaging revealed left hydronephrosis and hydroureter, with apparent obstruction on the left pelvic sidewall associated with the presence of a round lesion approximately 36 mm in diameter (Fig. 1). The left ovary appeared to be in close relation to the obstructing lesion, but separate. The right renal tract was normal. Her serum creatinine level was elevated at 102 μmol/L, but tumour markers were equivocal with normal results for carcinoembryonic antigen and CA-125, but an elevated level of CA19.9 (84 kU/L). The woman had undergone hysterectomy 8 years prior, for menorrhagia associated with a fundal leiomyoma (fibroid), and the uterus had been morcellated to effect delivery. No other abnormality had been observed at the time of hysterectomy, and the ovaries and fallopian tubes had been preserved. The patient had been completely well and asymptomatic in the intervening period. After the diagnosis of ureteric obstruction was made she wished to delay definitive surgery as her daughter was about to get married, so as an interim
measure a left ureteric stent was passed, although the obstruction proved very difficult to negotiate. One month later, after the wedding, a laparotomy was performed that revealed normal intraperitoneal appearances, with a normal left ovary and tube. The retroperitoneum was entered and the left pelvic ureter was dissected free and found to be obstructed by a large round tumour (Fig. 2). The tumour was dissected from the ureter and the stent left in place for later retrieval. The patient recovered uneventfully, and the histology revealed a benign leiomyoma (fibroid). Uterine fibroids are extremely common, with the majority of women having at least one fibroid by the time of menopause.1 Until recently, the presence of fibroids remote from the uterus itself was uncommon, but the increasing use of laparoscopic morcellation techniques for hysterectomy and management of fibroids has been associated with reports of intraperitoneal ‘seeding’ and growth of intraperitoneal ‘daughter’ fibroids.2 Growth of retroperitoneal
Fig. 1. Abdominopelvic computed tomography showing left ureter obstructed by the tumour (arrow).
Fig. 2. Dissection of the left pelvic ureter with the tumour in place. The ureter has been stented.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
fibroids elsewhere in the genitourinary tract is exceedingly rare. Leiomyoma of the kidney has been described, arising from either the renal capsule, or very rarely from the renal vein.3 While there are many reports of renal leiomyomata in the literature, there are fewer than a dozen reported cases of leiomyoma of the ureter since the original report in 1955, with only four in female patients.4–10 Because of the almost universal presentation with ureteric obstruction and hydronephrosis, older case reports generally report removal of the ureter and kidney. The more recent reports describe management like ours, with intraoperative frozen section and preservation of the urinary structures. With the increasing use of laparoscopic treatments for fibroids,1 with either myomectomy and morcellation of the fibroids, or laparoscopic hysterectomy with morcellation, similar cases may become more common in the coming years. The risk of intraperitoneal seeding is now being recognized, and techniques such as morcellation within a bag are being trialled to reduce this risk.11
References 1. Daniels B, Robson S. Uterine fibroids. O&G Mag. 2012; 14: 58–60. 2. Ostrzenski A. Uterine leiomyoma particle growing in an abdominal-wall incision after laparoscopic retrieval. Obstet. Gynecol. 1997; 89: 853–4. 3. Nouralizadeh A, Tabibi A, Mahmoudnejad N, Taheri M, Torbati P. Partial ureterectomy for a huge primary leiomyoma of the ureter. J. Pak. Med. Assoc. 2010; 60: 62–4.
Images for surgeons
4. Yashi M, Hashimoto S, Muraishi O, Tozuka K, Tokue A. Leiomyoma of the ureter. Urol. Int. 2000; 64: 40–2. 5. Leighton KM. Leiomyoma of the ureter. Br. J. Urol. 1955; 27: 256–7. 6. Naruse K, Yamada Y, Aoki S, Taki T, Honda N, Iwafuchi H. A case of primary leiomyoma of the ureter. Int. J. Urol. 2007; 14: 248–50. 7. Kao VC, Graff PW, Rappaport H. Leiomyoma of the ureter. A histologically problematic rare tumour confirmed by immunohistochemical studies. Cancer 1969; 24: 535–42. 8. Sekar N, Nagrani B, Yadav RV. Ureterocele with leiomyoma of ureter. Br. J. Urol. 1980; 52: 400. 9. Zaitoon MM. Leiomyoma of ureter. Urology 1986; 28: 50–1. 10. Igarashi OSH, Nakada J, Nishida A, Shirai T, Mechida T. A case of leiomyoma of the ureter. Jpn. J. Clin. Urol. 1994; 48: 328–30. 11. Kho KA, Anderson TL, Nezhat CH. Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice. Obstet. Gynecol. 2014; 124: 787–93.
Michelle Englund,* FRANZCOG Simon McCredie,† FRACS Steve Robson,‡ FRANZCOG *Gosford Hospital, Gosford, New South Wales, Australia, †Canberra Hospital, Canberra, Australian Capital Territory, Australia and ‡Australian National University, Canberra, Australian Capital Territory, Australia doi: 10.1111/ans.12972
© 2015 Royal Australasian College of Surgeons
