International Urology and Nephrology 7 (1), pp. 49--53 (1975)
Retrocaval Ureter with Carcinoma of the Renal Pelvis: Report of a Case K. SAGAMI, K. TANAKA, M. MIZOGUCH~, T. ISHmE Urological Clinic, Hiroshima Prefectural Hospital and Department of Urology, Hiroshima University School of Medicine, Hiroshima, Japan (Received August 26, 1974)
A case of retrocaval ureter associated with carcinoma of the renal pelvis has been presented. This is the 2nd such case out of 110 cases reported in Japan. It is suggested that long term stagnation of urine is the cause for such a high incidence of malignant neoplasm involving the renal pelvis.
Retrocaval ureter is a rare congenital anomaly and was first mentioned in literature by Hochstetter in 1892 [4]. To date, there have been 143 cases reported in English literature [2] and an additional 110 cases reported in Japan [7]. A recent observation of one such case associated with carcinoma of the renal pelvis is reported herein.
Case report A 38-year-old salesman was referred to the Urologic Clinic, Hiroshima Prefectural Hospital with a history of intermittent painless gross hematuria 4 years in duration. Physical examination revealed no abnormalities. Urinalysis revealed 20 to 25 red blood cells and t5 to 20 white blood cells per high power field and a rod per several high power fields. The hematocrit was found to be 46 per cent, white blood count 8,290, red blood count 503 x 104, hemoglobin 15.1 g per dl., and platelet count 175,000. The serum electrolyte level was within normal limits, with serum creatinine 1.2 mg per dl. and blood urea nitrogen 13.6 mg per dl., phenolsulphthalein excretion was 20 per cent for 15 rain. and 67.5 per cent for 120 rain. Cystoscopically, a weaker motion of the right ureteral orifice was observed. A 1-hour excretory urogram (Fig. 1) was carried out and showing evidence of pale concentration of dye in the right kidney and medially displaced S-shaped ureteric shadow with obstruction and dilatation above. There was no clear visualization of filling defects in the grossly dilated calyceal system of the right kidney. The left kidney and ureter were well revealed with no signs of obstruction. Retrograde pyelography (Fig. 2) revealed an S-shaped dilated ureter at the juncture of the middle and upper third of the right ureter. Marked displacement of the lower 4
International Urology and Nephrology 7, 1975
50
K. Sagami et al. : Retrocaval ureter with pelvic carcinoma
Fig. i. I. V. P. 60 minutes after injection shows pale concentration of dye in right kidney and medially displaced ureter
Fig. 2. Retrograde pyelogram demonstrates filling defect in lower pelvis and calyces of right kidney and S-shaped dilated ureter
K. Sagami et al.: Retrocaval ureter with pelvic carcinoma
51
calyceal system upwards, and obvious filling defects in the lower half of the pelviocalyceal system were observed. Aortography (Fig. 3) demonstrated an increased vascularity with large tumor vessels. The abnormal staining mass occupied the
Fig. 3. Arterial phase of selective renal arteriogram shows a cluster of a b n o r m a l vessels
Fig. 4. Photograph of the kidney, Note papillary carcinoma of the renal pelvis 4*
International Urology and Nephrology 7, 1975
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K, Sagami et aL: Retrocaval ureter with pelvic carcinoma
lower half of the right kidney displacing the lower calyceal group upwards. Renoscan revealed a cold spot area in the lower half of the right kidney corresponding to the area showing abnormal vessels.
Fig. 5. Photomicrograph of representative section. Note well differentiated papillary structure of the carcinoma cells. H & E, reduced from • 100 On September 11, 1973, a flank approach to the right kidney was performed. The dilated ureter was ligated at the point across the inferior caval vein and nephrectomy was accomplished. Bisection of the kidney (Fig. 4) revealed a mass of papillary tumor extending into the renal pelvis, originating from the lower pelvis. Microscopic examination (Fig. 5) revealed a relatively well differentiated transitional cell carcinoma which showed no evidence of deep penetration through the basement membrane or of vascular invasion.
Discussion
Though reports have been increasing along with the advance of urologic examinations, retrocaval ureter is a rare anomaly and its rarity has been indicated by the fact that it was observed in 0.04 to 0.09 per cent of cadavers [1, 6]. Also, the incidence of neoplasm of the renal pelvis is low. It is reported in a ratio of one such neoplasm to 10,138 new registrants [3], about which less than 2 per cent International Urology and Nophrology 7, 1975
K. Sayami et al. : Retrocaval ureter with pelvic carcinoma
53
of urogenital neoplasm is reported [5]. This case is the 2nd in Japan and the incidence of neoplasm occurring in the retrocaval ureter is surprisingly high, i.e.c.8 per cent of 110 reported cases in Japan. It has been a well accepted fact for many years that cancer may develop in response to chronic irritation such as stones, often associated with stagnation of the urine, or that malignant change may occur in some indolent inflammatory lesions caused by some possible carcinogen such as amine derivatives in the urine [8]. Many cases of retrocaval ureter are associated with hydronephrotic changes, and the high incidence of neoplasm in retrocaval ureter suggests that the development of neoplasm depends upon stagnation of the urine causing chronic irritation or inflammation in the renal pelvis. Further, congenital maldevelopment of the kidney often associated in the retrocaval ureter has some role in the development of the neoplasm.
References 1. Abeshouse, B. S., Tankin, L. H. : Retrocaval ureter; Report of a case and a review of the literature. Amer. J. Surg. 84, 383 (1952). 2, Berkian, R. A. : Retrocaval ureter; Report of a case with operative correction. J. Amer. Osteopath. Ass. 66, 621 (1967). 3. H!ggins, C. C. : Tumor of the renal pelvis; Review of forty-seven cases. Ann. Surg. 137, 195 (1953). 4. Hochstetter, F.: Beitrfige zur Entwicklungsgeschichte des Venensystems der Amnioten. II. Reptilien (Lacerta, Tropidonotus). Morphol. Jahrb. (Leipzig) 19, 428 (1892). 5. Newsam, J. E.: The diagnosis of ureteric tumors. Brit. J. UroL 38, 268 (1966). 6. Nielsen, P. B.: Retrocaval ureter; Report of a case. Acta Radiol. 51, 179 (1959). 7. Nishio, S., Kono, S., Shin, T.: Retrocaval ureter; Report of 2 cases. Acta Urol. Jap. 19, 737 (1973). 8. Taylor, W. E. : Tumor of the kidney pelvis. J. Urol. 82, 452 (1059).
International Urology and Nephrology 7, 1975
Retrocaval Ureter with Carcinoma of the Renal Pelvis: Report of a Case K. SAGAMI, K. TANAKA, M. MIZOGUCH~, T. ISHmE Urological Clinic, Hiroshima Prefectural Hospital and Department of Urology, Hiroshima University School of Medicine, Hiroshima, Japan (Received August 26, 1974)
A case of retrocaval ureter associated with carcinoma of the renal pelvis has been presented. This is the 2nd such case out of 110 cases reported in Japan. It is suggested that long term stagnation of urine is the cause for such a high incidence of malignant neoplasm involving the renal pelvis.
Retrocaval ureter is a rare congenital anomaly and was first mentioned in literature by Hochstetter in 1892 [4]. To date, there have been 143 cases reported in English literature [2] and an additional 110 cases reported in Japan [7]. A recent observation of one such case associated with carcinoma of the renal pelvis is reported herein.
Case report A 38-year-old salesman was referred to the Urologic Clinic, Hiroshima Prefectural Hospital with a history of intermittent painless gross hematuria 4 years in duration. Physical examination revealed no abnormalities. Urinalysis revealed 20 to 25 red blood cells and t5 to 20 white blood cells per high power field and a rod per several high power fields. The hematocrit was found to be 46 per cent, white blood count 8,290, red blood count 503 x 104, hemoglobin 15.1 g per dl., and platelet count 175,000. The serum electrolyte level was within normal limits, with serum creatinine 1.2 mg per dl. and blood urea nitrogen 13.6 mg per dl., phenolsulphthalein excretion was 20 per cent for 15 rain. and 67.5 per cent for 120 rain. Cystoscopically, a weaker motion of the right ureteral orifice was observed. A 1-hour excretory urogram (Fig. 1) was carried out and showing evidence of pale concentration of dye in the right kidney and medially displaced S-shaped ureteric shadow with obstruction and dilatation above. There was no clear visualization of filling defects in the grossly dilated calyceal system of the right kidney. The left kidney and ureter were well revealed with no signs of obstruction. Retrograde pyelography (Fig. 2) revealed an S-shaped dilated ureter at the juncture of the middle and upper third of the right ureter. Marked displacement of the lower 4
International Urology and Nephrology 7, 1975
50
K. Sagami et al. : Retrocaval ureter with pelvic carcinoma
Fig. i. I. V. P. 60 minutes after injection shows pale concentration of dye in right kidney and medially displaced ureter
Fig. 2. Retrograde pyelogram demonstrates filling defect in lower pelvis and calyces of right kidney and S-shaped dilated ureter
K. Sagami et al.: Retrocaval ureter with pelvic carcinoma
51
calyceal system upwards, and obvious filling defects in the lower half of the pelviocalyceal system were observed. Aortography (Fig. 3) demonstrated an increased vascularity with large tumor vessels. The abnormal staining mass occupied the
Fig. 3. Arterial phase of selective renal arteriogram shows a cluster of a b n o r m a l vessels
Fig. 4. Photograph of the kidney, Note papillary carcinoma of the renal pelvis 4*
International Urology and Nephrology 7, 1975
52
K, Sagami et aL: Retrocaval ureter with pelvic carcinoma
lower half of the right kidney displacing the lower calyceal group upwards. Renoscan revealed a cold spot area in the lower half of the right kidney corresponding to the area showing abnormal vessels.
Fig. 5. Photomicrograph of representative section. Note well differentiated papillary structure of the carcinoma cells. H & E, reduced from • 100 On September 11, 1973, a flank approach to the right kidney was performed. The dilated ureter was ligated at the point across the inferior caval vein and nephrectomy was accomplished. Bisection of the kidney (Fig. 4) revealed a mass of papillary tumor extending into the renal pelvis, originating from the lower pelvis. Microscopic examination (Fig. 5) revealed a relatively well differentiated transitional cell carcinoma which showed no evidence of deep penetration through the basement membrane or of vascular invasion.
Discussion
Though reports have been increasing along with the advance of urologic examinations, retrocaval ureter is a rare anomaly and its rarity has been indicated by the fact that it was observed in 0.04 to 0.09 per cent of cadavers [1, 6]. Also, the incidence of neoplasm of the renal pelvis is low. It is reported in a ratio of one such neoplasm to 10,138 new registrants [3], about which less than 2 per cent International Urology and Nophrology 7, 1975
K. Sayami et al. : Retrocaval ureter with pelvic carcinoma
53
of urogenital neoplasm is reported [5]. This case is the 2nd in Japan and the incidence of neoplasm occurring in the retrocaval ureter is surprisingly high, i.e.c.8 per cent of 110 reported cases in Japan. It has been a well accepted fact for many years that cancer may develop in response to chronic irritation such as stones, often associated with stagnation of the urine, or that malignant change may occur in some indolent inflammatory lesions caused by some possible carcinogen such as amine derivatives in the urine [8]. Many cases of retrocaval ureter are associated with hydronephrotic changes, and the high incidence of neoplasm in retrocaval ureter suggests that the development of neoplasm depends upon stagnation of the urine causing chronic irritation or inflammation in the renal pelvis. Further, congenital maldevelopment of the kidney often associated in the retrocaval ureter has some role in the development of the neoplasm.
References 1. Abeshouse, B. S., Tankin, L. H. : Retrocaval ureter; Report of a case and a review of the literature. Amer. J. Surg. 84, 383 (1952). 2, Berkian, R. A. : Retrocaval ureter; Report of a case with operative correction. J. Amer. Osteopath. Ass. 66, 621 (1967). 3. H!ggins, C. C. : Tumor of the renal pelvis; Review of forty-seven cases. Ann. Surg. 137, 195 (1953). 4. Hochstetter, F.: Beitrfige zur Entwicklungsgeschichte des Venensystems der Amnioten. II. Reptilien (Lacerta, Tropidonotus). Morphol. Jahrb. (Leipzig) 19, 428 (1892). 5. Newsam, J. E.: The diagnosis of ureteric tumors. Brit. J. UroL 38, 268 (1966). 6. Nielsen, P. B.: Retrocaval ureter; Report of a case. Acta Radiol. 51, 179 (1959). 7. Nishio, S., Kono, S., Shin, T.: Retrocaval ureter; Report of 2 cases. Acta Urol. Jap. 19, 737 (1973). 8. Taylor, W. E. : Tumor of the kidney pelvis. J. Urol. 82, 452 (1059).
International Urology and Nephrology 7, 1975
