URETERAL STUMP CALCULI RICHARD H. ROSE, M.D. JACOB HEYMAN, M.D. HARRY GRABSTALD, M.D. From the Division of Urology, Department of Surgery, Beth Israel Medical Center, New York, New York
ABSTBACT--We report 2 cases of ureteral stump calculi presenting years after nephrectomy. Stones in the ureteral stump are extremely uncommon, and their occurrence has led us to review the possible mechanisms underlying their etiology.
The segment of ureter remaining after nephrectomy is :rarely a source of significant pathology. Symptoms attributable to this site are therefore often overlooked because of this rarity and because of the vagaries and the usual late onset of symptoms. On occasion, however, significant pathology is found in the ureteral stump. Some of the more common diseases affecting the stump include infections, stones, tumors, and obstruction with and without associated infection. Urothelial cancer following nephreetomy without total ureterectomy is not within the domain of this discussion. The 2 patients presented here were asymptomatic for some years after nephrectomy, and the diagnosis of ureteral stump disease was significantly delayed. The unusual presentation and findings presented here should remind us to consider the ureteral stump as a cause for symptomatology. Reviewing the possible causes for lithiasis within a ureteral stump, it may be possible to isolate a subset population, identifiable preoperatively, which is at increased risk for stone formation. Perhaps these patients would merit total ureterectomy along with nephrectomy.
ways normal. She had recurrent urinary tract infections and intermittent right lower quadrant pains of three years' duration. She had known asymptomatie cholelithiasis and an end eolostomy secondary to an abdominoperineal resection. The renal blood profile was normal. Abdominal films taken in 1985 revealed calcifications in the right pelvis which were thought to be phleboliths. Continued symptomatology prompted repeat films in 1987, and now these calcifications were considered to be ureteral stump calculi (Fig. 1A). Cystoscopy was performed, and an attempt to catheterize the ureteral stump was unsuccessful. Calculus debris was visualized at the right ureteral orifice. A voiding eystourethrogram showed left vesicoureteral reflux and a duplicated system (Fig. 1B). The patient continued to have recurrent urinary tract infections and worsening intermittent abdominal pains. She was operated on and extraperitoneal ureterectomies of a duplicated right system were carried out. The distal ureferal stump contained multiple calculi which conformed to the shape of the ureter (Fig. tC). The patient is currently free of symptoms and doing well.
Case Reports
Case 2 A sixty-four-year-old man presented to the urology service complaining of recurrent urinary tract infections of four years" duration. His past urologic history was significant for a left nephrectomy in 1948 for trauma and a
Case ] A seventy-six-year-old white woman underwent a right nephrectomy in 1961 for stone disease and was followed through the years with several abdominal radiographs which were al-
UROLOGY
/
JUNE 1990
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VOLUME XXXV, NUMBER 6
527
FmURE 1. (A) KUB film showing right pelvic calcifications (arrows) thought to be calculi within ureteral stump. (t3) Voiding cystourethrogram shows left vesicoureteral reflux and duplicated system, (C) Gross specimen of distal ureteral stum~ containing multiple calculi.
FIGURE 2, (A) Abdominal film shows several round calcifications in left pelvis. (B) Cystogram revealed reflux into left ureteral stump outlining numerous stones. (C) C T scan of pelvis confirmed findings of ureteral stump calculi.
transurethral prostateetomy in 1982 for benign prostatie hyperplasia. At the time of the prostateetomy, the patient was told that his ureteral stump contained numerous stones. Physical examination was unremarkable except for a well-healed left flank incision. Urine analysis revealed pyuria and a urine culture was positive for Eseherichia coll. On abdominal x-ray film several round calcifications in the left pelvis were noted (Fig. 2A). A eystogram revealed reflux into a sausage-shaped left ureteral
stump outlining numerous stones (Fig, 2B). Cystoscopy showed purulent material effluxing from the left ureteral orifice. CT scan of the pelvis confirmed all the mentioned findings (Figl 2C). A course of antibiotics was initiated, and an extraperitoneal left ureteral stmnp excision was carried out. The stump contained m a w stones. Stone analysis was n o t done. Postopera= tivety, the patient did well and his symptom~ resolved. One and one-half years after surgery he died of a myocardial infarct.
528
UROLOGY
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JUNE 1990
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VOLUME XXX~ NUMBEB 6
Comment
Conclusion
Stones in the retained ureter are distinctly uncommon as evidenced by the paucity of reports in the literature. 1 The conditions favoring primary stone formation in a ureteral stump may be present preoperatively. If these conditions are identified before nephreetomy, such patients can undergo uretereetomy as well, and avert potential stump calculi. In most cases the stump empties its contents. Occasionally small amounts of material are produced by the ureteral mueosa and the epithelial lining sears down, obliterating its lumen. ~If, however, obstruetAon is present below the ligated upper end of the ureter, peristalsis persists and stasis with infection results, a,4 Under these conditions, stones may form. Similarly, if a refluxing ureteral stum p is considered a direct extension of the bladder, acting essentially as a bladder diverticulum, one can see how a poorly drained ureter contributes to calculus formation. Ureteral stump pathology, albeit uncommon, is an important and much overlooked entity. This may lend support for preoperative evaluation of the ureter in certain patients requiring nephreetomy.~ Today, there are many diagnostic options including retrograde ureterography, intravenous pyelography, voiding eystourethrography, and ureteroseopy, which can identify conditions favoring stone formation. The presence of reflux or distal ureteral obstruction may warrant a consideration of a planned uretereetomy at the time of nephreetomy. For the post,nephreetomy patient in whom ipsilateral vague abdominal pains, hematuria, or pyuria deve!ops I ureteral stump pathology must be considered and the ureteral remnant assessed, ~ ModMities such as retrograde ureterography, voiding eystourethrography, and ureterose0py may be helpful. C T scan imaging and uttras0no~aphy are also diagnostic maneuvers whieh can confirm ureteral stump Iithiasis.7
At present, complete ureterectomy with nephrectomy is done only in selected cases. Urothelial cancers of the upper urinary tract, and selected eases of renal tuberculosis with ureteral involvement require complete ureterectomy in addition to nephreetomy. 8 Other conditions requiring nephreetomy, however, are not accompanied by complete uretereetomy because of the increased operative time, The often needed second incision is not thought to be justifiable. We believe it may be important to ascertain preoperatively, whether or not the ureter empties completely and whether reflux is present. Those patients who have factors which delay emptying merit consideration of uretereetomy at the time of nephreetomy. These 2 patients with post-nephreetomy ureteral stump calculi, emphasize this point and remind us to consider stump pathology in the symptomatic post-nephrectomy patient.
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
10 Nathan D. Perlman Place New York, New York 10003
(DR. ROSE) References 1. Malek RS, Moghaddam A, Furlow WL, and Greene LF: Symptomatic ureteral stumps, J Urol 106:521 (1971). 2. Strong DW, Pearse HD, Tank GS, and Hodges CV: The ureteraI stump after nephroureterectomy, J Urol 115:654 (1976). 3. Bergman H, and Hotchkiss RS: The ureteral stump, in: The Ureter, ed 2, New York, Springer-Verlag, 1981, chap 32, pp 686696. 4. Nengu V, Ioanid CP, and Angeleseu N: Disorders of the ureteral stump; analysis of 35 cases, Int Nephrol Urol 5:363 (1973). 5. Bergman H, and Lockhart J: Surgery of the ureteral stump, in Kaufman JJ (Ed): Current Urologic Therapy, ed 2, Philadelphia, W.B. Saunders Co, 1985, pp 213-214. 6. Burghele T, Ioanid CR and Galesanu M: Incidence and complications of ureteral stump pathology, Int Nephrot Urol 11: 169 (1979). 7. Pollack HM, Banner MP, and Popky GL: Radiologie evaluation of the ureteral stump, Radiology 144:225 (1982). 8. Schneiderman C: Complications in the ureteral stump after nephreetomy, Can J Urol 11:374 (1968).
529
ABSTBACT--We report 2 cases of ureteral stump calculi presenting years after nephrectomy. Stones in the ureteral stump are extremely uncommon, and their occurrence has led us to review the possible mechanisms underlying their etiology.
The segment of ureter remaining after nephrectomy is :rarely a source of significant pathology. Symptoms attributable to this site are therefore often overlooked because of this rarity and because of the vagaries and the usual late onset of symptoms. On occasion, however, significant pathology is found in the ureteral stump. Some of the more common diseases affecting the stump include infections, stones, tumors, and obstruction with and without associated infection. Urothelial cancer following nephreetomy without total ureterectomy is not within the domain of this discussion. The 2 patients presented here were asymptomatic for some years after nephrectomy, and the diagnosis of ureteral stump disease was significantly delayed. The unusual presentation and findings presented here should remind us to consider the ureteral stump as a cause for symptomatology. Reviewing the possible causes for lithiasis within a ureteral stump, it may be possible to isolate a subset population, identifiable preoperatively, which is at increased risk for stone formation. Perhaps these patients would merit total ureterectomy along with nephrectomy.
ways normal. She had recurrent urinary tract infections and intermittent right lower quadrant pains of three years' duration. She had known asymptomatie cholelithiasis and an end eolostomy secondary to an abdominoperineal resection. The renal blood profile was normal. Abdominal films taken in 1985 revealed calcifications in the right pelvis which were thought to be phleboliths. Continued symptomatology prompted repeat films in 1987, and now these calcifications were considered to be ureteral stump calculi (Fig. 1A). Cystoscopy was performed, and an attempt to catheterize the ureteral stump was unsuccessful. Calculus debris was visualized at the right ureteral orifice. A voiding eystourethrogram showed left vesicoureteral reflux and a duplicated system (Fig. 1B). The patient continued to have recurrent urinary tract infections and worsening intermittent abdominal pains. She was operated on and extraperitoneal ureterectomies of a duplicated right system were carried out. The distal ureferal stump contained multiple calculi which conformed to the shape of the ureter (Fig. tC). The patient is currently free of symptoms and doing well.
Case Reports
Case 2 A sixty-four-year-old man presented to the urology service complaining of recurrent urinary tract infections of four years" duration. His past urologic history was significant for a left nephrectomy in 1948 for trauma and a
Case ] A seventy-six-year-old white woman underwent a right nephrectomy in 1961 for stone disease and was followed through the years with several abdominal radiographs which were al-
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
527
FmURE 1. (A) KUB film showing right pelvic calcifications (arrows) thought to be calculi within ureteral stump. (t3) Voiding cystourethrogram shows left vesicoureteral reflux and duplicated system, (C) Gross specimen of distal ureteral stum~ containing multiple calculi.
FIGURE 2, (A) Abdominal film shows several round calcifications in left pelvis. (B) Cystogram revealed reflux into left ureteral stump outlining numerous stones. (C) C T scan of pelvis confirmed findings of ureteral stump calculi.
transurethral prostateetomy in 1982 for benign prostatie hyperplasia. At the time of the prostateetomy, the patient was told that his ureteral stump contained numerous stones. Physical examination was unremarkable except for a well-healed left flank incision. Urine analysis revealed pyuria and a urine culture was positive for Eseherichia coll. On abdominal x-ray film several round calcifications in the left pelvis were noted (Fig. 2A). A eystogram revealed reflux into a sausage-shaped left ureteral
stump outlining numerous stones (Fig, 2B). Cystoscopy showed purulent material effluxing from the left ureteral orifice. CT scan of the pelvis confirmed all the mentioned findings (Figl 2C). A course of antibiotics was initiated, and an extraperitoneal left ureteral stmnp excision was carried out. The stump contained m a w stones. Stone analysis was n o t done. Postopera= tivety, the patient did well and his symptom~ resolved. One and one-half years after surgery he died of a myocardial infarct.
528
UROLOGY
/
JUNE 1990
/
VOLUME XXX~ NUMBEB 6
Comment
Conclusion
Stones in the retained ureter are distinctly uncommon as evidenced by the paucity of reports in the literature. 1 The conditions favoring primary stone formation in a ureteral stump may be present preoperatively. If these conditions are identified before nephreetomy, such patients can undergo uretereetomy as well, and avert potential stump calculi. In most cases the stump empties its contents. Occasionally small amounts of material are produced by the ureteral mueosa and the epithelial lining sears down, obliterating its lumen. ~If, however, obstruetAon is present below the ligated upper end of the ureter, peristalsis persists and stasis with infection results, a,4 Under these conditions, stones may form. Similarly, if a refluxing ureteral stum p is considered a direct extension of the bladder, acting essentially as a bladder diverticulum, one can see how a poorly drained ureter contributes to calculus formation. Ureteral stump pathology, albeit uncommon, is an important and much overlooked entity. This may lend support for preoperative evaluation of the ureter in certain patients requiring nephreetomy.~ Today, there are many diagnostic options including retrograde ureterography, intravenous pyelography, voiding eystourethrography, and ureteroseopy, which can identify conditions favoring stone formation. The presence of reflux or distal ureteral obstruction may warrant a consideration of a planned uretereetomy at the time of nephreetomy. For the post,nephreetomy patient in whom ipsilateral vague abdominal pains, hematuria, or pyuria deve!ops I ureteral stump pathology must be considered and the ureteral remnant assessed, ~ ModMities such as retrograde ureterography, voiding eystourethrography, and ureterose0py may be helpful. C T scan imaging and uttras0no~aphy are also diagnostic maneuvers whieh can confirm ureteral stump Iithiasis.7
At present, complete ureterectomy with nephrectomy is done only in selected cases. Urothelial cancers of the upper urinary tract, and selected eases of renal tuberculosis with ureteral involvement require complete ureterectomy in addition to nephreetomy. 8 Other conditions requiring nephreetomy, however, are not accompanied by complete uretereetomy because of the increased operative time, The often needed second incision is not thought to be justifiable. We believe it may be important to ascertain preoperatively, whether or not the ureter empties completely and whether reflux is present. Those patients who have factors which delay emptying merit consideration of uretereetomy at the time of nephreetomy. These 2 patients with post-nephreetomy ureteral stump calculi, emphasize this point and remind us to consider stump pathology in the symptomatic post-nephrectomy patient.
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
10 Nathan D. Perlman Place New York, New York 10003
(DR. ROSE) References 1. Malek RS, Moghaddam A, Furlow WL, and Greene LF: Symptomatic ureteral stumps, J Urol 106:521 (1971). 2. Strong DW, Pearse HD, Tank GS, and Hodges CV: The ureteraI stump after nephroureterectomy, J Urol 115:654 (1976). 3. Bergman H, and Hotchkiss RS: The ureteral stump, in: The Ureter, ed 2, New York, Springer-Verlag, 1981, chap 32, pp 686696. 4. Nengu V, Ioanid CP, and Angeleseu N: Disorders of the ureteral stump; analysis of 35 cases, Int Nephrol Urol 5:363 (1973). 5. Bergman H, and Lockhart J: Surgery of the ureteral stump, in Kaufman JJ (Ed): Current Urologic Therapy, ed 2, Philadelphia, W.B. Saunders Co, 1985, pp 213-214. 6. Burghele T, Ioanid CR and Galesanu M: Incidence and complications of ureteral stump pathology, Int Nephrot Urol 11: 169 (1979). 7. Pollack HM, Banner MP, and Popky GL: Radiologie evaluation of the ureteral stump, Radiology 144:225 (1982). 8. Schneiderman C: Complications in the ureteral stump after nephreetomy, Can J Urol 11:374 (1968).
529
