URETERAL STUMP CARCINOMA INCIDENTALLY FOUND AT CYSTECTOMY FOR BLADDER CANCER STUART BOWERS, M.D. ROBERT C. FLANIGAN, M.D.

GORDON J. KINZLER, M.D. JOHN S. WHEELER, JR., M.D. DANIEL J. CULKIN, M.D.

From the Department of Urology, Loyola University Medical Center, Maywood, and Urology Section, Hines Veterans Administration Medical Center, Hines, Illinois

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report on a sixty-five-year-old man with hematuria secondary to superficial blade of previous urethral trauma, a complete transurethral resection of his bladder ~e done. He, therefore, underwent cystectomy, at which time we incidentally zl cell carcinoma of the left ureteral stump that had been left from a previous left World War H-related injury. This case underscores the importance of a thorough complete urinary tract in a patient with hematuria or other urinary tract symp~vious cause is found for his symptoms.

9rs of the ureteral stump after for nonmalignant disease are tumors present a significant 9blem. Since the first reported nd Casella, 1 19 other eases of pri)f ureteral stump after nephreemalignant disease have been re~elieve our ease represents the ~ch case and fifth ease wherein '.rump tumor appeared eoncomt bladder cancer. This ease also longest interval (38 years) from to diagnosis of a transitional cell CC) of the ureteral stump (Table zee report our case and review the Case Report hire man presented in ing of a recent episode as unable to void, a n d 00 cc of bloody urine. years he had had ina. Significant past histma in World War II

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(1944) when the patient was shot through the symphysis pubis sustaining bowel, bladder, and urethral injuries. He had several pelvic operations requiring placement of a temporary suprapubic cystostomy and colostomy which were revised later that year. Three years later, his course was complicated by left orchitis and left pyelonephritis, requiring a left orchiectomy and left nephrectomy. He had no other significant past medical history and was in good overall health at the time of his presentation. Physical examination was unremarkable except for well-healed left flank and low midline abdominal incisional scars. Findings on genitourinary examination were unremarkable except for absent left testicle. The patient underwent an intravenous urogram and cystogram which showed a normal right kidney and right collecting system, nonvisualization of the left kidney consistent with a previous left nephrectomy, and a filling defect on the left side of the bladder (Fig. 1). At cystoseopy, a tight urethral stricture was noted requiring urethrotomy. A tumor of the left lateral wall of the bladder was found, obscuring the

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the fibrotic urethra and bladder neck it was di.,~li~N fieult to maneuver the reseetoscope to aeeo plish a thorough resection. Pathologic evalu~ tion revealed transitional cell carcinoma, grad~ I-II with invasion of lamina propria butyl~ muscle invasion. It was thought that cancer w ~ left behind. Metastatic evaluation gave neg~ tive findings, and computerized tomograp~ (CT scan) of the abdomen and pelvis show~ only thickening of the left anterior bladd~ wall consistent with tumor. In March 1987 the patient agreed to and ~ derwent a radical eysteetomy. The surgi6~ findings included negative pelvic lymph n o d ~ minimal residual Stage T~, grade II transiti0ri~ cell carcinoma with focal anaplastic grade ! ~ transitional cell eareinoma of bladder of the 1 ~ lateral wall, a loci of well-differentiated s m ~ glandular adenocareinoma (Gleason S t a g ~ and 2) of the prostate, and, of particular l ~ terest, a 23-cm long, 1 cm in diameter sausag~ like segment of left ureteral stump (Fig. 2). H ~ tologie evaluation of the left ureteral s t u ~ revealed a Stage T~ grade II papillary t r a ~ tional cell carcinoma replacing the entire ureter. The patient tolerated the procedure ff/~°~ and revealed no evidence of recurrent d i s e ~ six months postoperatively.

FIGURE1. Cystogram shows filling defect on left lateral wall of bladder from papillary transitional cell carcinoma.

Comment

left ureteral orifice. Therefore, retrograde pyelography could not be done to evaluate the left ureteral stump. Two transurethral resections of the bladder tumor were attempted, but due to

It is urinary tl treated nephrour, ureteral s

FICURE2. (A) Sausage-like tumor-filled left ureteral stump found at time of operation, (B) Gross pathh!~ ., of ureteral tumor and bladder after resection, forceps-identified bladder tumor.

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TABLEI.

Primary ureteral stump tumors after nephrectomy for benign disease

Interval (Yrs) Between Nephrectomy and Ureteral Carcinoma

Histology of Ureteral Tumor

Concomitant Bladder Cancer

14 24 2 4 27 7 42 45 12 4 11 5 6 1 1 2 4 6 15 36 38

Squamous cell Transitional cell Transitional cell Transitional cell Transitional cell Squamous cell Squamous cell Squamous cell Squamous cell Transitional cell Transitional cell Transitional cell Transitional cell Transitional cell Transitional cell Transitional cell Transitional cell Transitional cell Transitional cell Adenocarcinoma Transitional cell

No No No No No No No No No Yes No Yes No No No Yes No No No Yes Yes

presumably secondary to the 'e of this tumor, placing the enat risk for TCC recurrence. .omplete n e p h r o u r e t e r e c t o m y ! the intramural ureter and an d e r c u f f is u s u a l l y r e c o m wever, is significant in that it imary t u m o r of the ureteral g nephrectomy for nonmaligThis e n t i t y was d e f i n e d by primary tumor in the residual From previous nephrectomy or reterectomy, where there had Lumor of renal p a r e n c h y m a , t upper ureter. Wisheart v comfy of these tumors with tumors eter expecting to find both tu~r features. He found that both d clinically with a similar fie1ell-known triad of hematuria, Lss. Cystoscopy and retrograde ',re the most helpful diagnostic tmors. 7 raluation of reported ureteral ?ter nephrectomy for nonmalig~ws an incidence of 71 percent t squamous cell carcinoma, and 9carcinoma (Table I). Because

Series Loef and Casella 1 Baker and Graf2 Baker and Graf2 Taylor and Berry3 Bennetts, et al. 4 Moore5 Amara Wisheart 7 Sozer8 Watts ~ Watts 9 Summers, et al. lo Andronaco and Brownn Malek12 Malek12 Malek1~ Malek~ Tolley and Castro 13 Mullen and Kovacs'4 Brawer and Waisman t5 Kinzler, et al.

the incidence of squamous cell cancer of the ureter in the normal, intact system is much less (4-12%), 18,19 the relatively high incidence of squamous cell carcinoma in the ureteral stump is thought to be due to precedent squamous metaplasia. 2° Another difference is seen with the incidence of multiple tumor occurrences within the ureter: 10 percent in intact ureters vs 37 percent in ureteral stumps, v This was difficult to assess in our patient since his entire ureteral stump was filled with tumor. T h e fact t h a t our patient's t u m o r arose thirty-eight years after nephrectomy represents the longest interval reported between nephrectomy and the appearance of a transitional cell carcinoma of the ureteral stump (Table I). This case also represents the fifth ureteral stump tumor after nephrectomy for nonmalignant disease arising concomitantly with a remote bladder tumor, a condition reported previously in only 20 percent of such cases (Table I). O n e p e r c e n t of all u r e t e r a l s t u m p s postnephrectomy for benign disease are symptomatic. 21 In 10 percent of these symptomatic stumps, ureteral cancer will be found21; that is w h y the retained ureteral stump should be viewed as an integral part of the urinary tract and a potential site for the development of a malignancy.

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Cystoscopy, retrograde pyelography, and cytologic examination are recommended in these patients. CT scan and nuclear magnetic resonance imaging (NMR) may play an important adjunctive role in diagnosing these lesions in the future. Of the 20 reported cases, only 6 (30 %) had evidence of distant metastases. 14,1~ Treatment of a ureteral stump malignancy is complete removal of the ureteral stump and involved lymph nodes. In our patient intravesical chemotherapy, with bladder surveillance directed at treatment of presumed superficial bladder cancer, might have delayed the diagnosis of the ureteral tumor. The fact that in our case ureteral stump pathology was identified only at the time of radical cystectomy for incompletely reseeted tumor, underscores the need for careful evaluation of the ureteral stump in all patients with urinary symptoms, even if there are other pathologic findings. With early diagnosis and appropriate treatmenbthese patients can have a good prognosis. 2160 South First Avenue Maywood, Illinois 60153

(DR. KINZLER)

(1955). 5. Moore T: Lesions of the ureteric stump after nephreet6~ Br J Urol 29:268 (1957). 6. Amar AD: Squamous cell carcinoma of ureteral sturn~ years after nephreetomy, J Urol 91:337 (1964). 7. Wisheart JD: Primary tumors of the ureteric stump folio ing nephrectomy, Br J Urol 40:344 (1968). 8. 8ozer IT: Squamous cell carcinoma and calculi in ure[~ stump: 12 years post-nephrectomy, J Urol 99:264 (1968). 9. Watts HG: Primary tumors of the uretreral stump: rep0~f 2 eases and review of literature, J Urol 104:258 (1970). 10. Summers J, Wflkerson J, and Foster S: Transitional cel][~', cinoma in a residual ureter after nephreetomy for infeetio~ Urol 108:246 (1972). 11. Andronaco JT, and Brown HE: Primary tumors of thei teral stump following nephreetomy for nonmalignant disease port of a case and review of literature, J Urol 108:706 (197'.i 12. Malek RS: Primary tumors of the ureteric stump, Br J) 45:391 (1973). 13. Tolley DA, and Castro JE: Primary urothelial turn0 ureteric stump, Urology 11:398 (1978). 14. Mullen JB, and Kovacs K: Primary carcinoma of the teral stump: a ease report and a review of literature, J Urol

113 (1980). 15. Brawer MK, and Waisman J: Papillary adenocarcinor~ ureter, Urology 19:205 (1989,). 16. Strong DW, and Pearse HD: Recurrent urothelial t~ following surgery for transitional cell carcinoma of the tlU urinary tract, Cancer 38:2178 (1976). 17. Kakizoe T, et aI: Transitional cell carcinoma of the blai in patients with renal pelvic and ureteral cancer, J Urol 12;i

(1980).

References 1. Loef JA, and Casella PA: Squamous cell carcinoma occurring in the stump of a chronically infected ureter many years after nephrectomy, J Urol 67:159 (1952). 2. Baker WJ, and Graf EC: Tumors of the ureter, J Urol 70: 390 (1953).

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3. Taylor A, and Berry JV: Primary carcinoma of residual ei eer, J Urol 72:817 (1954) . . . . 4. Bennetts FA, et al: Diseases of ureteral stump, J Urol 7a:i

18, Abeshouse BS: Primary benign and malignant tumoi the ureter. A review of the literature and report of i benign aft malignant tumors, Am J Surg 91:237 (1956). .,~,~ 19. MeIntyre D, Pyrah LN, and Raper FP: Primary ure~l neoplasma: with a report of 40 eases, Br J Urol 37:160 (1 9.0. MaeClean JT, and Fowler VB: Pathology of tumors C ~ renal pelvis and ureter, J Urol 75:384 (1956). 21. Malek RS, Moghaddam A, Furlow WL, and Greenff Symptomatic ureteral stumps, J Urol 106:521 (1971).

UROLOGY

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VOLUME XXXVII,

Ureteral stump carcinoma incidentally found at cystectomy for bladder cancer.

We report on a sixty-five-year-old man with hematuria secondary to superficial bladder cancer. Because of previous urethral trauma, a complete transur...
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