found in known cases of leukaemia, but it may be the first clinical manifestation of an undiagnosed leukaemia (Sridhar and Woodhouse, 1983). According to the histological type of leukaemia, relief of symptoms may be achieved with chemotherapy or radiotherapy (Merimsky et al., 1981). In CLL, however, prostatic resection with haematological support is usually a safe and effective treatment. PCM is a systemic mycosis that starts as a pulmonary infection after inhalation of the causal agent. It itends to remain subclinical and pulmonary lesions may be invisible on chest X-ray. Dissemination to other organs, including the genitourinary tract, occurs early in the pulmonary phase and can remain dormant for years (Cechella et al., 1982).

References Cechella, M. S., Melo, C. R., Melo, I. S. et 111. (1982). Paracoccidioidomicose genital masculina. Rev. Inst. Med. Trop. Sdo Paulo, 24,240-245. Merimsky, E., Baratz, M. and Kahn, Y. (1981). Leukaemic infiltration of the prostate. Br. J . Urol., 53, 150-151. Sridhar, K. N. and Woodhouse, C. R. J. (1983). Prostatic infiltration in leukaemia and lymphoma. Eur. Urol., 9, 153156.

Requests for reprints to: C. R. Melo, Department of Pathology, Federal University, 97, 119 Santa Maria, RS, Brazil.


Ureteric-Anal Canal Fistula Secondary to Ureteric Calculus


U. V. SATHAYE, K. V. SHAH and K. P. PARIKH, Division of Urology, Institute of Kidney Diseases and Research Centre, Ahrnedabad, India

Case Report A 14-year-old boy presented with a 3-year history of continuous urinary leak from the anus; he had a normal voiding pattern and faecal continence. Two months previously he had undergone an anal fistulectomy for the same leak which was from a perianal site at that time. General examination was unremarkable. Local examination showed a continuous urinary leak from the anus and perianal scarring due to previous surgery. Investigations revealed normal renal function. A urine culture was sterile. Plain X-ray showed a large opaque stone in the line of the right lower ureter. IVU showed a normal left upper tract and right hydroureteronephrosis due to a lower ureteric stone (Fig. 1). Examination under

Fig. 2



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

Ureteric-anal canal fistula secondary to ureteric calculus.

330 BRITISH JOURNAL OF UROLOGY found in known cases of leukaemia, but it may be the first clinical manifestation of an undiagnosed leukaemia (Sridha...
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