We report a case of a benign fibroepithelial polyp of the lowermost ureter, which prolapsed into the bladder and was associated with a huge, impacted ureteral stone. The polyp was considered to have resulted from chronic irritation of the ureteral mucosa caused by the stone. Review of the literature showed that six out of 74 reported cases had concomitant stones but the polyp was apparently caused by the calculi in only one case

Terachi, Toshiro

Terai, Akito

Yoshida, Shuzo

Kyoto University Research Information Repository

Title Prolapsed benign polyp of ureter associated with giant ureteralcalculusAuthor(s)Terai, Akito; Terachi, Toshiro; Yoshida, ShuzoCitation泌尿器科紀要 (1989), 35(5): 871-873Issue Date1989-05URL http://hdl.handle.net/2433/116525RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityActa Urol. Jpn. 34: 871-873, 1989 871 PROLAPSED BENIGN POLYP OF URETER ASSOCIATED WITH GIANT URETERAL CALCULUS Akito TERAI, Toshiro TERACHI and Shuzo YOSHIDA From the Department if Urology, Kurashiki Central Hospital We report a case of a benign fibroepithelial polyp of the lowermost ureter, which prolapsed into the bladder and was associated with a huge, impacted ureteral stone. The polyp was considered to have resulted from chronic irritation of the ureteral mucosa caused by the stone. Review of the literature showed that six out of 74 reported cases had concomitant stones but the polyp was apparently caused by the calculi in only one case. Key words: Ureteral polyp, Prolapse, Giant ureteral stone INTRODUCTION Benign fibrous polyps of the ureter are rare and only 74 cases have been reported in the literature!). The majority of them had unknown causes. Herein, we report a case of a fibroepithelial polyp of the ureter which prolapsed into the bladder and was associated with a huge impacted ureteral stone. CASE REPORT A 37-year-old male was hospitalized be-cause of right lower abdominal pain. He had had transient attacks of pain in the same region several times a year for the past twenty years. An intravenous urogram showed a giant ureteral stone in the right lowermost ureter, multiple small renal stones in the right lower calyx associated with a marked hydronephrosis and a 2 em filling defect in the bladder (Fig. 1). On cystoscopy, an irregularly polypoid tumor with a smooth surface was seen in the position corresponding to the right ureteral orifice, which itself was unidentifiable (Fig. 2). Transurethral resection was performed. The tumor was firm and bled little and on resecting its pedicle, a normal ureteral lumen could be observed in the medial aspect of the cut surface. Microscopically, the tumor was composed of loose connective tissue covered by normal transitional epithelium. Multiple subepithelial cell nests, so-called Brunn's nests, were also present but inflammatory cell infiltration was scarce (Fig. 3). Histological diagnosis was a benign fibroepithelial polyp. Considering the benign nature of the disease, percutaneous nephrolithotomy (PNL) was performed at first and all renal stones were easily removed. A post-operative nephrostogram revealed that the right ureter was markedly dilated throughout its length but showed active peristaltic movements. Open ureterolithot-omy was carried out five days after PNL. There was much difficulty in dissecting the ureter owing to severe periureteral adhesion. On ureterotomy, the ureteral wall was found to be markedly thickened and the stone to be impacted snugly. The ureteral mucosa distal to the calculi showed tiny polypoid lesions, which were neither resected nor coagulated. A 8.5 Fr single.J ureteral stent was placed in the kidney and bladder to exit from a per-cutaneous cystostomy. Postoperative conva-lescense was uneventful. The ureteral stent was removed on the eighth post-operative day and the nephrostomy catheter on the tenth day. An intravenous uro-gram at one month postoperatively showed that right hydronephrosis was persistent but excretory function recovered consid-erably. The calculus measured 4 x 3 x 3 cm and weighed 15 g. Its surface had a rough dentation and a cut section showed multiple concentric layers of crystalliza-872 Acta Urol. Jpn . Vol. 35, TO. 5, 1989 Fig. I . In trave nous urogram shows right hydronephrosis, gian t calc ulu s an d in tr avesical fi llin g defect (arrow ). Fig. 2. Cystosco py shows ir regul ar and polypoid t um or. Fig. 3. Mi cr oscopicall y, t um or consists of loose connect ive ti ssue surrounded with transi-ti on a l epi theliu m. Subepitheli a l cell nes ts can be seen ( H & E, x 40 ). Fi g . 4. C ut sur face of calcul us shows m ul t iple conce n tri c layars of crystallization. tion (Fig . 4) . Stone analysis revealed that a ll pa rts of the uretera l stone consisted purely of calcium oxa la te, as well as the rena l ca lculi . DISCUSSION Ben ign fi broepithelia l polyps of the ureter a re ra re. Such factors as obstruc-tion , trauma, irritation , infection , exo-genous or endogenous carcinogens, hor-monal imba lance , and a llergy ha ve been proposed as causative age ntsl) . Stones may cause chronic irrita tion of the ure-tera l wa ll , with or without urina ry infec-tion but their actua l role is un certain. Of 74 patients with histologica lly proved benign fibrous polyps of the ureter recently rev iewed by Chang et a ll). only six had polyps associated with concomitant sto-nes t- 6) . In three of them t -~) coexistence of stones and polyps see ms to be incidental because stones we re in the calyces . One pa tient4) had passed uretera l ca lculi spon-taneously fi ve years previously a nd had a nother concomita nt stone in the calyx. Another pa tient5) had a ure teral stone with a severa l-month duration cauda l to the polyp. The case reported by \1elicow e t a 1.6) is interes tin g in this regard . The patient had severe hydroureteronephrosis with pyonephrosis, a stricture at the left ure-teropelvic j unction and a 4 cm polyp suspending from it. There were multiple renal ca lculi , a sma ll uretera l calculus impacted a t the stri cture a nd two large ca lculi (each 2 x 2 x 1.5 cm. 5g) 111 the lower ureter. All calculi were clearly 111-fection-re la ted ones . A logica l explana-Terai， etal.: Prolasped ureteraI polyp， Giant ureteral stone 873 tion seems to be that both the stricture and polyp resulted from constant irritation of the ureteral mucosa at the ureteropelvic junction caused by urinary calculi. It is hard to believe in our case that such a giant and spiculate ca1culus descended from the kidney. The impacted stone must have increased in the ureter. The ureter must be markedly dilated for a ureteral stone to grow into an ovoid shape， instead of an elongated form as a giant ureteral stone usually does. Further-more， a long time is necessary for a stone to grow to this large size in thl; absence of urinary Infectlon. In our case， we be-lieve that the stone was impacted in thぞlowermost ureter at the Waldyer's sheath and that the polyp developed as a local reaction to chronic irritation caused bv the stone. The stone must have been present for over twenty years， as the pa-tient's history shows， and urinary infection must have played no role in the process of stone growthヲ asstone analysis shows. The causes of the majority of fibroepi・和文抄録thelial polyps are unknown and they are usuallv considered to be hamartomatous growth. Although the histological appear-ance may be identical， th守 polypin our case was probably a local response to chronic irritation and may be pathogenet-ically di行erentfrom other reported cases. REFERENCES 1) Chang HH， Ray P， Ockuly E and Guinan P: Benign fibrous uretera1 po1yps. Uro1ogy 30: 114-118， 1987 2) Howard TL: Giant po1yps of ureter. J Urol 79: 397-402， 1953 3) Sommerhaug RG and Mason T: Peutz噌Jeghers syndrome and ureteral po1yposis. JAMA 211: 120-122、19704) Hughes FA and Da¥，is CS: Multiple benign uretera1 fibrous po1yps. Am J Rentogenol 126: 723-727， 1976 5) Vandendris M: Fibrous po1yp of the ureter. Br J Urol 51・233，1979 6) Melicow MM and Findlay HV: Primary benign tumors of the ureter. Surg Gynecol & Obstet 54: 680-689， 1932 (Accepted for publication May 31， 1988) 尿管ポリープの臆l陀内脱出を伴った巨大尿管結石の 1例倉敷中央病院泌尿器科〔部長:吉田修三)寺井章人，寺地敏郎，吉田修三37歳男性が， 20年以上前から間欠的に継続する右下 による慢性的刺激の結果生じたものと思われた.外国腹部痛のため入院した.右尿管下端部の巨大結石およ の文献で尿管の線維上皮性ポリープは74例報告されてび尿管ポリープ(径 2cm)の膨坑内脱出が認めら いるが，結石を合併したものは6例のみで，両者の困れ，経尿道的ボリープ切除と右尿管切石術により治癒 果関係は不明で、あった.白験例は組織学的には線維上せしめた.ポリープは組織学的に良性の線維上皮性ポ 皮性ポリープと診断されたが，他のものとは発生機序リープであった.結石は 4x 3 x 3 cm， 15 gで純粋な が異なるのかもしれない.シュウ酸カノレシウムからなっていた.ポリープは結石 〔泌尿器要 35:871-873， 1989) 

尿管ポリープの膀胱内脱出を伴った巨大尿管結石の1例

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尿管ポリープの膀胱内脱出を伴った巨大尿管結石の1例

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