|Year : 2009 | Volume
| Issue : 2 | Page : 64-66
Ureteral stump transitional cell carcinoma after radical nephrectomy: A case report with review of literature
B Satheesan, Sunil B Jayanand, N Kathiresan
Division of Genitor-urinary Oncology, Department of Surgical Oncology, Cancer Institute (W.I.A.), Sardar Patel Road, Adyar, Chennai - 600 020, India
|Date of Submission||29-Dec-2008|
|Date of Acceptance||14-Jan-2009|
|Date of Web Publication||26-Sep-2009|
Division of Surgical Oncology, Cancer Institute (W.I.A), Sardar Patel Road, Adyar, Chennai - 600 036
| Abstract|| |
Primary transitional cell carcinoma (TCC) of the ureter accounts for less than 1% of all malignancies of upper genitourinary tract .Ureteral stump after radical nephrectomy may develop malignancy very rarely, TCC being the commonest. Definite risk exists if the urinary bladder harbored TCC. Presence of TCC of the urinary bladder and persistent urinary tract infections in a nephrectomized patient may indicate closer evaluation.
Keywords: Radical nephrectomy, ureteral carcinoma, ureteral stump
|How to cite this article:|
Satheesan B, Jayanand SB, Kathiresan N. Ureteral stump transitional cell carcinoma after radical nephrectomy: A case report with review of literature. Urol Ann 2009;1:64-6
|How to cite this URL:|
Satheesan B, Jayanand SB, Kathiresan N. Ureteral stump transitional cell carcinoma after radical nephrectomy: A case report with review of literature. Urol Ann [serial online] 2009 [cited 2020 Jan 19];1:64-6. Available from: http://www.urologyannals.com/text.asp?2009/1/2/64/56043
| Introduction|| |
Primary ureteral carcinoma is a rare cancer that accounts for about 1% of all malignancies of the upper genitourinary tract. The most common histological type is transitional cell carcinoma (TCC) (90%). It is a disease of old age with slight male preponderance. Primary tumor in ureteral stump is very rare with less than 30 cases reported in the literature so far. ,,,, Many of the reported cases had previous or coexisting primary bladder tumors. This has lead to the hypothesis of reflux into the ureteral stump with subsequent implantation of tumor cells. We present a patient with a primary urethral stump cancer along with the relevant literature on the subject.
| Case Report|| |
A 62-year-old gentleman presented in 1999 with history of right loin pain, the evaluation of which revealed a right renal tumor and left hydronephrosis due to a stricture in the left lower ureter. He had a history of partial gastrectomy done 20 years back for benign gastric ulcer. He subsequently underwent left ureteric stenting followed by right radical nephrectomy in November 1999. The postoperative histopathology revealed a pT2 N0 tumor of clear cell carcinoma grade I [Figure 1]. The ureteric stent was removed with the resolution of left hydronephosis on follow-up. In June 2000, he presented with painless gross hematuria and cystoscopy revealed papillary TCC on the right lateral wall extending up to bladder neck. The ultrasonography (USG) revealed a bladder tumor with nonvisualization of the right ureteric stump. Transurethral resection of bladder tumor (TURBT) was done and the histopathology revealed TCC grade II Ng intermediate pTa (WHO/SIUP 1998). He subsequently received adjuvant intravesical BCG (weekly instillations for six weeks followed by monthly maintenance instillations for six months from July 2000 to March 2001). In August 2002, he was detected to have recurrence in the bladder at the same site. TURBT was performed in September 2002 with postoperative histopathology revealing papillary TCC grade II pTa. He received adjuvant intravesical BCG until June 2003. Subsequent check cystoscopies revealed no recurrence until November 2004. In November 2004, follow-up cystoscopy revealed a large papillary tumor near right ureteric orifice. The computed tomography (CT) scan and USG showed dilated right ureteric stump with suspected tumor [Figure 2]. Cystoscopic resection of the protruding fronds was done to assess the adjacent bladder mucosa. The tumor was found protruding from the right ureteric orifice but there was no tumor in the bladder. In January 2005, he underwent resection of right ureteric stump with cuff of bladder and pelvic lymphadenectomy. The postoperative period was uneventful. The pathology report showed papillary TCC extending up to muscle, but muscle being free [Figure 3]. The bladder cuff was free of tumor or carcinoma in situ. All pelvic nodes were found to be free of metastasis. Ureteroscopy of the left ureter was done after four weeks and there was no stricture or any significant pathology. He is on regular follow up.
| Discussion|| |
Primary ureteral stump carcinoma is rare with only about 30 case reports being available to date. Nonetheless, this entity has generated many discussions on the pathogenesis. Reflux of tumor-cell-containing urine into stump has been proposed as a probable mechanism in patients with history of bladder cancers. However, routine resection of entire ureter at the time of nephrectomy for benign condition and non-TCC tumors of kidney is not supported by evidence. Malek et al. studied the outcome of ureteral stump in 4883 nephrectomies performed for benign diseases of the kidney between 1935 and 1963.  The incidence of symptomatic ureteric stump was 0.86% (42 cases). The incidence of malignant diseases arising in the ureteral stump was 0.88% of total nephrectomies, but among the symptomatic stump, the malignancy was found in 9.5% of cases (4 out of 42 cases).
Mullen et al. in his review on 21 cases of ureteral stump carcinoma, the interval between nephrectomy and ureteral stump carcinoma was reported as 12 years. Seventy one percent of the patients had TCC, 24% being squamous cell carcinoma, and 5% adenocarcinoma. Around five cases of ureteric stump squamous cell carcinoma are reported in the literature. They were associated with ureteric calculi and chronic inflammation of the stump. Four cases of ureteric stump carcinoma after nephrectomy for renal cell carcinoma have been reported in the literature. In another study of 318 consecutive patients who underwent simple nephrectomy for benign pathology, eight ureteral stump tumors were detected. The mean interval between nephrectomy and ureteral stump tumor was 76.5 months. Six of them had TCC and the rest had squamous cell carcinoma.  Hematuria was the major presenting symptom. Two patients with TCC of the ureteral stump developed bladder TCC on follow up.  The incidence of multiple tumors in the ureteral stump appears to be higher than with intact ureter (37% vs. 10%).  There are case reports of metastases in the ureteric stumps following nephrectomy for renal cell carcinoma.
Ureteral stump cancer can be detected on imaging following persistent symptoms ranging from hematuria to intractable urinary tract infections. Occasionally, incidental imaging also picks up a few cases. Micturating cystourethrogram may detect a dilated ureteric stump with irregular filling defect. Associated calculi may also be found, especially in squamous cell carcinoma. Retrograde pyelography, CT scan, and magnetic resonance imaging apart from urerteroscopy may provide diagnostic information. 
The management of ureteral stump cancer is secondary ureterectomy with removal of a cuff of bladder with or without lymph nodal sampling or dissection.  Laparoscopic resection is feasible in symptomatic distended ureteric stump though its application in malignancy is unclear due to scarcity of the condition. Laser fulguration and electrocoagulation of the tumor are other options in high-risk patients.
The prognosis of this rare condition depends on the histological type, grade of the tumor, and occurrence of subsequent bladder tumor. Squamous cell carcinoma generally carries a poor prognosis.
| References|| |
|1.||Malek RS, Moghaddam A, Fortow WL, Greene LF. Symptomatic ureteral stump. J Urol 1971;106:521-8. |
|2.||Mullen JB, Kovacs L. Primary carcinoma of the ureteral stump: A case report and a review of literature. J Urol 1980;125:113-5. |
|3.||Kinzler GJ, Wheeler JS Jr, Culkin DJ, Bowers S, Flanigan RC. Ureteral stump carcinoma incidentally found at cystectomy for bladder cancer. Urology 1991;37:273-6. |
|4.||Kim YJ, Jeon SH, Huh JS, Chang SG. Long-term follow up of ureteral stump after nephrectomy for benign renal disease. Eur Urol 2004;46:748-52. |
|5.||Wisheart JD. Primary tumour of ureteric stump following nephrectomy: Presentation of a case and review of literature. Br J Urol 1968;40:344-9. |
|6.||Pollack HM, Banner MP, Popky GL. Radiologic evaluation of the ureteral stump. Radiology 1982;144:225-30. |
[Figure 1], [Figure 2], [Figure 3]