Teaching Case

Hematuria and right flank pain.

Since 6 months right flank pain and hematuria. No other symptoms or biological alterations were associated. Physical examination showed no costovertebral angle tenderness. Urine colture was negative and urine cytology showed no malignant cells.

Primary ureteral neoplasms are rare. Benign tumors, epithelial and nonepithelial lesions, account for 20% of all ureteral tumors. Nonepithelial neoplasms derive from mesodermal tissue and include leiomyomas, fibromas, neurofibromas, granulomas, endometriomas, lymphangiomas and fibroepithelial polips, the most common of the group (30 % of all benign tumors). No cases of malignant trasformation have been reported. The fibroepithelial polip occurs more frequently in male than female (male to female ratio 3:2), during the second-fourth decades of life, despite several cases have been described in children. Preoperative diagnosis is important to avoid nephrectomy, that is performed in case of malignancy. Etiology of these lesions is unclear, although various factors, such as infection, chronic irritation, obstruction and trauma, have been proposed. Fibroepithelial polyp usually appears as a solitary lesion at the ureteral upper third, slightly more frequently involving the left rather than the right ureter. Rarely bilateral or multiple ureteral polyps have been described. Usually patients present with hematuria (58%) and flank pain owing to obstructive hydronephrosis (79%). Pain is typically intermittent. Sometimes colics for partial obstruction or ureteral intussusception or peduncle torsion may occur (fig. 1 A, B). At the right ureteral proximal third, intravenous pyelogam showed a smooth, mobile, elongated filling defect (fig. 2 A, B). Ureteroscopy showed two ureteral polyps (fig. 3 A, B) with a smooth epithelial surface, but only with retrogade pyelogram the origin at the ureteropelvic junction was discovered (fig. 4). Conservative surgery with local resection of the ureteral segment and tumor excision was performed (fig. 5 A, B). The histological examination of the resected specimen (fig. 6) confirmed the diagnosis of fibroepithelial polip (fig. 7 A, B). The follow-up at 6 months showed an excellent postoperative result (fig. 8).