Quiz: Retrograde pyelogram for positive cytology

A 76-year-old female presents with a history of microhematuria and two positive cytologies for urothelial carcinoma obtained from bladder washings. Cystoscopy was negative for any obvious lesions in the bladder. She has no prior urologic history, denies any smoking history, and denies recurrent urinary tract infections (UTIs). A retrograde pyelogram (RPG) was performed on the right side as shown in figure 1. The left side RPG was unremarkable. Ureteroscopy was performed on the right side and three lesions were encountered as shown in figure 2. 

Figure 1.

Figure 2.

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Answer

A. Ureteral biopsy

Discussion

This is an unusual case as these lesions on ureteroscopy appear to be ureteritis cystica, a benign condition. However, the patient has not had a prior history of recurrent UTIs and has two positive cytologies. In this case, it is most prudent to biopsy these lesions endoscopically to confirm this is in fact benign. Ureteral biopsy was pursued in this patient and the pathology came back as malignant high-grade urothelial carcinoma inside of a cyst.

The prevalence of ureteritis cystica is unknown, with only a few hundred reports in the literature. It is a rare, benign condition that affects older adults with a slight female predominance. It is most often associated with chronic urothelial inflammation from recurrent UTIs or nephrolithiasis. There are cases of ureteritis cystica that may be much more extensive and involve almost the entire ureter. On RPG these lesions will appear hemispheric, in contrast to air bubbles, which are round. On ureteroscopy it may give off a fat-like appearance which may often appear because of yellowish gelatinous material in the cysts. There are a few reported cases where ureteritis cystica was diagnosed in a patient with concomitant urothelial carcinoma. The appearance of the lesions in our case mimicked ureteritis cystica but was actually a malignant cyst. Therefore, ureteral biopsy in light of the positive cytology was the right course of action.

Suggested reading

Ureteritis cystica. J Urol 2015; 193:1379-80.

http://learningradiology.com/archives2011/COW%20478Ureteritis%20cystica/ureteritiscorrect.htm

Igor Sorokin, MD, Assistant Professor at the University of Massachusetts, Worcester, MA, is section editor for Urology Times Clinical Quiz.