A 37-year-old female was found to have an incidental bladder lesion in 2007 at age 30 during ultrasonography investigation for subfertility. A transurethral resection of bladder tumor was performed, during which the lesion was found to extend into the proximal right ureter. Ureteroscopy was performed and the tumor was resected from the bladder and distal ureter. Histopathology showed a fibroepithelial polyp with no evidence of urothelial dysplasia or malignancy. Her medical history included two previous cesarean sections, lifelong nonsmoker, and no prior exposure to carcinogenic chemicals.
She subsequently developed recurrence of bladder tumors in 2010 and 2012 with the histopathology showing as papillary ureteritis with evidence of mitotic activity. She was commenced on a course of intravesical bacillus Calmette-Guerin (BCG) for the recurrence of her bladder tumors and the mitotic activity. Following completion of her BCG course, she remained tumor free at 3 and 6 months check with cystoscopies.
Eight months following BCG, she developed right-sided flank pain and although the bladder was clear of recurrence, a retrograde pyelogram was performed because of her previous distal right ureteral lesion. Although the distal ureter was clear, there was a new development of a large proximal ureter obstructing the polypoid lesion. A CT intravenous pyelogram showed that the lesion was 4.2 x 0.1 x 1.8 cm (Fig. 2). It is hypothesized that the previous resection at the right distal ureter had allowed reflux of the BCG proximally, stimulating the growth of this proximal ureteral granuloma.
Given the patient's age and history of recurrent bladder and ureteral tumors, a right nephroureterectomy and autotransplantation were carried out. A laparoscopic nephroureterectomy was performed that identified the right kidney with two renal arteries and a long renal vein with multiple segmental veins. The ureter was dissected away and the bladder stapled and the renal arteries and veins were ligated, with a warm ischemia time of 5 minutes.
Following cold perfusion, back table exploration of the kidney was performed with flexible ExURS, which identified the proximal ureteral lesion (Fig. 3). ExURS confirmed the intraluminal lesion margins, allowing for resection of the lesion and distal ureter with adequate proximal length for reimplantation. Intraoperative frozen section of the proximal ureteral lesion shows inflamed granulation tissue with chronic histiocytic reaction, suggestive of a poorly formed granuloma.
Reimplantation of the kidney into the right pelvis was performed by a vascular surgeon, with anastomosis of the renal vein to the external iliac vein and the renal artery to the external iliac artery. The ureter was then reimplanted into the bladder by the urology team with 4-0 polydioxanone and a Double-J stent.
Postoperatively, the patient made an uncomplicated recovery with adequate urine output through an indwelling catheter. Her renal function on discharge was excellent with a serum creatinine of 58 muM and an estimated glomerular filtration rate of 91. She underwent an effective trial of void 2 weeks postoperatively and her stent was removed 3 weeks postoperatively. Formal histopathology of the ureteral tumor showed mucosal ulceration with moderate active chronic inflammation and granulomatous inflammatory reaction. Stains for acid-fast bacilli were negative and Mycobacterium tuberculosis complex polymerase chain reaction was also negative.