|Ahead of print publication
Thulium laser ablation for ureteritis cystica
Sanjay P Kolte1, Meenal S Kolte1, Vivek P Bhargava1, Sonal A Bhuyar2
1 Department of Urology, Sparsh Urology and Kidney Hospital, Nagpur, Maharashtra, India
2 Department of Obstetrics and Gynaecology, PDMMC, Amravati, Maharashtra, India
|Date of Submission||26-Jan-2022|
|Date of Decision||08-Jul-2022|
|Date of Acceptance||12-Jul-2022|
|Date of Web Publication||17-Sep-2022|
Sanjay P Kolte,
Sparsh Urology and Kidney Hospital, 35 Balraj Marg, Dhantoli, Nagpur - 440 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Patients with ureteral obstruction often present a diagnostic dilemma on imaging techniques. Ureteritis cystica (UC) is one benign condition which can occasionally be a cause of ureteric obstruction and almost always eludes diagnosis unless ureteroscopic examination is performed. Although no definitive operative technique has been defined for its cure in the literature, ureteroscopic laser ablation is an effective minimally invasive option. We hereby present a short case report of thulium laser ablation in an elderly female with UC in the left upper ureter.
Keywords: Ablation, laser, thulium, ureteritis cystica
| Introduction|| |
Ureteritis cystica (UC) is a benign condition, commonly affecting the upper ureter and renal pelvis. The condition is usually but not always associated with recurrent urinary tract infection or urolithiasis., It mainly affects older patients with a slight female predominance. It is usually asymptomatic but can rarely lead to obstruction causing pain and renal impairment. It has to be differentiated from ureteric tumors, polyps, radiolucent calculi, and infections due to gas-forming organisms. Once diagnosed, treatment is aimed at alleviation of symptoms and cure.
| Case Report|| |
A 67-year-old female patient presented with left flank pain of 1 month duration. She had mild hematuria for the past 3 days. She was hypertensive but did not have diabetes mellitus. There was no history of urinary tract infections. She was a nonsmoker. Past medical history was unremarkable. A urinalysis showed pH of 6, 10–12 red blood cells, and 8–10 pus cells. The complete blood count and renal function tests were within normal limits. An X-ray kidney-ureter-bladder did not show any abnormal calcifications. Computed tomography (CT) urography was suggestive of left-sided hydronephrosis with obstruction in the upper ureter and reduced concentration of contrast on that side [Figure 1]. The cause of obstruction could not be detailed on CT examination. There was no retroperitoneal or abdominal lymphadenopathy. Cystoscopy and left ureteroscopy were performed. There were multiple thin-walled cysts popping inside the lumen of the upper ureter [Figure 2]. The ureter proximal and distal to these lesions was found to be normal. A thulium laser ablation of these cysts was carried out. Thick cloudy fluid drained from the cyst. The material was collected by ureteral washings for cytological evaluation. It revealed benign atypia consistent with reactive transitional cells and no evidence of malignant cells. Abundant neutrophils were also seen. All visible cysts were similarly punctured and ablated with low-energy thulium laser [Figure 3]. A 6/26 F double J stent was placed.
The patient had a normal convalescence and the stent was removed after 1 month. She had complete resolution of symptoms and hydronephrosis at 1 year of follow-up.
| Discussion|| |
UC is a rare condition with only a few cases reported in the literature. It was first reported by Morgagni in 1761, and the first radiographic description was by Jacoby and Joelson in 1929. The location of the cysts generally is highest in the proximal ureter but can be found at any level in the urothelium., UC may also be associated with chronic urothelial irritation. Nephrolithiasis and urinary tract infections have been demonstrated as the causes of UC in the literature. The clinical presentation is variable, but UC is usually detected during the evaluation of urinary tract infections (82%), lithiasis (53%), or hematuria (52%). Our patient presented with flank pain and hematuria. Cystoscopy confirmed hematuria from the left ureteric orifice. On ureteroscopy, the cysts were found in the upper ureter occupying a segment of almost 3 cm, about 5 cm distal to the uretero-pelvic junction (UPJ). These cysts were easily punctured and ablated with low-energy holmium laser. The pathological features of UC include areas of glandular metaplasia secondary to chronic urothelial inflammation. Proliferation of epithelial bodies into the underlying mucosa leads to the formation of small cysts called Von Brunn nests., In our patient, the cytology revealed benign atypia consistent with reactive transitional cells, no evidence of malignant cells, and abundance of neutrophils. For reasons unclear, the left ureter is more commonly affected than the right, with a reported 2:1 left: right predominance. Management of UC is aimed at relief of symptoms as well as alleviation of proximal ureteral obstruction to optimally preserve renal function. Ureteroscopic resection with loop electrocautery or laser ablation is safe and well tolerated with acceptable outcome in affected patients. As is stated in the literature, UC is more prevalent in older women, which is in line with the demographic characteristics of the present case also. The finding of a large number of cysts in the proximal third of the ureter is in keeping with previous reports that the number of cysts is greatest within the upper third of the ureter and decreases distally. We were able to successfully carry out thulium laser ablation of all the visible cysts, thereby achieving total relief of obstruction. The energy used was 15 W. We could not find any reports of thulium laser being used for ablation of the cysts in UC in the literature search. Thus, we performed it without any prior trails to follow and found it simple and effective. In most of the cysts, a simple puncture with the thulium laser was all that was needed. However, where essential, the walls of the cysts were ablated. There was no hematuria following the procedure, and the recovery was uneventful.
| Conclusion|| |
The case elucidates the use of thulium laser for successful ablation of cysts in UC. It may thus represent an important tool for minimally invasive treatment of the condition in selected cases. The advantage of the procedure is the accomplishment of total ablation of cysts, thereby avoiding major tissue injury and hence the sequelae of postoperative fibrosis and strictures of the ureter. In addition, the barbotage and tissue availability allow precise diagnosis and exclusion of any remote possibility of malignancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ordon M, Ray AA, D'A Honey RJ. Ureteritis cystica: A rare cause of ureteral obstruction. J Endourol 2010;24:1391-3.
Tan A, Unluoglu S, Bayol U, Emil Sayhan S, Altinel D. Ureteritis cystica presenting with atrophic kidney: Report of a case. ScientificWorldJournal 2010;10:1535-8.
Padilla-Fernández B, Díaz-Alférez F, Herrero-Polo M, Martín-Izquierdo M, Silva-Abuín J, Lorenzo-Gómez M. Ureteritis cystica: Important consideration in the differential diagnosis of acute renal colic. Clin Med Insights Case Rep 2012;5:29-33.
Parekh JD, Iguidbashian J, Andukuri V. Ureteritis cystica: An unusual presentation in an otherwise healthy female. Cureus 2018;10:e2490.
Glaser ZA, Fougerousse JA, Galgano SJ, Magi-Galluzzi C, Rais-Bahrami S. High-volume concurrent polypoid ureteritis and ureteritis cystica manifesting with ureteral obstruction. Urology 2020;136:e7-11.
He YR, Kam J, Chan HF. A rare case of extensive unilateral ureteritis cystica. Urology 2020;138:e3-4.
Wagenknecht LV, Remé H, Wagenknecht DP. Pyelo-ureteritis cystica. Report of two cases and review of literature. Urol Int 1972;27:439-48.
[Figure 1], [Figure 2], [Figure 3]