Figure 1
Axial CT of the abdomen
Fig. 1 CT at presentation demonstrating bilateral staghorn calculi.
Ureteritis cystica masquerading as Steinstrasse following PCNL
SectionUroradiology & genital male imaging
Case TypeClinical Cases
AuthorsAli T, Shaida N, Winterbottom A
Connected authors
74 years, male
Clinical History
A 74-year-old male patient of Nepalese origin presented with acute abdominal pain. The patient was found to be in profound urosepsis and was admitted to the intensive care unit (ICU) for circulatory support and haemofiltration. Significant past medical history included bilateral renal staghorn calculi diagnosed eight years earlier.
Imaging Findings
CT of the abdomen confirmed bilateral staghorn calculi (Fig 1). Following an emergency right sided nephrostomy, the patient was subsequently discharged in view of a planned bilateral percutanoues nephrolithotomy (PCNL).
The patient, however, presented again with recurrent symptoms. He was treated with bilateral nephrostomies and subsequently underwent an uncomplicated right PCNL. Four weeks later a left-sided PCNL (Fig 2) was performed and a good reduction in stone burden was achieved. However, the patient spiked a temperature following clamping of the left nephrostomy and a left nephrostogram (Fig 3) demonstrated multiple filling defects within the left ureter; presumed to be residual calculi. These findings persisted seven days later (Fig 4). Therefore an antegrade ureteric stent was inserted and the patient was discharged. Follow up six weeks later for stent removal demonstrated ureteritis cystica on ureteroscopy, instead of calculi, and the patient was discharged on a course of antibiotics.
The patient, however, presented again with recurrent symptoms. He was treated with bilateral nephrostomies and subsequently underwent an uncomplicated right PCNL. Four weeks later a left-sided PCNL (Fig 2) was performed and a good reduction in stone burden was achieved. However, the patient spiked a temperature following clamping of the left nephrostomy and a left nephrostogram (Fig 3) demonstrated multiple filling defects within the left ureter; presumed to be residual calculi. These findings persisted seven days later (Fig 4). Therefore an antegrade ureteric stent was inserted and the patient was discharged. Follow up six weeks later for stent removal demonstrated ureteritis cystica on ureteroscopy, instead of calculi, and the patient was discharged on a course of antibiotics.
Discussion
Ureteritis cystica is a benign condition characterised by multiple urothelial cystic lesions arising from Brunns epithelial cells, which populate the submucosa of the urinary tract. These cystic lesions arise as a result of chronic irritation or inflammation. Since being first described by Morgagni [1] numerous cases have been reported in relation to a variety of associations such as nephrolithiasis, infection and schistosomiasis [2] and with a variety of presentations [3-6], however with no malignant association [7-8].
Generally, the condition is asymptomatic and picked up as an incidental finding on imaging or at ureteroscopy. The condition may be unilateral or bilateral and appears more common in females than males. It is also more commonly identified in the elderly population, which may reflect an increase in the prevalence of urinary tract infection.
Radiologically, the condition is most commonly seen on contrast urography whether performed as an intravenous urogram, as a retrograde pyelogram or, as in our case when a dedicated nephrostogram was performed. CT or MRI evaluation is reserved for cases where there is diagnostic uncertainty. The primary radiological abnormality is the presence of multiple filling defects within the ureter on contrast studies. The filling defects are well defined, measure up to 5mm in size, smooth in outline and may lead to a scalloped appearance of the ureter [8]. Importantly there is usually no associated obstruction of the urinary tract.
Our case highlights the importance of considering ureteritis cystica in the differential diagnosis of filling defects in the ureter. The appearances of the nephrostogram post PCNL were initially interpreted as being secondary to calculi (Steinstrasse). At this stage the patient had developed a fever after clamping of his nephrostomy, therefore this would appear to be a reasonable conclusion, although the fact that no hold up of contrast medium was seen was not typical. On the second nephrostogram the continued and fixed presence of the filling defects in a clinically well patient was suggestive of an alternative pathology. As there remained diagnostic uncertainty at this stage, the patient was treated with insertion of a ureteric stent. Only on subsequent ureteroscopy was this confirmed to be ureteritis cystica with no residual calculi demonstrated in the ureter.
Ureteritis cystica is a benign, indolent condition characterised by multiple filling defects in the ureter on contrast urography. Its principal significance is that it can simulate other, more sinister lesions amongst a wide differential diagnosis.
Generally, the condition is asymptomatic and picked up as an incidental finding on imaging or at ureteroscopy. The condition may be unilateral or bilateral and appears more common in females than males. It is also more commonly identified in the elderly population, which may reflect an increase in the prevalence of urinary tract infection.
Radiologically, the condition is most commonly seen on contrast urography whether performed as an intravenous urogram, as a retrograde pyelogram or, as in our case when a dedicated nephrostogram was performed. CT or MRI evaluation is reserved for cases where there is diagnostic uncertainty. The primary radiological abnormality is the presence of multiple filling defects within the ureter on contrast studies. The filling defects are well defined, measure up to 5mm in size, smooth in outline and may lead to a scalloped appearance of the ureter [8]. Importantly there is usually no associated obstruction of the urinary tract.
Our case highlights the importance of considering ureteritis cystica in the differential diagnosis of filling defects in the ureter. The appearances of the nephrostogram post PCNL were initially interpreted as being secondary to calculi (Steinstrasse). At this stage the patient had developed a fever after clamping of his nephrostomy, therefore this would appear to be a reasonable conclusion, although the fact that no hold up of contrast medium was seen was not typical. On the second nephrostogram the continued and fixed presence of the filling defects in a clinically well patient was suggestive of an alternative pathology. As there remained diagnostic uncertainty at this stage, the patient was treated with insertion of a ureteric stent. Only on subsequent ureteroscopy was this confirmed to be ureteritis cystica with no residual calculi demonstrated in the ureter.
Ureteritis cystica is a benign, indolent condition characterised by multiple filling defects in the ureter on contrast urography. Its principal significance is that it can simulate other, more sinister lesions amongst a wide differential diagnosis.
Differential Diagnosis List
Ureteritis Cystica
Steinstrasse (calculi)
Transitional cell carcinoma
Air bubbles
Clots
Causes of extrinsic compression of the ureter
Final Diagnosis
Ureteritis Cystica
References
[1] Morgagni G (1822) De Sedibus et Causis Morborum per Anatomen İndigatis: Libri Quinque. William Cooke Translations 316-411
[2] Rothschild JG, Wu G (2011) A Radiologic Pathologic Correlation. J Clin Imaging Sci 1: 23 (PMID: 21966620)
[3] Mahboubi S, Duckett JN, Spackman TJ (1976) Ureteritis cystica after treatment of cyclophosphamide-induced hemorrhagic cystitis. Urology 7:521-3 (PMID: 1274014)
[4] Padilla-Fernández B, Díaz-Alférez FJ, Herrero-Polo M, Martín-Izquierdo M, Silva-Abuín JM, Lorenzo-Gómez JF (2012) Ureteritis Cystica: Important Consideration in the Differential Diagnosis of Acute Renal Colic. Clin Med insights Case Rep 5:29-33 (PMID: 22474406)
[5] Tan A, Unluoglu S, Bayol U, Emil Sayhan S, Altinel D (2010) Ureteritis cystica presenting with atrophic kidney: report of a case. Scientific World Journal 10:1535-8 (PMID: 20694450)
[6] Parker B, Patel B, Coffield KS (2002) Ureteritis cystica presenting as a retractile ureteral polyp. J Urol 168(1):195-6 (PMID: 12050527)
[7] Duffin TK, Regan JB, Hernandez-Graulau JM. (1994) Ureteritis cystica with a 17-year follow up. J Urol 151(1): 142-3 (PMID: 8254795)
[8] Menéndez V, Sala X, Alvarez-Vijande R, Solé M, Rodriguez A, Carretero P (1997) Cystic pyeloureteritis: review of 34 cases. Radiologic aspects and differential diagnosis. Urology 50(1):31-7 (PMID: 9218015)
Case information
| URL: | https://www.eurorad.org/case/11043 |
| DOI: | 10.1594/EURORAD/CASE.11043 |
| ISSN: | 1563-4086 |
Figure 2
Coronal CT reformat and Fluoroscopic images
Fig 2A: Reformatted image demonstrating staghorn calculus in the
left kidney. 2B: control fluoroscopic image.
2C-D: PCNL procedure.
Figure 3
Nephrostogram
Figures 3A-B: Nephrostogram demonstrating multiple filling defects
in the left ureter.
Figure 4
Nephrostogram
Fig 4 A-B: Second nephrostogram confirming persistence of the ureteric
filling defects. Note the similarity of the configuration of the filling defects between Figs 4B and 3B
Axial CT of the abdomen
Fig. 1 CT at presentation demonstrating bilateral staghorn calculi.
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, UK
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, UK
Coronal CT reformat and Fluoroscopic images
Fig 2A: Reformatted image demonstrating staghorn calculus in the
left kidney. 2B: control fluoroscopic image.
2C-D: PCNL procedure.
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Nephrostogram
Figures 3A-B: Nephrostogram demonstrating multiple filling defects
in the left ureter.
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Nephrostogram
Fig 4 A-B: Second nephrostogram confirming persistence of the ureteric
filling defects. Note the similarity of the configuration of the filling defects between Figs 4B and 3B
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK