Isolated ureteric endometriosis presenting as a ureteric tumor
A 32 year old lady presented with recent onset left flank pain which was not associated with any precipitating events. She had chronic lower back pain. She had no gross hematuria, fever or lower urinary tract symptoms. Her menstrual history was normal. She reported no abdominal or pelvic pain, no dyspareunia and had normal bowl motion. She gave no history of smoking, past medical surgical or gynecological treatment or intervention. Examination of the patient revealed no abdominal or pelvic tenderness or masses. Urine analyis showed microscopic hematuria and pyuria. Urine culture was positive for Klebsielae pneumoniae. Serum creatinine was 59 umol/L. CT scan without contrast showed no stones and mild left hydronephrosis. The patient was discharged on antibiotics and analgesics for follow up. A 7 day course of ciprofloxacin eradicated the infection. Imaging for evaluation of the lower back pain indicated osteoarthritis at vertebra L5-S1. A bone scan confirmed this diagnosis and accidentally revealed poor tracer uptake of the left kidney. The patient was referred to Urology.\nAn intravenous urography showed no excretion from the left kidney []. A diuretic renogram using 99mTc-MAG3 showed poor excretion of the left kidney []. A retrograde study was carried out which revealed a short narrow segment in the ureter at the junction of the lumbar and pelvic ureter []. Ureteroscopy showed a papillary growth obstructing the lumen of the ureter. A cold cup biopsy was taken from the lesion. A double J stent was left indwelling. Microscopic pathology was not conclusive indicating an inflammatory process. A repeat renal scan with the JJ stent indwelling for 16 days, failed to show any improvement in renal function or excretion []. The patient was informed that in view of the poor functioning kidney and the high risk of harboring a malignant ureteric tumor surgery is indicated. A robotic nephroureterctomy with a bladder cuff was carried out with an uneventful course. During the surgery the left ureter was seen at the pelvic brim surrounded by adhesions and scar tissue. No other gross lesions were identified intraoperatively. Macroscopic examination of the ureter at the site of narrowing showed a firm nodule covered by bluish-red mucosa measuring 1.5 × 1.5 cm. Microscopic examination of the ureteric nodule revealed benign endometrial gland and stroma underlining the normal urothelium [Figure –]. Immunohistochemical studies were performed for estrogen receptor and CD10. The endometrial glands were positive for Estrogen receptor [] while the endometrial stroma was positive for CD10 [].