Hindawi Publishing Corporation
Advances in Urology
Volume 2012, Article ID 656023, 3 pages
ARare Locationof Metastasis fromProstate Cancer:
SebastianSchneider,DieterPopp, Stefan Denzinger,andWolfgang Otto
Department of Urology, St. Joseph’s Mecial Center, University of Regensburg, Landshuter Straße 65, 93053 Regensburg, Germany
Correspondence should be addressed to Wolfgang Otto, firstname.lastname@example.org
Received 17 June 2011; Accepted 6 July 2011
Academic Editor: Maximilian Burger
Copyright © 2012 Sebastian Schneider et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Prostate carcinoma is a very rare origin of metastatic disease in the ureter. We report a case of a 74-year-old man who presented
in November 2008 initially with flank pain and lower urinary tract symptoms. Diagnostic investigation revealed a skeletal
metastasizing prostate carcinoma, and the cause for the flank pain was a hydronephrosis due to ureteral metastasis diagnosed
by biopsy. Antihormonal treatment led to disappearance of the hydronephrosis; however, further progress finally ended in acute
liver failure with patient’s death in July 2010.
The ureter is a rare location of metastasis for primary tumors
of any kind. In 1909, Stow described the first case of a truly
metastatic ureteral lesion from a lymphosarcoma . The
most common malignant tumors metastasizing to the ureter
are breast cancer followed by stomach cancer and colorectal
cancer. Only 43 cases of metastasis in the ureter by primary
adenocarcinoma of the prostate have been reported during
the last century [2–7]. We present the first case of such a
patient since the last 2 years.
A 74-year-old man in November 2008 first presented at an
outpatient urologist, due to lower urinary tract symptoms
and intermittent pain of the right flank. The digital rectal
examination revealed an enlarged, palpatory suspicious
prostate gland with an endured left lobe. The PSA level was
a low differentiated adenocarcinoma of the prostate gland
(Grade 2, Gleason score 7 = 3 + 4). Further diagnostics with
bone scan and ultrasound provided the evidence of diffuse
skeletal metastasis as well as an hydronephrosis of the right
kidney. Because of the findings, an antihormonal therapy
with LHRH-analogues was initiated.
As further diagnostics, an intravenous pyelography
showed a delayed excretion of the right kidney and a signifi-
cant hydronephrosis with a dilated ureter. Cause of the
prestenotic dilatation was a stricture of the lower part of the
ureter (Figure 1). Due to the unclear nature of the stricture, a
intraluminal ureteral mass at the height of the bifurcation of
the A. iliaca (Figures 2 and 3). An extraluminal compression
of the ureter, as shown with lymph nodes or other solid
masses, could not be demonstrated. In addition, there was
no evidence of suspicious enlarged subdiaphragmal or pelvic
lymph nodes. The blood and urine counts were except for
a microscopic hematuria inconspicuous. Ureterorenoscopy
with biopsy of the ureteral mass was the next step in the
diagnosis of the patient. In ureterorenoscopy, the reported
intraluminal mass was found in the distal ureter, as well as
in the middle ureter. After collecting urine for cytology, each
of the intraluminal lesions underwent biopsy. Histology
by immunohistochemical analysis revealed a metastasis of
the ureter by a prostate adenocarcinoma. Cytology did not
reveal pathological result.
Because of the symptomatic hydronephrosis and sus-
pected ureteral tumor, we first placed a nephrostomy after
ureterorenoscopy. Postoperatively, there were no complica-
tions, but at the fourth postoperative day, the nephrostomy
2 Advances in Urology
Figure 1: Retrograde pyelography showing an obstruction of the
lower part of the right ureter.
dislocated. Since then, however, no relevant hydronephrosis
insertion of a nephrostomy was indicated.
The following procedure in case of multiple skeletal
metastasis by prostate cancer was a continuation of the
therapy with LHRH analogues in combination with zole-
dronic acid infusions once a month. In June 2009, PSA
progress led to maximum antihormonal therapy with LHRH
analogues and antiandrogene. Further progress in January
stopped by appearance of liver metastases. In July 2010, the
patient died of acute liver failure without having experienced
In 1999, Haddad described over all 38 cases of prostate
carcinoma with at least one ureteral metastasis. For this
paper, the authors considered data from the last century
until 1987 . For example, McLean showed 1956 of 10,223
Figure 2: Computer tomography with hydronephrosis of the right
Figure 3: Presentation of an intraluminal ureteral mass of the right
upper urinary tract in computer tomography of the pelvis.
cancer patients with only 18 cases of ureteral metastasis,
and even only one of them related to a prostate carcinoma
. Kirshbaum et al., 1933, also demonstrated the rarity
of ureteral metastasis by a series of 4,860 autopsies. They
found in these patients only 5 ureteral metastasis, and only
2 of them were metastatic from adenocarcinoma of the
prostate gland . In a case report, Hulse and O’Neill
described a true ureteral metastasis of a prostate carcinoma
associated with a ureteral stone . Cohen et al. underlined
in 1974 the uncommon way of metastasis to the ureter
from a prostate carcinoma. They showed 3,200 autopsies
with 31 cases of ureteral metastasis but none of them with
a prostate cancer as origin . Singh et al. presented in
2009 a case report of a man with a locally advanced prostate
cancer and bone metastasis with ureteral metastasis in both
ureters . In 2007, Marzi described another case with
undifferentiated prostate cancer and neoplastic metastasis of
prostatic origin in both ureters too . Jung et al. showed
a ureteral metastasis from prostate adenocarcinoma after
bilateral orchiectomy in 2000, and Yonneau et al. presented
in 1999 a patient with an episode of renal colic and a ureteric
Advances in Urology3 Download full-text
tumor with a history of prostatectomy for prostate cancer.
They performed ureterectomy, and histology examination
revealed a metastasis from prostatic adenocarcinoma to the
ureter [6, 7]. Altogether, only 43 cases of an adenocarcinoma
of the prostate metastatic to the ureter have been reported
in the last century [2–7]. In the first half of the last
century, these ureteral metastases have been only developed
by incidental finding during autopsy. Later ultrasonography
and ureteroscopy have been established, so that also clinical
cases were reported. However, only a few patients with
ureteral metastasis are identified, because up to 85% patients
are staying asymptomatic . In case of disorders, the most
frequently is flank pain (15–50%), hematuria is rather rare
(16%) [3, 11].
In our case, the patient complained intermittent right
flank pain together with a hydronephrosis of the right upper
urinary tract. During medication with LHRH analogue,
hydronephrosis disappeared completely.
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