Pseudo-tumours of the urinary tract in patients with spinal cord injury/spina bifida

Article (PDF Available)inSpinal Cord 42(5):308-12 · June 2004with 25 Reads
DOI: 10.1038/sj.sc.3101594 · Source: PubMed
Abstract
To raise awareness of pseudo-tumours of urinary tract, as pseudo-tumours represent benign mass lesions simulating malignant neoplasms. Accurate diagnosis helps to avoid unnecessary surgery in spinal cord injury patients. Regional Spinal Injuries Centre, Southport, UK CASE REPORTS: Pseudo-tumour of kidney: A 58-year-old man with tetraplegia developed a right perirenal haematoma while taking warfarin; ultrasound and CT scanning showed no evidence of tumour in the right kidney. The haematoma was drained percutaneously. After 8 months, during investigation of a urine infection, ultrasound and CT scan revealed a space-occupying lesion in the mid-pole of the right kidney. CT-guided biopsy showed features suggestive of an organising haematoma; the lesion decreased in size over the next 13 months, thus supporting the diagnosis. Pseudo-tumour of urinary bladder: A frail, 34-year-old woman, who had spina bifida, marked spinal curvature and pelvic tilt, had been managing her neuropathic bladder with pads. She had recurrent vesical calculi and renal calculi. CT scan was performed, as CT would be the better means of evaluating the urinary tract in this patient with severe spinal deformity. CT scan showed a filling defect in the base of the bladder, and ultrasound revealed a sessile space-occupying lesion arising from the left bladder wall posteriorly. Flexible and, later, rigid cystoscopy and biopsy demonstrated necrotic slough and debris but no tumour. Ultrasound scan after 2 weeks showed a similar lesion, but ultrasound-guided biopsy was normal with nothing to explain the ultrasound appearances. A follow-up ultrasound scan about 7 weeks later again showed an echogenic mass, but the echogenic mass was seen to move from the left to the right side of the bladder on turning the patient, always maintaining a dependent position. The echogenic bladder mass thus represented a collection of debris, which had accumulated as a result of chronic retention of urine and physical immobility. Recognising the true, non-neoplastic nature of these lesions enabled us to avoid unnecessary surgical procedures in these patients, who were at high risk of surgical complications because of severely compromised cardiac and respiratory function.
Case Report
Pseudo-tumours of the urinary tract in patients with spinal cord injury/
spina bifida
S Vaidyanathan*
,1
, PL Hughes
2
, P Mansour
3
, BM Soni
1
, Gurpreet Singh
1
, JWH Watt
1
,TOo
1
and P Sett
1
1
Regional Spinal Injuries Centre, District General Hospital, Southport PR8 6PN, UK;
2
Department of Radiology,
District General Hospital, Southport PR8 6PN, UK;
3
Department of Cellular Pathology, District General Hospital,
Southport PR8 6PN, UK
Objective: To raise awareness of pseudo-tumours of urinary tract, as pseudo-tumours
represent benign mass lesions simulating malignant neoplasms. Accurate diagnosis helps to
avoid unnecessary surgery in spinal cord injury patients.
Setting: Regional Spinal Injuries Centre, Southport, UK
Case reports: Pseudo-tumour of kidney: A 58-year-old man with tetraplegia developed a right
perirenal haematoma while taking warfarin; ultrasound and CT scanning showed no evidence of
tumour in the right kidney. The haematoma was drained percutaneously. After 8 months,
during investigation of a urine infection, ultrasound and CT scan revealed a space-occupying
lesion in the mid-pole of the right kidney. CT-guided biopsy showed features suggestive of an
organising haematoma; the lesion decreased in size over the next 13 months, thus supporting the
diagnosis. Pseudo-tumour of urinary bladder: A frail, 34-year-old woman, who had spina bifida,
marked spinal curvature and pelvic tilt, had been managing her neuropathic bladder with pads.
She had recurrent vesical calculi and renal calculi. CT scan was performed, as CT would be the
better means of evaluating the urinary tract in this patient with severe spinal deformity. CT scan
showed a filling defect in the base of the bladder, and ultrasound revealed a sessile space-
occupying lesion arising from the left bladder wall posteriorly. Flexible and, later, rigid
cystoscopy and biopsy demonstrated necrotic slough and debris but no tumour. Ultrasound
scan after 2 weeks showed a similar lesion, but ultrasound-guided biopsy was normal with
nothing to explain the ultrasound appearances. A follow-up ultrasound scan about 7 weeks later
again showed an echogenic mass, but the echogenic mass was seen to move from the left to the
right side of the bladder on turning the patient, always maintaining a dependent position. The
echogenic bladder mass thus represented a collection of debris, which had accumulated as a
result of chronic retention of urine and physical immobility.
Conclusion: Recognising the true, non-neoplastic nature of these lesions enabled us to avoid
unnecessary surgical procedures in these patients, who were at high risk of surgical
complications because of severely compromised cardiac and respiratory function.
Spinal Cord (2004) 42, 308–312. doi:10.1038/sj.sc.3101594; Published online 2 March 2004
Keywords: pseudo-tumours – kidney – urinary bladder; spinal cord injury; spina bifida
Background
Pseudo-tumours are non-neoplastic space-occupying
lesions, which mimic neoplasms. We describe pseudo-
tumours of the urinary tract in two patients with
neuropathic bladder.
A spinal cord injury (SCI) patient developed a
perirenal haematoma while taking warfarin and,
subsequently, resolving haematoma mimicked a
neoplastic lesion of the kidney.
A female patient with spina bifida underwent
investigations when she developed urinary infection.
Ultrasound scan of the urinary bladder showed a
sessile space-occupying lesion, which tested our
ingenuity in clinical diagnosis.
It is crucial that we diagnose neoplastic lesions of
the urinary tract in patients with neuropathic bladder
*Correspondence: S Vaidyanathan, Regional Spinal Injuries Centre,
District General Hospital, Town Lane, Southport, Merseyside, PR8
6PN, UK
This article is dedicated to the memory of Mr John Ashcroft, who was
a patient of Regional Spinal Injuries Centre, Southport.
Spinal Cord
(2004) 42, 308– 312
&
2004 International Spinal Cord Society All rights reserved 1362-4393/04
$
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without delay, as classic symptoms of vesical
malignancy may be absent in these patients.
1
The cases,
which we present here, illustrate that it is equally
important that we recognise pseudo-tumours of the
urinary tract when they occur, so that unnecessary
surgery is avoided in this group of patients, who often
have compromised cardiac and respiratory function.
Case presentation
Case 1: pseudo-tumour of kidney
A 58-year-old man with C-4 tetraplegia developed a
right perirenal haematoma, related to warfarin therapy,
which was drained percutaneously.
2
After 8 months, the
patient developed a fever, and urine culture grew
Pseudomonas species resistant to gentamicin, ciproflox-
acin, cefotaxime and ceftazidime; he was treated with
colistin 1.5 million units, administered intravenously,
every 8 h. Ultrasound examination of the kidneys
revealed a space-occupying lesion of 5.7 cm diameter
arising from the mid-pole of the right kidney (Figure 1),
with no perinephric fluid collection. The left kidney was
normal. CT scanning showed a 5 cm solid mass lesion
involving the upper and mid-pole of the right kidney.
The fat planes anterior, lateral and medial to the right
kidney were well preserved, but there was a marked
irregular thickening of the posterior renal fascia; it was
difficult to say whether this was due to residual
thickening from previous infection or due to local
tumour infiltration.
CT-guided biopsy was performed using an 18 gauge
Trucut needle under local anaesthesia, with the patient
lying on his left side (Figure 2); the lateral approach was
preferred as a patient with C-4 tetraplegia would not be
able to maintain adequate oxygenation by breathing
spontaneously if lying prone.
Histology showed variably cellular connective tissue
with focally prominent haemosiderin deposition. Some
fibroblast nuclei were rather plump, resembling those
seen in granulation tissue, but there was no mitotic
activity or true nuclear atypia. The cellular areas
alternated with thickened, hyaline collagen bundles.
There was mild to moderate chronic inflammation,
including a population of plasma cells. There was no
evidence of neoplasia (Figure 3). The histological
differential diagnosis was of organising granulation
tissue or an organising haematoma.
This patient has been doing well. Ultrasound scan
was performed 3 months later and the scan showed
some decrease in size of the space-occupying lesion
since the last examination. The lesion now measured
Figure 1 Ultrasound of the right kidney (12112002) showed a
hypo-reflective space-occupying lesion, which was arising from
the mid-pole and distorting the renal outline
Figure 2 CT scan of the upper abdomen performed during
CT-guided biopsy of the mass lesion in the right kidney
(04122002): the tip of the Trucut needle was located within the
space-occupying lesion. The patient was lying on his left side
for the biopsy. The lateral approach was preferable to the
prone position for CT-guided biopsy, as this patient with C-4
tetraplegia would not be able to maintain adequate oxygena-
tion on spontaneous breathing, if he were to lie on his stomach
Figure 3 Histology of CT-guided biopsy of space-occupying
lesion in the right kidney: plump fibroblasts resembling those
seen in granulation tissue, but with no features of neoplasia,
alternating with hyaline collagen bundles
Pseudo-tumours of urinary tract
S Vaidyanathan et al
309
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3.4 3.3 2.9 cm
3
(Figure 4). A follow-up scan was
performed 10 months later. This ultrasound scan
showed a normal left kidney. The right kidney was
smaller in size, with some loss of cortical thickness at the
upper and lower poles. Infolded cortex in the mid-pole
of the right kidney was giving the effect of a space-
occupying lesion. This measured 2 cm in diameter and
was smaller than the previous examination. The final
diagnosis was a pseudo-tumour of the right kidney.
There was no evidence of malignancy in the right
kidney.
Case 2: pseudo-tumour of urinary bladder
This female patient (born in 1968) with spina bifida,
paraplegia and marked spinal and pelvic curvature
had been managing her neuropathic bladder with an
indwelling urethral catheter and pads. In 1995, she
underwent suprapubic cystolithotomy. In 1996, she
developed urinary infection. CT confirmed a large right
pyonephrosis with obstruction at the pelviureteric
junction by a large calculus. CT-guided nephrostomy
was done. Subsequently, right pyelolithotomy was
performed. In 1998, stones were detected in the urinary
bladder. The stones were crushed and removed endos-
copically. There was recurrence of vesical calculi a year
later and electrohydraulic lithotripsy of bladder stones
was carried out. In January 2002, there was recurrence
of bladder stones. Cystoscopy was performed; stones
were crushed and removed fully. In November 2002,
ultrasound of the abdomen was performed because she
had been getting recurrent urinary infections. It showed
staghorn calculus in the left kidney and there was
moderate hydronephrosis. The urine looked clear. The
right kidney was not seen due to scoliosis. The
radiologist recommended CT scan, as CT would be
the better means of evaluating the urinary tract in this
patient with severe spinal deformity.
A CT scan of the abdomen was carried out in
December 2002 before and after injection of intravenous
contrast. The right kidney was small and hydronephro-
tic with staghorn-type calculi in the renal pelvis and
lower pole calyces. The left kidney was large and mildly
hydronephrotic with calculi in the renal pelvis and lower
pole. There was marked distortion of anatomy by the
patient’s severe scoliosis. Both kidneys were functioning,
with contrast opacifying the pelvicalyceal systems.
Bladder calculi were not present, but there was a filling
defect in the bottom of the bladder (Figure 5), which
raised the possibility of a bladder neoplasm. Ultrasound
of the bladder was therefore performed, which showed a
sessile space-occupying lesion measuring
5.2 3.6 1.2 cm
3
in the left bladder wall posteriorly.
There was no evidence of extravesical invasion
(Figure 6).
Because of the ultrasound appearances, flexible
cystoscopy was performed on the same day. Cystoscopy
showed necrotic slough and debris in the bladder, but no
tumour was visible. Biopsies were taken, and histology
revealed nonkeratinising squamous epithelium with
moderately inflamed underlying stroma and pieces of
inflammatory slough (Figure 7).
Since flexible cystoscopy and biopsy did not reveal
any neoplastic lesion, cystoscopy was performed under
anaesthesia about 3 weeks later. No tumour was found.
Biopsies of bladder mucosa were taken from the dome,
right and left lateral walls, posterior wall and bladder
base and all showed only mildly inflamed mucosa with
no evidence of dysplasia or malignancy. The patient was
catheterised for 48 h after the cystoscopy, but subse-
quently reverted to the regime of using pads. After 2
weeks, a follow-up ultrasound scan of urinary bladder
revealed a space-occupying lesion in the left side of the
bladder, with no significant interval change since the last
scan. Ultrasound-guided biopsy of the lesion was
Figure 4 Follow-up ultrasound scans of the right kidney
(18022003): a decrease in the size of the space-occupying lesion
can be appreciated when compared with the ultrasound scan
performed 3 months ago (Figure 1)
Figure 5 Delayed contrast CT of abdomen (06122002)
showed a filling defect, which was situated posteriorly in the
urinary bladder. The filling defect was outlined by positive
contrast in the urine
Pseudo-tumours of urinary tract
S Vaidyanathan et al
310
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therefore performed using a 20 gauge Trucut needle;
neither anaesthesia nor sedation were needed. This
biopsy showed a normal full thickness bladder wall,
lined by glycogenated, nonkeratinising, squamous,
epithelium; there was no evidence of keratinising
squamous metaplasia, dysplasia or malignancy
(Figure 8). There was nothing histologically to explain
the ultrasound appearances of a bladder mass.
A follow-up bladder ultrasound scan was performed
about 7 weeks later with the patient lying supine, and yet
again showed a space-occupying lesion in the left side of
the bladder. However, on turning the patient onto her
right side, the echogenic mass moved from the left side
of the bladder to the right, the lesion maintaining the
most dependent position in the bladder (Figure 9).
Colour flow Doppler showed no blood flow within the
lesion. These findings confirmed that the mass identified
on ultrasound merely represented a collection of debris
in the most dependent part of the bladder.
Discussion
Pseudo-tumours of the kidney can be due to a surprising
variety of underlying conditions, including:
Infolding of the columns of Bertin.
3
Specific infections such as uro-genital tuberculosis.
4
Renal involvement in primary Sjogren’s syndrome.
5
Migration of an accessory spleen into the site of the
cuneiform nephrectomy.
6
Packing of an operative renal defect with retro-
peritoneal fat.
7
Figure 6 Ultrasound of the urinary bladder (17122002)
showed a 5.2 3. 6 1.2 cm sessile space-occupying lesion
arising from the left bladder wall. There was no evidence of
any local extravesical invasion
Figure 7 Histology of bladder biopsy taken with a flexible
cystoscope (HP02/12413): Inflammatory slough, comprising
purulent exudate, superficial squames and necrotic debris.
Fungi are absent (PAS-diastase, original magnification 100)
Figure 8 Histology of ultrasound-guided Trucut biopsy of
the space-occupying lesion (HP03/00636): core biopsy shows a
normal bladder wall (H&E, original magnification 40)
Figure 9 Ultrasound of urinary bladder after turning the
patient to the right side (04032003): the echogenic mass was
seen to move position to the right side of the urinary bladder
on real time scanning
Pseudo-tumours of urinary tract
S Vaidyanathan et al
311
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Haematomas arising in the context of severe haemo-
philia A or B or von Willebrand disease.
8
Local hypertrophy secondary to infectious, vascular,
or traumatic lesions.
9
In patient number 1, organised haematoma and
infolded cortex in the mid-pole of the kidney simulated
a space-occupying lesion.
In patient number 2, intravesical urinary debris
resembled closely a bladder neoplasm. During real-time
ultrasound scanning of the urinary bladder in this
patient with spina bifida and marked pelvic tilt, changes
in the position of the echogenic mass were observed as
the patient was turned from one side to the other. This
provided a vital clue that the mass in the bladder repre-
sented debris, which had accumulated in the most depen-
dent part of the bladder. This patient was very frail, and
during the daytime was confined to her reclining
wheelchair in which she would be propped up with her
legs straight, as she could not bend her knees. She was
unable to perform transfers from the chair or from the
bed, and could not turn herself. By wearing pads and
allowing spontaneous passage of urine, she was not
emptying her bladder completely. A combination of
three predisposing factors, namely chronic retention of
urine, physical immobility and urinary infection, led to a
quite and rapid build-up of debris in the bladder.
We learned from this patient that spinal cord injury
patients, who are at high risk for developing debris in
the bladder, should undergo ultrasound scans of the
bladder in different positions to detect the movement of
any echogenic mass. Performing ultrasound scans of the
bladder in both supine and lateral positions is analogous
to the dictum that kidney scans should be performed in
supine and sitting positions if milk of calcium is
suspected. Repeating the scan after a thorough bladder
washout would also help to distinguish between bladder
neoplasms and mere debris.
Conclusion
Patients with neuropathic bladder may develop unusual
lesions in the kidneys or bladder, and these patients
require detailed investigations to distinguish between
true neoplasms and pseudo-tumours, as observed in the
two patients described in this report. Recognising the
true, non-neoplastic nature of these lesions enabled us to
avoid unnecessary surgical procedures in these patients,
who were at high risk of surgical complications because
of severely compromised cardiac and respiratory
function.
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2 Vaidyanathan S et al. How should an infected perinephric
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