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Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00182-7
10.1016/j.eucr.2024.102828
102828
Inflammation and Infection
Fibroepithelial polyps causing obstructive hydronephrosis treated with pyeloplasty: A case report
Balcazar Jonathan Alexis j.balcazar@tcu.edu
⁎
Hoselton Anne Shirley
Park Kyung
Endsley Dakota
Shah Parth
Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX, USA
⁎ Corresponding author. j.balcazar@tcu.edu
22 8 2024
9 2024
22 8 2024
56 10282821 7 2024
13 8 2024
20 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Fibroepithelial polyps (FEP) are rare benign tumors urinary collecting system. Diagnosis is suspected on Computed Tomography (CT) and confirmed via histopathology. Treatment options vary from historic nephroureterectomy to more contemporary methods of ablation. Authors present a case of a symptomatic FEP causing left-sided hydronephrosis and episodic flank pain treated by a urologic surgeon. The patient underwent robotic pyeloplasty and excision of the tumors, yielding preserved renal function and resolution of the hydronephrosis.

Keywords

Fibroepithelial polyp
Hydronephrosis
Pyeloplasty
Endoscopic
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pmc1 Introduction

Fibroepithelial polyps are rare benign tumors of mesodermal origin that can appear in the renal pelvis, ureter, bladder, and posterior urethra. Primary ureteral neoplasms make up <1 % of all genitourinary neoplasms. Amongst these, benign tumors make up around 20 % of cases. While the exact etiology of FEP is unknown, it is postulated that they have a congenital or inflammatory origin.1

Here we report a case of a large fibroepithelial polyp in the proximal ureter causing intermittent ureteropelvic junction (UPJ) obstruction in a 35-year-old man that was treated by robotic pyeloplasty after the FEP was refractory to endoscopic ablation.

2 Case study

A 35-year-old male with no urologic history or previous abdominal surgery was evaluated for persistent left flank pain and nausea. He states that he experiences pain 4-5 times per year prior to evaluation with the most recent episode being the most severe and intractable. Initial urinalysis was unremarkable. CT of the abdomen and pelvis demonstrated multiple 16 mm × 8 mm left ureteral calcification with increased soft tissue located at the UPJ and extending into the mid to distal portion of the ureter with hydronephrosis by CT. The right ureter and kidney were unremarkable.

Lasix renal scan demonstrated preserved renal function and good drainage time with split function calculated at 49 % and 51 % of the left and right kidneys, respectively. Left diagnostic ureteroscopy revealed multiple fibroepithelial polyps with overlaying calcifications that were causing obstruction of the proximal collecting system (Fig. 1). FEPs emanated from the confluence of the UPJ and extended downwards to the proximal/mid ureter. Histopathologic results were compatible with that of fibroepithelial polyps.Fig. 1 Endoscopic imaging of the multiple FEPs causing left-sided obstructive hydronephrosis. Images are ordered A-D from most proximal to most distal in the left ureter.

Fig. 1

The patient underwent endoscopic ablation twice, however ultimately, he was recommended to undergo robotic left pyeloplasty/excision of FEPs given the large volume of tumor. The largest tumor excised measure over 3 cm in length (Fig. 2). The patient did well postoperatively and denied any hematuria dysuria, flank pain, nausea, vomiting, fever, or chills.Fig. 2 Gross specimen of the largest FEP measured approximately 3.2 cm causing the obstruction of the patient's left ureter status post excision and robotic pyeloplasty.

Fig. 2

1 month, post procedure, CT Intravenous Pyelogram (CT IVP) demonstrated severe persistent left hydronephrosis with decreased caliber change at the UPJ with nonspecific urothelial thickening at the UPJ/proximal ureter. 3-month CT scan demonstrated resolution of left-sided hydronephrosis without any recurrence of FEPs. Lasix renal scan demonstrated preserved renal function. The patient has remained symptom free since surgery.

CT scans and pathologic imaging were not available however, the endoscopic and gross images demonstrate the presence and excision of the fibroepithelial polyps.

3 Discussion

Approximately 85 % of FEPs are found in the ureter, with 62 % being found in the proximal ureter.2 On gross examination, FEPs are typically smooth vermiform projections. While most FEP are between 1 and 5 cm, they have been reported to be as long as 17 cm.3 On histopathology, FEPs are characterized by a core of fibrous mesodermal tissue encapsulated in transitional epithelial cells.4 There has been an increasing incidence of FEPs in recent years, likely due to the advances in endoscopic visualization.2

FEPs can be discovered incidentally and asymptomatic,5 or they can cause hematuria, ureteral obstruction, and hydronephrosis.2,6,7 Imaging of FEP, which can include CT, CT IVP, or magnetic resonance imaging (MRI), typically shows a radiolucent filling defect.8

The non-specific presentation and imaging require urothelial malignancy to be ruled out. For this reason, excision and histopathologic evaluation are necessary. Historically, aggressive nephrectomy and nephroureterectomy were performed. An endoscopic approach is now preferred, and the excision can be done with electrocautery or a laser. For more complicated cases, a laparoscopic excision can be performed.2 More aggressive treatment modalities include ureterotomy, partial ureterectomy or nephroureterectomy.9 After the excisional biopsy confirms FEP, no additional therapy is warranted, unless to resolve any associated obstruction of the collecting system.

4 Conclusion

FEPs may be confirmed via imaging and histopathology. In patients with FEPs refractory to endoscopic ablation, robotic-assisted pyeloplasty is an acceptable alternative as demonstrated by our patient's outcome. Follow-up imaging may be used to confirm absence of obstruction and Lasix Renal Scan to confirm preserved renal function.

Acknowledgements and funding sources

Publication charges for this article were supported by the 10.13039/100008439 Texas Christian University Library Open Access Fund.

CRediT authorship contribution statement

Jonathan Alexis Balcazar: Writing – review & editing, Writing – original draft, Visualization, Software, Resources, Project administration, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Anne Shirley Hoselton: Writing – review & editing, Validation. Kyung Park: Writing – review & editing, Validation. Dakota Endsley: Validation. Parth Shah: Supervision, Methodology.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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