Urinary: Ureter

Question 1

Where are the most common locations for kidney stones to get stuck?

Answer 1

• Pelviureteric junction
• Ureterovesicular junction
• Pelvic brim (pelvic inlet)

Question 2

Ureteral wall calcifications…

Answer 2

• Tuerculosis
• Schistosomiasis

Question 3

Fluid-filled cysts within the walls of the ureter…

Answer 3

Ureteritis cystica

Note: This is due to chronic inflammation (e.g. stones, infection) and most often seen in diabetics with recurrent UTIs.

Question 4

Small ureteral outpouchings

Answer 4

Ureteral pseudodiverticulosis

Note: This is due to chronic inflammation (e.g. stones, infection) and carries a higher risk of cancer.

Question 5

Malakoplakia

Answer 5

A rare chronic granulomatous condition that creates soft tissue modularity/plaques in the bladder and ureters, often leading to obstruction, in the setting of chronic UTIs (highly associated with E. coli)

Note: This is most common in immunocompromised females.

Question 6

Which is premalignant: Leukoplakia or Malakoplakia?

Answer 6

Leukoplakia is premalignant for squamous cell cancer

Note: Malakoplakia is NOT premalignant.

Question 7

Malakoplakia is most common in what pt population?

Answer 7

Immunocompromised females

Note: Malakoplakia occurs in the setting of chronic E. coli UTIs.

Question 8

Immunocompromised female with recurrent UTIs

Answer 8

Think Malakoplakia (bladder/ureter mucosal mass, often causing obstruction)

Note: This is not malignant or even premalignant.

Question 9

Leukoplakia

Answer 9

Squamous metaplasia secondary to chronic urinary tract irritation (e.g. stones, infection)

Note: This is premalignant for squamous cell carcinoma (unlike malakoplakia).

Question 10

Common causes of retroperitoneal fibrosis

Answer 10

• Idiopathic (75%)
• Radiation
• Medications
• Inflammation (e.g. pancreatitis, pyelonephritis)
• Malignancy (e.g. desmoplastic reaction, lymphoma)

Question 11

What medications are associated with retroperitoneal fibrosis?

Answer 11

• Methyldopa
• Ergotamine
• Methysergide

Question 12

Retroperitoneal fibrosis is associated with what syndrome?

Answer 12

IgG4 disorders (autoimmune pancreatitis, Riedel’s thyroiditis, inflammatory pseudotumor)

Question 13

Is retroperitoneal fibrosis hot on PET imaging?

Answer 13

Retroperitoneal fibrosis is hot in the active stage and then becomes cold in its late stages

Question 14

Retroperitoneal fibrosis is radiotracer-avid on what nuclear imaging studies?

Answer 14

• Gallium scan
• PET/CT

Note: This is true during the metabolically active early stages, but not during chronic stages.

Question 15

Differential

Answer 15

Lateral deviation of the ureters:

• Retroperitoneal lymphadenopathy
• Aortic aneurysm
• Psoas hypertrophy (if proximal ureter only)

Question 16

Differential

Answer 16

Medial deviation of the ureters:

• Retroperitoneal fibrosis (most common)
• Pelvic lipomatosis
• Retrocaval ureter (if right side only)
• Psoas hypertrophy (if distal ureter)

Question 17

Elderly pt with atrial fibrillation

Answer 17

Think subepithelial renal pelvis hematoma

Note: This usually occurs in pts on long term anticoagulation (e.g. afib). This is a classic mimic of transitional cell carcinoma (which would enhance on post contrast imaging).

Question 18

Answer 18

Think subepithelial renal pelvis hematoma

Note: Nonenhancing thickening of the upper ureter.

Question 19

What is the most common type of collecting system cancer?

Answer 19

Transitional cell carcinoma/urothelial carcinoma (90%)

Note: Squamous cell carcinoma is the second most common.

Question 20

Retrograde pyelogram

Answer 20

Transitional cell carcinoma

Note: This is the “goblet sign” of ureteral dilatation both proximal and distal to the obstruction (the dilatation distal to the obstruction looks like a goblet).

Question 21

Where is transitional cell cancer most common?

Answer 21

Places where urine sits static the longest:

Bladder > renal pelvis > ureter

Question 22

Which portion of the ureter is most likely to have transitional cell carcinoma?

Answer 22

Bottom 1/3 (75%)

Question 23

Balkan nephropahty

Answer 23

A rare degenerative nephropathy endemic to the Balkan states that has a very high risk of renal pelvis and upper ureter transitional cell carcinomas

Note: Thought to be due to eating aristolochic acid (in the seeds of a Balkan herb).

Question 24

Risk factor for squamous cell carcinoma of the collecting system?

Answer 24

Schistosomiasis

Question 25

What are the most common primary cancers to metastasize to the ureter?

Answer 25

• GI
• Prostate
• Renal
• Breast

Note: This is rare, but usually appears as an infiltrating periureteral mass with transmural involvement.

Question 26

Fibroepithelial polyp

Answer 26

A benign polyp of the renal pelvis or upper ureter that mimics transitional cell carcinoma (usually diagnosed post nephrectomy as you can’t tell the difference on imaging alone)

Question 27

What features favor transitional cell carcinoma over a fibroepithelial polyp?

Answer 27

• Older pt (>60)
• Irregular margins
• Fixed filling defect (fibroepithelial polyps can be mobile)

Note: Fibroepithelial polyps should basically always be surgically removed because there is no way to tell its not TCC.

Question 28

Risk factors for transitional cell carcinoma

Answer 28

• Smoking
• Azo dye
• Cyclophosphamide
• Aristolochic acid (Balkan herb in Balkan nephropathy)
• Horseshoe kidney
• Urolithiasis
• Ureteral pseudodiverticulosis
• Hereditary non-polyposis colon cancer (type 2)