Distal ureteral stricture: A unexpected complication of further adjuvant intravesical mitomycin C thermotherapy

Abstract

We present a case of distal ureteral obstruction in relation to further adjuvant intravesical thermochemotherapy with mitomycin C (MMC) for non-muscle invasive bladder cancer (NMIBC). We also discuss the diagnostic procedures and management of this recurrent case. IntroductionTransuretral resection of the bladder tumour (TURBT) is still recognized as the primary treatment option for non-muscle invasive bladder tumours (NMIBT). However, recurrence and progression are still issues despite the radical resection. The European Association of Urology (EAU) has recommendations regarding adjuvant intravesical chemotherapy in relation to risk group stratification of NMIBC.1 Mitomycin C (MMC) is one of the commonly used agents for further adjuvant intravesical treatment of intermediate and highrisk NMIBT. Moreover, adjuvant thermochemotherapy with MMC has been presented as a hopeful treatment option for further intravesical therapy in patients with high-risk tumours.2 In this report, we present a case of a ureteral orifice and distal ureter stenosis developed after adjuvant intravesical therapy as a potential side effect of MMC thermotherapy. Case reportA 65-year-old man underwent TURBT for a primary, highgrade, NMIBT (pT1G3) localized at the junction of the bladder base and left lateral bladder wall, about 2 cm away from the left ureteral orifice. The resection did not include the left ureteric orifice region and both the bladder wall and orifice were intact after resection. One early intravesical instillation of 40 mg MMC in 50 mL saline was administered postoperatively. The convalescence period was uncomplicated. A secondary resection was performed 4 weeks after the primary resection and the pathological assessment revealed inflammatory reactive changes with infiltration of eosinophils and giant cells. Ultrasonographic evaluation of the urogenital tract was normal 2 months after the primary resection. In light of the pathological evaluation of the primary tumour, we planned to administer further adjuvant intravesical immunotherapy with Bacillus Calmette-Guérin (BCG). However, the patient was unable to supply the BCG preparations. Therefore, we decided to continue further adjuvant intravesical treatment with MMC thermochemotherapy.After the decompression of the bladder, the thermotherapy was administered with the usage of the bladder wall thermochemotherapy (BWT) system (Pelvix TT system, Elmedical Ltd., Hod Hasharon, Israel) by insitillation of 40 mg MMC in 50 mg distilled water for 50 minutes with uniform 44°C temparature on the bladder wall. This induction therapy was performed weekly for 6 weeks. The patient then complained about ambiguous flank pain on the left side after 6 doses of thermochemotherapy. The ultrasonografic evaluation of the kidneys revealed a mild-to-moderate dilatation of left ureter and collecting system. Non-contrast and contrast-enhanced abdominal computed tomography scan confirmed left hydroureteronephrosis without concomitant urinary stones (Fig. 1). Transurethral resection of the obst...

A guidewire introducer as a ureteral foreign body: A case report

“…Although rarely encountered, infectious pathologies, iatrogenic causes, ureteral stones, and their subsequent treatment via ureteroscopy and ureteral access sheaths are blamed for ureteral injury and subsequent ureteral strictures. [8][9][10][11][12][13][14] In this Fig. 1.…”