Journal of Pediatric Surgery Case Reports 17 (2017) 9e10

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Journal of Pediatric Surgery Case Reports

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Urethral polyp e A cause of neonatal urinary obstruction

M. Borges-Dias a, *, R. Lamas-Pinheiro a, L. Carmo a, C. Ramalho b, A.C. Fragoso a, C. Mariz a,
~o-Costa a
J. Esteva
a ~o Joa
Pediatric Surgery Department, Hospital Sa ~o, Faculty of Medicine, Porto, Portugal
b
Gynecology & Obstetrics Department, Hospital Sa~o Joa
~o, Faculty of Medicine, Porto, Portugal

a r t i c l e i n f o

Article history: Postnatal US showed bilateral grade V ureterohydronephrosis

Received 18 July 2016
Received in revised form
31 October 2016
Accepted 5 November 2016
Available online 11 November 2016
1. Introduction
Urothelial polyps arising from the lower urinary tract are very
rare with only isolated or scattered cases reported in pediatric
population [1e7].
This article describes the fth reported neonatal case of poste-
rior urethral polyp and reviews the more recent reported cases
addressing the etiology, clinical presentation, histology, treatment
and outcome.
2. Case report
A 29-year-old pregnant woman was referred for evaluation of
male fetal megacystis and bilateral ureterohydronephrosis identi-
ed on ultrasound (US) at 20th week of gestation. Subsequent US
showed persistent bladder and ureteric dilations as well as pelvi-
caliectasis. The amniotic uid volume was adequate and kept
stable.
A cesarean section was performed at 39th gestational week.
Neonatal physical examination showed an abnormally distended
abdomen with a palpable bladder; the abdominal musculature was
normal and no other abnormal features were identied. Bladder
was easily catheterized with immediate drainage of clear urine.
(SFU) and an enlarged thick-walled bladder; an echogenic round
pediculated mass arising from the proximal urethra was also
identied (Fig. 1).
The voiding cystourethrogram (VCUG) revealed an enlarged
bladder with irregular walls, left active vesicouretheral reux
(VUR) and an ovoid mobile lling defect 10 mm in diameter in the
posterior urethra. The newborn remained with bladder catheter
and prophylactic antibiotics until the 20th day. At this time, a
cystourethroscopy conrmed the polypoid lesion arising from the
proximal urethra, and excluded posterior urethral valves. A com-
plete excision with cold knife and electro-cautery was performed,
and a urethral catheter was left in place. Postoperative course was
uneventful with normal voiding after removal of bladder catheter
at the 3rd day, the neonate being discharged on the same day. The
histologic examination was consistent with a broepithelial polyp,
i.e. papillary fronds with brovascular cores lined by transitional
urothelium.
After 4 years of follow-up the child is voiding spontaneously
with no urinary tract infections. Mild ureterohydronephrosis with
slightly reduced renal parenchyma is still observed. The bladder
wall thickness was normal, with no signicant post void residual
urine volume. Serum creatinine values have reached a nadir of
0,2 mg/dL.
3. Discussion
Fetal low urinary tract obstruction is usually due to posterior
urethral valve (PUV) [7,8] and can lead to variable changes on the
prenatal US from mild to severe signs such as anhydramnios,
massive megacystis, renal dysplasia and pulmonary failure [8].
Sir Henry Thompson (1855) reported the rst case of urethral

* Corresponding author. Pediatric Surgery Department, Hospital Sa ~o Joa

~o, Faculty of Medicine, Alameda Prof. Hern^
ani Monteiro, 4200e319, Porto, Portugal.
E-mail addresses: mariana.bg.dias@gmail.com (M. Borges-Dias), rubenlms@hotmail.com (R. Lamas-Pinheiro), leonorfmcarmo@gmail.com (L. Carmo), catarina.fragoso@
gmail.com (A.C. Fragoso), carlosmariz@gmail.com (C. Mariz), estevao@med.up.pt (J. Estev~ao-Costa).

http://dx.doi.org/10.1016/j.epsc.2016.11.005
2213-5766/ 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
10 M. Borges-Dias et al. / Journal of Pediatric Surgery Case Reports 17 (2017) 9e10

life, with an average age at presentation of 5.2 years [6]. The

overall male predominance of UP was also apparent in the cur-
rent review. US (Fig. 1), VCUG and uroowmetry support the
diagnosis; however UP can only be conrmed by cystourethro-
scopy, which may also be therapeutic [1,5e7,9,10]. The tran-
surethral resection of the UP is curative, being the gold standard
treatment, even in the neonate [1,3e5,9]. Nevertheless, an open
transvesical removal is a valid option if dimensions of the polyp
do not allow its removal by minimal invasive techniques [4,6].
The prognosis is favorable, with no recurrences described else-
where [3e7,9].

Fig. 1. Urethral polyp on US.

Table 1
Characterization of 10-years previously reported and present cases of neonatal urethral polyps.

References Age/Sex Pre-natal suspicion Clinical presentation Diagnostic workup Histology Associated
malformations

Sitaparra A. et al. 6 days/Male No Distal urethral Physical examination Fibrovascular stalk No

(2005) [1] protrusion Ultrasound-normal covered with transitional
epithelium
Tsuang W et al. 1 day/Male Mild right Asymptomatic Ultrasoundeecogenic mass Fibroepithelial polyp No
(2006) [2] Hydronephrosis Voiding cystourethrogramemoving lling
defect within bladder neck
Bertolotti A. et al. 1 day/Female No Protruding Mass biopsy Smooth muscle bundles No
(2008) [11] interlabial mass Normal ultrasound with some nerves
Kesan K et al. 7 days/Male Bilateral uretero Urinary retention Ultrasoundebilateral moderate Fibroepithelial polyp Posterior
(2014) [9] hydronephrosis and deranged renal ureterohydronephrosis; thickened bladder urethral
function wall valves
Present case 1 Day/Male Megacystis; Distended abdomen Ultrasound - Bilateral grade V Fibroepithelial polyp No
bilateral uretero with palpable ureterohydronephrosis;
hydronephrosis bladder Voiding cystourethrogram - enlarged bladder
with irregular walls; active left
vesicouretheral reux

polyp in a human autopsy [7]. Posterior UP are benign lesions References

[2,6], located in the bladder or urethra. Characterization of the
four previously published reported cases in the last 10 years plus
the present one are summarized in Table 1. UP may be asymp-
tomatic or present with obstructive urinary symptoms, hema-
turia, infection or inter-labial mass in female patients [1,3]. No
malignant degeneration was described in the literature [9,10],
even though malignant neoplasms must be included in their
differential diagnosis [1,4].
The embryologic origin and etiology are still unclear. Whether
it is due to a developmental error in the invagination process of
the glandular material of the inner zone of the prostate or ves-
tiges of Mller's tubercle that fail to regress is still discussed
[1,5,6,10]. Congenital, irritative, infectious, obstructive or trau-
matic etiology cannot be excluded [3,6,9]. Histology usually re-
veals brovascular cores, sometimes complemented with smooth
muscle, nerves, or glands, covered by transitional urothelium
[1,3,5,6]. Downs et al. and Akbarzadeh et al. described two large
series of lower urinary tract broepithelial polyps, with 20 and
18 patients respectively, but none of them presented cases in the
newborn period.
The proximal UP are mostly diagnosed in the rst decade of
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