UROPATHOLOGY
POST-SURGICAL NECROBIOTIC GRANULOMAS OF URINARY BLADDER JOHN N. EBLE, M.D. EVELYN R. BANKS, M.D. From the Department of Pathology and the Laboratory for Experimental Oncology, Indiana University School of Medicine and Laboratory Service, the Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
ABSTRACT-Palisading necrobiotic granulomas of the prostate are an uncommon but well-recognized sequela of transurethral surgery. Similar granulomas occurring in 3 patients after transurethral surgery of the urinary bladder are reported. In each case, the lesions were discovered as a result of biopsies done subsequent to transurethral resections of bladder tumors. An idiosyncratic hypersensitivity reaction to a diathermically induced change in the antigenicity of the subepithelial connective tissue is suggested as the cause of these granulomas.
Since 1972, transurethral surgery of the prostate has been implicated as the cause of necrotizing palisading granulomas, with and without tissue eosinophilia.I-7 More recently, the histologic features characteristic of post-surgical granulomas have been described not only in the prostate but also in the kidney, uterine cervix, fallopian tube, and ovary.8-12 Only one report has dealt with post-surgical granulomas in the urinary bladder. 13 All of these reports reinforce the concept of an iatrogenic etiology for these lesions. \"'e describe 3 cases in which palisading necrobiotic granulomas were found in the urinary bladders of men who had had repeated transurethral resections and biopsies for noninvasive urothelial carcinomas. The potential etiologies of these lesions are reviewed, and it is suggested that the lesions share a common etiology in antigenic alteration of the connective tissue under the influence of diathermy heating. Case Reports
Case 1 An eighty-nine-year-old white man underwent his first transurethral resection in May, 1981, for a noninvasive papillary urothelial carcinoma, Grade lIllY. Three and one-half 454
months later, rebiopsy specimens showed chronic inflammation and one small granuloma. In 1982, superficially invasive urothelial carcinoma was diagnosed, however, at that time the patient refused further treatment. At the third admission, in August, 1984, he had severe hematuria and a large papillary carcinoma was found on the right wall of the bladder along with multiple others at other sites. The tumor on the right wall was partially resected transurethrally, but because of concern for perforation the procedure was terminated after resecting 40 g of tissue. The tumor was diagnosed as superficially invasive papillary urothelial carcinoma, Grade lIllY. Fourteen days later, the patient was operated on to complete the resection of this tumor. The tumor again was shown to be a papillary urothelial carcinoma and palisading granulomas with eosinophils were also present. The patient had no history of tuberculosis, sarcoidosis, or rheumatoid arthritis. There was no clinical or laboratory evidence for these diseases nor was there eosinophilia. He denied a history of asthma and allergies. Microbiologi.c cultures of the urine before and after the surgIcal procedures were sterile.
UROLOGY
!
MAY 1990
/
VOLU.\1E
xxxv,
NUMBER
:"5
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POST-SURGICAL NECROBIOTIC GRANULOMAS OF URINARY BLADDER JOHN N. EBLE, M.D. EVELYN R. BANKS, M.D. From the Department of Pathology and the Laboratory for Experimental Oncology, Indiana University School of Medicine and Laboratory Service, the Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
ABSTRACT-Palisading necrobiotic granulomas of the prostate are an uncommon but well-recognized sequela of transurethral surgery. Similar granulomas occurring in 3 patients after transurethral surgery of the urinary bladder are reported. In each case, the lesions were discovered as a result of biopsies done subsequent to transurethral resections of bladder tumors. An idiosyncratic hypersensitivity reaction to a diathermically induced change in the antigenicity of the subepithelial connective tissue is suggested as the cause of these granulomas.
Since 1972, transurethral surgery of the prostate has been implicated as the cause of necrotizing palisading granulomas, with and without tissue eosinophilia.I-7 More recently, the histologic features characteristic of post-surgical granulomas have been described not only in the prostate but also in the kidney, uterine cervix, fallopian tube, and ovary.8-12 Only one report has dealt with post-surgical granulomas in the urinary bladder. 13 All of these reports reinforce the concept of an iatrogenic etiology for these lesions. \"'e describe 3 cases in which palisading necrobiotic granulomas were found in the urinary bladders of men who had had repeated transurethral resections and biopsies for noninvasive urothelial carcinomas. The potential etiologies of these lesions are reviewed, and it is suggested that the lesions share a common etiology in antigenic alteration of the connective tissue under the influence of diathermy heating. Case Reports
Case 1 An eighty-nine-year-old white man underwent his first transurethral resection in May, 1981, for a noninvasive papillary urothelial carcinoma, Grade lIllY. Three and one-half 454
months later, rebiopsy specimens showed chronic inflammation and one small granuloma. In 1982, superficially invasive urothelial carcinoma was diagnosed, however, at that time the patient refused further treatment. At the third admission, in August, 1984, he had severe hematuria and a large papillary carcinoma was found on the right wall of the bladder along with multiple others at other sites. The tumor on the right wall was partially resected transurethrally, but because of concern for perforation the procedure was terminated after resecting 40 g of tissue. The tumor was diagnosed as superficially invasive papillary urothelial carcinoma, Grade lIllY. Fourteen days later, the patient was operated on to complete the resection of this tumor. The tumor again was shown to be a papillary urothelial carcinoma and palisading granulomas with eosinophils were also present. The patient had no history of tuberculosis, sarcoidosis, or rheumatoid arthritis. There was no clinical or laboratory evidence for these diseases nor was there eosinophilia. He denied a history of asthma and allergies. Microbiologi.c cultures of the urine before and after the surgIcal procedures were sterile.
UROLOGY
!
MAY 1990
/
VOLU.\1E
xxxv,
NUMBER
:"5
.' ':-
':.\ -:. :~~.
':. ,
-':/'., :,i>':'X,;:,":' ' ..
.
",',
"
r:
r'"·(,,,'7;.'1:!;;II , '~' '-'.', •. J
'>'"
' ..' , -.. ' • • ,
..
'
I::'f:r\'~
~)~; /~;~:j~~~2}(:::}'
