Müllerianosis of the ureter: a metaplastic lesion

Müllerianosis, Endocervicosis, and Endosalpingiosis of the Urinary Tract: A Literature Review

INTRODUCTION AND HYPOTHESIS

We reviewed reported cases of endocervicosis, endosalpingiosis, and müllerianosis of the bladder or ureters in women in order to highlight these conditions as distinct from endometriosis or adenomyosis.

METHODS

Medline and Scopus searches of all cases published till the October 1, 2017. All retrieved references were searched manually to identify relevant articles.

RESULTS

Twenty-six articles reported endocervicosis. These included 37 cases described by the authors as endocervicosis of the bladder. We identified 7 case reports of bladder endosalpingiosis. There were 26 publications including 27 cases of müllerianosis of the bladder and 3 cases affecting the lower ureter. Literature descriptions are limited but available accounts do not point to features that uniquely distinguished these conditions. Affected women tended to be older, and in many cases, there was a possible relation to past surgery and particularly to hysterectomy and caesarean sections. Many cases were reported in postmenopausal women. Local excision was sufficient in most cases.

CONCLUSION

The etiology of these conditions remains speculative, but case reports raise a possible link to pelvic surgery. There is a need for more detailed accounts of these lesions, which should be considered in the differential diagnosis of pre- and postmenopausal women with pelvic pain, dyspareunia, lower abdominal pain or discomfort, dysuria, frequency, or hematuria.

Incidental vaginal müllerianosis

Müllerianosis is the term used to designate lesions composed of an admixture of two or three types of müllerian-derivation glands in heterotopic location. In this report, we describe a case of incidental vaginal müllerianosis in a 59-year-old woman who underwent rectosigmoidectomy for rectal adenocarcinoma. In the vaginal cuff removed for neoplastic invasion, a separate multilocular mass measuring 1.5cm was found. The microscopic examination of the vaginal wall revealed endosalpingeal, endocervical and endometrial dilated or cystic glands with predominance of the endosalpingeal epithelium. Müllerian epithelium showed positivity for cytokeratins 7 and 8/18, high molecular weight cytokeratin, estrogen receptor alpha, and androgen receptor. The periglandular stroma was condensed and reactive for smooth-muscle actin, h-caldesmon, and CD10. To the best of our knowledge, a case of vaginal müllerianosis has not been previously reported. This lesion should be differentiated form vaginal adenosis and primary well-differentiated vaginal adenocarcinoma. The vagina should be added to the list of locations in which müllerianosis can be observed.

Müllerianosis of the Urinary Bladder: A Rare Tumorlike Lesion

Müllerianosis was first described as a rare entity consisting of an admixture of cervical, tubaric, or endometrial epithelium within the lamina propria and muscularis propria of the urinary bladder. This lesion occurs mainly in the dome or posterior wall of the urinary bladder in women of fertile age. Its clinical presentation is characterized by hematuria, pelvic pain, and dysuria, nonspecific symptoms that are related to the responsiveness of müllerian glands to hormonal stimuli. The major interest of müllerianosis resides in its similarity, from clinical, cytologic, and histologic viewpoints, to more threatening conditions, such as neoplasias. The clinical context and the identification of periglandular endometrial stroma at histologic examination with conventional hematoxylin-eosin stain, as well as the immunohistochemical demonstration of estrogen and progesterone receptors in the glands, are of diagnostic utility in the differential diagnosis. Müllerianosis may be responsive to gonadotropin-releasing hormone agonists. Surgical resection may be justified in the case of clinical symptoms refractory to hormone therapy.

Müllerianosis: four developmental (embryonic) mullerian diseases

The theory of müllerianosis predicts that embryonic müllerian tissue, misplaced during organogenesis, results in the formation of 4 benign müllerian diseases-developmental adenomyosis, endometriosis, endosalpingiosis, and endocervicosis-(developmental müllerian diseases) that will be identified in human female fetuses, infants, children, adolescents, and adults. Direct evidence is presented to support the existence of developmental adenomyosis, developmental endometriosis, and developmental endocervicosis in human female fetuses along with strong circumstantial evidence supporting the existence of all 4 developmental müllerian diseases in human female infants, children, adolescents, and adults. This evidence throws light upon the pathogenesis of rare müllerian lesions whose pathogenesis remains inexplicable by classical and modern theories. Furthermore, this research has scientific and clinical relevance: scientific relevance because it opens up a new field of comparative research-the 4 developmental müllerian diseases complement the 4 acquired müllerian diseases; clinical relevance because it identifies rare müllerian diseases curable by complete surgical excision.

Mullerianosis: a rare cause of acute renal colic

A 50-year-old woman presented to the urology department with an acute history suggestive of left-sided renal colic. There were no other associated symptoms, but urine dipstick revealed non-visible haematuria. CT-KUB revealed a soft tissue mass at the left vesico-ureteric junction. Flexible cystoscopy demonstrated a mass intruding into the posterior bladder. A transurethral resection of the bladder 'tumour' was undertaken, and it was noted that the mass was not macroscopically consistent with transitional cell carcinoma. Histology demonstrated Müllerianosis, a rare lesion characterised by locally invasive growth of tissue originating from the Müllerian (paramesonephric) duct. The patient was seen by gynaecologist who initiated hormone treatment with an lutenising hormone--releasing hormone (LH-RH) analogue. Urological follow-up 3 months later highlighted ongoing pelvic pain but no further colicky loin pain. Repeat cystoscopy showed the mass had become smaller and the left ureter was laterally displaced. Further gynaecological input is planned if symptoms are ongoing.

Mullerianosis of the urinary bladder: report of a case with diagnosis suggested in urine cytology and review of literature

Mullerianosis of the urinary bladder is a rare entity characterized by the presence of an admixture of at least two types of mullerian tissue in the muscularis propria of the bladder. We report a case of mullerianosis of the urinary bladder in a 28-year-old nulliparous woman with no history of pelvic surgery or endometriosis, and the diagnosis of mullerianosis was suggested initially in urine cytopathology report. In this study, previously reported cases of mullerianosis of urinary bladder are reviewed, and differential diagnosis of endometrial-like cells in the urine has been discussed. Fewer than 20 cases of mullerianosis of the urinary bladder have been reported in the literature, and only one of these cases had cytological description in a urine specimen. Most of patients were of reproductive age ranging from 28 to 53 years and had no previous history of pelvic surgery or Cesarean section. The clinical presentations frequently were abdominal/pelvic pain and dysuria/hematuria, which may or may not be associated with menstruation. Radiologic study revealed polypoid, mass-like lesion ranging from 1 to 4.5 cm in size, predominantly involving the dome or posterior wall of the bladder. Histological sections showed two or more of the three related benign mullerian glandular epithelial proliferations-endometriosis, endosalpingiosis, and endocervicosis. Most of the patients have good prognosis with medical management.

Müllerianosis of Ureter: A Rare Cause of Hydronephrosis

Müllerianosis of the urinary tract is a very rare and morphologically complex tumor-like lesion. It is composed of several types of müllerian-type lesions, including endometriosis, endocervicosis, and endosalpingiosis. We present a case of ureteral müllerianosis in woman with a history of a cesarean section about 20 years previously but with silent clinical symptoms. She was treated with segmental ureteral resection, followed by ureteroureteral anastomosis. The pathogenesis and treatment of this lesion are discussed.

Management of endosalpingiosis of urinary bladder

We report on a 48-year-old woman who presented with abnormal uterine bleeding secondary to uterine fibroids and who was found to have incidental endosalpingiosis of the urinary bladder. Follow-up is necessary for bladder endosalpingiosis because of its tendency to recur. Follow-up should include cystoscopy and renal, and possibly pelvic, ultrasonography.

Mullerianosis of the mesosalpinx: a case report

We report a case of mullerianosis of the mesosalpinx, the appearance of which simulated metastatic adenocarcinoma. The patient was a 37-year-old woman with a mixed epithelial cystadenoma of borderline malignancy associated with endometriosis in both ovaries. The left mesosalpinx contained a firm, 2.2-cm, gray-white mass that on microscopic examination consisted of glands lined mostly by endocervical-type epithelium with admixed tubal-type glands and foci of endometriosis. Rupture of glands with extravasation of mucin into the surrounding stroma was observed, but there was no desmoplastic stromal reaction. Awareness of this relatively uncommon lesion is critical to avoid misdiagnosis and overly aggressive treatment.