Methysergide-induced retroperitoneal fibrosis: successful outcome and two new laboratory features

Retroperitoneal Fibrosis With Periaortic and Pericardial Involvement

A 66-year old man, who had been diagnosed with dilated cardiomyopathy and felt a progressive shortness of breath and fatigability, was admitted to hospital. Computed tomography showed a thickening of the aortic wall from the aortic arch to the aortic bifurcation, as well as mild pleural and pericardial effusion. Intravenous pyelography showed severe ureteral stenosis, along with hydronephrosis, of the left side. There was a marked increase in C-reactive protein and the erythrocyte sedimentation rate, but the serology for connective tissue disease and perinuclear antineutrophil cytoplasmic antibodies was negative. Retroperitoneal fibrosis (RPF) with intrathoracic extension was diagnosed. After confirming the absence of malignant disease, an oral predonisolone treatment of 30 mg/day was started, and this ameliorated the ureteral obstruction, aortic wall thickening and pericardial effusion. The patient had been taking 300 mg of loxoprofen sodium for headaches every day for 16 years. The relationship between loxoprofen, cardiomyopathy and RPF remains unclear. There is a possibility of RPF in the patients with a thickening of thoracic aortic wall, as in this case.

Primary and postoperative retroperitoneal fibrosis-experience with 18 cases

OBJECTIVES

Retroperitoneal fibrosis (RPF) is an uncommon disease complicated by ureteral entrapment. Its etiology includes several medications, periaortic inflammation, abdominal and retroperitoneal operations, radiotherapy, and malignancy. We present 18 patients, 14 of whom developed RPF after surgery and radiotherapy.

METHODS

During the past 12 years, we treated 7 women and 11 men. The diagnosis was based on intravenous urography, retrograde pyelography, and computed tomography features. Computed tomography-guided or intraoperative biopsies were taken to differentiate benign from malignant fibrosis. In all patients, percutaneous stent nephrostomies or internal stents were inserted before surgery. The operation included ureterolysis with an omental flap or ureteral reimplantation. Follow-up included renal function tests, intravenous urography, and computed tomography.

RESULTS

The mean patient age was 57.3 years (range 36 to 85). Fourteen patients developed RPF after abdominal or retroperitoneal surgery. Three had primary RPF and one malignant RPF due to metastatic disease. Six patients also underwent radiotherapy. The mean time between the insults to the diagnosis of RPF was 18.6 months (range 1 to 96). Ten patients had bilateral obstruction. Fourteen patients underwent surgery and four were treated with stenting only. Of the 14 patients who underwent surgery, 10 had a normal intravenous urogram postoperatively and 4 had decreased function of the formerly obstructed kidney. In 1 patient, re-entrapment of the ureter appeared owing to pelvic recurrence of tumor. At last follow-up, 1 patient waits with stents. The mean follow-up time was 22 months (range 4 to 52).

CONCLUSIONS

The etiology of RPF varies. The unique feature of our series was the high incidence of patients who developed RPF after surgery and radiotherapy to the retroperitoneum. Nephrostomy drainage and ureteral stenting facilitated surgery. Ureterolysis combined with wrapping the ureter with an omental flap or re-implantation ensured good anatomic and functional results.