Distant ureteric metastasis of prostate cancer four years post radical prostatectomy

Abstract

We describe a case of a 78-year-old male with a history of Gleason score 9 prostate cancer treated with a robotic-assisted radical prostatectomy, who developed symptoms of right ureteric obstruction four years later.

Diagnostic evaluation revealed right sided hydroureteronephrosis on imaging. Further correlation with prostate specific antigen (PSA) and histopathology from a distal ureterectomy with reimplantation revealed metastatic prostate cancer as the cause of obstruction with incidental focal carcinoma in situ (CIS) also identified.

This case highlights the diagnostic challenges and management strategies for ureteric metastasis of prostate cancer and contributes to the limited body of literature on such cases.

Highlights

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Prostate cancer can metastasize to the ureter years after primary treatment, challenging diagnosis.
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Differentiating ureteric metastasis from primary urothelial carcinoma requires thorough evaluation.
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Initial benign biopsy results may miss metastatic disease; surgical intervention can be crucial.
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Persistent PSA monitoring post-prostatectomy aids in detecting late metastasis and recurrence.
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A multidisciplinary approach improves outcomes in rare metastatic prostate cancer cases.

1 Introduction

Prostate cancer is one of the most prevalent malignancies affecting men, particularly in men over the age of 65. The majority of cases are diagnosed when the disease is localised to the prostate. However, a significant number of cases progress to advanced metastatic disease, necessitating aggressive treatment strategies including surgery, radiation, and systemic therapies. Prostate cancer has the potential to metastasize to various organs, with common sites including bones, lymph nodes, lungs, and liver. Metastasis to the ureter is exceedingly rare, with fewer than 50 documented cases in the literature.

The clinical presentation of ureteric metastasis from prostate cancer often mimics that of primary urothelial carcinoma or benign conditions such as ureteral strictures. Patients can present with symptoms of ureteral obstruction, such as flank pain, haematuria, and hydronephrosis. The rarity of ureteric metastasis from prostate cancer necessitates a high index of suspicion and thorough diagnostic evaluation to differentiate it from primary ureteral tumours and other benign conditions.

We present the case of a 78-year-old gentleman with a history of Gleason score 9 prostate cancer, previously treated with a radical prostatectomy, who presented four years after his initial surgical management with symptomatic right-sided distal ureteric obstruction and hydroureteronephrosis. Subsequent endoscopic assessment demonstrated an obstructive distal ureteric lesion on ureteroscopy which was suggestive of a ureteric urothelial carcinoma, as well as an incidental finding of two bladder tumours near the right ureteric orifice. A distal ureterectomy was performed and histopathology demonstrated metastatic prostate cancer as the cause of ureteric obstruction, with incidental focal CIS also found in the ureter. This case report contributes to the limited body of literature on this uncommon metastatic pathway, underscoring the importance of considering metastatic prostate cancer in the differential diagnosis of ureteral obstruction, in patients with a history of prostate cancer. ^,

2 Case presentation

A 78-year-old male presented to his primary health provider complaining of constant right iliac fossa pain, occurring on a background of Gleason score 9 prostate cancer having been treated with a robotic-assisted radical prostatectomy four years prior. Serum biochemistry demonstrated an eGFR of 52, reduced from a previous level of 83 four years prior. A Computed Tomography (CT) scan of the abdomen and pelvis with portal venous contrast was performed and demonstrated moderate right-sided hydroureteronephrosis ( Figure A ). This was secondary to a 13 × 6mm intraluminal obstructive lesion identified 2cm proximal to the vesicoureteral junction, while the bladder, contralateral ureter and kidney appeared normal. His most recent PSA level ∼3.5 months prior to presentation was 0.16, after previously being unrecordable (<0.008) for over three years.

The patient was referred to a urologist, and further investigation with cystoscopy and uretereoscopy was performed. Cystoscopy revealed an incidental finding of two bladder tumours close to the right ureteric orifice. These were removed and sent for pathological analysis which demonstrated high-grade non-invasive urothelial carcinoma (HGTa). An intraoperative right retrograde pyelogram demonstrated a visible filling defect in the distal right ureter ( Figure B ). Right ureteroscopy revealed an obstructive mucosal lesion in the distal right ureter which was biopsied, and a ureteric stent was placed at the end of the case ( Figure C, D ). The biopsy of the circumferential distal ureteric lesion was reported as benign.