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Distortion and displacement of the renal pelvis and calices by extrarenal lesions
242
JOURNAL
DISTORTION
OF
THE
FACULTY
OF
RADIOLOGISTS
AND DISPLACEMENT OF THE RENAL CALICES BY EXTRARENAL LESIONS
PELVIS
AND
BY J. O. Y. COLE, M . D . , D . M . R . E . RADIOLOGIST~ N.~vV. HOSPITALS AREA, LONDONDERRY,
N. IRELAND
IT is well known that displacement of the kidney may be produced by both extra- and intrarenal space-occupying lesions. It is generally assumed, however, that distortion of the renal pelvis and calices is caused by intrarenal lesions only. Five cases are described to show that extrarenal lesions can produce distortion as well as displacement of the renal pelvis and calices. CASE
REPORTS
Case I (H. K. F / z 8 ) . - - T w o years' history of a swelling in the left hypochondrium which had lately become larger prior to admission to hospital. There were no renal symptoms. A smooth ovoid mass about the size
Fig. 314. Case I. Hydatid cyst in left lobe of liver. Intravenous pyelogram showing displacement and distortion of the left renal pelvis. The upper calices are compressed. The lower and middle caliees are obliterated owing to pressure.
of a Jaffa orange was palpable in the left h y p o c h o n d r i u m . Preliminary X - r a y examination did not reveal any renal enlargement. Intravenous pyelography (Fig. 314) showed some medial displacement and distortion of the left renal pelvis. T h e u p p e r calices were seen to be compressed. T h e middle and lower calices were not outlined : this p r e s u m a b l y being due to pressure. Barium meal examination s h o w e d indentation of the stomach by the mass, which was lying to the outer side of the mid-portion of the greater curvature. At operation a large hydatid cyst (confirmed histologically) was found in the left lobe of the liver and almost completely s u r r o u n d e d by the latter. T h e Casoni test was negative. T h e patient had lived in South Africa until the age of three, Case 2 (F. H. F / z i ) . - - F i v e weeks' history of aching pain u n d e r the right lower ribs, m o s t severe posteriorly. O n admission to hospital her temperature was io3.4 ° F. T h e r e were no renal s y m p t o m s . O n examination there was tenderness in the right h y p o c h o n d r i u m with some resistance in the right loin. Preliminary X - r a y examination demonstrated p o o r definition of the right renal outline. T h e psoas outline could not be seen on the right
DISPLACEMENT
OF
KIDNEY
BY
LESIONS
243
side. Intravenous pyelography (Fig. 3z,5) showed compression and distortion of the pelvis and calices of the right kidney. Aspiration was performed and a quantity of pus obtained from a large right-sided perinephric abscess.
Case 3 (A. L. F/45).--Three days' history of left-sided pain. On examination there was a large spleen. Preliminary X-ray examination revealed a high renal shadow, intravenous pyelography (Fig. 316) showed upward displacement and compression of the left renal pelvis and calices, particularly the lower and middle groups which were obliterated by pressure. Case 4 (M. JR. F/49).--Three and a half years' history of a steadily growing tumour in the left side of the abdomen. The patient began to lose weight and to develop attacks of morning drowsiness. Intravenous
I
?
Fig. 315.--Case 2. Perinephric abscess, Intravenous pyelogram showing typical compressionand distortion of right renal pelvis and calices, pyelography (Fig. 317) showed downward displacement of the left kidney with distortion of the renal pelvis and the upper and middle calices. Laparotomy was performed and a large retroperitoneaI turnout found. The hypersomnic attacks became more frequent and the tumour continued to swell. Further laparotomy 2½ years later showed an enormous cystic swelling lying behind the transverse colon and mesocolon. The tumour was thought to have arisen from the pancreas. On section it was thought to be a h~emangioblastoma.
Case 5 (W. P. M/57).--One month's history of a continuous aching pain in the left side of the abdomen. Varicose veins were present in both legs. The abdomen gradually became distended. Retrograde pyelography (Fig. 318) showed that the left renal pelvis and ureter were displaced to the right of the spine. The pelvis lay at the level of the 4th lumbar vertebra and was rotated and compressed. There was flattening of the upper major calix. At operation a large retroperitoneal sarcoma showing myxomatous degeneration was found in close relationship to the upper pole of the left kidney, grossly displacing it.
DISCUSSION I n each o f t h e s e five cases t h e r e is d i s t o r t i o n of t h e renal pelvis a n d calices d u e to direct p r e s s u r e f r o m an e x t r a r e n a l s p a c e - o c c u p y i n g lesion. I n four cases t h e lesion involves t h e left side,
244
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
i i.d"
Fig. 3 I6.--Case 3. Enlarged spleen. Intravenous pyelogram showing upward displacement and compression of the renal pelvis and calices, particularly the lower and middle groups which are obliterated by pressure.
Fig. 317.--Case 4.
Haemangioblastoma. Intravenous pyelogram showing displacement and distortion of the left renal pelvis and upper and middle calices.
DISPLACEMENT
OF
KIDNEY
BY
LESIONS
245
suggesting that in view of its anatomical situation the left kidney is more prone to pressure distortion from such causes. It is interesting to note that in three out of these four cases there is also displacement of the kidney. Shambaugh (i936) has observed that when the left kidney is displaced
Fig. 3~8.--Case 5. Retroperitoneal sarcoma. Retrograde pyelogram showing gross displacement of the left ureter and renal pelvis downwards and to the right of the spine. T h e pelvis lies at the level of the 4th lumbar vertebra and is rotated and compressed sightly. T h e r e is flattening of the u p p e r major calix.
by a mass in the abdomen the tumour usually proves to be extraperitoneal. In two of the last three cases noted above (Cases 4, 5) the tumour is found to be extraperitoneal. SUMMARY Five cases are presented to draw attention to the fact that extrarenal space-occupying lesions can produce not only displacement but also distortion of the renal pelvis and calices. This is particularly evident on the left side because of its anatomical relations.
Acknowledgements.--Cases x, 2, 4 were noted in the X-ray Department, Manchester Royal Infirmary, and Cases 3, 5 in the X-ray Department, St. Thomas's Hospital, S.E.r. I wish to thank Dr. E. D. Gray, Director, X-ray Department, Manchester Royal Infirmary, and Dr. J. W. McLaren, Director, X-ray Department, St. Thomas's Hospital, for permission to publish these cases and also for their helpful advice in preparing this paper. REFERENCE SHAMBAUGH,
P. (1936), Radiology, 26, 335.
JOURNAL
DISTORTION
OF
THE
FACULTY
OF
RADIOLOGISTS
AND DISPLACEMENT OF THE RENAL CALICES BY EXTRARENAL LESIONS
PELVIS
AND
BY J. O. Y. COLE, M . D . , D . M . R . E . RADIOLOGIST~ N.~vV. HOSPITALS AREA, LONDONDERRY,
N. IRELAND
IT is well known that displacement of the kidney may be produced by both extra- and intrarenal space-occupying lesions. It is generally assumed, however, that distortion of the renal pelvis and calices is caused by intrarenal lesions only. Five cases are described to show that extrarenal lesions can produce distortion as well as displacement of the renal pelvis and calices. CASE
REPORTS
Case I (H. K. F / z 8 ) . - - T w o years' history of a swelling in the left hypochondrium which had lately become larger prior to admission to hospital. There were no renal symptoms. A smooth ovoid mass about the size
Fig. 314. Case I. Hydatid cyst in left lobe of liver. Intravenous pyelogram showing displacement and distortion of the left renal pelvis. The upper calices are compressed. The lower and middle caliees are obliterated owing to pressure.
of a Jaffa orange was palpable in the left h y p o c h o n d r i u m . Preliminary X - r a y examination did not reveal any renal enlargement. Intravenous pyelography (Fig. 314) showed some medial displacement and distortion of the left renal pelvis. T h e u p p e r calices were seen to be compressed. T h e middle and lower calices were not outlined : this p r e s u m a b l y being due to pressure. Barium meal examination s h o w e d indentation of the stomach by the mass, which was lying to the outer side of the mid-portion of the greater curvature. At operation a large hydatid cyst (confirmed histologically) was found in the left lobe of the liver and almost completely s u r r o u n d e d by the latter. T h e Casoni test was negative. T h e patient had lived in South Africa until the age of three, Case 2 (F. H. F / z i ) . - - F i v e weeks' history of aching pain u n d e r the right lower ribs, m o s t severe posteriorly. O n admission to hospital her temperature was io3.4 ° F. T h e r e were no renal s y m p t o m s . O n examination there was tenderness in the right h y p o c h o n d r i u m with some resistance in the right loin. Preliminary X - r a y examination demonstrated p o o r definition of the right renal outline. T h e psoas outline could not be seen on the right
DISPLACEMENT
OF
KIDNEY
BY
LESIONS
243
side. Intravenous pyelography (Fig. 3z,5) showed compression and distortion of the pelvis and calices of the right kidney. Aspiration was performed and a quantity of pus obtained from a large right-sided perinephric abscess.
Case 3 (A. L. F/45).--Three days' history of left-sided pain. On examination there was a large spleen. Preliminary X-ray examination revealed a high renal shadow, intravenous pyelography (Fig. 316) showed upward displacement and compression of the left renal pelvis and calices, particularly the lower and middle groups which were obliterated by pressure. Case 4 (M. JR. F/49).--Three and a half years' history of a steadily growing tumour in the left side of the abdomen. The patient began to lose weight and to develop attacks of morning drowsiness. Intravenous
I
?
Fig. 315.--Case 2. Perinephric abscess, Intravenous pyelogram showing typical compressionand distortion of right renal pelvis and calices, pyelography (Fig. 317) showed downward displacement of the left kidney with distortion of the renal pelvis and the upper and middle calices. Laparotomy was performed and a large retroperitoneaI turnout found. The hypersomnic attacks became more frequent and the tumour continued to swell. Further laparotomy 2½ years later showed an enormous cystic swelling lying behind the transverse colon and mesocolon. The tumour was thought to have arisen from the pancreas. On section it was thought to be a h~emangioblastoma.
Case 5 (W. P. M/57).--One month's history of a continuous aching pain in the left side of the abdomen. Varicose veins were present in both legs. The abdomen gradually became distended. Retrograde pyelography (Fig. 318) showed that the left renal pelvis and ureter were displaced to the right of the spine. The pelvis lay at the level of the 4th lumbar vertebra and was rotated and compressed. There was flattening of the upper major calix. At operation a large retroperitoneal sarcoma showing myxomatous degeneration was found in close relationship to the upper pole of the left kidney, grossly displacing it.
DISCUSSION I n each o f t h e s e five cases t h e r e is d i s t o r t i o n of t h e renal pelvis a n d calices d u e to direct p r e s s u r e f r o m an e x t r a r e n a l s p a c e - o c c u p y i n g lesion. I n four cases t h e lesion involves t h e left side,
244
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
i i.d"
Fig. 3 I6.--Case 3. Enlarged spleen. Intravenous pyelogram showing upward displacement and compression of the renal pelvis and calices, particularly the lower and middle groups which are obliterated by pressure.
Fig. 317.--Case 4.
Haemangioblastoma. Intravenous pyelogram showing displacement and distortion of the left renal pelvis and upper and middle calices.
DISPLACEMENT
OF
KIDNEY
BY
LESIONS
245
suggesting that in view of its anatomical situation the left kidney is more prone to pressure distortion from such causes. It is interesting to note that in three out of these four cases there is also displacement of the kidney. Shambaugh (i936) has observed that when the left kidney is displaced
Fig. 3~8.--Case 5. Retroperitoneal sarcoma. Retrograde pyelogram showing gross displacement of the left ureter and renal pelvis downwards and to the right of the spine. T h e pelvis lies at the level of the 4th lumbar vertebra and is rotated and compressed sightly. T h e r e is flattening of the u p p e r major calix.
by a mass in the abdomen the tumour usually proves to be extraperitoneal. In two of the last three cases noted above (Cases 4, 5) the tumour is found to be extraperitoneal. SUMMARY Five cases are presented to draw attention to the fact that extrarenal space-occupying lesions can produce not only displacement but also distortion of the renal pelvis and calices. This is particularly evident on the left side because of its anatomical relations.
Acknowledgements.--Cases x, 2, 4 were noted in the X-ray Department, Manchester Royal Infirmary, and Cases 3, 5 in the X-ray Department, St. Thomas's Hospital, S.E.r. I wish to thank Dr. E. D. Gray, Director, X-ray Department, Manchester Royal Infirmary, and Dr. J. W. McLaren, Director, X-ray Department, St. Thomas's Hospital, for permission to publish these cases and also for their helpful advice in preparing this paper. REFERENCE SHAMBAUGH,
P. (1936), Radiology, 26, 335.