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Pararenal Pseudocyst
Vol. 97, JI/far.
THB JOURNAL OF UROLOGY
Copyright @) 1967 by The Williams & Wilkins Co.
Pn'.nteri
U)3.11c
P ARARENAL PSEUDOCYST HENRY C. HUDSON From the
AND
RUBE R. HUNDLEY
of Urology, Carraway Methodist Hospital, n1,rm·iri.lrnam Alabama
Cystic structures occurring in close relation to the kidney and its are rare and their classification is obscure. Excellent articles have been published using various terms to describe these structures and their occurrences. Most pseudocysts in the renal fossa are a result of trauma, either accidental or an operative complication. In reports in the literature cases of pseudocysts resulting from an accident outnumber those resulting from postoperative complications. The purpose of this article is to: 1) report 2 cases of pararenal pseudocyst occurring as post-operative complications of pyelolithotomies, 2) present a brief review of this relatively new entity and 3) illustrate a more conservative approach to treatment when the condition is detected early. CASJ~ 'REPORTS
Case 1. A 53-year-old white woman was admitted to Carraway Methodist Hospital on August 23, 1963 with an upper respiratory infection. There were no genitourinary tract complaints. The past medical history was noncontributory and included only three previous hospital admissions: 1) pneumonia in 1958, 2) excision of thumbnail in 1956, 3) hysterectomy in 1950. The family history revealed no previous genitourinary tract abnormalities. Physical examination revealed a normotensive white woman with no positive findings except those of a routine upper respiratory infection. On excretory urography a l cm. calculus in the left infundibulum and an enlarged left lower pole of the kidney were noted. A left retrograde pyelogram revealed a large left lower pole with compression of the middle and lower calyces. The re-mainder of the diagnostic study was negative. A urinalysis was negative. On September 6 a left pyelolithotomy was done and a cyst was removed from the lower pole through a left anterior subcostal incision. The single cyst arose from the lower pole without any connection being found to the calyceal system. The cyst dome was excised and a defect in the lower pole of the kidney was closed with interrupted deep vertical mattress 0 chromic sutures tied over oxycel gauze. The Accepted for publication April 5, 1966.
calculus was removed with curved stone through a 2 cm. vertical incision in the left pelvis. The incision in the pelvis was cloRed with interrupted No. 4-0 chromic sutures and penrenal fat was sutured over the incision. The ureter was not splinted. A Penrose drain was put in Gerota's fascia and brought out through 1,he most lateral part of the incision. Convalescence was uncomplicated; the drain and sutures were removed in 8 days. On September 17 an urogram revealed some extravasation of dye out. side the left renal pelvis (fig. 1, The was discharged from the hospital 9 operatively. She was seen in the office on October 7 at which time she complained of pain 2 or 3 in dura. tion in the area of the incision. Physical examination revealed only tenderness in the site of the left upper quadrant of the abdomen but no masses could be palpated. Urinalysis showed 10 tu 15 white blood cells per low power field. The patient was afebrile. Complete blood counl, creatinine and blood urea nitrogen (BUN) were all normal. On October 13 the patient was readmitted to the hospital because of the m the left flank and a bulging, palpable mass abnul grapefruit size in this area. The patient was afebrile and the urine culture was negative. AJJ excretory urogram revealed left a soft tissue shadow in the left flank slightly below the level of the left iliac cre8t 1, B). On October 15, with the patient under heavy sedation and with the aid of local novocain anesthesia, a stab wound was made over the bulging mass in the most fluctuant part in tlie left posterior lateral flank area. This revealed about 300 to 400 cc of straw-colored fluid, non. odorous and negative on culture. A Penrose drain was placed through the stab wound, down toward the lower pole of the kidney and sutured in A No. 6 ureteral catheter ,ms passed cystoscop"" ically up the left ureter without difficulty and .left in the left renal pelvis, exiting through the urethra. along with a No. 16 Foley catheter in the bladdeL A retrograde pyelogram revealed extravasation of dye from the pelvis (fig. 2, A.). Urine drained from
440
HUDSON AND HUNDLEY
Fm. 1
Fm. 2
the left flank and also from the ureteral catheter. Both catheters were removed 11 days postoperatively and 14 days postoperatively there was no drainage, no pain and the patient was still afebrile. She was discharged from the hospital 15
days postoperatively. She was followed every 2 weeks in the office and continued to be free of pain and drainage without any mass palpated in the left flank area. An excretory urogram on May 22, 1964 revealed bilateral function in 5 minutes.
PARARENAL PSEUDOCYST
Drainage was excellent on the right and good on the left side. Very little to no calycectasis was noted on the left (fig. 2, B). The urine culture was still negative. The patient's last visit to the office was in December 1964, at which time she was still asymptomatic and a urinalysis was negative. Case 2. A 30-year-old white woman was admitted to Carraway Methodist Hospital on October 17, 1960, with intermittent left flank pain, 1 month in duration. There were no lower urinary tract complaints. The past medical history was non-contributory as was the family history. Physical examination revealed tenderness in the left flank to palpation and percussion. No masses were palpated. There was no fever. An occasional red and white blood cell per low power field was noted. A negative urine culture was obtained. An excretory urogram revealed good function bilaterally, but a buckshot size stone was seen in the left superior calyx. The patient continued to have pain. On October 18 a left pyelolithotomy was done through a left anterior subcostal incision. A 2 cm. vertical incision was made in the left renal pelvis anteriorly and using the stone forceps the stone was removed from the superior calyx without any difficulty. The incision was closed with continuous 4-0 chromic suture and fat was sutured over the incision. A Penrose drain was left in Gerota's fascia and the ureter
441
was not splinted. Convalescence was uncomplicated and the patient was discharged on October 26 in good condition. The incision looked good and was not tender. No masses were palpated. The next clinic visit was on December 6 at which time the patient complained of pain in the left flank, 7 to 10 days in duration. She had also noticed swelling in the left flank and abdomen several days in duration. Examination revealed a large mass, at least grapefruit size, in the left upper quadrant. The mass was not tender; it felt hard and was not movable. BUN and creatinine were within normal limits. The patient was scheduled for an excretory urogram but instead she went to another hospital and another urologist. At the other hospital an excretory urogram revealed poor and delayed function of the left kidney with marked pyelectasis and calycectasis. A soft tissue mass could be seen at the lower pole of the left kidney extending down over the ileum (fig. 3, A). A retrograde pyelogram was made (fig. 3, B and C). On December 14 the patient had a left nephrectomy without complications. According to the operative note a large cyst arose from the vicinity of the left lower renal pole and measured about 30 cm. in diameter, occupying most of the left abdomen and part of the left lower quadrant. The cyst was drained of straw-colored fluid. Microscopic description of the cyst wall revealed
FIG, 3
HUDSON AND HUNDLEY
442
sparsely infiltrated lymphocytes and dense collagen tissue. DISCUSSION
The entity of cyst collection of serous or urinelike fluid in the region of the kidney and its pelvis is unusual. Crabtree reviewed the literature from Hawkin's first report of this entity in 1834 to his own 3 cases in 1935.1· 2 Included in his series were 23 cases, the last three of which were his own cases. Crabtree's article greatly helped to clarify the pathogenesis and established this condition as an entity. In 1952 Spriggs reviewed and classified cases of perinephric cysts: 1) perinephric extravasation of urine, 2) perinephric hematoma, 3) perinephric cyst of doubtful origin.a Thompson believes the simplest grouping of cysts of the renal region would be encompassed by the terms renal, pararenal, and perinephric, 4 pararenal cyst being best defined as divorced from the renal parenchyma and capsule, yet so closely associated with the capsule that differentiation cannot be made. The entity of pararenal pseudocyst formed from extravasated urine has not been reported very often in the literature. Pyrah and Smiddy reported 2 cases of pararenal pseudohydronephrosis. 5 In one patient this developed following an operation on the ureteropelvic junction. Sauls and Nesbit reported 4 cases. 6 Three cases were postoperative complications (1 pyeloplasty, 1 pyelolithotomy, 1 ureterolithotomy) and the other case was secondary to accident trauma. Arduino and associates reported 1 case following a ureteropyeloplasty. 7 Some of the confusion about this entity is illustrated in the terms pseudohydronephrosis, perirenal cyst, perinephric cyst and hydrocele renalis used in the literature. On the matter of etiological derivation most authors have related this entity to trauma. Of the 1 Crabtree, E. G.: Pararenal pseudo-hydronephrosis with report of 3 cases. Tr. Amer. Ass. G.U. Surg., 28: 9, 1935. 2 Hawkins: Cited by Crabtree. 1 3 Spriggs, A. I.: Perinephric cysts. J. Urol., 67:
414, 1952.
4 Thompson, I. M.: Peripelvic lymphatic renal cysts. J. Urol., 78: 343, 1957. 5 Pyrah, L. N. and Smiddy, F. G.: Pararenal pseudo-hydronephrosis: A report of 2 cases. Brit. J. Urol., 25: 239, 1953. 6 Sauls, C. L. and Nesbit, R. M.: Pararenal pseudocysts: A report of 4 cases. J. Urol., 87: 288-
296, 1962.
7 Arduino, L. J., Perlstein, G. B., Jr. and Glucksman, M.A.: Pararenal pseudocysts. Amer. J. Surg., 103: 758-760, 1962.
23 cases reviewed by Crabtree1 all were secondary to trauma except one reported by Block in 1932,8 which was a result of pelvic rupture secondary to a pelvic stone. Crabtree listed several important factors involved as probable etiological factors: 1) laceration of the cortex extending into the calyx, pelvis or ureter with fragmentation of calyx and/ or ureteral tear, 2) failure of original injury to heal before urine extravasation, and 3) ureteral obstruction, either already present or constriction of ureter by tissue reaction.1 An important predisposing cause in this condition is urinary obstruction, existing before the time of injury, as a rupture of hydronephrotic kidney or resulting from injury itself. Several case reports have been attributed to congenital urinary tract obstruction. Pautler and Garvey reported 1 case in a 15month-old boy with congenital perinephric cyst. 9 They felt this fitted into Spriggs first grouping of "perinephric extravasation of urine". 3 In this case there was no history of trauma but there was urinary tract obstruction resulting in a fistula between hydronephrotic and perinephric cavities. Spriggs reviewed 2 cases occurring in newborns which he classified as perinephric cyst of doubtful origin.a Neither patient had a history of trauma but did have perinephric cysts, one from congenital ureteral stenosis. He felt that most of these cases were due to organizing hematoma and/or serous perinephric effusion. Most cases reported in the literature prior to 1961 have been secondary to accidental trauma. Our 2 case reports and 3 cases previously referred to in this paper were complications following an upper ureteral or renal pelvis operation. The most common finding noted in our review of the literature has been a mass on the affected side, slight tenderness, little fever, pain and usually negative urine. Time of onset has varied from days to years. One of the patients reported by Sauls and Nesbit 6 had a pyelolithotomy, did well for 2 years and then came back to the hospital complaining of intermittent flank pain. Right renal exploration revealed a large pararenal pseudocyst. Both of our patients had the classical symptoms previously outlined. Both had flank masses, both were afebrile, both had moderate pain and both had negative urine. In the first Block, W.: Cited by Crabtree. 1 Pautler, E. E., Jr. and Garvey, F. K.: Perinephric cyst: Report of case associated with ureteropelvic occlusion and congenital hydronephrosis. J. Urol., 70: 840, 1953. 8
9
PARARENAL PSEUDOCYST
patient a mass developed about 5 weeks postoperatively and in the second patient a mass developed 2 weeks postoperatively, both following uncomplicated pyelolithotomies. In figure 1, A there is extravasation of from the renal pelvis into the perirenal area,. This extravasation was confirmed by ,,,,1-.rnoT,ir! pyelography even though it was done after the cyst was drained. In case 2 retrograde pyelography did not show extravasation of dye or communication between the pelvis and cyst. ),rduino and associates demonstrated in their case report a connection between the cystic mass and the renal pelvis. 6 DIAGNOSIS AND ·TREATMENT
T'he diagnosis of pararenal pseudocysts should noi; be difficult in who have had an operation on or experienced trauma to the upper urinary tract collecting system. Particularly is this true when the previously discussed findings are apparent. Early diagnosis and treatment are extremely important before there is irreversible renal damage. 4, cases of pararenal Sauls and Nesbit cyst, three of which were complications of an operation to the renal pelvis or upper ureter. 6 Their first case was ,~,a~-vHuM to ii, pyeloplasty; on exploration severe renal damage was noted necessitating a nephrec tomy. The second case occurred after a pyelolithotomy and had open surgical ureterolysis and drainage followed by an intubated ureterostomy utilizing a red rubber T-tube for 6 weeks. Retrograde pyelography 3 months later showed much less hydronephrosis. Their third case occurred following uretero., Mhotomy and was surgically drained twice, but continued to show extravasation of dye from the upper ureter until indwelling ureteral catheter
drainage was established. The Arduino and associates ,rns treated only 1Yith indwelling ureteral catheter for wceks, 7 One year later vealed only minimal hydronephrosis on Uie affected side. Our case 1 demonstrates simiht! conservative management. VI" e believe that indwelling ureteral catheter is nece"sary to insun, proper drainage and intercept further tions. In the past year I have not splinted ureterolithotomies with an catheter unless undue trauma occurred to the ureter or pelvis during the operation. The herein reported are the only ones encountered operative complications in the 15 years of urological practice. Our case 1 had positive extravasation of urine without a definite con.munication. ·with this in mind we feel that renal flank drainage and indwelling ureteni.l. catheter drainage are of paramount importance preventing recurrence of extrarenal accumulation of urine and renal damage, and that early sis and conservative treatment of this before irreversible renal damage occurs, n1ay pre. serve a functioning kidney. SUMMARY
Two cases of pararenal pseudocyst renal pelvic operations have been presented. One patient was treated successfully with conservsi,ive management; the other patient went to anotLw1· hospital and was treated by nephrectomy. To our knowledge these are the sixth and seventh tcase,i occurring as postoperative complications. A plea, is made for a more conservative ap. proach in the management of pararenal cyst. brief summary of the literature is ,wno,m,·orl with comments.
THB JOURNAL OF UROLOGY
Copyright @) 1967 by The Williams & Wilkins Co.
Pn'.nteri
U)3.11c
P ARARENAL PSEUDOCYST HENRY C. HUDSON From the
AND
RUBE R. HUNDLEY
of Urology, Carraway Methodist Hospital, n1,rm·iri.lrnam Alabama
Cystic structures occurring in close relation to the kidney and its are rare and their classification is obscure. Excellent articles have been published using various terms to describe these structures and their occurrences. Most pseudocysts in the renal fossa are a result of trauma, either accidental or an operative complication. In reports in the literature cases of pseudocysts resulting from an accident outnumber those resulting from postoperative complications. The purpose of this article is to: 1) report 2 cases of pararenal pseudocyst occurring as post-operative complications of pyelolithotomies, 2) present a brief review of this relatively new entity and 3) illustrate a more conservative approach to treatment when the condition is detected early. CASJ~ 'REPORTS
Case 1. A 53-year-old white woman was admitted to Carraway Methodist Hospital on August 23, 1963 with an upper respiratory infection. There were no genitourinary tract complaints. The past medical history was noncontributory and included only three previous hospital admissions: 1) pneumonia in 1958, 2) excision of thumbnail in 1956, 3) hysterectomy in 1950. The family history revealed no previous genitourinary tract abnormalities. Physical examination revealed a normotensive white woman with no positive findings except those of a routine upper respiratory infection. On excretory urography a l cm. calculus in the left infundibulum and an enlarged left lower pole of the kidney were noted. A left retrograde pyelogram revealed a large left lower pole with compression of the middle and lower calyces. The re-mainder of the diagnostic study was negative. A urinalysis was negative. On September 6 a left pyelolithotomy was done and a cyst was removed from the lower pole through a left anterior subcostal incision. The single cyst arose from the lower pole without any connection being found to the calyceal system. The cyst dome was excised and a defect in the lower pole of the kidney was closed with interrupted deep vertical mattress 0 chromic sutures tied over oxycel gauze. The Accepted for publication April 5, 1966.
calculus was removed with curved stone through a 2 cm. vertical incision in the left pelvis. The incision in the pelvis was cloRed with interrupted No. 4-0 chromic sutures and penrenal fat was sutured over the incision. The ureter was not splinted. A Penrose drain was put in Gerota's fascia and brought out through 1,he most lateral part of the incision. Convalescence was uncomplicated; the drain and sutures were removed in 8 days. On September 17 an urogram revealed some extravasation of dye out. side the left renal pelvis (fig. 1, The was discharged from the hospital 9 operatively. She was seen in the office on October 7 at which time she complained of pain 2 or 3 in dura. tion in the area of the incision. Physical examination revealed only tenderness in the site of the left upper quadrant of the abdomen but no masses could be palpated. Urinalysis showed 10 tu 15 white blood cells per low power field. The patient was afebrile. Complete blood counl, creatinine and blood urea nitrogen (BUN) were all normal. On October 13 the patient was readmitted to the hospital because of the m the left flank and a bulging, palpable mass abnul grapefruit size in this area. The patient was afebrile and the urine culture was negative. AJJ excretory urogram revealed left a soft tissue shadow in the left flank slightly below the level of the left iliac cre8t 1, B). On October 15, with the patient under heavy sedation and with the aid of local novocain anesthesia, a stab wound was made over the bulging mass in the most fluctuant part in tlie left posterior lateral flank area. This revealed about 300 to 400 cc of straw-colored fluid, non. odorous and negative on culture. A Penrose drain was placed through the stab wound, down toward the lower pole of the kidney and sutured in A No. 6 ureteral catheter ,ms passed cystoscop"" ically up the left ureter without difficulty and .left in the left renal pelvis, exiting through the urethra. along with a No. 16 Foley catheter in the bladdeL A retrograde pyelogram revealed extravasation of dye from the pelvis (fig. 2, A.). Urine drained from
440
HUDSON AND HUNDLEY
Fm. 1
Fm. 2
the left flank and also from the ureteral catheter. Both catheters were removed 11 days postoperatively and 14 days postoperatively there was no drainage, no pain and the patient was still afebrile. She was discharged from the hospital 15
days postoperatively. She was followed every 2 weeks in the office and continued to be free of pain and drainage without any mass palpated in the left flank area. An excretory urogram on May 22, 1964 revealed bilateral function in 5 minutes.
PARARENAL PSEUDOCYST
Drainage was excellent on the right and good on the left side. Very little to no calycectasis was noted on the left (fig. 2, B). The urine culture was still negative. The patient's last visit to the office was in December 1964, at which time she was still asymptomatic and a urinalysis was negative. Case 2. A 30-year-old white woman was admitted to Carraway Methodist Hospital on October 17, 1960, with intermittent left flank pain, 1 month in duration. There were no lower urinary tract complaints. The past medical history was non-contributory as was the family history. Physical examination revealed tenderness in the left flank to palpation and percussion. No masses were palpated. There was no fever. An occasional red and white blood cell per low power field was noted. A negative urine culture was obtained. An excretory urogram revealed good function bilaterally, but a buckshot size stone was seen in the left superior calyx. The patient continued to have pain. On October 18 a left pyelolithotomy was done through a left anterior subcostal incision. A 2 cm. vertical incision was made in the left renal pelvis anteriorly and using the stone forceps the stone was removed from the superior calyx without any difficulty. The incision was closed with continuous 4-0 chromic suture and fat was sutured over the incision. A Penrose drain was left in Gerota's fascia and the ureter
441
was not splinted. Convalescence was uncomplicated and the patient was discharged on October 26 in good condition. The incision looked good and was not tender. No masses were palpated. The next clinic visit was on December 6 at which time the patient complained of pain in the left flank, 7 to 10 days in duration. She had also noticed swelling in the left flank and abdomen several days in duration. Examination revealed a large mass, at least grapefruit size, in the left upper quadrant. The mass was not tender; it felt hard and was not movable. BUN and creatinine were within normal limits. The patient was scheduled for an excretory urogram but instead she went to another hospital and another urologist. At the other hospital an excretory urogram revealed poor and delayed function of the left kidney with marked pyelectasis and calycectasis. A soft tissue mass could be seen at the lower pole of the left kidney extending down over the ileum (fig. 3, A). A retrograde pyelogram was made (fig. 3, B and C). On December 14 the patient had a left nephrectomy without complications. According to the operative note a large cyst arose from the vicinity of the left lower renal pole and measured about 30 cm. in diameter, occupying most of the left abdomen and part of the left lower quadrant. The cyst was drained of straw-colored fluid. Microscopic description of the cyst wall revealed
FIG, 3
HUDSON AND HUNDLEY
442
sparsely infiltrated lymphocytes and dense collagen tissue. DISCUSSION
The entity of cyst collection of serous or urinelike fluid in the region of the kidney and its pelvis is unusual. Crabtree reviewed the literature from Hawkin's first report of this entity in 1834 to his own 3 cases in 1935.1· 2 Included in his series were 23 cases, the last three of which were his own cases. Crabtree's article greatly helped to clarify the pathogenesis and established this condition as an entity. In 1952 Spriggs reviewed and classified cases of perinephric cysts: 1) perinephric extravasation of urine, 2) perinephric hematoma, 3) perinephric cyst of doubtful origin.a Thompson believes the simplest grouping of cysts of the renal region would be encompassed by the terms renal, pararenal, and perinephric, 4 pararenal cyst being best defined as divorced from the renal parenchyma and capsule, yet so closely associated with the capsule that differentiation cannot be made. The entity of pararenal pseudocyst formed from extravasated urine has not been reported very often in the literature. Pyrah and Smiddy reported 2 cases of pararenal pseudohydronephrosis. 5 In one patient this developed following an operation on the ureteropelvic junction. Sauls and Nesbit reported 4 cases. 6 Three cases were postoperative complications (1 pyeloplasty, 1 pyelolithotomy, 1 ureterolithotomy) and the other case was secondary to accident trauma. Arduino and associates reported 1 case following a ureteropyeloplasty. 7 Some of the confusion about this entity is illustrated in the terms pseudohydronephrosis, perirenal cyst, perinephric cyst and hydrocele renalis used in the literature. On the matter of etiological derivation most authors have related this entity to trauma. Of the 1 Crabtree, E. G.: Pararenal pseudo-hydronephrosis with report of 3 cases. Tr. Amer. Ass. G.U. Surg., 28: 9, 1935. 2 Hawkins: Cited by Crabtree. 1 3 Spriggs, A. I.: Perinephric cysts. J. Urol., 67:
414, 1952.
4 Thompson, I. M.: Peripelvic lymphatic renal cysts. J. Urol., 78: 343, 1957. 5 Pyrah, L. N. and Smiddy, F. G.: Pararenal pseudo-hydronephrosis: A report of 2 cases. Brit. J. Urol., 25: 239, 1953. 6 Sauls, C. L. and Nesbit, R. M.: Pararenal pseudocysts: A report of 4 cases. J. Urol., 87: 288-
296, 1962.
7 Arduino, L. J., Perlstein, G. B., Jr. and Glucksman, M.A.: Pararenal pseudocysts. Amer. J. Surg., 103: 758-760, 1962.
23 cases reviewed by Crabtree1 all were secondary to trauma except one reported by Block in 1932,8 which was a result of pelvic rupture secondary to a pelvic stone. Crabtree listed several important factors involved as probable etiological factors: 1) laceration of the cortex extending into the calyx, pelvis or ureter with fragmentation of calyx and/ or ureteral tear, 2) failure of original injury to heal before urine extravasation, and 3) ureteral obstruction, either already present or constriction of ureter by tissue reaction.1 An important predisposing cause in this condition is urinary obstruction, existing before the time of injury, as a rupture of hydronephrotic kidney or resulting from injury itself. Several case reports have been attributed to congenital urinary tract obstruction. Pautler and Garvey reported 1 case in a 15month-old boy with congenital perinephric cyst. 9 They felt this fitted into Spriggs first grouping of "perinephric extravasation of urine". 3 In this case there was no history of trauma but there was urinary tract obstruction resulting in a fistula between hydronephrotic and perinephric cavities. Spriggs reviewed 2 cases occurring in newborns which he classified as perinephric cyst of doubtful origin.a Neither patient had a history of trauma but did have perinephric cysts, one from congenital ureteral stenosis. He felt that most of these cases were due to organizing hematoma and/or serous perinephric effusion. Most cases reported in the literature prior to 1961 have been secondary to accidental trauma. Our 2 case reports and 3 cases previously referred to in this paper were complications following an upper ureteral or renal pelvis operation. The most common finding noted in our review of the literature has been a mass on the affected side, slight tenderness, little fever, pain and usually negative urine. Time of onset has varied from days to years. One of the patients reported by Sauls and Nesbit 6 had a pyelolithotomy, did well for 2 years and then came back to the hospital complaining of intermittent flank pain. Right renal exploration revealed a large pararenal pseudocyst. Both of our patients had the classical symptoms previously outlined. Both had flank masses, both were afebrile, both had moderate pain and both had negative urine. In the first Block, W.: Cited by Crabtree. 1 Pautler, E. E., Jr. and Garvey, F. K.: Perinephric cyst: Report of case associated with ureteropelvic occlusion and congenital hydronephrosis. J. Urol., 70: 840, 1953. 8
9
PARARENAL PSEUDOCYST
patient a mass developed about 5 weeks postoperatively and in the second patient a mass developed 2 weeks postoperatively, both following uncomplicated pyelolithotomies. In figure 1, A there is extravasation of from the renal pelvis into the perirenal area,. This extravasation was confirmed by ,,,,1-.rnoT,ir! pyelography even though it was done after the cyst was drained. In case 2 retrograde pyelography did not show extravasation of dye or communication between the pelvis and cyst. ),rduino and associates demonstrated in their case report a connection between the cystic mass and the renal pelvis. 6 DIAGNOSIS AND ·TREATMENT
T'he diagnosis of pararenal pseudocysts should noi; be difficult in who have had an operation on or experienced trauma to the upper urinary tract collecting system. Particularly is this true when the previously discussed findings are apparent. Early diagnosis and treatment are extremely important before there is irreversible renal damage. 4, cases of pararenal Sauls and Nesbit cyst, three of which were complications of an operation to the renal pelvis or upper ureter. 6 Their first case was ,~,a~-vHuM to ii, pyeloplasty; on exploration severe renal damage was noted necessitating a nephrec tomy. The second case occurred after a pyelolithotomy and had open surgical ureterolysis and drainage followed by an intubated ureterostomy utilizing a red rubber T-tube for 6 weeks. Retrograde pyelography 3 months later showed much less hydronephrosis. Their third case occurred following uretero., Mhotomy and was surgically drained twice, but continued to show extravasation of dye from the upper ureter until indwelling ureteral catheter
drainage was established. The Arduino and associates ,rns treated only 1Yith indwelling ureteral catheter for wceks, 7 One year later vealed only minimal hydronephrosis on Uie affected side. Our case 1 demonstrates simiht! conservative management. VI" e believe that indwelling ureteral catheter is nece"sary to insun, proper drainage and intercept further tions. In the past year I have not splinted ureterolithotomies with an catheter unless undue trauma occurred to the ureter or pelvis during the operation. The herein reported are the only ones encountered operative complications in the 15 years of urological practice. Our case 1 had positive extravasation of urine without a definite con.munication. ·with this in mind we feel that renal flank drainage and indwelling ureteni.l. catheter drainage are of paramount importance preventing recurrence of extrarenal accumulation of urine and renal damage, and that early sis and conservative treatment of this before irreversible renal damage occurs, n1ay pre. serve a functioning kidney. SUMMARY
Two cases of pararenal pseudocyst renal pelvic operations have been presented. One patient was treated successfully with conservsi,ive management; the other patient went to anotLw1· hospital and was treated by nephrectomy. To our knowledge these are the sixth and seventh tcase,i occurring as postoperative complications. A plea, is made for a more conservative ap. proach in the management of pararenal cyst. brief summary of the literature is ,wno,m,·orl with comments.