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Unsuspected Adnexal Masses in Renal Transplant Recipients
0022-534 7 /82/1285-1019$02.00/0
Vol. 128, Noverr1ber
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1982 by The Williams & Wilkins Co.
UNSUSPECTED ADNEXAL MASSES IN RENAL TRANSPLANT RECIPIENTS READ VAUGHAN, SIDNEY G HENDERSON,* MATY RAHATZAD AND JOHN BARRY From the Department of Radiology, Division of Urology, Oregon Health Sciences University, Portland, Oregon
ABSTRACT
Post-transplant sonograms in 74 female recipients less than 40 years old revealed unsuspected adnexal masses in 5 (7 per cent). Sonographically, these masses were difficult to distinguish from other post-transplant fluid collections, such as lymphoceles, urinomas or abscesses and, consequently, led to further diagnostic evaluations in 4 patients. Of the adnexal masses 4 were excised surgically: 2 were hemorrhagic ovarian cysts, 1 was a follicular ovarian cyst and 1 was a paraovarian cyst. A coexisting gynecologic mass should be included in the differential diagnosis of a perinephric mass in female transplant recipients. Pre-transplant sonograms to identify or exclude occult pelvic masses in women may be of benefit in simplifying the postoperative management and minimizing unnecessary diagnostic evaluation. Ultrasonography is well established in the evaluation ofrenal transplant recipients. 1' 2 Ultrasonography is used primarily to determine the size and architecture of the allograft and to detect post-transplant complications, such as obstruction, lymphoceles, urinomas, abscesses or hematomas. 3- 5 We herein report on 5 female kidney graft recipients whose post-transplant management would have been simplified by the performance of pre-transplant sonograms to identify occult adnexal masses that were not detected on routine bimanual pelvic examination. MATERIALS AND METHODS
Between January 1, 1975 and July 1, 1981, 363 kidney transplants were performed at our university and 74 were in women <40 years old. All recipients had baseline sonograms within 48 hours of transplantation. Although formal pelvic sonograms were not done the bladder and adjacent pelvic organs were visualized frequently because of the location of the kidney graft within the true pelvis. RESULTS
Of the 74 female recipients 5 had sonolucent adnexal masses on the postoperative sonograms, including 4 in the adjacent ipsilateral adnexa and 1 in the contralateral adnexa. Further diagnostic testing, including repeat sonograms, computerized tomography (CT) and percutaneous aspiration, was necessary in 4 patients" Cases 1 to 4 eventually underwent surgical excision of the adnexal masses unrelated to the kidney graft. CASE REPORTS
Case 1. L. Mo, a 24-year-old insulin-dependent diabetic, received a cadaver kidney transplant into the right iliac fossa on July 21, 1979" A sonogram 2 days after transplantation demonstrated a normal allograft and a fluid-filled mass with internal echoes in the right adnexa (fig. 1, A). Aside from an easily reversed acute rejection episode convalescence was uneventful and the patient was discharged from the hospital 13 days after transplantation" She was rehospitalized 2 weeks later because of fever and purulent wound drainage. Ultrasonography demonstrated a thin layer of fluid around the kidney graft and the aforementioned right adnexal mass. The renal transplant was explored surgically and drained widely. The peritoneum was not entered. Ultrasonography the day after wound drainage demonstrated absence of perinephric fluid but no change in the adnexal mass. CT confirmed the presence of a large, low density Accepted for publication February 19, 1982. * Requests for reprints: Department of Diagnostic Radiology, Oregon Health Sciences University, 3181 So W. Sam Jackson Park Rd", Portland, Oregon 97201.
Fr Go 1. Case 1. A, longitudinal pelvic sonogram. B, CT scan of pelvis. Mass (M) lying posterior to bladder (B) and compressing rectum (R) was interpreted initially as pelvic abscess but at operation proved to be right hemorrhagic ovarian cyst" S, sigmoid. T, transplant. 1017
1018
VAUGHAN AND ASSOCIATES
mass in the right true pelvis (fig. 1, B). Ultrasound-directed percutaneous aspiration was unsuccessful. Because of fever, leukocytosis and kidney graft rejection an exploratory laparotomy was done 6 weeks after transplantation. A 9 X 5 X 3 cm. hemorrhagic ovarian cyst was removed. There was approximately 70 ml. blood in the cul-de-sac but no evidence of a pelvic abscess. The kidney graft was rejected. The patient refused maintenance dialysis and died on March 24, 1980.
FIG. 2. Case 2. Transverse sonogram of upper pelvis. After percutaneous aspiration of blood this complex mass was believed to be postoperative hemorrhage related to transplant (T). At operation right hemorrhagic ovarian cyst was excised. S, spine.
FIG. 3. Case 3. Longitudinal pelvic sonogram. Mixed-echo mass (M) in cul-de-sac proved to be 4 cm. follicular cyst of right ovary. B, bladder. U, uterus. V, vagina.
Case 2. J. B., a 29-year-old woman with end stage renal disease owing to glomerulonephritis, received a cadaver kidney graft on May 20, 1981. Ultrasonography 1 day after transplantation revealed a small perinephric fluid collection superior to the kidney graft and a 4 X 6 cm. sonolucent mass with internal echoes medial to the transplant (fig. 2). Percutaneous aspiration yielded 12 ml. bloody fluid and it was believed that the mass most likely represented postoperative hemorrhage. An allograft nephrectomy was done 2 days postoperatively because of renal vein thrombosis. Bimanual examination at that time disclosed a right adnexal mass. The peritoneum was entered and a 6 cm. hemorrhagic ovarian mass was excised. Case 3. A. S., a 17-year-old woman with end stage renal disease of unknown origin, received a maternal kidney graft on September 26, 1978. The sonogram following transplantation was normal. A second ultrasound examination 7 days postoperatively revealed a sonolucent mass in the right adnexa (fig. 3). Serial sonograms demonstrated the transient appearance of internal echoes within the mass. Because of irreversible rejection this kidney graft was replaced with a cadaver kidney transplant on November 14, 1978. Postoperative sonograms again revealed a sonolucent right adnexal mass. A lymphocele developed around the kidney graft and accelerated rejection led to allograft nephrectomy, at which time a 4 cm. follicular cyst of the right ovary was removed. Case 4. K. M., a 19-year-old woman, received a paternal kidney graft on May 10, 1976. Postoperative sonography demonstrated a cystic right adnexal mass (fig. 4). A prior abdominal sonogram done because of abdominal pain showed that the pelvic mass had been present before transplantation. Convalescence was uneventful and the patient was discharged from the hospital 2 weeks postoperatively with normal renal function. Exploratory laparotomy was done 4 weeks later because of a
FIG. 4. Case 4. Longitudinal pelvic sonogram. Sonolucent mass (M) compresses superior aspect of bladder (B). Mass was unchanged from preoperative scans, therefore, no further diagnostic studies were done. Eventually, 4 X 6 cm. paraovarian cyst was excised.
1019 mnal.l bowel obsizuction. A X 6 cm. cyst, un2·elated to the bowel obstruction or a.u.o,µw.,,s, was excised. Case 5. P. P., a •-vPRr-n woman with end stage renal disease secondary to pyelonephritis, received a cadaver kidney gwft into the left iliac fossa on October 28, 1980. A sonogram 48 hours after transplantation demonstrated a normal graft and a 5 cm. sonolucent mass in the region of the right adnexa (fig. 5). The patient experienced an episode of acute rejection, which was reversed easily, and the remainder of convalescence was uneventful. Serial sonograms showed no change in the pelvic mass until 9 days postoperatively when internal echoes were observed on 1 series of scans. A followup sonogram 18 days postoperatively and several subsequent scans failed to demonstrate the previous mass. The etiology of the sonolucent mass was unknown. No further diagnostic studies were done and the patient was discharged from the hospital in good condition. DISCUSSION
Ultrasound is an effective method to detect renal transplant complications, such as hematomas, lymphoceles and abscesses, which generally appear as sonolucent perinephric fluid collections. Because of their anatomic proximity to the renal graft
pre-€X1£ting adnexAf 1nasse3 I~_ay silnulate SUCb
.rrncr.v,h~
and lead to unnecessary uY>,;L,vou~ evaluation transplant period. The laxge ovarian cyst in case 1 sonograms, CT scans, attempted aspiration and, finally, to exploratory laparotomy for a presumed pelvic abscess. During the complicated postoperative course of case 2 blood aspirated from a peri.nephric mass led to a presumptive diagnosis of posttransplant hemorrhage but at operntion the mass proved to be an intraperitoneal hemorrhagic ovarian cyst. In case 4 knowledge of a pre-existing pelvic mass prevented possible confusion with other perinephric fluid collections and simplified the postoperative management. Our experience suggested that unsuspected adnexal masses may be detected in approximately 7 per cent of female transplant recipients <40 years old. Pre-transplant sonograms to identify or exclude occult pelvic masses may simplify the postoperative management, prevent confusion with transplant complications and help minimize unnecessary diagnostic evaluation. REFERENCES
1. Kurtz, A. B., Rubin, C. S., Cole-Beuglet, C., Brennan, R. E., Curtis,
2.
3.
4" 5.
J. A and Goldberg, B. B.: Ultrasound evaluation of the renal transplant. J.A.M.A., 243: 2429, 1980. Hricak, H., Toledo-Pereyra, L. H., Eyler, W.R. and Madrazo, B. L.: Role of ultrasound in renal transplantation: a review of clinical and experimental observations. Dial. Transplant., 8: 818, 1979. Coyne, S.S., Walsh, J. W., Tisnado, J., Brewer, W. H., Sharpe, A. R., Jr., Amendola, M. A., Mendez-Picon, G. and Lee, H. M.: Surgically correctable :renal transplant complications. Amer. J. Roentgen., 136: 1113, 1981. Becker, J. A. and Kutcher, R.: Urologic compiications of renal transplantation. Semin. Roentgen., 13: 341, 1978. Maklad, N. F., Wright, C. H. and Rosenthal, S. J.: Gray scale ultrnsonic appearances of renal transplant :rejection. Radiology, 131: 711, 1979. EDITORIAL COMMENT
FIG. 5. Case 5. Transverse sonogram of uppei· pelvis. Sonolucent mass (Ii,f) in right adnexa was present initially on serial postoperative sonograms. Mass resolved spontaneously 18 days postoperatively. Its etiology was unknovm and no further evaluation was done. 'J.~ transplant.
Ultrasonography is a widely used and valuable noninvasive study for the diagnosis of technical complications after renal transplantation. These data support inclusion of pelvic ultrasonography as part of the pre-transplant evaluation of women less than 40 years old. The preliminary detection of adnexal masses in such patients cannot only simplify the interpretation of post-transplant studies but also allow a corrective operation, if indicated, to be done with a diminished risk before transplantation. Andrew C. Novick Department Urology Cleveland Foundation Cleveland, Ohio
Vol. 128, Noverr1ber
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1982 by The Williams & Wilkins Co.
UNSUSPECTED ADNEXAL MASSES IN RENAL TRANSPLANT RECIPIENTS READ VAUGHAN, SIDNEY G HENDERSON,* MATY RAHATZAD AND JOHN BARRY From the Department of Radiology, Division of Urology, Oregon Health Sciences University, Portland, Oregon
ABSTRACT
Post-transplant sonograms in 74 female recipients less than 40 years old revealed unsuspected adnexal masses in 5 (7 per cent). Sonographically, these masses were difficult to distinguish from other post-transplant fluid collections, such as lymphoceles, urinomas or abscesses and, consequently, led to further diagnostic evaluations in 4 patients. Of the adnexal masses 4 were excised surgically: 2 were hemorrhagic ovarian cysts, 1 was a follicular ovarian cyst and 1 was a paraovarian cyst. A coexisting gynecologic mass should be included in the differential diagnosis of a perinephric mass in female transplant recipients. Pre-transplant sonograms to identify or exclude occult pelvic masses in women may be of benefit in simplifying the postoperative management and minimizing unnecessary diagnostic evaluation. Ultrasonography is well established in the evaluation ofrenal transplant recipients. 1' 2 Ultrasonography is used primarily to determine the size and architecture of the allograft and to detect post-transplant complications, such as obstruction, lymphoceles, urinomas, abscesses or hematomas. 3- 5 We herein report on 5 female kidney graft recipients whose post-transplant management would have been simplified by the performance of pre-transplant sonograms to identify occult adnexal masses that were not detected on routine bimanual pelvic examination. MATERIALS AND METHODS
Between January 1, 1975 and July 1, 1981, 363 kidney transplants were performed at our university and 74 were in women <40 years old. All recipients had baseline sonograms within 48 hours of transplantation. Although formal pelvic sonograms were not done the bladder and adjacent pelvic organs were visualized frequently because of the location of the kidney graft within the true pelvis. RESULTS
Of the 74 female recipients 5 had sonolucent adnexal masses on the postoperative sonograms, including 4 in the adjacent ipsilateral adnexa and 1 in the contralateral adnexa. Further diagnostic testing, including repeat sonograms, computerized tomography (CT) and percutaneous aspiration, was necessary in 4 patients" Cases 1 to 4 eventually underwent surgical excision of the adnexal masses unrelated to the kidney graft. CASE REPORTS
Case 1. L. Mo, a 24-year-old insulin-dependent diabetic, received a cadaver kidney transplant into the right iliac fossa on July 21, 1979" A sonogram 2 days after transplantation demonstrated a normal allograft and a fluid-filled mass with internal echoes in the right adnexa (fig. 1, A). Aside from an easily reversed acute rejection episode convalescence was uneventful and the patient was discharged from the hospital 13 days after transplantation" She was rehospitalized 2 weeks later because of fever and purulent wound drainage. Ultrasonography demonstrated a thin layer of fluid around the kidney graft and the aforementioned right adnexal mass. The renal transplant was explored surgically and drained widely. The peritoneum was not entered. Ultrasonography the day after wound drainage demonstrated absence of perinephric fluid but no change in the adnexal mass. CT confirmed the presence of a large, low density Accepted for publication February 19, 1982. * Requests for reprints: Department of Diagnostic Radiology, Oregon Health Sciences University, 3181 So W. Sam Jackson Park Rd", Portland, Oregon 97201.
Fr Go 1. Case 1. A, longitudinal pelvic sonogram. B, CT scan of pelvis. Mass (M) lying posterior to bladder (B) and compressing rectum (R) was interpreted initially as pelvic abscess but at operation proved to be right hemorrhagic ovarian cyst" S, sigmoid. T, transplant. 1017
1018
VAUGHAN AND ASSOCIATES
mass in the right true pelvis (fig. 1, B). Ultrasound-directed percutaneous aspiration was unsuccessful. Because of fever, leukocytosis and kidney graft rejection an exploratory laparotomy was done 6 weeks after transplantation. A 9 X 5 X 3 cm. hemorrhagic ovarian cyst was removed. There was approximately 70 ml. blood in the cul-de-sac but no evidence of a pelvic abscess. The kidney graft was rejected. The patient refused maintenance dialysis and died on March 24, 1980.
FIG. 2. Case 2. Transverse sonogram of upper pelvis. After percutaneous aspiration of blood this complex mass was believed to be postoperative hemorrhage related to transplant (T). At operation right hemorrhagic ovarian cyst was excised. S, spine.
FIG. 3. Case 3. Longitudinal pelvic sonogram. Mixed-echo mass (M) in cul-de-sac proved to be 4 cm. follicular cyst of right ovary. B, bladder. U, uterus. V, vagina.
Case 2. J. B., a 29-year-old woman with end stage renal disease owing to glomerulonephritis, received a cadaver kidney graft on May 20, 1981. Ultrasonography 1 day after transplantation revealed a small perinephric fluid collection superior to the kidney graft and a 4 X 6 cm. sonolucent mass with internal echoes medial to the transplant (fig. 2). Percutaneous aspiration yielded 12 ml. bloody fluid and it was believed that the mass most likely represented postoperative hemorrhage. An allograft nephrectomy was done 2 days postoperatively because of renal vein thrombosis. Bimanual examination at that time disclosed a right adnexal mass. The peritoneum was entered and a 6 cm. hemorrhagic ovarian mass was excised. Case 3. A. S., a 17-year-old woman with end stage renal disease of unknown origin, received a maternal kidney graft on September 26, 1978. The sonogram following transplantation was normal. A second ultrasound examination 7 days postoperatively revealed a sonolucent mass in the right adnexa (fig. 3). Serial sonograms demonstrated the transient appearance of internal echoes within the mass. Because of irreversible rejection this kidney graft was replaced with a cadaver kidney transplant on November 14, 1978. Postoperative sonograms again revealed a sonolucent right adnexal mass. A lymphocele developed around the kidney graft and accelerated rejection led to allograft nephrectomy, at which time a 4 cm. follicular cyst of the right ovary was removed. Case 4. K. M., a 19-year-old woman, received a paternal kidney graft on May 10, 1976. Postoperative sonography demonstrated a cystic right adnexal mass (fig. 4). A prior abdominal sonogram done because of abdominal pain showed that the pelvic mass had been present before transplantation. Convalescence was uneventful and the patient was discharged from the hospital 2 weeks postoperatively with normal renal function. Exploratory laparotomy was done 4 weeks later because of a
FIG. 4. Case 4. Longitudinal pelvic sonogram. Sonolucent mass (M) compresses superior aspect of bladder (B). Mass was unchanged from preoperative scans, therefore, no further diagnostic studies were done. Eventually, 4 X 6 cm. paraovarian cyst was excised.
1019 mnal.l bowel obsizuction. A X 6 cm. cyst, un2·elated to the bowel obstruction or a.u.o,µw.,,s, was excised. Case 5. P. P., a •-vPRr-n woman with end stage renal disease secondary to pyelonephritis, received a cadaver kidney gwft into the left iliac fossa on October 28, 1980. A sonogram 48 hours after transplantation demonstrated a normal graft and a 5 cm. sonolucent mass in the region of the right adnexa (fig. 5). The patient experienced an episode of acute rejection, which was reversed easily, and the remainder of convalescence was uneventful. Serial sonograms showed no change in the pelvic mass until 9 days postoperatively when internal echoes were observed on 1 series of scans. A followup sonogram 18 days postoperatively and several subsequent scans failed to demonstrate the previous mass. The etiology of the sonolucent mass was unknown. No further diagnostic studies were done and the patient was discharged from the hospital in good condition. DISCUSSION
Ultrasound is an effective method to detect renal transplant complications, such as hematomas, lymphoceles and abscesses, which generally appear as sonolucent perinephric fluid collections. Because of their anatomic proximity to the renal graft
pre-€X1£ting adnexAf 1nasse3 I~_ay silnulate SUCb
.rrncr.v,h~
and lead to unnecessary uY>,;L,vou~ evaluation transplant period. The laxge ovarian cyst in case 1 sonograms, CT scans, attempted aspiration and, finally, to exploratory laparotomy for a presumed pelvic abscess. During the complicated postoperative course of case 2 blood aspirated from a peri.nephric mass led to a presumptive diagnosis of posttransplant hemorrhage but at operntion the mass proved to be an intraperitoneal hemorrhagic ovarian cyst. In case 4 knowledge of a pre-existing pelvic mass prevented possible confusion with other perinephric fluid collections and simplified the postoperative management. Our experience suggested that unsuspected adnexal masses may be detected in approximately 7 per cent of female transplant recipients <40 years old. Pre-transplant sonograms to identify or exclude occult pelvic masses may simplify the postoperative management, prevent confusion with transplant complications and help minimize unnecessary diagnostic evaluation. REFERENCES
1. Kurtz, A. B., Rubin, C. S., Cole-Beuglet, C., Brennan, R. E., Curtis,
2.
3.
4" 5.
J. A and Goldberg, B. B.: Ultrasound evaluation of the renal transplant. J.A.M.A., 243: 2429, 1980. Hricak, H., Toledo-Pereyra, L. H., Eyler, W.R. and Madrazo, B. L.: Role of ultrasound in renal transplantation: a review of clinical and experimental observations. Dial. Transplant., 8: 818, 1979. Coyne, S.S., Walsh, J. W., Tisnado, J., Brewer, W. H., Sharpe, A. R., Jr., Amendola, M. A., Mendez-Picon, G. and Lee, H. M.: Surgically correctable :renal transplant complications. Amer. J. Roentgen., 136: 1113, 1981. Becker, J. A. and Kutcher, R.: Urologic compiications of renal transplantation. Semin. Roentgen., 13: 341, 1978. Maklad, N. F., Wright, C. H. and Rosenthal, S. J.: Gray scale ultrnsonic appearances of renal transplant :rejection. Radiology, 131: 711, 1979. EDITORIAL COMMENT
FIG. 5. Case 5. Transverse sonogram of uppei· pelvis. Sonolucent mass (Ii,f) in right adnexa was present initially on serial postoperative sonograms. Mass resolved spontaneously 18 days postoperatively. Its etiology was unknovm and no further evaluation was done. 'J.~ transplant.
Ultrasonography is a widely used and valuable noninvasive study for the diagnosis of technical complications after renal transplantation. These data support inclusion of pelvic ultrasonography as part of the pre-transplant evaluation of women less than 40 years old. The preliminary detection of adnexal masses in such patients cannot only simplify the interpretation of post-transplant studies but also allow a corrective operation, if indicated, to be done with a diminished risk before transplantation. Andrew C. Novick Department Urology Cleveland Foundation Cleveland, Ohio