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A Case of Large Solitary Cyst of Kidney
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A CASE OF LARGE SOLITARY CYST OF KIDNEY MORRIS JOSEPH Passaic General Hospital
Received for publication October 17, 1926
Large solitary cysts of the kidney are quite rare and after carefully reviewing the literature on the subject I find the following case of such a nature as being worthy of record. It is seldom that the differential diagnosis of solitary cyst of the kidney is accurately made. In this case the complete absence of urinary complaint, the age of the patient, the probable duration of the trouble and the general examination would hardly have made one susp1c10us. Perhaps it was fortunate also as it would have been impossible to penetrate the affected ureter with a catheter without harm in attempting a cystoscopic examination. Further, had a kidney diagnosis been made and an exploration been attempted posteriorly it would have been utterly impossible to deliver a tumor of this magnitude intact. In attempting to deliver large renal cysts the records show that they were usually ruptured. As this was such an excellent specimen I felt it worth while preserving. M. A., aged seventy, female, white. Patient was admitted to the Passaic General Hospital July 5, 1926, complaining of rather severe pain and a mass in right abdomen. Her past history is negative aside from the diseases of childhood. She first noticed this trouble about three years ago when she was treated by her family physician, Dr. F. T. Van Urk, and after a short time felt better. She was comparatively free from symptoms after this attack until one week before admission when she was again seized with pains in the right abdomen, beginning under the right costal margin and radiating to the lower quadrant. The pains were severe and increased steadily since the first day. She was referred to the hospital with a diagnosis of ovarian cyst. She had her menopause 245
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many years ago and has had no urinary or gastrointestinal trouble of any kind. Physical examination shows a small, rather emaciated elderly woman. The mucous membranes are fair in color. The skin is wrinkled and dry. The tongue is coated, most of the teeth missing. Pupillary reflexes normal. No glandular enlargement. The heart sounds are clear and regular and of good quality. The lungs are clear, no rales present. There is no oedema of the extremities. The abdomen is distinctly distended over the entire right side with a large hard tumorlike mass, fairly mobile but painful when manipulated. It is a smooth, rounded mass extending almost from the costal margin above to within 3 fingers breadth above the pelvis and to the midline, throughout its entire length. The percussion note over the entire mass is flat. The left abdomen is entirely free from any tenderness or mass and is quite flaccid and easily palpable. Vaginal examination shows a small uterus, atrophied cervix, the adenxae could not be felt. Pressure in the right fornix causes pain. The temperature is 98.3°F., pulse 110. The urine shows a medium cloud of albumin, an occasional hyaline cast, some epithelium, many pus cells, otherwise negative. The sp. gr. is 1022. The white blood count is 9000. Small lymphocytes 10 per cent, large lymphocytes 25 per cent, polynuclear neutrophiles 60 per cent, eosinophiles 3 per cent, basophiles 4 per cent. Preoperative diagnosis. Ovarian cyst with twisted pedicle. Operation. A right pararectus incision about 12 inches long was made under spinai anesthesia (neocaine). The uterus and adnexae, likewise the abdominal viscera showed no relation to the tumor. Some dark brownish fluid was present in the peritoneal cavity. It was evident that we were dealing with a kidney tumor. The posterior peritoneum was opened and the tumor shelled out. It revealed a large cyst, about the size of a small watermelon. On its surface could be seen a flat, ribbon-like atrophied ureter. This was ligated. The kidney pedicle was doubly ligated and the tumor removed intact. There was only a semblance of kidney cortex at the extreme upper pole otherwise it was a large solitary cyst. Palpation of the left kidney revealed a round, smooth cyst of the lower pole about the size of a small orange. This was not disturbed. A cigarette drain was inserted to the right kidney bed and the wound closed. The patient made an uneventful recovery, the wound healing by first intention except for the serum which drained through the opening for
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about a week. She had no urinary difficulty after the operation and the phenolphathalein test showed 1st hr. 24 per cent; 2d hr. 11 per cent. She was discharged as cured on July 26, 1926-19 days after the operation. Her general condition was excellent.
The pathological report shows a large solitary cyst of the kidney with very little atrophied cortex at the upper pole. The tumor weighed 6 pounds, 11 ounces; was 10¾ inches long, 8 inches broad, 5 inches deep. The specimen was preserved without examining its contents.
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A CASE OF LARGE SOLITARY CYST OF KIDNEY MORRIS JOSEPH Passaic General Hospital
Received for publication October 17, 1926
Large solitary cysts of the kidney are quite rare and after carefully reviewing the literature on the subject I find the following case of such a nature as being worthy of record. It is seldom that the differential diagnosis of solitary cyst of the kidney is accurately made. In this case the complete absence of urinary complaint, the age of the patient, the probable duration of the trouble and the general examination would hardly have made one susp1c10us. Perhaps it was fortunate also as it would have been impossible to penetrate the affected ureter with a catheter without harm in attempting a cystoscopic examination. Further, had a kidney diagnosis been made and an exploration been attempted posteriorly it would have been utterly impossible to deliver a tumor of this magnitude intact. In attempting to deliver large renal cysts the records show that they were usually ruptured. As this was such an excellent specimen I felt it worth while preserving. M. A., aged seventy, female, white. Patient was admitted to the Passaic General Hospital July 5, 1926, complaining of rather severe pain and a mass in right abdomen. Her past history is negative aside from the diseases of childhood. She first noticed this trouble about three years ago when she was treated by her family physician, Dr. F. T. Van Urk, and after a short time felt better. She was comparatively free from symptoms after this attack until one week before admission when she was again seized with pains in the right abdomen, beginning under the right costal margin and radiating to the lower quadrant. The pains were severe and increased steadily since the first day. She was referred to the hospital with a diagnosis of ovarian cyst. She had her menopause 245
246
MORRIS JOSEPH
many years ago and has had no urinary or gastrointestinal trouble of any kind. Physical examination shows a small, rather emaciated elderly woman. The mucous membranes are fair in color. The skin is wrinkled and dry. The tongue is coated, most of the teeth missing. Pupillary reflexes normal. No glandular enlargement. The heart sounds are clear and regular and of good quality. The lungs are clear, no rales present. There is no oedema of the extremities. The abdomen is distinctly distended over the entire right side with a large hard tumorlike mass, fairly mobile but painful when manipulated. It is a smooth, rounded mass extending almost from the costal margin above to within 3 fingers breadth above the pelvis and to the midline, throughout its entire length. The percussion note over the entire mass is flat. The left abdomen is entirely free from any tenderness or mass and is quite flaccid and easily palpable. Vaginal examination shows a small uterus, atrophied cervix, the adenxae could not be felt. Pressure in the right fornix causes pain. The temperature is 98.3°F., pulse 110. The urine shows a medium cloud of albumin, an occasional hyaline cast, some epithelium, many pus cells, otherwise negative. The sp. gr. is 1022. The white blood count is 9000. Small lymphocytes 10 per cent, large lymphocytes 25 per cent, polynuclear neutrophiles 60 per cent, eosinophiles 3 per cent, basophiles 4 per cent. Preoperative diagnosis. Ovarian cyst with twisted pedicle. Operation. A right pararectus incision about 12 inches long was made under spinai anesthesia (neocaine). The uterus and adnexae, likewise the abdominal viscera showed no relation to the tumor. Some dark brownish fluid was present in the peritoneal cavity. It was evident that we were dealing with a kidney tumor. The posterior peritoneum was opened and the tumor shelled out. It revealed a large cyst, about the size of a small watermelon. On its surface could be seen a flat, ribbon-like atrophied ureter. This was ligated. The kidney pedicle was doubly ligated and the tumor removed intact. There was only a semblance of kidney cortex at the extreme upper pole otherwise it was a large solitary cyst. Palpation of the left kidney revealed a round, smooth cyst of the lower pole about the size of a small orange. This was not disturbed. A cigarette drain was inserted to the right kidney bed and the wound closed. The patient made an uneventful recovery, the wound healing by first intention except for the serum which drained through the opening for
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about a week. She had no urinary difficulty after the operation and the phenolphathalein test showed 1st hr. 24 per cent; 2d hr. 11 per cent. She was discharged as cured on July 26, 1926-19 days after the operation. Her general condition was excellent.
The pathological report shows a large solitary cyst of the kidney with very little atrophied cortex at the upper pole. The tumor weighed 6 pounds, 11 ounces; was 10¾ inches long, 8 inches broad, 5 inches deep. The specimen was preserved without examining its contents.