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A Large Retroperitoneal Lipoma
Vol. 118, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
A LARGE RETROPERITONEAL LIPOMA M. P. MCCARTHY, J. D. FROGGE, ROGER DELGADO
AND
PHILIP MAC
From the Naval Regional Medical Center, Camp Pendleton, California
ABSTRACT
A 60-year-old man with an asymptomatic 11-pound retroperitoneal lipoma excised through a supine subcostal modification of the- thoracoabdominal incision is reported. Herein we report an unusual incidental finding on a screening hypertensive excretory urogram (IVP). CASE REPORT
R. E., a 60-year-old man, was asymptomatic other than for what was thought to be essential hypertension. The highest recorded blood pressure was 150/90. A screening IVP was performed. A film of the kidneys, ureters and bladder demonstrated an absence of bowel gas in the right abdomen and there appeared to be some linear radiolucencies in the right upper quadrant. Both psoas shadows were visualized clearly. The left collecting system appeared to be normal. The right kidney was displaced to the left of the midline as well as anteriorly (fig. 1, A and B). A cystogram showed 2 normally located ureteral orifices and a right bulb pyelogram showed a non-obstructed right ureter that crossed the midline at L5. Physical examination revealed blood pressure 150/90 and
men on the right side, which crossed the midline extending to the left of the aorta. A venacavogram showed medial displacement of the vena cava without evidence of intrinsic involvement. Aortography demonstrated displacement of the aorta to the left and a right renal artery that had a normal origin but turned acutely to the left and crossed the midline. No distinct tumor vessels were identified (fig. 1, C). The mass was approached through a supine subcostal modification of the thoracoabdominal incision. A large fatty-appearing mass occupied the majority of the abdominal cavity (fig. 2, A). Biopsy revealed a lipoma. The left kidney and ureter were freed from the mass, which was excised. The mass filled a wash basin and weighed 11 pounds. A right nephropexy was performed. The postoperative course was marked by a low grade fever up to lOlF that lasted for 48 hours and cleared spontaneously. A mild, transient edema of the right lower extremity developed but there was no evidence ofthrom-
Fm. 1. A, preoperative film of kidneys, ureters and bladder. B, initial IVP. C, aortogram
pulse 80. The patient was afebrile. He was 71 inches tall and weighed 162 pounds. The abdomen was slightly protuberant and non-tender, and no masses were palpable. There were no varicoceles, hemorrhoids or any other varicosities. The remainder of the physical examination was within normal limits. Routine laboratory studies, urinary vanillyl mandelic acid and serum cortisol level were normal. An upper gastrointestinal series showed the stomach and C-loop to be displaced markedly to the left and anteriorly, with the majority of the bowel being displaced into the left lower quadrant. The liver scan did not show any filling defects, although the liver was displaced upwards. A bone scan was normal. Echography showed a large solid mass that filled the abdoAccepted for publication April 15, 1977. The opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Navy Medical Department at large.
bophlebitis. This ed~ma also cleared spontaneously without treatment. Blood pressure decreased initially to 130/80 but subsequently returned to the 150/90 range. A postoperative IVP demonstrated normal-appearing kidneys bilaterally (fig. 2, B). DISCUSSION
Because of the nature of the retroperitoneal space, tumors that arise there can often become quite large before causing symptoms. According to Rhamy a lipoma was reported in a 36-year-old woman who weighed 269 pounds, of which 179 pounds were lipoma!1 Reportedly, 85 per cent of all retroperitoneal tumors are malignant. 2 However, even with malignant tumors actual invasion or obstruction of surrounding tissues is relatively rare, presumably since most of these tumors are well encapsulated. According to Hinman lipomas appear to be the most common benign retroperitoneal tumors. They may originate in the perirenal fat, the mesenteric fat or in other 478
4'79
LARGE RETROPERITONEAL LIPOMA
FIG. 2. A, opening view. B, postoperative IVP
adipose tissue in the retroperitoneum. Their growth is slow and symptoms usually arise from pressure effects on adjacent organs, particularly when the patient reaches 40 or 50 years of age. 3 Lipomas, although benign, have a recurrence rate of 56 per cent. 1 The supine subcostal modification of the thoracoabdominal incision was described in 1974 by Cole and associates. 4 This incision combines the advantages of a thoracoabdominal incision, which allows for access high into the retroperitoneum beneath the diaphragm, and a transverse abdominal incision, which allows access to the great vessels, especially above the renal vessels. Cole and associates used this incision in 7 cases and most patients had a low grade fever for up to 72 hours, as in our case. This approach was ideal for our patient
and it would seem to be the incision of choice in cases of a retroperitoneal mass. RE.FERENCES
1. Rhamy, R. K.: Retroperitoneal tumors. In: Urologic Surgery,
2nd ed. Edited by J. F. Glenn and W. H. Boyce. New York: Harper & Row, Publishers, Inc., p. 862, 1975. 2. Vinik, M., Neal, M. P., Jr. and Freed, T. A.: Retroperitoneal angiography. South. Med. J., 61: 646, 1968. 3. Hinman, F.: The Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935. 4. Cole, A. T., Fried, F. A. and Bissada, N. K.: The supine subcostal modification of the thoraco-abdominal incision. J. Urol., 112: 168, 1974.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
A LARGE RETROPERITONEAL LIPOMA M. P. MCCARTHY, J. D. FROGGE, ROGER DELGADO
AND
PHILIP MAC
From the Naval Regional Medical Center, Camp Pendleton, California
ABSTRACT
A 60-year-old man with an asymptomatic 11-pound retroperitoneal lipoma excised through a supine subcostal modification of the- thoracoabdominal incision is reported. Herein we report an unusual incidental finding on a screening hypertensive excretory urogram (IVP). CASE REPORT
R. E., a 60-year-old man, was asymptomatic other than for what was thought to be essential hypertension. The highest recorded blood pressure was 150/90. A screening IVP was performed. A film of the kidneys, ureters and bladder demonstrated an absence of bowel gas in the right abdomen and there appeared to be some linear radiolucencies in the right upper quadrant. Both psoas shadows were visualized clearly. The left collecting system appeared to be normal. The right kidney was displaced to the left of the midline as well as anteriorly (fig. 1, A and B). A cystogram showed 2 normally located ureteral orifices and a right bulb pyelogram showed a non-obstructed right ureter that crossed the midline at L5. Physical examination revealed blood pressure 150/90 and
men on the right side, which crossed the midline extending to the left of the aorta. A venacavogram showed medial displacement of the vena cava without evidence of intrinsic involvement. Aortography demonstrated displacement of the aorta to the left and a right renal artery that had a normal origin but turned acutely to the left and crossed the midline. No distinct tumor vessels were identified (fig. 1, C). The mass was approached through a supine subcostal modification of the thoracoabdominal incision. A large fatty-appearing mass occupied the majority of the abdominal cavity (fig. 2, A). Biopsy revealed a lipoma. The left kidney and ureter were freed from the mass, which was excised. The mass filled a wash basin and weighed 11 pounds. A right nephropexy was performed. The postoperative course was marked by a low grade fever up to lOlF that lasted for 48 hours and cleared spontaneously. A mild, transient edema of the right lower extremity developed but there was no evidence ofthrom-
Fm. 1. A, preoperative film of kidneys, ureters and bladder. B, initial IVP. C, aortogram
pulse 80. The patient was afebrile. He was 71 inches tall and weighed 162 pounds. The abdomen was slightly protuberant and non-tender, and no masses were palpable. There were no varicoceles, hemorrhoids or any other varicosities. The remainder of the physical examination was within normal limits. Routine laboratory studies, urinary vanillyl mandelic acid and serum cortisol level were normal. An upper gastrointestinal series showed the stomach and C-loop to be displaced markedly to the left and anteriorly, with the majority of the bowel being displaced into the left lower quadrant. The liver scan did not show any filling defects, although the liver was displaced upwards. A bone scan was normal. Echography showed a large solid mass that filled the abdoAccepted for publication April 15, 1977. The opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Navy Medical Department at large.
bophlebitis. This ed~ma also cleared spontaneously without treatment. Blood pressure decreased initially to 130/80 but subsequently returned to the 150/90 range. A postoperative IVP demonstrated normal-appearing kidneys bilaterally (fig. 2, B). DISCUSSION
Because of the nature of the retroperitoneal space, tumors that arise there can often become quite large before causing symptoms. According to Rhamy a lipoma was reported in a 36-year-old woman who weighed 269 pounds, of which 179 pounds were lipoma!1 Reportedly, 85 per cent of all retroperitoneal tumors are malignant. 2 However, even with malignant tumors actual invasion or obstruction of surrounding tissues is relatively rare, presumably since most of these tumors are well encapsulated. According to Hinman lipomas appear to be the most common benign retroperitoneal tumors. They may originate in the perirenal fat, the mesenteric fat or in other 478
4'79
LARGE RETROPERITONEAL LIPOMA
FIG. 2. A, opening view. B, postoperative IVP
adipose tissue in the retroperitoneum. Their growth is slow and symptoms usually arise from pressure effects on adjacent organs, particularly when the patient reaches 40 or 50 years of age. 3 Lipomas, although benign, have a recurrence rate of 56 per cent. 1 The supine subcostal modification of the thoracoabdominal incision was described in 1974 by Cole and associates. 4 This incision combines the advantages of a thoracoabdominal incision, which allows for access high into the retroperitoneum beneath the diaphragm, and a transverse abdominal incision, which allows access to the great vessels, especially above the renal vessels. Cole and associates used this incision in 7 cases and most patients had a low grade fever for up to 72 hours, as in our case. This approach was ideal for our patient
and it would seem to be the incision of choice in cases of a retroperitoneal mass. RE.FERENCES
1. Rhamy, R. K.: Retroperitoneal tumors. In: Urologic Surgery,
2nd ed. Edited by J. F. Glenn and W. H. Boyce. New York: Harper & Row, Publishers, Inc., p. 862, 1975. 2. Vinik, M., Neal, M. P., Jr. and Freed, T. A.: Retroperitoneal angiography. South. Med. J., 61: 646, 1968. 3. Hinman, F.: The Principles and Practice of Urology. Philadelphia: W. B. Saunders Co., 1935. 4. Cole, A. T., Fried, F. A. and Bissada, N. K.: The supine subcostal modification of the thoraco-abdominal incision. J. Urol., 112: 168, 1974.