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Bilateral Renal Ectopia
BILATERAL RENAL ECTOPIA E. KING MORGAN
AND
CHARLES M. STONE
From the Urological Department of the Long Island College Hospital and the Long Island College of Medicine, Brooklyn, New York
Darner (1924) in a thorough review of the literature collected only 16 authentic cases of bilateral renal ectopia. To these there should be added the cases of Walther (1921) and Du Bose (1915). Since then Harpster, McCown, Muschat, and Coppridge, have added reports. Two cases reported in the foreign literature, Schillings (1927) and Fernandez and Alba (1934) bring the total to 25. In 14 of these cases, the condition was not noted clinically. In 3 the diagnosis was made after operation. In only 8 the diagnosis has been made by pyelography. The case here reported was first investigated for pyuria and hematuria. No anomaly of the upper urinary tract was suspected. Case report. No. 4616, I. R., a 49-year-old white male, was admitted to the Long Island College Hospital, service of Dr. J. Sturdivant Read, July 7, 1936. He had been treated in the out-patient department for the preceding 2 months for urethral stricture. He failed to improve under routine treatment, and he was admitted to the hospital, as cystoscopy was impossible without anesthesia. His condition was of long standing. Seven years previously he had had a cystotomy for vesical calculus, and from that time had had difficult urination, frequency, nocturia, and intermittent hematuria of increasing severity. He had had several attacks of retention, but had voided each time after dilatation with a sound. His past history was irrelevant, he denied venereal infection. Physical examination revealed a pale, under-nourished, but not acutely ill white man. He had a suprapubic scar and bilateral inguinal herniae. External genitals were normal. The prostate was slightly enlarged, and somewhat soft. It was not tender. There was no renal tenderness. The rest of the findings were negative. Urine on admission was grossly bloody, reaction alkaline, albumin 2 plus, sugar negative, and contained numerous white and red blood cells. Residual was 1 half oz. Hemoglobin was 60 per cent. Blood sugar was 100, urea 45.6, urea nitrogen 21.3, creatinin 1.15, uric acid 3.6. Blood Wassermann and Kahn were negative. Cystoscopy under sacral anesthesia was carried out July 8. There was a marked chronic cystitis. There were many small papillary excrescences over the base of the bladder, and these were surrounded by a zone of inflammation. 427
428
E. KING MORGAN AND CHARLES M. STONE
Numerous hemorrhagic spots were seen over the dome of the bladder. Ureteral orifices were large and gaping, and were mistaken at first for cellules. There was considerable intrusion of the middle lobe of the prostate at the vesical neck, and moderate intrusion of both lateral lobes. The ureters were not catheterized. Plain x-ray film revealed right kidney shadow normal in size, contour and position; the left was not distinctly seen. There were no shadows of opaque calculi. Ureteral and bladder regions were negative. There was marked calcification, apparently in an enlarged prostate, extending several centimeters above the margin of the superior border of the symphysis. Cystourethrogram revealed a small bladder, contour slightly irregular. The left lateral superior border was flattened. No diverticula were demonstrable. There was some reflux into both ureters, with an appearance overlying the left sacrum of a kidney pelvis and calyces, probably an ectopic kidney. On the right side there was also some suggestion of an ectopic kidney pelvis overlying the lower sacrum. The urethra filled well, except that the superior portion appeared very narrow. Calcification in the prostatic region was still noticed. Impression: Calcification of prostate; bilateral pelvic kidneys. On July 10, intravenous urograms were made. Films were taken at 15 and 25 minutes after administration of Diodrast. Kidney shadows could not be clearly seen in the lumbar regions. There was faint, but definite evidence of dye overlying both sacro-iliac joints, apparently in ectopic kidney pelves. The ureters were demonstrable beyond these regions. The bladder was small. The base of the bladder was elevated by a large prostate which was markedly calcified. Diagnosis: Bilateral ectopic kidney, calcification and enlargement of the prostate. During the next few days the patient was given frequent bladder lavage and urinary sedatives. On July 14, cystoscopy was repeated, using spinal anesthesia. The capacity of the bladder was 125 cc. There was sight improvement in the inflammatory condition present. It again could not be determined whether there was an infiltrating neoplasm or simply a severe cystitis present. The right ureteral orifice was catheterized with a No. 6 opaque catheter for a distance of 14 cm. On the left side considerable difficulty was encountered and after much manipulation and changing of catheters a No. 8 non-opaque catheter was introduced. Urine obtained from the ureters was negative for pus, and contained only a few red cells on each side. Bilateral retrograd pyelography was done. The kidney outlines were not clearly seen. The kidney pelves were demonstrable on either side just medial to the sacro-iliac joints, with short and slightly tortuous ureters present extending down into the bladder. The kidney pelves and calcyes were well filled. Ureters were slightly dilated. There was no dye in the bladder. Conclusions: Bilateral ectopic kidneys with short ureters.
BILATERAL RENAL ECTOPIA
429
It was decided to explore the bladder for neoplasm and to remove the prostate. A retention catheter was inserted. Lavage was carried out twice daily. On July 21, blood nitrogen was normal. On July 24, suprapubic cystotomy was done. Inspection of the bladder revealed no neoplasm. Only a small portion of the prostate was intravesical. Calculi could be felt when the finger was introduced into the prostatic urethra. Enucleation was very difficult and was effected piecemeal. Eventually it was felt that all the prostate and calculi had been removed. A large Pezzer catheter was used to drain the bladder. Post-operative course was uneventful and the patient was discharged 15 days after operation. Follow-up in the outpatient department is being carried out. The patient voids easily, has a nocturia about twice a night, is in a state of much better general health, and has gained considerable weight. The urine is still hazy, there is no residual. Plain x-ray reveals three small calculi still in the prostatic area. Etiology. Hinman states that the cause of renal ectopy is a descent rather than a failure of renal ascent. The apparent ascent of the kidney is no more than a change in the relation of the kidney to the other viscera as the back straightens. The kidney pelvis is found opposite the second lumbar vertebra in the 9 to 10 mm. embryo which is less than 4 weeks old. As the back straightens, the kidney maintains this relationship. Failure of the ureter to lengthen or one of the older arteries to degenerate, pulls the kidney into the pelvis. SUMMARY
A case of bilateral renal ectopia in which the kidneys are normal except for their position is presented. The patient entered the hospital for a urologic complaint not related to the anomaly.
52 Remsen St. 340 Henry St. REFERENCES BRYAN: Surg ., Gynec. and Obstet., 21: 684, 1915. COPPRIDGE: Jour. Urol., 32: 231, 1934. DARNER: Jour. Urol., 12: 204, 1924. DuBosE: South. Med. Jour., 8: 785, 1915. FERNANDEZ AND ALBA: La. Med. Iber. Madrid, 28: 340, 1934. HARPSTER: Jour. Urol., 13: 309, 1925. McCowN: Jour. Urol., 22: 653, 1929. MuscHAT: Jour. Urol., 30: 483, 1933. SCHILLINGS: Arch. des Maladies des Reins, 3: 547, 1927. WALTHER: Surg., Gynec. and Obstet., 32: 82, 1921.
AND
CHARLES M. STONE
From the Urological Department of the Long Island College Hospital and the Long Island College of Medicine, Brooklyn, New York
Darner (1924) in a thorough review of the literature collected only 16 authentic cases of bilateral renal ectopia. To these there should be added the cases of Walther (1921) and Du Bose (1915). Since then Harpster, McCown, Muschat, and Coppridge, have added reports. Two cases reported in the foreign literature, Schillings (1927) and Fernandez and Alba (1934) bring the total to 25. In 14 of these cases, the condition was not noted clinically. In 3 the diagnosis was made after operation. In only 8 the diagnosis has been made by pyelography. The case here reported was first investigated for pyuria and hematuria. No anomaly of the upper urinary tract was suspected. Case report. No. 4616, I. R., a 49-year-old white male, was admitted to the Long Island College Hospital, service of Dr. J. Sturdivant Read, July 7, 1936. He had been treated in the out-patient department for the preceding 2 months for urethral stricture. He failed to improve under routine treatment, and he was admitted to the hospital, as cystoscopy was impossible without anesthesia. His condition was of long standing. Seven years previously he had had a cystotomy for vesical calculus, and from that time had had difficult urination, frequency, nocturia, and intermittent hematuria of increasing severity. He had had several attacks of retention, but had voided each time after dilatation with a sound. His past history was irrelevant, he denied venereal infection. Physical examination revealed a pale, under-nourished, but not acutely ill white man. He had a suprapubic scar and bilateral inguinal herniae. External genitals were normal. The prostate was slightly enlarged, and somewhat soft. It was not tender. There was no renal tenderness. The rest of the findings were negative. Urine on admission was grossly bloody, reaction alkaline, albumin 2 plus, sugar negative, and contained numerous white and red blood cells. Residual was 1 half oz. Hemoglobin was 60 per cent. Blood sugar was 100, urea 45.6, urea nitrogen 21.3, creatinin 1.15, uric acid 3.6. Blood Wassermann and Kahn were negative. Cystoscopy under sacral anesthesia was carried out July 8. There was a marked chronic cystitis. There were many small papillary excrescences over the base of the bladder, and these were surrounded by a zone of inflammation. 427
428
E. KING MORGAN AND CHARLES M. STONE
Numerous hemorrhagic spots were seen over the dome of the bladder. Ureteral orifices were large and gaping, and were mistaken at first for cellules. There was considerable intrusion of the middle lobe of the prostate at the vesical neck, and moderate intrusion of both lateral lobes. The ureters were not catheterized. Plain x-ray film revealed right kidney shadow normal in size, contour and position; the left was not distinctly seen. There were no shadows of opaque calculi. Ureteral and bladder regions were negative. There was marked calcification, apparently in an enlarged prostate, extending several centimeters above the margin of the superior border of the symphysis. Cystourethrogram revealed a small bladder, contour slightly irregular. The left lateral superior border was flattened. No diverticula were demonstrable. There was some reflux into both ureters, with an appearance overlying the left sacrum of a kidney pelvis and calyces, probably an ectopic kidney. On the right side there was also some suggestion of an ectopic kidney pelvis overlying the lower sacrum. The urethra filled well, except that the superior portion appeared very narrow. Calcification in the prostatic region was still noticed. Impression: Calcification of prostate; bilateral pelvic kidneys. On July 10, intravenous urograms were made. Films were taken at 15 and 25 minutes after administration of Diodrast. Kidney shadows could not be clearly seen in the lumbar regions. There was faint, but definite evidence of dye overlying both sacro-iliac joints, apparently in ectopic kidney pelves. The ureters were demonstrable beyond these regions. The bladder was small. The base of the bladder was elevated by a large prostate which was markedly calcified. Diagnosis: Bilateral ectopic kidney, calcification and enlargement of the prostate. During the next few days the patient was given frequent bladder lavage and urinary sedatives. On July 14, cystoscopy was repeated, using spinal anesthesia. The capacity of the bladder was 125 cc. There was sight improvement in the inflammatory condition present. It again could not be determined whether there was an infiltrating neoplasm or simply a severe cystitis present. The right ureteral orifice was catheterized with a No. 6 opaque catheter for a distance of 14 cm. On the left side considerable difficulty was encountered and after much manipulation and changing of catheters a No. 8 non-opaque catheter was introduced. Urine obtained from the ureters was negative for pus, and contained only a few red cells on each side. Bilateral retrograd pyelography was done. The kidney outlines were not clearly seen. The kidney pelves were demonstrable on either side just medial to the sacro-iliac joints, with short and slightly tortuous ureters present extending down into the bladder. The kidney pelves and calcyes were well filled. Ureters were slightly dilated. There was no dye in the bladder. Conclusions: Bilateral ectopic kidneys with short ureters.
BILATERAL RENAL ECTOPIA
429
It was decided to explore the bladder for neoplasm and to remove the prostate. A retention catheter was inserted. Lavage was carried out twice daily. On July 21, blood nitrogen was normal. On July 24, suprapubic cystotomy was done. Inspection of the bladder revealed no neoplasm. Only a small portion of the prostate was intravesical. Calculi could be felt when the finger was introduced into the prostatic urethra. Enucleation was very difficult and was effected piecemeal. Eventually it was felt that all the prostate and calculi had been removed. A large Pezzer catheter was used to drain the bladder. Post-operative course was uneventful and the patient was discharged 15 days after operation. Follow-up in the outpatient department is being carried out. The patient voids easily, has a nocturia about twice a night, is in a state of much better general health, and has gained considerable weight. The urine is still hazy, there is no residual. Plain x-ray reveals three small calculi still in the prostatic area. Etiology. Hinman states that the cause of renal ectopy is a descent rather than a failure of renal ascent. The apparent ascent of the kidney is no more than a change in the relation of the kidney to the other viscera as the back straightens. The kidney pelvis is found opposite the second lumbar vertebra in the 9 to 10 mm. embryo which is less than 4 weeks old. As the back straightens, the kidney maintains this relationship. Failure of the ureter to lengthen or one of the older arteries to degenerate, pulls the kidney into the pelvis. SUMMARY
A case of bilateral renal ectopia in which the kidneys are normal except for their position is presented. The patient entered the hospital for a urologic complaint not related to the anomaly.
52 Remsen St. 340 Henry St. REFERENCES BRYAN: Surg ., Gynec. and Obstet., 21: 684, 1915. COPPRIDGE: Jour. Urol., 32: 231, 1934. DARNER: Jour. Urol., 12: 204, 1924. DuBosE: South. Med. Jour., 8: 785, 1915. FERNANDEZ AND ALBA: La. Med. Iber. Madrid, 28: 340, 1934. HARPSTER: Jour. Urol., 13: 309, 1925. McCowN: Jour. Urol., 22: 653, 1929. MuscHAT: Jour. Urol., 30: 483, 1933. SCHILLINGS: Arch. des Maladies des Reins, 3: 547, 1927. WALTHER: Surg., Gynec. and Obstet., 32: 82, 1921.