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Conservative Surgical Management of Benign Hematuria
THE JOURNAL OF UROLOGY
Vol. 86, No. 5 November 1961 Copyright © 1961 by The Williams & Wilkins Co. Printed in U.S.A.
CONSERVATIVE SURGICAL MANAGEMENT OF BENIGN HEMATURIA A. PAGE HARRIS, NEIL 0. CHAMBERLAIN
AND
PHILLIPP. PORCH
From the Division of Urology, Department of Surgery, Vanderbilt Medical Center, Nashville 5, Tenn.
Protracted unilateral renal hematuria from non-malignant causes will occasionally resist medical management and require surgical extirpation of the offending kidney. Although this course of action serves to solve the immediate problem, one cannot help but sense the threat of similar difficulty later appearing in the remaining kidney. It would seem then that a more conservative approach to surgery would be worthy of consideration where one felt
two preoperatively. Many defy diagnosis even after histological study of the removed kidney. The cause-effect relationship of sickle cell trait and gross hematuria is usually inferred after other gross causes have been satisfactorily excluded. Reasoning as above, conservative surgical management was planned for a patient who was considered to have intractable gross hematuria secondary to a sickle cell trait, with a rather
FIG. 1. A, initial retrograde pyelogram suggests pelvic and upper calyx blood clot. B, second retrograde pyelogram 2 weeks later still suggests intrapelvic blood clot of different configuration.
from his clinical impression that he was dealing with a benign condition. Notable among these benign conditions giving rise to alarming blood loss are sickle cell trait,1 hemangioma, 2- 4 and telangiectasia. 5 Rarely can one accurately diagnose either of the latter Accepted for publication April 18, 1961. 1 Goodwin, W. E., Alston, E. and Semans, J. H.: Hematuria and sickle cell disease. J. Urol., 63: 79, 1950.
2 Levan, R. A. J. and Balme, Harold: Angioma of the kidney. Brit. J. Surg., 23: 282, 1935. 3 Rapaport, A. E.: Hematuria due to papillary hemangioma of the renal pelvis. Arch. Path., 40: 84, 1945. 4 Rives, H. F. and Pool, T. L.: Hemangioma of the kidney. J.A.M.A., 126: 1187, 1914. 5 Maslow, L.A. and Aron, E.: Varicosities of the kidney and pelvis. J. Urol., 61: 719, 1949.
504
surprising outcome. The essential features of his clinical course are described below. CLINICAL SUMMARY
After 5 days of gross painless hematuria a 50year-old Negro sought medical attention. This prolonged bleeding had caused him to become quite weak. He stated that each of his previous similar episodes, the earliest dating back 20 years, had ceased spontaneously usually after 1 day's duration. Each attack had one thing in common. This consisted of the consumption of an enormous quantity of beer on the day prior to onset. Nothing else in the history was helpful in clarifying his problem; nor was the physical
COXSJ~BVATJ.V:E\ SUTIGlCAL :\,IAi\AGEME?\'T OF HENIG?\ HE~IAT'tJRIA
F:w. 2. A, rnpresen ~ative section of resect0d portion of kidney. B, low poi, er· view of ~ected ltemangioma. Higher power shows definite endoUieliaJ lining;.
505
506
HARRIS, CHAMBERLAIN AND PORCH
examination, which reYealed no significant abnormalities. Immediate cystoscopy was performed. After the bladder had been evacuated of numerous clots, bloody efflux was noted to be issuing from the left ureteral orifice. A normal configuration of the left collecting system was demonstrated by intraYenous and retrograde urography (fig. 1,A). A suggestive filling defect was seen in the pelvis but was interpreted as representing blood c:lots. A normal ureterogram was also visualized. Not until one week later did the patient consent to hospitalization, during which time his hematuria persisted and his hemoglobin dropped from 10.1 to 7.5 gm. per cent. During the ensuant 5 day period of complete bed rest the intravenous administration of 2 liters of freshly drawn blood and I liter of fresh plasma. caused only transient decrease in the amount of left renal bleeding. The discovery of an SA type hemoglobin by electrophoresis was the only positive clue as to the etiology of the bleeding in an extensiYe laboratory study. Accordingly, the remedies which have been beneficial to others with hematuria secondary to sickle cell trait were instituted. However, transfusions of fresh blood, adequate hydration, intravenous sodium bicarbonate, nasal oxygen, antibiotics, and atabrine hydrochloride were without appreciable effect. Silver nitrate was instilled into the renal pelvis on successive days, first in 0.5 per cent solution, then in 2 per cent solution. This accomplished little other than to cause the patient to have severe colicky left flank pain. The left retrograde pyelogram (fig. 1,B) was repeated and again the findings ,vere compatible with a blood clot in the renal pelvis without calyceal distortion. Surgery seemed to offer the only solution. Since the history was adjudged accurate, a conservatiYe surgical approach was planned, the logic for which is outlined in the introduction. In addition, the probability of this bleeding being secondary to a malignant neoplasm was considered quite unlikely. The left kidney was exposed through a left lateral subcostal incision and delivered into the wound. The renal pelvis was exposed and opened widely. Free clots were washed out of the pelYis, after which inspection of the mucosa revealed no abnormality. Upon clearing the field
of vision the bleeding was observed to be coming from the upper pole calyces. The renal artery was then isolated and traced to its second division. The superior quadrantic artery was occluded with a non-crushing clamp. This maneuver resulted in immediate cessation of the intra pelvic bleeding. The capsule stripped easily away from the infarcted upper pole. Partial nephrectomy was performed along the line of demarcation. Closure of the capsule and pelvis proceeded without incident. No further gross hematuria was noted during the patient's postoperative course. The resected portion of the kidney failed to reveal the histological stigmata usually associated with sickle cell trait (fig. 2,A), i.e. focal medullary hemorrhage and microinfarcts in the renal parenchyma 6 . Instead, the microscopic sections revealed a small cavernous hemangioma (fig. 2,B) which grossly was barely visible as a submucosal hemorrhagic cyst of the upper minor calyx. DISCUSSION
The preoperative surgical plan in this case was carried out to the letter but was successful for reasons other than that for which it was designed. It is not inconceivable, however, that this procedure would be applicable to persons with sickle cell trait. In certain instances the microinfarcts might be suitably located for segmental resection of the kidney in lieu of its total removal. This must have been a chance association of sickle cell trait with a hemangioma since there are no other recorded instances of their coexistence. SUMMARY AND CO:',CLUSIOKS
The clinical summary of a patient who had uncontrollable unilateral renal hematuria secondary to a, hemangioma of one of the left upper renal papillae and associated sickle cell trait is presented. Successful conservative surgical management by segmental renal resection in this case suggests that more consideration for its use should be made in instances of benign but extensiYe renal hemorrhage. 6 Bernstein, J. and Whitten, C. F.: A histologic appraisal of the kidne)- in sickle cell anemia. Arch. Path., 70: 407, 1960.
Vol. 86, No. 5 November 1961 Copyright © 1961 by The Williams & Wilkins Co. Printed in U.S.A.
CONSERVATIVE SURGICAL MANAGEMENT OF BENIGN HEMATURIA A. PAGE HARRIS, NEIL 0. CHAMBERLAIN
AND
PHILLIPP. PORCH
From the Division of Urology, Department of Surgery, Vanderbilt Medical Center, Nashville 5, Tenn.
Protracted unilateral renal hematuria from non-malignant causes will occasionally resist medical management and require surgical extirpation of the offending kidney. Although this course of action serves to solve the immediate problem, one cannot help but sense the threat of similar difficulty later appearing in the remaining kidney. It would seem then that a more conservative approach to surgery would be worthy of consideration where one felt
two preoperatively. Many defy diagnosis even after histological study of the removed kidney. The cause-effect relationship of sickle cell trait and gross hematuria is usually inferred after other gross causes have been satisfactorily excluded. Reasoning as above, conservative surgical management was planned for a patient who was considered to have intractable gross hematuria secondary to a sickle cell trait, with a rather
FIG. 1. A, initial retrograde pyelogram suggests pelvic and upper calyx blood clot. B, second retrograde pyelogram 2 weeks later still suggests intrapelvic blood clot of different configuration.
from his clinical impression that he was dealing with a benign condition. Notable among these benign conditions giving rise to alarming blood loss are sickle cell trait,1 hemangioma, 2- 4 and telangiectasia. 5 Rarely can one accurately diagnose either of the latter Accepted for publication April 18, 1961. 1 Goodwin, W. E., Alston, E. and Semans, J. H.: Hematuria and sickle cell disease. J. Urol., 63: 79, 1950.
2 Levan, R. A. J. and Balme, Harold: Angioma of the kidney. Brit. J. Surg., 23: 282, 1935. 3 Rapaport, A. E.: Hematuria due to papillary hemangioma of the renal pelvis. Arch. Path., 40: 84, 1945. 4 Rives, H. F. and Pool, T. L.: Hemangioma of the kidney. J.A.M.A., 126: 1187, 1914. 5 Maslow, L.A. and Aron, E.: Varicosities of the kidney and pelvis. J. Urol., 61: 719, 1949.
504
surprising outcome. The essential features of his clinical course are described below. CLINICAL SUMMARY
After 5 days of gross painless hematuria a 50year-old Negro sought medical attention. This prolonged bleeding had caused him to become quite weak. He stated that each of his previous similar episodes, the earliest dating back 20 years, had ceased spontaneously usually after 1 day's duration. Each attack had one thing in common. This consisted of the consumption of an enormous quantity of beer on the day prior to onset. Nothing else in the history was helpful in clarifying his problem; nor was the physical
COXSJ~BVATJ.V:E\ SUTIGlCAL :\,IAi\AGEME?\'T OF HENIG?\ HE~IAT'tJRIA
F:w. 2. A, rnpresen ~ative section of resect0d portion of kidney. B, low poi, er· view of ~ected ltemangioma. Higher power shows definite endoUieliaJ lining;.
505
506
HARRIS, CHAMBERLAIN AND PORCH
examination, which reYealed no significant abnormalities. Immediate cystoscopy was performed. After the bladder had been evacuated of numerous clots, bloody efflux was noted to be issuing from the left ureteral orifice. A normal configuration of the left collecting system was demonstrated by intraYenous and retrograde urography (fig. 1,A). A suggestive filling defect was seen in the pelvis but was interpreted as representing blood c:lots. A normal ureterogram was also visualized. Not until one week later did the patient consent to hospitalization, during which time his hematuria persisted and his hemoglobin dropped from 10.1 to 7.5 gm. per cent. During the ensuant 5 day period of complete bed rest the intravenous administration of 2 liters of freshly drawn blood and I liter of fresh plasma. caused only transient decrease in the amount of left renal bleeding. The discovery of an SA type hemoglobin by electrophoresis was the only positive clue as to the etiology of the bleeding in an extensiYe laboratory study. Accordingly, the remedies which have been beneficial to others with hematuria secondary to sickle cell trait were instituted. However, transfusions of fresh blood, adequate hydration, intravenous sodium bicarbonate, nasal oxygen, antibiotics, and atabrine hydrochloride were without appreciable effect. Silver nitrate was instilled into the renal pelvis on successive days, first in 0.5 per cent solution, then in 2 per cent solution. This accomplished little other than to cause the patient to have severe colicky left flank pain. The left retrograde pyelogram (fig. 1,B) was repeated and again the findings ,vere compatible with a blood clot in the renal pelvis without calyceal distortion. Surgery seemed to offer the only solution. Since the history was adjudged accurate, a conservatiYe surgical approach was planned, the logic for which is outlined in the introduction. In addition, the probability of this bleeding being secondary to a malignant neoplasm was considered quite unlikely. The left kidney was exposed through a left lateral subcostal incision and delivered into the wound. The renal pelvis was exposed and opened widely. Free clots were washed out of the pelYis, after which inspection of the mucosa revealed no abnormality. Upon clearing the field
of vision the bleeding was observed to be coming from the upper pole calyces. The renal artery was then isolated and traced to its second division. The superior quadrantic artery was occluded with a non-crushing clamp. This maneuver resulted in immediate cessation of the intra pelvic bleeding. The capsule stripped easily away from the infarcted upper pole. Partial nephrectomy was performed along the line of demarcation. Closure of the capsule and pelvis proceeded without incident. No further gross hematuria was noted during the patient's postoperative course. The resected portion of the kidney failed to reveal the histological stigmata usually associated with sickle cell trait (fig. 2,A), i.e. focal medullary hemorrhage and microinfarcts in the renal parenchyma 6 . Instead, the microscopic sections revealed a small cavernous hemangioma (fig. 2,B) which grossly was barely visible as a submucosal hemorrhagic cyst of the upper minor calyx. DISCUSSION
The preoperative surgical plan in this case was carried out to the letter but was successful for reasons other than that for which it was designed. It is not inconceivable, however, that this procedure would be applicable to persons with sickle cell trait. In certain instances the microinfarcts might be suitably located for segmental resection of the kidney in lieu of its total removal. This must have been a chance association of sickle cell trait with a hemangioma since there are no other recorded instances of their coexistence. SUMMARY AND CO:',CLUSIOKS
The clinical summary of a patient who had uncontrollable unilateral renal hematuria secondary to a, hemangioma of one of the left upper renal papillae and associated sickle cell trait is presented. Successful conservative surgical management by segmental renal resection in this case suggests that more consideration for its use should be made in instances of benign but extensiYe renal hemorrhage. 6 Bernstein, J. and Whitten, C. F.: A histologic appraisal of the kidne)- in sickle cell anemia. Arch. Path., 70: 407, 1960.