Dismembered Infundibulopyelostomy: Improved Technique Forcorrecting Vascular Obstruction of Thesuperior Infundibulum

Vol. 101, Feb. Printed in U.S.A.

THE JouRNAL OF UROLOGY

Copyright © 1969 by The Williams & Wilkins Co.

DISMEMBERED INFUNDIBULOPYELOSTOl\IY: IMPROVED TECHNIQUE FOR CORRECTING VASCULAR OBSTRUCTION OF THE SUPERIOR INFUNDIBULUM ELWIN E. FRALEY From the Siirgery Branch, 1Vational Cancer Institute, National I nslitutes of Health, Bethescla, iv! arylancl

Although both radiologists and urologists long have recognized that renal arteries and renal veins can produce radiographic filling defects by impinging upon the infundibula, 1- 4 only recently has it been appreciated that these crossing vessels may have clinical significance. In 2 recent papers the author described 5 cases of a previously unrecognized syndrome of nephralgia caused by intrarenal vascular obstruction of the superior infundibulum. 5 • 6 These reports detailed the anatomic and radiographic findings in this abnormality and outlined the surgical techniques used to correct the obstructions. The purpose of this communication is to record two additional cases of vascular obstruction of the superior infundibulum and to describe an improved technique for correcting one form of this abnormality. CASB REPORTS

Case 1. P .-:VI., a 52-year-old woman, entered the hospital with a 12-year history of intermittent right flank pain. The patient was in good health until pain developed mainly in the right costovertebral angle and flank but occasionally radiated to the groin. Also, at times, the discomfort was felt in the right upper quadrant anteriorly. Because of the persistence of the pain without apparent cause a cholecystectomy was done, but symptoms remained unchanged. A subsequent

Accepted for publication March 15, 1968. 1 Baum, S. and Gillenwater, J, Y.: Renal artery impressions on the renal pelvis. J. Urol., 95: 139145, 1966. 2 Kreel, L. and Pyle, R.: Arterial impressions on the renal pelvis. Brit. J. Radiol., 35: 609-613, 1962. 3 Meng, C, H. and Elkin, M.: Venous impressions on calyceal system. Radiology, 87: 878-882, 1966. 4 Tille, D.: Nicht pathologische Fullungsdefekte des Nierenbeckens and der Nierenkelche. Deutsch. Med. Wschr., 85: 1414-1415, 1960. 5 Fraley, E. E.: Vascular obstruction of superior infundibul um causing nephralgia: a new syndrome. New Engl. J. Med,, 275: 1403-1409, 1966. 6 Fraley, E. E.: Surgical correction of intrarenal disease. I. Obstructions of the superior infundibulum. J. Urol., 98: 54-64, 1967. 144

excretory urogram revealed a right renal abnormality. The patient was told that she had a birth defect in her kidney and that, if discomfort persisted, she would need a nephrectomy. The patient denied all other urinary tract symptoms. Physical examination revealed only mild right costovertebral angle tenderness. The cholecystectomy incision was well-healed. The hemogram, urinalysis and basic chemistries were all within normal limits. A urine culture was sterile. The excretory urogram showed a long right superior infundibulum that was somewhat dilated proximal to a filling defect in its mid-portion (fig. 1, A.). The upright film indicated that the obstruction was accentuated by kinking of the infundibulum as the kidney descended even though there was only minimal renal mobility (fig.1,B). Cystoscopy was unremarkable and a right retrograde pyelogram again demonstrated a welldefined filling defect in the infundibulum that did not disappear with over-distention of the proximal collecting system. There was retention of dye in the infundibulum proximal to the filling defect on the 30-minute drainage film of the retrograde pyelogram. This delay in drainage from the superior calyx was approximately equal in both supine and upright positions. A cine excretory urogram showed interference with the delivery of dye from a proximal superior calyx and infundibulum into the renal pelvis. The infundibular obstruction again appeared to be increased when the patient was upright. Selective right renal arteriography and venography demonstrated an artery crossing the infundibulum in the area of the filling defect (fig. 1, C and D). A lateral projection on the arteriogram indicated that the artery crossed dorsally to the infundibulum and that the infundibulum was caught in a vascular vise between the artery and the main renal vein. A diagnosis of vascular obstruction of the superior infundibulum was made and the patient was explored. The anatomical basis of the ob-

.DJSl\iUDlVIBERED INFUNDIBULOPYELOSTOMY

·B'rn. 1. Case L.!I_, excretory urogram shows right superior calycectasis proximal to persistcu1; miJinfundibular filling defect. B, upright film of excretory urograrn demonstrates kinkillg of infu11dibL1l1uu and accentuation of infnndibular obstructioll associated wit-h mild renal ptosis. C:, SA!ective right rer,a 1 arteriogrnm illustrates to posterior renal vascular segment crossing superior infunclibul um rit siLe of pyelographic filling D, right renal venograrn. Main renal vein also crosses iufund.ibulum at sit(, of obstntct,ion.

struction was exactly as lll"edided from the preoperative arteriogram; that is, the superior infunclibulum was compressed bct\\'een the artery supplying the posterior renal vascular ~egment and the overlying main renal Yein (fig. 2). The site of the obstruction ,ms essentially extra.renal. To relien' this obstruGtioll, the infnndibulurn was

transected at the infundibulopch·ic junction aud then it was placed dorsal to the artery. A s1nall. catheter was passed into the infundibulum to rule out intrinsic obstruction. The lumen of the infuudibulum was abo visualized clearly by ml! iug the infundibulum back 011 itself to r,xpo~e the point of obstruction. The i11fundibuluru was thou

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Fm. 2. Case 1. Right kidney completely mobilized as seen dorsally. Artery to posterior vascular segment is obstructing superior infundibulum by compressing it ventrally against main renal vein. To correct obstruction, infundibulum was transected at infundibulopelvic junction and then infundibulum was transposed dorsally to artery. Infundibulum was anastomosed to pelvis with single running suture. Kidney was turned and fixed in position so artery remained away from infundibulum. anastomosed to the pelvis with a single running layer of 5-zero chromic catgut suture (fig. 2). The patient was asymptomatic 6 months postoperatively. The excretory urogram showed less superior calycectasis and no infundibular filling defect. Case 2. J.C., a 22-year-old man, entered the hospital with a 1-year history of intermittent right flank pain. The patient was well until the onset of low back and right costovertebral angle pain. The discomfort became progressively worse and just prior to admission to the hospital acute exacerbation was associated with the passage of tea-colored urine. Physical examination was unremarkable except for right costovertebral angle tenderness. Routine laboratory studies including urinalysis were all within normal limits. The urine was sterile.

An excretory urogram showed right superior calycectasis and a persistent filling defect on the right superior infundibulum (fig. 3). There was no abnormal mobility in the upright position. Cystoscopy was unremarkable. A retrograde pyelogram demonstrated entrapment of dye in the right superior calyx after 30 minutes even though the patient was kept in steep reverse Trendelenberg position to facilitate drainage. The previously noted filling defect also ,vas clearly demonstrated. A cine excretory urogram showed marked hold up of dye and interference with infundibular peristalsis in the area of the infundibular filling defect. A selective right renal angiogram demonstrated what appeared to be the artery to the posterior renal vascular segment compressing the infundibulum and producing the persistent radiographic filling defect. We concluded that the patient also had obstruction of the right superior infundibulum that was causing pain from periodic over-distention of the calyx. Surgical exploration revealed that the artery to the posterior vascular segment was compressing the infundibulum against overlying renal substance and the main renal vein (fig. 4). The obstruction was intrarenal in location. The abnormality was exposed by careful dissection in the pyelorenal sinus. Surgical repair consisted of a dismembered infundibulopyelostomy similar to that performed in case 1. One year postoperatively the patient was without symptoms. The excretory urogram showed less superior calycectasis and no infundibular filling defect. DISCUSSION

It is well known that pain can result from obstruction to urine flow and stretching of the ureter or renal pelvis. Similarly, pain associated with obstruction of the infundibulum probably is caused by periodic over-distention of the calyx major and its surrounding smooth muscle. Although pain secondary to obstruction in the proximal urinary tract is usually referred to the flank or costovertebral angle it may be vaguely localized in the right upper quadrant. Case 1 clearly illustrates how nephralgia can be confused with the pain of biliary tract disease, and thus this case emphasizes the importance of considering nephralgia in the differential diagnosis of right upper quadrant pain.

JJISl\iIE:VIBERED INFUNDIB ULOPYEL0ST0Iv1Y

Fm. 3. Case 2, Excretory nrograms show persistent filling defect in infundibul1rn1 and rrrnrked rit;ht superior caiycectasis.

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Fm. 4, Case 2. Right kidney completely mobilized and viewed dorsally. Site of obstruction was intrarenal in location. Artery to posterior vascular segment was compressing infundibulum against renal substance, correction of was essentially as in figure 2,

The most frequent benign causei:i of chronic flank pain are probably pyelonephritis, stone~ and gross anatomical abnorrnalitie,s 8uch as metero pelvic junction obstruction. All of these conditions usually are easily diagnosed. Hmrnver two common causes of chronic neplualgia, tosis and vascular obstruction of the infundibu-lum, may go undetected unlcs;; subtle abnor malities in the excretory urogram arc interpreted. In fact, the excretory urograrn from. patients with nephroptosis may be normal and renal ptosis will not be seen unlc~s upright films are obtained. The findings in vascular obstruction of the infundibulmn consist of a well-defined radiographic filling defect in the infunclibulurn and delayed emptying of the obstructed on the late drainage films of the Further specialized studies such as cine excretory urography and angiography are of course in substantiating this diagnosis. A more, description of the radiographic finding,; in rnscu lar obstruction of the infumlibulum ha~ been presented elsewhere. 7 The operative procedure u~ed to relieve ,·asm,.7 Nebesar, R. A., Pollard, J, J. and Fraley, .E. E,: Renal vascular impressions: incidence 8.nr! clinical significance. Amer. J. Roentgen., 10l: 719-727, 1967.

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lar obstruction of the infundibulum vanes depending upon the anatomy. 5 • 6 For example, if the offending vessel is a vein, simply dividing it will usually correct the abnormality. However, renal arteries are end-arteries and they cannot be interrupted without death of a significant amount of renal tissue. The operative technique presented herein was conceived for cases in which an artery coursing dorsally to the infundibulum causes an obstruction by compression of the infundibulum ventrally against either renal veins (case 1) or overlying kidney (case 2). Because the artery cannot be divided the infundibulum must be repositioned away from the obstructing vessel. This maneuver can be accomplished by transecting the mid-portion of the infundibulum and performing an infundibuloinfundibulostomy ventral to the artery. However, in the one previous case in which this procedure was done, 6 technical difficulty was encountered because of the small size of the mid-infundibulum and its relative inaccessibility, An infundibulopyelostomy on the other hand is easy to perform because of the greater size and extrarenal location of the structures. In addition, an infundibulopyelostomy is probably less likely to stricture. There are several other important aspects of surgical technique relating to these cases that

should be mentioned briefly. Adequate exposure of the upper pole and renal pedicle is absolutely essential and can usually only be achieved through an 11th or 12th rib incision. An intrinsic obstruction of the infundibulum must be ruled out. We have always checked the patency of the infundibulum with a small straight rubber catheter if the infundibulum is normal by palpation. Also, the lumen of the infundibulum usually can be exposed at some time during the surgical procedure. The kidney should be fixed in a position so that the previously obstructing vessel is held away from the infundibulum permanently. SU:MMARY

Two cases of vascular obstruction of the superior infundibulum are presented. The technique of infundibulopyelostomy which is outlined is suitable for correcting vascular obstruction of the infundibulum caused by an artery compressing the superior infundibulum ventrally against either the main renal vein or kidney. Infundibulopyelostomy is preferred to infundibuloinfundibulostomy because it is easier technically and the anastomosis is probably less prone to stricture. The importance of considering the kidney as a possible source of vague abdominal pain is emphasized.