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Duplication of Renal Pelvis and Ureter: Unsuccessful Heminephrectomy
DUPLICATION OF RENAL PELVIS AND URETER "C.:\'SUCCESSFUL HEMINEPHRECTO:i\IY FRAN"K S. SCHOONOVER Mayo Foundation, Rochester, Minnesota Received for publication May 27, 1922
Case A 387672, Mr. C. F. P., aged twenty-eight years, came to the Mayo Clinic March 29, 1922, complaining of pain in the region of the bladder and right loin and persistent pyuria of seven years' duration. At fourteen, he had had gonorrhea which was mild and apparently cured, as it gave no symptoms for seven years. Onset of the present trouble occurred with chills, fever, vomiting and slight bladder pain. A few days later he noticed pus in the urine and a purulent urethral discharge in the morning. The condition was diagnosed specific urethritis. He was treated without relief by injections, prostatic massage and finally vasotomy with seminal vesicle injection. At the time of his registration at the Clinic he had moderate pyuria, occasional attacks of chills and fever with dull pain referred to the right loin, and urinary frequency. Rectal examination revealed slight chronic prostatitis. Blood pressure was 118 systolic and 78 diastolic; temperature and pulse were normal. Blood examination showed hemoglobin 77 per cent, with 7200 leukocytes. The urine had a specific gravity of 1.020, a trace of albumin, and 60 pus cells to a field and colon bacilli were found on culture. Prostatic smear and urethral secretion ,vere negative for gonococci. The renal functional test showed a 50 per cent return of phenolsulphonephthalein in two hours. The blood urea was 35 mg. for each 100 cc. of blood, and the Wassermann test on the blood was negative. Roentgen ray of the urinary tract was also negative. 155
156
FRANK S. SCHOONOVER
Cystoscopic examination revealed a moderate degree of diffuse cystitis. The left ureteral orifice was normal. On the right of the trigone were two openings less than 1 cm. apart; the median or lower orifice was normal. The lateral orifice was dilated, the
Fm. 1.
COMPLETE DUPLICATION oF PELVIS AND URETER
Note close proximity of the two pelves. pelvis.
Moderate dilatation of the lower
opening being fully 1 cm. in diam_e ter and turbid urine was exuded from the latter on pressure. Catheters were introduced to a normal length into both ureters on. the right. A pyelogram on the right showed two distinct pelves, the upper pelvis normal
DUPLICATION OF RENAL PELVIS AND URETER
157
in contour although small, with a normal ureter and the lower pelvis and ureter irregularly dilated (fig. 1). A pyelogram on the left showed a similar duplication of the pelvis of the left kidney
FIG. 2.
COMPLETE DUPLICATION OF URETER; LOWER PORTION OF URETERS IN COM:VION SHEATH WHICH COULD NOT BE DIVIDED \VITHOUT OPENDrG EITHER URETER
158
FRANK S. SCHOONOVER
but the two ureters were anastomosed about 15 cm. above the bladder. On differential functional test with phenolsulphonephthalein there was a 10 per cent return of the dye in fifteen minutes from the upper pelvis on the right and only a trace from the lower and a 15 per cent combined return in fifteen minutes on the left. A diagnosis was made of complete duplication of the right renal pelvis and ureter, with infected hydronephrosis and atrophy of the lower segment. Heminephrectomy was considered indicated. At operation the diagnosis was corroborated. The entire right kidney was smaller than normal .and there was no external demarcation of the two segments. The two ureters were intimately related and covered by a common sheath extending for a distance of about 10 cm. above the bladder (fig. 2). As it was impossible to separate them, it was necessary to perform a complete nephro-ureterectomy. After removal, the two ureters were found to be so adherent that it was impossible to separate them without opening into either ureter. On section of the kidney, the two pelves were found to be so closely adjacent that heminephrectomy would have been very difficult. The ureter leading to the lower pelvis was markedly dilated, the lower third having a maximal diameter of 2 cm. Ligation of the ureter in its upper portion where it is free was not deemed advisable, since the lower portion might act as a diverticulum. DISCUSSION
This case is of interest in that heminephrectomy was indicated by the localization of infection and comparative function of the two segments, although anatomically this was impossible. The surgical indications for heminephrectomy are: localization of the infection to one segment; marked reduction of function in one segment and normal function in the other; and sufficient distance separating the two pelves to permit bisection. If ureterectomy is also indicated, it is necessary that the two ureters be independent and not enclosed by a common sheath, as was true in the case reported. It is evident, therefore, that in this case two essential requisites for successful heminephrectomy and ureterectomy were absent.
Case A 387672, Mr. C. F. P., aged twenty-eight years, came to the Mayo Clinic March 29, 1922, complaining of pain in the region of the bladder and right loin and persistent pyuria of seven years' duration. At fourteen, he had had gonorrhea which was mild and apparently cured, as it gave no symptoms for seven years. Onset of the present trouble occurred with chills, fever, vomiting and slight bladder pain. A few days later he noticed pus in the urine and a purulent urethral discharge in the morning. The condition was diagnosed specific urethritis. He was treated without relief by injections, prostatic massage and finally vasotomy with seminal vesicle injection. At the time of his registration at the Clinic he had moderate pyuria, occasional attacks of chills and fever with dull pain referred to the right loin, and urinary frequency. Rectal examination revealed slight chronic prostatitis. Blood pressure was 118 systolic and 78 diastolic; temperature and pulse were normal. Blood examination showed hemoglobin 77 per cent, with 7200 leukocytes. The urine had a specific gravity of 1.020, a trace of albumin, and 60 pus cells to a field and colon bacilli were found on culture. Prostatic smear and urethral secretion ,vere negative for gonococci. The renal functional test showed a 50 per cent return of phenolsulphonephthalein in two hours. The blood urea was 35 mg. for each 100 cc. of blood, and the Wassermann test on the blood was negative. Roentgen ray of the urinary tract was also negative. 155
156
FRANK S. SCHOONOVER
Cystoscopic examination revealed a moderate degree of diffuse cystitis. The left ureteral orifice was normal. On the right of the trigone were two openings less than 1 cm. apart; the median or lower orifice was normal. The lateral orifice was dilated, the
Fm. 1.
COMPLETE DUPLICATION oF PELVIS AND URETER
Note close proximity of the two pelves. pelvis.
Moderate dilatation of the lower
opening being fully 1 cm. in diam_e ter and turbid urine was exuded from the latter on pressure. Catheters were introduced to a normal length into both ureters on. the right. A pyelogram on the right showed two distinct pelves, the upper pelvis normal
DUPLICATION OF RENAL PELVIS AND URETER
157
in contour although small, with a normal ureter and the lower pelvis and ureter irregularly dilated (fig. 1). A pyelogram on the left showed a similar duplication of the pelvis of the left kidney
FIG. 2.
COMPLETE DUPLICATION OF URETER; LOWER PORTION OF URETERS IN COM:VION SHEATH WHICH COULD NOT BE DIVIDED \VITHOUT OPENDrG EITHER URETER
158
FRANK S. SCHOONOVER
but the two ureters were anastomosed about 15 cm. above the bladder. On differential functional test with phenolsulphonephthalein there was a 10 per cent return of the dye in fifteen minutes from the upper pelvis on the right and only a trace from the lower and a 15 per cent combined return in fifteen minutes on the left. A diagnosis was made of complete duplication of the right renal pelvis and ureter, with infected hydronephrosis and atrophy of the lower segment. Heminephrectomy was considered indicated. At operation the diagnosis was corroborated. The entire right kidney was smaller than normal .and there was no external demarcation of the two segments. The two ureters were intimately related and covered by a common sheath extending for a distance of about 10 cm. above the bladder (fig. 2). As it was impossible to separate them, it was necessary to perform a complete nephro-ureterectomy. After removal, the two ureters were found to be so adherent that it was impossible to separate them without opening into either ureter. On section of the kidney, the two pelves were found to be so closely adjacent that heminephrectomy would have been very difficult. The ureter leading to the lower pelvis was markedly dilated, the lower third having a maximal diameter of 2 cm. Ligation of the ureter in its upper portion where it is free was not deemed advisable, since the lower portion might act as a diverticulum. DISCUSSION
This case is of interest in that heminephrectomy was indicated by the localization of infection and comparative function of the two segments, although anatomically this was impossible. The surgical indications for heminephrectomy are: localization of the infection to one segment; marked reduction of function in one segment and normal function in the other; and sufficient distance separating the two pelves to permit bisection. If ureterectomy is also indicated, it is necessary that the two ureters be independent and not enclosed by a common sheath, as was true in the case reported. It is evident, therefore, that in this case two essential requisites for successful heminephrectomy and ureterectomy were absent.