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Excision of Pyelocaliceal Diverticulum Under Renal Hypothermia
0022-5347 /82/1272-0294$02.00/0 Vol. 127, February Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Case Reports EXCISION OF PYELOCALICEAL DIVERTICULUM UNDER RENAL HYPOTHERMIA H. NORMAN NOE*
AND
N. V. RAGHAV AIAH
From the Department of Urology, University of Tennessee Center for the Health Sciences and LeBonheur Children's Medical Center, Memphis, Tennessee
ABSTRACT
Large symptomatic pyelocaliceal diverticula are uncommon. While treating these diverticula in children, it is important to conserve as much kidney tissue as possible. A large type I pyelocaliceal diverticulum in a 6-year-old girl was excised successfully in toto under renal hypothermia with minimal kidney damage. This approach to these diverticula under renal hypothermia is not only useful for total excision but also could be helpful for removing stones from the diverticula. Pyelocaliceal diverticula are eventrations of the upper collecting system lying within the renal parenchyma and communicating with the main collecting system via a narrow channel. 1 Usually, they are asymptomatic and are detected incidentally on an excretory urogram (IVP). A large symptomatic pyelocaliceal diverticulum is uncommon. CASE REPORT
A 6-year-old white girl was hospitalized for evaluation of recurrent attacks of right flank pain with high fever. She had been evaluated for urinary frequency, urgency and dysuria 3 years previously. At that time a voiding cystourethrogram was normal and the IVP revealed a small 1 cm. type I pyelocaliceal diverticulum in the upper pole of the right kidney (fig. 1). Physical examination revealed right flank tenderness. Urinalysis demonstrated significant pyuria and bacteriuria. Urine culture yielded Escherichia coli. A voiding cystourethrogram after adequate infection control was normal and showed no evidence of vesicoureteral reflux. An IVP revealed that the diverticulum had markedly increased in size to 2 cm. (fig. 2). Because of the recurrent and severe right pyelonephritis with the marked increase in the size of the diverticulum, we elected to excise the diverticulum. Conservation of as much of the renal tissue as possible was desirable. After the urinary tract infection was adequately controlled the right kidney was explored through a standard flank incision and isolated from the other retroperitoneal structures by a rubber dam. We administered 7.5 gm. mannitol intravenously. The renal artery was then clamped with a bulldog vascular clamp. The kidney was covered with ice slush prepared from Ringer's lactate solution and, after adequate cooling, a capsular incision was made on the lateral edge of the kidney in the upper pole region along Brodel's line. The kidney tissue was divided bluntly and the diverticulum was identified. An avascular plane was developed between normal kidney tissue and the diverticulum. With blunt and sharp dissection, the entire diverticulum was easily dissected free from the rest of the kidney tissue and the neck of the diverticulum connecting with the minor calix was identified. The diverticulum with its neck was excised in
toto and the defect in the minor calix was closed with 5-zero chromic suture. Obvious bleeding points and visible cortical vessels were suture ligated with 4-zero chromic sutures, and the capsular incision was closed with continuous 2-zero chromic suture. The vascular clamp was then removed from the renal artery and the kidney was observed for significant bleeding. The kidney immediately regained its normal appearance and only minimal bleeding was noted. The flank wound was closed leaving a Penrose drain in the perirenal space. Convalescence was uneventful. An IVP 3 months postoperatively revealed normal kidney function and no loss of renal tissue (fig. 3). The patient has not experienced further infections or attacks of pyelonephritis since surgery. DISCUSSION
The incidence of pyelocaliceal diverticula in children is approximately 3.3 per 1,000 IVPs. 2 It is generally considered to be congenital in origin. 1' 3 These diverticula represent failure of the third and fourth order divisions of the ureteral bud to degenerate at the 5 mm. stage of the embryo. 2 Although others have suggested its origin from a localized cortical abscess draining into the caliceal system and from vesicoureteral reflux, these theories have not been substantiated.4 There are 2 main anatomical varieties of these diverticula. Type I diverticula are the most common and are related closely to a minor calix, are often within the cup of the calix and are commonly seen in the poles of kidneys, especially the upper pole. Type II diverticula have a direct communication to the renal pelvis or adjacent major calix. The diverticulum in our case was type I. These diverticula usually are detected incidentally on routine IVPs. Occasionally, they may be symptomatic as in our case. The patients may present with pain, hematuria and symptoms of pyelonephritis if the diverticulum is either infected or is the seat of stone formation. Rarely, it may be palpated as a flank mass but physical examination usually is unremarkable. 2 A plain film of the abdomen may reveal a stone in the diverticulum. The IVP is usually diagnostic in outlining the diverticulum. These diverticula are to be differentiated on an Accepted for publication May 22, 1981. IVP from tuberculous cavities, papillary necrosis and tumor * Requests for reprints: LeBonheur Children's Medical Center, 848 Adams, Suite 403, Memphis, Tennessee 38103. necrosis. If the neck of the diverticulum is occluded these 294
I
EXCISION OF PYELOCALICEAL DIVERTICULtJM
Frn. 1. Initial IVP (15-minute film) shows 1.0 cm. type I diverticulum in upper pole of right kidney
FIG. 2. IVP (15-minute film) 3 years after initial IVP shows enlarged diverticulum to 2 cm.
1
FIG. 3. Postoperative IVP (15-minute film) shows good renal function without cortical loss
295
296
NOE AND RAGHAVAIAH
diverticula can present as space-occupying lesions in relation to the minor calices. These lesions are then to be differentiated from renal neoplasm, cysts, or segmental or nonfunctioning hydronephrosis as well as adjacent extrarenal masses. 2 Sonography, computerized tomography and renal arteriography will be helpful to differentiate them from neoplasms. The complications of these diverticula could be infection, abscess formation, stone formation in the diverticulum and spontaneous rupture of the diverticulum. The incidence of stone formation is reported between 9.5 and 39 per cent. 5• 6 The incidence of complications occurring from pyelocaliceal diverticula is not exactly known. However, the diverticulum detected during childhood needs close followup with periodic IVPs, particularly in the presence of urinary symptoms. Of the 13 well documented and followed cases of diverticula in children 8 (62 per cent) ultimately underwent surgery within 3.7 years after initial discovery. 3 Most pyelocaliceal diverticula do not require treatment and the necessity for operative intervention would depend on the presence or absence of complications. Hitherto, large diverticula destroying most of the kidney tissue were treated by nephrectomy. The smaller and medium-sized symptomatic diverticula were managed by either partial nephrectomy for polar lesions, wedge excision, deroofing of the cavity or marsupialization of the diverticulum. 2• 7• 8 Although clamping of the renal artery was suggested in cases of brisk bleeding during any of the aforementioned procedures,2 excision of the diverticulum in toto under renal hypothermia with control of the renal artery
has not been described thus far. The advantages of this method are obvious. The diverticulum can be excised in toto under a bloodless field with precise closure of the communicating channel into the minor calix with minimal loss of kidney tissue. Such factors are particularly important when operating on children. This method could also be well applied in removing stones from such diverticula and could be used in most hospital settings by experienced surgeons. REFERENCES 1. Timmons, J. W., Jr., Malek, R. S., Hattery, R.R. and DeWeerd, J.
H.: Caliceal diverticulum. J. Urol., 114: 6, 1975. 2. Wulfsohn, M.A.: Pyelocaliceal diverticula. J. Urol., 123: 1, 1980. 3. Lister, J. and Singh, H.: Pelvicalyceal cysts in childhood. J. Ped. Surg., 8: 901, 1973. 4. Amar, A. D.: The clinical significance ofrenal calii;eal diverticulum in children: relation to vesicoureteral reflux. J. Urol., 113: 255, 1975. 5. Abeshouse, B. S. and Abeshouse, G. A.: Calyceal diverticulum: a report of sixteen cases and review of the literature. Urol. Int., 15: 329, 1963. 6. Middleton, A. W., Jr. and Pfister, R. C.: Stone-containing pyelocaliceal diverticulum: embryogenic, anatomic, radiologic and clinical characteristics. J. Urol., 111: 2, 1974. 7. Devine, C. J., Jr., Guzman, J. A., Devine, P. C. and Poutasse, E. F.: Calyceal diverticulum. J. Urol., 101: 8, 1969. 8. Williams, G., Blandy, J. P. and Tresidder, G. C.: Communicating cysts and diverticula of the renal pelvis. Brit. J. Urol., 41: 163, 1969.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Case Reports EXCISION OF PYELOCALICEAL DIVERTICULUM UNDER RENAL HYPOTHERMIA H. NORMAN NOE*
AND
N. V. RAGHAV AIAH
From the Department of Urology, University of Tennessee Center for the Health Sciences and LeBonheur Children's Medical Center, Memphis, Tennessee
ABSTRACT
Large symptomatic pyelocaliceal diverticula are uncommon. While treating these diverticula in children, it is important to conserve as much kidney tissue as possible. A large type I pyelocaliceal diverticulum in a 6-year-old girl was excised successfully in toto under renal hypothermia with minimal kidney damage. This approach to these diverticula under renal hypothermia is not only useful for total excision but also could be helpful for removing stones from the diverticula. Pyelocaliceal diverticula are eventrations of the upper collecting system lying within the renal parenchyma and communicating with the main collecting system via a narrow channel. 1 Usually, they are asymptomatic and are detected incidentally on an excretory urogram (IVP). A large symptomatic pyelocaliceal diverticulum is uncommon. CASE REPORT
A 6-year-old white girl was hospitalized for evaluation of recurrent attacks of right flank pain with high fever. She had been evaluated for urinary frequency, urgency and dysuria 3 years previously. At that time a voiding cystourethrogram was normal and the IVP revealed a small 1 cm. type I pyelocaliceal diverticulum in the upper pole of the right kidney (fig. 1). Physical examination revealed right flank tenderness. Urinalysis demonstrated significant pyuria and bacteriuria. Urine culture yielded Escherichia coli. A voiding cystourethrogram after adequate infection control was normal and showed no evidence of vesicoureteral reflux. An IVP revealed that the diverticulum had markedly increased in size to 2 cm. (fig. 2). Because of the recurrent and severe right pyelonephritis with the marked increase in the size of the diverticulum, we elected to excise the diverticulum. Conservation of as much of the renal tissue as possible was desirable. After the urinary tract infection was adequately controlled the right kidney was explored through a standard flank incision and isolated from the other retroperitoneal structures by a rubber dam. We administered 7.5 gm. mannitol intravenously. The renal artery was then clamped with a bulldog vascular clamp. The kidney was covered with ice slush prepared from Ringer's lactate solution and, after adequate cooling, a capsular incision was made on the lateral edge of the kidney in the upper pole region along Brodel's line. The kidney tissue was divided bluntly and the diverticulum was identified. An avascular plane was developed between normal kidney tissue and the diverticulum. With blunt and sharp dissection, the entire diverticulum was easily dissected free from the rest of the kidney tissue and the neck of the diverticulum connecting with the minor calix was identified. The diverticulum with its neck was excised in
toto and the defect in the minor calix was closed with 5-zero chromic suture. Obvious bleeding points and visible cortical vessels were suture ligated with 4-zero chromic sutures, and the capsular incision was closed with continuous 2-zero chromic suture. The vascular clamp was then removed from the renal artery and the kidney was observed for significant bleeding. The kidney immediately regained its normal appearance and only minimal bleeding was noted. The flank wound was closed leaving a Penrose drain in the perirenal space. Convalescence was uneventful. An IVP 3 months postoperatively revealed normal kidney function and no loss of renal tissue (fig. 3). The patient has not experienced further infections or attacks of pyelonephritis since surgery. DISCUSSION
The incidence of pyelocaliceal diverticula in children is approximately 3.3 per 1,000 IVPs. 2 It is generally considered to be congenital in origin. 1' 3 These diverticula represent failure of the third and fourth order divisions of the ureteral bud to degenerate at the 5 mm. stage of the embryo. 2 Although others have suggested its origin from a localized cortical abscess draining into the caliceal system and from vesicoureteral reflux, these theories have not been substantiated.4 There are 2 main anatomical varieties of these diverticula. Type I diverticula are the most common and are related closely to a minor calix, are often within the cup of the calix and are commonly seen in the poles of kidneys, especially the upper pole. Type II diverticula have a direct communication to the renal pelvis or adjacent major calix. The diverticulum in our case was type I. These diverticula usually are detected incidentally on routine IVPs. Occasionally, they may be symptomatic as in our case. The patients may present with pain, hematuria and symptoms of pyelonephritis if the diverticulum is either infected or is the seat of stone formation. Rarely, it may be palpated as a flank mass but physical examination usually is unremarkable. 2 A plain film of the abdomen may reveal a stone in the diverticulum. The IVP is usually diagnostic in outlining the diverticulum. These diverticula are to be differentiated on an Accepted for publication May 22, 1981. IVP from tuberculous cavities, papillary necrosis and tumor * Requests for reprints: LeBonheur Children's Medical Center, 848 Adams, Suite 403, Memphis, Tennessee 38103. necrosis. If the neck of the diverticulum is occluded these 294
I
EXCISION OF PYELOCALICEAL DIVERTICULtJM
Frn. 1. Initial IVP (15-minute film) shows 1.0 cm. type I diverticulum in upper pole of right kidney
FIG. 2. IVP (15-minute film) 3 years after initial IVP shows enlarged diverticulum to 2 cm.
1
FIG. 3. Postoperative IVP (15-minute film) shows good renal function without cortical loss
295
296
NOE AND RAGHAVAIAH
diverticula can present as space-occupying lesions in relation to the minor calices. These lesions are then to be differentiated from renal neoplasm, cysts, or segmental or nonfunctioning hydronephrosis as well as adjacent extrarenal masses. 2 Sonography, computerized tomography and renal arteriography will be helpful to differentiate them from neoplasms. The complications of these diverticula could be infection, abscess formation, stone formation in the diverticulum and spontaneous rupture of the diverticulum. The incidence of stone formation is reported between 9.5 and 39 per cent. 5• 6 The incidence of complications occurring from pyelocaliceal diverticula is not exactly known. However, the diverticulum detected during childhood needs close followup with periodic IVPs, particularly in the presence of urinary symptoms. Of the 13 well documented and followed cases of diverticula in children 8 (62 per cent) ultimately underwent surgery within 3.7 years after initial discovery. 3 Most pyelocaliceal diverticula do not require treatment and the necessity for operative intervention would depend on the presence or absence of complications. Hitherto, large diverticula destroying most of the kidney tissue were treated by nephrectomy. The smaller and medium-sized symptomatic diverticula were managed by either partial nephrectomy for polar lesions, wedge excision, deroofing of the cavity or marsupialization of the diverticulum. 2• 7• 8 Although clamping of the renal artery was suggested in cases of brisk bleeding during any of the aforementioned procedures,2 excision of the diverticulum in toto under renal hypothermia with control of the renal artery
has not been described thus far. The advantages of this method are obvious. The diverticulum can be excised in toto under a bloodless field with precise closure of the communicating channel into the minor calix with minimal loss of kidney tissue. Such factors are particularly important when operating on children. This method could also be well applied in removing stones from such diverticula and could be used in most hospital settings by experienced surgeons. REFERENCES 1. Timmons, J. W., Jr., Malek, R. S., Hattery, R.R. and DeWeerd, J.
H.: Caliceal diverticulum. J. Urol., 114: 6, 1975. 2. Wulfsohn, M.A.: Pyelocaliceal diverticula. J. Urol., 123: 1, 1980. 3. Lister, J. and Singh, H.: Pelvicalyceal cysts in childhood. J. Ped. Surg., 8: 901, 1973. 4. Amar, A. D.: The clinical significance ofrenal calii;eal diverticulum in children: relation to vesicoureteral reflux. J. Urol., 113: 255, 1975. 5. Abeshouse, B. S. and Abeshouse, G. A.: Calyceal diverticulum: a report of sixteen cases and review of the literature. Urol. Int., 15: 329, 1963. 6. Middleton, A. W., Jr. and Pfister, R. C.: Stone-containing pyelocaliceal diverticulum: embryogenic, anatomic, radiologic and clinical characteristics. J. Urol., 111: 2, 1974. 7. Devine, C. J., Jr., Guzman, J. A., Devine, P. C. and Poutasse, E. F.: Calyceal diverticulum. J. Urol., 101: 8, 1969. 8. Williams, G., Blandy, J. P. and Tresidder, G. C.: Communicating cysts and diverticula of the renal pelvis. Brit. J. Urol., 41: 163, 1969.