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Glass Foreign Object in the Kidney
Vol. 106, December
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1971 by The Williams & Wilkins Co.
Pediatric Urology GLASS FOREIGN OBJECT IN THE KIDNEY MELVIN F. RUSSI, ALAN R. BUTLER, RUTH A. PICK
AND
WILLIAM R. FAIR*
From the Department of Surgery, Division of Urology, and Department of Radiology, Stanford University School of Medicine, Stanford, California
Renal foreign objects from non-violent trauma are rare. 1 A case of glass foreign object in the kidney, occurring from minor trauma and present for nearly 5 years, is reported herein. CLINICAL SUMMARY
M. SlVIR 30 12 96, an 8-year-old white boy, had painless intermittent gross hematuria 18 months in duration. After the first episode in October 1967, he was evaluated by his physician; physical examination. was normal. The white blood count, erythrocyte sedimentation rate and antistreptolysin titer were normal. Blood urea nitrogen. was 6 mg. per 100 ml. (mg. per cent). The excretory urogram (IVP) revealed a 20 by 4 mm. lenticular density within the mid lateral aspect of the left kidney, extending beyond the lateral border. There was minimal scarring around the density and the pelviocaliceal systems were normal bilaterally (part A of figure). Cystoscopy and retrograde pyelography were negative. The family was reassured, but 3 recurrent episodes of hematuria after exercise prompted referral for consultation. Physical examination in July 1969 was again normal. The urine was sterile and free of cells and protein. An intermediate purified protein derivative skin test was non-reactive. It was elected to repeat cystoscopy during an episode of hematuria. Gross painless hematuria occurred in September 1969 but subsided spontaneously before cystoscopic localization could be performed. On a repeat IVP the lenticular density had migrated further into the kidney, involving the infundibulum of the lower pole calices, which were dilated Accepted for publication December 1970. Supported by United States Public Health Service Training Grant No. 5 ToI Am 05513. * Requests for reprints: Division of Urology, Stanford University School of Medicine, Stanford, California 94305. 1 Osmond, J. D.: Foreign bodies in the kidney. Radiology, 60: 375, 1953.
(part B of figure). Further questioning disclosed that the patient had fallen on a broken cola bottle when he was 3% years old, sustaining an apparent superficial laceration to the left flank with no immediate complications. Inspection of the skin over the left superior-anterior iliac disclosed a 1 cm. scar. In view of these findings. it was believed that the density within the left kidney most likely represented a glass fragment. The patient was admitted to the hospital for cystoscopy and left retrograde pyelography, which disclosed a normal bladder and confirmed the changes in the left kidney. The complete blood count was normal, the urine was sterile and the serum creatinine was 0.7 mg. per cent with a creatinine clearance of 118.2 ml. per minute per 1.73 J\12. Left renal exploration through a subcostal flank incision revealed a 1.9 cm. splinter of greenish-tinted glass buried in the substance of the kidney and surrounded by a dense white connective tissue. The splinter protruded through Gerota's fascia as if it were hinged to the tip of the 12th costal cartilage. The parenchyma overlying the lower calix appeared thin, but the remainder of the lower pole appeared The glass was removed intact and the defect was closed with chromic gut and gelfoam. Biopsy of the lower pole was normal. Convalescence vrns unremarkable and creatinine clearance 4 postoperatively was unchanged. The IVP obtained 3 months later showed persistent dilation of the lower calices (part C of figure). DISCUSSION
In 1940 Wilhelmi emphasized the rarity of renal foreign objects after searching the world literature of the previous decade and finding 13 cases. 2 All patients had hematuria and only one 2 Wilhelmi, 0. J.: Foreign body in the kidney. J. Urol., 43: 182, 1940.
931
932
RUSSI AND ASSOCIATES
A, nephrotomogram shows glass fragment (arrow) partially in kidney. Collecting system is not involved. B, IVP 2 years later shows glass has moved further into kidney causing partial obstruction of lower pole calix. Arrow points to cortical retraction about fragment. C, 3 months after removal of glass there is persistent calicectasis and cortical scarring.
had a sterile urine. Infections could not be cured until the foreign object was removed. Most patients eventually had nephrectomy. In Wilhelmi's case, removal of a darning needle, without nephrectomy, resulted in normal recovery. In 1953 Osmond analyzed 26 of 34 previously reported cases and reported 4 new cases. 1 The foreign objects reached the kidneys by intestinal migration, ascending the ureter, or by cutaneous transgression. Findings in order of frequency were flank pain, hematuria and symptoms of urinary infection. Nephrectomy was performed in 10 patients but the remainder had nephrostomy or pyelotomy. In 1953 Nelson reported removing a bobby pin from the lower pole pelvis of a kidney
with a duplicated collecting system in a 4-year-old girl who had had renal colic with gross hematuria. 3 In 1955 Gondos reported on a fish bone in the left kidney, migrating from the large intestine and presenting as a perirenal abscess. 4 In 1967 Yue summarized 11 cases from the literature and added a case of renal foreign object expressly attributed to trans-intestinal migration• and a Nelson, 0. A., Kretz, A. W., McCormack, J. L., Docter, J.M. and Douglass, C. W.: A bobby pin in the kidney pelvis. J. Urol., 69: 618, 1953. 4 Gondos, B.: Foreign body in the left kidney and ureter. J. Urol., 73: 35, 1955. 5 Yue, K. P. and Johnson, H. W.: Foreign body in the kidney: trans-intestinal migration. J. Urol., 98: 172, 1967.
933
GLASS FOREIGN OBJECT IN KIDNEY
Thomas reported a patient in whom a nail entered the kidney from the duodenum. 6 In 1968 Baird again reviewed the literature regarding ingested foreign objects migrating to the kidney and added 3 new cases. 7 Recently, Bretland and Blacklock reported a most interesting case of a grenade fragment entering the kidney, which was found a year later when colic occurred; the fragment migrated down the ureter. 8 These authors reviewed the literature in detail and the Thomas, W. J.: A renal foreign body of alimentary origin. Brit. J. Surg., 54: 1036, 1967. 7 Baird, J. M. and Spence, H. M.: Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. J. Urol., 99: 675, 1968. 8 Bretland, P. M. and Blacklock, N. J.: Grenade ±ragment in the ureter: a recent case; with a review of the literature on foreign bodies in the kidney and ureter. Brit. J. Ural., 40: 223, 1968. 6
only glass foreign object reported was a broken thermometer that had ascended from the bladdeL Our case graphically demonstrates that glass is radiopaque and can be seen in soft tissues because its density is greater than water. 9 If a roentgenogram had been obtained when the patient first sustained the laceration, the glass foreign body could have been seen and removed. SUMMARY
An 8-year-old boy with intermittent hematuria owing to a glass fragment in the kidney is described. The literature is discussed and the importance of roentgenographic examination with any trauma involving glass is emphasized. 9 Felman, A. H. and Fisher, M. S.: The radiographic detection of glass in soft tissue. Radiology, 92: 1529, 1969.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1971 by The Williams & Wilkins Co.
Pediatric Urology GLASS FOREIGN OBJECT IN THE KIDNEY MELVIN F. RUSSI, ALAN R. BUTLER, RUTH A. PICK
AND
WILLIAM R. FAIR*
From the Department of Surgery, Division of Urology, and Department of Radiology, Stanford University School of Medicine, Stanford, California
Renal foreign objects from non-violent trauma are rare. 1 A case of glass foreign object in the kidney, occurring from minor trauma and present for nearly 5 years, is reported herein. CLINICAL SUMMARY
M. SlVIR 30 12 96, an 8-year-old white boy, had painless intermittent gross hematuria 18 months in duration. After the first episode in October 1967, he was evaluated by his physician; physical examination. was normal. The white blood count, erythrocyte sedimentation rate and antistreptolysin titer were normal. Blood urea nitrogen. was 6 mg. per 100 ml. (mg. per cent). The excretory urogram (IVP) revealed a 20 by 4 mm. lenticular density within the mid lateral aspect of the left kidney, extending beyond the lateral border. There was minimal scarring around the density and the pelviocaliceal systems were normal bilaterally (part A of figure). Cystoscopy and retrograde pyelography were negative. The family was reassured, but 3 recurrent episodes of hematuria after exercise prompted referral for consultation. Physical examination in July 1969 was again normal. The urine was sterile and free of cells and protein. An intermediate purified protein derivative skin test was non-reactive. It was elected to repeat cystoscopy during an episode of hematuria. Gross painless hematuria occurred in September 1969 but subsided spontaneously before cystoscopic localization could be performed. On a repeat IVP the lenticular density had migrated further into the kidney, involving the infundibulum of the lower pole calices, which were dilated Accepted for publication December 1970. Supported by United States Public Health Service Training Grant No. 5 ToI Am 05513. * Requests for reprints: Division of Urology, Stanford University School of Medicine, Stanford, California 94305. 1 Osmond, J. D.: Foreign bodies in the kidney. Radiology, 60: 375, 1953.
(part B of figure). Further questioning disclosed that the patient had fallen on a broken cola bottle when he was 3% years old, sustaining an apparent superficial laceration to the left flank with no immediate complications. Inspection of the skin over the left superior-anterior iliac disclosed a 1 cm. scar. In view of these findings. it was believed that the density within the left kidney most likely represented a glass fragment. The patient was admitted to the hospital for cystoscopy and left retrograde pyelography, which disclosed a normal bladder and confirmed the changes in the left kidney. The complete blood count was normal, the urine was sterile and the serum creatinine was 0.7 mg. per cent with a creatinine clearance of 118.2 ml. per minute per 1.73 J\12. Left renal exploration through a subcostal flank incision revealed a 1.9 cm. splinter of greenish-tinted glass buried in the substance of the kidney and surrounded by a dense white connective tissue. The splinter protruded through Gerota's fascia as if it were hinged to the tip of the 12th costal cartilage. The parenchyma overlying the lower calix appeared thin, but the remainder of the lower pole appeared The glass was removed intact and the defect was closed with chromic gut and gelfoam. Biopsy of the lower pole was normal. Convalescence vrns unremarkable and creatinine clearance 4 postoperatively was unchanged. The IVP obtained 3 months later showed persistent dilation of the lower calices (part C of figure). DISCUSSION
In 1940 Wilhelmi emphasized the rarity of renal foreign objects after searching the world literature of the previous decade and finding 13 cases. 2 All patients had hematuria and only one 2 Wilhelmi, 0. J.: Foreign body in the kidney. J. Urol., 43: 182, 1940.
931
932
RUSSI AND ASSOCIATES
A, nephrotomogram shows glass fragment (arrow) partially in kidney. Collecting system is not involved. B, IVP 2 years later shows glass has moved further into kidney causing partial obstruction of lower pole calix. Arrow points to cortical retraction about fragment. C, 3 months after removal of glass there is persistent calicectasis and cortical scarring.
had a sterile urine. Infections could not be cured until the foreign object was removed. Most patients eventually had nephrectomy. In Wilhelmi's case, removal of a darning needle, without nephrectomy, resulted in normal recovery. In 1953 Osmond analyzed 26 of 34 previously reported cases and reported 4 new cases. 1 The foreign objects reached the kidneys by intestinal migration, ascending the ureter, or by cutaneous transgression. Findings in order of frequency were flank pain, hematuria and symptoms of urinary infection. Nephrectomy was performed in 10 patients but the remainder had nephrostomy or pyelotomy. In 1953 Nelson reported removing a bobby pin from the lower pole pelvis of a kidney
with a duplicated collecting system in a 4-year-old girl who had had renal colic with gross hematuria. 3 In 1955 Gondos reported on a fish bone in the left kidney, migrating from the large intestine and presenting as a perirenal abscess. 4 In 1967 Yue summarized 11 cases from the literature and added a case of renal foreign object expressly attributed to trans-intestinal migration• and a Nelson, 0. A., Kretz, A. W., McCormack, J. L., Docter, J.M. and Douglass, C. W.: A bobby pin in the kidney pelvis. J. Urol., 69: 618, 1953. 4 Gondos, B.: Foreign body in the left kidney and ureter. J. Urol., 73: 35, 1955. 5 Yue, K. P. and Johnson, H. W.: Foreign body in the kidney: trans-intestinal migration. J. Urol., 98: 172, 1967.
933
GLASS FOREIGN OBJECT IN KIDNEY
Thomas reported a patient in whom a nail entered the kidney from the duodenum. 6 In 1968 Baird again reviewed the literature regarding ingested foreign objects migrating to the kidney and added 3 new cases. 7 Recently, Bretland and Blacklock reported a most interesting case of a grenade fragment entering the kidney, which was found a year later when colic occurred; the fragment migrated down the ureter. 8 These authors reviewed the literature in detail and the Thomas, W. J.: A renal foreign body of alimentary origin. Brit. J. Surg., 54: 1036, 1967. 7 Baird, J. M. and Spence, H. M.: Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. J. Urol., 99: 675, 1968. 8 Bretland, P. M. and Blacklock, N. J.: Grenade ±ragment in the ureter: a recent case; with a review of the literature on foreign bodies in the kidney and ureter. Brit. J. Ural., 40: 223, 1968. 6
only glass foreign object reported was a broken thermometer that had ascended from the bladdeL Our case graphically demonstrates that glass is radiopaque and can be seen in soft tissues because its density is greater than water. 9 If a roentgenogram had been obtained when the patient first sustained the laceration, the glass foreign body could have been seen and removed. SUMMARY
An 8-year-old boy with intermittent hematuria owing to a glass fragment in the kidney is described. The literature is discussed and the importance of roentgenographic examination with any trauma involving glass is emphasized. 9 Felman, A. H. and Fisher, M. S.: The radiographic detection of glass in soft tissue. Radiology, 92: 1529, 1969.