THE JOURNAL OF UROLOGY
Vol. 62, No. 4, October 1949
Printed in U.S.A.
HEMANGIOMA OF A RENAL PAPILLA: CASE REPORT E. C. WILLIAMS From the Department of Urology, Hermann Hospital, Hoilston, Texas
This case is presented for the purpose of once again emphasizing hemangioma as a cause of persistent hematuria of obscure origin. Particularly stressed is that type of unilateral bleeding in which radiological findings, after repeated upper tract studies, are insignificant or absent. Every urologist is faced, on occasion, with the difficult clinical problem of whether or not surgical intervention is justified in these cases. The literature has been carefully reviewed on several occasions in the last 20 or 30 years. The most recent review by White and Braunstein (1946) states that there had been fewer than 42 cases of hemangioma reported since first described by Virchow. A survey of the literature was made by this writer in an attempt to determine whether or not pyelographic evidence of pathological changes were noted. Reports in which pyelograms showed minimal or absence of suggestive changes were extremely rare. The overwhelming preponderance of cases show some radiological deformity. It is thought that perhaps cases of the type reported below may be often overlooked until severe renal pain or hemorrhage warrants surgical treatment. The utopian treatment of the small angiomatous lesions of the kidney is undoubtedly electrocoagulation or partial renal resection as reported in the excellent work of Hamm (1946). The difficulty which confronts the operator in locating these minute lesions, through a pyelotomy opening, stands in the way of such an ideal in conservative renal surgery. CASE REPORT
J. C., a 51 year old Negro, was first seen in the clinic in 1941, complaining of left loin pain and blood in the urine, intermittently for 9 months. The general physical examination was essentially negative except for definite left costovetebral angle tenderness on deep palpation. The external genitalia and prostate were essentially negative. The voided urine in three glasses was grossly bloody The urine otherwise was essentially negative. The blood count, blood chemistry and the vVassermann were normal. Cystoscopy revealed a normal bladder and urethra. The urine from the right ureteral orifice was clear; that from the left was grossly bloody. No. 5 flute catheters passed to each renal pelvis with ease and without evidence of obstruction. No residual urine was obtained. Intravenous indigo carmine appeared from both sides in normal time and in good concentration. The urine specimens were negative except for blood in the left kidney specimen. Guinea pig inocculation was negative. The plain x-ray and retrograde pyelograms were negative except for mild clubbing of the calyces on the left side (fig. 1). A chest film was negative. Cystoscopy 3 times in a period of 3 months resulted in identical findings. 436
HEMANGIOMA OF A RENAL PAPILLA
Fm. l. Left ureteropyelogram with varying amounts of opaque medium. Angioma, found at surgery, in superior calyx, is not evident in roentgenograms.
Fm. 2. Angiomatous lesion of papilla, showing newly formed, thin-walled blood spaces.
The patient was not seen again until 6 years later, complaining of the same symptoms, which had been present constantly for 3 years prior to re-admission.
E. C. WILLIAMS
For 3 or 4 weeks the pain had been incapacitating and he had passed many small string-like clots. The findings in the general physical examination, urine, blood chemistry, diagnostic study and pyelograms were essentially the same as previously noted in 1941. In view of the incapacitating pain and continuing hemorrhage, a left nephrectomy was performed on February 9, 1948, after exploration of the left kidney revealed only bloody urine in the renal pelvis. The patient had an uneventful postoperative course and was discharged from the hospital on the seventh postoperative day. The pathological report of the surgical tissue was as follows: Grossly, the kidney was normal in size, shape and color, but with persistent lobulation. The papilla, in the superior calyx, bulged slightly and the tip was more reddened than normally noted. The pelvis and ureter were normal but contained many flecks of old blood. Microscopically, the section through the previously described papilla showed many thin walled vessels engorged with blood. There was a peripheral area composed of newlyformed thin walled blood spaces which was typical of a small angioma. This pathology was sufficient to account for the hemorrhage. Diagnosis: Hemangioma of renal papilla. (See figure 2.) The patient has been followed closely in the clinic since surgery, and was last seen in July of this year, at which time the right kidney was rechecked and found to be entirely normal. SUMMARY
A very brief review of the literature, with report of a case of small renal hemangioma, is made for the purpose of stressing this pathological change as a cause of renal pain and hematuria in the absence of significant radiological findings. It is thought that perhaps these smaller hemangiomata are much more frequently present than the literature would indicate. The writer will be ever on guard to eradicate these smaller lesions with conservative surgical procedures, short of nephrectomy.
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