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Hypertension Associated with Solitary Renal Cyst: Report of Two Cases
HYPERTENSION ASSOCIATED WITH SOLITARY RENAL CYST: REPORT OF TWO CASES 1 HENRY A. R. KREUTZMANN From the Department of Urology, Mt. Zion Hospital, San Francisco
The subject of hypertension in unilateral kidney disease raises a number of questions: In the first place, what conditions are able to produce hypertension; in the second place, does unilateral renal disease produce this condition in a sufficient number of cases to warrant complete urological investigation and possible operation. And lastly, will renal surgery result in a normal pressure; an amelioration of symptoms or an arrest in the progress of the disease. These questions are of importance to the urologist, as he is frequently called upon by other physicians to decide whether a patient with hypertension should be investigated from a urological standpoint. Sufficient time has now elapsed since Goldblatt's original work to evaluate the results and draw definite conclusions. The types of unilateral renal conditions reported in the literature which have been enumerated as causing hypertension and relieved by surgery are many and of a most diverse nature. This has caused confusion as the increased blood pressure cannot be explained by a single pathological entity. In general, however, it appears to occur most often where there is a decrease in the caliber of the renal vessels. This is substantiated by the literature in which some type of chronic pyelonephritis is mentioned as the most common unilateral lesion. Solitary renal cyst is one of the rarer causes of hypertension. Up to the present time only 2 cases have been reported. Pierce, Bower and Burns mention 1 case in which the blood pressure was normal 3½ years after operation. The second is that of Farrell and Young, in ,Yhich the blood pressure was 114 systolic and 74 diastolic 10 months after surgery. 'We wish to report 2 more cases of hypertension due to solitary renal cyst treated by us during the past 3 years. Case 1. Mrs. E. G., aged 69, referred by Dr. S. Lazar, complained of hypertension. The past history was irrelevant. Since 1938 the patient had had numerous physical examinations each year and was always found to be in good physical condition. The blood pressure, taken many times between August 1938 and August 1942, varied from 168/88 to 174/88. This latter pressure was noted in 1940. Readings in 1941 and 1942 varied between 150/94 to 168/94. In December 1942 the patient complained of undue fatigue and nervousness. She was found to have suddenly a blood pressure of 252/132. Bed rest with diet and sedatives produced no change in the pressure. An intravenous pyelogram ordered by Dr. Lazar showed a normal right kidney. In the left kidney, the roentgenologist reported that the middle and inferior 1 Read by title at the meeting of the Western Section of the American Urolo12;ical Association. Riverside, Calif., May 1, 1946. 467
468
HENRY A. R. KREUTZMANN
calyces were widely separated by a smooth mass measuring 4½ by 8 cm. This mass appeared to be continuous with the nodular shadow along the lateral margin of this kidney. The mass produced a pressure defect of the lower pelvis and infundibulum. Conclusion: Tumor mass in the left kidney causing distortion of the middle and inferior calyces and pressure defect of the pelvis. The heart showed moderate enlargement of the left ventricle. The fundi of both eyes showed no hemorrhages or exudate. The arteries were somewhat narrowed, the terminal vessels were moderately tortuous. The blood pressure was 252/132.
FIG. 1. Case 1. Left pyelogram, showing distortion of calyces due to intrarenal cyst
Kidney investigation showed no pus or red blood cells in either kidney. Urine cultures were negative. Phthalein injected intravenously appeared from both catheters in 4 minutes. Over a 15 minute period 25 per cent of the dye was secreted by the right kidney and 20 per cent by the left kidney. A retrograde pyelogram emphasized the same filling defect in the left kidney as was found at intravenous pyelography (fig. 1). In view of the localized bulging of the dorsum of the left kidney in the region of the displaced calyces, a diagnosis of solitary renal cyst was made preoperatively. Operation was performed January 23, 1943. There was a decreased amount of perirenal fat about the left kidney and it was exposed without difficulty. A cyst about the size of a lemon was found protruding from the dorsum of the kidney. It was aspirated and 120 cc clear, light yellow fluid was removed.
469
HYPERTENSION WITEt RENAL CYST
The redundent walls were cut.away, and examination showed the cyst to have penetrated down to the mucosa of the renal pelvis. It completely split the kidney leaving a portion about two-thirds the entire length of the kidney above and one-third below. It was impossible to remove the walls of the sac from the renal substance. In order to prevent recurrence of the cyst, the surfaces of the sac were scarified to produce bleeding and the surfaces were then approximate<;! with a number of fine chromic sutures. It was interesting to note that at the instant the sac was emptied, the systolic pressure dropped from 210 to 140 and the diastolic from 108 to 90 (fig. 2). On discharge from the hospital, the patient's blood pressure was 162/82. One Operation begun
240 2 3o
2 20
O
5
10
IS
2s
M
,n
35
45
40
50
60
70
j\
I ,
Systo ic
Asp,rotio o cyst
'\
210
200 190
80 170
/
60
I
so
End of
operation
50 14
'\
I
Dlost1 ic \
20 110
'= 90
b-- I--.
-
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r-...-
80
Frn. 2. Case 1. Showing blood pressure throughout surgery, and sudden drop when cyst was aspirated
year later, January 1944, it was 156/88. Two years later, January 1945, the pressure was 162/90. In August 1945 the patient had a left mastectomy for carcinoma of the left breast. Three years after operation, January 1946, the pressure was 156/94, approximately the same as before the sudden rise occurred. Case 2. Mrs. N. P., aged 50, referred by Dr. R. Alexander, complained chiefly of nervousness, dizziness, and dyspnea. She had a dull pain in the right lower abdomen and in the right kidney region. The patient had undergone an operation for glaucoma of the right eye followed by loss of vision 4 years ago; otherwise there was nothing of significance. The patient's complaints began about 4 years ago, but lately had become
470
HENRY A. R. KREUTZMANN
more intense, especially the pain in the abdomen and kidney region. On exertion, such as walking upstairs or uphill, she became dyspneic and had palpitation. The blood pressure was 210/125; the pulse rate 100. Palpation of the abdomen revealed a mass on the right side which was smooth, rounded and tender, and appeared to be part of the right kidney. A kidney investigation was done September 4, 1943. Urine specimens from both kidneys showed no pus cells, and the cultures were negative. Phthalein injected intravenously appeared from both catheters in 5 minutes. Over a 15 minute period, 14 per cent of the dye was obtained from the left and 15 per cent from the right kidney. Retrograde pyelography showed a normal left kidney. On the right side a Grade I hydronephrosis with a large solitary cyst protruding from the dorsum of the kidney approximately half way from both poles was noted. The preoperative diagnosis was hypertension possibly due to solitary cyst of the right kidney. Operation was performed September 14, 1943. The kidney was exposed without difficulty, and a cyst the size of a small orange was found occupying the middle portion of the kidney. The entire cyst wall protruding beyond the kidney was removed. It was then noted that the cyst extended down to the renal pelvis and actually split the kidney into two equal sized portions. On approximating the two halves, the kidney appeared of normal size, so it was decided not to remove it. As it was impossible to dissect the sac wall from the renal tissue, the surface of the cyst was scarified. The two halves of the kidney were then held together with a number of fine chromic sutures passed through the cyst walls. It was interesting to observe that throughout the manipulation and removal of the cyst, the patient's blood pressure fluctuated widely and was consistently lower after evacuation of the cyst. On leaving the hospital, the patient's blood pressure was 150/105. Her blood pressure since discharge has been taken every few months. It now appears to be fixed at 170/100. Fourteen months ago she fractured her left hip and had a pin inserted by open operation. She had no untoward effects and made an uncomplicated recovery. Although at the present time her blood pressure is higher than normal, her symptoms have disappeared and she is able to do her household work without discomfort. In comparing these 2 cases we find a continued good result in the first patient where the increased pressure was of short duration; while in the second, where it was long standing, we cannot claim a cure. However, the second patient has had considerable relief and the progress of her disease has been definitely stopped. This bears out the statement of Schroeder and Fish that hypertension of more than 2 years' duration is irreversible and that surgery after this time is of little value. A good deal of the confusion as to the efficacy _of surgery is the fact that many
HYPERTENSION WITH RENAL CYST
471
authors rush into print and report a cure if the blood pressure remains normal a few months after surgery, not realizin~ that the pressure can resume its original _ high levels years la~er. In consequence, the conclusi,;ms reachE;id have been far from unanimous. Smith, Goldring and .Chasis, after reviewing the literatµre, conclude that out of 86 cases reported as cured only 11 .met .their criteria of what they consider a favorable result. In order to obtain an accurate estimate of the number of patients who have been cured, we have reviewed every case reported up to the present time. Included in our list are only those patients in whom the blood pressure was not higher than 150 systolic and 90 diastolic at least 1 year after surgery. Our findings have been very encouraging. We have collected from the literature 54 cases that have met our criteria. In some instances, the recorded pressure was normal 4 to 5 years after operation. It was also very gratifying to note the 1arge number of patients relieved of their symptoms and with a permanent reduction of blood pressure several years later. The fact that patients have responded to surgery proves that unilateral kidney disease is the sole etiological factor in producing hypertension in certain cases. It is also evident that the percentage of cures is very small compared to the number of hypertensives found annually. In fact, Braasch states that the incidence of surgical lesions among patients with hypertension amenable t o operation is less than one per cent. We should not be discouraged by the small number of successful cases reported. Instead, we should strive by investigative means to discover more patients who may be relieved by surgery before they have reached the stage where the condition is irreversible. In order for us to determine whether or not a urological investigation or at least excretory urograms should be made, certain definite facts must first be ascertained. 1. We must be sure the condition is not one of essential hypertension. 2. It must be realized that no reduction in blood pressure will occur if the affected kidney is functionless. 3. In all instances, the arterial pressure must be persistently elevated. 4. The increased blood pressure should be less than two years duration in order to obtain a cure. However, in long standing cases surgery may result in relief of symptoms or an arrest of the disease. 5. It is most important that the opposite kidney be normal. Deaths within a short time have been reported following nephrectomy where the other kidney showed decreased function. If these premises are met, a urological investigation should be made and no doubt more cases will be found where surgery will be of distinct benefit, either in bringing the pressure back to normal or in arresting the upward trend.
472
.HENRY A. R . KB.lllUTZl\lANN SUMMARY
· Two cases of hypertension due to solitary renal cyst are reported. ·· In both cases a persistent drop in pressure occurred following destruction of the cysts. · A review of the literature on hypertension due to unilateral kidney disease showed 54 cases with normal blood pressure one .fo five years after surgery. The data necessary to the urologist before deciding to investigate or operate on a patient has been enumerated. 2000 Van Ness Ave., San Francisco, Calif. REFERENCES BRAASCH, W. F.: Canadian M.A.J., 46: 9, 1942. FARRELL, JAMES I. AND YOUNG, RICHARD H.: J . A. M.A., 118: 711, 1942. PIERCE, ALEXANDER E., BOWER, JOHN 0. AND BuRNs, JoHN C.: Ann. Int. Med., 20: 994 June 1944. SCHROEDER, HENRY A . AND FrsH, GEORGE W.: Am. J. Med. Sci., 199: 601 , 1940. SMITH, GoLDRING, AND CHASIS: NewYorkAcad. Med. Bull., 19: 449, 1943
The subject of hypertension in unilateral kidney disease raises a number of questions: In the first place, what conditions are able to produce hypertension; in the second place, does unilateral renal disease produce this condition in a sufficient number of cases to warrant complete urological investigation and possible operation. And lastly, will renal surgery result in a normal pressure; an amelioration of symptoms or an arrest in the progress of the disease. These questions are of importance to the urologist, as he is frequently called upon by other physicians to decide whether a patient with hypertension should be investigated from a urological standpoint. Sufficient time has now elapsed since Goldblatt's original work to evaluate the results and draw definite conclusions. The types of unilateral renal conditions reported in the literature which have been enumerated as causing hypertension and relieved by surgery are many and of a most diverse nature. This has caused confusion as the increased blood pressure cannot be explained by a single pathological entity. In general, however, it appears to occur most often where there is a decrease in the caliber of the renal vessels. This is substantiated by the literature in which some type of chronic pyelonephritis is mentioned as the most common unilateral lesion. Solitary renal cyst is one of the rarer causes of hypertension. Up to the present time only 2 cases have been reported. Pierce, Bower and Burns mention 1 case in which the blood pressure was normal 3½ years after operation. The second is that of Farrell and Young, in ,Yhich the blood pressure was 114 systolic and 74 diastolic 10 months after surgery. 'We wish to report 2 more cases of hypertension due to solitary renal cyst treated by us during the past 3 years. Case 1. Mrs. E. G., aged 69, referred by Dr. S. Lazar, complained of hypertension. The past history was irrelevant. Since 1938 the patient had had numerous physical examinations each year and was always found to be in good physical condition. The blood pressure, taken many times between August 1938 and August 1942, varied from 168/88 to 174/88. This latter pressure was noted in 1940. Readings in 1941 and 1942 varied between 150/94 to 168/94. In December 1942 the patient complained of undue fatigue and nervousness. She was found to have suddenly a blood pressure of 252/132. Bed rest with diet and sedatives produced no change in the pressure. An intravenous pyelogram ordered by Dr. Lazar showed a normal right kidney. In the left kidney, the roentgenologist reported that the middle and inferior 1 Read by title at the meeting of the Western Section of the American Urolo12;ical Association. Riverside, Calif., May 1, 1946. 467
468
HENRY A. R. KREUTZMANN
calyces were widely separated by a smooth mass measuring 4½ by 8 cm. This mass appeared to be continuous with the nodular shadow along the lateral margin of this kidney. The mass produced a pressure defect of the lower pelvis and infundibulum. Conclusion: Tumor mass in the left kidney causing distortion of the middle and inferior calyces and pressure defect of the pelvis. The heart showed moderate enlargement of the left ventricle. The fundi of both eyes showed no hemorrhages or exudate. The arteries were somewhat narrowed, the terminal vessels were moderately tortuous. The blood pressure was 252/132.
FIG. 1. Case 1. Left pyelogram, showing distortion of calyces due to intrarenal cyst
Kidney investigation showed no pus or red blood cells in either kidney. Urine cultures were negative. Phthalein injected intravenously appeared from both catheters in 4 minutes. Over a 15 minute period 25 per cent of the dye was secreted by the right kidney and 20 per cent by the left kidney. A retrograde pyelogram emphasized the same filling defect in the left kidney as was found at intravenous pyelography (fig. 1). In view of the localized bulging of the dorsum of the left kidney in the region of the displaced calyces, a diagnosis of solitary renal cyst was made preoperatively. Operation was performed January 23, 1943. There was a decreased amount of perirenal fat about the left kidney and it was exposed without difficulty. A cyst about the size of a lemon was found protruding from the dorsum of the kidney. It was aspirated and 120 cc clear, light yellow fluid was removed.
469
HYPERTENSION WITEt RENAL CYST
The redundent walls were cut.away, and examination showed the cyst to have penetrated down to the mucosa of the renal pelvis. It completely split the kidney leaving a portion about two-thirds the entire length of the kidney above and one-third below. It was impossible to remove the walls of the sac from the renal substance. In order to prevent recurrence of the cyst, the surfaces of the sac were scarified to produce bleeding and the surfaces were then approximate<;! with a number of fine chromic sutures. It was interesting to note that at the instant the sac was emptied, the systolic pressure dropped from 210 to 140 and the diastolic from 108 to 90 (fig. 2). On discharge from the hospital, the patient's blood pressure was 162/82. One Operation begun
240 2 3o
2 20
O
5
10
IS
2s
M
,n
35
45
40
50
60
70
j\
I ,
Systo ic
Asp,rotio o cyst
'\
210
200 190
80 170
/
60
I
so
End of
operation
50 14
'\
I
Dlost1 ic \
20 110
'= 90
b-- I--.
-
\ \
r-...-
80
Frn. 2. Case 1. Showing blood pressure throughout surgery, and sudden drop when cyst was aspirated
year later, January 1944, it was 156/88. Two years later, January 1945, the pressure was 162/90. In August 1945 the patient had a left mastectomy for carcinoma of the left breast. Three years after operation, January 1946, the pressure was 156/94, approximately the same as before the sudden rise occurred. Case 2. Mrs. N. P., aged 50, referred by Dr. R. Alexander, complained chiefly of nervousness, dizziness, and dyspnea. She had a dull pain in the right lower abdomen and in the right kidney region. The patient had undergone an operation for glaucoma of the right eye followed by loss of vision 4 years ago; otherwise there was nothing of significance. The patient's complaints began about 4 years ago, but lately had become
470
HENRY A. R. KREUTZMANN
more intense, especially the pain in the abdomen and kidney region. On exertion, such as walking upstairs or uphill, she became dyspneic and had palpitation. The blood pressure was 210/125; the pulse rate 100. Palpation of the abdomen revealed a mass on the right side which was smooth, rounded and tender, and appeared to be part of the right kidney. A kidney investigation was done September 4, 1943. Urine specimens from both kidneys showed no pus cells, and the cultures were negative. Phthalein injected intravenously appeared from both catheters in 5 minutes. Over a 15 minute period, 14 per cent of the dye was obtained from the left and 15 per cent from the right kidney. Retrograde pyelography showed a normal left kidney. On the right side a Grade I hydronephrosis with a large solitary cyst protruding from the dorsum of the kidney approximately half way from both poles was noted. The preoperative diagnosis was hypertension possibly due to solitary cyst of the right kidney. Operation was performed September 14, 1943. The kidney was exposed without difficulty, and a cyst the size of a small orange was found occupying the middle portion of the kidney. The entire cyst wall protruding beyond the kidney was removed. It was then noted that the cyst extended down to the renal pelvis and actually split the kidney into two equal sized portions. On approximating the two halves, the kidney appeared of normal size, so it was decided not to remove it. As it was impossible to dissect the sac wall from the renal tissue, the surface of the cyst was scarified. The two halves of the kidney were then held together with a number of fine chromic sutures passed through the cyst walls. It was interesting to observe that throughout the manipulation and removal of the cyst, the patient's blood pressure fluctuated widely and was consistently lower after evacuation of the cyst. On leaving the hospital, the patient's blood pressure was 150/105. Her blood pressure since discharge has been taken every few months. It now appears to be fixed at 170/100. Fourteen months ago she fractured her left hip and had a pin inserted by open operation. She had no untoward effects and made an uncomplicated recovery. Although at the present time her blood pressure is higher than normal, her symptoms have disappeared and she is able to do her household work without discomfort. In comparing these 2 cases we find a continued good result in the first patient where the increased pressure was of short duration; while in the second, where it was long standing, we cannot claim a cure. However, the second patient has had considerable relief and the progress of her disease has been definitely stopped. This bears out the statement of Schroeder and Fish that hypertension of more than 2 years' duration is irreversible and that surgery after this time is of little value. A good deal of the confusion as to the efficacy _of surgery is the fact that many
HYPERTENSION WITH RENAL CYST
471
authors rush into print and report a cure if the blood pressure remains normal a few months after surgery, not realizin~ that the pressure can resume its original _ high levels years la~er. In consequence, the conclusi,;ms reachE;id have been far from unanimous. Smith, Goldring and .Chasis, after reviewing the literatµre, conclude that out of 86 cases reported as cured only 11 .met .their criteria of what they consider a favorable result. In order to obtain an accurate estimate of the number of patients who have been cured, we have reviewed every case reported up to the present time. Included in our list are only those patients in whom the blood pressure was not higher than 150 systolic and 90 diastolic at least 1 year after surgery. Our findings have been very encouraging. We have collected from the literature 54 cases that have met our criteria. In some instances, the recorded pressure was normal 4 to 5 years after operation. It was also very gratifying to note the 1arge number of patients relieved of their symptoms and with a permanent reduction of blood pressure several years later. The fact that patients have responded to surgery proves that unilateral kidney disease is the sole etiological factor in producing hypertension in certain cases. It is also evident that the percentage of cures is very small compared to the number of hypertensives found annually. In fact, Braasch states that the incidence of surgical lesions among patients with hypertension amenable t o operation is less than one per cent. We should not be discouraged by the small number of successful cases reported. Instead, we should strive by investigative means to discover more patients who may be relieved by surgery before they have reached the stage where the condition is irreversible. In order for us to determine whether or not a urological investigation or at least excretory urograms should be made, certain definite facts must first be ascertained. 1. We must be sure the condition is not one of essential hypertension. 2. It must be realized that no reduction in blood pressure will occur if the affected kidney is functionless. 3. In all instances, the arterial pressure must be persistently elevated. 4. The increased blood pressure should be less than two years duration in order to obtain a cure. However, in long standing cases surgery may result in relief of symptoms or an arrest of the disease. 5. It is most important that the opposite kidney be normal. Deaths within a short time have been reported following nephrectomy where the other kidney showed decreased function. If these premises are met, a urological investigation should be made and no doubt more cases will be found where surgery will be of distinct benefit, either in bringing the pressure back to normal or in arresting the upward trend.
472
.HENRY A. R . KB.lllUTZl\lANN SUMMARY
· Two cases of hypertension due to solitary renal cyst are reported. ·· In both cases a persistent drop in pressure occurred following destruction of the cysts. · A review of the literature on hypertension due to unilateral kidney disease showed 54 cases with normal blood pressure one .fo five years after surgery. The data necessary to the urologist before deciding to investigate or operate on a patient has been enumerated. 2000 Van Ness Ave., San Francisco, Calif. REFERENCES BRAASCH, W. F.: Canadian M.A.J., 46: 9, 1942. FARRELL, JAMES I. AND YOUNG, RICHARD H.: J . A. M.A., 118: 711, 1942. PIERCE, ALEXANDER E., BOWER, JOHN 0. AND BuRNs, JoHN C.: Ann. Int. Med., 20: 994 June 1944. SCHROEDER, HENRY A . AND FrsH, GEORGE W.: Am. J. Med. Sci., 199: 601 , 1940. SMITH, GoLDRING, AND CHASIS: NewYorkAcad. Med. Bull., 19: 449, 1943