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Management of intrarenal peripelvic cysts
MANAGEMENT OF INTRARENAL PERIPELVIC CYSTS KARL-ERIC LEONARD EDUARDO PABLO
JOHANSON, PLAINE,
M.D.
FARCON,
MORALES,
M.D. M.D.
M.D.
From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT -The results of surgical management of 11 cases of apparent intrarenal peripelvic cysts are presented. One unsuspected malignant tumor was found in spite of the benign appearance of the lesion on preoperative nephrotomogram and selective renal angiography. The unique features of peripelvic cysts, which make their diagnosis and treatment particularly difficult, are discussed. The necessity fm surgical management of peripelvic cysts to relieve obstruction and preserve renal tissue is stressed.
Intrarenal peripelvic cysts arise in the region of the hilum of the kidney intimately associated, but not communicating, with the renal pelvis, infunBecause of the restricted dibula, or calyces. confines of the area, they frequently cause significant obstruction of the pyelocalyceal system with progressive destruction of renal tissue. In the past exploration often led to unnecessary nephrectomy. Now, however, increasing facility with extended transhilar intrarenal dissection has made these lesions more amenable to exploration and excision. We present our recent experience with their surgical management. Material Eleven patients with apparent intrarenal peripelvic cysts, producing significant distortion and obstruction of the pyelocalyceal system, were operated on at New York University Medical Center from January, 1973, to June, 1974 (Table I). There were 8 men and 3 women, ranging in age from thirty-eight to sixty-six years. The left kidney was involved in all but 4 cases. The most common symptom was flank pain, while hematuria was present in 3 patients. The lesion was a fortuitous finding on intravenous pyelogram performed for symptoms of the lower tract in 3 patients.
514
Preoperative urologic evaluation included infusion intravenous pyelogram and retrograde pyelography where indicated, nephrotomography, and selective renal angiography. Technique When no lesion can be seen protruding from the surface of the kidney, the transhilar intrarenal dissection is employed. The kidney must be mobilized, thus affording direct visualization of the renal hilum. A cleavage plane is made between the renal pelvis and the peripelvic fat and renal parenchyma. The latter are lifted up with the help of malleable brain retractors bent at the desired angle. 1The complete pelvis, infundibula, and the beginning of the major calyces are exposed at this stage with direct visualization of the cyst (Fig. 1A). The cyst wall can be dissected away from the renal parenchyma and the pelvis with excision of a major portion of the cyst wall (Fig. 1B). If the cyst has attained such a size that it bulges out over the surface of the kidney, it is unroofed and as much of the cyst wall is excised as necessary. A piece offat can then be placed in the bed of the cyst to minimize recurrence. The kidney is placed back into its normal position, and flank incision is closed in the usual manner with drainage.
UROLOGY
I NOVEMBER1974
/ VOLUMEIV,NUMBER5
TPlBLE
Case Number
I.
Finding in 11 cases, January. 197.3, to June, (A’etc York l_‘nioer.sity Medical Center)
Sex and Age
Side
Clinical Picture
Radiographic
1
M,47
Left
Flank pain
2
M.51
Left
3
F.60
Left
Flank pain; hematuria Hematuria
4
M.61
Left
5
M.63
Left
Lower tract symptoms Flank pain
6
Cl.59
Left
Flank pain
7
M,66
Left
8
F.57
Right
Flank pain; hematuria Flank pain
9
hf.53
Right
10
M.62
Right
11
F,38
Right
Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic distortion; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic distortion; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis
Lower tract symptoms Lower tract symptoms Flank pain
Results There were no morbid conditions or deaths related to the surgical procedure. One patient underwent a nephrectomy. The patient (Case 6) was a fifty-nine-year-old man with pain in the left flank. An intravenous pyelogram showed a space-occupying lesion in the midportion of the left kidney, producing distortion and obstruction of the pyelocalyceal system (Fig. 2,4). Nephrotomography demonstrated an intrarenal avascular mass. A left selective renal angiogram failed to reveal any evidence of neovascularity (Fig. 2B). At surgery a solid mass was found unexpectedly after employing the transhilar dissection. Nephrectomy was performed, and the histopathologic examination revealed adenocarcinoma (Fig. 2C). The remaining 10 cases proved to be peripelvic cysts as diagnosed preoperatively. The postoperative intravenous pyelograms showed marked improvement in the pyelographic appearance of all cases. The following 2 cases document the overall satisfactory results obtained. This sixty-three-year-old man (Case 5) was admitted with left flank pain. Intravenous pyelogram showed a mass in the left kidney producing pelvic distortion and hydronephrosis (Fig. 3A).
UHOLOGY
/ NOVEMBER
lY7.l/ VOLUME
IV.NUMBEHS
Findings
1974
Treatment
Pathology
Follow-Up Intravenous Pyelogram
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Nephrectomy
Adenocarcinoma
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good __-
Nephrotomography and a left selective renal angiogram confirmed the avascular lesion. Employing the transhilar approach, most of the cyst wall was excised. Postoperative intravenous pyelogram showed marked improvement of the pyelocalyceal appearance (Fig. 3B). Another patient (Case 9), a fifty-three-year-old man, was admitted for evaluation of symptoms of the lower tract. On intravenous pyelogram a mass in the midportion of the right kidney was noted, producing compression of the renal pelvis and caliectasis (Fig. 4A). A retrograde pyelogram confirmed these findings (Fig. 4B). At surgery, the cyst wall was excised, and the postoperative intravenous pyelogram three weeks later showed marked improvement (Fig. 4C).
Comment Cystic disorders of the kidney are of interest both because of their potentially destructive nature and the diagnostic problems they present. Intrarenal peripelvic cysts, because of their location, represent an even more challenging problem in diagnosis and management. The pathogenesis and source of peripelvic cysts are obscure.
515
FIGURE 1. (A) Zntrarenal peripelvic cyst exposed via transhilar dissection; (B) cyst wall partially excised.
FIGURE2. Case 6. (A) Z&ravenous pyelogram demonstrating crescent-shaped defknity of left renal pelvis, attenuation of upper infundibulum, and hydronephrosis; (B) left selective renal arteriogram, absence of any neovasculariiy; (d) gross specimen: adenockino~a.
Henthorne2 called attention to the possible lymphangiomatous origin of this cyst. He postulates that the “peripelvic lymphatic cyst” develops from a lymphatic ectasia caused by chronic inflammatory changes. According to Allen3 these cysts are remnants of Wolffian bodies. These cysts contribute approximately 5 per cent of renal cysts in a nephrotomic survey of renal masses.4 They are generally of moderate size, spherical, solitary, and unilocular. The fluid within is usually clear or yellowish in color, but never hemorrhagic. The commonest age group is the fifth and sixth decades.
Although there is a wide variety of pelvic and calyceal deformities seen on the intravenous pyelogram, the typical picture is of a perihilar mass which compresses and distorts the pelvis and the calyces without invasion. The renal pelvis may be hardly visible or commonly may be crescent shaped. In most cases there is infundibular attenuation and narrowing either by stretching of the infkndibulum over the cyst or compression. Although the size of the cyst contributes to the degree of obstruction, it is the position of the cyst, in relation to the calyceal infundibulum, and its ability to expand with or without causing com-
FIGURE3. Case 5. (A) Zntravenous pyelogrum demonstrating left renal pelvic obstruction and hydronephrosis; (B) postoperative film demonstrating normalappearing left pyelocalyceal system.
FIGURE4. Case 9. (A) Preoperative intravenous pyelogram demonstrating right renal pelvic obstruction and hydronephrosis; (B) right retrograde pyelogram; (C) postoperative intravenous pyelogram demonstrating marked improvement of right pyelocalyceal system.
pression of the surrounding tissue, that determines the degree of obstruction. The retrograde pyelogram may serve as a supplementary examination in outlining the contour of the cyst and may be helpful in differentiating papillary neoplasm of the renal pelvis and pelvic diverticulum. Prior to the advent of nephrotomography and aortography, the detection of a space-occupying lesion of the kidney was an indication for surgical exploration. This was mandatory to rule out malignant tumor. With the use of nephrotomog-
raphy and aortography, the diagnosis of renal cysts versus tumors can be made with a high degree (90 to 95 per cent) of accuracy.5 When supplemented by translumbar percutaneous aspiration, the degree of diagnostic accuracy is claimed to rise to approximately 98 to 99 per cent. These figures have convinced many nonurologists and urologists to advocate the nonsurgical management of renal cysts. Intrarenal peripelvic cysts, however, because of their location, present a unique diagnostic
problem and if treated nonsurgically, can result in extensive kidney destruction. The overlying kidney tissue makes it more difficult to differentiate cyst from malignant tumor by nephrotomography and renal angiography. In addition percutaneous aspiration of peripelvic cysts can be a hazardous technique because of the close proximity of the major hilar vessels. In our recent experience an unsuspected case of renal cancer was found at the time of surgical intervention in spite of the benign appearance demonstrated during nephrotomography and selective renal angiography. It therefore appears that despite modern radiologic techniques the diagnosis of peripelvic cyst is not so indisputably infallible that surgical intervention can be deferred. Particularly interesting is the destructive effect caused by peripelvic cysts not only by obstruction of the pelvis and calyces but also by direct compression of the parenchyma in the midportion of the kidney. The extent of renal destruction is best appreciated after large peripelvic cysts have been removed; the two poles of the kidney are held together by a thin isthmus of compressed parenchyma and easily fold over each other. We strongly believe that the treatment of peripelvic cysts causing hydronephrosis should be surgical. The use of the extended transhilar technique now makes it possible to explore and excise intrarenal cysts without undue harm to the kidney. We have seen dramatic improvement in the pyelographic appearance, postoperatively, in all of our cases.
518
Summary We have presented the results of the surgical management of 11 cases of apparent intrarenal peripelvic cysts. Because of their location, these cysts can be difficult to distinguish from malignant tumors and, in this small series, one unsuspected case of renal carcinoma was found in spite of the benign-appearing nephrotomogram and selective renal angiogram on preoperative studies. We have illustrated with pre- and postoperative pyelograms how the obstruction and hydronephrosis, frequently caused by peripelvic cysts, can be relieved following their excision. Surgical intervention is, therefore, necessary to preserve renal tissue as well as to rule out a possible malignant tumor. 560 First Avenue New York, New York 10016 (DR. JOHANSON)
References 1. MAHMOOD, P., and MORALES, P.: Extended pyelolithotomy (Gil Vemet’s pyelotomy), J. Urol. 109: 722 (1973). 2. HENTHORNE, J. C.: Peripelvic lymphatic cysts of kidney: a review of the literature on peripelvic cysts, Am. J. Clin. Pathol. 8: 28 (1938). 3. ALLEN, A. C.: The Kidney: Medical and Surgical Diseases, New York, Grune and Stratton, Inc., 1962, p. 11. 4. DUBILIER, W., Jr., and EVANS, J. A. : Peripelvic cyst of kidney, Radiology, 71: 404 (1958). Differentiation between renal cyst and 5. WISE, M. F.: carcinoma, J. Urol. 101: 137 (1969).
UROLOGY / NOVEMBER1974 / VOLUME IV, NUMBER5
JOHANSON, PLAINE,
M.D.
FARCON,
MORALES,
M.D. M.D.
M.D.
From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT -The results of surgical management of 11 cases of apparent intrarenal peripelvic cysts are presented. One unsuspected malignant tumor was found in spite of the benign appearance of the lesion on preoperative nephrotomogram and selective renal angiography. The unique features of peripelvic cysts, which make their diagnosis and treatment particularly difficult, are discussed. The necessity fm surgical management of peripelvic cysts to relieve obstruction and preserve renal tissue is stressed.
Intrarenal peripelvic cysts arise in the region of the hilum of the kidney intimately associated, but not communicating, with the renal pelvis, infunBecause of the restricted dibula, or calyces. confines of the area, they frequently cause significant obstruction of the pyelocalyceal system with progressive destruction of renal tissue. In the past exploration often led to unnecessary nephrectomy. Now, however, increasing facility with extended transhilar intrarenal dissection has made these lesions more amenable to exploration and excision. We present our recent experience with their surgical management. Material Eleven patients with apparent intrarenal peripelvic cysts, producing significant distortion and obstruction of the pyelocalyceal system, were operated on at New York University Medical Center from January, 1973, to June, 1974 (Table I). There were 8 men and 3 women, ranging in age from thirty-eight to sixty-six years. The left kidney was involved in all but 4 cases. The most common symptom was flank pain, while hematuria was present in 3 patients. The lesion was a fortuitous finding on intravenous pyelogram performed for symptoms of the lower tract in 3 patients.
514
Preoperative urologic evaluation included infusion intravenous pyelogram and retrograde pyelography where indicated, nephrotomography, and selective renal angiography. Technique When no lesion can be seen protruding from the surface of the kidney, the transhilar intrarenal dissection is employed. The kidney must be mobilized, thus affording direct visualization of the renal hilum. A cleavage plane is made between the renal pelvis and the peripelvic fat and renal parenchyma. The latter are lifted up with the help of malleable brain retractors bent at the desired angle. 1The complete pelvis, infundibula, and the beginning of the major calyces are exposed at this stage with direct visualization of the cyst (Fig. 1A). The cyst wall can be dissected away from the renal parenchyma and the pelvis with excision of a major portion of the cyst wall (Fig. 1B). If the cyst has attained such a size that it bulges out over the surface of the kidney, it is unroofed and as much of the cyst wall is excised as necessary. A piece offat can then be placed in the bed of the cyst to minimize recurrence. The kidney is placed back into its normal position, and flank incision is closed in the usual manner with drainage.
UROLOGY
I NOVEMBER1974
/ VOLUMEIV,NUMBER5
TPlBLE
Case Number
I.
Finding in 11 cases, January. 197.3, to June, (A’etc York l_‘nioer.sity Medical Center)
Sex and Age
Side
Clinical Picture
Radiographic
1
M,47
Left
Flank pain
2
M.51
Left
3
F.60
Left
Flank pain; hematuria Hematuria
4
M.61
Left
5
M.63
Left
Lower tract symptoms Flank pain
6
Cl.59
Left
Flank pain
7
M,66
Left
8
F.57
Right
Flank pain; hematuria Flank pain
9
hf.53
Right
10
M.62
Right
11
F,38
Right
Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic distortion; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic distortion; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis Pelvic obstruction; hydronephrosis
Lower tract symptoms Lower tract symptoms Flank pain
Results There were no morbid conditions or deaths related to the surgical procedure. One patient underwent a nephrectomy. The patient (Case 6) was a fifty-nine-year-old man with pain in the left flank. An intravenous pyelogram showed a space-occupying lesion in the midportion of the left kidney, producing distortion and obstruction of the pyelocalyceal system (Fig. 2,4). Nephrotomography demonstrated an intrarenal avascular mass. A left selective renal angiogram failed to reveal any evidence of neovascularity (Fig. 2B). At surgery a solid mass was found unexpectedly after employing the transhilar dissection. Nephrectomy was performed, and the histopathologic examination revealed adenocarcinoma (Fig. 2C). The remaining 10 cases proved to be peripelvic cysts as diagnosed preoperatively. The postoperative intravenous pyelograms showed marked improvement in the pyelographic appearance of all cases. The following 2 cases document the overall satisfactory results obtained. This sixty-three-year-old man (Case 5) was admitted with left flank pain. Intravenous pyelogram showed a mass in the left kidney producing pelvic distortion and hydronephrosis (Fig. 3A).
UHOLOGY
/ NOVEMBER
lY7.l/ VOLUME
IV.NUMBEHS
Findings
1974
Treatment
Pathology
Follow-Up Intravenous Pyelogram
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Nephrectomy
Adenocarcinoma
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good
Excision ofcyst
Wall of cyst
Good __-
Nephrotomography and a left selective renal angiogram confirmed the avascular lesion. Employing the transhilar approach, most of the cyst wall was excised. Postoperative intravenous pyelogram showed marked improvement of the pyelocalyceal appearance (Fig. 3B). Another patient (Case 9), a fifty-three-year-old man, was admitted for evaluation of symptoms of the lower tract. On intravenous pyelogram a mass in the midportion of the right kidney was noted, producing compression of the renal pelvis and caliectasis (Fig. 4A). A retrograde pyelogram confirmed these findings (Fig. 4B). At surgery, the cyst wall was excised, and the postoperative intravenous pyelogram three weeks later showed marked improvement (Fig. 4C).
Comment Cystic disorders of the kidney are of interest both because of their potentially destructive nature and the diagnostic problems they present. Intrarenal peripelvic cysts, because of their location, represent an even more challenging problem in diagnosis and management. The pathogenesis and source of peripelvic cysts are obscure.
515
FIGURE 1. (A) Zntrarenal peripelvic cyst exposed via transhilar dissection; (B) cyst wall partially excised.
FIGURE2. Case 6. (A) Z&ravenous pyelogram demonstrating crescent-shaped defknity of left renal pelvis, attenuation of upper infundibulum, and hydronephrosis; (B) left selective renal arteriogram, absence of any neovasculariiy; (d) gross specimen: adenockino~a.
Henthorne2 called attention to the possible lymphangiomatous origin of this cyst. He postulates that the “peripelvic lymphatic cyst” develops from a lymphatic ectasia caused by chronic inflammatory changes. According to Allen3 these cysts are remnants of Wolffian bodies. These cysts contribute approximately 5 per cent of renal cysts in a nephrotomic survey of renal masses.4 They are generally of moderate size, spherical, solitary, and unilocular. The fluid within is usually clear or yellowish in color, but never hemorrhagic. The commonest age group is the fifth and sixth decades.
Although there is a wide variety of pelvic and calyceal deformities seen on the intravenous pyelogram, the typical picture is of a perihilar mass which compresses and distorts the pelvis and the calyces without invasion. The renal pelvis may be hardly visible or commonly may be crescent shaped. In most cases there is infundibular attenuation and narrowing either by stretching of the infkndibulum over the cyst or compression. Although the size of the cyst contributes to the degree of obstruction, it is the position of the cyst, in relation to the calyceal infundibulum, and its ability to expand with or without causing com-
FIGURE3. Case 5. (A) Zntravenous pyelogrum demonstrating left renal pelvic obstruction and hydronephrosis; (B) postoperative film demonstrating normalappearing left pyelocalyceal system.
FIGURE4. Case 9. (A) Preoperative intravenous pyelogram demonstrating right renal pelvic obstruction and hydronephrosis; (B) right retrograde pyelogram; (C) postoperative intravenous pyelogram demonstrating marked improvement of right pyelocalyceal system.
pression of the surrounding tissue, that determines the degree of obstruction. The retrograde pyelogram may serve as a supplementary examination in outlining the contour of the cyst and may be helpful in differentiating papillary neoplasm of the renal pelvis and pelvic diverticulum. Prior to the advent of nephrotomography and aortography, the detection of a space-occupying lesion of the kidney was an indication for surgical exploration. This was mandatory to rule out malignant tumor. With the use of nephrotomog-
raphy and aortography, the diagnosis of renal cysts versus tumors can be made with a high degree (90 to 95 per cent) of accuracy.5 When supplemented by translumbar percutaneous aspiration, the degree of diagnostic accuracy is claimed to rise to approximately 98 to 99 per cent. These figures have convinced many nonurologists and urologists to advocate the nonsurgical management of renal cysts. Intrarenal peripelvic cysts, however, because of their location, present a unique diagnostic
problem and if treated nonsurgically, can result in extensive kidney destruction. The overlying kidney tissue makes it more difficult to differentiate cyst from malignant tumor by nephrotomography and renal angiography. In addition percutaneous aspiration of peripelvic cysts can be a hazardous technique because of the close proximity of the major hilar vessels. In our recent experience an unsuspected case of renal cancer was found at the time of surgical intervention in spite of the benign appearance demonstrated during nephrotomography and selective renal angiography. It therefore appears that despite modern radiologic techniques the diagnosis of peripelvic cyst is not so indisputably infallible that surgical intervention can be deferred. Particularly interesting is the destructive effect caused by peripelvic cysts not only by obstruction of the pelvis and calyces but also by direct compression of the parenchyma in the midportion of the kidney. The extent of renal destruction is best appreciated after large peripelvic cysts have been removed; the two poles of the kidney are held together by a thin isthmus of compressed parenchyma and easily fold over each other. We strongly believe that the treatment of peripelvic cysts causing hydronephrosis should be surgical. The use of the extended transhilar technique now makes it possible to explore and excise intrarenal cysts without undue harm to the kidney. We have seen dramatic improvement in the pyelographic appearance, postoperatively, in all of our cases.
518
Summary We have presented the results of the surgical management of 11 cases of apparent intrarenal peripelvic cysts. Because of their location, these cysts can be difficult to distinguish from malignant tumors and, in this small series, one unsuspected case of renal carcinoma was found in spite of the benign-appearing nephrotomogram and selective renal angiogram on preoperative studies. We have illustrated with pre- and postoperative pyelograms how the obstruction and hydronephrosis, frequently caused by peripelvic cysts, can be relieved following their excision. Surgical intervention is, therefore, necessary to preserve renal tissue as well as to rule out a possible malignant tumor. 560 First Avenue New York, New York 10016 (DR. JOHANSON)
References 1. MAHMOOD, P., and MORALES, P.: Extended pyelolithotomy (Gil Vemet’s pyelotomy), J. Urol. 109: 722 (1973). 2. HENTHORNE, J. C.: Peripelvic lymphatic cysts of kidney: a review of the literature on peripelvic cysts, Am. J. Clin. Pathol. 8: 28 (1938). 3. ALLEN, A. C.: The Kidney: Medical and Surgical Diseases, New York, Grune and Stratton, Inc., 1962, p. 11. 4. DUBILIER, W., Jr., and EVANS, J. A. : Peripelvic cyst of kidney, Radiology, 71: 404 (1958). Differentiation between renal cyst and 5. WISE, M. F.: carcinoma, J. Urol. 101: 137 (1969).
UROLOGY / NOVEMBER1974 / VOLUME IV, NUMBER5