Pararenal pseudocyst

Pararenal

Pseudocyst”

LINO J. ARDUINO, M.D., GEORGE B. PERLSTEIN, JR., M.D., Des Moines, Iowa, AND MICHEL A. GLUCKSMAN, M.D., Cincinnati, Ohio

Laboratory examination reveaIed the white bIood ceI1 count to be 12,400 per cu. mm., with a moderate shift to the Ieft, hemogIobin 14 gm. per cent and hematocrit 47 per cent. UrinaIysis showed ten to tweIve white bIood ceIIs per high power fieId, and was steriIe on cuIture. BIood urea nitrogen, creatinine, caIcium, phosphorous, and seroIogic test for syphilis, were al1 within norma Iimits. PhenoIsuIfonthaIein excretion was 30 per cent in thirty minutes, and 6.5 per cent in sixty. Excretory urogram demonstrated definite dilatation of the right peIvis, caIyces and infundibuIa, with moderate diIatation of the Ieft peIvis onIy. At surgery on June 13, 1960, the right renaI peIvis was found to be distended with about z ounces of cIear urine. There was a stricture at the ureteropeIvic junction over which coursed a smaI1 artery and vein. A CuIp ureteropyeIopIasty was performed, and a venting incision made in the posterior portion of the pelvis. The anastomosis was cIosed without spIinting, and a Penrose drain was pIaced in the renaI fossa adjacent to the venting incision and brought out through the wound. PostoperativeIy, profuse urinary drainage issued from the incision. This subsided graduaIIy, and had stopped aItogether by the fourteenth postoperative day; the drain was removed. During this time the patient’s temperature ranged from 99.5 to 100.5~~. One week Iater, physica examination reveaIed the presence of an iI defined mass in the upper right quadrant of the abdomen, which was not producing symptoms. PIain roentgenogram of the abdomen reveaIed a homogeneous density occupying the upper right quadrant. Excretory urography showed prompt biIatera1 appearance of contrast medium, several coIIections of which were seen on the right, the Iargest were 3 to 4 cm. in diameter, thought to represent the renaI pelvis. Two days Iater, physica examination faiIed to revea1 the mass, and the patient was given a month’s Ieave of absence. On August 2, 1960, foIIow-up studies again reveaIed the presence of a smooth, we11 defined mass in the upper right abdomina1 quadrant.

From tbe Department of Surgery, Section of Urology, Veterans Administration Center, Des Moines, Iowa.

structures applied to, adjacent to, or surrounding the kidney and/or renal peIvis are rare in occurrence. The cause may be obscure, and the CIassification confused by the variety of terms used in the literature to describe this condition. The following case report iIIustrates the deveIopment of a pararenal pseudocyst as a postoperative compIication, resuIting from a fistula at the site of pyeIoureteropIasty, cIearIy demonstrated on pyeIography.

C

.YSTIC

CASE

REPORT

A twenty-three year oId soIdier was initiaIIy seen on May 26, 1960, compIaining of pain in the right flank without radiation, nausea nor vomiting of six hours’ duration after an acute onset. The first episode had occurred about four months prior to this hospita1 admission when the abrupt onset of pain in the right flank and nausea awakened him from sleep, but Iasted onIy four hours. A urinalysis was negative, and suIfonamide medication was prescribed for two days by his physician. For the next three months the patient was asymptomatic. Four weeks prior to the present attack, he was again stricken with pain in the right ffank and nausea whiIe at rest. Symptoms remitted within an hour or two, and he was again symptomfree unti1 this hospitaIization. The only symptoms had been nausea, vomiting and the nonradiating ffank pain. No history of other previous genitourinary probIems, nor of recent or remote trauma to the abdomen were noted. On admission physica examination reveaIed a we11 deveIoped and we11 nourished man, neither acutely nor chronicaIIy iI1. BIood pressure was 130/-/o mm. Hg; he was afebrile, and the onIy finding of significance was moderate tenderness of the right costovertebra1 angIe. Neither kidney was paIpated, nor were other abdomina1 masses paIpated.

* Accepted for pubIication December 7, rg6r. American

Journal

of Surgery,

Volume

103,

June 1962

758

PararenaI The patient was still urograms demonstrated the mass and the right

Pseudocyst

symptom-free. Retrograde a communication between renal pelvis. (Fig. I.) Dark

fluid was obtained from the right uretera catheter, which was left indweIling. This urine was steriIe on culture, as was the midstream voided urine. The catheter was left in place for three weeks, during which time urinary output from the affected side was normaI. Repeated retrograde studies after this interval of catheter drainage faiIed to revea1 the mass or any extravasation. Five weeks after remova of the ureteral catheter, excretory urograms showed moderate hydronephrosis on the right, and the ureteral catheter was reinserted for five days to ensure adequate drainage. Neither the mass nor extravasation of contrast medium was demonstrable and the patient was discharged from the hospita1. A recent communication, May II, 1961, from

the patient indicated that he is in good health, working full time, and compIeteIy asymptomatic. Excretory urography obtained by his physician, eight months after surgery, failed to demonstrate a right pararena mass or extravasation, aIthough some degree of hydronephrosis persists. COMMENTS

FIG. I. Oblique right retrograde pyeIogram with indwelling ureteral catheter clearly demonstrating the fist&us communication (marked by the arrow) between the renal p&is and the pseudocyst.

The entity of cystic structures in close reIationship to the kidney and its peIvis is both unusual and vague as to cause and cIassifIcation. Spriggs [I] in a review of the Iiterature to 1952, presented a system of cIassification outlining three groups distinct from poIycystic disease. These are (I) perinephric extravasation of urine, (2) perinephric hematoma and (3) perinephric cysts of doubtfu1 origin. Trauma, either accidental or surgica1, is usuaIIy the cause factor in the first two types. Crabtree [2] Iisted three factors, which together with trauma, must be present in order to produce the pseudocyst. These are (I) a compIete tear of a collecting system, calyx, ureter, renal peIvis or a wide separation of cortical fragments, (2) failure of the defect to seal off prior to the escape of a quantity of urine and (3) the presence of an obstructed ureter beIow the site of the injury. Thompson [3] differentiated between pararenaI and perinephric fIuid coIIections, wherein the former are extrinsic to the renaI parenchyma and capsuIe, but cIoseIy associa.ted with them in the renai fossa; the latter are within the capsule of the kidney, or so cIoseIy associated with the capsuIe that differentiation cannot be made. PeripeIvic lymphatic cysts

are incIuded in the perinephric form of Auid collections. Pyrah and Smiddy 141 in 1952 reported two cases of pararena pseudohydronephrosis, one deveIoped following surgery on the ureteropeIvic junction. Neither pus nor urine was found within the sac on subsequent exploration, and a tota absence of perinephric fat was noted. Sauls and Nesbit [i;], in reporting four cases of this entity, found no fat and only fibrous tissue lining the pseudocyst wall by specia1 staining technics. CuIture of the fluid yielded no growth in three of the instances, leading them to postulate that, had the urine been infected, an abscess rather than a pseudocyst wouId have resuIted. Razzaboni [6], in producing the Iesion experimentaIIy, found aImost compIete Iipolysis taking pIace within five days after continued urinary extravasation into the renal fossa. Our patient presented unusual features in that retrograde pyeIography demonstrated cIearIy the communication between renal peIvis and pseudocyst. In addition, the pseudocyst 759

Arduino,

PerIstein

disappeared and did not recur in the four months foIIowing treatment by uretera catheter drainage. Pyrah and Smiddy [4] did not beIieve that catheter drainage aIone was suff~cient treatment, but SauIs and Nesbit [5] have supplied a possibIe expIanation for our resuIt in their observation that the pseudocyst does not have an epitheIia1 Iining. With a catheter spIinting the uretera defect and draining the renaI peIvis, the defect cIosed with subsequent disappearance of the pseudocyst. One of the cases reported by SauIs and Nesbit [5] formed a pseudocyst fohowing a ureteroIithotomy, and was found to have a defect in the upper ureter when subsequent surgery was performed. However the defect did not hea postoperativeIy unti1 indwehing uretera catheter drainage was used, confirmed by excretory urography two and a half months Iater. PyrIoureteropIasty, without splinting, wouId appear to create the conditions necessary to fuIfiI1 :Crabtree’s [2] criteria for the deveIopment of a pararena pseudocyst. A quantity of urine may continue to escape either from the suture Iine or from a venting incision, and the ureter distaIIy may be occluded by a blood cIot, hematoma or edema. Furthermore, the

and GIucksman frequent use of antibiotics in the preoperative and postoperative periods may tend to steriIize the urine, minimizing the tendency toward abscess formation. SUMMARY

To our knowIedge, the foregoing case report is the fifth exampIe to appear in the literature of the deveIopment of a pararena pseudocyst as a postoperative complication, and the first to respond primariIy to conservative management. Some of the more pertinent points reIating to this probIem are taken from the extant Iiterature. REFERENCES I.

2.

3. 4.

,$. 6.

SPRIGGS, A. I. Perinephric

cysts. J. &ok,

67:

414,

1952. CRABTREE, E. G. PararenaI pseudo-hydronephrosis, with reoort of three cases. Tr. Am. A. Genito-Win. Surgeok, 28: g, 1935. THOMPSON, I. M. Peripelvic lymphatic renaI cysts. J. Ural., 78: 343, 1957. PYRAH. L. N. and SMIDDY. F. G. PararenaI Dseudohgdionephrosis; a repok of two cases. hit. J. Ural., 25: 239, 1953. SAULS. C. L. and NESBIT. R. M. Pararenal Dseudocysts. To be published.’ RAZZABONI, G. Pseudo-hydronephrosis. Arch. Ital. Di Cbir., 6: 365, 1922.