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Pelvic Kidney and Renal Vessels in a Newborn Child1
PELVIC KIDNEY AND RENAL VESSELS IN A NEWBORN CHILD 1 GEORGE A. BOYLSTON AND BARRY J. ANSON From the Northwestern University Medical School, Chicago
Congenital malplacement of the kidney is not extremely uncommon although estimates of its incidence vary considerably. For instance, Campbell (1930) collected 72 cases of renal dystopia from 47,477 autopsy protocols (0.15 per cent); Stewart and Lodge (1923) found 3 cases in 6,500 autopsies (0.04 per cent). Reports of renal dystopia in the young are exceedingly rare; one case, in an infant 12 weeks of age was reported by Campbell (1930); another in a child 14 months of age was found by Thomas and Barton (1936). The youngest case in a series of 20 seen at the Mayo Clinic between 1910 and 1926 occurred in an eleven-yearold child (Mayo and Johnson, 1926). It is patent that these dystopic kidneys are discovered only by accident in the very young, since they are composed of functionally competent tissue. There have been only a few reports of dystopic kidneys which have had a principal artery derived from a contralateral arterial trunk; in a study of ten dystopic kidneys Anitschkow (1912) found one supplied by an artery arising from the contralateral common iliac, another from the aorta at its bifurcation (middle sacral); Sexton (1935) described a case of renal dystopia in a female 37 years old in which one of the 3 renal arteries arose from the bifurcation of the aorta. "Horseshoe" kidneys may derive part of their arterial supply from the middle sacral as well as from the common iliac (see fig. p., in Anson, Richardson, and Minear 1936). These arterial anomalies are evidently due to the persistence of vascular channels present in the embryo. From a study of the embryonic blood-supply of the kidneys and related organs, Bremer (1915) found that there is an absence of specificity in the developing channels in this visceral network, the ultimate supply of an individual organ being governed merely by mechanical convenience. A permanent renal vessel is then merely one of the numerous embryonic sprouts, sent out from the aortic endothelium, which intercommunicate both vertically and horizontally. An extra renal branch from either iliac or middle sacral artery represents 1 Contribution no. 274 from the Anatomical Laboratory of Northwestern University Medical School. 502
PELVIC KIDNEY AND RENAL VESSELS IN NEWBORN
503
a persistence of the more caudal elements in this anastomotic network. Kidneys and renal vessels. In the authors' specimen of a newborn female the right kidney was lobulated, of normal size and form; it was The supplied by a single renal artery, drained by a single renal right ureter was normal in calibre and course.
Fm. L Kidneys and their blood-vessels in a newborn female child. peritoneum removed except in area of sigmoid colon. (¾ natural size.) anomalous left kidney at the level indicated in fig. 1
Digestive tube aud a. A section of the
On the left side the kidney and the renal vessels presented striking anomalies. The lacked the typical reniform shape; the entire organ was flattened, being only one-fourth as thick as wide (fig. Its outline was therefore oval rather than circular~-the length being greater than the width (fig. 1). The actual measurements were as follows: length, 4 cm.; width, 2.8 cm.; thickness, (l 7 cm. The renal pelvis, small in was situated almost in the center of the organ, 1); the hilus, in which it rested, resembled a sulcus facing anteriorly
504
GEORGE A. BOYLSTON AND BARRY J. ANSON
(fig. la) more than it did a hilus of normal kidney. The superolateral two-thirds of the anomalous kidney lay within the greater pelvis, the inferomedial one-third within the lesser pelvis; molded against the pelvic brim, it rested upon the left common iliac artery by which its posterior surface was grooved. In their unusual arrangement the arterial supply and the venous drainage matched the peculiarity of the renal form. There were 2 renal arteries and 2 veins (fig. 1). The superior one of the 2 renal arteries arose from the aorta at the level of origin of the inferior mesenteric artery; following a transverse course, until it reached a midpoint on the superior margin, the vessel turned sharply downward, accompanied the vein into the renal hilus. The inferior one of the renal arteries arose from the common iliac artery of the opposite side 1.5 cm. below the bifurcation of the aorta; following a direct transverse course the artery entered the hilus, again accompanied by a renal vein. The small middle sacral artery did not send branches to the kidney. The superior one of the two renal veins, leaving the upper portion of the hilus, joined the left ovarian vein to form a common vein trunk which, after following an oblique course, emptied into the inferior vena cava at a high abdominal level. The inferior one of the veins crossed the medial half of the kidney, at first following the course of the artery of iliac origin; then turning upward it entered the inferior vena cava as a split vessel superior to the point of junction of the common iliac veins. The right ureter was normal. That of the left side was much shorter than normal. Leaving the anteriorly placed hilus (where it was related on both superior and medial aspects to an artery and vein) it followed a somewhat sigmoid course into the urinary bladder. Histologically, the left kidney seemed entirely normal in structure; there was no evidence of cystic or other pathological condition. Digestive tube. In addition to the left renal anomally already described, there existed in this infant an interesting malrotation of the large and small bowel. The caecum lay in the left lower quadrant, immediately over the dystopic kidney; from the caecum the vermiform appendix projected to the right. The ascending colon crossed the abdomen from left lower to right upper quadrant to reach a normally situated hepatic flexure. The remainder of the colon and sigmoid were normally placed. The right lower and a large part of the right upper quadrants of the abdomen were occupied by small bowel. The duodenojejunal flexure lay free between the unfused mesentery of the transverse colon and the mesentery of the sigmoid colon.
PELVIC KIDNEY AND RENAL VESSELS IN NEWBORN
505
REFERENCES ANITSCHKOW, N. N.: Study of renal vessels in congenital renal dystopy.
Virch. Arch., 207: 213-235, 1912. ANSON, B. J., RICHARDSON, G. A. AND MINEAR, W. L.: Variations in number and arrangement of renal vessels. J. UroL, 36: 211-219, 1936. BREMER, J. L.: Origin of renal artery. Am. J. Anat., l.8: 179-200, 1915. CAMPBELL, M. E,: Renal ectopy. J UroL, 24: 187-195, 1930. MAYO, W. C. AND JOHNSON, A. C.: Ectopic kidney presenting as a pelvic tumor. Surg. CJin. N. Amer., 6: 1121-1123, 1926. SEXTON, W. G.: Renal ectopia. J. UroL, 33: 521-525, 1935.
STEWART, M. J. AND LODGE, S. D.: On unilateral fused kidneys and allied renal malformations. Brit. J. Surg., 11: 27-37, 1923. THOMAS, G. J. AND BARTON, J C. · Ectopic pelvic kidney. J. A. M. A., 106: 197-199, 1936.
Congenital malplacement of the kidney is not extremely uncommon although estimates of its incidence vary considerably. For instance, Campbell (1930) collected 72 cases of renal dystopia from 47,477 autopsy protocols (0.15 per cent); Stewart and Lodge (1923) found 3 cases in 6,500 autopsies (0.04 per cent). Reports of renal dystopia in the young are exceedingly rare; one case, in an infant 12 weeks of age was reported by Campbell (1930); another in a child 14 months of age was found by Thomas and Barton (1936). The youngest case in a series of 20 seen at the Mayo Clinic between 1910 and 1926 occurred in an eleven-yearold child (Mayo and Johnson, 1926). It is patent that these dystopic kidneys are discovered only by accident in the very young, since they are composed of functionally competent tissue. There have been only a few reports of dystopic kidneys which have had a principal artery derived from a contralateral arterial trunk; in a study of ten dystopic kidneys Anitschkow (1912) found one supplied by an artery arising from the contralateral common iliac, another from the aorta at its bifurcation (middle sacral); Sexton (1935) described a case of renal dystopia in a female 37 years old in which one of the 3 renal arteries arose from the bifurcation of the aorta. "Horseshoe" kidneys may derive part of their arterial supply from the middle sacral as well as from the common iliac (see fig. p., in Anson, Richardson, and Minear 1936). These arterial anomalies are evidently due to the persistence of vascular channels present in the embryo. From a study of the embryonic blood-supply of the kidneys and related organs, Bremer (1915) found that there is an absence of specificity in the developing channels in this visceral network, the ultimate supply of an individual organ being governed merely by mechanical convenience. A permanent renal vessel is then merely one of the numerous embryonic sprouts, sent out from the aortic endothelium, which intercommunicate both vertically and horizontally. An extra renal branch from either iliac or middle sacral artery represents 1 Contribution no. 274 from the Anatomical Laboratory of Northwestern University Medical School. 502
PELVIC KIDNEY AND RENAL VESSELS IN NEWBORN
503
a persistence of the more caudal elements in this anastomotic network. Kidneys and renal vessels. In the authors' specimen of a newborn female the right kidney was lobulated, of normal size and form; it was The supplied by a single renal artery, drained by a single renal right ureter was normal in calibre and course.
Fm. L Kidneys and their blood-vessels in a newborn female child. peritoneum removed except in area of sigmoid colon. (¾ natural size.) anomalous left kidney at the level indicated in fig. 1
Digestive tube aud a. A section of the
On the left side the kidney and the renal vessels presented striking anomalies. The lacked the typical reniform shape; the entire organ was flattened, being only one-fourth as thick as wide (fig. Its outline was therefore oval rather than circular~-the length being greater than the width (fig. 1). The actual measurements were as follows: length, 4 cm.; width, 2.8 cm.; thickness, (l 7 cm. The renal pelvis, small in was situated almost in the center of the organ, 1); the hilus, in which it rested, resembled a sulcus facing anteriorly
504
GEORGE A. BOYLSTON AND BARRY J. ANSON
(fig. la) more than it did a hilus of normal kidney. The superolateral two-thirds of the anomalous kidney lay within the greater pelvis, the inferomedial one-third within the lesser pelvis; molded against the pelvic brim, it rested upon the left common iliac artery by which its posterior surface was grooved. In their unusual arrangement the arterial supply and the venous drainage matched the peculiarity of the renal form. There were 2 renal arteries and 2 veins (fig. 1). The superior one of the 2 renal arteries arose from the aorta at the level of origin of the inferior mesenteric artery; following a transverse course, until it reached a midpoint on the superior margin, the vessel turned sharply downward, accompanied the vein into the renal hilus. The inferior one of the renal arteries arose from the common iliac artery of the opposite side 1.5 cm. below the bifurcation of the aorta; following a direct transverse course the artery entered the hilus, again accompanied by a renal vein. The small middle sacral artery did not send branches to the kidney. The superior one of the two renal veins, leaving the upper portion of the hilus, joined the left ovarian vein to form a common vein trunk which, after following an oblique course, emptied into the inferior vena cava at a high abdominal level. The inferior one of the veins crossed the medial half of the kidney, at first following the course of the artery of iliac origin; then turning upward it entered the inferior vena cava as a split vessel superior to the point of junction of the common iliac veins. The right ureter was normal. That of the left side was much shorter than normal. Leaving the anteriorly placed hilus (where it was related on both superior and medial aspects to an artery and vein) it followed a somewhat sigmoid course into the urinary bladder. Histologically, the left kidney seemed entirely normal in structure; there was no evidence of cystic or other pathological condition. Digestive tube. In addition to the left renal anomally already described, there existed in this infant an interesting malrotation of the large and small bowel. The caecum lay in the left lower quadrant, immediately over the dystopic kidney; from the caecum the vermiform appendix projected to the right. The ascending colon crossed the abdomen from left lower to right upper quadrant to reach a normally situated hepatic flexure. The remainder of the colon and sigmoid were normally placed. The right lower and a large part of the right upper quadrants of the abdomen were occupied by small bowel. The duodenojejunal flexure lay free between the unfused mesentery of the transverse colon and the mesentery of the sigmoid colon.
PELVIC KIDNEY AND RENAL VESSELS IN NEWBORN
505
REFERENCES ANITSCHKOW, N. N.: Study of renal vessels in congenital renal dystopy.
Virch. Arch., 207: 213-235, 1912. ANSON, B. J., RICHARDSON, G. A. AND MINEAR, W. L.: Variations in number and arrangement of renal vessels. J. UroL, 36: 211-219, 1936. BREMER, J. L.: Origin of renal artery. Am. J. Anat., l.8: 179-200, 1915. CAMPBELL, M. E,: Renal ectopy. J UroL, 24: 187-195, 1930. MAYO, W. C. AND JOHNSON, A. C.: Ectopic kidney presenting as a pelvic tumor. Surg. CJin. N. Amer., 6: 1121-1123, 1926. SEXTON, W. G.: Renal ectopia. J. UroL, 33: 521-525, 1935.
STEWART, M. J. AND LODGE, S. D.: On unilateral fused kidneys and allied renal malformations. Brit. J. Surg., 11: 27-37, 1923. THOMAS, G. J. AND BARTON, J C. · Ectopic pelvic kidney. J. A. M. A., 106: 197-199, 1936.