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Preoperative Identification of a Hydronephrotic Sac with Sequential 99mTc DTPA Imaging: Case Report
Vol. 109, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
PREOPERATIVE IDENTIFICATION OF A HYDRONEPHROTIC SAC WITH SEQUENTIAL 99 mTc DTPA IMAGING: CASE REPORT CLAUDE RAYNAUD, CONSTANTIN KOUTOULIDIS, JEAN CENDRON
AND
LEONARD M. FREEMAN*
From the French Atomic Energy Commission, Biology Division, Service Hospitalier Frederic Joliot, Orsay and Saint Vincent-de-Paul Hospital, Paris, France
occurs on excretory The abiiity of radionuclide to reveal functioning kidneys has been demonstrated, primarily with 131I vH•u,c,uCHHµ l, 2 Technetium 99m chelate and iron-ascorbate complex have been used with some success in similar problems. 2 -• In most situations it is sufficient to ascertain the presence and size of the poorly functioning kidney, which often requires images of 2 to 3 hours or more. In our case a large hydronephrotic sac was completely filled on delayed 99 mTc diethylenetriamine pentaacetic acid (DTP A) studies, allowing the diagnosis to be established in a child with an asymptomatic abdominal mass. CASE REPORT
P. L., a 5-year-old normal-appearing black boy, underwent routine physical examination in July 1971. An extremely large and soft abdominal mass was on the left side. The mass did not cross the midline. There was no associated pain, tenderness, fever or hypertension. Complete urinalysis, including bacterial studies, was normal as were the blood chemistry studies. An IVP showed a slightly enlarged right Accepted for publication November 10, 1972. * On sabbatical leave from Department of Radiology, Hospital of the Albert Einstein College of Medicine, Bronx, New York 10461. 1 Freeman, L. M.: Clinical aspects of dynamic renal imaging with radiochlormerodrin, technetium-99m pertechnetate and 131 I-orthoiodohippurate. In: Clinical Dynamic Function Studies with Radionuclides. Edited by M. N. Croll, L. W. Brady, H. R. Tatem and T. Honda. New York: Appleton-Century-Crofts, 1972. 2 Hayes, M. and Taplin, G. V.: Comparison of '"Ihippuran and 99 mTc-chelate for monitoring renal homotransplant function. J. Nucl. Med. (abst.), 12: 437, 1971. 3 Gottschalk, A.: Renal scanning. J.A.M.A., 202: 221, 1967. 'Sandler, M., Bell, E.G., Berg, B. C., Duxbury, C. E. and McAfee, J. G.: Renal transplant evaluation using reduced "mTc. J. Nucl. Med. (abst.), H: 359, 1970.
bowel gas made exact size determination difficult (see figure). The intrarenal architecture and excretion were normal. The left failed to even on 1-hour films. The z-ight ureter and bladder were normal and retrograde pyelography were performed with the child under general anesthesia. The bladder was normal and both ureteral orifices were present. A left ureteral catheter outlined a normal caliber, medially displaced ureter, particularly in its upper portion. Contrast medium, with some difficulty, filled the upper ureter and a dilated structure, probably representing a deformed renal pelvis. No filling was seen of intrarenal structures. The suggested diagnosis was a ureteropelvic junction obstruction. The cause of blockage was not clear. On October 25 sequential scintiphotos were obtained after the intravenous administration of 5 m Ci. of 99 mTc DTP A. Progressive filling of a large amorphous-shaped pouch was noted for the first 45 minutes. Delayed studies, including decubitus views at 2 and 17 hours delineated the exact size and limits of this large hydronephrotic sac. Quantitative fixation studies with 197Hg-Cl 2 revealed 4.1 per cent of the injected dose in the left kidney (normal 26 plus or minus 3.5 per cent) and 40.3 per cent of the injected dose in the right kidney (normal 27 plus or minus 3.5 per cent). This finding is consistent with successful compensatory hypertrophy. 5 ' 6 Laparotomy was performed on November 25. The large hydronephrotic cavity contained 1,250 ml. urine. The renal parenchyma was 1 ml. thick. A left nephrectomy was performed and convalescence was uneventful. 'Raynaud, C., Desgrez, A. and Kellershohn, C.: Measurement of renal mercury uptake by external counting: separate functional testing of each kidney. J. Urol., !l!l: 248, 1968. 6 Raynaud, C., Ricard, 8., Karam, Y. and Kellershohn, C.: The use of the renal uptake of 197 Hg as a method for testing the functional value of each kidney. J. Nucl. Med., H: 125, 1970.
1034
RAYNAUD AND ASSOCIATES
1.V. P. L
0_12"
2h.
R
5'
2h.(decubitus)
D.T.P.A.
Retrograde Pyelography
25'
17h.
45'
17 h.(decubitus)
Tc99m
Diagnostic studies oriented in posterior-anterior projection. IVP fails to show any excretion on left side but shows slightly enlarged right kidney. Retrograde pyelogram reveals medial displacement of upper ureter and filling with difficulty of dilated irregular renal pelvis. An O to 12-second exposure after intravenous ••mTc DTPA shows abdominal aorta and vascularization of right kidney only. Sequential scintiphotos up to 45 minutes reveal slow filling of large amorphous-shaped structure on left side. Bladder is well filled at this time. Delayed scintiphotos at 2 and 17 hours show further filling of hydronephrotic sac. Studies in decubitus position show more homogenous distribution of activity which further helps to delineate limits of sac.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
PREOPERATIVE IDENTIFICATION OF A HYDRONEPHROTIC SAC WITH SEQUENTIAL 99 mTc DTPA IMAGING: CASE REPORT CLAUDE RAYNAUD, CONSTANTIN KOUTOULIDIS, JEAN CENDRON
AND
LEONARD M. FREEMAN*
From the French Atomic Energy Commission, Biology Division, Service Hospitalier Frederic Joliot, Orsay and Saint Vincent-de-Paul Hospital, Paris, France
occurs on excretory The abiiity of radionuclide to reveal functioning kidneys has been demonstrated, primarily with 131I vH•u,c,uCHHµ l, 2 Technetium 99m chelate and iron-ascorbate complex have been used with some success in similar problems. 2 -• In most situations it is sufficient to ascertain the presence and size of the poorly functioning kidney, which often requires images of 2 to 3 hours or more. In our case a large hydronephrotic sac was completely filled on delayed 99 mTc diethylenetriamine pentaacetic acid (DTP A) studies, allowing the diagnosis to be established in a child with an asymptomatic abdominal mass. CASE REPORT
P. L., a 5-year-old normal-appearing black boy, underwent routine physical examination in July 1971. An extremely large and soft abdominal mass was on the left side. The mass did not cross the midline. There was no associated pain, tenderness, fever or hypertension. Complete urinalysis, including bacterial studies, was normal as were the blood chemistry studies. An IVP showed a slightly enlarged right Accepted for publication November 10, 1972. * On sabbatical leave from Department of Radiology, Hospital of the Albert Einstein College of Medicine, Bronx, New York 10461. 1 Freeman, L. M.: Clinical aspects of dynamic renal imaging with radiochlormerodrin, technetium-99m pertechnetate and 131 I-orthoiodohippurate. In: Clinical Dynamic Function Studies with Radionuclides. Edited by M. N. Croll, L. W. Brady, H. R. Tatem and T. Honda. New York: Appleton-Century-Crofts, 1972. 2 Hayes, M. and Taplin, G. V.: Comparison of '"Ihippuran and 99 mTc-chelate for monitoring renal homotransplant function. J. Nucl. Med. (abst.), 12: 437, 1971. 3 Gottschalk, A.: Renal scanning. J.A.M.A., 202: 221, 1967. 'Sandler, M., Bell, E.G., Berg, B. C., Duxbury, C. E. and McAfee, J. G.: Renal transplant evaluation using reduced "mTc. J. Nucl. Med. (abst.), H: 359, 1970.
bowel gas made exact size determination difficult (see figure). The intrarenal architecture and excretion were normal. The left failed to even on 1-hour films. The z-ight ureter and bladder were normal and retrograde pyelography were performed with the child under general anesthesia. The bladder was normal and both ureteral orifices were present. A left ureteral catheter outlined a normal caliber, medially displaced ureter, particularly in its upper portion. Contrast medium, with some difficulty, filled the upper ureter and a dilated structure, probably representing a deformed renal pelvis. No filling was seen of intrarenal structures. The suggested diagnosis was a ureteropelvic junction obstruction. The cause of blockage was not clear. On October 25 sequential scintiphotos were obtained after the intravenous administration of 5 m Ci. of 99 mTc DTP A. Progressive filling of a large amorphous-shaped pouch was noted for the first 45 minutes. Delayed studies, including decubitus views at 2 and 17 hours delineated the exact size and limits of this large hydronephrotic sac. Quantitative fixation studies with 197Hg-Cl 2 revealed 4.1 per cent of the injected dose in the left kidney (normal 26 plus or minus 3.5 per cent) and 40.3 per cent of the injected dose in the right kidney (normal 27 plus or minus 3.5 per cent). This finding is consistent with successful compensatory hypertrophy. 5 ' 6 Laparotomy was performed on November 25. The large hydronephrotic cavity contained 1,250 ml. urine. The renal parenchyma was 1 ml. thick. A left nephrectomy was performed and convalescence was uneventful. 'Raynaud, C., Desgrez, A. and Kellershohn, C.: Measurement of renal mercury uptake by external counting: separate functional testing of each kidney. J. Urol., !l!l: 248, 1968. 6 Raynaud, C., Ricard, 8., Karam, Y. and Kellershohn, C.: The use of the renal uptake of 197 Hg as a method for testing the functional value of each kidney. J. Nucl. Med., H: 125, 1970.
1034
RAYNAUD AND ASSOCIATES
1.V. P. L
0_12"
2h.
R
5'
2h.(decubitus)
D.T.P.A.
Retrograde Pyelography
25'
17h.
45'
17 h.(decubitus)
Tc99m
Diagnostic studies oriented in posterior-anterior projection. IVP fails to show any excretion on left side but shows slightly enlarged right kidney. Retrograde pyelogram reveals medial displacement of upper ureter and filling with difficulty of dilated irregular renal pelvis. An O to 12-second exposure after intravenous ••mTc DTPA shows abdominal aorta and vascularization of right kidney only. Sequential scintiphotos up to 45 minutes reveal slow filling of large amorphous-shaped structure on left side. Bladder is well filled at this time. Delayed scintiphotos at 2 and 17 hours show further filling of hydronephrotic sac. Studies in decubitus position show more homogenous distribution of activity which further helps to delineate limits of sac.