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Pseudo-Tumors of the Kidney Secondary to Anticoagulant Therapy
Vol. 106, October Printed in U.S.A..
THE JOURNAL OF UROLOGY
Copyright© 1971 hy The Williams & Wilkins Co.
PSEUDO-TUMORS OF THE KIDNEY SECONDARY TO ANTICOAGULANT THERAPY MILTON E. KLINGEH, BARTON TANENBAUM
AND
ALBEHTO ELGUEZABAL
From the Departmen/.s of Urology and Pathology, Jewish Hospital and ill edical Center, and Department of Urology, State University of New York, Downstate Medical Center, Brooklyn, New York
l\Iany patients with thromboembolic disease have derived great benefit from anticoagulant drugs. Anticoagulants are efficacious in treatment and prophylaxis of these disorders and, in many instances, are lifesaving. However, their use is not without complications. ":\1inor bleeding episodes are common and serious hemorrhagic phenomena have been reported. \Vhat may be considered minor bleeding in an organ with free access to the outside of the body may be serious in another organ, such as the eye or brain, in which vital activities take place in a relatively confined space and even slight bleeding can cause serious disruption in function. The literature contains numerous reports 011 the deleterious effects of these drugs and refers to many instances in which serious hemorrhagic disturbances and death have resulted from their use. 1- 3 Cases reported include intracranial, intrathoracic and intra-abdominal bleeding as well as oral, dermal, mammary and genital hemorrhage. 4 , 5 Especially since the advent of inexpensive, conveniently administered drugs, it has become extremely important to know of their potential risks and to weigh their true efficacy against their dangers. 6 Proper controls must be considered in the routine administration of these drugs. Even at so-called safe levels and under the best of circumstances, the action of the drug may give rise to serious bleeding. The incidence of bleeding as a Accepted for publication December 1970. 1 Powers, J. S., Jr.: Toxicity of dicumarol; review of the literature and report of two cases. Ann. Intern. Med., 32: 146, l!J50. 2 Shlevin, E. L. and Lederer, M.: Uncontrollable hemorrhage after dicoumarol therapy with autopsy findings. Ann. Intern. Med., 21: 332, 1944. 3 Wright, L. T. and Rothman, M.: Deaths from dicumarol. Arch. Surg., 62: 23, 1951. 4 Pastor, B. H., Resnick, M. E. and Rodman, T.: Serious hemorrhagic complications of anticoagulant therapy. J.A.M.A., 180: 747, 1962. 5 Phelps, E. T.: Symposium on current concepts of pathogenesis and treatment; dangers of dicumarol therapy . .M. Clin. North America, 34:
complication of anticoagulant therapy has been reported to be between 3.6 and 48 per cent. 7 Prothrombin determinations taken at the time of bleeding have not been elevated consistently. Indeed various clotting factors, platelet factors and even capillary permeability may be affected by coumadin and related drugs and have been implicated as responsible etiologic agents in the bleeding which may occur. This implies that the prothrombin level is not always a reliable guide and the patients who are supposedly in good anticoagulant control are subject to the risk of hemorrhage. Roos and van Joost found that the prothrombin time of 70 per cent of their patients with bleeding was within the therapeutic range. 7 Hence, although prothrombin time is a useful guide, it is by no means infallible. UROLOGICAL IMPLICATIONS
Of particular interest is the effect of oral anticoagulant drug toxicity on the urinary tract. Herein we describe a special aspect of coumadi11 or dicumarol toxicity, namely the instances in which renal or perirenal bleeding has produced pyelographic deformities which mimic renal neoplasm. :1Iicroscopic hematuria is common in patients undergoing anticoagulant therapy. Gross bleeding occurs less often but is by no means uncommon. Paradoxically, such bleeding often results in the passage of clots or their retention in the renal pelvis or in the bladder. Ureteral colic is a common complaint as small clots are passed through the ureter. Such episodes of urinary bleeding usually are benign and respond promptly to discontinuation of the anticoagulant drug, the administration of neutralizing agents and, if necessary, the occasional use of blood transfusions. Fatal bleeding from the urinary tract as a result of anticoagulants is rare. An occasional dramatic case is reported such as Hibner's pa7 Roos, J. and Joost, M. E., van: The cause of bleeding during anticoagulant treatment. Acta Med. Scand., 178: 129, 1965.
1791, 1950.
Fuller, J. A.: Experiences with long-term anticoagulant treatment. Lancet, 2: 489, 1959. 6
507
508
KLINGER, TANENBAUM AND ELGUEZABAL
tient in whom nephrectomy was necessary because of spontaneous rupture of the kidney with massive hemorrhage complicating anticoagulation therapy. 8 In every instance of urinary bleeding occurring during the course of anticoagulant therapy, thorough investigation by excretory urography (IVP) and cystoscopy should be insisted upon to ascertain whether the bleeding is merely incidental to the drug or whether the drug has initiated the bleeding from a hitherto silent lesion such as a stone, tumor, stricture, infection or the like. Thirteen of 16 patients investigated by Antolak and :Mellinger had underlying urinary tract disease when investigated for coumarin-induced hematuria. 9 Nathan and Kimball reported that 191 cases of occult malignancy including 75 malignancies of the urinary tract were uncovered when bleeding in the course of anticoagulant therapy was studied. 10 Apparently susceptible areas may not exhibit gross bleeding until anticoagulants are administered. In most cases in which no pre-existing urological disease is present, an IVP will indicate the presence of normal renal, ureteral and vesical architecture. Major changes in the radiographic appearance of the urinary tract generally do not occur. At times blood clots in the renal pelvis or bladder may appear as filling defects. Temporary suppression of renal function may be present.owing to ureteral obstruction with clots. None of these situations demands special treatment except perhaps the evacuation of bladder clots which may cause retention of urine. Surgical intervention for diagnosis or for treatment is rarely necessary and infrequently reported. However, there are some instances, as illustrated by the cases reported herein, in which bleeding results in such pyelographic distortions as to suggest the presence of a renal tumor. Proper management of such a patient is uncertain. Should one await the resolution of what might be a renal or perirenal hematoma when the delay could mean postponing the 8 Hibner, R. W.: Spontaneous rupture of the kidney with massive hemorrhage. A complication of anticoagulation. Amer. J. Surg., 118: 637, 1969. 9 Antolak, S. J., Jr. and Mellinger, G. T.: Urologic evaluation of hematuria occurring during anticoagulant therapy. J. Ural., 101: 111, 1969. 10 Nathan, D. A. and Kimball, S. G.: The detection of occult tumors during anticoagulant therapy. In: Anticoagulant Therapy in Ischemic Heart Disease. Edited by E. S. Nichol. New York: Grune & Stratton, p. 119, 1965.
removal of a malignant growth? An operation on such a patient implies increased risk since he is suffering from some arterial, venous or embolic disturbance which originally necessitated the anticoagulant drug. l; se of more sophisticated diagnostic x-ray techniques such as nephrotomography and selective renal angiography to further define the diagnosis probably will be unrewarding since the hematoma is actually a solid mass and will therefore yield the same type of radiographic picture as a tumor. The reports by Sukthomya and Levin11 and Kaufman and McLellan12 describing pseudo-tumors of the kidney uncovered during anticoagulant therapy parallel our experience and are the only other such reports found in the literature. In the study by Sukthomya and Levin 1 patient proved to have a peripelvic hematoma at operation. The other patient had a mass in the upper pole of the kidney but was not wbjected to operation. The x-ray appearance of the kidney returned to normal after 10 weeks. Similarly, 2 patients in the study by Kaufman and ::\IcLellan had pseudo-tumors of the kidney but did not undergo operation. Their lesions regressed spontaneously after some time. A calculated risk had been taken by these investigators, for had the findings remained the same and the lesion finally proved to be a tumor, valuable time would have been lost. CASE REPORTS
Case 1. S. S., a 74-year-old white man, had been on long-term anticoagulant therapy with coumadin because of coronary artery disease. Appropriate laboratory controls were in effect but, nevertheless, sudden profuse bleeding was noted from the urinary tract. In addition, there was severe left flank and left ureteral pain and numerous clots were passed. Medication was stopped immediately and the patient was referred for urological study. He had consulted us approximately a year previously for mild prostatic symptoms. The IVP at that time showed no abnormality of the upper urinary tract. However, the present IVP showed an absence of dye excre11 Sukthomya, C. and Levin, B.: Pseudotumors of kidney secondary to anticoagulant therapy. Radiology, 88: 701, 1967. 12 Kaufman, S. A. and McLellan, P.: Urinary tract complications of anticoagulation therapy; "pseudotumor" of the kidney. Brit. J. Radial.,
41: 180, 1968.
PSEUDO-TUMORS OF KIDNEY SECONDARY TO ANTICOAGULAI,T THERAPY
FIG. 1. Case l. A, left retrograde nephrotomogram confirms presence
509
shows tumor deformity in lower pole of left kidney. mass in lower pole of left kidney .
tion from the left . The right side was normal. The was admitted to the hospital and cystoscopy and were performed. The bladder was free of disease other than some trabeculation to a modercharacter. enlarged prostate The left ureter was catheterized. Initially, clear urine emerged from the catheter but this soon gave way to a efflux. Retrograde pyelography showed the type of architectural delesion of the whether this was a The possiappearance could have resulted from benign cyst formation was not considered since the IVP a year previwas normal. hP,·Pt,w0 it seemed that an operation would be necessary. N eph rotomostudies showed of a solid mass in the was_ deferred because we have further confirmed our clinical impression and would not have clarified the problem further nor precluded the for exploration. was . Its external surface did not suggest a An aspirating needle was inserted into the region of ,man,,~1·.c,n
disease and dark blood. Still unsure a:, to whether the lesion was a tumor or that the risk and doing anything other than be detrimental. Hence the war, removed in routine manner. Convalescence was unevent,ful. The a short segment of the ureter. The ~,sas unrcoff with ease. The markable. The 1'74 gm. and The external surmeasured 13 with a few scat-
m were pi esen t in the cortex. Two ealicec, and minor ones were filled. and with dark red blood clots with the surrounding (fig. rhage extended to the were hemorrhagic and in the dots. The clots were removed as uo gross underlying lesicms of the mucosa, Yessel,; or were noted. The and portion of ureter were of normal devoid of blood, with a smooth, ~"".,."'"-"'' mucosa. No other notable findings were encountered circumscribed
510
KLINGER, TANENBAUM AND ELGUEZABAL
FIG. 2. Case 1. Cut surface of kidney shows 2 large hematomas in lower half of kidney.
hemorrhagic tips of pyramids with blood extending to the calices and adjacent fat with focal peripheral fibroblastic proliferation and fat necrosis. Elastic stain revealed no evidence of hemangioma or arteriovenous malformations. :\Tultiple sections revealed no neoplasm. The cause or origin of bleeding was not evident from the slides. :Moderate nephrosclerosis, a few interstitial petechiae and occasional proximal and
distal tubules with red blood cells were the only findings in the rest of the parenchyma. The main arteries, except for moderate arteriosclerosis, were unremarkable. The veins were normal. Case 2. L. G., a 53-year-old white man, was admitted to the hospital because of severe pain in the right flank. Urological consultation was requested when an IVP showed no excretion of dye from the right kidney. For some weeks prior to hospitalization the patient had been taking coumadin because of a phlebothrombotic process in the lower extremity. However, no blood was noted in the urine. Some fullness was present in the upper right quadrant of the abdomen, although a mass could not be palpated. There was right costovertebral tenderness. The remainder of the examination presented no significant findings. Laboratory studies were within normal limits except the hemoglobin which was 8 gm. This promptly returned to normal when the patient received a transfusion. The IVP revealed no excretion of dye from the right kidney and a marked lateral deflection of the left kidney (fig. 3, ;1). Cystoscopy revealed a normal bladder. At retrograde pyelography the catheter passed into the right renal pelvis after being temporarily halted about two-thirds of the way up. On entry into the renal pelvis a profuse flow of bloody urine issued from the catheter. Retrograde pyelography demonstrated a large
Fw. 3. Case 2. A, IVP shows absence of dye excretion from right kidney and lateral displaceµient of left ureter. B, right retrograde pyelogram shows large mass at lower pole of kidney.
PSEUDO-TUMORS OF KIDNEY SECONDARY TO ANTICOAGULANT THERAPY
mass in the right kidney (fig. 3, B). The upper part of the ureter was deflected and there was no semblance of caliceal or pelvic detail. A presumptive diagnosis of renal neoplasm was made. The displacement of the left ureter was thought to represent either direct extension of a tumor across the midline or a mass of enlarged retroperitoneal nodes. Although we realized that the entire process might be due to bleeding secondary to anticoagulant therapy, the findings were so typical of tumor that simply to observe the patient and await developments seemed unjustified. Therefore, we decided to explore. The right kidney was exposed through a flank incision which included removal of the eleventh rib because of the anticipated size of the mass. The mass and surrounding tissue were densely adherent to the posterior abdominal wall. As the mass was dissected free it was seen to be a huge collection of partially clotted blood which appeared to be located in the perirenal tissues between the renal capsule and the kidney. Normal tissue planes were totally obliterated so that clear definition was impossible. After the blood was removed, a small, discolored kidney was seen which appeared to have several infarcted areas in its lower pole. It did not have the appearance of a viable organ and, therefore, was removed in customary fashion without difficulty. The incision then was extended across the abdomen, the peritoneum overlying the great vessels gently dissected away to expose the mass on the left side of the retroperitoneal space. The mass was a large smooth-walled cyst which had no connection with the surrounding structures. It was enclosed and self-contained. In its interior was a large amount of viscid, dark brown liquid having the appearance of liquified old blood. The lesion undoubtedly was an encapsulated hematoma. It seemed apparent that the process represented coumadin-induced abnormal bleeding-subcapsular or perirenal in the kidney and liquified, encapsulated hematoma in the retroperitoneal space. Hence, nothing further was done to the retroperitoneal mass after it was emptied. The gross specimen contained several large,
511
raised irregular areas with serpiginous borders on the cortical surface and in the cortex on cut section. These areas were suggestive of infarction. No point of parenchymal rupture could be uncovered. Microscopic study showed necrotizing papillitis and nephro-arteriolosclerosis. No reason for a possible spontaneous rupture of the kidney, such as tumor, stone or periarteritis nodosa, was found. In reconstructing the pathogenesis of the renal lesion one must suppose that sufficient bleeding occurred in the perirenal tissues or the subcapsular space to compress the pedicle, thereby interrupting the blood supply of the kidney while simultaneously displacing and compressing the ureter sufficient to cause obstruction to outflow. In retrospect it appears that, had the nature of the lesion been known, spontaneous resolution might well have occurred and an operation would have been unnecessary. However, faced with inconclusive data, reliable exclusion of neoplasm was impossible without exploration. If tumor is not found at exploration, only simple drainage of the blood or hematoma is necessary when the disease is located in the perinephric tissues or on the surface of the kidney. However, hematomas within the substance of the kidney (as typified by case 1) would remain a problem unless the kidney were opened. SUMMARY
Two cases are reported to illustrate one of the less commonly encountered effects of coumadin toxicity on the urinary tract. The clinical picture and x-ray findings in these cases suggested the need for surgical exploration and, perhaps, nephrectomy. The alternative to operation in these cases is watchful waiting, which entails the risk of delay in the removal of a possible renal tumor. Should the nature of the lesion be apparent at the time of operation, only evacuation of blood and drainage are necessary. In cases in which the lesion is wholly contained within the substance of the kidney-as in case 1-nephrectomy still may be the proper solution unless one is prepared for nephrotomy and its complications.
THE JOURNAL OF UROLOGY
Copyright© 1971 hy The Williams & Wilkins Co.
PSEUDO-TUMORS OF THE KIDNEY SECONDARY TO ANTICOAGULANT THERAPY MILTON E. KLINGEH, BARTON TANENBAUM
AND
ALBEHTO ELGUEZABAL
From the Departmen/.s of Urology and Pathology, Jewish Hospital and ill edical Center, and Department of Urology, State University of New York, Downstate Medical Center, Brooklyn, New York
l\Iany patients with thromboembolic disease have derived great benefit from anticoagulant drugs. Anticoagulants are efficacious in treatment and prophylaxis of these disorders and, in many instances, are lifesaving. However, their use is not without complications. ":\1inor bleeding episodes are common and serious hemorrhagic phenomena have been reported. \Vhat may be considered minor bleeding in an organ with free access to the outside of the body may be serious in another organ, such as the eye or brain, in which vital activities take place in a relatively confined space and even slight bleeding can cause serious disruption in function. The literature contains numerous reports 011 the deleterious effects of these drugs and refers to many instances in which serious hemorrhagic disturbances and death have resulted from their use. 1- 3 Cases reported include intracranial, intrathoracic and intra-abdominal bleeding as well as oral, dermal, mammary and genital hemorrhage. 4 , 5 Especially since the advent of inexpensive, conveniently administered drugs, it has become extremely important to know of their potential risks and to weigh their true efficacy against their dangers. 6 Proper controls must be considered in the routine administration of these drugs. Even at so-called safe levels and under the best of circumstances, the action of the drug may give rise to serious bleeding. The incidence of bleeding as a Accepted for publication December 1970. 1 Powers, J. S., Jr.: Toxicity of dicumarol; review of the literature and report of two cases. Ann. Intern. Med., 32: 146, l!J50. 2 Shlevin, E. L. and Lederer, M.: Uncontrollable hemorrhage after dicoumarol therapy with autopsy findings. Ann. Intern. Med., 21: 332, 1944. 3 Wright, L. T. and Rothman, M.: Deaths from dicumarol. Arch. Surg., 62: 23, 1951. 4 Pastor, B. H., Resnick, M. E. and Rodman, T.: Serious hemorrhagic complications of anticoagulant therapy. J.A.M.A., 180: 747, 1962. 5 Phelps, E. T.: Symposium on current concepts of pathogenesis and treatment; dangers of dicumarol therapy . .M. Clin. North America, 34:
complication of anticoagulant therapy has been reported to be between 3.6 and 48 per cent. 7 Prothrombin determinations taken at the time of bleeding have not been elevated consistently. Indeed various clotting factors, platelet factors and even capillary permeability may be affected by coumadin and related drugs and have been implicated as responsible etiologic agents in the bleeding which may occur. This implies that the prothrombin level is not always a reliable guide and the patients who are supposedly in good anticoagulant control are subject to the risk of hemorrhage. Roos and van Joost found that the prothrombin time of 70 per cent of their patients with bleeding was within the therapeutic range. 7 Hence, although prothrombin time is a useful guide, it is by no means infallible. UROLOGICAL IMPLICATIONS
Of particular interest is the effect of oral anticoagulant drug toxicity on the urinary tract. Herein we describe a special aspect of coumadi11 or dicumarol toxicity, namely the instances in which renal or perirenal bleeding has produced pyelographic deformities which mimic renal neoplasm. :1Iicroscopic hematuria is common in patients undergoing anticoagulant therapy. Gross bleeding occurs less often but is by no means uncommon. Paradoxically, such bleeding often results in the passage of clots or their retention in the renal pelvis or in the bladder. Ureteral colic is a common complaint as small clots are passed through the ureter. Such episodes of urinary bleeding usually are benign and respond promptly to discontinuation of the anticoagulant drug, the administration of neutralizing agents and, if necessary, the occasional use of blood transfusions. Fatal bleeding from the urinary tract as a result of anticoagulants is rare. An occasional dramatic case is reported such as Hibner's pa7 Roos, J. and Joost, M. E., van: The cause of bleeding during anticoagulant treatment. Acta Med. Scand., 178: 129, 1965.
1791, 1950.
Fuller, J. A.: Experiences with long-term anticoagulant treatment. Lancet, 2: 489, 1959. 6
507
508
KLINGER, TANENBAUM AND ELGUEZABAL
tient in whom nephrectomy was necessary because of spontaneous rupture of the kidney with massive hemorrhage complicating anticoagulation therapy. 8 In every instance of urinary bleeding occurring during the course of anticoagulant therapy, thorough investigation by excretory urography (IVP) and cystoscopy should be insisted upon to ascertain whether the bleeding is merely incidental to the drug or whether the drug has initiated the bleeding from a hitherto silent lesion such as a stone, tumor, stricture, infection or the like. Thirteen of 16 patients investigated by Antolak and :Mellinger had underlying urinary tract disease when investigated for coumarin-induced hematuria. 9 Nathan and Kimball reported that 191 cases of occult malignancy including 75 malignancies of the urinary tract were uncovered when bleeding in the course of anticoagulant therapy was studied. 10 Apparently susceptible areas may not exhibit gross bleeding until anticoagulants are administered. In most cases in which no pre-existing urological disease is present, an IVP will indicate the presence of normal renal, ureteral and vesical architecture. Major changes in the radiographic appearance of the urinary tract generally do not occur. At times blood clots in the renal pelvis or bladder may appear as filling defects. Temporary suppression of renal function may be present.owing to ureteral obstruction with clots. None of these situations demands special treatment except perhaps the evacuation of bladder clots which may cause retention of urine. Surgical intervention for diagnosis or for treatment is rarely necessary and infrequently reported. However, there are some instances, as illustrated by the cases reported herein, in which bleeding results in such pyelographic distortions as to suggest the presence of a renal tumor. Proper management of such a patient is uncertain. Should one await the resolution of what might be a renal or perirenal hematoma when the delay could mean postponing the 8 Hibner, R. W.: Spontaneous rupture of the kidney with massive hemorrhage. A complication of anticoagulation. Amer. J. Surg., 118: 637, 1969. 9 Antolak, S. J., Jr. and Mellinger, G. T.: Urologic evaluation of hematuria occurring during anticoagulant therapy. J. Ural., 101: 111, 1969. 10 Nathan, D. A. and Kimball, S. G.: The detection of occult tumors during anticoagulant therapy. In: Anticoagulant Therapy in Ischemic Heart Disease. Edited by E. S. Nichol. New York: Grune & Stratton, p. 119, 1965.
removal of a malignant growth? An operation on such a patient implies increased risk since he is suffering from some arterial, venous or embolic disturbance which originally necessitated the anticoagulant drug. l; se of more sophisticated diagnostic x-ray techniques such as nephrotomography and selective renal angiography to further define the diagnosis probably will be unrewarding since the hematoma is actually a solid mass and will therefore yield the same type of radiographic picture as a tumor. The reports by Sukthomya and Levin11 and Kaufman and McLellan12 describing pseudo-tumors of the kidney uncovered during anticoagulant therapy parallel our experience and are the only other such reports found in the literature. In the study by Sukthomya and Levin 1 patient proved to have a peripelvic hematoma at operation. The other patient had a mass in the upper pole of the kidney but was not wbjected to operation. The x-ray appearance of the kidney returned to normal after 10 weeks. Similarly, 2 patients in the study by Kaufman and ::\IcLellan had pseudo-tumors of the kidney but did not undergo operation. Their lesions regressed spontaneously after some time. A calculated risk had been taken by these investigators, for had the findings remained the same and the lesion finally proved to be a tumor, valuable time would have been lost. CASE REPORTS
Case 1. S. S., a 74-year-old white man, had been on long-term anticoagulant therapy with coumadin because of coronary artery disease. Appropriate laboratory controls were in effect but, nevertheless, sudden profuse bleeding was noted from the urinary tract. In addition, there was severe left flank and left ureteral pain and numerous clots were passed. Medication was stopped immediately and the patient was referred for urological study. He had consulted us approximately a year previously for mild prostatic symptoms. The IVP at that time showed no abnormality of the upper urinary tract. However, the present IVP showed an absence of dye excre11 Sukthomya, C. and Levin, B.: Pseudotumors of kidney secondary to anticoagulant therapy. Radiology, 88: 701, 1967. 12 Kaufman, S. A. and McLellan, P.: Urinary tract complications of anticoagulation therapy; "pseudotumor" of the kidney. Brit. J. Radial.,
41: 180, 1968.
PSEUDO-TUMORS OF KIDNEY SECONDARY TO ANTICOAGULAI,T THERAPY
FIG. 1. Case l. A, left retrograde nephrotomogram confirms presence
509
shows tumor deformity in lower pole of left kidney. mass in lower pole of left kidney .
tion from the left . The right side was normal. The was admitted to the hospital and cystoscopy and were performed. The bladder was free of disease other than some trabeculation to a modercharacter. enlarged prostate The left ureter was catheterized. Initially, clear urine emerged from the catheter but this soon gave way to a efflux. Retrograde pyelography showed the type of architectural delesion of the whether this was a The possiappearance could have resulted from benign cyst formation was not considered since the IVP a year previwas normal. hP,·Pt,w0 it seemed that an operation would be necessary. N eph rotomostudies showed of a solid mass in the was_ deferred because we have further confirmed our clinical impression and would not have clarified the problem further nor precluded the for exploration. was . Its external surface did not suggest a An aspirating needle was inserted into the region of ,man,,~1·.c,n
disease and dark blood. Still unsure a:, to whether the lesion was a tumor or that the risk and doing anything other than be detrimental. Hence the war, removed in routine manner. Convalescence was unevent,ful. The a short segment of the ureter. The ~,sas unrcoff with ease. The markable. The 1'74 gm. and The external surmeasured 13 with a few scat-
m were pi esen t in the cortex. Two ealicec, and minor ones were filled. and with dark red blood clots with the surrounding (fig. rhage extended to the were hemorrhagic and in the dots. The clots were removed as uo gross underlying lesicms of the mucosa, Yessel,; or were noted. The and portion of ureter were of normal devoid of blood, with a smooth, ~"".,."'"-"'' mucosa. No other notable findings were encountered circumscribed
510
KLINGER, TANENBAUM AND ELGUEZABAL
FIG. 2. Case 1. Cut surface of kidney shows 2 large hematomas in lower half of kidney.
hemorrhagic tips of pyramids with blood extending to the calices and adjacent fat with focal peripheral fibroblastic proliferation and fat necrosis. Elastic stain revealed no evidence of hemangioma or arteriovenous malformations. :\Tultiple sections revealed no neoplasm. The cause or origin of bleeding was not evident from the slides. :Moderate nephrosclerosis, a few interstitial petechiae and occasional proximal and
distal tubules with red blood cells were the only findings in the rest of the parenchyma. The main arteries, except for moderate arteriosclerosis, were unremarkable. The veins were normal. Case 2. L. G., a 53-year-old white man, was admitted to the hospital because of severe pain in the right flank. Urological consultation was requested when an IVP showed no excretion of dye from the right kidney. For some weeks prior to hospitalization the patient had been taking coumadin because of a phlebothrombotic process in the lower extremity. However, no blood was noted in the urine. Some fullness was present in the upper right quadrant of the abdomen, although a mass could not be palpated. There was right costovertebral tenderness. The remainder of the examination presented no significant findings. Laboratory studies were within normal limits except the hemoglobin which was 8 gm. This promptly returned to normal when the patient received a transfusion. The IVP revealed no excretion of dye from the right kidney and a marked lateral deflection of the left kidney (fig. 3, ;1). Cystoscopy revealed a normal bladder. At retrograde pyelography the catheter passed into the right renal pelvis after being temporarily halted about two-thirds of the way up. On entry into the renal pelvis a profuse flow of bloody urine issued from the catheter. Retrograde pyelography demonstrated a large
Fw. 3. Case 2. A, IVP shows absence of dye excretion from right kidney and lateral displaceµient of left ureter. B, right retrograde pyelogram shows large mass at lower pole of kidney.
PSEUDO-TUMORS OF KIDNEY SECONDARY TO ANTICOAGULANT THERAPY
mass in the right kidney (fig. 3, B). The upper part of the ureter was deflected and there was no semblance of caliceal or pelvic detail. A presumptive diagnosis of renal neoplasm was made. The displacement of the left ureter was thought to represent either direct extension of a tumor across the midline or a mass of enlarged retroperitoneal nodes. Although we realized that the entire process might be due to bleeding secondary to anticoagulant therapy, the findings were so typical of tumor that simply to observe the patient and await developments seemed unjustified. Therefore, we decided to explore. The right kidney was exposed through a flank incision which included removal of the eleventh rib because of the anticipated size of the mass. The mass and surrounding tissue were densely adherent to the posterior abdominal wall. As the mass was dissected free it was seen to be a huge collection of partially clotted blood which appeared to be located in the perirenal tissues between the renal capsule and the kidney. Normal tissue planes were totally obliterated so that clear definition was impossible. After the blood was removed, a small, discolored kidney was seen which appeared to have several infarcted areas in its lower pole. It did not have the appearance of a viable organ and, therefore, was removed in customary fashion without difficulty. The incision then was extended across the abdomen, the peritoneum overlying the great vessels gently dissected away to expose the mass on the left side of the retroperitoneal space. The mass was a large smooth-walled cyst which had no connection with the surrounding structures. It was enclosed and self-contained. In its interior was a large amount of viscid, dark brown liquid having the appearance of liquified old blood. The lesion undoubtedly was an encapsulated hematoma. It seemed apparent that the process represented coumadin-induced abnormal bleeding-subcapsular or perirenal in the kidney and liquified, encapsulated hematoma in the retroperitoneal space. Hence, nothing further was done to the retroperitoneal mass after it was emptied. The gross specimen contained several large,
511
raised irregular areas with serpiginous borders on the cortical surface and in the cortex on cut section. These areas were suggestive of infarction. No point of parenchymal rupture could be uncovered. Microscopic study showed necrotizing papillitis and nephro-arteriolosclerosis. No reason for a possible spontaneous rupture of the kidney, such as tumor, stone or periarteritis nodosa, was found. In reconstructing the pathogenesis of the renal lesion one must suppose that sufficient bleeding occurred in the perirenal tissues or the subcapsular space to compress the pedicle, thereby interrupting the blood supply of the kidney while simultaneously displacing and compressing the ureter sufficient to cause obstruction to outflow. In retrospect it appears that, had the nature of the lesion been known, spontaneous resolution might well have occurred and an operation would have been unnecessary. However, faced with inconclusive data, reliable exclusion of neoplasm was impossible without exploration. If tumor is not found at exploration, only simple drainage of the blood or hematoma is necessary when the disease is located in the perinephric tissues or on the surface of the kidney. However, hematomas within the substance of the kidney (as typified by case 1) would remain a problem unless the kidney were opened. SUMMARY
Two cases are reported to illustrate one of the less commonly encountered effects of coumadin toxicity on the urinary tract. The clinical picture and x-ray findings in these cases suggested the need for surgical exploration and, perhaps, nephrectomy. The alternative to operation in these cases is watchful waiting, which entails the risk of delay in the removal of a possible renal tumor. Should the nature of the lesion be apparent at the time of operation, only evacuation of blood and drainage are necessary. In cases in which the lesion is wholly contained within the substance of the kidney-as in case 1-nephrectomy still may be the proper solution unless one is prepared for nephrotomy and its complications.