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Re: Congenital Absence of the Kidney: Problems in Diagnosis and Management, by J. R. Cope and S. E. Trickey, J. Urol., 127: 10-12, 1982
0022-534 7/82/1283-0604$02.00/0 Vol. 128, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Letters to the Editor 5. Bree, R. L. and Silver, T. M.: Differential diagnosis of hypoechoic and anechoic masses with gray scale sonography: new observations. J. Clin. Ultrasound, 7: 249, 1979. 6. Maklad, N. F.: Ultrasonic evaluation of renal transplants. Semin. Ultrasound II, 1: 88, 1981. 7. Hillman, B. J., Birnholz, J. C. and Busch, G. J.: Correlation of echographic and histologic findings in suspected renal allograft rejection. Radiology, 132: 673, 1979. 8. Hricak, H., Toledo-Pereyra, L. H., Eyler, W. R., Madrazo, B. L. and Zammit, M.: The role of ultrasound in the diagnosis of kidney allograft rejection. Radiology, 132: 667, 1979. 9. Hricak, H., Cruz, C., Eyler, W.R., Madrazo, B. L., Romanski, R. and Sandler, M. A.: Acute post-transplantation renal failure: differer.tial diagnosis by ultrasound. Radiology, 139: 441, 1981.
RE: THE PRACTICAL VALUE OF DIAGNOSTIC ULTRASOUND IN UROLOGY
Roger C. Sanders J. Ural., 126: 283-287, 1981
To the Editor. Doctor Sanders lists a septum as a confirmatory sign of a renal cyst. Since I always have considered the presence of a septum to indicate not a simple cyst but a complex lesion compatible with a possible multilocular cyst, stringy blood clots or a neoplastic process have I been unnecessarily concerned about this matter? Doctor Sanders also uses the term "lateral shades sign" without defining it. Instead, one is referred to an article that is not fully cited. 1 Would it not be a good idea for an author to define relatively new terms such as this one and/or list the references completely to aid the reader? Does renal transplant rejection have a typical pattern on ultrasound? The criteria listed by Doctor Sanders in figure 7 on page 285, except for increase in kidney size, are the opposite of the criteria presented by Barrientos and associates in the same issue of this Journal.2 Respectfully, Ira Schwartz Division of Urology, Department of Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania 19104 Reply by Author. In stating that additional ultrasonic signs of a cyst are the presence of a septum and the "lateral shade sign", I was discussing the distinction between a cyst and a solid homogeneous mass. The presence of a septum is conclusive proof that a structure is fluid-filled. Nearly all septa occur within benign cysts and the practical implication is that the cyst needs to be punctured more than once to perform a satisfactory cyst puncture. Benign multilocular cysts do contain typical numerous thick septa. Septa also can be seen within necrotic neoplasms but, in general, they are of no pathological significance. Septa can be confused with mass lesions in the border of a cyst if a careful scanning technique is not used. I am surprised that Doctor Schwartz refers to the "lateral shade sign" as a new sign. In the fast-moving field of ultrasound it was described as long ago as 1977. 3- 5 My brief review could have had literally hundreds of references but I did not attempt to give any new information or provide a comprehensive list of references. I am glad that Doctor Schwartz raises the question of the ultrasonic appearance of rejection in renal transplants. The suggestion of Barrientos and associates that the renal sinus echoes become more pronounced in rejection is contrary to the extensive literature on renal transplant assessment by ultrasound.2 Various authors have stated that the sinus echoes decrease in size and extent in the course of renal failure. B-9 My own experience has been that sinus echoes become less obvious in acute rejection. Hricak and associates have shown that in rejection there is "uneven widening of perilobular and intralobular adipose tissue septa by edema and mononuclear cell infiltrates". 9 They suggest that fat cells are separated by enlarged septa and that this could be responsible for the change in the spatial pattern of the renal sinus. Later, in the progress of rejection, the volume of adipose tissue actually decreases with subsequent fibrosis, fat cell atrophy and fat cell loss. Fat is considered to be the major cause of sinus echogenicity by most authors. 1. Sanders, R. C.: Kidney. In: Ultrasound in Cancer. Edited by B. Goldberg. London: Churchill Livingstone, pp. 68-69, 1981. 2. Barrientos, A., Leiva, 0., Diaz-Gonzalez, R., Polo, G., Ruilope, L. M., Alcazar, J.M., Rodicio, J. L., Borobia, V. and Navas, J.: The value of ultrasonic scanning in the differentiation of acute posttransplant renal failure. J. Ural., 126: 308, 1981. 3. Jellins, J., Kossof, G. and Reeve, T. S.: Detection and classification of liquid-filled masses in the breast by gray scale echography. Radiology, 125: 205, 1977. 4. Kobayashi, T.: Gray-scale echography for breast cancer. Radiology, 122: 207, 1977.
RE: CONGENITAL ABSENCE OF THE KIDNEY: PROBLEMS IN DIAGNOSIS AND MANAGEMENT
J. R. Cope and S. E. Trickey J. Ural., 127: 10-12, 1982
To the Editor. In their excellent article the authors state that one of their cases represents " ... the only published account of carcinoma of the ureter draining a single kidney". I would like to correct this statement and refer the authors to our article published in 1978. 1 Respectfully, Andrei N. Lupu Division of Urology UCLA School of Medicine 10833 Le Conte Avenue Los Angeles, California 90024
Reply by Authors. We thank Doctor Lupu for his kind words about our paper and, in particular, for drawing our attention to his joint report with Doctor Lieber, in which they published the first account of ureteral carcinoma draining a single kidney. Although our patient was investigated and studied in 1970, some 2 years earlier than their patient, we were incorrect in claiming that our case was the first one to be published and would like to thank Doctor Lupu for pointing this out. We can only sincerely apologize for our oversight. 1. Lieber, M. M. and Lupu, A. N.: High grade invasive ureteral transitional cell carcinoma with a congenital solitary kidney: long-term survival after ureterectomy and radiation therapy. J. Ural., 120: 368, 1978. HORSESHOE KIDNEY IN A PATIENT WITH SITUS INVERSUS TOTALIS
To the Editor. A 43-year-old Japanese man was hospitalized for dull pain in the right loin and microscopic hematuria. He had been well until this hospitalization. General examination revealed an inverse position of the heart, stomach and liver. An electrocardiogram showed dextrocardia. A genital examination revealed that the right testicle was more dependent than the left one. An excretory urogram delineated a right hydronephrotic kidney, with a stone in the renal pelvis, and a vertical axis. A midstream aortogram revealed a horseshoe kidney. A computerized tomography (CT) scan demonstrated the definite situs of the viscera and an accurate renal outline. Thus, diagnosis was horseshoe kidney coexisting with situs inversus totalis. The patient was explored through a midline incision and the diagnosis was confirmed. Right pyelolithotomy, resection of the isthmus and bilateral nephropexy were performed. The high incidence of congenital anomalies in the person with situs inversus has been well documented. Cases reported concerning renal anomalies include agenesis, 1' 2 hypoplasia, 3 ectopia4 ' 5 and poly cystic kidney. 6 Although there is no clear embryologic evidence on when sides are determined in man the association of renal anomalies may reflect a common genetic or exogenous etiology of situs inversus. In the
604
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
Letters to the Editor 5. Bree, R. L. and Silver, T. M.: Differential diagnosis of hypoechoic and anechoic masses with gray scale sonography: new observations. J. Clin. Ultrasound, 7: 249, 1979. 6. Maklad, N. F.: Ultrasonic evaluation of renal transplants. Semin. Ultrasound II, 1: 88, 1981. 7. Hillman, B. J., Birnholz, J. C. and Busch, G. J.: Correlation of echographic and histologic findings in suspected renal allograft rejection. Radiology, 132: 673, 1979. 8. Hricak, H., Toledo-Pereyra, L. H., Eyler, W. R., Madrazo, B. L. and Zammit, M.: The role of ultrasound in the diagnosis of kidney allograft rejection. Radiology, 132: 667, 1979. 9. Hricak, H., Cruz, C., Eyler, W.R., Madrazo, B. L., Romanski, R. and Sandler, M. A.: Acute post-transplantation renal failure: differer.tial diagnosis by ultrasound. Radiology, 139: 441, 1981.
RE: THE PRACTICAL VALUE OF DIAGNOSTIC ULTRASOUND IN UROLOGY
Roger C. Sanders J. Ural., 126: 283-287, 1981
To the Editor. Doctor Sanders lists a septum as a confirmatory sign of a renal cyst. Since I always have considered the presence of a septum to indicate not a simple cyst but a complex lesion compatible with a possible multilocular cyst, stringy blood clots or a neoplastic process have I been unnecessarily concerned about this matter? Doctor Sanders also uses the term "lateral shades sign" without defining it. Instead, one is referred to an article that is not fully cited. 1 Would it not be a good idea for an author to define relatively new terms such as this one and/or list the references completely to aid the reader? Does renal transplant rejection have a typical pattern on ultrasound? The criteria listed by Doctor Sanders in figure 7 on page 285, except for increase in kidney size, are the opposite of the criteria presented by Barrientos and associates in the same issue of this Journal.2 Respectfully, Ira Schwartz Division of Urology, Department of Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania 19104 Reply by Author. In stating that additional ultrasonic signs of a cyst are the presence of a septum and the "lateral shade sign", I was discussing the distinction between a cyst and a solid homogeneous mass. The presence of a septum is conclusive proof that a structure is fluid-filled. Nearly all septa occur within benign cysts and the practical implication is that the cyst needs to be punctured more than once to perform a satisfactory cyst puncture. Benign multilocular cysts do contain typical numerous thick septa. Septa also can be seen within necrotic neoplasms but, in general, they are of no pathological significance. Septa can be confused with mass lesions in the border of a cyst if a careful scanning technique is not used. I am surprised that Doctor Schwartz refers to the "lateral shade sign" as a new sign. In the fast-moving field of ultrasound it was described as long ago as 1977. 3- 5 My brief review could have had literally hundreds of references but I did not attempt to give any new information or provide a comprehensive list of references. I am glad that Doctor Schwartz raises the question of the ultrasonic appearance of rejection in renal transplants. The suggestion of Barrientos and associates that the renal sinus echoes become more pronounced in rejection is contrary to the extensive literature on renal transplant assessment by ultrasound.2 Various authors have stated that the sinus echoes decrease in size and extent in the course of renal failure. B-9 My own experience has been that sinus echoes become less obvious in acute rejection. Hricak and associates have shown that in rejection there is "uneven widening of perilobular and intralobular adipose tissue septa by edema and mononuclear cell infiltrates". 9 They suggest that fat cells are separated by enlarged septa and that this could be responsible for the change in the spatial pattern of the renal sinus. Later, in the progress of rejection, the volume of adipose tissue actually decreases with subsequent fibrosis, fat cell atrophy and fat cell loss. Fat is considered to be the major cause of sinus echogenicity by most authors. 1. Sanders, R. C.: Kidney. In: Ultrasound in Cancer. Edited by B. Goldberg. London: Churchill Livingstone, pp. 68-69, 1981. 2. Barrientos, A., Leiva, 0., Diaz-Gonzalez, R., Polo, G., Ruilope, L. M., Alcazar, J.M., Rodicio, J. L., Borobia, V. and Navas, J.: The value of ultrasonic scanning in the differentiation of acute posttransplant renal failure. J. Ural., 126: 308, 1981. 3. Jellins, J., Kossof, G. and Reeve, T. S.: Detection and classification of liquid-filled masses in the breast by gray scale echography. Radiology, 125: 205, 1977. 4. Kobayashi, T.: Gray-scale echography for breast cancer. Radiology, 122: 207, 1977.
RE: CONGENITAL ABSENCE OF THE KIDNEY: PROBLEMS IN DIAGNOSIS AND MANAGEMENT
J. R. Cope and S. E. Trickey J. Ural., 127: 10-12, 1982
To the Editor. In their excellent article the authors state that one of their cases represents " ... the only published account of carcinoma of the ureter draining a single kidney". I would like to correct this statement and refer the authors to our article published in 1978. 1 Respectfully, Andrei N. Lupu Division of Urology UCLA School of Medicine 10833 Le Conte Avenue Los Angeles, California 90024
Reply by Authors. We thank Doctor Lupu for his kind words about our paper and, in particular, for drawing our attention to his joint report with Doctor Lieber, in which they published the first account of ureteral carcinoma draining a single kidney. Although our patient was investigated and studied in 1970, some 2 years earlier than their patient, we were incorrect in claiming that our case was the first one to be published and would like to thank Doctor Lupu for pointing this out. We can only sincerely apologize for our oversight. 1. Lieber, M. M. and Lupu, A. N.: High grade invasive ureteral transitional cell carcinoma with a congenital solitary kidney: long-term survival after ureterectomy and radiation therapy. J. Ural., 120: 368, 1978. HORSESHOE KIDNEY IN A PATIENT WITH SITUS INVERSUS TOTALIS
To the Editor. A 43-year-old Japanese man was hospitalized for dull pain in the right loin and microscopic hematuria. He had been well until this hospitalization. General examination revealed an inverse position of the heart, stomach and liver. An electrocardiogram showed dextrocardia. A genital examination revealed that the right testicle was more dependent than the left one. An excretory urogram delineated a right hydronephrotic kidney, with a stone in the renal pelvis, and a vertical axis. A midstream aortogram revealed a horseshoe kidney. A computerized tomography (CT) scan demonstrated the definite situs of the viscera and an accurate renal outline. Thus, diagnosis was horseshoe kidney coexisting with situs inversus totalis. The patient was explored through a midline incision and the diagnosis was confirmed. Right pyelolithotomy, resection of the isthmus and bilateral nephropexy were performed. The high incidence of congenital anomalies in the person with situs inversus has been well documented. Cases reported concerning renal anomalies include agenesis, 1' 2 hypoplasia, 3 ectopia4 ' 5 and poly cystic kidney. 6 Although there is no clear embryologic evidence on when sides are determined in man the association of renal anomalies may reflect a common genetic or exogenous etiology of situs inversus. In the
604