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Solitary Serous Cysts of the Kidney
SOLITARY SEROUS CYSTS OF THE KIDNEY J. S. GROVE Chfrago, Illinois
In recent years several excellent articles dealing with solitary serous cysts of the kidney have been written (1). To date 153 cases have been reported not including the one reported here. From the above number of reported cases urologists have been led to believe that the condition was a relatively rare one; however, Branch (2), recently made a statement much to the contrary in which he said that these cysts were not uncommon, but were merely not reported by pathologists. He states that they are present in 3 to 5 per cent of all autopsies. In a personal inquiry to two pathologists of wide experience Branch's observations were corroborated (3). Because of the paucity of pyelographic studies in these cases this paper is written. In addition some pressure symptoms which these cysts can cause is here demonstrated. In most of the reported cases the urinary symptoms have been very slight or negative, one's attention being drawn to the genitourinary tract by the presence of a palpable tumor mass in the abdomen, or as a result of exclusion of the kidney as a source of pathology. Furthermore, in these cases cystoscopic and functional tests are usually negative, and for these reasons pre-operative diagnoses of solitary serous cysts of the kidney have been uncommon. It is interesting to note that this condition is now being thought of more frequently, as witnessed by the fact that Bugbee (4) recently made a pre-operative diagnosis of solitary cyst of the kidney in a case having a palpable tumor mass with negative cystoscopic and functional findings. Numerous authors have emphasized the fact that under the classification of solitary serous cysts one should not include hemorrhagic cysts, congenital polycystic kidney, cysts in an arteriosclerotic kidney and cysts originating in interstitial nephritis. 661 THE JOURNAL OF' UROLOGY, VOL, XXIII, NO.
6
662
J. S. GROVE
As to the origin of these cysts several theories have been advanced, namely, (a) embryonal rests proliferating under the influence of extrinsic causes, (b) failure of union of tubules and glomeruli, (c) the retention or inflammatory cysts due to constriction of tubules by fibrous tissue or blocking of the glomeruli or tubules by desquamated and degenerated cells, favored perhaps by small hemorrhages and (d) the one most recently advanced by Kampmeier (5) that renal cysts are produced by the persistence and expansion of cystic tubules which had failed to collapse. As these cysts do not communicate with the calyces or kidney pelvis, pyelograms will usually show no distortion of the pelvis unless the cyst is large enough to bulge into it. If the cyst is at the upper pole it may by its weight push the kidney down producing an ectopia as in the case reported here. In addition with the displacement of the kidney various deformities of the ureter may be produced which may cause symptoms referable to the urinary tract. From the above one can gain the impression that there are no typical pyelographic findings for solitary cysts of the kidney. In the case here reported it was very difficult to palpate the tumor because it was at the upper pole and under the left costal arch. However, during the gastro-intestinal x-ray studies it was noted that the stomach was pushed over to the right (fig. 1). This immediately led to the suspicion of either a kidney, splenic or pancreatic tumor. Cystoscopic study did not give any aid except to show an ectopic kidney probably pushed down by some extrinsic cause. A pre-operative diagnosis of kidney tumor was made. CASE REPORT
February 28, 1928. S. G., white, female, single, aged forty-three. Chief complaint. Complained of headaches, pressure in the epigastrium and substernal regions. This pressure was not intense, came on irrespective of meals, and lasted only for a short time. There were no attacks of an angina! nature. Her headaches were general in nature, .not related to her abdominal distress, and at times rather severe. There was no nausea or vomiting. There were no complaints referable to the genito-urinary tract.
SOLITARY SEROUS CYSTS OF KIDNEY
663
Past history. During the past few years she had been under the care of a physician for hypertension. Her past surgical and medical history were negative. She had her menopause four years ago.
R FIG. 1
Family history. There were no family constitutional diseases. Physical examination. Revealed a slight enlargement of her thyroid. Her lungs did not reveal any changes. She had a systolic murmur over
664
J. S. GROVE
the base of the heart and the second aortic was accentuated. Her blood pressure was 168/114. Abdominal examination revealed a full-
FIG.2
ness in the epigastrium with a full area over the stomach region. The entire left upper quadrant was also obliterated by a somewhat cystic feeling mass. There were no irregularities felt over the mass. Rectal
SOLITARY SEROUS CYSTS OF KIDNEY
665
and pelvic examination were negative. Her blood count was 4,850,000 reds, 8200 whites and a hemoglobin of 86 per cent (Sahli). Differential count showed 22 small lymphocytes and 78 polymorphonuclears. There were no abnormal forms noted. Gastro-intestinal fluoroscopic report (Dr. S. A. Portis). The caraiac opening of the stomach is to the right of the vertebral column. The stomach occupies the right half of the abdomen. Duodenal bulb is situated behind the stiomach and when broyght into view is negative. The right half of the diaphragm seems to cover the liver. Underneath the left diaphragm there is a region of similar density as that on the right. The stomach is empty at the end of four hours. Twenty-four-hour observation. The transverse colon is depressed somewhat downward and has a distinct angulation between the middle and the splenic flexure (fig. 2). Forty-eight-hour observation. The transverse colon is still depressed by the mass in the left upper quadrant (fig. 2). Plates of the stomach show it to be pushed over to the right (fig. l). On one plate there is a suggestion of a circular mass occupying the left half of the abdomen and extending down from the costal margin. Plates of the kidney region show what appears to be a small kidney on the right side and there is large circular mass on the left side which appears as though it is superimposed on the kidney shadow. Urological examination. February 27, 1928, phenolsulphonephthal-· ein 35 per cent first hour, 40 per cent second hour. Blood chemistry: urea 12 mgm. per 100 cc. Blood sugar 90 mgm. per 100 cc. Blood Wassermann negative. Cystoscopy. Revealed a normal bladder, both ureteral orifices were normal and easily catheterized. VVithdrawal test on the left side 12 cc. of clear urine. None on the right. Left pyelogram made. Indigocarmine appeared on the left side in 4½ minutes in good concentration, on the right side in 4 minutes in good concentration. Examination. Examination of urine from left kidney showed a very faint trace of albumin. No sugar. No red blood cells. No pus cells. Few uric acid crystals. From right kidney: Trace albumin. No sugar. One to 2 red blood cells per high power field. No pus cells. Left pyelogram shows a rn,phroptosis of third degree with tortuosity and kinking of ureter. Slight degree of hydronephrosis. Pelvis and calyces practically normal (fig. 3). Diagnosis. Tumor mass pressing on kidney. In passing it may be said that a more positive diagnosis of kidney tumor could have been
666
J. S. GROVE
made by taking a plate of the kidney with pressure applied against the side of the tumor so as to displace it. If there would have been displacement of the ureter on pressure than one could have been sure of the mass being attached to the kidney.
Fm. 3
Operation. March 24, 1928. (Dr. H. M. Richter.) Ethylene anesthesia. Incision made anteriorly over the tumor mass. On opening the abdomen a very large tumor presented to the left side of the abdomen,
SOLITARY SEROUS CYSTS OF KIDNEY
667
very cystic in nature. An opening was made in the gastro-colic omentum and the mass was then explored. It measured approximately 15 by 12 by 8 inches. The tumor was found to be a cyst arising from the upper pole of the kidney. The upper pole of the kidney was resected and the cut end of the kidney was closed by suturing the omentum to it. There was no connection between the pelvis and the cyst. In addition to the large cyst there were two or three pea sized cysts of no consequence. The right kidney was palpated and found to be normal. The kidney was dropped back into position and the abdomen closed without drainage. The tumor consisted of a large thin-walled sac containing clear fluid. It weighed 6½ pounds (fig;. 4).
Fm. 4
Since the operation the patient's blood pressure has not dropped, varying from 156/110 to 192/120. However, the pressure symptoms in the epigastric and substernal regions have disappeared. SUMMARY
1. A case of solitary cyst of the kidney is reported, which was
large enough to produce pressure symptoms referable to the gastro-in testinal tract. 2. Functional and cystoscopic studies did not reveal any abnormal findings. 3. Although the cyst was a large one, it was possible to do a par-
668
J. S. GROVE
tial resection, and save a good portion of normally functionating kidney. 4. As more and more of these cases are being reported it would seem advisable to keep this condition in mind when dealing with kidney tumors, which are symptomless. 5. These tumors are not uncommon as witnessed by the observations of pathologists. I wish to express my appreciation to Drs. S. A. Portis and H. M. Richter for permitting me to use their reports in the publication of this paper. REFERENCES (1) KRETSCHMER, H. L.: Jour. Urol., 1920, iv, 567. HARPSTER, C. M. ET AL.: Jour. Urol., 1924, xi, 157. KERWIN, T. J.: Jour. Urol., 1926, xv, 273. McKrM, G. F., AND SMITH, P. G.: Jour. Urol., 1924, xii, 635. CARSON, W. J.: Ann. Surg., 1928, lxxxvii, 250. (2) BRANCH, C. F.: Jour. Urol., 1929, xxi, 451. (3) WELLS, H. G.: Department of Pathology, University of Chicago. Personal communication. JAFFE, R. H.: Department of Pathology, Cook County Hospital, Chicago. Personal communication. (4) BUGBEE, H. G.: Jour. Urol., 1929, xxi, 363. (5) KAMPMEIER, 0.: Surg., Gynecol., and Obstet., 1923, xxxvi, 208.
In recent years several excellent articles dealing with solitary serous cysts of the kidney have been written (1). To date 153 cases have been reported not including the one reported here. From the above number of reported cases urologists have been led to believe that the condition was a relatively rare one; however, Branch (2), recently made a statement much to the contrary in which he said that these cysts were not uncommon, but were merely not reported by pathologists. He states that they are present in 3 to 5 per cent of all autopsies. In a personal inquiry to two pathologists of wide experience Branch's observations were corroborated (3). Because of the paucity of pyelographic studies in these cases this paper is written. In addition some pressure symptoms which these cysts can cause is here demonstrated. In most of the reported cases the urinary symptoms have been very slight or negative, one's attention being drawn to the genitourinary tract by the presence of a palpable tumor mass in the abdomen, or as a result of exclusion of the kidney as a source of pathology. Furthermore, in these cases cystoscopic and functional tests are usually negative, and for these reasons pre-operative diagnoses of solitary serous cysts of the kidney have been uncommon. It is interesting to note that this condition is now being thought of more frequently, as witnessed by the fact that Bugbee (4) recently made a pre-operative diagnosis of solitary cyst of the kidney in a case having a palpable tumor mass with negative cystoscopic and functional findings. Numerous authors have emphasized the fact that under the classification of solitary serous cysts one should not include hemorrhagic cysts, congenital polycystic kidney, cysts in an arteriosclerotic kidney and cysts originating in interstitial nephritis. 661 THE JOURNAL OF' UROLOGY, VOL, XXIII, NO.
6
662
J. S. GROVE
As to the origin of these cysts several theories have been advanced, namely, (a) embryonal rests proliferating under the influence of extrinsic causes, (b) failure of union of tubules and glomeruli, (c) the retention or inflammatory cysts due to constriction of tubules by fibrous tissue or blocking of the glomeruli or tubules by desquamated and degenerated cells, favored perhaps by small hemorrhages and (d) the one most recently advanced by Kampmeier (5) that renal cysts are produced by the persistence and expansion of cystic tubules which had failed to collapse. As these cysts do not communicate with the calyces or kidney pelvis, pyelograms will usually show no distortion of the pelvis unless the cyst is large enough to bulge into it. If the cyst is at the upper pole it may by its weight push the kidney down producing an ectopia as in the case reported here. In addition with the displacement of the kidney various deformities of the ureter may be produced which may cause symptoms referable to the urinary tract. From the above one can gain the impression that there are no typical pyelographic findings for solitary cysts of the kidney. In the case here reported it was very difficult to palpate the tumor because it was at the upper pole and under the left costal arch. However, during the gastro-intestinal x-ray studies it was noted that the stomach was pushed over to the right (fig. 1). This immediately led to the suspicion of either a kidney, splenic or pancreatic tumor. Cystoscopic study did not give any aid except to show an ectopic kidney probably pushed down by some extrinsic cause. A pre-operative diagnosis of kidney tumor was made. CASE REPORT
February 28, 1928. S. G., white, female, single, aged forty-three. Chief complaint. Complained of headaches, pressure in the epigastrium and substernal regions. This pressure was not intense, came on irrespective of meals, and lasted only for a short time. There were no attacks of an angina! nature. Her headaches were general in nature, .not related to her abdominal distress, and at times rather severe. There was no nausea or vomiting. There were no complaints referable to the genito-urinary tract.
SOLITARY SEROUS CYSTS OF KIDNEY
663
Past history. During the past few years she had been under the care of a physician for hypertension. Her past surgical and medical history were negative. She had her menopause four years ago.
R FIG. 1
Family history. There were no family constitutional diseases. Physical examination. Revealed a slight enlargement of her thyroid. Her lungs did not reveal any changes. She had a systolic murmur over
664
J. S. GROVE
the base of the heart and the second aortic was accentuated. Her blood pressure was 168/114. Abdominal examination revealed a full-
FIG.2
ness in the epigastrium with a full area over the stomach region. The entire left upper quadrant was also obliterated by a somewhat cystic feeling mass. There were no irregularities felt over the mass. Rectal
SOLITARY SEROUS CYSTS OF KIDNEY
665
and pelvic examination were negative. Her blood count was 4,850,000 reds, 8200 whites and a hemoglobin of 86 per cent (Sahli). Differential count showed 22 small lymphocytes and 78 polymorphonuclears. There were no abnormal forms noted. Gastro-intestinal fluoroscopic report (Dr. S. A. Portis). The caraiac opening of the stomach is to the right of the vertebral column. The stomach occupies the right half of the abdomen. Duodenal bulb is situated behind the stiomach and when broyght into view is negative. The right half of the diaphragm seems to cover the liver. Underneath the left diaphragm there is a region of similar density as that on the right. The stomach is empty at the end of four hours. Twenty-four-hour observation. The transverse colon is depressed somewhat downward and has a distinct angulation between the middle and the splenic flexure (fig. 2). Forty-eight-hour observation. The transverse colon is still depressed by the mass in the left upper quadrant (fig. 2). Plates of the stomach show it to be pushed over to the right (fig. l). On one plate there is a suggestion of a circular mass occupying the left half of the abdomen and extending down from the costal margin. Plates of the kidney region show what appears to be a small kidney on the right side and there is large circular mass on the left side which appears as though it is superimposed on the kidney shadow. Urological examination. February 27, 1928, phenolsulphonephthal-· ein 35 per cent first hour, 40 per cent second hour. Blood chemistry: urea 12 mgm. per 100 cc. Blood sugar 90 mgm. per 100 cc. Blood Wassermann negative. Cystoscopy. Revealed a normal bladder, both ureteral orifices were normal and easily catheterized. VVithdrawal test on the left side 12 cc. of clear urine. None on the right. Left pyelogram made. Indigocarmine appeared on the left side in 4½ minutes in good concentration, on the right side in 4 minutes in good concentration. Examination. Examination of urine from left kidney showed a very faint trace of albumin. No sugar. No red blood cells. No pus cells. Few uric acid crystals. From right kidney: Trace albumin. No sugar. One to 2 red blood cells per high power field. No pus cells. Left pyelogram shows a rn,phroptosis of third degree with tortuosity and kinking of ureter. Slight degree of hydronephrosis. Pelvis and calyces practically normal (fig. 3). Diagnosis. Tumor mass pressing on kidney. In passing it may be said that a more positive diagnosis of kidney tumor could have been
666
J. S. GROVE
made by taking a plate of the kidney with pressure applied against the side of the tumor so as to displace it. If there would have been displacement of the ureter on pressure than one could have been sure of the mass being attached to the kidney.
Fm. 3
Operation. March 24, 1928. (Dr. H. M. Richter.) Ethylene anesthesia. Incision made anteriorly over the tumor mass. On opening the abdomen a very large tumor presented to the left side of the abdomen,
SOLITARY SEROUS CYSTS OF KIDNEY
667
very cystic in nature. An opening was made in the gastro-colic omentum and the mass was then explored. It measured approximately 15 by 12 by 8 inches. The tumor was found to be a cyst arising from the upper pole of the kidney. The upper pole of the kidney was resected and the cut end of the kidney was closed by suturing the omentum to it. There was no connection between the pelvis and the cyst. In addition to the large cyst there were two or three pea sized cysts of no consequence. The right kidney was palpated and found to be normal. The kidney was dropped back into position and the abdomen closed without drainage. The tumor consisted of a large thin-walled sac containing clear fluid. It weighed 6½ pounds (fig;. 4).
Fm. 4
Since the operation the patient's blood pressure has not dropped, varying from 156/110 to 192/120. However, the pressure symptoms in the epigastric and substernal regions have disappeared. SUMMARY
1. A case of solitary cyst of the kidney is reported, which was
large enough to produce pressure symptoms referable to the gastro-in testinal tract. 2. Functional and cystoscopic studies did not reveal any abnormal findings. 3. Although the cyst was a large one, it was possible to do a par-
668
J. S. GROVE
tial resection, and save a good portion of normally functionating kidney. 4. As more and more of these cases are being reported it would seem advisable to keep this condition in mind when dealing with kidney tumors, which are symptomless. 5. These tumors are not uncommon as witnessed by the observations of pathologists. I wish to express my appreciation to Drs. S. A. Portis and H. M. Richter for permitting me to use their reports in the publication of this paper. REFERENCES (1) KRETSCHMER, H. L.: Jour. Urol., 1920, iv, 567. HARPSTER, C. M. ET AL.: Jour. Urol., 1924, xi, 157. KERWIN, T. J.: Jour. Urol., 1926, xv, 273. McKrM, G. F., AND SMITH, P. G.: Jour. Urol., 1924, xii, 635. CARSON, W. J.: Ann. Surg., 1928, lxxxvii, 250. (2) BRANCH, C. F.: Jour. Urol., 1929, xxi, 451. (3) WELLS, H. G.: Department of Pathology, University of Chicago. Personal communication. JAFFE, R. H.: Department of Pathology, Cook County Hospital, Chicago. Personal communication. (4) BUGBEE, H. G.: Jour. Urol., 1929, xxi, 363. (5) KAMPMEIER, 0.: Surg., Gynecol., and Obstet., 1923, xxxvi, 208.