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Surgical Emergencies Caused by Simple or Solitary Renal Cyst
THE JOURNAL OF UROLOGY
Vol. 63, No. 2, February 1950 Printed in U.S.A.
SURGICAL EMERGENCIES CAUSED BY SIMPLE OR SOLITARY RENAL CYST NORBORNE B. POWELL From the Department of Urology, Baylor University, College of Medicine, Houston, Texas
Simple or solitary cyst of the kidney is found infrequently, but it is indeed rare for a renal cyst to rupture spontaneously and cause a surgical emergency. 'Within the past year, 2 cases have been seen in which a large simple cyst ruptured spontaneously and produced a situation in which the diagnosis and treatment were of the utmost urgency. A review of the literature has revealed only 4 similar cases. Apparently the first report was by Le Comte in 1935 who had 2 cases. One was a 34 year old white woman -whose cystic clear cell carcinoma ruptured spontaneously and a nephrectomy was done 30 hours later. The second case was a traumatic rupture of a simple cyst in a solitary kidney. Operation was delayed 2 weeks due to absence of acute symptoms. Barney in 1936 reported the rupture of a multiple hemorrhagic cyst of the kidney. In 1939 Wehrbein had a case of urinary extravasation due to a ruptured renal cyst, but there was no emergency as operation was delayed 6 weeks. Guitaret of Argentina in 1943 and Bruyere of France in 1945 reported a spontaneous rupture of a solitary cyst, each case requiring immediate surgery. Since the excellent experimental work of Kampmier in 1923, there has been a better understanding of the pathogenisis. He examined many fetal kidneys and found cysts in a surprising number. He postulated that a congenital defect often was the cause of a slmvly developing cyst in later adult life. However, Hepler in 1930 found solitary cyst rare in kidneys of autopsied infants. Experimentally he was able to produce a renal cyst by fulgurating a renal papilla of a rabbit's kidney, then ligating the posterior branch of the renal artery. Autopsy 16 days later showed a typical solitary cyst of the kidney. Prior to 1926, Young found no case of simple renal cyst in 12,500 urological admissions to the Brady Urological Institute. During the next decade, Fish diagnosed 32 cases in almost 12,000 urological admissions. Today simple cyst is diagnosed even more frequently due to improvement in x-ray technique and increasing awareness by urologists. All writers on the subject of renal cysts have distinguished between polycystic renal disease and simple cysts. The former is a congenital and often hereditary trait in which hypertension almost always is found. The latter may or may not be congenital, is usually unilateral, is not hereditary, and seldom carries a grave prognosis. One might infer, therefore, that simple cystic disease of the kidney is a slowly developing, often symptomless condition. Herbst and Polkey differentiated solitary or simple cyst of the kidney from the retention cyst of chronic nephritis, polycystic renal disease, tuberculous cyst, neoplastic cyst, and hydatid disease. Wheeler and also Dean advocated diagnosis and even treatment of solitary renal cyst by aspiration. Stirling found that only 31 of the reported cysts were hemorrhagic while Munger maintained that 203
204
NORBORNE B. POWELL
there have been only 19. Bockus added 3 more cases in 1940. Lowsley and Curtis stress the association of renal malignancy with hemorrhagic cysts. Nearly all advocate nephrectomy in hemorrhagic cysts of the kidney, in contradistinction to conservative resection of serous cyst whenever possible. Gutierrez listed the following diagnostic points in simple renal cyst: 1) compression of the renal pelvis or one or more calyces: 2) change in axis of the kidneys; 3) medial displacement of the ureter; 4) rotation of renal pelvis up or down; 5) visualization of the shadow of the cyst; 6) crescent shape of pelvis or calyces; 7) calcification of cyst; 8) visible psoas shadow through wall of cyst; 9) shadow of cyst anterior to kidney; 10) visualization of cyst by pyelovenous backflow. Practically all authors remark on the greater incidence of cyst in the lower pole compared to the upper pole, and its even more rare occurence in the middle of the kidney. Quinby and Bright reported 4 operative cases of upper pole cysts of the right kidney, and commented on the similarity of symptoms. CASE REPORTS
Case 1. Mr. W. D. J. (Hermann Hospital No. 107005), a 55 year old white man, was seen on October 13, 1947 with a chief complaint of a mass in the right abdomen, disorientation, and weakness of the left leg of 3 weeks' duration. Present illness began suddenly with the onset of severe headache, vomiting, and unconsciousness. When hospitalized a mass was found in the right abdomen which had not been present previously. Spinal tap revealed bloody fluid. He was unable to void and was catheterized on numerous occasions. Past history revealed high blood pressure of several months' duration. Two weeks after the onset of his illness he was transferred to a Houston hospital ·where a marked increase was noted in the size of the abdominal mass. (This probably was due to a second hemorrhage into the renal cyst.) The temperature was 98.2, pulse 68, respiration 18, blood pressure 190/120. The patient appeared ill and mentally confused. The eyes could not rotate to the left, the tongue deviated slightly to the left and moderate nuchal rigidity was present. There was a large mass in the right abdomen which was non-tender, and extended from the costal margin to the crest of the ilium. The prostate was one plus enlarged. Clinical impression: 1) hypertension; 2) subarachnoid hemorrhage; 3) hemorrhage into a renal tumor. Urinalysis: 20-30 white blood cells per high power field, 10-15 red blood cells per high power field, rare granular casts, negative sugar and albumin. Complete blood count: red cell count 3,200,000; white cell count 10,000; hemoglobin 65 per cent. Blood urea nitrogen: 15 mg. per 100 cc. Plain x-rays and excretory urograms showed a large smooth mass in the right upper quadrant and a normal left kidney and ureter. There was delayed function of the right kidney with practically no concentration. Retrograde pyelography revealed a huge mass occupying the lower pole of the right kidney which was suggestive of a hypernephroma with hemorrhage (fig. 1). On October 16, 1947 a nephrectomy was done after a tremendous cystic lower pole was drained of 4000 cc of old bloody fluid (fig. 2). Pathologic diagnosis was simple cyst of the kidney with old hemorrhage.
SURGICAL EMERGENCIES CAUSED BY RENAL CYSTS
205
The postoperative course was characterized by abdominal distension and urinary retention for 4 or 5 weeks. There was a slight residual paralysis of the left leg and a definite personality change due to the subarachnoid hemorrhage which initiated the present illness. The patient was seen on January 15, 1948, three months after operation, at which time he had been voiding satisfactorily for
FIG. I
FIG. 2
several ,veeks. His blood pressure was 190/110 and except for a slight weakness in the left foot there was no appreciable paralysis. Case 2. Mrs. A. F. (Heights Hospital No. 24995), a 54 year old white woman, was admitted January 9, 1948, with a chief complaint of a sharp cutting pain in the left costovertebral angle, precordial pain and fainting. The onset of a sudden severe pain in her back occurred as she reached for an object on a shelf. She fainted twice within the next hour and was in mild shock when hospitalized. Physical examination revealed a patient in obvious shock and in severe pain. Temperature 98.2, pulse 80, respiration 18, blood pressure 80/50. The head, neck, chest, and pelvis were essentially normal. The abdomen showed marked tender-
206
NORBORNE B. POWELL
ness and a mass 6 by 6 inches in the left flank. The urinalysis was negative. The red cell count was 3,610,000 with a 74 per cent hemoglobin. The white cell count as 9,000 with a normal differential.
FIG. 3
FIG. 4
For 3 days the blood pressure varied from a low of 80/50 to a high of 130/70. On two occasions during this time, the patient had a shock-like syndrome characterized by a drop in blood pressure to 90/60, profuse sweating, and unconsciousness. In spite of the obvious shock the pulse remained slow and was never over 90. (This probably was due to pressure on the vagus nerve by the retroperitoneal hematoma.)
SURGICAL EMERGENCIES CAUSED BY RENAL CYSTS
207
The patient was first seen by me 72 hours after admission and diagnosis of perinephric hemorrhage was made. Intravenous urograms, done that night without preparation and with the portable bedside x-ray unit (fig. 3), demonstrated no stones. The right kidney and ureter were normal. The left kidney showed the upper pole fairly well outlined, and an indefinite mass in the lower pole which was interpreted as a renal cyst with acute hemorrhage. Twelve hours later on January 13, 1948, the abdomen was explored through a left transverse incision and a retroperitoneal mass was demonstrated. After the peritoneum was closed the perinephric fascia was incised. There was a sudden welling-up of blood so the pedicle was clamped quickly. On freeing the kidney, a large ruptured hemorrhagic cyst was found occupying the lower pole. Because of the precarious condition of the patient, the size of the cyst, and the possibility of there being a malignancy deep in the wall, a nephrectomy was done (fig. 4). Closure was in the usual manner. The patient left the table in fairly good condtion. Two pints of blood -were given during the procedure. Convalescense ,vas essentially normal, characterized by an immediate postoperative rise in blood pressure that varied from 130/80 to 150/90. The pulse never rose over 110 and ranged between 80 and 90. On discharge the blood pressure was 128/78, and the pulse 70. Pathologist's report: Solitary renal cyst, ruptured, with hemorrhage. The patient was last seen October 7, 1948, at which time there was no complaint referable to the urinary system. Blood pressure was 130/72. SUMMARY
Two cases of simple renal cyst with acute hemorrhage are reported. Both were surgical emergencies treated by nephectomy with recovery. Apparently this is the fifth report in the literature of renal cyst rupturing spontaneously and calling for immediate surgery. The importance of urograms and treatment is discussed. Two additional cases of hemorrhagic renal cysts are added to the literature. 801 Hermann Professional Bldg., Houston, Texas REFERENCES BARNEY, J. D.: J. Urol., 36: 602-608, 1936. BocKus, H. L., KROHN, S. E. AND MULLEN, E. A.: Urol. & Cu tan. Rev., 44: 448-450, 1940. BRUYERE, A.: Lyon chir., 40: 76-77, 1945. DEAN, A. L.: Trans. Am. Assoc. Genito-Urin. Surg., 39: 91-95, 1939. FISH, G. w.: J. A. M.A., 112: 514-518, 1939. GurTARET, M. S.: Rev. Asoc. Med. Argent., 57: 949-953, 1943. GUTIERREZ, R.: Arch. Surg., 44: 279-318, 1942. HEPLER, A. B.: Surg., Gynec. & Obst., 50: 668-687, 1930. HERBST, R.H. AND PoLKEY, H.J.: J. Urol., 37: 490-503, 1937. KAMPMIER, 0. F.: Surg., Gynec. & Obst., 36: 208-216, 1923. LECOMTE, R. M.: Urol. & Cutan. Rev., 39: 13-16, 1935. LowsLEY, 0. S. AND CURTIS, M. S.: J. A. M.A., 127: 1112-1119, 1945. MuNGER,A.D.: J. Urol.,27:73-84, 1932. QUINBY, W. C. AND BRIGH'r, E. F.: J. Urol., 33: 201-214, 1935. STIRLING, W. C.: J. Urol., 25: 213-221, 1931. WEHRBEIN, H. L.: Brooklyn Hosp. J., 1: 33-36, 1939. WHEELER, B. C.: New Eng. J. Med., 226: 55-57, 1942. YouNG, H. H. AND DAVIS, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926.
Vol. 63, No. 2, February 1950 Printed in U.S.A.
SURGICAL EMERGENCIES CAUSED BY SIMPLE OR SOLITARY RENAL CYST NORBORNE B. POWELL From the Department of Urology, Baylor University, College of Medicine, Houston, Texas
Simple or solitary cyst of the kidney is found infrequently, but it is indeed rare for a renal cyst to rupture spontaneously and cause a surgical emergency. 'Within the past year, 2 cases have been seen in which a large simple cyst ruptured spontaneously and produced a situation in which the diagnosis and treatment were of the utmost urgency. A review of the literature has revealed only 4 similar cases. Apparently the first report was by Le Comte in 1935 who had 2 cases. One was a 34 year old white woman -whose cystic clear cell carcinoma ruptured spontaneously and a nephrectomy was done 30 hours later. The second case was a traumatic rupture of a simple cyst in a solitary kidney. Operation was delayed 2 weeks due to absence of acute symptoms. Barney in 1936 reported the rupture of a multiple hemorrhagic cyst of the kidney. In 1939 Wehrbein had a case of urinary extravasation due to a ruptured renal cyst, but there was no emergency as operation was delayed 6 weeks. Guitaret of Argentina in 1943 and Bruyere of France in 1945 reported a spontaneous rupture of a solitary cyst, each case requiring immediate surgery. Since the excellent experimental work of Kampmier in 1923, there has been a better understanding of the pathogenisis. He examined many fetal kidneys and found cysts in a surprising number. He postulated that a congenital defect often was the cause of a slmvly developing cyst in later adult life. However, Hepler in 1930 found solitary cyst rare in kidneys of autopsied infants. Experimentally he was able to produce a renal cyst by fulgurating a renal papilla of a rabbit's kidney, then ligating the posterior branch of the renal artery. Autopsy 16 days later showed a typical solitary cyst of the kidney. Prior to 1926, Young found no case of simple renal cyst in 12,500 urological admissions to the Brady Urological Institute. During the next decade, Fish diagnosed 32 cases in almost 12,000 urological admissions. Today simple cyst is diagnosed even more frequently due to improvement in x-ray technique and increasing awareness by urologists. All writers on the subject of renal cysts have distinguished between polycystic renal disease and simple cysts. The former is a congenital and often hereditary trait in which hypertension almost always is found. The latter may or may not be congenital, is usually unilateral, is not hereditary, and seldom carries a grave prognosis. One might infer, therefore, that simple cystic disease of the kidney is a slowly developing, often symptomless condition. Herbst and Polkey differentiated solitary or simple cyst of the kidney from the retention cyst of chronic nephritis, polycystic renal disease, tuberculous cyst, neoplastic cyst, and hydatid disease. Wheeler and also Dean advocated diagnosis and even treatment of solitary renal cyst by aspiration. Stirling found that only 31 of the reported cysts were hemorrhagic while Munger maintained that 203
204
NORBORNE B. POWELL
there have been only 19. Bockus added 3 more cases in 1940. Lowsley and Curtis stress the association of renal malignancy with hemorrhagic cysts. Nearly all advocate nephrectomy in hemorrhagic cysts of the kidney, in contradistinction to conservative resection of serous cyst whenever possible. Gutierrez listed the following diagnostic points in simple renal cyst: 1) compression of the renal pelvis or one or more calyces: 2) change in axis of the kidneys; 3) medial displacement of the ureter; 4) rotation of renal pelvis up or down; 5) visualization of the shadow of the cyst; 6) crescent shape of pelvis or calyces; 7) calcification of cyst; 8) visible psoas shadow through wall of cyst; 9) shadow of cyst anterior to kidney; 10) visualization of cyst by pyelovenous backflow. Practically all authors remark on the greater incidence of cyst in the lower pole compared to the upper pole, and its even more rare occurence in the middle of the kidney. Quinby and Bright reported 4 operative cases of upper pole cysts of the right kidney, and commented on the similarity of symptoms. CASE REPORTS
Case 1. Mr. W. D. J. (Hermann Hospital No. 107005), a 55 year old white man, was seen on October 13, 1947 with a chief complaint of a mass in the right abdomen, disorientation, and weakness of the left leg of 3 weeks' duration. Present illness began suddenly with the onset of severe headache, vomiting, and unconsciousness. When hospitalized a mass was found in the right abdomen which had not been present previously. Spinal tap revealed bloody fluid. He was unable to void and was catheterized on numerous occasions. Past history revealed high blood pressure of several months' duration. Two weeks after the onset of his illness he was transferred to a Houston hospital ·where a marked increase was noted in the size of the abdominal mass. (This probably was due to a second hemorrhage into the renal cyst.) The temperature was 98.2, pulse 68, respiration 18, blood pressure 190/120. The patient appeared ill and mentally confused. The eyes could not rotate to the left, the tongue deviated slightly to the left and moderate nuchal rigidity was present. There was a large mass in the right abdomen which was non-tender, and extended from the costal margin to the crest of the ilium. The prostate was one plus enlarged. Clinical impression: 1) hypertension; 2) subarachnoid hemorrhage; 3) hemorrhage into a renal tumor. Urinalysis: 20-30 white blood cells per high power field, 10-15 red blood cells per high power field, rare granular casts, negative sugar and albumin. Complete blood count: red cell count 3,200,000; white cell count 10,000; hemoglobin 65 per cent. Blood urea nitrogen: 15 mg. per 100 cc. Plain x-rays and excretory urograms showed a large smooth mass in the right upper quadrant and a normal left kidney and ureter. There was delayed function of the right kidney with practically no concentration. Retrograde pyelography revealed a huge mass occupying the lower pole of the right kidney which was suggestive of a hypernephroma with hemorrhage (fig. 1). On October 16, 1947 a nephrectomy was done after a tremendous cystic lower pole was drained of 4000 cc of old bloody fluid (fig. 2). Pathologic diagnosis was simple cyst of the kidney with old hemorrhage.
SURGICAL EMERGENCIES CAUSED BY RENAL CYSTS
205
The postoperative course was characterized by abdominal distension and urinary retention for 4 or 5 weeks. There was a slight residual paralysis of the left leg and a definite personality change due to the subarachnoid hemorrhage which initiated the present illness. The patient was seen on January 15, 1948, three months after operation, at which time he had been voiding satisfactorily for
FIG. I
FIG. 2
several ,veeks. His blood pressure was 190/110 and except for a slight weakness in the left foot there was no appreciable paralysis. Case 2. Mrs. A. F. (Heights Hospital No. 24995), a 54 year old white woman, was admitted January 9, 1948, with a chief complaint of a sharp cutting pain in the left costovertebral angle, precordial pain and fainting. The onset of a sudden severe pain in her back occurred as she reached for an object on a shelf. She fainted twice within the next hour and was in mild shock when hospitalized. Physical examination revealed a patient in obvious shock and in severe pain. Temperature 98.2, pulse 80, respiration 18, blood pressure 80/50. The head, neck, chest, and pelvis were essentially normal. The abdomen showed marked tender-
206
NORBORNE B. POWELL
ness and a mass 6 by 6 inches in the left flank. The urinalysis was negative. The red cell count was 3,610,000 with a 74 per cent hemoglobin. The white cell count as 9,000 with a normal differential.
FIG. 3
FIG. 4
For 3 days the blood pressure varied from a low of 80/50 to a high of 130/70. On two occasions during this time, the patient had a shock-like syndrome characterized by a drop in blood pressure to 90/60, profuse sweating, and unconsciousness. In spite of the obvious shock the pulse remained slow and was never over 90. (This probably was due to pressure on the vagus nerve by the retroperitoneal hematoma.)
SURGICAL EMERGENCIES CAUSED BY RENAL CYSTS
207
The patient was first seen by me 72 hours after admission and diagnosis of perinephric hemorrhage was made. Intravenous urograms, done that night without preparation and with the portable bedside x-ray unit (fig. 3), demonstrated no stones. The right kidney and ureter were normal. The left kidney showed the upper pole fairly well outlined, and an indefinite mass in the lower pole which was interpreted as a renal cyst with acute hemorrhage. Twelve hours later on January 13, 1948, the abdomen was explored through a left transverse incision and a retroperitoneal mass was demonstrated. After the peritoneum was closed the perinephric fascia was incised. There was a sudden welling-up of blood so the pedicle was clamped quickly. On freeing the kidney, a large ruptured hemorrhagic cyst was found occupying the lower pole. Because of the precarious condition of the patient, the size of the cyst, and the possibility of there being a malignancy deep in the wall, a nephrectomy was done (fig. 4). Closure was in the usual manner. The patient left the table in fairly good condtion. Two pints of blood -were given during the procedure. Convalescense ,vas essentially normal, characterized by an immediate postoperative rise in blood pressure that varied from 130/80 to 150/90. The pulse never rose over 110 and ranged between 80 and 90. On discharge the blood pressure was 128/78, and the pulse 70. Pathologist's report: Solitary renal cyst, ruptured, with hemorrhage. The patient was last seen October 7, 1948, at which time there was no complaint referable to the urinary system. Blood pressure was 130/72. SUMMARY
Two cases of simple renal cyst with acute hemorrhage are reported. Both were surgical emergencies treated by nephectomy with recovery. Apparently this is the fifth report in the literature of renal cyst rupturing spontaneously and calling for immediate surgery. The importance of urograms and treatment is discussed. Two additional cases of hemorrhagic renal cysts are added to the literature. 801 Hermann Professional Bldg., Houston, Texas REFERENCES BARNEY, J. D.: J. Urol., 36: 602-608, 1936. BocKus, H. L., KROHN, S. E. AND MULLEN, E. A.: Urol. & Cu tan. Rev., 44: 448-450, 1940. BRUYERE, A.: Lyon chir., 40: 76-77, 1945. DEAN, A. L.: Trans. Am. Assoc. Genito-Urin. Surg., 39: 91-95, 1939. FISH, G. w.: J. A. M.A., 112: 514-518, 1939. GurTARET, M. S.: Rev. Asoc. Med. Argent., 57: 949-953, 1943. GUTIERREZ, R.: Arch. Surg., 44: 279-318, 1942. HEPLER, A. B.: Surg., Gynec. & Obst., 50: 668-687, 1930. HERBST, R.H. AND PoLKEY, H.J.: J. Urol., 37: 490-503, 1937. KAMPMIER, 0. F.: Surg., Gynec. & Obst., 36: 208-216, 1923. LECOMTE, R. M.: Urol. & Cutan. Rev., 39: 13-16, 1935. LowsLEY, 0. S. AND CURTIS, M. S.: J. A. M.A., 127: 1112-1119, 1945. MuNGER,A.D.: J. Urol.,27:73-84, 1932. QUINBY, W. C. AND BRIGH'r, E. F.: J. Urol., 33: 201-214, 1935. STIRLING, W. C.: J. Urol., 25: 213-221, 1931. WEHRBEIN, H. L.: Brooklyn Hosp. J., 1: 33-36, 1939. WHEELER, B. C.: New Eng. J. Med., 226: 55-57, 1942. YouNG, H. H. AND DAVIS, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926.