- Email: [email protected]
Surgical Treatment of Disease of Horseshoe Kidneys1
SURGICAL TREATMENT OF DISEASE OF HORSESHOE KIDNEYS 1 A. E. GOLDSTEIN
AND
B. S. ABESHOUSE
From the Department of Genito-Urinary Surgery, Sinai Hospital, Baltimore
The most interesting and quite common renal anomaly known as horseshoe kidney has been designated as a disease in itself. Gutierrez in his splendid monograph, "The Clinical Management of Horseshoe Kidney," published in 1934, elaborates in a most masterly manner on the condition. Foley in 1935 and again in 1940 published the results and very ably discussed the surgical correction of the horseshoe kidney. Since Foley's report in 1940 a few others have published clinical reports of individual cases, the most recent being by Sugg and another by Fitzgerald. Since a horseshoe kidney may not be affected by any definite pathological condition but still produce symptoms of pain and other vague disturbances of unknown origin, it is necessary that these patients be given some consideration. It is also quite possible as we have seen in our own small experience that the anomalous organ exists and has existed over a period of years without the production of any symptoms whatsoever but merely was discovered by accidental means. Should this patient be subjected to surgery? Finally, the occurrence of various pathological entities in the horseshoe kidney, the same as occurs in the normal organ with the production of symptoms definitely characteristic of the particular renal lesion does necessitate some form of surgical intervention. To assume, as some authors wish to advocate, that the horseshoe kidney per se is the etiologic factor in the production of all disease found in this anomalous organ seems quite improbable since pathologic conditions as, hydronephrosis, pyonephrosis, calculi, tuberculosis, neoplasm, etc., are so common in the normal kidney. Likewise, to perform a symphysiotomy and nephropexy on all horseshoe kidneys in the absence of any pathological process or of any symptoms referable to the kidney or any other organ or tract in the body would seem that unnecessary surgery is being performed. If one wishes to speculate that a horseshoe kidney per se is a potential surgical problem and on that basis perform surgery, we believe that the procedure would not be warranted. With the above preliminary remarks we have revised somewhat the grouping of horseshoe kidney disease and diseases of horseshoe kidneys. Since we are, in this discussion, interested primarily in the surgical treatment of the disease of horseshoe kidneys, we shall confine our remarks principally to this phase of it. We have had under our observation in the past 8 years, 8 cases of horseshoe kidney. Because of their unusual interest as a group of cases and because of some unusual features in the surgical treatment of these cases we felt justified in reporting them. 1 Read at annual meeting, MidAtlantic Branch, American Urological Association, Philadelphia, Pa., April 11, 1942. 42
SURGERY OF HORSESHOE KIDNEYS
43
CASE REPORTS
Case 1. S. B., 35, male, examined November 26, 1934. He complained of pain in the left side. The past and family histories were unimportant. Twentyfour hours before admission he had a dull pain, which has been constant, in the left lumbar region, radiating upward. He had noticed some urinary frequency but no hematuria, and some nausea, vomiting and slight diarrhea. Abdominal examination revealed some tenderness in the left upper abdominal region and tenderness in the left lumbar region. No mass was palpable. The genitalia, including the prostate, showed no pathological changes. The voided urine showed a moderate number of white and red blood cells. The blood showed an increased white count of 19,000 leukocytes, with 83 per cent polymorphonuclear cells. On cystoscopy, the bladder was negative. A No. 6 catheter encountered no obstruction in either ureter. The urine from each kidney was negative for pus cells. The capacity of the left kidney pelvis was 30 cc. No relative phenolsulphonephthalein test was done. The blood urea always ranged between 20 and 30 mg. per cent. A plain film showed evidence of a semicircular mass crossing in front of the fourth lumbar vertebra, showing a union of probably both lower poles of the kidneys. Both psoas muscle shadows were visualized. A shadow about the size of a marble was seen in the region of the left kidney pelvis. Intravenous pyelograms, as well as retrograde pyelograms, revealed a dilated left pelvis with the calyces pointing medially and downward and the pelvis of the right kidney not dilated, but its calyces pointing downward and pushed somewhat medially. The shadow on the left seemed to be in the pelvis of the left kidney. Diagnosis: Renal calculus, left; horseshoe kidney (fig. 1). The kidney was exposed through a left lumbar oblique incision extraperitoneally, cutting through the muscles in the usual way by A.E. Goldstein on December 11, 1934. After the diagnosis of horseshoe kidney -was verified by feeling the isthmus of cortical tissue, which was 3 cm. in diameter, an observation was made of the position of the pelvis -with its blood supply. The plevis was on the anterior surface and the blood supply behind this. The renal artery came off from the abdominal aorta. The pelvis was opened anteriorly and the stone removed. The pelvis was not sutured. There was no division of the kidney performed. Drains were inserted in the usual manner and the wound closed. He had urinary drainage for 8 days and then the -wound gradually closed. Epididymitis developed and later on infection in his original renal wound which had to be drained. He was discharged from the hospital on the seventieth postoperative day. VVhen last seen in 1941 he was in excellent condition and was not suffering in any fashion because the kidney had not been sectioned. Both kidneys were free from disease. Case 2. A.H. L., 25, male, single, dentist, was examined on Kovember 5, 1938. He complained of pain in the left lumbar region. The family history was unimportant. In 1933 a diagnosis of left renal calculus was made but not of a horseshoe kidney.
44
A. E. GOLDSTEIN AND B. S. ABESHOUSE
For the past few weeks prior to admission, the patient had been having a dull pain in his left loin, non-radiating, not sharp or colicky; no chills, fever, nausea or vomiting. On November 3, 1938, after spending the day hunting, he had painless hematuria, which was present on 2 voidings. He also had pain in the left kidney region. There was no pain on hyperextension or flexion of back. Physical examination was essentially negative except for tenderness over the left upper quadrant and left costrovertebral angle. No mass was palpable. The genitalia were negative. The urine was negative for albumin and sugar; microscopically it showed an occasional red blood cell and polymorphonuclear cell. On November 7, 1938, intravenous urograms were made. A plain film taken before the injection of the dye showed a calcified shadow in the region of the upper portion of the left half of a horseshoe kidney. The 5 minute film after the in-
Fm. 1. Case L
Stone in left section of horseshoe kidney
jection of the dye showed both kidney pelves to be filled well. Both pelves were rotated anteriorly and situated closer to the midline than normal. The shadow in question appeared to be in the pelvis of the kidney. A 15 minute film showed essentially the same findings. Diagnosis: Calculus in the left half of the horseshoe kidney (fig. 2). The patient was admitted to the Sinai Hospital on April 30, 1939. The operation was performed by B. S. Abeshouse. The calculus was removed from the left half of the horseshoe kidney through a left Israel kidney incision under avertin-ether anaesthesia. He was discharged from the hospital in excellent condition. The patient did very well until September 21, 1939 when he had an attack of pain in the loin and chills apd fever. The urine contained many pus cells. The patient was re-admitted to the Sinai Hospital on October 3, 1939. Cystoscopy
SuRGERY OF HORSESHOE KIDNEYS
45
and pyelography were performed. A plain film showed 2 radiable shadows about the size of a pea in the region of the left kidney. Bilateral pyelogram showed the right half of the horseshoe kidney to be normal. The left half showed a marked dilatation of the pelvis and calyces with incomplete filling. The upper shadow was in the kidney and the lower shadow was in the upper third of the ureter. Diagnosis: Calculous pyonephrosis of the left half of the horseshoe kidney. A left heminephrectomy was done under avertin-ether anesthesia, through a left kidney incision extraperitoneally by Dr. B. S. Abeshouse. The patient made an uneventful recovery except for an episode of fever 13 days after the operation, which was due to an infection in his wound, which
Fm. 2. Case 2.
Ca!culous pyonephrosis, left section of horseshoe kidney
cleared up under treatment. He was discharged from the hospital on November 6, 1939. The wound was closed except for a small gaping of the skin in one portion. This cleared. The patient returned for subsequent examinations. The last examination was on January 29, 1942. The wound was entirely healed. There was no pain or discomfort and no urinary symptoms. Urine was negative. Case 3. L. C., female, 77, was first examined May 6, 1941. This patient was admitted to the hospital for an operation because of a carcinoma of the sigmoid. During the course of the examination it was deemed advisable to have a urological examination. A cystoscopic and pyelographic examination revealed that the pelves and
46
A. E. GOLDSTEIN AND B. S. ABESHOUSE
calyces were slightly dilated with the calyces of both kidneys pointing medially and downward. Purulent urine was found in the left kidney. No symptoms were present referable to kidney disease. Diagnosis: Horseshoe kidney (fig. 3); infected hydronephrosis, left. Case 4. IVI. F., male, 31, was first seen August 25, 1941, complaining of pain in the left lumbar region. The family and past histories were unimportant. In February 1941 a sharp pain developed in his left lumbar region which recurred on several occasions. In April 1941 he observed blood in his urine. This recurred 10 days later and he had not seen any since. He had not had any urinary frequency. The attacks were never accompanied by chills, fever, nausea or vomiting. He had no other important symptoms.
FIG. 3 FIG. 4 FIG. 3. Case 3. Infected hydronephrosis, left section of horseshoe kidney FIG. 4. Case 4. Renal calculi, left section of horseshoe kidney
Some tenderness was present in the left upper abdomen and left lumbar region. A firm palpable mass extended from the midline below the umbilicus to the left upper abdomen. A voided specimen of urine was cloudy due to phosphates. Specific gravity was 1.020. Albumin and sugar was negative. Microscopically there were a few red blood cells. The prostate and genitalia were normal. Under sodium pentothal anaesthesia cystoscopy revealed no pathological findings in the bladder. The ureteral catheters encountered no obstruction. The urine from both kidneys was clear. Thirty per cent phenolsulphonephthaline was excreted in ½ hour from the left kidney and 32 per cent from the right kidney. The plain film revealed a semicircular shadow crossing the third and fourth lumbar vertebra. There were 3 calcified shadows on the left side which appeared to be in the renal region. The borders of the psoas muscles ·were not visualized.
SURGERY OF HORSESHOE KIDNEYS
47
Intravenous urograms demonstrated one of the shadows to be in the pelvis of the left kidney and the other 2 in a lower calyx. The calyces of both kidneys pointed medially and downward, and the pelvis on the left was slightly dilated. Retrograde pyelograms revealed a similar picture. Diagnosis: Renal calculi, left (fig. 4); horseshoe kidney. On August 27, 1941, under avertin-ether anesthesia, the left portion of the horseshoe kidney was exposed extraperitoneally through an oblique lumbar incision in the usual way by A. E. Goldstein. After the diagnosis of the horseshoe kidney was verified, the calculus -was removed from the anterior dilated pelvis. The other 2 small shadows were not located. No sutures were taken in the pelvis, but it was drained. No section of the isthmus, which was 2 cm. in diameter, was made but it was found to be of thick parenchymal tissue. A large renal vein crossed the upper portion of the pelvis and there were several aberrant arteries. The renal artery came off from the abdominal aorta. Closure was made in the usual manner. :Motion pictures were taken of the operation. Urinary drainage ceased -after 14 days and he -was discharged from the hospital on the seventeenth postoperative day. vVhen last seen 3 months after operation, he was free from symptoms and an x-ray showed the 2 small shadows together in a lower minor calyx. Case 5. H. S., male, 53, was first examined October 29, 1941. He complained of weakness and general pains. _ The family and past histories were unimportant. Three months before admission a sharp pain developed in his right lower abdomen; he said he felt as if something had given away. He noticed blood in his urine shortly after this. Since his first attack of pain and bleeding there has been numerous recurrences. This has been accompanied by some nausea, vomiting and gradual weakness, cough, chills at times, shortness of breath and pains in his chest. A large hard mass was palpable in the abdomen; it occupied the entire right side, extending over to the midline and down to the crest of the ilium. Some tenderness was present over this mass. The prostate was slightly larger than normal. A urinalysis was negative. Under sodium pentothal anesthesia, cystoscopy was performed. The bladder was negative. A No. 6 catheter did not encounter any obstruction in either ureter. Urine from each kidney was slightly bloody due to trauma. Phenolsulphonephthalein tests from each kidney were unsatisfactory but there ,vas a total output of 40 per cent in 1 hour and 5 minutes. The blood pressure was 132/90. A plain film showed a shadow of a large mass occupying the right abdomen. The psoas muscle shadows were not visible. Ko evidence in either kidney of calculi. A chest film showed a small circular shadow in the lower right lung. An intravenous urogram revealed only a small amount of dye appearing in circular shadows in the left kidney, but no dye appeared in the right kidney in 15 minutes. Retrograde pyelograms, repeated on 2 occasions, demonstrated a definite compression of the minor calyces against the middle major calyx, some lengthening
48
A. E. GOLDSTEIN AND B. S. ABESHOUSE
of the middle major calyx, also some obliteration of this as well as complete obliteration of the lower major calyx. The pelvis and calyces were pointing medially and downward. The pelvis and calyces on the left are not clearly visualized excepting for some circular shadows which are pointing downward and medially. Diagnosis: Renal neoplasm, right (figs. 5 and 6); horseshoe kidney; metastasis to the right lung. On November 12, 1941, a right heminephrectomy was performed by A. E. Goldstein and B. S. Abeshouse. The usual right lumbar incision was made and the usual approach made to the kidney. After the diagnosis of a tumor in a horseshoe kidney was verified, the right section of the kidney was removed. The isthmus was at the lower pole, crossing the vertebral column at about the third
FIG. 5 FIG. 6 FIG. 5. Case 5. Renal neoplasm in right section of horseshoe kidney (preoperative) FIG. 6. Case 5. Postoperative heminephrectomy of right section of horseshoe kidney. Left section showing
lumbar vertebra in front of the abdominal aorta and was 4 cm. in width. The Hagenbach type of suturing was used. The tumor occupied the entire kidney down to and including part of the isthmus. It was a typical Grawitz tumor both grossly and microscopically. There was no unusual bleeding. Closure was in the usual manner with drainage. There was some urinary drainage for 14 days after the operation. This was probably due to cutting across the calyces of the left kidney. He was discharged from the hospital on the twenty-second postoperative day, feeling very well. Motion pictures were taken of this operation. Since then his strength improved until about February 1, 1942 when he began to lose ground. Another x-ray of the chest was taken and the metastatic area seems to have increased in size.
SURGERY OF HORSESHOE KIDNEYS
49
Case 6. P. L., female, 57, was first examined December 16, 1941. She complained of pain around the umbilicus. The family history -was unimportant. The past history was important only from the standpoint that she had been in the hospital on previous occasions for a cardiac condition as well as for her abdominal pain but never had a urologic examination. About 8 weeks ago she had a sudden nauseating sensation while in bed for a cardiac condition. She began having periumbilical pains before and after eating. She had a great deal of distention, some vomiting and diarrhea. Recently she had some frequency of urination, no haematuria. A palpable mass was present in the right lower abdomen. There -was some tenderness alRo in this area. The blood pressure -was 155/90. The total phe-
FIG. 8 FIG. 7 FIG. 7. Case 6. Calcified cyst of right section of horseshoe kidney FIG. 8. Case 6. Showing left section of horseshoe kidney
nolsulphonephthalein output -was 57 per cent for 2 hours and 10 minutes. The genitalia were negative. A catheterized specimen of urine was negative for pus and blood cells. Cystoscopy under sodium pentothal anesthesia was negative. Ko obstruction was present in either ureter. A plain film showed the lmrnr pole of the kidneys pointing to the midline with a definite shadow of a semilunar shape crossing the fourth lumbar vertebra. There was also a calcified shadow in the upper pole of the right kidney pointing medially. This measured about 5 by 2 cm. Retrograde pyelograms, which were also taken stereoscopically, sho"-ed the shadow in question coming off the upper major calyx on the right. The pelvis on the right was dilated with the calyces pointing medially and downward. On the left, the kidney is lower than the right and seems to be over the vertebral column
50
A. E. GOLDSTEIN AND B. S. ABESHOUSE
between the second and fifth lumbar vertebra. The calyces also pointed medially. Diagnosis: Calcified cyst of the right kidney (figs. 7 and 8); horseshoe kidney. The patient refused an operation. Case 7. C. H., female, 35, was first examined March 1, 1935. (See figure 9.) She complained of some menstrual disorders. She had had occasional slight urinary frequency. In a routine examination a horseshoe kidney was discovered. Case 8. H. E., female, 36, was first examined March 1, 1942. (See figure 10.) She complained of some low right abdominal pain for 7 days prior to her admission to the hospital. This was thought to be caused by her appendix. This was removed and she has been apparently well. Recent postoperative routine examination revealed a horseshoe kidney. This case is to be studied further.
FIG. 9
FIG. 10
FIG. 9. Case 7. Horseshoe kidney without symptoms FIG. 10. Case 8. Horseshoe kidney without symptoms CLASSIFICATION OF GROUPS OF HORSESHOE KIDXEYS
We believe it convenient and necessary to classify the horseshoe kidney into the following groups: Group 1: Cases of horseshoe kidney with or without symptoms referable to the kidney or related organs but with a definite renal pathological lesion. Group 2: Cases of horseshoe kidney with symptoms referable either to the kidney or other related organs in the absence of definite renal disease. Group 3: Cases of horseshoe kidney without symptoms referable either to the kidney or other related organs or tracts in the absence of any renal disease. It is in the latter group that the anomalous condition is most usually found accidentally in the course of a routine examination. It has never given rise to any symptoms of any kind nor has it caused or become the subject of any patho-
SURGERY OF HORSESHOE KIDNEYS
51
logical process in the kidney. We believe that no surgery should be performed simply on the speculation of a possible potential lesion. Careful observation of the patient should be made and at any time should symptoms arise or a pathologic process be encountered, it is quite time enough to carry out any necessary procedure. Two of our cases have been placed in this group. The cases falling into our group 2 are the ones that have aroused considerable attention in the past few years and have been discussed thoroughly by Foley. , In his discussion of this group, we believe that some of his cases definitely demonstrate disease in the kidney and should be considered as pathological horseshoe kidneys. Likewise in the group of cases that he compiled, which were reported prior to his, we believe that one of the cases reported by Baker and Colston was also a definite pathological horseshoe kidney. Cases without definite renal pathological changes but presenting symptoms either of renal or other origin should certainly receive the benefit of surgery by performing symphysiotomy and nephropexy. As to whether all of these cases will benefit by the operation is not definite in our opinion. We are quite certain that failures are going to be reported. In view of the fact that something must be done about these cases they should be given the benefit of the doubt. Unfortunately none of our cases could be classified in this group. Should we have had any in this group we would not have hesitated performing a symphysiotomy and nephropexy. MATERIAL
As previously mentioned, 8 cases of horseshoe kidney have been observed by us. Six of these presented some pathological renal process and all 6 presented symptoms referable to some pathological renal disease. Therefore, according to our classification all 6 of these cases fell into our first group, i.e., symptoms plus pathological change. The other 2 cases did not fall into the second group, i.e., symptoms without pathological change, but fell into the third group which we believe does not require surgery. Inasmuch as our interest in this discourse is entirely surgical, we shall base our remarks on these 6 cases. Surgery was recommended for these 6 cases, but to date only 4 have been operated upon. One of the other 2 is to be operated upon, while in the remaining 1 an operation was not feasible because of a general carcinomatosis. One of the 4 cases (Case 2) was operated on twice, first a pyelotomy for a calculus and later a heminephrectomy was done. Therefore 5 operative procedures were performed in 4 cases. PROCEDURE
We are convinced that the extra peritoneal route is the most feasible, because of an easier approach, because there is less opportunity for infection such as peritonitis in the infected cases and certainly less shock and postoperative distention. We therefore employ an elongated lumbar oblique incision, approaching the kidney in the usual manner by cutting the various muscle layers. The superior triangle is exposed and opened and then the fatty layers over the kidney are opened. The peritoneum is stripped medially. The lower portion of the inci-
52
A. E. GOLDSTEIN AND B. S. ABESHOUSE
sion should be carried toward the midline so as to be able to examine the isthmus of the horseshoe kidney. This can be done. by proper and gentle retraction. After the diagnosis has been verified by observation, surgery to the kidney is performed. In the cases of pyelotomy or ureterotomy these structures are easily approached because most of the time they are on the anterior surface of the kidney or slightly medial. The vessels are usually behind or slightly above the pelvis of the kidney. We do not suture the pelvis or ureter after incision, so as to avoid stricture formation. If heminephrectomy is to be performed the kidney must be well exposed and freed of all its adhesions as well as gently dissecting it away from the abdominal vessels. After the kidney is freed, the ureter should be divided and tied. All the vessels should be ligated with chronic catgut No 3. The kidney is now ready for hemisection. Crushers should now be placed across the isthmus but not too tightly, otherwise the kidney will be macerated. A transverse, or preferably a wedge shaped incision is made between the crushers, delivering the kidney. If only one crusher can be applied, then the incision should be made in front of the crusher allowing it to remain on the kidney which is to be left behind. Hagenbach or mattress sutures of chronic catgut No. 1 should be taken through the cut end of the kidney placing a piece of fat between the loops of catgut as well as under the ties. Usually 3 of these sutures will control any bleeding. Rubber tissue drains are inserted and the wound closed · in the usual manner of any renal wound. SEX AND AGES
The 4 patients operated on were males and their ages were 25, 31, 35, and 53 years. The patient to be operated on is a female, 57 years of age. The one of pyonephrotic horseshoe kidney which could not be operated on because of general carcinomatosis was a female, 77 years of age. SYMPTOMS
The 6 cases described here which fell under the surgical group presented symptoms referable to the disease that was present in the kidney and not to the fact of the horseshoe kidney per se. These symptoms included pain in the lumbar and abdominal regions, nausea and vomiting, chills, urinary frequency and hematuria. In 2 of the cases umbilical pain was present. In 2 of the cases chronic constipation was complained of. DIAGNOSIS
The diagnosis of horseshoe kidney with or without a pathologic renal disease is made both by the abdominal examination together with the roentgen studies. In the studies of plain roentgen films one should look for semicircular shadows across the vertebral column either below or above; sometimes the obliteration of psoas muscle shadows are of tremendous value. Intravenous or retrograde ureteropyelograms taken preferably stereoscopically, demonstrating bilateral variations of the pelves and calyces are of extreme importance, particularly if the calyces point medially or downward or both. The pelves and ureters seem to be
SURGERY OF HORSESHOE KIDNEYS
53
placed anteriorly which is fairly pathognomic of horseshoe kidney. In addition to these observations, the particular pathology will present itself in each kidney. OTHER OBSERVATIONS
Peculiarly, in the 6 surgical and the other two non-surgical cases, the isthmus in all was between the lower poles of the kidneys, crossing the vertebral column between the third and fourth lumbar vertebra. In the 4 cases operated on the isthmus was comprised of parenchymal tissue. The vessels in these 4 cases demonstrated the origin from the abdominal aorta with other smaller aberrant vessels going to the kidneys. The isthmus :in the 4 cases operated on measured between 3 and 5 cm. in width. RESULTS
Four cases were operated on 5 times without any immediate or late mortality. The cases have been followed from 3 months to 8 years. In 1 case the calculus was removed from the pelvis without a hemisection of the kidney. This patient has been followed for 8 years. There has been no recurrent disease in that kidney and the other kidney has remained negative. In another case a calculus was removed from the pelvis but those :in the calyces were not removed. A hemisection of the kidney had not been done. He has been followed for only 3 months. He still has 2 very small calculi in the lower calyces of his left kidney, but apparently has not been disturbed. In the third case, a calculus was removed from the pelvis of the kidney in the presence of an infection. Following the removal of the calculus the infection did not clear up and necessitated a heminephrectomy. In a fourth case, a heminephrectomy was performed for a renal neoplasm in the right section of the horseshoe kidney in the presence of metastasis in the right lung. This was done principally to relieve pain and hematuria. He was followed for 9 months with immediate relief. Metastasis of the lung is beginning to increase at present. CONCLUSIONS
Eight cases of horseshoe kidney are presented, 6 with definite renal disease and symptoms of some nature and 2 without renal disease or symptoms. A revised classification is presented. Four cases were operated upon, in 2 of which a heminephrectomy was performed. All the cases were operated on extraperitoneally. The 4 cases observed at operation had thick parenchymal tissue forming the isthmus at the lower poles. In these same 4 cases, the renal artery came from the abdominal aorta. No immediate or late mortality resulted in the surgical treatment of these cases. Horseshoe kidneys that are exposed because of renal disease should have hemisection after the pathologic process has been corrected.
54
A. E. GOLDSTEIN AND B. S. ABESHOUSE
Horseshoe kidneys with small calculi in the calyces should be heminephrectomi?;ed. Horseshoe kidneys causing gain or other symptoms without renal disease should be sectioned.
3505 N. Charles St., Baltimore, Md. REFERENCES FITZGERALD, JoHN S.: A case of papillary carcinoma in a horseshoe kidney. N. Y. State J. Med., 41: 1941. FoLEY, F. E. B.: Operative Division of the Horseshoe Kidney. Minnesota Med. Jour., 18: 1935, pp. 176. FoLEY, F. E. B.: Surgical Correction of Horseshoe Kidney. J. A. M.A., 116: 1940. GUTIERREZ, RoBERT: The Clinical Management of Horseshoe Kidney. New York, Paul B. Hoeber, Inc., 1934. SuGG, ALFRED R.: Horseshoe kidney. Jour. Oklahoma State Med. Jour., 33: 1940.
AND
B. S. ABESHOUSE
From the Department of Genito-Urinary Surgery, Sinai Hospital, Baltimore
The most interesting and quite common renal anomaly known as horseshoe kidney has been designated as a disease in itself. Gutierrez in his splendid monograph, "The Clinical Management of Horseshoe Kidney," published in 1934, elaborates in a most masterly manner on the condition. Foley in 1935 and again in 1940 published the results and very ably discussed the surgical correction of the horseshoe kidney. Since Foley's report in 1940 a few others have published clinical reports of individual cases, the most recent being by Sugg and another by Fitzgerald. Since a horseshoe kidney may not be affected by any definite pathological condition but still produce symptoms of pain and other vague disturbances of unknown origin, it is necessary that these patients be given some consideration. It is also quite possible as we have seen in our own small experience that the anomalous organ exists and has existed over a period of years without the production of any symptoms whatsoever but merely was discovered by accidental means. Should this patient be subjected to surgery? Finally, the occurrence of various pathological entities in the horseshoe kidney, the same as occurs in the normal organ with the production of symptoms definitely characteristic of the particular renal lesion does necessitate some form of surgical intervention. To assume, as some authors wish to advocate, that the horseshoe kidney per se is the etiologic factor in the production of all disease found in this anomalous organ seems quite improbable since pathologic conditions as, hydronephrosis, pyonephrosis, calculi, tuberculosis, neoplasm, etc., are so common in the normal kidney. Likewise, to perform a symphysiotomy and nephropexy on all horseshoe kidneys in the absence of any pathological process or of any symptoms referable to the kidney or any other organ or tract in the body would seem that unnecessary surgery is being performed. If one wishes to speculate that a horseshoe kidney per se is a potential surgical problem and on that basis perform surgery, we believe that the procedure would not be warranted. With the above preliminary remarks we have revised somewhat the grouping of horseshoe kidney disease and diseases of horseshoe kidneys. Since we are, in this discussion, interested primarily in the surgical treatment of the disease of horseshoe kidneys, we shall confine our remarks principally to this phase of it. We have had under our observation in the past 8 years, 8 cases of horseshoe kidney. Because of their unusual interest as a group of cases and because of some unusual features in the surgical treatment of these cases we felt justified in reporting them. 1 Read at annual meeting, MidAtlantic Branch, American Urological Association, Philadelphia, Pa., April 11, 1942. 42
SURGERY OF HORSESHOE KIDNEYS
43
CASE REPORTS
Case 1. S. B., 35, male, examined November 26, 1934. He complained of pain in the left side. The past and family histories were unimportant. Twentyfour hours before admission he had a dull pain, which has been constant, in the left lumbar region, radiating upward. He had noticed some urinary frequency but no hematuria, and some nausea, vomiting and slight diarrhea. Abdominal examination revealed some tenderness in the left upper abdominal region and tenderness in the left lumbar region. No mass was palpable. The genitalia, including the prostate, showed no pathological changes. The voided urine showed a moderate number of white and red blood cells. The blood showed an increased white count of 19,000 leukocytes, with 83 per cent polymorphonuclear cells. On cystoscopy, the bladder was negative. A No. 6 catheter encountered no obstruction in either ureter. The urine from each kidney was negative for pus cells. The capacity of the left kidney pelvis was 30 cc. No relative phenolsulphonephthalein test was done. The blood urea always ranged between 20 and 30 mg. per cent. A plain film showed evidence of a semicircular mass crossing in front of the fourth lumbar vertebra, showing a union of probably both lower poles of the kidneys. Both psoas muscle shadows were visualized. A shadow about the size of a marble was seen in the region of the left kidney pelvis. Intravenous pyelograms, as well as retrograde pyelograms, revealed a dilated left pelvis with the calyces pointing medially and downward and the pelvis of the right kidney not dilated, but its calyces pointing downward and pushed somewhat medially. The shadow on the left seemed to be in the pelvis of the left kidney. Diagnosis: Renal calculus, left; horseshoe kidney (fig. 1). The kidney was exposed through a left lumbar oblique incision extraperitoneally, cutting through the muscles in the usual way by A.E. Goldstein on December 11, 1934. After the diagnosis of horseshoe kidney -was verified by feeling the isthmus of cortical tissue, which was 3 cm. in diameter, an observation was made of the position of the pelvis -with its blood supply. The plevis was on the anterior surface and the blood supply behind this. The renal artery came off from the abdominal aorta. The pelvis was opened anteriorly and the stone removed. The pelvis was not sutured. There was no division of the kidney performed. Drains were inserted in the usual manner and the wound closed. He had urinary drainage for 8 days and then the -wound gradually closed. Epididymitis developed and later on infection in his original renal wound which had to be drained. He was discharged from the hospital on the seventieth postoperative day. VVhen last seen in 1941 he was in excellent condition and was not suffering in any fashion because the kidney had not been sectioned. Both kidneys were free from disease. Case 2. A.H. L., 25, male, single, dentist, was examined on Kovember 5, 1938. He complained of pain in the left lumbar region. The family history was unimportant. In 1933 a diagnosis of left renal calculus was made but not of a horseshoe kidney.
44
A. E. GOLDSTEIN AND B. S. ABESHOUSE
For the past few weeks prior to admission, the patient had been having a dull pain in his left loin, non-radiating, not sharp or colicky; no chills, fever, nausea or vomiting. On November 3, 1938, after spending the day hunting, he had painless hematuria, which was present on 2 voidings. He also had pain in the left kidney region. There was no pain on hyperextension or flexion of back. Physical examination was essentially negative except for tenderness over the left upper quadrant and left costrovertebral angle. No mass was palpable. The genitalia were negative. The urine was negative for albumin and sugar; microscopically it showed an occasional red blood cell and polymorphonuclear cell. On November 7, 1938, intravenous urograms were made. A plain film taken before the injection of the dye showed a calcified shadow in the region of the upper portion of the left half of a horseshoe kidney. The 5 minute film after the in-
Fm. 1. Case L
Stone in left section of horseshoe kidney
jection of the dye showed both kidney pelves to be filled well. Both pelves were rotated anteriorly and situated closer to the midline than normal. The shadow in question appeared to be in the pelvis of the kidney. A 15 minute film showed essentially the same findings. Diagnosis: Calculus in the left half of the horseshoe kidney (fig. 2). The patient was admitted to the Sinai Hospital on April 30, 1939. The operation was performed by B. S. Abeshouse. The calculus was removed from the left half of the horseshoe kidney through a left Israel kidney incision under avertin-ether anaesthesia. He was discharged from the hospital in excellent condition. The patient did very well until September 21, 1939 when he had an attack of pain in the loin and chills apd fever. The urine contained many pus cells. The patient was re-admitted to the Sinai Hospital on October 3, 1939. Cystoscopy
SuRGERY OF HORSESHOE KIDNEYS
45
and pyelography were performed. A plain film showed 2 radiable shadows about the size of a pea in the region of the left kidney. Bilateral pyelogram showed the right half of the horseshoe kidney to be normal. The left half showed a marked dilatation of the pelvis and calyces with incomplete filling. The upper shadow was in the kidney and the lower shadow was in the upper third of the ureter. Diagnosis: Calculous pyonephrosis of the left half of the horseshoe kidney. A left heminephrectomy was done under avertin-ether anesthesia, through a left kidney incision extraperitoneally by Dr. B. S. Abeshouse. The patient made an uneventful recovery except for an episode of fever 13 days after the operation, which was due to an infection in his wound, which
Fm. 2. Case 2.
Ca!culous pyonephrosis, left section of horseshoe kidney
cleared up under treatment. He was discharged from the hospital on November 6, 1939. The wound was closed except for a small gaping of the skin in one portion. This cleared. The patient returned for subsequent examinations. The last examination was on January 29, 1942. The wound was entirely healed. There was no pain or discomfort and no urinary symptoms. Urine was negative. Case 3. L. C., female, 77, was first examined May 6, 1941. This patient was admitted to the hospital for an operation because of a carcinoma of the sigmoid. During the course of the examination it was deemed advisable to have a urological examination. A cystoscopic and pyelographic examination revealed that the pelves and
46
A. E. GOLDSTEIN AND B. S. ABESHOUSE
calyces were slightly dilated with the calyces of both kidneys pointing medially and downward. Purulent urine was found in the left kidney. No symptoms were present referable to kidney disease. Diagnosis: Horseshoe kidney (fig. 3); infected hydronephrosis, left. Case 4. IVI. F., male, 31, was first seen August 25, 1941, complaining of pain in the left lumbar region. The family and past histories were unimportant. In February 1941 a sharp pain developed in his left lumbar region which recurred on several occasions. In April 1941 he observed blood in his urine. This recurred 10 days later and he had not seen any since. He had not had any urinary frequency. The attacks were never accompanied by chills, fever, nausea or vomiting. He had no other important symptoms.
FIG. 3 FIG. 4 FIG. 3. Case 3. Infected hydronephrosis, left section of horseshoe kidney FIG. 4. Case 4. Renal calculi, left section of horseshoe kidney
Some tenderness was present in the left upper abdomen and left lumbar region. A firm palpable mass extended from the midline below the umbilicus to the left upper abdomen. A voided specimen of urine was cloudy due to phosphates. Specific gravity was 1.020. Albumin and sugar was negative. Microscopically there were a few red blood cells. The prostate and genitalia were normal. Under sodium pentothal anaesthesia cystoscopy revealed no pathological findings in the bladder. The ureteral catheters encountered no obstruction. The urine from both kidneys was clear. Thirty per cent phenolsulphonephthaline was excreted in ½ hour from the left kidney and 32 per cent from the right kidney. The plain film revealed a semicircular shadow crossing the third and fourth lumbar vertebra. There were 3 calcified shadows on the left side which appeared to be in the renal region. The borders of the psoas muscles ·were not visualized.
SURGERY OF HORSESHOE KIDNEYS
47
Intravenous urograms demonstrated one of the shadows to be in the pelvis of the left kidney and the other 2 in a lower calyx. The calyces of both kidneys pointed medially and downward, and the pelvis on the left was slightly dilated. Retrograde pyelograms revealed a similar picture. Diagnosis: Renal calculi, left (fig. 4); horseshoe kidney. On August 27, 1941, under avertin-ether anesthesia, the left portion of the horseshoe kidney was exposed extraperitoneally through an oblique lumbar incision in the usual way by A. E. Goldstein. After the diagnosis of the horseshoe kidney was verified, the calculus -was removed from the anterior dilated pelvis. The other 2 small shadows were not located. No sutures were taken in the pelvis, but it was drained. No section of the isthmus, which was 2 cm. in diameter, was made but it was found to be of thick parenchymal tissue. A large renal vein crossed the upper portion of the pelvis and there were several aberrant arteries. The renal artery came off from the abdominal aorta. Closure was made in the usual manner. :Motion pictures were taken of the operation. Urinary drainage ceased -after 14 days and he -was discharged from the hospital on the seventeenth postoperative day. vVhen last seen 3 months after operation, he was free from symptoms and an x-ray showed the 2 small shadows together in a lower minor calyx. Case 5. H. S., male, 53, was first examined October 29, 1941. He complained of weakness and general pains. _ The family and past histories were unimportant. Three months before admission a sharp pain developed in his right lower abdomen; he said he felt as if something had given away. He noticed blood in his urine shortly after this. Since his first attack of pain and bleeding there has been numerous recurrences. This has been accompanied by some nausea, vomiting and gradual weakness, cough, chills at times, shortness of breath and pains in his chest. A large hard mass was palpable in the abdomen; it occupied the entire right side, extending over to the midline and down to the crest of the ilium. Some tenderness was present over this mass. The prostate was slightly larger than normal. A urinalysis was negative. Under sodium pentothal anesthesia, cystoscopy was performed. The bladder was negative. A No. 6 catheter did not encounter any obstruction in either ureter. Urine from each kidney was slightly bloody due to trauma. Phenolsulphonephthalein tests from each kidney were unsatisfactory but there ,vas a total output of 40 per cent in 1 hour and 5 minutes. The blood pressure was 132/90. A plain film showed a shadow of a large mass occupying the right abdomen. The psoas muscle shadows were not visible. Ko evidence in either kidney of calculi. A chest film showed a small circular shadow in the lower right lung. An intravenous urogram revealed only a small amount of dye appearing in circular shadows in the left kidney, but no dye appeared in the right kidney in 15 minutes. Retrograde pyelograms, repeated on 2 occasions, demonstrated a definite compression of the minor calyces against the middle major calyx, some lengthening
48
A. E. GOLDSTEIN AND B. S. ABESHOUSE
of the middle major calyx, also some obliteration of this as well as complete obliteration of the lower major calyx. The pelvis and calyces were pointing medially and downward. The pelvis and calyces on the left are not clearly visualized excepting for some circular shadows which are pointing downward and medially. Diagnosis: Renal neoplasm, right (figs. 5 and 6); horseshoe kidney; metastasis to the right lung. On November 12, 1941, a right heminephrectomy was performed by A. E. Goldstein and B. S. Abeshouse. The usual right lumbar incision was made and the usual approach made to the kidney. After the diagnosis of a tumor in a horseshoe kidney was verified, the right section of the kidney was removed. The isthmus was at the lower pole, crossing the vertebral column at about the third
FIG. 5 FIG. 6 FIG. 5. Case 5. Renal neoplasm in right section of horseshoe kidney (preoperative) FIG. 6. Case 5. Postoperative heminephrectomy of right section of horseshoe kidney. Left section showing
lumbar vertebra in front of the abdominal aorta and was 4 cm. in width. The Hagenbach type of suturing was used. The tumor occupied the entire kidney down to and including part of the isthmus. It was a typical Grawitz tumor both grossly and microscopically. There was no unusual bleeding. Closure was in the usual manner with drainage. There was some urinary drainage for 14 days after the operation. This was probably due to cutting across the calyces of the left kidney. He was discharged from the hospital on the twenty-second postoperative day, feeling very well. Motion pictures were taken of this operation. Since then his strength improved until about February 1, 1942 when he began to lose ground. Another x-ray of the chest was taken and the metastatic area seems to have increased in size.
SURGERY OF HORSESHOE KIDNEYS
49
Case 6. P. L., female, 57, was first examined December 16, 1941. She complained of pain around the umbilicus. The family history -was unimportant. The past history was important only from the standpoint that she had been in the hospital on previous occasions for a cardiac condition as well as for her abdominal pain but never had a urologic examination. About 8 weeks ago she had a sudden nauseating sensation while in bed for a cardiac condition. She began having periumbilical pains before and after eating. She had a great deal of distention, some vomiting and diarrhea. Recently she had some frequency of urination, no haematuria. A palpable mass was present in the right lower abdomen. There -was some tenderness alRo in this area. The blood pressure -was 155/90. The total phe-
FIG. 8 FIG. 7 FIG. 7. Case 6. Calcified cyst of right section of horseshoe kidney FIG. 8. Case 6. Showing left section of horseshoe kidney
nolsulphonephthalein output -was 57 per cent for 2 hours and 10 minutes. The genitalia were negative. A catheterized specimen of urine was negative for pus and blood cells. Cystoscopy under sodium pentothal anesthesia was negative. Ko obstruction was present in either ureter. A plain film showed the lmrnr pole of the kidneys pointing to the midline with a definite shadow of a semilunar shape crossing the fourth lumbar vertebra. There was also a calcified shadow in the upper pole of the right kidney pointing medially. This measured about 5 by 2 cm. Retrograde pyelograms, which were also taken stereoscopically, sho"-ed the shadow in question coming off the upper major calyx on the right. The pelvis on the right was dilated with the calyces pointing medially and downward. On the left, the kidney is lower than the right and seems to be over the vertebral column
50
A. E. GOLDSTEIN AND B. S. ABESHOUSE
between the second and fifth lumbar vertebra. The calyces also pointed medially. Diagnosis: Calcified cyst of the right kidney (figs. 7 and 8); horseshoe kidney. The patient refused an operation. Case 7. C. H., female, 35, was first examined March 1, 1935. (See figure 9.) She complained of some menstrual disorders. She had had occasional slight urinary frequency. In a routine examination a horseshoe kidney was discovered. Case 8. H. E., female, 36, was first examined March 1, 1942. (See figure 10.) She complained of some low right abdominal pain for 7 days prior to her admission to the hospital. This was thought to be caused by her appendix. This was removed and she has been apparently well. Recent postoperative routine examination revealed a horseshoe kidney. This case is to be studied further.
FIG. 9
FIG. 10
FIG. 9. Case 7. Horseshoe kidney without symptoms FIG. 10. Case 8. Horseshoe kidney without symptoms CLASSIFICATION OF GROUPS OF HORSESHOE KIDXEYS
We believe it convenient and necessary to classify the horseshoe kidney into the following groups: Group 1: Cases of horseshoe kidney with or without symptoms referable to the kidney or related organs but with a definite renal pathological lesion. Group 2: Cases of horseshoe kidney with symptoms referable either to the kidney or other related organs in the absence of definite renal disease. Group 3: Cases of horseshoe kidney without symptoms referable either to the kidney or other related organs or tracts in the absence of any renal disease. It is in the latter group that the anomalous condition is most usually found accidentally in the course of a routine examination. It has never given rise to any symptoms of any kind nor has it caused or become the subject of any patho-
SURGERY OF HORSESHOE KIDNEYS
51
logical process in the kidney. We believe that no surgery should be performed simply on the speculation of a possible potential lesion. Careful observation of the patient should be made and at any time should symptoms arise or a pathologic process be encountered, it is quite time enough to carry out any necessary procedure. Two of our cases have been placed in this group. The cases falling into our group 2 are the ones that have aroused considerable attention in the past few years and have been discussed thoroughly by Foley. , In his discussion of this group, we believe that some of his cases definitely demonstrate disease in the kidney and should be considered as pathological horseshoe kidneys. Likewise in the group of cases that he compiled, which were reported prior to his, we believe that one of the cases reported by Baker and Colston was also a definite pathological horseshoe kidney. Cases without definite renal pathological changes but presenting symptoms either of renal or other origin should certainly receive the benefit of surgery by performing symphysiotomy and nephropexy. As to whether all of these cases will benefit by the operation is not definite in our opinion. We are quite certain that failures are going to be reported. In view of the fact that something must be done about these cases they should be given the benefit of the doubt. Unfortunately none of our cases could be classified in this group. Should we have had any in this group we would not have hesitated performing a symphysiotomy and nephropexy. MATERIAL
As previously mentioned, 8 cases of horseshoe kidney have been observed by us. Six of these presented some pathological renal process and all 6 presented symptoms referable to some pathological renal disease. Therefore, according to our classification all 6 of these cases fell into our first group, i.e., symptoms plus pathological change. The other 2 cases did not fall into the second group, i.e., symptoms without pathological change, but fell into the third group which we believe does not require surgery. Inasmuch as our interest in this discourse is entirely surgical, we shall base our remarks on these 6 cases. Surgery was recommended for these 6 cases, but to date only 4 have been operated upon. One of the other 2 is to be operated upon, while in the remaining 1 an operation was not feasible because of a general carcinomatosis. One of the 4 cases (Case 2) was operated on twice, first a pyelotomy for a calculus and later a heminephrectomy was done. Therefore 5 operative procedures were performed in 4 cases. PROCEDURE
We are convinced that the extra peritoneal route is the most feasible, because of an easier approach, because there is less opportunity for infection such as peritonitis in the infected cases and certainly less shock and postoperative distention. We therefore employ an elongated lumbar oblique incision, approaching the kidney in the usual manner by cutting the various muscle layers. The superior triangle is exposed and opened and then the fatty layers over the kidney are opened. The peritoneum is stripped medially. The lower portion of the inci-
52
A. E. GOLDSTEIN AND B. S. ABESHOUSE
sion should be carried toward the midline so as to be able to examine the isthmus of the horseshoe kidney. This can be done. by proper and gentle retraction. After the diagnosis has been verified by observation, surgery to the kidney is performed. In the cases of pyelotomy or ureterotomy these structures are easily approached because most of the time they are on the anterior surface of the kidney or slightly medial. The vessels are usually behind or slightly above the pelvis of the kidney. We do not suture the pelvis or ureter after incision, so as to avoid stricture formation. If heminephrectomy is to be performed the kidney must be well exposed and freed of all its adhesions as well as gently dissecting it away from the abdominal vessels. After the kidney is freed, the ureter should be divided and tied. All the vessels should be ligated with chronic catgut No 3. The kidney is now ready for hemisection. Crushers should now be placed across the isthmus but not too tightly, otherwise the kidney will be macerated. A transverse, or preferably a wedge shaped incision is made between the crushers, delivering the kidney. If only one crusher can be applied, then the incision should be made in front of the crusher allowing it to remain on the kidney which is to be left behind. Hagenbach or mattress sutures of chronic catgut No. 1 should be taken through the cut end of the kidney placing a piece of fat between the loops of catgut as well as under the ties. Usually 3 of these sutures will control any bleeding. Rubber tissue drains are inserted and the wound closed · in the usual manner of any renal wound. SEX AND AGES
The 4 patients operated on were males and their ages were 25, 31, 35, and 53 years. The patient to be operated on is a female, 57 years of age. The one of pyonephrotic horseshoe kidney which could not be operated on because of general carcinomatosis was a female, 77 years of age. SYMPTOMS
The 6 cases described here which fell under the surgical group presented symptoms referable to the disease that was present in the kidney and not to the fact of the horseshoe kidney per se. These symptoms included pain in the lumbar and abdominal regions, nausea and vomiting, chills, urinary frequency and hematuria. In 2 of the cases umbilical pain was present. In 2 of the cases chronic constipation was complained of. DIAGNOSIS
The diagnosis of horseshoe kidney with or without a pathologic renal disease is made both by the abdominal examination together with the roentgen studies. In the studies of plain roentgen films one should look for semicircular shadows across the vertebral column either below or above; sometimes the obliteration of psoas muscle shadows are of tremendous value. Intravenous or retrograde ureteropyelograms taken preferably stereoscopically, demonstrating bilateral variations of the pelves and calyces are of extreme importance, particularly if the calyces point medially or downward or both. The pelves and ureters seem to be
SURGERY OF HORSESHOE KIDNEYS
53
placed anteriorly which is fairly pathognomic of horseshoe kidney. In addition to these observations, the particular pathology will present itself in each kidney. OTHER OBSERVATIONS
Peculiarly, in the 6 surgical and the other two non-surgical cases, the isthmus in all was between the lower poles of the kidneys, crossing the vertebral column between the third and fourth lumbar vertebra. In the 4 cases operated on the isthmus was comprised of parenchymal tissue. The vessels in these 4 cases demonstrated the origin from the abdominal aorta with other smaller aberrant vessels going to the kidneys. The isthmus :in the 4 cases operated on measured between 3 and 5 cm. in width. RESULTS
Four cases were operated on 5 times without any immediate or late mortality. The cases have been followed from 3 months to 8 years. In 1 case the calculus was removed from the pelvis without a hemisection of the kidney. This patient has been followed for 8 years. There has been no recurrent disease in that kidney and the other kidney has remained negative. In another case a calculus was removed from the pelvis but those :in the calyces were not removed. A hemisection of the kidney had not been done. He has been followed for only 3 months. He still has 2 very small calculi in the lower calyces of his left kidney, but apparently has not been disturbed. In the third case, a calculus was removed from the pelvis of the kidney in the presence of an infection. Following the removal of the calculus the infection did not clear up and necessitated a heminephrectomy. In a fourth case, a heminephrectomy was performed for a renal neoplasm in the right section of the horseshoe kidney in the presence of metastasis in the right lung. This was done principally to relieve pain and hematuria. He was followed for 9 months with immediate relief. Metastasis of the lung is beginning to increase at present. CONCLUSIONS
Eight cases of horseshoe kidney are presented, 6 with definite renal disease and symptoms of some nature and 2 without renal disease or symptoms. A revised classification is presented. Four cases were operated upon, in 2 of which a heminephrectomy was performed. All the cases were operated on extraperitoneally. The 4 cases observed at operation had thick parenchymal tissue forming the isthmus at the lower poles. In these same 4 cases, the renal artery came from the abdominal aorta. No immediate or late mortality resulted in the surgical treatment of these cases. Horseshoe kidneys that are exposed because of renal disease should have hemisection after the pathologic process has been corrected.
54
A. E. GOLDSTEIN AND B. S. ABESHOUSE
Horseshoe kidneys with small calculi in the calyces should be heminephrectomi?;ed. Horseshoe kidneys causing gain or other symptoms without renal disease should be sectioned.
3505 N. Charles St., Baltimore, Md. REFERENCES FITZGERALD, JoHN S.: A case of papillary carcinoma in a horseshoe kidney. N. Y. State J. Med., 41: 1941. FoLEY, F. E. B.: Operative Division of the Horseshoe Kidney. Minnesota Med. Jour., 18: 1935, pp. 176. FoLEY, F. E. B.: Surgical Correction of Horseshoe Kidney. J. A. M.A., 116: 1940. GUTIERREZ, RoBERT: The Clinical Management of Horseshoe Kidney. New York, Paul B. Hoeber, Inc., 1934. SuGG, ALFRED R.: Horseshoe kidney. Jour. Oklahoma State Med. Jour., 33: 1940.