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Ureteroscopic Visualization of a Cavernous Hemangioma of the Renal Pelvis
0022-534 7 /89 /1434-0788$02.00 /0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 143, April
Printed in U.S.A.
Case Reports URETEROSCOPIC VISUALIZATION OF A CAVERNOUS HEMANGIOMA OF THE RENAL PELVIS RONALD C. MOTLEY, DAVIDE. PATTERSON*
AND
LOUIS H. WEILAND
From the Department of Urology and Section of Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
We describe a 54-year-old man in whom a capillary hemangioma of the renal pelvis was suspected ureteroscopically before excision. To our knowledge, this is the first case reported of this entity managed in this fashion. (J. Ural., 143: 788-790, 1990) Capillary hemangioma of the renal pelvis is a rare lesion, with fewer than 100 cases reported in the literature and only 25 cases at the Mayo Clinic since its inception. Most patients have been treated with nephrectomy because of the difficulty with preoperative distinction between this entity and a malignant lesion. We report a case of renal pelvic hemangioma managed by ureteropyeloscopy. CASE REPORT
A 54-year-old white man presented for a second opinion on the evaluation and treatment of a filling defect found in the right renal pelvis on an excretory urogram (IVP) performed for gross total painless hematuria. An attempt at ureteropyeloscopy of the right collecting system by the local urologist resulted in massive bleeding from the right renal pelvis after passage of the guide wire. The condition stabilized with bed rest and fluids, and the remaining hospital course was uneventful. The patient presented to us about 5 months later. The first episode of gross painless hematuria occurred 23 years previously. An IVP at that time revealed a 1. 7 cm. defect in the right renal pelvis, however, the patient was lost to followup. The next episode of hematuria resulted in the aforementioned hospitalization. The patient had no other urological symptoms. Physical examination revealed a well developed, moderately obese man in no apparent distress. Laboratory studies included a chest radiograph, electrocardiogram, complete blood count, chemistry studies, urinalysis, urine culture and cytology, IVP, and computerized tomography (CT) of the abdomen and pelvis. Other than pyuria, the blood and urine study results were negative. The IVP revealed a filling defect that was approximately 3 cm. in diameter (somewhat larger than the filling defect described 23 years earlier) (fig. 1). A CT scan of the kidney demonstrated a filling defect in the inferior part of the right renal pelvis corresponding to that seen on the IVP (fig. 2), as well as small benign cysts in both kidneys. Cystoscopic findings were negative, and ureteroscopy was performed. A rigid ureteroscope was introduced over a 0.38inch guide wire after dilation of the right orifice with an Olbert balloon catheter. The guide wire was advanced no farther than the level of the mid ureter to avoid traumatizing the renal pelvic mass and, thus, precipitating bleeding. The ureteroscope was advanced into the renal pelvis and the lesion was visualized (fig. 3). A rounded protrusion was noted emanating from the lateral portion of the renal pelvis and covered with what apAccepted for publication October 13, 1989. *Requests for reprints: Mayo Clinic, 200 First St. S. W., Rochester, Minnesota 55905.
1111111111 FIG. 1. Right renal pelvic filling defect of 3 cm.
peared to be normal smooth renal pelvic mucosa. No areas of hemorrhage or necrosis were seen. All data suggested a nonmalignant process, and the patient was prepared for a right flank exploration with excision of the lesion. A right flank incision was made just below the 12th rib, and the right kidney and pelvis were exposed. Pelviotomy was performed, and a 3 X 2 cm. pedunculated round lesion was found. The lesion was excised at its base and the base was carefully fulgurated. Exploration of the pelvis revealed no other lesions. Frozen section histopathological evaluation revealed a papillary cavernous hemangioma, 2.4 X 1.5 X 0.9 cm. in dimension (fig. 4). Excellent hemostasis was achieved and the renal pelvis was closed. Convalescence was uneventful. At 10-month followup the patient had had no recurrence of hematuria. A recent IVP revealed normal collecting systems bilaterally (fig. 5).
788
URETEROSCOPIC VISUALIZATION OF RENAL PELVIC HEMANGIOMA
789
FIG. 2. CT scan confirms intrapelvic solid filling defect
FIG. 4. Microscopic section shows vascular neoplasm with channels of various sizes, larger ones having papillary infoldings of endothelial lining. Surface of angioma has thinned t ransit ional epithelial lining of renal pelvis. H & E , reduced from XlOO.
FIG. 3. Artist's rendition of endoscopic view DISCUSSION
Hemangiomas are more common in the skin, mucous membranes and liver rather than the kidney.1 The primary symptom of renal pelvic hemangioma is intermittent and at times profuse hematuria. In 41 % of the cases renal colic is present secondary to blood clots and in 85% of the cases onset is before 40 years of age. There appears to be no sex predilection. The lesions range from several millimeters to several inches in diameter. Riley and Swann described these lesions in several locations in the kidney, including the cortex, medulla, tips of papillae and pelvis (subepithelially). 1 Swan and Balme stated that most renal pelvic capillary hemangiomas studied were situated immediately beneath the mucous membrane lining the pelvis or 1 of the calices. 2 Hemorrhage occurred when the lesion ruptured through the lining. In 1867 Virchow first described this lesion2 as consisting of multiple subcapsular capillary angiomas found
FIG. 5. IVP 10 months postoperatively
790
MOTLEY, PATTERSON AND WEILAND
in an autopsy specimen. The first clinical case was reported in 1904 by Fenwick, who described 6 cases of hematuria secondary to renal varix. 3 The primary treatment for this lesion has been simple nephrectomy, sometimes performed as an emergency procedure because of life-threatening hemorrhage but usually done because the distinction between a malignant and a benign process could not be established preoperatively. Vinocur and associates recommended conservative management, depending on the age of the patient who had clinical findings suggestive of a hemangioma.4 They made special reference to conservative management in children. Several interesting points arise in our case. To our knowledge our case is the first report of ureteroscopic visualization of this lesion. Our gross visual findings confirmed those of Swan and Balme, who in a study more than half a century ago indicated that most of these lesions appeared to be submucosal. 2 Coincidentally, this lesion had been present for at least 23 years, and this duration exceeded by 3 years that of the first case reported at the Mayo Clinic by Judd and Simon in 1928. 5 To our knowledge, this is the longest duration of such a lesion reported.
A key point is that when evaluating renal or ureteral lesions with the ureteroscope, the guide wire should not be passed closer than 3 to 4 cm. proximal to the lesion (from the orientation of the surgeon). This restriction will avoid inadvertent trauma to the lesion that may result in such severe hemorrhage that the procedure has to be terminated because of obscured visualization. We offer this case report with the consideration that with ureteroscopy, more renal-sparing procedures could be performed. REFERENCES
1. Riley, A. and Swann, W. J., Jr.: Angioma of the kidney. Urol. Cutan. Rev., 45: 377, 1941. 2. Swan, R.H. J. and Balme, H.: Angioma of the kidney: report of a case with an analysis of 26 previously reported cases. Brit. J. Surg., 23: 282, 1935. 3. Fenwick, E. H.: A Handbook of Clinical Electric-Light Cystoscopy. London: J. & A. Churchill, pp. 392-405, 1904. 4. Vinocur, C., Hitzig, G., Marboe, C. and Hensle, T. W.: Renal pelvic tumors in childhood. Urology, 16: 393, 1980. 5. Judd, E. S. and Simon, H. E.: Angioma of the kidney. Surg., Gynec. & Obst., 46: 711, 1928.
Vol. 143, April
Printed in U.S.A.
Case Reports URETEROSCOPIC VISUALIZATION OF A CAVERNOUS HEMANGIOMA OF THE RENAL PELVIS RONALD C. MOTLEY, DAVIDE. PATTERSON*
AND
LOUIS H. WEILAND
From the Department of Urology and Section of Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
We describe a 54-year-old man in whom a capillary hemangioma of the renal pelvis was suspected ureteroscopically before excision. To our knowledge, this is the first case reported of this entity managed in this fashion. (J. Ural., 143: 788-790, 1990) Capillary hemangioma of the renal pelvis is a rare lesion, with fewer than 100 cases reported in the literature and only 25 cases at the Mayo Clinic since its inception. Most patients have been treated with nephrectomy because of the difficulty with preoperative distinction between this entity and a malignant lesion. We report a case of renal pelvic hemangioma managed by ureteropyeloscopy. CASE REPORT
A 54-year-old white man presented for a second opinion on the evaluation and treatment of a filling defect found in the right renal pelvis on an excretory urogram (IVP) performed for gross total painless hematuria. An attempt at ureteropyeloscopy of the right collecting system by the local urologist resulted in massive bleeding from the right renal pelvis after passage of the guide wire. The condition stabilized with bed rest and fluids, and the remaining hospital course was uneventful. The patient presented to us about 5 months later. The first episode of gross painless hematuria occurred 23 years previously. An IVP at that time revealed a 1. 7 cm. defect in the right renal pelvis, however, the patient was lost to followup. The next episode of hematuria resulted in the aforementioned hospitalization. The patient had no other urological symptoms. Physical examination revealed a well developed, moderately obese man in no apparent distress. Laboratory studies included a chest radiograph, electrocardiogram, complete blood count, chemistry studies, urinalysis, urine culture and cytology, IVP, and computerized tomography (CT) of the abdomen and pelvis. Other than pyuria, the blood and urine study results were negative. The IVP revealed a filling defect that was approximately 3 cm. in diameter (somewhat larger than the filling defect described 23 years earlier) (fig. 1). A CT scan of the kidney demonstrated a filling defect in the inferior part of the right renal pelvis corresponding to that seen on the IVP (fig. 2), as well as small benign cysts in both kidneys. Cystoscopic findings were negative, and ureteroscopy was performed. A rigid ureteroscope was introduced over a 0.38inch guide wire after dilation of the right orifice with an Olbert balloon catheter. The guide wire was advanced no farther than the level of the mid ureter to avoid traumatizing the renal pelvic mass and, thus, precipitating bleeding. The ureteroscope was advanced into the renal pelvis and the lesion was visualized (fig. 3). A rounded protrusion was noted emanating from the lateral portion of the renal pelvis and covered with what apAccepted for publication October 13, 1989. *Requests for reprints: Mayo Clinic, 200 First St. S. W., Rochester, Minnesota 55905.
1111111111 FIG. 1. Right renal pelvic filling defect of 3 cm.
peared to be normal smooth renal pelvic mucosa. No areas of hemorrhage or necrosis were seen. All data suggested a nonmalignant process, and the patient was prepared for a right flank exploration with excision of the lesion. A right flank incision was made just below the 12th rib, and the right kidney and pelvis were exposed. Pelviotomy was performed, and a 3 X 2 cm. pedunculated round lesion was found. The lesion was excised at its base and the base was carefully fulgurated. Exploration of the pelvis revealed no other lesions. Frozen section histopathological evaluation revealed a papillary cavernous hemangioma, 2.4 X 1.5 X 0.9 cm. in dimension (fig. 4). Excellent hemostasis was achieved and the renal pelvis was closed. Convalescence was uneventful. At 10-month followup the patient had had no recurrence of hematuria. A recent IVP revealed normal collecting systems bilaterally (fig. 5).
788
URETEROSCOPIC VISUALIZATION OF RENAL PELVIC HEMANGIOMA
789
FIG. 2. CT scan confirms intrapelvic solid filling defect
FIG. 4. Microscopic section shows vascular neoplasm with channels of various sizes, larger ones having papillary infoldings of endothelial lining. Surface of angioma has thinned t ransit ional epithelial lining of renal pelvis. H & E , reduced from XlOO.
FIG. 3. Artist's rendition of endoscopic view DISCUSSION
Hemangiomas are more common in the skin, mucous membranes and liver rather than the kidney.1 The primary symptom of renal pelvic hemangioma is intermittent and at times profuse hematuria. In 41 % of the cases renal colic is present secondary to blood clots and in 85% of the cases onset is before 40 years of age. There appears to be no sex predilection. The lesions range from several millimeters to several inches in diameter. Riley and Swann described these lesions in several locations in the kidney, including the cortex, medulla, tips of papillae and pelvis (subepithelially). 1 Swan and Balme stated that most renal pelvic capillary hemangiomas studied were situated immediately beneath the mucous membrane lining the pelvis or 1 of the calices. 2 Hemorrhage occurred when the lesion ruptured through the lining. In 1867 Virchow first described this lesion2 as consisting of multiple subcapsular capillary angiomas found
FIG. 5. IVP 10 months postoperatively
790
MOTLEY, PATTERSON AND WEILAND
in an autopsy specimen. The first clinical case was reported in 1904 by Fenwick, who described 6 cases of hematuria secondary to renal varix. 3 The primary treatment for this lesion has been simple nephrectomy, sometimes performed as an emergency procedure because of life-threatening hemorrhage but usually done because the distinction between a malignant and a benign process could not be established preoperatively. Vinocur and associates recommended conservative management, depending on the age of the patient who had clinical findings suggestive of a hemangioma.4 They made special reference to conservative management in children. Several interesting points arise in our case. To our knowledge our case is the first report of ureteroscopic visualization of this lesion. Our gross visual findings confirmed those of Swan and Balme, who in a study more than half a century ago indicated that most of these lesions appeared to be submucosal. 2 Coincidentally, this lesion had been present for at least 23 years, and this duration exceeded by 3 years that of the first case reported at the Mayo Clinic by Judd and Simon in 1928. 5 To our knowledge, this is the longest duration of such a lesion reported.
A key point is that when evaluating renal or ureteral lesions with the ureteroscope, the guide wire should not be passed closer than 3 to 4 cm. proximal to the lesion (from the orientation of the surgeon). This restriction will avoid inadvertent trauma to the lesion that may result in such severe hemorrhage that the procedure has to be terminated because of obscured visualization. We offer this case report with the consideration that with ureteroscopy, more renal-sparing procedures could be performed. REFERENCES
1. Riley, A. and Swann, W. J., Jr.: Angioma of the kidney. Urol. Cutan. Rev., 45: 377, 1941. 2. Swan, R.H. J. and Balme, H.: Angioma of the kidney: report of a case with an analysis of 26 previously reported cases. Brit. J. Surg., 23: 282, 1935. 3. Fenwick, E. H.: A Handbook of Clinical Electric-Light Cystoscopy. London: J. & A. Churchill, pp. 392-405, 1904. 4. Vinocur, C., Hitzig, G., Marboe, C. and Hensle, T. W.: Renal pelvic tumors in childhood. Urology, 16: 393, 1980. 5. Judd, E. S. and Simon, H. E.: Angioma of the kidney. Surg., Gynec. & Obst., 46: 711, 1928.