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PubMed1983

Benign causes of acquired ureteropelvic junction obstruction: a uroradiologic spectrum.

Five different benign causes of ureteropelvic junction obstruction in adults without prior obstructive history are presented: aortic aneurysm, renal cyst, xanthogranulomatous pyelonephritis, eosinophilic ureteritis, and a crossing blood vessel. Although uncommon, these etiologies warrant consideration when an adult patient presents with ureteropelvic junction obstruction without a prior history of obstruction.

Adult↗
PubMed1980

Pathologic and immunologic considerations in malakoplakia.

A case of malakoplakia of the kidney is presented. Purified plasma membranes from the malakoplakia lesions stimulate blast transformation of the patient's autologous lymphocytes indicating the persistence of bacterial antigens which stimulate primarily thymus-derived lymphocytes. The skin test immunologic competence of the patient and the peripheral blood monocyte chemotactic response were normal. The pathologic findings and these immunologic studies are discussed in relation to xanthogranulomatous pyelonephritis and megalocytic interstitial nephritis and the pathogenesis of this disease.

Chemotaxis, Leukocyte↗
PubMed1976

Pyonephrosis.

The clinical and radiological features of pyonephrosis are reviewed, based on a consecutive series of 40 cases. There were 32 female and eight male patients, with a peak incidence in the 50-59 year age group. In 63% of cases the right kidney was involved. Almost all patients complained of loin pain and 48% had lower urinary tract symptoms. In 58% of cases a renal mass was palpable. An anaemia, pyuria and elevated blood sedimentation rate were usual. Plain films of the abdomen revealed enlargement of the outline of the involved kidney in 75%, ipsilateral absence of the psoas shadow in 63% and urinary tract calculi in 60%. At high-dose excretion urography a nephrogram was obtained in 58% of cases and a pyelogram produced in 34%. No single clinical or radiological entity emerged, there being an unbroken spectrum of disease ranging from infected hydronephrosis to xanthogranulomatous pyelonephritis. There is an increasing incidence of calculi, loss of the renal and psoas outlines and reduced renal function with increasing chronicity of disease. High-dose excretion urography is the investigation of choice since not only may the diagnosis be established but also there precise pathological state of the involved kidney. Further radiological investigation is infrequently required.

Adolescent↗
PubMed1999

With advances in medical imaging can the radiologist reliably diagnose Wilms' tumours?

AIM: To evaluate whether radiologists can accurately differentiate Wilms' tumours from other paediatric abdominal masses with renal involvement using modern imaging methods alone. METHODS: From February 1993 to June 1997, 23 patients presented to the Paediatric Oncology Service at The Royal Hospital for Sick Children, Edinburgh with an intra-abdominal mass which had renal involvement. Nine patients had Wilms' tumours, 12 had neuroblastomas, one patient had xanthogranulomatous pyelonephritis and there was a single case of a mesoblastic nephroma. In each case, two radiologists retrospectively reviewed the initial imaging examinations and independently reached a radiological diagnosis. RESULTS: The radiologists were concordant and reached the correct diagnosis in 20/23 cases (87%), unsure of the diagnosis in one case (4.3 %) and discordant in two cases (8.7 %). Radiologists should be aware that a mesoblastic nephroma can have identical imaging features to a Wilms' tumour. In most cases, ultrasound and a chest X-ray were sufficient to reach the correct diagnosis although computed tomography (CT) and magnetic resonance imaging were superior for demonstrating the relationship of the mass to the great vessels, retroperitoneum and spinal canal. Inferior vena cava invasion was strongly predictive of a Wilms' tumour. Displacement of the great vessels, extension of the mass across the mid-line, renal displacement and tumour calcification on CT were more suggestive of a neuroblastoma although these features were also seen in a significant number of patients with Wilms' tumours. Encasement of vessels by tumour, a paravertebral mass and spinal canal invasion were highly predictive of neuroblastoma. CONCLUSION: In this study, radiologists were accurate at diagnosing Wilms' tumours using modern imaging methods, however, care should be taken in children who are less than 1 year of age as a mesoblastic nephroma may have identical imaging characteristics.

Child↗
PubMed1986

Real-time renal sonography in spinal cord injury patients: prospective comparison with excretory urography.

A prospective blinded comparison of real-time renal sonography and excretory urography was done in 202 urologically asymptomatic patients with spinal cord injury who underwent periodic evaluation. Sonography identified 31 of 31 renal masses (100 per cent) (30 cysts and 1 xanthogranulomatous pyelonephritis), whereas excretory urography identified 14 of 31 masses (45 per cent). Of the 398 kidneys evaluated hydronephrosis owing to an obstructive etiology was noted in 7, all of which (100 per cent) were identified on excretory urography and 6 (86 per cent) were identified on sonography. Only 12 of the 48 kidneys (25 per cent) with typical changes of chronic pyelonephritis on excretory urography were diagnosed correctly by ultrasound. Sonography identified 18 of 23 kidneys (78 per cent) with calculi compared to 20 of 23 (87 per cent) by excretory urography. Although 127 abnormalities were noted in 202 patients, only 21 dictated a change in management. Thirteen abnormalities were visible on a plain film of the kidneys, ureters and bladder (3 kidneys with stones, 1 ureteral stone and 9 bladders with stones). We conclude that sonography and excretory urography are excellent diagnostic modalities for the evaluation of the kidneys. Sonography, plain radiograph of the abdomen and post-contrast injection x-rays on excretory urography frequently offer complementary diagnostic information. The noninvasive nature of ultrasound examination and lack of x-ray exposure combined with no need for special patient preparation make ultrasound examination extremely attractive in this patient population. It is recommended that real-time renal ultrasound and a plain radiograph of the abdomen be used on an alternate basis with excretory urography for the routine followup of spinal cord injury patients.

Adult↗
PubMed1982

Staghorn calculis: its clinical presentation, complications and management.

There were 95 patients (105 kidneys) with staghorn calculi evaluated clinically and 84 kidneys were studied on a pathologic basis. Only 1 percent of the patients could be defined as having a silent stone calculus. Clinical complications occurred in 53 per cent of the patients. Of 84 kidneys submitted for a pathoanatomic study (surgical evaluation and/or histopathology) pyonephrosis was found in 20 per cent, xanthogranulomatous pyelonephritis in 8 per cent, end stage pyelonephritic kidney in 6 per cent, end state hydronephrotic kidney in 7 per cent, severe pyelonephritic changes in 7 per cent and a perinephric abscess in 5 per cent. The kidney was considered to be relatively undamaged in 51 per cent of the cases. Complete removal of the calculus and appropriate medical adjunctive therapy should be done early in the course of the disease in an attempt to prevent complications and renal deterioration. The results of treatment are discussed and compared to those obtained in a group of patients who initially were managed conservatively.

Adolescent↗
PubMed1976

Evaluation of renal masses including retrograde renal brushing.

1. The evaluation of renal masses has become an increasingly important topic because of the increasing incidence of kidney cancer, the improved cure rate of renal carcinoma with the proper preoperative diagnosis, and the proliferation in renal mass diagnostic methodology. 2. A variety of benign entities can produce an abnormal renal mass with attendant difficulties in being distinguished from malignant neoplasms. Among these benign lesions are: simple renal cysts, polycystic kidneys, congenital variations in renal size and shape, segmental renal hypertrophy, renal infarcts, intrarenal hematomas, renal hamartomas, renal leiomyomas, renal adenomas, renal angiomas, renal fibrolipomatosis, hydronephrosis of a duplicated collecting system, renal abscesses, and xanthogranulomatous pyelonephritis. 3. Nephrotomography, nephrosonography (ultrasound), adrenalin renal arteriography, selective magnification renal arteriography, renal venography and cavography, lymphangiography, renal scintillation scanning, abnormal levels of enzymes in blood and urine, immunologic studies (circulating antibodies and tumor-associated antigens), percutaneous needle aspirations, and retrograde renal brushing have all increased the diagnostic accuracy of determining the etiology of renal masses. None of these diagnostic procedures is infallible. A judicious combination of procedures gives the most reliable diagnostic results. 4. A search continues for (a) chemical agent(s) or a chemical profile in the blood or urine which is (are) specific for renal carcinoma, but as yet this is an investigational area and not a practical clinical reality.

Diagnosis, Differential↗
PubMed1987

Renal epithelial hyperplastic and neoplastic proliferation in autosomal dominant polycystic kidney disease.

The early v late occurrence of tubular epithelial hyperplasia and the frequency and malignant potential of renal neoplasms in autosomal dominant polycystic kidney disease (ADPKD) are controversial. The kidneys from 87 patients with documented or presumed ADPKD, removed at autopsy (n = 49) or prior to transplantation (n = 38), were thoroughly sectioned and examined. Hyperplastic polyps were found in 90.8% of the patients, even in the absence of renal insufficiency or marked renal enlargement. However, their number was significantly higher in the patients with advanced stages of the disease, and especially in those with a history of dialysis. Hyperplastic polyps were not detected in eight cases, seven of which had no evidence of epithelial hyperplasia, despite thorough examination of multiple sections. A total of 42 neoplasms were observed in 24.1% of the patients. One patient had bilateral low-grade clear cell adenocarcinoma. Another patient had a transitional cell neoplasm. The remaining 39 neoplasms were microscopic adenomas. Neoplasms tended to occur more often in men and older patients. None of these neoplasms had been clinically diagnosed, and no metastasis had occurred. Nonneoplastic mass lesions were observed in two patients: one had malacoplakia and the other had xanthogranulomatous pyelonephritis.

Adenoma↗
PubMed1997

Renal and perirenal abscesses.

Our knowledge of the spectrum of renal abscesses has evolved as a result of more sensitive radiologic techniques. The classification of intrarenal abscesses currently includes acute focal bacterial nephritis, acute multifocal bacterial nephritis, renal cortical abscess, renal corticomedullary abscess, and xanthogranulomatous pyelonephritis. The clinical presentation of these entities does not differentiate them, however, and various radiographic studies are helpful in making the diagnosis. The intrarenal abscess is usually treated successfully with antibiotic therapy alone. Antistaphylococcal therapy is indicated for the renal cortical abscess, whereas therapy directed against the common gram-negative uropathogens is indicated for most of the other entities. The perinephric abscess is often an elusive diagnosis, has a more serious prognosis, and is more difficult to treat. Drainage of the abscess and sometimes partial or complete nephrectomy, in addition to antibiotic therapy, are required for resolution.

Abscess↗
PubMed2002

Pathological spectrum of nephrectomies in a general hospital.

OBJECTIVES: To first categorize a series of nephrectomies according to underlying pathology, as practised in a major general hospital in the north of Jordan, and then compare the results with published figures for Western countries. Also, to create standards for future evaluation of nephrectomies performed by laparoscopy. METHODS: The hospital and pathological records of 423 consecutive nephrectomies performed at Princess Basma Teaching Hospital in the north of Jordan during the period of 1991 to 2000 were reviewed. RESULTS: Benign disease led to surgery in 298 cases, of which 161 were secondary to infection-related conditions. Malignancy resulted in the removal of 125 kidneys. The rate of nephrectomy for benign conditions has declined during the last few years in comparison with that for malignant conditions. Patients operated on for benign diseases were younger [mean age, 38.4 years] than those with malignant tumours [mean age, 46.7 years]. CONCLUSIONS: The mean age of patients undergoing surgery for benign and malignant disease was lower than in publications from Western countries. The frequency of nephrectomy performed for tuberculosis, hydatid disease, and xanthogranulomatous pyelonephritis is still higher than the rates published in Western countries. There is a remarkably low frequency of upper urothelial carcinoma compared with Western countries, probably due to environmental differences and genetic susceptibilities. Malignant renal tumours tend to affect people at a remarkably young age in Jordan, which is thought to be a reflection of the high proportion of young people. Nephrectomy for malignant disease had a higher rate of complications (16.8%) than for benign conditions [9.4%; p less than 0.0228]. The re-operation rate was 3.1% for all patients who underwent nephrectomy. The overall 30-day mortality rate was 0.9%. Both screening and education programmes are needed to decrease the rate of nephrectomy for preventable conditions.

Adolescent↗
PubMed1998

A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications.

OBJECTIVE: To present the complications from our first 100 cases of laparoscopic nephrectomy, a technically demanding procedure requiring lengthy experience, and to define the risk factors. PATIENTS AND METHODS: Indications for laparoscopic nephrectomy included patients requiring nephrectomy for benign pathology and those requiring nephroureterectomy for upper tract transitional cell carcinoma confined to the upper ureter and/or renal pelvis. All patients were operated on by one surgeon (D.A.T.) via a transperitoneal route and data on diagnosis, outcome and complications collected prospectively. RESULTS: The overall complication rate was 18%, of which 3% were major and 15% minor complications. Five cases were converted to open surgery electively. Complications and conversions were associated with a history of pyonephrosis, previous renal surgery, staghorn calculi, polycystic kidney disease, and xanthogranulomatous pyelonephritis. While there was no discernible decline in the decrease in complications with experience, operative duration decreased from a mean of 204 min for the first 20 cases to 108 min for the last 20. Complications and conversions were more closely associated with diagnosis than with the surgeon's experience. CONCLUSION: Laparoscopic nephrectomy and nephroureterectomy can be undertaken for a variety of indications with reasonable complication and conversion rates. Although inflammatory conditions increase the difficulty of these procedures, we feel that patients requiring nephrectomy for benign disease should be offered a trial of laparoscopic surgery.

Adolescent↗
PubMed1999

Lymphoepithelioma-like carcinoma of the renal pelvis.

We report the first documented case of undifferentiated carcinoma of the renal pelvis with a prominent lymphoid stroma (lymphoepithelioma-like carcinoma [LELC]). LELCs are morphologically identical to nasopharyngeal carcinoma and are rarely seen in the urinary tract, with only isolated cases involving the urinary bladder and ureter. The tumor was composed entirely of large pale staining malignant epithelial cells with ill-defined borders arranged in syncytial sheets separated by mainly reactive lymphocytes, occasional plasma cells and histiocytes. Tumor cells were immunoreactive to cytokeratin and were negative for leukocyte common antigen. Awareness of LELC is important, as it should be distinguished from lymphoma or inflammatory lesions including, xanthogranulomatous pyelonephritis.

Aged↗
PubMed2005

Urinary nuclear matrix protein 22 for diagnosis of renal cell carcinoma.

OBJECTIVE: To determine the incidence of positive urinary nuclear matrix protein 22 (NMP22) values, which are currently used to detect transitional cell carcinoma of the bladder, in renal cell carcinoma (RCC). MATERIAL AND METHODS: Urinary NMP22 values were determined preoperatively in 41 patients in whom a solid renal mass had been detected using CT and who were scheduled for radical nephrectomy; 38 of these patients were diagnosed with RCC. Two patients had xanthogranulomatous pyelonephritis and one had metastasis of a small cell adenocarcinoma to the kidney; these patients were excluded from the study. A total of 30 patients with kidney stones and simple renal cysts were used as controls. RESULTS: The urinary NMP22 values of the RCC patients were significantly higher than those of the controls. Of the 38 patients with RCC, 23 (60.5%) had positive urinary NMP22 values > or =10 U/ml. There were four measurements above this cut-off level in the control group. Urinary NMP22 values increased with an increase in pathologic tumor stage, but the correlation was not statistically significant. There was no correlation between grade and urinary NMP22 or between tumor burden and urinary NMP22. CONCLUSIONS: The urinary NMP22 test may help to diagnose RCC and may also result in an increase in the incidental discovery of RCC. As elevated urinary NMP22 levels have also been found to occur in RCC, patients with suspected bladder cancer and positive urinary NMP22 levels should be more broadly evaluated. Specific NMP assays for renal tumor cells may increase the utility of the test for RCC.

Biomarkers, Tumor↗
PubMed1999

Retroperitoneal access for transperitoneal laparoscopy in patients at high risk for intra-abdominal scarring.

BACKGROUND AND PURPOSE: Adhesions from prior extensive open abdominal surgery can make initial transperitoneal access for laparoscopy hazardous. An alternative to open port placement is a retroperitoneal approach to the peritoneal cavity. We describe our retroperitoneal access for transperitoneal laparoscopy and evaluate the success of the subsequent laparoscopic procedure. PATIENTS AND METHODS: Eight patients with a history of abdominal surgery have undergone retroperitoneal access to the peritoneum prior to a laparoscopic urologic procedure. With the patient in a lateral decubitus position, the retroperitoneum is entered with a 10-mm Visiport device (US Surgical Corp., Norwalk, CT) along the posterior axillary line. A working space is bluntly created, the peritoneum identified anterior to the colon, and the endoscope passed through a peritoneotomy. The abdomen is then inspected, transperitoneal ports are strategically placed under direct vision, and the intended procedure is commenced. RESULTS: In all cases, retroperitoneal access to the peritoneum and subsequent trocar placement was successful. In five cases, the intended procedure was completed laparoscopically. In a case of bilateral ureterolysis, one side was completed laparoscopically; however, the other required open conversion. In two nephrectomies for xanthogranulomatous pyelonephritis (XGP), open conversion was necessary because of fibrosis. CONCLUSION: Retroperitoneal access to the peritoneal cavity permits safe and effective port placement when previous abdominal surgery makes initial transabdominal access difficult. However, despite successful access, in patients at risk for extensive perinephric fibrosis (e.g., XGP), a high incidence of open conversion may be expected.

Abdomen↗
PubMed1984

Computed tomography of ileal loop urinary diversion in adults.

Surgically-placed urinary conduits remain the most common form of long-term, supravesical urinary drainage. We reviewed CT scans of 16 patients with ileal loops examined during a 3-year period to assess normal loop anatomy and associated pathological conditions. Computed tomography was indicated when conventional studies were considered inadequate. Indications for studies were suspected tumor recurrence in 12 (75%) and abscess localization in four (25%). The normal CT ileal loop lies medial to the cecum at the level of the sacral promontory. In 12 patients, CT identified abnormalities related to ileal loop diversion. Clinically unsuspected nontumorous complications (xanthogranulomatous pyelonephritis, pelvic abscess, and peristomal hernia) were detected by CT in patients with suspected tumor recurrence.

Abscess↗
PubMed2000

Benign tumors and tumor-like lesions of the adult kidney. Part II: Benign mesenchymal and mixed neoplasms, and tumor-like lesions.

In this review article the benign tumors and tumor-like lesions of the adult kidney are discussed. The incidence of benign renal tumors is low, especially when compared to renal cell carcinomas, as most are detected incidentally or at autopsy. Some of these tumors, as their names imply, are unique to the kidney, e.g., renal adenoma, metanephric adenoma, renal oncocytoma, nephrogenic adenofibroma, mesoblastic nephroma, capsuloma, juxtaglomerular cell tumor, renomedullary interstitial cell tumor (medullary fibroma), cystic nephroma, cystic partially differentiated nephroblastoma, and cystic hamartoma of the renal pelvis, while others, such as angiomyolipoma, leiomyoma, hemangioma, lipoma, etc., are not unique to the kidney and show similar morphologic features in the other sites they affect. Of the tumor-like lesions, xanthogranulomatous pyelonephritis, malakoplakia, and renal cysts are the most common. The other entities, such as fibroepithelial polyp, are rare, most having been the topic of case reports. In Part I of this paper the benign epithelial tumors of the kidney were previously discussed. This paper (Part II) is devoted to the benign mesenchymal tumors, mixed mesenchymal and epithelial tumors, and the tumor-like lesions.

Adenoma↗
PubMed2004

Selective approach for transperitoneal and extraperitoneal endoscopic nephrectomy in children.

PURPOSE: From the experience of a large combined series of transperitoneal (TP) and retroperitoneal (RP) endoscopic complete and partial nephroureterectomies in children, we present a logical selective endoscopic approach to benign renal pathology. MATERIALS AND METHODS: During a 5-year period 122 complete nephrectomies and nephroureterectomies (bilateral 2, invisible ectopic 8) and 63 partial nephroureterectomies for duplex (52 upper, 8 lower) or singleton polar disease (xanthogranulomatous pyelonephritis 1, cyst 2) were performed. Of the partial nephrectomies, ureterectomy, bladder repair and lower moiety reimplantation were performed in 8. Patient age ranged from 2.7 months to 14 years (mean 2.9 years). Preoperative weight ranged from 2.7 to 98 kg (mean 12.3). The position of the renal remnant, the presence or absence of a refluxing ureter and the need for ureterectomy were the major determining factors affecting choice of endoscopic approach. RESULTS: A total of 179 (96.7%) procedures were successfully completed endoscopically. The 6 open conversions (3.2%) occurred early in our experience. The operating time reflected the complexity of the excision and lower urinary reconstruction (lateral and posterior RP 25 to 145 minutes [mean 92]) TP with ureterocelectomy and bladder neck repair 105 to 355 minutes [mean 153]. Hospital stay for RP and simple TP was 1.5 days (mean 1 to 4) and for complicated TP 2 to 8 days (mean 3.5). CONCLUSIONS: We suggest a posterior retroperitoneal approach with isolated renal excision without extended ureterectomy. The lateral retroperitoneal approach allows complete ureterectomy as well as better exposure to horseshoe and pelvic kidneys and, therefore, avoids exposure to intraperitoneal structures. Finally, the transperitoneal approach is recommended when complete moiety excision with lower urinary reconstruction is anticipated.

Adolescent↗