SPONTANEOUS
RUPTURE OF RENAL PELVIS
DAVID J, CARO, M.D. ROBERT
S. WALDBAUM,
M.D.
From the Department of Surgery (Urology), Cornell University Medical College, and North Shore University Hospital, Manhasset, New York
ABSTRACT - A seventy-seven-year-old female with progressive abdominal signs for twenty-four hours was found to have had a spontaneous rupture of the renal pelvis with massive urinary extravasation.
Rupture of the kidney usually presents as an acute abdominal crisis with pain, a mass, and signs of massive blood loss.’ Rupture of the renal pelvis may also present as an acute abdominal crisis, but because of the lack of blood loss, the insidious onset, and lack of urinary symptoms, it may be a diagnostic dilemma.2 The following is a case of spontaneous rupture of the renal pelvis which initially presented as a diagnostic problem. Case Report On June 19, 1974, a seventy-seven-year-old female was seen at the North Shore University Hospital emergency room with the acute onset of nausea, vomiting, and pain in the left upper quadrant. Abdominal examination showed only minimal abdominal distention and mild tenderness in the left upper quadrant. Bowel sounds were active, and findings on rectal examination were negative. She was afebrile with 9,500 white blood cells and normal results on urinalysis. A flat plate of the abdomen was unremarkable. She was released from the emergency room but returned ten hours later with increased abdominal pain. On admission her blood pressure was 190/120 mm. Hg and pulse 120. She manifested localized tenderness over the left colic gutter and costovertebral angle with Presented at the Annual Meeting of New York Section, American Urological Association, Inc., Bermuda, September 21, 1975.
410
guarding and rebound in the left upper quadrant. Her white blood cell count was 13,900 and urinalysis showed 4 plus bacteria with 2 white blood cells per high-power field, blood urea nitrogen 39 mg. and creatinine 1.5 mg. per 100 ml., and a normal amylase. Abdominal films showed some distended loops of small bowel without evidence of free air or obstruction. Eight hours later in spite of hydration, intravenous antibiotics, and nasogastric suctioning, there was no clinical improvement. An intravenous pyelogram showed massive extravasation from the left kidney with a pyelonephritic right kidney (Fig. 1A and B). Cystoscopy and retrograde pyelography were carried out to localize any distal obstruction but none was seen (Fig. 1C). She was explored through a left twelfth rib incision, and at least 1,500 cc. of urine were drained from her flank. No specific point of rupture could be located, and because of the condition of the kidney a left nephrectomy was performed. Findings at exploration of the peritoneal cavity were negative. She improved dramatically postoperatively and was discharged on her tenth postoperative day. The patient was last seen one year postoperatively and was doing well. Her blood urea nitrogen was 28 mg. and creatinine 1.4 mg. per 100 ml., and urinalysis revealed no abnormality. An intravenous pyelogram again showed mild pyelonephritic changes in her remaining right kidney. The pathologic report described a 132Gm. kidney with marked hydronephrosis and
UROLOGY / OCTOBER 1976 / VOLUME VIII, NUMBER 4
tion.
thinned renal cortex. No definite site of rupture was located. Microscopically, extensive acute and chronic pyelitis and focal pyelonephritis, arterial, and arteriolar sclerosis, and perirenal and peripelvic inflammation were found. Comment Of the two main classifications of kidney rupture, parenchymal rupture is more common. 1,3*4-6Renal pelvic rupture is more subtle in presentation because the obvious systemic and local signs of blood loss do not occur. Although a handful of case reports profess no preexisting pathologic condition in a spontaneously ruptured renal pelvis, most have some underlying pathologic problem. ‘-’ Hydronephrosis is the most common underlying cause especially when the pelvis is extrarenal or immobile because of adhesions.‘@‘* Stones (either through obstruction or pressure necrosis), infections, tumor strictures, or adhesions from previous surgery are other leading causes of rupture. The rupture may be truly spontaneous or due to minimal trauma which is overlooked. Pathophysiology It has been shown experimentally that a simple increase in hydrostatic pressure within the renal pelvis to 150 cm. is sufficient to cause rupture. 13*14Yet rupture of the kidney pelvis is not common. Various compensatory mechanisms actively prevent significant renal damage. One physiologic defense is the distensibility of the ureter and renal pelvis.15 Pressure multiplied by volume is equal to a
UROLOGY
!
OCTOBER
1976 / VOLUME
VIII,
NUMBER 4
constant; therefore, if the diameter of the ureter is increased, the pressure will decrease accordingly. It has been clearly shown in clinical pyelographic studies that dye may extravasate through a rupture of a calyceal fornix. The urine then escapes into the sinus of the kidney alongside the infundibulum of the calyx. The extravasate penetrates a porous leaf of the capsule and permeates the peripelvic and perirenal tissues. l6 This is considered a normal physiologic mechanism to deal with acutely increased intrapelvic pressure. This is well described by Hinman17 as forniceal backflow. Absorption may occur via the lymphatic or venous channels, but extravasate that spreads to the tissue especially around the renal pelvis and hilum may result in sinointerstitial absorption. The latter mechanism may lead to diffuse fibrosis and consequent hydronephrosis, which allows for the real possibility of future renal pelvis rupture. l3 The mechanism is probably due to organization by the connective tissue or urinary precipitates leading to cicatrix formation and stenosis by contraction.r8 Diagnosis Fever is usually present and may be due to infection but more commonly secondary to absorption of fibrin and urine constituents. A mass is present and is related to the quantity of escaped urine, but it may be difficult to appreciate because of abdominal and lumbar muscle guarding. Pain onset is usually sudden and severe and is due to irritation of perirenal
411
tissues. Gastrointestinal complaints are pronounced and lead to the great problems in diagnosis. These symptoms are the result of reflex stimulation of the intestines by urinary irritation or pressure on the abdominal viscera due to the mass of the extravasated urine. Urinary findings are conspicuous by their absence. Urinalysis also is usually nondiagnostic. Pelvic rupture on the right side can mimic appendicitis or cholecystitis while rupture on the left side can be taken for diverticulitis or pancreatitis. Strangulated bowel obstruction, perforated ulcer, bowel neoplasm, ischemic bowel disease, and dissecting aortic aneurysm can also be differential diagnostic problems. 535 Plandome Road Manhasset, New York 11030 (DR. WALDBAUM) References 1. HERITAGE, K. : Spontaneous circumrenal hematoma, Proc. R. Sot. Med. 27: 1105 (1934). 2. MASSON, J. C., DOREMIEUX, J., and BOLLACK, C.: Spontaneous rupture of a healthy kidney pelvis, Ann. Urol. 6: 23 (1972). 3. JOACHIM, G. R., and BECKER,. E. L.: Spontaneous rupture of the kidney, Arch. Intern. Med. 115: 176 (1965). 4. POLKEY, H. J., and VYNALEK, W. J.: Spontaneous nontraumatic perirenal and renal hematomas, Arch. Surg. 26: 196 (1933). Spontaneous rupture of kidney, Br. 5. SHAW, R. E.: J. Surg. 45: 68 (1957).
412
6. LUNA, I., LEADBETTER, R. L., and GILBERT, D. R.: Spontaneous rupture of the kidney. A complication of anticoagulation; report of two cases, J. Urol. 109: 788 (1973). 7. SMULEWICZ, J. J., DORFMAN, J., CAGAN, S., and SEERY, W. H.: Spontaneous rupture of the collecting system of the kidney - an evaluation, ibid. 104: 507 (1970). 8. HIBNER, R. W.: Spontaneous rupture of the kidney with massive hemorrhage. A complication of anticoagulation, Am. J. Surg. 118: 637 (1969). 9. VALTONEN, E. J.: Spontaneous rupture of an apparently normal kidney - some criticism concerning this diagnosis, Br. J. Urol. 38: 484 (1966). intraperitoneal rupture of 10. GLEN, E. S.: Spontaneous ibid. 41: 414 (1969). hydronephrosis, 11. ABESHOUSE, B. S.: Rupture of the kidney pelvis. Review of the literature, Surg. Gynecol. Obstet. 60: 710 (1935). 12. BOLLACK, C., MASSON, J. C., and DOREMIEUX, J.: Spontaneous ruptures of the upper urinary apparatus (four cases), J. Urol. Nephrol. (Paris) 77: 856 (1971). caliceal ruptures 13. REZICINER, S. : Nontraumatic (three cases), ibid. 77: 856 (1971). 14. AUVERT, J. : Reflux starting with the pelvis studied by urinary manometrics. Pathogenesis of ascending interstitial nephritis, ibid. 63: 824 (1957). of kidney tumors and 15. NYSTROM, T. G.: Rupture hydronephrosis, Acta Chir. Stand. 93: 513 (1946). 16. HARROW, B. R., and SLOANE, J. A.: Pyelorenal extravasation during excretory urography, J. Urol. 85: 995 (1961). extravasation during 17. HINMAN, F., JR. : Peripelvic intravenous urography. Evidence of an additional route for backflow after urethral obstruction, ibid. 85: 385 (1961). The 18. HAMPERL, H., and DALLENBACH, F. D.: extravasation and precipitation of urine in the hilus of the kidneys, J. Mt. Sinai Hosp. 24: 929 (1957).
UROLOGY
/
OCTOBER 1976 / VOLUME VIII, NUMBER 4
RUPTURE OF RENAL PELVIS
DAVID J, CARO, M.D. ROBERT
S. WALDBAUM,
M.D.
From the Department of Surgery (Urology), Cornell University Medical College, and North Shore University Hospital, Manhasset, New York
ABSTRACT - A seventy-seven-year-old female with progressive abdominal signs for twenty-four hours was found to have had a spontaneous rupture of the renal pelvis with massive urinary extravasation.
Rupture of the kidney usually presents as an acute abdominal crisis with pain, a mass, and signs of massive blood loss.’ Rupture of the renal pelvis may also present as an acute abdominal crisis, but because of the lack of blood loss, the insidious onset, and lack of urinary symptoms, it may be a diagnostic dilemma.2 The following is a case of spontaneous rupture of the renal pelvis which initially presented as a diagnostic problem. Case Report On June 19, 1974, a seventy-seven-year-old female was seen at the North Shore University Hospital emergency room with the acute onset of nausea, vomiting, and pain in the left upper quadrant. Abdominal examination showed only minimal abdominal distention and mild tenderness in the left upper quadrant. Bowel sounds were active, and findings on rectal examination were negative. She was afebrile with 9,500 white blood cells and normal results on urinalysis. A flat plate of the abdomen was unremarkable. She was released from the emergency room but returned ten hours later with increased abdominal pain. On admission her blood pressure was 190/120 mm. Hg and pulse 120. She manifested localized tenderness over the left colic gutter and costovertebral angle with Presented at the Annual Meeting of New York Section, American Urological Association, Inc., Bermuda, September 21, 1975.
410
guarding and rebound in the left upper quadrant. Her white blood cell count was 13,900 and urinalysis showed 4 plus bacteria with 2 white blood cells per high-power field, blood urea nitrogen 39 mg. and creatinine 1.5 mg. per 100 ml., and a normal amylase. Abdominal films showed some distended loops of small bowel without evidence of free air or obstruction. Eight hours later in spite of hydration, intravenous antibiotics, and nasogastric suctioning, there was no clinical improvement. An intravenous pyelogram showed massive extravasation from the left kidney with a pyelonephritic right kidney (Fig. 1A and B). Cystoscopy and retrograde pyelography were carried out to localize any distal obstruction but none was seen (Fig. 1C). She was explored through a left twelfth rib incision, and at least 1,500 cc. of urine were drained from her flank. No specific point of rupture could be located, and because of the condition of the kidney a left nephrectomy was performed. Findings at exploration of the peritoneal cavity were negative. She improved dramatically postoperatively and was discharged on her tenth postoperative day. The patient was last seen one year postoperatively and was doing well. Her blood urea nitrogen was 28 mg. and creatinine 1.4 mg. per 100 ml., and urinalysis revealed no abnormality. An intravenous pyelogram again showed mild pyelonephritic changes in her remaining right kidney. The pathologic report described a 132Gm. kidney with marked hydronephrosis and
UROLOGY / OCTOBER 1976 / VOLUME VIII, NUMBER 4
tion.
thinned renal cortex. No definite site of rupture was located. Microscopically, extensive acute and chronic pyelitis and focal pyelonephritis, arterial, and arteriolar sclerosis, and perirenal and peripelvic inflammation were found. Comment Of the two main classifications of kidney rupture, parenchymal rupture is more common. 1,3*4-6Renal pelvic rupture is more subtle in presentation because the obvious systemic and local signs of blood loss do not occur. Although a handful of case reports profess no preexisting pathologic condition in a spontaneously ruptured renal pelvis, most have some underlying pathologic problem. ‘-’ Hydronephrosis is the most common underlying cause especially when the pelvis is extrarenal or immobile because of adhesions.‘@‘* Stones (either through obstruction or pressure necrosis), infections, tumor strictures, or adhesions from previous surgery are other leading causes of rupture. The rupture may be truly spontaneous or due to minimal trauma which is overlooked. Pathophysiology It has been shown experimentally that a simple increase in hydrostatic pressure within the renal pelvis to 150 cm. is sufficient to cause rupture. 13*14Yet rupture of the kidney pelvis is not common. Various compensatory mechanisms actively prevent significant renal damage. One physiologic defense is the distensibility of the ureter and renal pelvis.15 Pressure multiplied by volume is equal to a
UROLOGY
!
OCTOBER
1976 / VOLUME
VIII,
NUMBER 4
constant; therefore, if the diameter of the ureter is increased, the pressure will decrease accordingly. It has been clearly shown in clinical pyelographic studies that dye may extravasate through a rupture of a calyceal fornix. The urine then escapes into the sinus of the kidney alongside the infundibulum of the calyx. The extravasate penetrates a porous leaf of the capsule and permeates the peripelvic and perirenal tissues. l6 This is considered a normal physiologic mechanism to deal with acutely increased intrapelvic pressure. This is well described by Hinman17 as forniceal backflow. Absorption may occur via the lymphatic or venous channels, but extravasate that spreads to the tissue especially around the renal pelvis and hilum may result in sinointerstitial absorption. The latter mechanism may lead to diffuse fibrosis and consequent hydronephrosis, which allows for the real possibility of future renal pelvis rupture. l3 The mechanism is probably due to organization by the connective tissue or urinary precipitates leading to cicatrix formation and stenosis by contraction.r8 Diagnosis Fever is usually present and may be due to infection but more commonly secondary to absorption of fibrin and urine constituents. A mass is present and is related to the quantity of escaped urine, but it may be difficult to appreciate because of abdominal and lumbar muscle guarding. Pain onset is usually sudden and severe and is due to irritation of perirenal
411
tissues. Gastrointestinal complaints are pronounced and lead to the great problems in diagnosis. These symptoms are the result of reflex stimulation of the intestines by urinary irritation or pressure on the abdominal viscera due to the mass of the extravasated urine. Urinary findings are conspicuous by their absence. Urinalysis also is usually nondiagnostic. Pelvic rupture on the right side can mimic appendicitis or cholecystitis while rupture on the left side can be taken for diverticulitis or pancreatitis. Strangulated bowel obstruction, perforated ulcer, bowel neoplasm, ischemic bowel disease, and dissecting aortic aneurysm can also be differential diagnostic problems. 535 Plandome Road Manhasset, New York 11030 (DR. WALDBAUM) References 1. HERITAGE, K. : Spontaneous circumrenal hematoma, Proc. R. Sot. Med. 27: 1105 (1934). 2. MASSON, J. C., DOREMIEUX, J., and BOLLACK, C.: Spontaneous rupture of a healthy kidney pelvis, Ann. Urol. 6: 23 (1972). 3. JOACHIM, G. R., and BECKER,. E. L.: Spontaneous rupture of the kidney, Arch. Intern. Med. 115: 176 (1965). 4. POLKEY, H. J., and VYNALEK, W. J.: Spontaneous nontraumatic perirenal and renal hematomas, Arch. Surg. 26: 196 (1933). Spontaneous rupture of kidney, Br. 5. SHAW, R. E.: J. Surg. 45: 68 (1957).
412
6. LUNA, I., LEADBETTER, R. L., and GILBERT, D. R.: Spontaneous rupture of the kidney. A complication of anticoagulation; report of two cases, J. Urol. 109: 788 (1973). 7. SMULEWICZ, J. J., DORFMAN, J., CAGAN, S., and SEERY, W. H.: Spontaneous rupture of the collecting system of the kidney - an evaluation, ibid. 104: 507 (1970). 8. HIBNER, R. W.: Spontaneous rupture of the kidney with massive hemorrhage. A complication of anticoagulation, Am. J. Surg. 118: 637 (1969). 9. VALTONEN, E. J.: Spontaneous rupture of an apparently normal kidney - some criticism concerning this diagnosis, Br. J. Urol. 38: 484 (1966). intraperitoneal rupture of 10. GLEN, E. S.: Spontaneous ibid. 41: 414 (1969). hydronephrosis, 11. ABESHOUSE, B. S.: Rupture of the kidney pelvis. Review of the literature, Surg. Gynecol. Obstet. 60: 710 (1935). 12. BOLLACK, C., MASSON, J. C., and DOREMIEUX, J.: Spontaneous ruptures of the upper urinary apparatus (four cases), J. Urol. Nephrol. (Paris) 77: 856 (1971). caliceal ruptures 13. REZICINER, S. : Nontraumatic (three cases), ibid. 77: 856 (1971). 14. AUVERT, J. : Reflux starting with the pelvis studied by urinary manometrics. Pathogenesis of ascending interstitial nephritis, ibid. 63: 824 (1957). of kidney tumors and 15. NYSTROM, T. G.: Rupture hydronephrosis, Acta Chir. Stand. 93: 513 (1946). 16. HARROW, B. R., and SLOANE, J. A.: Pyelorenal extravasation during excretory urography, J. Urol. 85: 995 (1961). extravasation during 17. HINMAN, F., JR. : Peripelvic intravenous urography. Evidence of an additional route for backflow after urethral obstruction, ibid. 85: 385 (1961). The 18. HAMPERL, H., and DALLENBACH, F. D.: extravasation and precipitation of urine in the hilus of the kidneys, J. Mt. Sinai Hosp. 24: 929 (1957).
UROLOGY
/
OCTOBER 1976 / VOLUME VIII, NUMBER 4
