0022-5347/79/1223-0394$02.00/0 Vol. 122, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
WHAT ABOUT THE OTHER KIDNEY? LAWREN CE S. ROSS
AND
DAVID PRESMAN
From the Division of Urology, Michael Reese Hospital and Medical Center, Chicago, Illinois
ABSTRACT
Sophisticated diagnostic techniques have made the isolation of renal lesions more accurate. However, it must be remembered that simultaneous bilateral kidney pathology can exist in any patient. The most obvious lesion may not be the most important. Four cases are presented to illustrate this point. As radiographic, endoscopic, sonographic and isotopic techniques improve we become increasingly adept at making accurate diagnoses of renal lesions preoperatively. 1 When we see a lesion in 1 kidney on excretory urography (IVP) we often proceed to retrograde pyelography, angiography, dynamic renal scans or echography to confirm or strengthen our diagnosis. However, as we concentrate on the seemingly obvious lesion in 1 kidney we may forget that there is another side to every story as well as every patient. During the last 10 years we have encountered several patients whose clinical findings have demonstrated graphically that we must always remember that renal lesions can exist in both kidneys simultaneously. CASE REPORTS
Case 1. A. M., a 50-year-old white man, was first seen in December 1967 with total, gross hematuria and right flank pain. An IVP revealed a filling defect in the right renal pelvis. A small indentation also was noted in the left renal pelvis but it was not considered pathological. Cystoscopy and right retrograde pyelography confirmed the filling defect (fig. 1, A). Right nephroureterectomy for transitional cell carcinoma of the pelvis was done. Accepted for publication December 22, 1978.
A repeat IVP 3 months later showed a small persistent defect in the left pelvis (fig. 1, B). Repeat urinalysis at 5 and 6 months postoperatively showed micropyuria without symptoms. Because of this and the radiographic findings, left renal exploration was done. A papillary transitional cell carcinoma of the renal pelvis was found and excised with a segment of the pelvis. It was a grade II lesion with no infiltration. The patient is well with a normal left kidney on IVP. Case 2. L. P., a 70-year-old black woman, was seen in January 1974 because of total, gross, painless hematuria. An IVP showed a normal right kidney and poor visualization on the left side. A left retrograde pyelogram showed stretching and deformity of the upper pole infundibulum and calix (fig. 2, A). Renal angiography was done with flush and bilateral selective studies. The right kidney appeared normal, however, it was believed that there was a cyst in the left upper pole. Urine cytology was class II and class III. The patient had a recurrent episode of gross hematuria while in the hospital and a left renal exploration was done. A benign cyst was found and unroofed. No other lesions were noted. The gross hematuria recurred 1 year later and a repeat IVP showed a normal left kidney and non-function on the right side. Cystoscopy and right retrograde pyelography showed complete obstruction of the right ureter (fig. 2, B). Urine cytology was
Fm. 1. Case 1. A, right retrograde pyelogram shows large tumor. B, IVP 3 months later reveals persistent lucent defect in left pelvis 394
WHAT ABOUT THE OTHER KIDNEY?
395
FIG. 2. Case 2. A, left retrograde shows distortion of upper pole calices. B, right retrograde 1 year later
FIG. 3. Case 3. A, angiogram shows large cyst in left kidney. B, angiogram reveals exophytic tumor of right lower pole. IVP appeared normal
now class IV. A right nephroureterectomy for a squamous cell carcinoma of the renal pelvis and ureter was done. The patient died_ 5 months later of widely dissemi1;1ated squamous cell carcmoma. Case 3. I. C., a 64-year-old white man, was first seen in July 1975 because of microhematuria with no urologic symptoms. The right kidney appeared normal on an IVP. There was an obvious mass lesion in the mid portion of the left kidney with displacement and distortion of the calices. Cystoscopy was unremarkable. Renal angiography was done and the left selective films showed an avascular smooth walled
lesion believed to be a benign cyst (fig. 3, A). Right selective studies revealed an unexpected large vascular tumor of the lower pole (fig. 3, B). The patient underwent a right radical thoracoabdominal nephrectomy and is well. Case 4. M. B., a 53-year-old white man, was seen for hypertension in May 1975. An IVP revealed a huge left exophytic renal or suprarenal mass that was confirmed by tomography. The right kidney appeared entirely normal (fig. 4, A). Adrenal function studies were normal. Urinalysis was unremarkable. Renal angiography was done. The left selective studies showed normal renal architecture with the kidney displaced
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Fm. 4. Case 4. A, tomogram shows normal right kidney and huge left suprarenal mass. B, angiogram of left adrenal cyst
FIG. 5. Selective angiogram of right kidney in case 4. A, small area of medial parenchyma is not filled. B, second renal artery is supplying unexpected tumor.
inferiorly by the huge mass. Catheterization of the left inferior phrenic artery revealed a large adrenal mass (fig. 4, B). Selective studies of the opposite side initially seemed to confirm the presence of a normal right kidney but there was an area of parenchyma that did not fill (fig. 5, A). A second right renal artery was found, which was supplying a small hypemephroma within the kidney (fig. 5, B). Transabdominal exploration was done with right radical nephrectomy and umoofing of a benign left adrenal cyst. DISCUSSION
These cases have led us to re-examine several aspects of our method of evaluation of renal lesions. In cases of hematuria we must strive to follow the precepts of our earliest teachers and make all attempts to cystoscope patients while they are actively
bleeding. All of our sophisticated studies may be of little value if we fail to localize the site of bleeding. Despite the need to reduce the numbers and costs of medical tests, we must remain willing to repeat IVPs at short intervals whenever we suspect a lesion that is not initially grossly obvious. 2 Nephrotomograms should be a routine part of all IVPs whenever the early films in a routine study suggest a mass or filling defect. 3 In many cases the tendency to proceed from urography directly to renal angiography should be resisted. We must remember that retrograde pyelography, using the added techniques of diluted contrast medium and rotation films, as well as echography can give much useful diagnostic information. Renal angiography remains one of our most accurate diagnostic tools but there has been a trend to eliminate flush films and bilateral studies in an attempt to decrease patient costs and medical risks. 4 Until recently in our institution only unilateral
397
WHAT ABOUT THE OTHER KIDNEY?
selective renal angiography was done on the side of a suspected lesion. Several of the cases, such as those presented herein, have proved this to be unwise. We now insist on bilateral selective studies in all patients undergoing renal angiography. In our experience the risk to the patient is less than the risk of missing an unsuspected lesion. Differential renal cytology by retrograde catheterization or brushing should be considered in selected cases of suspected urothelial tumors. 5• 6 Newer cytologic techniques that are simple, inexpensive and increasingly accurate may aid in the discovery of such tumors at an early stage. 7 Finally, we must remember that whenever we look at an IVP, whenever we find ourselves confidently diagnosing a renal lesion, we must stop and ask the critical question: What about the other kidney?
REFERENCES 1. Evans, J.: The accuracy of diagnostic radiology, arteriography and
nephrotomography. J.A.M.A., 204: 223, 1968. 2. Rothschild, B. and Gleckman, R.: Beware of the normal excretory urogram. J. Urol., 114: 438, 1975. 3. Emmett, J. L.: Clinical Urography, 2nd ed. Philadelphia: W. B. Saunders Co., 1964. 4. Klein, L. A. and Einsberg, H.: Extended angiography in diagnosis and treatment ofrenal carcinoma. J. Urol., 114: 366, 1975. 5. Haleem, S. A., Sprayregan, S. and Siegelman, S. S.: Preoperative diagnosis of renal pelvic carcinoma. J. Urol., 108: 695, 1972. 6. Gill, W. B., Lu, C. T. and Thomsen, S.: Retrograde brushing: a new technique for obtaining histologic and cytologic material from ureteral, renal pelvic and renal caliceal lesions. J. Urol., 109: 573, 1973. 7. Sternheimer, R.: A supravital cytodiagnostic stain for urinary sediments. J.A.M.A., 231: 826, 1975.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
WHAT ABOUT THE OTHER KIDNEY? LAWREN CE S. ROSS
AND
DAVID PRESMAN
From the Division of Urology, Michael Reese Hospital and Medical Center, Chicago, Illinois
ABSTRACT
Sophisticated diagnostic techniques have made the isolation of renal lesions more accurate. However, it must be remembered that simultaneous bilateral kidney pathology can exist in any patient. The most obvious lesion may not be the most important. Four cases are presented to illustrate this point. As radiographic, endoscopic, sonographic and isotopic techniques improve we become increasingly adept at making accurate diagnoses of renal lesions preoperatively. 1 When we see a lesion in 1 kidney on excretory urography (IVP) we often proceed to retrograde pyelography, angiography, dynamic renal scans or echography to confirm or strengthen our diagnosis. However, as we concentrate on the seemingly obvious lesion in 1 kidney we may forget that there is another side to every story as well as every patient. During the last 10 years we have encountered several patients whose clinical findings have demonstrated graphically that we must always remember that renal lesions can exist in both kidneys simultaneously. CASE REPORTS
Case 1. A. M., a 50-year-old white man, was first seen in December 1967 with total, gross hematuria and right flank pain. An IVP revealed a filling defect in the right renal pelvis. A small indentation also was noted in the left renal pelvis but it was not considered pathological. Cystoscopy and right retrograde pyelography confirmed the filling defect (fig. 1, A). Right nephroureterectomy for transitional cell carcinoma of the pelvis was done. Accepted for publication December 22, 1978.
A repeat IVP 3 months later showed a small persistent defect in the left pelvis (fig. 1, B). Repeat urinalysis at 5 and 6 months postoperatively showed micropyuria without symptoms. Because of this and the radiographic findings, left renal exploration was done. A papillary transitional cell carcinoma of the renal pelvis was found and excised with a segment of the pelvis. It was a grade II lesion with no infiltration. The patient is well with a normal left kidney on IVP. Case 2. L. P., a 70-year-old black woman, was seen in January 1974 because of total, gross, painless hematuria. An IVP showed a normal right kidney and poor visualization on the left side. A left retrograde pyelogram showed stretching and deformity of the upper pole infundibulum and calix (fig. 2, A). Renal angiography was done with flush and bilateral selective studies. The right kidney appeared normal, however, it was believed that there was a cyst in the left upper pole. Urine cytology was class II and class III. The patient had a recurrent episode of gross hematuria while in the hospital and a left renal exploration was done. A benign cyst was found and unroofed. No other lesions were noted. The gross hematuria recurred 1 year later and a repeat IVP showed a normal left kidney and non-function on the right side. Cystoscopy and right retrograde pyelography showed complete obstruction of the right ureter (fig. 2, B). Urine cytology was
Fm. 1. Case 1. A, right retrograde pyelogram shows large tumor. B, IVP 3 months later reveals persistent lucent defect in left pelvis 394
WHAT ABOUT THE OTHER KIDNEY?
395
FIG. 2. Case 2. A, left retrograde shows distortion of upper pole calices. B, right retrograde 1 year later
FIG. 3. Case 3. A, angiogram shows large cyst in left kidney. B, angiogram reveals exophytic tumor of right lower pole. IVP appeared normal
now class IV. A right nephroureterectomy for a squamous cell carcinoma of the renal pelvis and ureter was done. The patient died_ 5 months later of widely dissemi1;1ated squamous cell carcmoma. Case 3. I. C., a 64-year-old white man, was first seen in July 1975 because of microhematuria with no urologic symptoms. The right kidney appeared normal on an IVP. There was an obvious mass lesion in the mid portion of the left kidney with displacement and distortion of the calices. Cystoscopy was unremarkable. Renal angiography was done and the left selective films showed an avascular smooth walled
lesion believed to be a benign cyst (fig. 3, A). Right selective studies revealed an unexpected large vascular tumor of the lower pole (fig. 3, B). The patient underwent a right radical thoracoabdominal nephrectomy and is well. Case 4. M. B., a 53-year-old white man, was seen for hypertension in May 1975. An IVP revealed a huge left exophytic renal or suprarenal mass that was confirmed by tomography. The right kidney appeared entirely normal (fig. 4, A). Adrenal function studies were normal. Urinalysis was unremarkable. Renal angiography was done. The left selective studies showed normal renal architecture with the kidney displaced
396
ROSS AND PRESMAN
Fm. 4. Case 4. A, tomogram shows normal right kidney and huge left suprarenal mass. B, angiogram of left adrenal cyst
FIG. 5. Selective angiogram of right kidney in case 4. A, small area of medial parenchyma is not filled. B, second renal artery is supplying unexpected tumor.
inferiorly by the huge mass. Catheterization of the left inferior phrenic artery revealed a large adrenal mass (fig. 4, B). Selective studies of the opposite side initially seemed to confirm the presence of a normal right kidney but there was an area of parenchyma that did not fill (fig. 5, A). A second right renal artery was found, which was supplying a small hypemephroma within the kidney (fig. 5, B). Transabdominal exploration was done with right radical nephrectomy and umoofing of a benign left adrenal cyst. DISCUSSION
These cases have led us to re-examine several aspects of our method of evaluation of renal lesions. In cases of hematuria we must strive to follow the precepts of our earliest teachers and make all attempts to cystoscope patients while they are actively
bleeding. All of our sophisticated studies may be of little value if we fail to localize the site of bleeding. Despite the need to reduce the numbers and costs of medical tests, we must remain willing to repeat IVPs at short intervals whenever we suspect a lesion that is not initially grossly obvious. 2 Nephrotomograms should be a routine part of all IVPs whenever the early films in a routine study suggest a mass or filling defect. 3 In many cases the tendency to proceed from urography directly to renal angiography should be resisted. We must remember that retrograde pyelography, using the added techniques of diluted contrast medium and rotation films, as well as echography can give much useful diagnostic information. Renal angiography remains one of our most accurate diagnostic tools but there has been a trend to eliminate flush films and bilateral studies in an attempt to decrease patient costs and medical risks. 4 Until recently in our institution only unilateral
397
WHAT ABOUT THE OTHER KIDNEY?
selective renal angiography was done on the side of a suspected lesion. Several of the cases, such as those presented herein, have proved this to be unwise. We now insist on bilateral selective studies in all patients undergoing renal angiography. In our experience the risk to the patient is less than the risk of missing an unsuspected lesion. Differential renal cytology by retrograde catheterization or brushing should be considered in selected cases of suspected urothelial tumors. 5• 6 Newer cytologic techniques that are simple, inexpensive and increasingly accurate may aid in the discovery of such tumors at an early stage. 7 Finally, we must remember that whenever we look at an IVP, whenever we find ourselves confidently diagnosing a renal lesion, we must stop and ask the critical question: What about the other kidney?
REFERENCES 1. Evans, J.: The accuracy of diagnostic radiology, arteriography and
nephrotomography. J.A.M.A., 204: 223, 1968. 2. Rothschild, B. and Gleckman, R.: Beware of the normal excretory urogram. J. Urol., 114: 438, 1975. 3. Emmett, J. L.: Clinical Urography, 2nd ed. Philadelphia: W. B. Saunders Co., 1964. 4. Klein, L. A. and Einsberg, H.: Extended angiography in diagnosis and treatment ofrenal carcinoma. J. Urol., 114: 366, 1975. 5. Haleem, S. A., Sprayregan, S. and Siegelman, S. S.: Preoperative diagnosis of renal pelvic carcinoma. J. Urol., 108: 695, 1972. 6. Gill, W. B., Lu, C. T. and Thomsen, S.: Retrograde brushing: a new technique for obtaining histologic and cytologic material from ureteral, renal pelvic and renal caliceal lesions. J. Urol., 109: 573, 1973. 7. Sternheimer, R.: A supravital cytodiagnostic stain for urinary sediments. J.A.M.A., 231: 826, 1975.
