Left Ureteral Orifice Research Articles

Renal carcinoma diagnosed by cyst puncture: a case of mistaken identity.

Cyst puncture is considered to be the most accurate method of differentiating between cyst and carcinoma of the kidney. According to Buttarazzi Poutasse, Devine, Fiveash and Devine, (1968), “the use of this procedure in more than 800 patients has been reported without a single case report of a falsely negative study”. The basis of this case report is a patient whose cyst puncture findings fulfilled the accepted criteria of malignancy and in whom no evidence of malignancy could be found after nephrectomy. A 41-year-old male developed left costo-vertebral angle pain while jogging one evening four days prior to hospital admission. The pain increased in intensity radiating to the peri-umbilical region and was followed by nausea and vomiting. Next morning the pain had eased, but he noted fresh blood mixed evenly throughout his urine. The patient had never before experienced similar episodes and his previous health had always been good. Examination at this time was essentially negative except for tenderness in the left costo-vertebral angle. The urine analysis showed numerous red cells, a few white cells and 4 + protein. An admission diagnosis of left renal calculus was made. In hospital intravenous pyelography (Fig. 1) with nephrotomography (Fig. 2) and retrogade pyelography were carried out. At cystoscopy blood was noted coming from the left ureteric orifice but no calculus was found.

Angiographie Demonstration of a Benign Tumor of the Ureter

The diagnosis of ureteral tumor may be suggested preoperatively in about 70 per cent of all cases by means of such diagnostic technics as urinary sediment examination, cytology, intravenous urography, cystoscopy, and retrograde pyelography (1). Percutaneous aortography and selective arteriography are potential methods of increasing the diagnostic accuracy. Boijsen in 1962 first described the demonstration of 2 ureteral neoplasms by aortic angiography and selective renal angiography (2). The histological examination revealed a transitional-cell carcinoma in both patients, who were later included in a series of 17 cases of ureteral tumors reported by Jö(5). Five of these were examined by angiography. Only in Boijsen's patients was pathologic vasculature demonstrated. The purpose of this report is to present an additional instance of preoperative demonstration of a ureteral neoplasm by selective renal angiography. A 34-year-old female entered the University of Chicago Clinics with a history of gross hematuria and low-grade fever of three weeks duration. Bleeding had ceased three days prior to admission. Urinalysis revealed 4-8 RBC/HPF on unspun specimen. No abnormal cells were seen. Intravenous urography demonstrated a normal right kidney and collecting system, but the left kidney was not visualized, although its size and contour appeared normal on a preliminary film. Nonopacified material in the right side of the bladder was presumed to represent blood clots. At cystoscopy clots were seen oozing from the left ureteral orifice. At retrograde pyelography, however, the distal left ureter was normal, but obstruction to the retrograde flow of contrast material occurred at the level of the pelvic brim (Fig. 1). A selective left renal arteriogram demonstrated a convolution of small irregular vessels over the psoas muscle at the level of the third lumbar vertebra (Figs. 2 and 3). These tumor vessels were supplied from a capsular branch of the renal artery extending along the left ureter. Dense accumulation of contrast material persisted in the tumor following injection. An aortogram revealed that this tumor was supplied solely from the renal artery and not from other branches of the aorta. A diagnosis of a probably malignant tumor of the ureter was made. Laparotomy disclosed a well encapsulated tumor at the junction of the middle and the upper thirds of the ureter, loosely adherent to the psoas muscle. The renal pelvis was markedly distended and contained blood clots. A left nephroureterectomy was performed. Dissection showed a mass 9 cm long, with a diameter of 1 cm, which had arisen from the wall of the ureter and invaded the lumen and extended externally. The tumor was diagnosed as a leiomyoma. The histopathologic features of this tumor will be described in a separate report (6). Discussion With the usual diagnostic methods, a presumptive diagnosis of ureteral tumor can be made in a majority of cases.

THE RESPONSE OF NEOPLASTIC RENAL VESSELS TO EPINEPHRINE IN MAN.

Neoplasms parasitize: the diversion of nutrients and oxygen is accomplished through the creation of a new vascular bed, which siphons blood from the organism into the tumor. The neovascular architecture differs from the old; it has been suggested that its response to conventional neurohumoral stimuli differs from that of normal vessels (3). The evidence, however, is fragmentary at best. Some years ago, as a first step toward testing this hypothesis, we undertook a study of the response of the normal renal vascular bed in dogs to one specific drug, namely, epinephrine (1). More recently, I have investigated the effect of epinephrine on the tumor vessels in malignant hypernephroma in man, an effect which is of interest and perhaps of some importance. Clinical Porblem The patient, a 69-year-old man, had his first bout of painless, gross hematuria two months prior to admission. This subsided spontaneously. Two days before admission, he suffered a recurrence, associated with minimal left flank pain. On admission, physical examination demonstrated no gross abnormalities. The blood pressure was 158/88. The patient was obese and weighed 213 pounds. Laboratory data included a blood urea nitrogen of 22.5 and the finding of grossly bloody urine. On intravenous urography, contrast concentration in the collecting system was poor on both sides. The right kidney was thought normal, the left possibly enlarged, but with inadequate definition of calyces and pelvis. Cystoscopy revealed a slightly edematous and erythematous left ureteral orifice, with a small fragment of foreign material protruding from it. A single spurt of blood was noted, entering the bladder from the left ureter. Retrograde pyelography demonstrated a normal right kidney. On the left side, there was some distortion of the middle and lower pole calyces and their infundibula. The pyelogram was considered abnormal, but not conclusive as to the diagnosis. As a consequence, the patient was referred to the author for renal arteriography. The clinical problem, then, was sharply defined: what was the cause of the hematuria? Was there, in brief, a surgical lesion such as carcinoma in the left kidney? Could a diagnosis specific enough to warrant surgery in this obese, 69-year-old man be established? Experimental Problem If a carcinoma was present, as seemed likely, a comparison of the response of tumor vessels and of normal vessels to a specific pharmacologic agent might be feasible. For such a comparison, it was necessary that distinctive tumor vessels subserving the tumor be defined, and that the blood supply of the tumor be clearly distinguishable from adjacent normal vessels. Obviously, a control renal arteriographic study was required. Thereafter, the drug might be injected directly into the renal artery, followed by additional renal arteriograms.

Renal Papillary Necrosis

Renal papillary necrosis, called also necrosis of the renal papillae, necrotizing papillitis, and papillitis necroticans, is an uncommon condition, usually found in diabetic patients, although it may occur in non-diabetics. It has been recognized pathologically for many years, having been first described by von Friedreich in 1877 (1). Since that time 181 cases have been recorded, of which only 10 per cent failed to show evidence of diabetes, obstructive uropathy, or both (2). Because this disease is not well known, usually being discovered unexpectedly at necropsy, it is felt worthwhile to report a single case diagnosed radiographically during life. To our knowledge there has been no previous report of this type in the radiological literature. Olsson (3) in 1939 presented a case diagnosed by a gas pyelogram obtained as a result of fermentation of sugar in the urine of a diabetic. In 1945 Eskelund (4) published a case of necrotizing papillitis of the kidney following retrograde pyelography in a fifty-five-year-old female with pyelonephritis who died in a state of uremia, the diagnosis being based on post-mortem examination. In spite of the high mortality in these cases, the correct antemortem diagnosis is of more than academic interest, since the disease has two important characteristics that require a proper therapeutic regimen: (1) It is a suddenly developing and rapidly progressing necrotizing bacterial lesion that must be treated aggressively and without delay. (2) The selective necrosis involving the tips of the papillae impairs the urinary drainage of the associated nephrons, making definitely hazardous the use of sulfonamide drugs and related compounds with their known tendency to precipitate out in the renal tubules under conditions of urinary stasis or acid-base imbalance. Recent reports by Harrison and Bailey (5), Robbins, Mallory, and Kinney (6), Edmunson, Martin, and Evans (7), Robbins and Angrist (8), Muirhead, Vanatta, and Grollman (9), Swartz (10), and Garrett, Norris, and Vellios (11) all add emphasis to these points. Case Report A 55-year-old non-diabetic white male was admitted to the New York Hospital because of intermittent hematuria of three months duration. Cystoscopy revealed bleeding from the left ureteral orifice and poor function on the right. A right ureteral obstruction at 15 cm. was noted, together with an edematous and hemorrhagic appearing bladder mucosa. Blood clots were passed frequently. A chest film was negative for evidence of pulmonary disease. Blood pressure on admission was 180/110. The blood chemistry was within normal limits. Urine cultures yielded alpha Streptococcus, hemolytic Streptococcus, Staphylococcus aureus, and Corynebacterium. Smears and cultures on three separate occasions were negative for acid-fast bacilli.

Delayed Excretory Urography: Value of the Twenty-Four-Hour Urogram

With excretory urography one of the manifestations of acute or chronic ureteral obstruction is a delay in the appearance of the contrast substance in the collecting system on the affected side, whether it be from an intrinsic or an extrinsic cause. When the ureteral obstruction is recent, whether due directly or indirectly to the passage of a stone, the delay manifests itself first by an accentuation of the kidney shadow on the involved side, commonly known as a positive nephrogram. If a stone shadow is noted, it is sometimes assumed that this is the site of the obstruction. In some cases, however, when no such shadow is present, it may be assumed that the obstruction is due to a non-opaque stone or to accompanying spasm. In either case, if necessary, the studies are carried beyond the nephrogram stage up to one to four hours. Usually by that time the collecting system and ureter will be well outlined to the point of block. If the point of obstruction has not then been established accurately, clinical judgment will determine whether to catheterize the ureter or to use more conservative measures. In the last few months we have had three cases in which an examination was made twenty-four hours after the injection of the dye. Earlier studies failed to establish the point of block, but in each instance the collecting system and ureter on the affected side were clearly outlined to the site of obstruction in the twenty-four-hour study. In one case the shadows were still present at forty-eight hours. We are reporting the findings and clinical courses in these three cases to illustrate the value of twenty-four-hour excretory urograms in acute ureteral obstruction. Case Reports Case 1: A 38-year-old white married soldier entered the hospital on May 4, 1944, complaining of soreness in his left side and scrotum for twenty-four hours before admission. During that time there was an acute episode with sudden radiation of pain from the left loin to the left scrotum. The patient went to the Dispensary and was given some medication for relief; there was no blood in the urine. He went to bed but did not feel well. The following afternoon he had another acute attack, which required morphine, and he was admitted shortly thereafter. The physical examination revealed no gross abnormalities. The temperature was 99°. There was pain in the left loin and costovertebral angle on deep pressure and percussion. The urine now contained many red blood cells. Sedatives and fluids were prescribed. Cystoscopy was done the morning of May 5, 1944. A catheter was placed in the left ureteral orifice and an obstruction was met just beyond (Fig. 1). Attempts to pass a bougie, a Johnson basket, and a stone dislodger were all unsuccessful. Following this, the upper leaf of the left ureteral orifice was incised with cystoscopic scissors. After the cystoscopy, excretory urograms were made. The preliminary plain abdominal film showed both kidneys outlined in normal position.

Roentgen Visualization of Some of the Commoner Lesions of the Lower Genito-Urinary Tract

SINCE the discovery of the x-rays by Roentgen, radiologists have been using them as a diagnostic aid in many diseases. In modern medicine the roentgen ray is almost indispensable in the diagnosis of lesions of the genito-urinary tract. This paper will be confined to some of the lesions of the lower genito-urinary tract, which we hope to show by the use of contrast medium. This paper is not written with the thought of showing any new diagnostic procedures or disease, but merely as a review of some of the lesions of the lower genito-urinary tract. Case 1. Dermoid. Colored female, aged 21 years. This patient was seen in April, 1938, complaining of frequency and burning on urination and pain in the lower left quadrant. There was some hematuria. On cystoscopic examination there was seen evidence of cystitis, and the bladder capacity was only 90 c.c. of urine. There was a tumor mass about the left ureteral orifice from which hair appeared to be growing. From an air cystogram there appeared an irregular, fuzzy m...

Aplastic kidneys: Case report

In favor of the diagnosis of a functionless tuberculous kidney on the left were: (i) the history of previous pulmonary tuberculosis; (2) absence of function from the left kidney; (3) calcified areas in the left kidney region. Against the diagnosis of tuberculosis were: (1) the absence of urinary symptoms; (2) the normal bladder mucosa; (3) failure to find tubercle organism in the urine. In favor of aplasia of the kidney were: (1) the presence of a bicornuate uterus; (2) absence of the left ureteral orifice and smooth deformity of the left side of the bladder; (3) absence of function from the left kidney. The diagnosis of aplasia was made and confirmed by operation and pathologic examination. Injection of air into the renal fossa was used as an additional aid in diagnosis. This procedure carries with it the danger of air embolism and is open to criticism on that ground. The patient has experienced no pain since operation. It is difficult to explain this happy circumstance by nephrectomy. It is also too early after operation to be sure that the pain will not recur. In the meanwhile we have dilated the right ureter.

Hodgkin's Disease Involving the Bladder: Report of a Case

Though Hodgkin9s disease has been found in practically every organ and tissue of the body, reports of its occurrence in the bladder are few and meager, while careful search of the literature fails to disclose a single case of the transformation of a Hodgkin9s granuloma in the bladder to a sarcoma. Case Report E. G., a white man forty-one years old, was admitted to the Saratoga Hospital on April 6, 1935, complaining of intermittent hematuria, urgency, frequency, and nocturia accompanied by chills and fever, of four months9 duration. Except for a gastric ulcer ten years earlier, diagnosed by x-ray, the past history was of no significance. The patient was well developed and well nourished, with an irreducible right inguinal hernia and an atrophied right testicle. Cystoscopy revealed a thickened bladder mucosa, an easily bleeding trigone, and an inflamed prostatic urethra. Near the upper and inner side of the left ureteral orifice was a papilloma which was considered benign, though no biopsy was done. The patient was treated with silver nitrate irrigations (1:5000) and instillations of 10 per cent argyrol. Hematuria ceased soon after treatment but recurred June 1, 1935. The patient was then seen at the Albany Hospital by Dr. J. E. Heslin, who observed on physical examination (July 22, 1935), in addition to the above findings, a fullness of the left prostatic lobe with evidence of induration in the region of the left seminal vesicle. X-ray examination was negative for stone.

Case of Stenosis of the Left Ureteric Orifice following (in One Year) Removal of an Extensive Villous Papilloma of the Bladder by Open Diathermy. Pyonephrosis. Nephrectomy

Case of Stenosis of the Left Ureteric Orifice following (in One Year) Removal of an Extensive Villous Papilloma of the Bladder by Open Diathermy. Pyonephrosis. Nephrectomy