Perinephric Collection Research Articles

Renal lymphangiectasia

Renal lymphangiectasia is a benign disorder of renal lymphatics. Seldom observed, the pathophysiology is unclear. The clinical course may vary, and management alternatives range from percutaneous drainage in symptomatic cases to pharmacological substitutes in the form of anti-hypertensives and diuretics. We present a case of bilateral perinephric collections on imaging, which presented with gross ascites, abdominal pain and reversible hypertension. Ultrasound examination indicated ascites. Computerized tomography revealed bilateral symmetrical large perinephric collections. This is consistent with the appearance of renal lymphangiectasis (enlarged kidneys with fluid collections seen to be abutting the surrounding structures) reported in the literature. Needle aspiration of the perinephric fluid was undertaken, and laboratory analysis was carried out, which revealed a protein level of 643 mg dl(-1) and a total leucocyte count of 50, of which 80% were lymphocytes. Thereafter, a diagnosis of renal lymphangiectasia was made, and conservative treatment with diuretics and anti-hypertensives was initiated. Reassessment at subsequent follow up visits showed improvement in the patient's clinical condition.

Nephrobronchial fistula – A case report

We report the case of a 58-year-old woman with a hydronephrotic left kidney who presented with a 4-month history of anorexia, weight loss and intermittent left loin pain associated with cloudy urine. Her urine grew lactose fermenting coliforms, and was treated with antibiotics. A computerized axial tomography scan (CT scan) was equivocal and she underwent retrograde ureteric stenting, which drained a pyonephrosis. She went on to develop a chest infection due to a lung abscess. A CT scan revealed a left perinephric collection extending across the diaphragm into the lower lobe of the left lung. She responded to antibiotics and awaits a nephrectomy.

Ultrasound as a reliable guidance system for percutaneous nephrostomy.

To determine the effectiveness and safety of ultrasound as a reliable guidance system for percutaneous nephrostomy (PCN). Quasi-experimental. Jinnah Postgraduate Medical Center, Karachi, Pakistan, from January 1997 to July 2005. One hundred and fifty-three PCN were performed in 140 patients, referred from the Department of Urology and Transplantation, JPMC. Out of 140 patients, 137 had obstructive uropathy (>1 cm dilated pelvicalyceal system) of different etiologies. Three patients with ureteral rupture (non dilated pelvicalyceal system) underwent PCN for urinary diversion in the surgical ICU. The technique involved a pre procedural scan, initial renal puncture, placement of a guide wire, tract dilation and placement of 8-12 F Nephrostomy tube, entirely under ultrasound guidance. The machine used was 'Just vision' or 'Eccocee' with 3.5 MHz variable frequency convex transducer. Effectiveness in terms of successful tube placement and safety in terms of complications were observed. Out of 153 patients there were 78 males and 62 females. The minimum age of patient was 13 years while maximum age was 68 years, all (100%) patients had successful placement of PCN. Minor complications like transient gross hematuria and small perinephric collection occurred in 13 cases (8.5%) but was dealt with effectively by conservative measures. No major complications like hemorrhage, sepsis or periorgan damage were encountered in any of the patients. Ultrasound was found to be a rapid, effective, radiation-free, portable and safe imaging modality with minimum rate of complications that could be used as a reliable guidance system for critical interventions like percutaneous nephrostomies without using fluoroscopic units.

Traumatic Extra Renal Rupture Of Cyst In Case Of Polycystic Renal Disease

Polycystic kidney disease is an autosomal dominant disease which may manifest in various forms. The traumatic rupture of cyst presents as emergency mimmiking any of the abdominal emergencies, but this has to be suspected in an undiagnosed case and thoroughly investigated before contemplating on treatment acute abdomen. INTRODUCTION Adult polycystic kidney disease is transmitted as an autosomal dominant trait and affects approximately 1 in 1000 people. Polycystic kidney disease usually manifests itself in the fourth decade and rupture of cysts usually occurs in the collecting system not extrarenally. 1 CASE HISTORY A 19 year old presented to the ER with complaints of pain in abdomen after being hit by football on the left side of abdomen. On examination he was having tachycardia. On catheterization there was hematuria which after some time cleared off. Abdomen was soft. Based on these findings a provisional diagnosis of renal trauma was made. A single shot IVU was done which showed spider leg deformity in right kidney which led to suspicion of polycystic kidney disease (photo1). USG was done which showed multiple cysts in both kidneys with left perinephric collection (photo2). A CECT was done which showed extravasations of contrast in the left perinephric region (photo3,4). Figure 1

Renal Allograft Hemodynamic and Diameter Changes After Living Donor Transplantation

Renal ultrasound is a valuable tool to measure allograft diameters and hemodynamic changes, some of which may help us to predict ongoing rejection. Longitudinal (L) and horizontal (H) diameters, and resistive index (RI) of intrarenal arteries of kidneys were measured before transplantation in the donor site, as well as 1 week after transplantation in the recipient site (7.5 MHz probe). We excluded patients with acute rejection, delayed graft function, perinephric collection, suspected allograft artery stenosis, or serum creatinine >2 mg/dL. Finally, allograft measurements were compared with the donor parameters. The mean values of L and H diameters in 32 normal allografts were: L 119 ± 10.4 mm; H 54 ± 8.4 mm; L/H ratio 2.25 ± 0.27; RI 0.57 ± 0.55. The mean values of these measurements when the kidney was in the donor body were: L 110 ± 9.4 mm; H 44.3 ± 5.4 mm; L/H ratio 2.97 ± 0.25; RI 0.61 ± 0.040. Both L and H diameters were increased significantly after transplantation, but the L/H ratio and RI were decreased significantly ( P < .05). The presumed physiologic explanations for these findings in allograft are increased blood flow, decreased intrarenal arterial resistance, stress relaxation, and lack of sympathetic innervation.

Surgical complications of patient undergoing renal transplantation in China

Introduction: Owing to the severe shortage of organ donation in our locality, large number of end‐stage renal failure (ESRF) patients have to consider the option of renal transplant in mainland China. The objective of this study is to assess the complication rate of patients having renal transplantation done in China.Patients and Method: Medical record of 119 patients with renal transplant done in China since 1/1/1990 were reviewed with particular attention to surgically related complications. Results were compared with some oversea series.Results: 109 out of 119 patients who had received renal transplant in China are being followed up at the time of review (nine died and one dropped out for unknown reason). The mean follow time was 32 months (1–123). Surgical complications occurred in 32 patients (26%). Four graft lost due to rupture arterial anastomosis, arterial thrombosis, venous thrombosis and anastomotic pseudoaneurysm. Ten patients(8%) had renal artery stenosis requiring angioplasty. nine patients (7.5%) had wound related problems (three gapped wound, four wound infection and two incisional hernia). Two patients (1.6%) with urinary leakage. Three patients (2.5%) with ureteric stricture. six patients (5%) had perinephric collection. One patient with wound haematoma in early postop period requiring clot evacuation.Discussion: The complications rate in our group is similar to oversea series. Renal transplantarion is the most cost‐effective treatment of ESRF. More and more patient had transplantation done in China. Patients frequently ask about the safety and results of having operation in China. Our result provide an insight into this question though more solid conclusion is required by gathering more results from other hospitals.

General Papers 12

Aims: A radical shift in management of abdominal sepsis from surgery to radiological drainage occurred in 20 years. This is safe and in majority it avoids the need for conventional surgery. When surgery is indicated it provides the roadmap by showing the exact nature of the abscess and its contents. This is a retrospective study from single centre to look at the outcome of management of localized intra-abdominal sepsis by using radiological guided drainage. Methods: All the patients who underwent radiological intervention for abdominal sepsis between 1995 and 2001 were included in the study. These were scanned and drains were inserted under radiological guidance under local anaesthetic. All these patients were followed up with antibiotics and drainograms when appropriate. Results: These patients were between ages of 14 and 84 years. A total of 216 procedures were performed. Twenty-four of them were diagnostic in that the patients were subjected to laparotomy or conservative management. A total of 192 patients had therapeutic aspiration or drainage. One hundred and forty-five patients had catheters inserted for continuous drainage and the rest had therapeutic aspiration. These patients included pelvic abscess (15 per cent), perinephric collections (12.4 per cent), subdiaphragmatic abscess (12 per cent), liver abscesses (8 per cent), pseudocysts (7 per cent), pericolic abscess (7.5 per cent), sub-hepatic abscess (5 per cent), psoas abscess (3.4 per cent), appendicular abscess (3.4 per cent), empyema gall bladder and pancreatic abscesses. Complications were minimal including transient sepsis, residual collection, haemorrhage into the cavity and persistent sinus. Our results include bacteriological studies of aspirates, which will be presented in detail at the time of presentation. Conclusion: Percutaneuos guided aspiration and drainage is a safe and effective alternative to conventional open surgical drainage. We recommend this as the first line of management.

Management of Major Blunt Renal Lacerations: Is a Nonoperative Approach Indicated?

Objectives: The aim of the study was to determine whether a nonoperative approach is able to reduce renal parenchymal loss after renal trauma. Methods: Sixty–four consecutive patients with major blunt renal lacerations were treated from 1988 to 1999. Initial management was conservative. In group 1 (35 patients) delayed hemorrhage, persistent urinoma or hemodynamic instability were dealt with by open surgery. In group 2 (29 patients), most complications were dealt with using endoscopic procedures; open surgery was reserved exclusively for major complications. Results: In group 1, 7 patients were not operated and 28 patients were managed surgically. Twenty (57%) patients underwent total (8) or partial (12) nephrectomy. In 8 patients the surgical intervention was open drainage of perinephric collection (6) and/or renorrhaphies (2). Four patients in this group developed urinary fistulae treated successfully with ureteral stents. Length of hospital stay was 9.6 days (3–25 days). In group 2, persistent hemodynamic instability led to nephrectomy in 1 case. The remaining 28 patients were managed conservatively, with endoscopic ureteric stenting in 5 cases. A persistent urinary extravasation with hyperthermia led to open drainage of perinephric urinoma (5) and renorrhaphy (2). No delayed nephrectomy was necessary. Average hospital stay was 12 days (5–21 days). Only 1 patient in this group developed hypertension. Conclusion: For most patients and with close follow–up available, conservative treatment represents a real alternative to open surgery in major blunt renal lacerations. In our experience, open surgery usually results in loss of renal parenchyma.

Helical CT evaluation of the perirenal space and its boundaries: a cadaveric study.

To determine whether the perirenal spaces communicate across the midline and with the pelvic extraperitoneal spaces. Helical CT was used to guide the sequential injection of 100-mL intravenous boluses of dilute contrast medium, up to 300 mL, into the perirenal space of eight embalmed cadavers (three male, five female; mean age at death, 82 years; range, 72-93 years), with four left-sided and four right-sided injections. All images were acquired after the final injection (300 mL total) to facilitate coronal and sagittal reconstruction of relevant images. All images were reviewed to assess the flow pathways of contrast medium from the perirenal space to other retroperitoneal spaces. In three cadavers that received left perirenal space injections and in two cadavers that received right perirenal space injections, communication was seen with the contralateral perirenal space through an area anterior to the aorta and inferior vena cava. In three cadavers that received right perirenal space injections, contrast material flowed from the right perirenal space to outline the bare area of the liver. Communication between the perirenal and pelvic extraperitoneal spaces was seen in all eight cadavers; contrast material extended into the pelvic extraperitoneal and presacral spaces. These findings show that the perirenal spaces communicate with each other across the midline and with the pelvic extraperitoneal spaces. Clinical implications are that perinephric collections can potentially flow into the pelvis or across the midline.

Incisional hernia: An unusual cause of acute pain and swelling following renal transplant

We present a case in which a strangulated incisional hernia following a renal transplant was sonographically diagnosed. The patient presented with acute pain and swelling over the transplant site 6 weeks after surgery. Sonograms showed a normal-sized kidney with normal echotexture, no evidence of hydronephrosis, and no perinephric collections. Color Doppler sonography and spectral analysis demonstrated normal blood flow throughout the kidney. Sonograms showed that the palpable mass was a dilated loop of fluid-filled small bowel. Sonography allowed the correct diagnosis to be established, and early surgical intervention allowed revascularization of viable bowel.

Ruptured fornix demonstrated during abscess drainage

A year-old diabetic man, an intravenous drug abuser, presented with right flank pain and fever 1 day prior to admission. Laboratory studies and vital signs were consistent with sepsis related to acute bacterial pyelonephritis and he was started on broad spectrum intravenous antibiotics. Computed tomography (CT) of the abdomen revealed an enlarged inhomogeneous reniform mass in the right renal fossa (Fig. 1). Ultrasound revealed the presence of a complex right perinephric collection. During percutaneous placement of a drainage catheter, contrast material was injected, revealing contrast opacification of the right perinephric collection, with fistulous communication with a lower pole calyx and opacification of the collecting system (Fig. 2). A percutaneous drainage catheter was left to drain the right perinephric abscess (Fig. 3). Urine culture grew Serratia marcesens. Culture of the perinephric abscess grew Staphylococcus aureus. The mixed bacterial organisms are likely a result of the patient’s intravenous drug abuse. The drainage catheter was left in place for 1 week and his clinical condition dramatically improved while on intravenous antibiotic therapy. A follow-up CT scan showed resolution of the perinephric abscess with minimal residual thickening in the posterior right perinephric space (Fig. 4). The unusual feature of this case is the demonstration of the fistulous communication of the perinephric abscess with the lower pole calyx. The radiologic finding supports the presence of a previously ruptured fornix complicating the clinical diagnosis of acute bacterial pyelonephritis. The combination of percutaneous drainage of the perinephric abscess with intravenous antibiotics and hydration resulted in rapid clinical improvement despite the severity of the infection. From the Department of Radiology, St. Luke’s–Roosevelt Hospital Center, New York, New York; and Queens–Long Island Medical Group, Elmhurst, New York Reprint requests: Wen Y. Wang, M.D., Section of Vascular and Interventional Radiology, Department of Radiology, St. Luke’s– Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025 Received: January 9, 1998, accepted (with revisions): April 17, 1998 FIGURE 1. CT image shows an enlarged right kidney with an area of decreased attenuation in the lower pole. IMAGES IN CLINICAL UROLOGY

Conservative management with percutaneous intervention of major blunt renal injuries

This retrospective study assessed the results of treatment of patients with renal trauma to determine the optimal management (conservative or surgical) for patients with grade III renal injuries. During the past 12 years 108 patients (including 43 children) with renal injuries were managed: 43 had grade I injuries (renal contusion), 33 had grade II (minor laceration), 31 had grade III (major laceration), and 1 had grade IV (pedicle injury). All patients with grades I and II injuries were successfully managed conservatively. The patient with renal pedicle injury underwent uneventful nephrectomy. Nineteen patients with grade III injuries (including 5 patients with shattered kidneys and 3 patients with polar avulsion) were managed conservatively, and 2 developed progressively enlarging urinomas that required percutaneous drainage with complete resolution. No patient in this group developed perinephric abscess or urinary fistulae, and no delayed nephrectomy was necessary. Long-term follow-up of 7 patients in this group, including 3 with shattered kidneys and 2 with polar avulsion, showed that none have developed hypertension. Twelve patients with grade III injuries were managed surgically. Six (50%) patients underwent total (4 patients) or partial (2 patients) nephrectomy. In 6 patients, the surgical intervention was only open drainage of the perinephric collection and/or parenchymal suturing. It was concluded that conservative management with timely percutaneous or endoscopic intervention in patients with major renal injuries results in minimal loss of renal tissue without significant late complications.

Anatomic communications between the three retroperitoneal spaces: determination by CT-guided injections of contrast material in cadavers.

A variety of retroperitoneal diseases such as pancreatitis, infection, and trauma may cause fluid collections in the three major retroperitoneal spaces. The purpose of our study was to elucidate flow patterns of fluid between the various compartments to assist the clinical-radiologic assessment and treatment of various retroperitoneal diseases. In eight cadavers, CT guidance was used to selectively inject 35-1000 ml of contrast medium by hand or power injector into five perirenal, two posterior pararenal, and two anterior pararenal spaces. After the injections, CT of the entire abdomen and pelvis was done with 10-mm-thick sections at intervals of 10-40 mm. All images were reviewed in detail by a group of experienced body imagers to assess the pathways of flow of contrast material between the three major retroperitoneal spaces. The caudal cone of perirenal fascia was uniformly patent. A narrow channel connected the two perirenal spaces in the midline; the posterior border of this channel abutted the anterior margins of the abdominal aorta and the inferior vena cava. The perirenal, anterior pararenal, and posterior pararenal spaces all communicated with the infrarenal space, which in turn connected with the extraperitoneal spaces in the pelvis. When large quantities of contrast medium are injected in the perirenal or pararenal spaces and the infrarenal space is filled, the infrarenal space may then serve as a conduit across the midline of the abdomen. The anterior pararenal space crossed the midline and had a distinct retrorenal extension but no intraperitoneal connection. The slender posterior pararenal space had an anterolateral extension en route to the prevesical space. Our findings show pathways and extensions of the perirenal, anterior pararenal, and posterior pararenal spaces that should be considered when assessing a variety of retroperitoneal diseases. Perinephric collections, such as hematomas and urinomas, have at least a potential conduit across the midline or into the pelvis. Our study explains how blood from a ruptured abdominal aortic aneurysm may enter either perinephric space. Anterior pararenal processes, such as pancreatitis or appendicitis, can extend into the pelvis or cross the midline, and posterior pararenal blood from trauma can also flow into the pelvis.

Book reviews

The second fully revised edition of Weill's text on renal sonography provides a thorough review of the subject based on the authors' many years of practice. The chapter on anatomy includes descriptions of normal variants and artefacts. Techniques are well described in a separate chapter. The remaining chapters cover hydronephrosis, cysts, tumours, infection and inflammatory disorders, congenital anomalies, trauma, perinephric collections and renal transplants. Two final chapters briefly review the use of ultrasound of the adrenal and of the lower tract—bladder, prostate and testis.

Bridging septa of the perinephric space: anatomic, pathologic, and diagnostic considerations.

The perinephric space is not a simple fat-filled chamber through which fluid may be distributed unhindered. It is divided into multiple compartments by fibrous lamellae, the bridging septa. Some of these structures arise from the renal capsule and extend to the perinephric fascia; others are attached only to the renal capsule and are arranged more or less parallel to the renal surface. Still others connect the anterior to the posterior leaves of the perinephric fascia. The resulting compartments exert an important influence on pathologic processes, resulting, for example, in limitation of the spread of pus and tamponade of bleeding points. The configuration of many perinephric collections can only be understood by knowledge of the existence and arrangement of these lamellae. The current criteria for differentiation of subcapsular from perinephric hematomas are shown to be in error, and a new sign for such differentiation is described. There are also implications regarding therapeutic drainage of perinephric abscesses, particularly by the percutaneous route. A new classification of the perinephric fascia is proposed.

Peripelvic extravasation and formation of perinephric urinoma after cystoscopy

A hitherto undescribed complication of cystoscopy is reported wherein peripelvic extravasation and perinephric collection of urine resulted from conventional cystoscopy examination in a patient with a small-capacity bladder and vesicoureteral reflux. Prompt recognition, institution of indwelling catheter drainage, and massive antibiotic therapy led to spontaneous resolution of the flank mass. In similar cases, we suggest the use of an Iglesias resectoscope with a continuous flow and suction evacuation, even for cystoscopy and bladder biopsy.

Perinephric abscess aspiration using ultrasound guidance

A perinephric is difficult to diagnose by clinical examination and traditional radiographic imaging techniques. Five cases are described in which the sonograms revealed a sonolucent perinephric collection suggestive of perinephric abscess. Diagnostic percutaneous aspiration performed under ultrasound guidance is a rapid, reliable, and safe means of distinguishing an abscess from a noninflammatory collection.

Sonography of the Page Kidney

We used sonography to investigate 3 patients with hypertension owing to a Page kidney phenomenon. In 2 cases a perinephric cystic collection was compressing the kidney, while in 1 case there was a large perinephric organized hematoma. When a Page kidney is suspected in a hypertensive patient sonography is a reasonable next step in the evaluation, after the excretory urogram, and may obviate the need for angiography.

Safety and efficacy of the supracostal access for percutaneous nephrolithotomy: Our initial experience

The aim of this study was to evaluate the safety and efficacy of the supracostal access for percutaneous nephrolithotomy (PCNL). Between July 2007 and June 2010, 122 patients underwent PCNL, of whom 28 (23%) had supracostal access. All procedures were performed in a single sitting under general anesthesia. The data were analysed for indications, stone clearance rates and the complications associated with supracostal puncture. The indications for a supracostal access were staghorn stones (50%), pelvis stones (28.5%), calyceal stones in high-lying kidney (18%) and upper ureter/ureteric stones (3.5%). All tracts were made in the 11th intercostal space. Single tract access was used in 22 cases (78%), but 6 (22%) required a second tract. Additional punctures were required mainly for staghorn stones (4 out of 14). Overall, 82% of the patients were rendered stone free or had clinically insignificant residual stones with PCNL monotherapy, and this increased to 96% with secondary procedures. In patients with staghorn stones, they were completely cleared in 78%. Overall complication rate was 28% and included hydrothorax in 3 (10%) patients, which required insertion of a chest tube. One (3.5%) patient developed haemothorax secondary to injury of the intercostal artery, pelvic perforation in 1 (3.5%), perinephric collection in 1 (3.5%), infection/sepsis in 2 (7%). Except those patients who had complication, all other patient recovered uneventfully. Postoperative hospital stay ranged from 2 to 9 days. In conclusion, supracostal access gives high clearance rate with acceptable complications and should not be avoided for fear of chest complications.

IRON DEFICIENCY AND ITS RELATION TO FOLIC-ACID STATUS IN PREGNANCY: RESULTS OF A CLINICAL TRIAL.

Urolithiasis is the most common non-obstetric complication in pregnancy and has the potential to cause grave consequences resulting in pregnancy loss. We present two such cases. First, a 24-year-old woman, 5 weeks pregnant with a history of urolithiasis presented with right flank pain and fever. She was found to have a right perinephric collection and during the course of her treatment suffered an abortion. The second case was a 25-year-old woman who presented in septic shock. She underwent emergency lower segment caesarean section elsewhere 10 days ago for intrauterine death at 38 weeks of gestation. On evaluation, she was found to have bilateral stone disease with a left subcapsular haematoma. Both the cases were managed conservatively and are planned for definitive management. Thus, women of childbearing age with diagnosed urolithiasis should get themselves evaluated and be free of stone disease before planning a family to prevent increased obstetric complications during pregnancy.