Renal Fossa Research Articles

Ex vivo renal artery reconstructions: Indications and techniques

Ex vivo renal artery surgery has been reported by several investigators and has extended the role of revascularization in the treatment of lesions previously managed by nephrectomy alone. Several techniques are available for use, and selection of the most appropriate method can be tailored to the specific anatomy being managed. Our total experience included 27 kidneys that have been managed by ex vivo renal artery reconstruction. Lesions managed in this manner include two kidneys with renal artery stenosis and renal tumors, one kidney with a congenital branch arteriovenous malformation, and 24 kidneys with branch occlusive or aneurysmal disease from fibromuscular dysplasia. Postoperative angiography was performed in 22 cases and defined successful revascularization without technical error in 20 cases. One operative death occurred as a result of myocardial infarction. One patient required reoperation to control bleeding, and two patients had temporary acute tubular necrosis during the postoperative period. Techniques employed included ex vivo repair with autotransplantation to the iliac system (six kidneys), mobilization and perfusion without transection of the renal vein (10 kidneys), and ex vivo perfusion and repair with replacement into the original renal fossa (11 kidneys). The authors believe this latter technique of reconstruction to be preferable to autotransplantation for the usual patient undergoing ex vivo repair of complex renovascular lesions.

Renal Angiosarcoma

Renal angiosarcoma, an uncommon vascular sarcoma, is primarily treated surgically. We present a patient who, at nephrectomy, had tumor adherent to the diaphragm and renal artery. Postoperative radiation was given to the renal fossa. Despite the subsequent development of bone and liver metastases, disease in the renal fossa was apparently controlled. Symptomatic bone lesions were effectively palliated with radiotherapy. This report confirms those of others suggesting that angiosarcoma does respond to radiation.

Technical refinements in percutaneous nephroureterolithotomy.

Percutaneous nephrostolithotomy and ureterolithotomy is now widely accepted as the preferred method of managing symptomatic upper urinary tract calculi. The success of these procedures depends on an optimally oriented, percutaneously established nephrocutaneous track. These nephrostomies are often technically difficult if the collecting system is unobstructed or if calculi interfere with percutaneous manipulations. Several technical refinements have been developed that have aided in the performance of over 200 such nephrostomies as well as percutaneous ureterolithotomy. These include the use of externally applied abdominal compression to distend the collecting system after intravenous administration of contrast material for renal puncture, distend the ureter beyond an obstructing ureteral calculus to aid in percutaneous extraction, and relocate ptotic kidneys back into the renal fossa to optimize renal access; targeting on an opaque caliceal calculus for nephrostomy puncture; use of a saline flush to confirm proper nephrostomy needle placement; and an accelerated method of track dilatation with semirigid fascial dilators. The value of air as contrast for postprocedural nephrostography is also discussed.

The Widened Renal Fossa Sign on Liver-Spleen Scintigraphy and Adrenal Disease

A widened renal fossa on the posterior view during liver-spleen scintigraphy using technetium Tc 99m sulfur colloid raises the possibility of renal or extrarenal disease. We encountered four patients with prominent renal fossae on liver-spleen scans. They were subsequently found to have lesions involving the right adrenal gland. Potential adrenal disease should be considered in patients whose liver-spleen scans show widened renal fossae.

The widened renal fossa sign on liver-spleen scintigraphy and adrenal disease

The widened renal fossa sign on liver-spleen scintigraphy and adrenal disease

Phantom kidney on perfusion renal imaging

A 67-year-old male presented with sudden onset of right flank pain and anuria. On examination he had signs of acute renal failure. An intravenous urogram showed a large right with poor filling of the lower pole calyceal system suspicious for having a renal mass. The left was not visualized. Renal ultrasonogram showed that the right was enlarged and measured 16 • 8 cm. There was distortion of the echo pattern at its lower pole while the remainder of the was unremarkable. No left could be identified. On the perfusion images of a 99~Tc-glucoheptonate renal scintiscan (Fig 1) there was prompt and relatively homogeneous perfusion to the right and there was simultaneous equal perfusion to a kidney like organ on the left side. On the static renal images (Fig 2) there was good uptake in the upper two-thirds of the right but decreased uptake in its lower pole. The well perfused organ in the left upper quadrant was very poorly visualized with its uptake similar to the uptake of the liver. A CT abdomen scan (Fig 3) clarified that there was no left kidney, and the spleen had migrated into the empty renal fossa causing a phantom on the perfusion renal images. The soft tissue mass in the lower part of the

Sonographic staging after nephrectomy for tumours.

Sonography for postoperative staging after malignant renal tumours was evaluated in this study based on multiple examinations in 63 patients. Sonography permits a critical examination of the liver, the abdomen in general, the retroperitoneal space, including the renal fossa and solitary kidney. Local recurrences after hypernephroma operation were found in 5.3% and after nephrectomy for renal pelvic carcinoma in 68%. Retroperitoneal lymph node metastases appeared in 17% of the patients operated on renal pelvic carcinoma and in 7.6% after hypernephroma operation. These data indicate that special attention should be drawn to the renal fossa after tumour nephrectomy. The higher incidence of recurrences in the renal fossa, and metastatic lymph node involvement in patients following nephrectomy for renal pelvic carcinoma compared with the situation after hypernephroma operation might be explained by the difference of the lymph drainage between the renal pelvis and renal parenchyma which, in addition, includes a separate ontogenetic development. The majority of secondary lesions in hypernephroma patients occur as lung and bone metastases which have been discovered by conventional X-ray examination. These data are not statistically evaluated in the study.

Pyeloscopy in Urothelial Tumors

Intraoperative pyeloscopy was performed on 18 consecutive patients with indeterminate pelvic or caliceal filling defects, subsequently proved to be transitional cell carcinomas. After nephroureterectomy local tumor recurrence in the region of the renal fossa developed in 2 patients. Intraoperative pyeloscopy entails significant risks and the seeding of transitional cell carcinoma is possible.

CT of the pancreatic tail.

The location of the pancreatic tail varies and is confined only by the limits of the anterior pararenal space and the left kidney. The morphology of the pancreatic tail and its location relative to the upper pole of the left kidney, the body of the pancreas, and the splenic hilum were assessed by body computed tomography in 101 patients with normal kidneys and in 15 patients with either small or absent left kidneys. In 97% of normal patients, the pancreatic tail was located anterior or anterolateral to the left kidney. In 75% of patients with surgically or congenitally absent kidneys, the pancreatic tail lay dorsomedial, adjacent to the spine, and occupied, with bowel and spleen, the empty renal fossa. Variation in pancreatic tail location may be of diagnostic importance in patients suspected of having mass lesions in the left mid-abdomen.

Computed tomography in the evaluation of post-nephrectomy patients.

Twenty-one CT examinations were performed in 19 patients who had undergone previous nephrectomy for renal carcinoma or retroperitoneal malignancy. Nine patients were free of disease and 10 had recurrence. Findings of recurrent disease included masses in the vacant renal fossa, inability to visualize the inferior vena cava or aorta, and ipsilateral psoas muscle thickening. Possible pitfalls in diagnosis are discussed.

Single Vaginal Ectolpic Ureter: A Case Report

AbstractThe seventh case of a female subject with a single, unilateral ectopic ureter draining to the vagina is reported. The renal unit was located in the renal fossa, whereas in 3 of the 7 cases reported it was within the pelvis. Although ectopia with ureteral duplication is not an uncommon anomaly the single ectopic ureter in the female subject is the rarest form of ureteral ectopia. Use of phenazopyridine hydrochloric acid as an excretory marker was most helpful in locating the vaginal orifice.

585 EFFECT OF LOW DOSE IRRADIATION ON SUBSEQUENT RENAL HYPERTROPHY IN CHILDREN WITH WILMS' TUMOR

The effects of irradiation (XRT) combined with multiagent chemotherapy (CT) on compensatory renal hypertrophy following nephrectomy in childhood have received little attention. Treatment details and serial intravenous urograms in 30 children with Wilms' tumor subjected to nephrectomy and postoperative XRT and/or CT were reviewed. Eleven children received whole abdomen XRT (WAXRT) which delivered 1200-1300 rad to the remaining kidney. Nineteen patients were given no initial irradiation to the remaining kidney (OXRT) with 17 receiving renal fossa treatment only and 2 no irradiation. Renal growth, assessed by seriallceph-alocaudad measurements in treated patients, was plotted and compared to previously published figures of normal growth as well as hypertrophy following nephrectomy for benign causes in childhood. The mean and median slope of renal growth for the WAXRT group was 0.50 and 0.37 respectively while it was 0.56 and 0.50 for the OXRT group. The cumulative slope for the WAXRT group was 0.43 versus 0.55 for the OXRT group. When children who required subsequent pulmonary irradiation which necessarily irradiated the upper portion of the kidney were excluded from the OXRT group, the cumulative slope increased to 0.62. These results suggest a possible effect of low dose irradiation on renal hypertrophy.

Malposition of the colon in right renal agenesis, ectopia, and anterior nephrectomy

Right renal agenesis, ectopia, or anterior nephrectomy can be identified by a characteristic malposition of the right colon. Barium enemas show that the posterior portion of the right colic (hepatic) flexure occupies the area of the right renal fossa. This change in position of the right colon was not observed as a normal variant in 100 randomly selected patients but was present in each of eight patients with agenesis, ectopia, or anterior nephrectomy. This malposition should not be mistaken for internal hernia, malrotation, or displacement by tumor mass or organomegaly. Nonvisualization of the right kidney on excretory urography with normal position of the colon excludes agenesis or ectopia as diagnostic considerations.

Venographic Localization of the Non-Palpable Undescended Testis in Children

In cases of bilateral non-palpable undescended testes in which human chorionic gonadotropin stimulation has shown the presence of testicular tissue and in cases of unilateral non-palpable undescended testes selective transfemoral gonadal venography with a modified Seldinger technique has been used for the preoperative localization of the non-palpable testis. Since the undescended testis may be located anywhere along the course of its embryologic descent, that is from the level of the renal fossa to its exit from the inguinal canal, preoperative localization will aid in the surgical management. Gonadal venography has proved to be accurate and safe, and has aided in the determination of the extent of surgical exploration in 9 children with 12 non-palpable undescended testes (6 right and 6 left).

PHEOCHROMOCYTOMA

In the 25-year period 1950-1975 forty-four patients with pheochromocytoma were observed at Vanderbilt University Affiliated Hospitals. Bilateral adrenal tumors occurred in 3 patients (6.8%) and extra-adrenal tumors occurred in 7 others (16%), 33 patients (75%) had single tumors arising in one of the adrenal glands; in one of these 5 years after operation, a malignant tumor developed in the same renal fossa. Five of the 44 patients (11.3%) proved to have malignant tumors and died with metastases. In 11 patients in the earlier years of this study the clinical diagnosis was not made and the tumor was identified by the pathologist at autopsy. There was a single postoperative fatality among the 33 patients in whom the clinical diagnosis was made. Seventy per cent of all survivors with benign tumors have remained normotensive during followup periods of one to 20 years.

The anatomic splenic flexure: an ultrasonic renal impostor

The anatomic splenic flexure of the colon occupies the left renal fossa in patients with agensis or ectopic of the left kidney. On ultrasonic scans, the colon filled with stool or fluid may simulate a kidney or mass. This mass is often comma shaped on the transverse scans and lacks good definition of its inferior margin on longitudinal scans. An evaluation of a patient with only right renal function should combine radiologic techniques with ultrasonography to establish the correct diagnosis.

Postoperative radiation therapy for residual Wilms' tumor.Review of group III patients in the National Wilms' tumor study

Fifty-eight patients with residual abdominal disease (Group III) are reviewed from National Wilm's Tumor Study "1. The totap III) are reviewed from National Wilm's Tumor Study No. 1. The total number of abdominal recurrences is relatively low (eight cases). Local irradiation of the renal fossa would seem to be sufficient treatment for disease believed to be limited to that region, including cases of local spillage. Whole abdominal irradiation is recommended for gross, diffuse peritoneal contamination.

Pheochromocytoma: present diagnosis and management.

In the 25-year period 1950-1975 forty-four patients with pheochromocytoma were observed at Vanderbilt University Affiliated Hospitals. Bilateral adrenal tumors occurred in 3 patients (6.8%) and extra-adrenal tumors occurred in 7 others (16%), 33 patients (75%) had single tumors arising in one of the adrenal glands; in one of these 5 years after operation, a malignant tumor developed in the same renal fossa. Five of the 44 patients (11.3%) proved to have malignant tumors and died with metastases. In 11 patients in the earlier years of this study the clinical diagnosis was not made and the tumor was identified by the pathologist at autopsy. There was a single postoperative fatality among the 33 patients in whom the clinical diagnosis was made. Seventy per cent of all survivors with benign tumors have remained normotensive during followup periods of one to 20 years.

Ultrasonic evaluation of the unilateral nonvisualized kidney

There are several techniques for evaluating the nonvisualized kidney. Nephrotomography may be helpful in those patients who have some remaining renal function. Radionuclide renal flow and imaging studies are more sensitive than nephrotomography in detecting hydronephrosis, the most common cause of unilateral renal nonvisualization, but also require some renal function to be of diagnostic value. Diagnostic ultrasound, since it is independent of renal function, is an even more sinsitive indicator of urinary obstruction, detecting those cases where no functioning renal parenchyma is present. This non-invasive technique can accurately guide percutaneous puncture of the collecting system, permitting antegrade localization of the obstructing lesion. When ultrasonography demonstrates a solid mass in the renal fossa, angiography is recommended for definitive diagnosis. When no kidney is identified renal venography may be useful in differentiating between a small nonfunctioning kidney and renal agenesis.

Bilateral complete renal duplication with total obstruction of both lower pole collecting systems

Sepsis and a flank mass developed in a twenty-two-year-old primagravida two days after a normal delivery. Urography showed normal upper pole collecting structures bilaterally. A spherical mass containing curvilinear calcification occupied the left lower pole, and a large inflammatory mass filled the right inferior renal fossa. Angiography and retrograde pyelography demonstrated marked bilateral lower pole hydronephrosis with complete obstruction of the ureter to each inferior duplicated collecting system.