Stoicescu, 1:12 Open Access Scientific Reports...Citation: Stoicescu M (2012) Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urography Lack of Kidney Function. 1:571 doi:10.4172

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Stoicescu, 1:12http://dx.doi.org/10.4172/scientificreports.571

Case Report Open Access

Open Access Scientific ReportsScientific Reports

Open Access

Volume 1 • Issue 12 • 2012

Keywords: Hydronephrosis; Lack of kidney function

IntroductionThe main reason for this case presentation was to discover the real

cause of the urographic lack of kidney function, which was detected in a young patient and to avoid the nephrectomy in order to save the kidney. In the first instance, when the patient was consulted, there was no clue of what the final diagnose would be.

Patient and Methods

AbstractObjectives: The main reason for this case presentation was to discover the real cause of the urographic lack

of kidney function that was detected in a young patient and to avoid the nephrectomy, in order to save the patient's kidney.

Methods: A clinical case of a young patient aged 19 is presented, who initially goes to the family doctor, as he felt a pain in the right lumbar area while he was making sudden moves or while playing football. The objective examination ascertained Giordano maneuver positive, vertebral and muscular sensitive points on the right side. After the usual laboratory tests were performed, following information was ascertained: ESR=18 mm/1 h- 36 mm/2 h, fibrinogen=240 mg%, urea=40 mg/dl, creatinine=13 mg/dl, the urinalysis examination was normal, urinary sediment: rare flat epithelial cells, rare leukocytes, culture of urine - no germs were developed. An abdominal ultrasound was required, which marked out the following dimensions of the right kidney: longitudinal diameter=132 mm, cortical=20 mm, homogeneous medullary and surprisingly a grade III hydronephrosis, left kidney was normal, in rest all the other abdominal organs was within normal ultrasound limits.

Results: After these laboratory investigations an unexpected diagnosis of grade III right kidney hydronephrosis ascertained degree I chronic renal failure. The patient was quickly hospitalized within the Urology Department. An intravenous urography with contrast substance was performed, which marked out of the urography lack of big kidney function. In addition, a MRI native abdominal examination was performed which ascertained the following: at the right kidney level a massive pyelocaliceal expansion, with cortical thickening. On the MRCP sequences a pyeloureteral expansion was observed, without visualising the ureters. So it was concluded that it was right hydronephrosis by high urethral obstruction.

Cause of hydronephrosis could be: urethral stone, nephroblastoma (Wilms tumor), high urothelial pyelocaliceal tumors, TB pyonephrosis, the pyeloureteral junction syndrome and a congenital malformation of the right kidney.

Finally, the cause of hydronephrosis was not found and this patient was sent to Urological Surgery Department for nephrectomy. The urological surgeon makes a classical surgery and he discovered a vascular congenital anomaly i.e. the right renal vein was strangling the right kidney in the middle area and an accessory branch of it strangled the ureters in initial area. A pyeloplasty was performed and the right kidney was saved.

Conclusion: Not every kidney diagnosed with urographic lack of kidney function should be removed. If the renal scintigraphy does not also indicate a lack of kidney function, namely if it still has a present function, we can try to save it.

Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urography Lack of Kidney FunctionManuela Stoicescu* Department of of Medical Disciplines, University of Oradea, Romania

g/dl, Ht=38, 7%, N=60%, E=2%, B=3%, L=34%, M=4%, PLT=234000/mm3, Blood glucose=94 mg/dl, Urea=40 mg/dl, creatinine=1.3 mg/dl, Creatinine clearance=105 ml/min, Densities in separate urination=1024. The urinalysis examination was within normal value limits, the urinary sediment: rare flat epithelial cells, rare leukocytes, culture of urine - no germs were developed. An abdominal ultrasound (Figure 1) was required, which marked out the dimensions of the right kidney which was as follows: longitudinal diameter=132 mm, cortical=20 mm, homogeneous medullary and surprisingly a grade III hydronephrosis, left kidney dimensions were as follows: longitudinal

A clinical case of a young patient aged 19 is presented, which initially goes to the family doctor, as he felt a pain in the right lumbar area while he was making sudden moves or while playing football. The pain that he was feeling had a pressure like nature, medium intensity, with duration of about 10 minutes, without irradiation, which ceased spontaneously. Within the objective examination is ascertained: 1.The Giordano maneuver positive on the right 2.The vertebral and muscular sensitive points on the right side, 3.Uretheric insensitive points, 4.BP=120/80 mmHg, 5.Otherwise the objective examination was within normal limits. After the usual laboratory tests were performed, following information was ascertained: ESR=18 mm/1h-36 mm/2h, Fibrinogen=240 mg%, WBC=5100/mm3, RBC=4.000000/mm3, Hb=12

*Corresponding author: Dr. Manuela Stoicescu, PhD, Consultant Internal Medicine, Faculty of Medicine and Pharmacy, Assistant Professor, Department of Medical Disciplines, University of Oradea, Romania, E-mail: [email protected]

Received November 12, 2012; Published November 22, 2012

Citation: Stoicescu M (2012) Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urography Lack of Kidney Function. 1:571 doi:10.4172/scientificreports.571

Copyright: © 2012 Stoicescu M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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renal failure. The patient was quickly committed in the Urolology Department. After the repeated abdominal ultrasound and laboratory tests confirmed the same results, an intravenous urography with contrast substance was performed (Figure 2a), which marked out a urographic lack of right kidney function, comparative with a normal intravenous urography (Figure 2b). Of course, the biggest problem was now the cause of the urographic lack of kidney function.

In addition, a MRI native abdominal examination was performed (Figure 3) (the patient’s state did not allow the contrast substance to be administered) the result of which was: at the right kidney level a massive pyelocaliceal expansion, with cortical thickening, and also a pyeloureteral expansion was observed, without visualising the urether. No abdominal adenopathywas revealed. No free fluid was found in the peritoneal cavity. The left kidney aspect with normal signal and the other abdominal organs had a normal aspect. Conclusion: Right hydronephrosis caused by a high ureteral obstruction.

DiscussionsOf course, at the time being the most important question was:

what was the cause of the right kidney hydronephrosis, respectively the urographic lack of kidney function?

1. Urethral stone, although this has not been marked out neither by the ultrasound, MRI- scan and urography, nor indirectly by ureter dilation detection because this was not at all visualized on the entire route.

diameter=107 mm, cortical=21 mm, homogeneous medullary, in rest all the other abdominal organs was within normal ultrasound limits.

Summary of the Results

Figure 1: Hydronephrosis grade III-right kidney.

Figure 2a: Urography lack of big right kidney function.

Figure 2b: Normal intravenous urography.

Figure 3: Abdominal MRI - Right hydronephrosis by high urethral obstruction.After these laboratory investigations an unexpected diagnosis of

grade III right kidney hydronephrosis ascertained 1st degree chronic



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2. Nephroblastoma (Wilms tumor) can represent 10% of the urographic lack of kidney function through the complete obstruction of the urinary tracts (basinet, ureter) or the complete destruction of the renal parenchyma and its replacement with tumor tissue, but the ultrasound examination and the MRI- scan did not mark out anything in this direction nor did the urography highlight any space replacing formation (lacunars images).

3. High urothelial pyelocaliceal tumors, but by performing intravenous urography no lacunars images were marked out, that could be suggestive in this meaning.

4. TB pyonephrosis can also determine, in rare cases, the urographic lack of kidney function, but in this case, the patient did not have any chills, fever, the laboratory test has marked out a slightly elevated ESR, but the fibrinogen was normal without leukocytosis, neutrophilia, and most important without lymphocytosis. The urinalysis and the urinary sediment were within the normal limits and also the urinalysis was negative. Because it is well known that Koch bacillus does not develop in normal culture medium so an insemination on a specific Lowenstein Jensen culture was performed, but the result was negative. The intra dermal reaction at tuberculin was negative as well. It is being mentioned that the history of the patient did not present any tuberculosis family contact. Rarely, the neglected, untreated pulmonary tuberculosis, can spread through blood to affect the kidney, but was not confirmed in the present case.

5. The pyeloureteral junction syndrome could have been another possible cause of hydronephrosis and of the urography lack of kidney function. But it is known, that this is a congenital disorder, which theoretically could have been overlooked until this age, if the patient has never been before examined, but until the present the patient did not have any lower or high urinary infections history (acute pyelonephritis) which should have appeared on a pyeloureteral junction syndrome congenital basis.

6. A congenital malformation of the right kidney could have been possible.

A renal scintigraphy would have been ideal, but this could not be performed. The renal scintigraphy has its important role in the diagnosis, in the quantitative assessment of the pre-surgical renal function, for patients that have a nephrectomy indication. Not every kidney that shows an urographic lack of kidney function must be removed, it might still have a present function, and must be tried to be saved. The truth is, that after this conclusion, the cause of hydronephrosis was not found and this patient was committed in the Urologic Department, was sent

to Urological Surgery Department for intention to nephrectomy. The urological surgeon, has thought of saving the kidney and decided to perform a laparoscopic surgery, but the laparoscopic surgery result was surprising, confusing even for the urological surgeon, which initially decided to perform a laparoscopic surgery, but in the end was forced to make a classical surgery because he observed laparoscopic a vascular congenital anomaly, namely the right renal vein was strangling the right kidney in the middle area, being very edematous-swollen. Moreover, another branch of it strangled the ureter in initial area. This required an intraoperative, classical way surgery of this unexpected venous vascular malformation and also a pyeloplasty has been performed in order to resolve the hydronephrosis, thus being able to save the right kidney. The histopathological examination result (Figure 4) has later shown: macroscopy-3/2 cm bassinet and microscopy with minimal lymphocytic inflammatory.

Conclusions1. We should never hurry to indicate nephrectomy in case of

detecting a urographic lack of kidney function.

2. Not every urographic lack of kidney function must be removed if the renal scintigraphy does not indicate a lack of kidney function, namely if it still has a present function, we can try to save it.

3. The preoperative quantitative evaluation for patients who require a “nephrectomy” is compulsory, because surprises may appear any time, just like in the clinical case of the 19 year patient that was presented.

Figure 4: Minimal lymphocytic inflammatory infiltrations.


TitleCorresponding authorAbstractKeywordsIntroductionPatient and Methods Summary of the Results DiscussionsConclusions Figure 1 Figure 2a Figure 2b Figure 3 Figure 4

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Stoicescu, 1:12 Open Access Scientific Reports...Citation: Stoicescu M (2012) Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urography Lack of Kidney Function. 1:571 doi:10.4172