THE
Vol. 114, July
JOURNAL OF UROLOGY
Printed in U.S..A.
Copyright© 1975 by The Williams & Wilkins Co.
ABERRANT RENAL PAPILLA: A DIAGNOSTIC DILEMMA ARTHUR E. FELDMAN, RONALD S. ROSENTHAL
AND
JOHN L. SHAW
From the Department of Surgery, Division of Urology, Abington Memorial Hospital, Abington, Pennsylvania
ABSTRACT
Filling defects of the renal pelvis not uncommonly present a difficult diagnostic challenge to the urologist and the radiologist. The precise etiology of the radiographic picture is not always evident, even after a battery of clinical tests. A pathologically proved case of an aberrant renal papilla is reported herein, and the significant differential diagnostic possibilities are considered and reviewed. One of the many pathologic entities presenting as a renal pelvic filling defect is the aberrant renal papilla described by Wolfson and Stowell' and more recently reviewed by Binder and associates. 2
tis. There was no dysuria, urinary frequency, abdominal or flank pain, fever or chills. Episodes of microscopic hematuria were noted during past bouts of cystitis. The patient denied weight loss,
FIG. 1. A, IVP demonstrated 5 mm. ovoid lucent defect in left renal pelvis. B, left retrograde pyeloureterogram also clearly shows defect in renal pelvis. CASE REPORT
J.M., a 40-year-old white woman, was admitted to the urology service for evaluation of a filling defect in the left renal pelvis, as noted on an excretory urogram (IVP) obtained 1 month prior to hospitalization for investigation of recurrent cystiAccepted for publication January 24, 1975. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Hot Springs, Virginia, October 24-26, 1974.
anemia, history of urolithiasis, tuberculosis, bleeding diathesis or use of anticoagulants. Physical examination revealed a well developed and well nourished woman, with normal temperature, respirations, blood pressure and pulse. No costovertebral angle tenderness was elicited and no abdominal or flank masses or bruits were noted. Laboratory studies showed a normal complete blood count, normal bleeding profiles, normal serum electrolytes and a creatinine of 0. 7 mg. per cent. The serum calcium was 9.0 mg. per cent, 144
ABERRANT RENAL PAPILLA
serum phosphorus was 3.5 mg. per cent, blood urea nitrogen was 15 mg. per cent, serum protein was normal and the serum uric acid was 6.5 mg. per cent. Urinalysis was negative and a urine culture revealed no growth. A repeat IVP demonstrated the persistence of a clearly defined 5 mm. ovoid lucent defect at the lateral aspect of the left renal as previously noted on the original IVP (fig. 1, A). Subsequent cystoscopic examination was normal. A left retrograde pyeloureterogram under monitored fluoroscopic guidance did not reveal movement of the defect with multiple changes (fig. 1, B). A halo effect was noted to circumscribe the area in question. Urine was negative. Because a malignant neoplasm could not be excluded an operation was performed. The left kidney was explored via a flank approach through the bed of the 12th rib. An extended pyelotomy incision after Gil-Vernet was accomplished, and an excisional biopsy was performed of a well rounded, smooth nodule of what appeared to be normal , parenchymal tissue. 3 Frozen section analysis confirmed the tissue as normal renal papilla (fig. 2). Convalescence was uneventful and the patient was discharged from the hospital 8 postoperaSix months later the was asymptomatic and the urine was negative. A followup IVP at that time was within normal limits with no evidence of a filling defect in the left renal pelvis (fig. 3). DISCUSSION
An aberrant renal is one of several clinical entities presenting as a radiolucent filling defect in the renal pelvis. Other entities may be differentiated by the intelligent selection of appropriate uroradiographic studies together with the complete clinical history and examination. However, an occasional lesion is virtually impossible to definitively diagnose preoperatively.
145
The embryogenesis of the tract is well known. Normal development permits renal tubular absorption to occur with the formation of vuvu,rn,,., ducts opening into each minor cal.ix. 4 An renal papilla, as described Wolfson and is "an otherwise normal renal papilla which jects directly into the lumen of the infundibuium without benefit of the normal, flared minor calix".' Building on the foundation of Osathanondh and Potter's microdissection, 5 Wolfson and Stowell postulated that an aberrant an infundibulum which has its normal terminal papillae".' Multiple draining into a single calix or a normal a short minor calix draining into an infundibulum (seen en face) may also present as a filling defect the renal pelvis. 1 The case described herein differs from the aforementioned hypothesis in that aberrant renal papilla emptied directly into the renal in lieu of a minor calix or infundibulum (fig. 4). 11Ve believe that 2 diagnostic radiologic signs of aber rant renal papilla illustrated by the present deserve special mention. are a halo effect surrounding the lucency and the lateral ,-,v,J,c;.vu the defect in the renal pelvis in major infundibulum. When confronted with filling defects of the renal pelvis, other pathologic lesions to be considered carcinoma, calculus, blood hypernephromatous extension, papilla of papillary necrosis, extrinsic pressure defects (parapelvic cysts, aneurysms and renal arteriovenous malformations, normal vessels normal parenchyma), benign tumors, eases, plasma cell granuloma, cavernous "-·"m-"-h·' oma and cholesteatoma of the renal pelvis. The classical triad of tumor, calculus and clot well known for causing renal filling defects and, therefore, needs little mention in this paper. "In some instances, hypernephroma may invade
Fm. 2. Normal renal papilla. Reduced from x430
146
FELDMAN, ROSENTHAL AND SHAW
FIG. 4. IVP reveals filling defect upper pole minor calix FIG. 3. Normal IVP 6 months postoperatively REFERENCES
the pelvis or occlude a portion of the caliceal system, producing a radiographic appearance indistinguishable from that produced by an epithelial tumor."• Two cases of fungal balls in the renal pelvis were reviewed recently by Boldus and associates. 7 Diabetics and patients with chronic debilitating diseases are more susceptible to fungal disease. Therefore, when filling defects in the renal pelvis present in these patients, one should be circumspect, as "fungal infestations of the kidney can ... produce conglomerates of organisms which then present as filling defects in the renal pelvis". 7 The fungal balls are composed of mycelia, necrotic debris and yeast forms. An accurate examination of the urinary sediment coupled with the radiologic picture is needed for presumptive diagnosis of candidiasis. Cholesteatoma of the renal pelvis may present as a radiolucent stringy defect in a renal pelvic mass. 8 The additional finding of cornified epithelium in the urine helps to confirm this curious diagnosis.
1. Wolfson, J. J. and Stowell, D. W.: Aberrant renal
Dr. Howard M. Pollack gave invaluable advice and permitted publication of figure 4.
8.
2.
3.
4.
5.
6. 7.
papilla simulating an intrarenal mass. Report of two cases. Radiology, 93: 812, 1969. Binder, R., Korobkin, M., Clark, R. E. and Palubinskas, A. J.: Aberrant papillae and other filling defects of the renal pelvis. Amer. J. Roentgen., 114: 746, 1972. Gil-Vernet, J. M.: Extended pyelolithotomy for removal of staghorn calculus. In: Current Controversies in Urologic Management. Edited by R. Scott. Philadelphia: W. B. Saunders Co., chapt. 18, essay 2, p. 321, 1972. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., vol. II, p. 1392, 1970. Osathanondh, V. and Potter, E. L.: Development of human kidney as shown by microdissection. I. Preparation of tissue with reasons for possible misinterpretation of observations. Arch. Path., 76: 271, 1963. Schapira, H. E. and Mitty, H. A.: Tumors of the renal pelvis: clinical review with emphasis on selective angiography. J. Urol., 106: 642, 1971. Boldus, R. A., Brown, R. C. and Culp, D. A.: Fungus balls in the renal pelvis. Radiology, 102: 555, 1972. Weitzner, S.: Cholesteatoma of the calix. J. Urol., 108: 365, 1972.
Vol. 114, July
JOURNAL OF UROLOGY
Printed in U.S..A.
Copyright© 1975 by The Williams & Wilkins Co.
ABERRANT RENAL PAPILLA: A DIAGNOSTIC DILEMMA ARTHUR E. FELDMAN, RONALD S. ROSENTHAL
AND
JOHN L. SHAW
From the Department of Surgery, Division of Urology, Abington Memorial Hospital, Abington, Pennsylvania
ABSTRACT
Filling defects of the renal pelvis not uncommonly present a difficult diagnostic challenge to the urologist and the radiologist. The precise etiology of the radiographic picture is not always evident, even after a battery of clinical tests. A pathologically proved case of an aberrant renal papilla is reported herein, and the significant differential diagnostic possibilities are considered and reviewed. One of the many pathologic entities presenting as a renal pelvic filling defect is the aberrant renal papilla described by Wolfson and Stowell' and more recently reviewed by Binder and associates. 2
tis. There was no dysuria, urinary frequency, abdominal or flank pain, fever or chills. Episodes of microscopic hematuria were noted during past bouts of cystitis. The patient denied weight loss,
FIG. 1. A, IVP demonstrated 5 mm. ovoid lucent defect in left renal pelvis. B, left retrograde pyeloureterogram also clearly shows defect in renal pelvis. CASE REPORT
J.M., a 40-year-old white woman, was admitted to the urology service for evaluation of a filling defect in the left renal pelvis, as noted on an excretory urogram (IVP) obtained 1 month prior to hospitalization for investigation of recurrent cystiAccepted for publication January 24, 1975. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Hot Springs, Virginia, October 24-26, 1974.
anemia, history of urolithiasis, tuberculosis, bleeding diathesis or use of anticoagulants. Physical examination revealed a well developed and well nourished woman, with normal temperature, respirations, blood pressure and pulse. No costovertebral angle tenderness was elicited and no abdominal or flank masses or bruits were noted. Laboratory studies showed a normal complete blood count, normal bleeding profiles, normal serum electrolytes and a creatinine of 0. 7 mg. per cent. The serum calcium was 9.0 mg. per cent, 144
ABERRANT RENAL PAPILLA
serum phosphorus was 3.5 mg. per cent, blood urea nitrogen was 15 mg. per cent, serum protein was normal and the serum uric acid was 6.5 mg. per cent. Urinalysis was negative and a urine culture revealed no growth. A repeat IVP demonstrated the persistence of a clearly defined 5 mm. ovoid lucent defect at the lateral aspect of the left renal as previously noted on the original IVP (fig. 1, A). Subsequent cystoscopic examination was normal. A left retrograde pyeloureterogram under monitored fluoroscopic guidance did not reveal movement of the defect with multiple changes (fig. 1, B). A halo effect was noted to circumscribe the area in question. Urine was negative. Because a malignant neoplasm could not be excluded an operation was performed. The left kidney was explored via a flank approach through the bed of the 12th rib. An extended pyelotomy incision after Gil-Vernet was accomplished, and an excisional biopsy was performed of a well rounded, smooth nodule of what appeared to be normal , parenchymal tissue. 3 Frozen section analysis confirmed the tissue as normal renal papilla (fig. 2). Convalescence was uneventful and the patient was discharged from the hospital 8 postoperaSix months later the was asymptomatic and the urine was negative. A followup IVP at that time was within normal limits with no evidence of a filling defect in the left renal pelvis (fig. 3). DISCUSSION
An aberrant renal is one of several clinical entities presenting as a radiolucent filling defect in the renal pelvis. Other entities may be differentiated by the intelligent selection of appropriate uroradiographic studies together with the complete clinical history and examination. However, an occasional lesion is virtually impossible to definitively diagnose preoperatively.
145
The embryogenesis of the tract is well known. Normal development permits renal tubular absorption to occur with the formation of vuvu,rn,,., ducts opening into each minor cal.ix. 4 An renal papilla, as described Wolfson and is "an otherwise normal renal papilla which jects directly into the lumen of the infundibuium without benefit of the normal, flared minor calix".' Building on the foundation of Osathanondh and Potter's microdissection, 5 Wolfson and Stowell postulated that an aberrant an infundibulum which has its normal terminal papillae".' Multiple draining into a single calix or a normal a short minor calix draining into an infundibulum (seen en face) may also present as a filling defect the renal pelvis. 1 The case described herein differs from the aforementioned hypothesis in that aberrant renal papilla emptied directly into the renal in lieu of a minor calix or infundibulum (fig. 4). 11Ve believe that 2 diagnostic radiologic signs of aber rant renal papilla illustrated by the present deserve special mention. are a halo effect surrounding the lucency and the lateral ,-,v,J,c;.vu the defect in the renal pelvis in major infundibulum. When confronted with filling defects of the renal pelvis, other pathologic lesions to be considered carcinoma, calculus, blood hypernephromatous extension, papilla of papillary necrosis, extrinsic pressure defects (parapelvic cysts, aneurysms and renal arteriovenous malformations, normal vessels normal parenchyma), benign tumors, eases, plasma cell granuloma, cavernous "-·"m-"-h·' oma and cholesteatoma of the renal pelvis. The classical triad of tumor, calculus and clot well known for causing renal filling defects and, therefore, needs little mention in this paper. "In some instances, hypernephroma may invade
Fm. 2. Normal renal papilla. Reduced from x430
146
FELDMAN, ROSENTHAL AND SHAW
FIG. 4. IVP reveals filling defect upper pole minor calix FIG. 3. Normal IVP 6 months postoperatively REFERENCES
the pelvis or occlude a portion of the caliceal system, producing a radiographic appearance indistinguishable from that produced by an epithelial tumor."• Two cases of fungal balls in the renal pelvis were reviewed recently by Boldus and associates. 7 Diabetics and patients with chronic debilitating diseases are more susceptible to fungal disease. Therefore, when filling defects in the renal pelvis present in these patients, one should be circumspect, as "fungal infestations of the kidney can ... produce conglomerates of organisms which then present as filling defects in the renal pelvis". 7 The fungal balls are composed of mycelia, necrotic debris and yeast forms. An accurate examination of the urinary sediment coupled with the radiologic picture is needed for presumptive diagnosis of candidiasis. Cholesteatoma of the renal pelvis may present as a radiolucent stringy defect in a renal pelvic mass. 8 The additional finding of cornified epithelium in the urine helps to confirm this curious diagnosis.
1. Wolfson, J. J. and Stowell, D. W.: Aberrant renal
Dr. Howard M. Pollack gave invaluable advice and permitted publication of figure 4.
8.
2.
3.
4.
5.
6. 7.
papilla simulating an intrarenal mass. Report of two cases. Radiology, 93: 812, 1969. Binder, R., Korobkin, M., Clark, R. E. and Palubinskas, A. J.: Aberrant papillae and other filling defects of the renal pelvis. Amer. J. Roentgen., 114: 746, 1972. Gil-Vernet, J. M.: Extended pyelolithotomy for removal of staghorn calculus. In: Current Controversies in Urologic Management. Edited by R. Scott. Philadelphia: W. B. Saunders Co., chapt. 18, essay 2, p. 321, 1972. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., vol. II, p. 1392, 1970. Osathanondh, V. and Potter, E. L.: Development of human kidney as shown by microdissection. I. Preparation of tissue with reasons for possible misinterpretation of observations. Arch. Path., 76: 271, 1963. Schapira, H. E. and Mitty, H. A.: Tumors of the renal pelvis: clinical review with emphasis on selective angiography. J. Urol., 106: 642, 1971. Boldus, R. A., Brown, R. C. and Culp, D. A.: Fungus balls in the renal pelvis. Radiology, 102: 555, 1972. Weitzner, S.: Cholesteatoma of the calix. J. Urol., 108: 365, 1972.
