Vol. 117, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1977 by The Williams & Wilkins Co.
ECHINOCOCCAL CYST OF THE KIDNEY J. GLENN HAINES, MICHAEL E. MAYO, T. NOEL K. ALLAN*
AND
JULIAN S. ANSELL
From the Departments of Urology and Radiology, University of Washington School of Medicine, Seattle, Washington
ABSTRACT
A renal echinococcal cyst presenting with ureteral obstruction is described. Characteristic diagnostic features, including renal angiography, are discussed. Whereas partial nephrectomy is appropriate for a small closed renal cyst, total nephrectomy is indicated for most large or open cysts. In the United States echinococcosis is a rare cause of renal calcification. The diagnosis sometimes may be suspected by characteristic findings on an abdominal x-ray and, thus, errors in diagnostic procedures and therapy can be avoided. CASE REPORT
A 51-year-old Lebanese man was hospitalized with a 3-day history of bilateral dull flank pain. Fourteen years previously he had passed gelatinous material in the urine after being unable to urinate for 48 hours. He lived in the city and denied
of the kidney consistent with chronic pyelonephritis (fig. 2). A retrograde ureterogram showed no obstruction but an open type of hydatid cyst in which the daughter cysts were outlined was seen. 1 A renal scan demonstrated only a 10 per cent function in the left kidney. Liver and lung scans were negative. A left nephrectomy was performed. The mass was markedly adherent to the diaphragm, aorta and peritoneum. The resected left kidney demonstrated a main cystic cavity filled with numerous small cysts and only a scant amount of fluid
Fm. 1. A, plain abaominal x-ray shows cyst-like lesion in left renal area. Curvilinear calcification is present (large arrow) and 2 small opacities are related to lower pole (small arrows). B, 2-hour film of IVP shows normal right kidney. Cyst-like lesion occupies upper half of left kidney and calicectasis is present in lower half. Renal opacification persists. any close contact with dogs or sheep. Physical examination (fig. 3). Microscopic examination confirmed the presence of revealed moderate left flank tenderness. A few white blood Echinococcus granulosus with scolices, and daughter and cells were seen on urinalysis but the urine culture was sterile. granddaughter cysts. Initial indirect hemagglutination for There was a 9 per cent eosinophilia. An abdominal x-ray echinococcus was 1 to 1,024, which decreased to 1 to 128, 6 demonstrated an 8 cm. mass lesion with curvilinear calcifica- weeks postoperatively. tion in the left renal area and 2 inferior opacities (fig. 1, A). DISCUSSION The excretory urogram (IVP) showed a normal right kidney and a cyst-like lesion in the upper half of th~ left kidney. The Many patients with renal echinococcosis are asymptomatic. remainder of the left kidney showed calicectasis and a persis- The most common presenting symptoms in order of frequency tent nephrogram at 2 hours (fig. 1, B). A 1 cm. cystic mass are flank mass, renal pain, hematuria and the passage of passed spontaneously 10 hours after the patient was hospital- hydatid material (grape skins) in the urine. 2 As with our ized, with immediate decrease in pain. Pathologic examinapatient ureteral obstruction by cyst contents may occur. Urition failed to demonstrate any scolex hooklets. nary scolices or daughter cysts are diagnostic. In our patient a Aortography, and selective renal and common hepatic artecystic structure was passed but no hooklets were identified. riography did not reveal any other cyst-like lesions. The left The initial diagnosis sometimes may be made radiologically renal artery was small with vascular changes in the lower half by the demonstration of a calcified cyst-like lesion. Smaller Accepted for publication December 3, 1976. calcified daughter cysts may be found within the main cyst or Read at annual meeting of Western Section, American Urological in the pelviocaliceal system. Echinococcosis often presents as a Association, San Diego, California, February 22-27, 1976. * Requests for reprints: Department of Radiology, Harborview non-calcified mass lesion on urography but ultrasonic examination should differentiate it from simple cysts. 3 • 4 Most tranMedical Center, 325 Ninth Ave., Seattle, Washington 98104. 788
789
ECHIJ:
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1977 by The Williams & Wilkins Co.
ECHINOCOCCAL CYST OF THE KIDNEY J. GLENN HAINES, MICHAEL E. MAYO, T. NOEL K. ALLAN*
AND
JULIAN S. ANSELL
From the Departments of Urology and Radiology, University of Washington School of Medicine, Seattle, Washington
ABSTRACT
A renal echinococcal cyst presenting with ureteral obstruction is described. Characteristic diagnostic features, including renal angiography, are discussed. Whereas partial nephrectomy is appropriate for a small closed renal cyst, total nephrectomy is indicated for most large or open cysts. In the United States echinococcosis is a rare cause of renal calcification. The diagnosis sometimes may be suspected by characteristic findings on an abdominal x-ray and, thus, errors in diagnostic procedures and therapy can be avoided. CASE REPORT
A 51-year-old Lebanese man was hospitalized with a 3-day history of bilateral dull flank pain. Fourteen years previously he had passed gelatinous material in the urine after being unable to urinate for 48 hours. He lived in the city and denied
of the kidney consistent with chronic pyelonephritis (fig. 2). A retrograde ureterogram showed no obstruction but an open type of hydatid cyst in which the daughter cysts were outlined was seen. 1 A renal scan demonstrated only a 10 per cent function in the left kidney. Liver and lung scans were negative. A left nephrectomy was performed. The mass was markedly adherent to the diaphragm, aorta and peritoneum. The resected left kidney demonstrated a main cystic cavity filled with numerous small cysts and only a scant amount of fluid
Fm. 1. A, plain abaominal x-ray shows cyst-like lesion in left renal area. Curvilinear calcification is present (large arrow) and 2 small opacities are related to lower pole (small arrows). B, 2-hour film of IVP shows normal right kidney. Cyst-like lesion occupies upper half of left kidney and calicectasis is present in lower half. Renal opacification persists. any close contact with dogs or sheep. Physical examination (fig. 3). Microscopic examination confirmed the presence of revealed moderate left flank tenderness. A few white blood Echinococcus granulosus with scolices, and daughter and cells were seen on urinalysis but the urine culture was sterile. granddaughter cysts. Initial indirect hemagglutination for There was a 9 per cent eosinophilia. An abdominal x-ray echinococcus was 1 to 1,024, which decreased to 1 to 128, 6 demonstrated an 8 cm. mass lesion with curvilinear calcifica- weeks postoperatively. tion in the left renal area and 2 inferior opacities (fig. 1, A). DISCUSSION The excretory urogram (IVP) showed a normal right kidney and a cyst-like lesion in the upper half of th~ left kidney. The Many patients with renal echinococcosis are asymptomatic. remainder of the left kidney showed calicectasis and a persis- The most common presenting symptoms in order of frequency tent nephrogram at 2 hours (fig. 1, B). A 1 cm. cystic mass are flank mass, renal pain, hematuria and the passage of passed spontaneously 10 hours after the patient was hospital- hydatid material (grape skins) in the urine. 2 As with our ized, with immediate decrease in pain. Pathologic examinapatient ureteral obstruction by cyst contents may occur. Urition failed to demonstrate any scolex hooklets. nary scolices or daughter cysts are diagnostic. In our patient a Aortography, and selective renal and common hepatic artecystic structure was passed but no hooklets were identified. riography did not reveal any other cyst-like lesions. The left The initial diagnosis sometimes may be made radiologically renal artery was small with vascular changes in the lower half by the demonstration of a calcified cyst-like lesion. Smaller Accepted for publication December 3, 1976. calcified daughter cysts may be found within the main cyst or Read at annual meeting of Western Section, American Urological in the pelviocaliceal system. Echinococcosis often presents as a Association, San Diego, California, February 22-27, 1976. * Requests for reprints: Department of Radiology, Harborview non-calcified mass lesion on urography but ultrasonic examination should differentiate it from simple cysts. 3 • 4 Most tranMedical Center, 325 Ninth Ave., Seattle, Washington 98104. 788
789
ECHIJ:
