Br. J. Surg. Vol. 63 (1976) 637-638
lntraperitoneal rupture of hydronephrotic kidney 0 . E K W U E M E A N D S. 0 . A D I B E * SUMMARY
Two cases of’intraperitonenl rupture of hydronephrotic kidney are presented. The possibility of making a preoperative diagnosis and the type of management are discussed.
THEincidence of injury to a hydronephrotic kidney is much higher than in a normal kidney (Opit et al., 1960; Persky and Forsythe, 1962; Moffat, 1963). Intraperitoneal rupture is much less common than extraperitoneal rupture. In a period of 2 weeks 2 patients presented with intraperitoneal rupture of a hydronephrotic kidney, and in both cases the diagnosis became obvious only at emergency exploratory laparotomy. The potential danger of nephrectomy for hydronephrosis in a patient in whom function of the contralateral kidney has not been adequately evaluated has prompted this report, with emphasis on the preoperative diagnosis and the management. Case reports Case 1 : U. E., a 14-year-old schoolboy, was rushed to hospital with severe abdominal pain of increasing intensity after sustaining a kick in the lower abdomen during a game of soccer. On examination the patient was conscious, pale and obviously in severe pain. The pulse was 96/min, and of poor volume, and the blood pressure was 100170 mm Hg. The abdomen was slightly distended, there was generalized tenderness with guarding and rebound tenderness and bowel sounds were absent. The left testis was noted to be at the inguinal canal. Diagnostic abdominal tap yielded bloodstained fluid, and micturition produced a few drops of blood clot. A diagnosis of intraperitoneal rupture of the bladder was made. At laparotomy the patient was found to have purulent peritonitis resulting from intraperitoneal rupture of a left ectopic hydronephrotic kidney. The left kidney was situated at the pelvic brim, and was vascularized from the left common iliac vessels. It consisted only of a large hydronephrotic sac which was firmly adherent to the peritoneum, with small remnants of renal parenchyma at the hilum. The right kidney was normal. Left nephrectomy and peritoneal toilet were performed. The postoperative course was uneventful and he was discharged on the twelfth postoperative day. On review 6 weeks later the patient gave no history suggestive of renal pathology. The blood pressure was normal, and the blood urea was 15 mg/100 ml. Excretory urography showed a normal right kidney. The patient declined any investigation or treatment of the incompletely descended left testis. Case 2 : A. N., a 31-year-old taxi driver, was kicked in the left hypochondrium during a scuffle with a passenger. He collapsed immediately and was rushed to hospital. H e had a history of recurrent episodes of pain in the loin and hypogastrium for which he had attended hospitals on several occasions with inconclusive results. On examination the patient was pale and restless and was groaning with pain. The pulse was 96/min and the blood pressure 100/60 mm Hg. The abdomen was distended, there was guarding and generalized tenderness which was most marked in the hypochondrium and bowel sounds were absent. H e passed 260 ml of clear urine, and a diagnostic abdominal
61
tap yielded non-clotting blood. A diagnosis of ruptured spleen was made. Plain X-rays of the abdomen revealed ‘opacities in the left lumbar area, ? renal calculi’, but this did not influence the diagnosis. At laparotomy the spleen was normal, but there was a rupture of a hydronephrotic left kidney containing one palpable stone. There was a rent in the overlying adherent peritoneum. A total of 1500 ml of blood was evacuated from the peritoneal cavity, and about the same volume from the extraperitoneal space. The right kidney was normal. A left nephrectomy was performed. Section of the excised kidney revealed two other stones and the histology showed features of hydronephrosis and chronic pyelonephritis. The postoperative course was uneventful. Repeated serum calcium, inorganic phosphorus and alkaline phosphatase estimations were normal.
Discussion Intraperitoneal rupture of a hydronephrotic kidney is an uncommon condition, inevitably presenting with signs of peritonitis. Preoperative diagnosis is difficult, and it is accepted that emergency laparotomy is necessary as a diagnostic measure (Glen, 1969). In the present 2 patients the diagnosis should have been suspected preoperatively, and this lapse has prompted a review of the diagnostic features in this condition. There is nearly always a history of urinary disease or renal colic, but this may not be easily elicited preoperatively as the patient may be too ill to give an accurate history or may not consider previous symptoms significant. Haematuria of varying degree is usually present (Shaw, 1957), but this may not be detected unless microscopic examination of the urine is undertaken as a routine. Plain X-rays of the abdomen may reveal calculi, and if excretory o r infusion pyelography is undertaken the rupture will be demonstrated. The finding of an undescended testis is also significant, as the incidence of urinary tract abnormalities, including ectopic kidneys and hydronephrosis, is high in this condition (Grossman and Ririe, 1968). In the present Case 1 the finding of an undescended testis would not have made intraperitoneal rupture of the bladder a less likely diagnosis, but it should have raised the possibility of a urinary tract abnormality. In Case 2 the clinical and the radiological findings should have been diagnostic. Although laparotomy is mandatory in all cases of intraperitoneal rupture of the kidney, preoperative diagnosis is not just of academic interest. Hydronephrosis is often bilateral, and radical surgery on the ruptured kidney should not be undertaken without evaluation of the function of the other kidney. All cases in which the clinical picture is suggestive of rupture should be subjected to careful investigation of the urinary tract including intravenous or infusion
* Department
of Surgery, University of Nigeria, Enugu.
637
0. Ekwueme and S. 0. Adibe urography and/or retrograde pyelography, so that the most suitable surgical treatment may be carried out. Even with a high index of suspicion, a correct preoperative diagnosis may still not be possible in a large proportion of patients, as the clinical state of a patient with a rigid abdomen and rebound tenderness may necessitate emergency laparotomy before a thorough urological investigation has been completed. Under such circumstances when the ruptured kidney is grossly diseased and the other kidney is normal, nephrectomy should be undertaken. The use of intravenous indigo carmine may be helpful as a measure of the function of the opposite kidney at operation (de Beer and Hesse, 1966). For less clear-cut cases, simple drainage has been advocated (Glen, 1969), to allow renal function to be fully investigated, with the possibility of elective conservative surgery in some cases.
Acknowledgement We are grateful to Mr R. C. 0. Eruchalu for permission to report Case 2.
638
References DE BEER L. and HESSE v. E. (1966) Hydronephrosis and renal trauma. Br. J. Surg. 53, 532-534. GLEN E. s. (1969) Spontaneous intraperitoneal rupture of hydronephrosis. Br. J. Urol. 41, 414-416. GROSSMAN H. and RIRIE D. G. (1968) The incidence of urinary tract anomalies in cryptorchid boys. Am. J. Roentgenol. Radium Ther. Nucl. Med. 103, 210-213. MOFFAT J. (1963) Injury to a hydronephrotic kidney. Nurs. Times 59, 606-608. OPIT L. J., MCKENNA K. P. and NAIRN D. E. (1960) Closed renal injury. Br. J. Surg. 48, 240-247. PERSKY L. and FORSYTHE w. E. (1962) Renal trauma in childhood. JAMA 18, 709-712. SHAW R. E. (1957) Spontaneous rupture of the kidney. Br. J. Surg. 45, 68-72.
lntraperitoneal rupture of hydronephrotic kidney 0 . E K W U E M E A N D S. 0 . A D I B E * SUMMARY
Two cases of’intraperitonenl rupture of hydronephrotic kidney are presented. The possibility of making a preoperative diagnosis and the type of management are discussed.
THEincidence of injury to a hydronephrotic kidney is much higher than in a normal kidney (Opit et al., 1960; Persky and Forsythe, 1962; Moffat, 1963). Intraperitoneal rupture is much less common than extraperitoneal rupture. In a period of 2 weeks 2 patients presented with intraperitoneal rupture of a hydronephrotic kidney, and in both cases the diagnosis became obvious only at emergency exploratory laparotomy. The potential danger of nephrectomy for hydronephrosis in a patient in whom function of the contralateral kidney has not been adequately evaluated has prompted this report, with emphasis on the preoperative diagnosis and the management. Case reports Case 1 : U. E., a 14-year-old schoolboy, was rushed to hospital with severe abdominal pain of increasing intensity after sustaining a kick in the lower abdomen during a game of soccer. On examination the patient was conscious, pale and obviously in severe pain. The pulse was 96/min, and of poor volume, and the blood pressure was 100170 mm Hg. The abdomen was slightly distended, there was generalized tenderness with guarding and rebound tenderness and bowel sounds were absent. The left testis was noted to be at the inguinal canal. Diagnostic abdominal tap yielded bloodstained fluid, and micturition produced a few drops of blood clot. A diagnosis of intraperitoneal rupture of the bladder was made. At laparotomy the patient was found to have purulent peritonitis resulting from intraperitoneal rupture of a left ectopic hydronephrotic kidney. The left kidney was situated at the pelvic brim, and was vascularized from the left common iliac vessels. It consisted only of a large hydronephrotic sac which was firmly adherent to the peritoneum, with small remnants of renal parenchyma at the hilum. The right kidney was normal. Left nephrectomy and peritoneal toilet were performed. The postoperative course was uneventful and he was discharged on the twelfth postoperative day. On review 6 weeks later the patient gave no history suggestive of renal pathology. The blood pressure was normal, and the blood urea was 15 mg/100 ml. Excretory urography showed a normal right kidney. The patient declined any investigation or treatment of the incompletely descended left testis. Case 2 : A. N., a 31-year-old taxi driver, was kicked in the left hypochondrium during a scuffle with a passenger. He collapsed immediately and was rushed to hospital. H e had a history of recurrent episodes of pain in the loin and hypogastrium for which he had attended hospitals on several occasions with inconclusive results. On examination the patient was pale and restless and was groaning with pain. The pulse was 96/min and the blood pressure 100/60 mm Hg. The abdomen was distended, there was guarding and generalized tenderness which was most marked in the hypochondrium and bowel sounds were absent. H e passed 260 ml of clear urine, and a diagnostic abdominal
61
tap yielded non-clotting blood. A diagnosis of ruptured spleen was made. Plain X-rays of the abdomen revealed ‘opacities in the left lumbar area, ? renal calculi’, but this did not influence the diagnosis. At laparotomy the spleen was normal, but there was a rupture of a hydronephrotic left kidney containing one palpable stone. There was a rent in the overlying adherent peritoneum. A total of 1500 ml of blood was evacuated from the peritoneal cavity, and about the same volume from the extraperitoneal space. The right kidney was normal. A left nephrectomy was performed. Section of the excised kidney revealed two other stones and the histology showed features of hydronephrosis and chronic pyelonephritis. The postoperative course was uneventful. Repeated serum calcium, inorganic phosphorus and alkaline phosphatase estimations were normal.
Discussion Intraperitoneal rupture of a hydronephrotic kidney is an uncommon condition, inevitably presenting with signs of peritonitis. Preoperative diagnosis is difficult, and it is accepted that emergency laparotomy is necessary as a diagnostic measure (Glen, 1969). In the present 2 patients the diagnosis should have been suspected preoperatively, and this lapse has prompted a review of the diagnostic features in this condition. There is nearly always a history of urinary disease or renal colic, but this may not be easily elicited preoperatively as the patient may be too ill to give an accurate history or may not consider previous symptoms significant. Haematuria of varying degree is usually present (Shaw, 1957), but this may not be detected unless microscopic examination of the urine is undertaken as a routine. Plain X-rays of the abdomen may reveal calculi, and if excretory o r infusion pyelography is undertaken the rupture will be demonstrated. The finding of an undescended testis is also significant, as the incidence of urinary tract abnormalities, including ectopic kidneys and hydronephrosis, is high in this condition (Grossman and Ririe, 1968). In the present Case 1 the finding of an undescended testis would not have made intraperitoneal rupture of the bladder a less likely diagnosis, but it should have raised the possibility of a urinary tract abnormality. In Case 2 the clinical and the radiological findings should have been diagnostic. Although laparotomy is mandatory in all cases of intraperitoneal rupture of the kidney, preoperative diagnosis is not just of academic interest. Hydronephrosis is often bilateral, and radical surgery on the ruptured kidney should not be undertaken without evaluation of the function of the other kidney. All cases in which the clinical picture is suggestive of rupture should be subjected to careful investigation of the urinary tract including intravenous or infusion
* Department
of Surgery, University of Nigeria, Enugu.
637
0. Ekwueme and S. 0. Adibe urography and/or retrograde pyelography, so that the most suitable surgical treatment may be carried out. Even with a high index of suspicion, a correct preoperative diagnosis may still not be possible in a large proportion of patients, as the clinical state of a patient with a rigid abdomen and rebound tenderness may necessitate emergency laparotomy before a thorough urological investigation has been completed. Under such circumstances when the ruptured kidney is grossly diseased and the other kidney is normal, nephrectomy should be undertaken. The use of intravenous indigo carmine may be helpful as a measure of the function of the opposite kidney at operation (de Beer and Hesse, 1966). For less clear-cut cases, simple drainage has been advocated (Glen, 1969), to allow renal function to be fully investigated, with the possibility of elective conservative surgery in some cases.
Acknowledgement We are grateful to Mr R. C. 0. Eruchalu for permission to report Case 2.
638
References DE BEER L. and HESSE v. E. (1966) Hydronephrosis and renal trauma. Br. J. Surg. 53, 532-534. GLEN E. s. (1969) Spontaneous intraperitoneal rupture of hydronephrosis. Br. J. Urol. 41, 414-416. GROSSMAN H. and RIRIE D. G. (1968) The incidence of urinary tract anomalies in cryptorchid boys. Am. J. Roentgenol. Radium Ther. Nucl. Med. 103, 210-213. MOFFAT J. (1963) Injury to a hydronephrotic kidney. Nurs. Times 59, 606-608. OPIT L. J., MCKENNA K. P. and NAIRN D. E. (1960) Closed renal injury. Br. J. Surg. 48, 240-247. PERSKY L. and FORSYTHE w. E. (1962) Renal trauma in childhood. JAMA 18, 709-712. SHAW R. E. (1957) Spontaneous rupture of the kidney. Br. J. Surg. 45, 68-72.
