Scand J Urol Nephrol 1 1 : 189-191, 1977
RENAL ENDOMETRIOSIS A case report Tore Gauperaa and Helge Stalsberg From the Departments of Surgery and Pathology, University of Tromsd, Tromsd, Norway
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Melbourne on 10/29/14 For personal use only.
(Submitted for publication March 21, 1976)
Abstract. In a 23-year-old woman with lumbar pain, an expansive process in the right kidney was demonstrated by I.V.P., retrograde pyelography and renal angiography. The histological examination subsequent to nephrectomy showed endometriosis in association with localized xanthogranulomatous pyelonephritis. Renal endometriosis has been described only eight times previously in the literature. The current case is discussed and compared with previous reports.
Endometriosis of the kidney is a rare condition, and only 8 cases have been reported in the literature (Marshall, 1943; Maslow & Learner, 1950; Fruhling & Blum, 1951; Fruhling, Hurter & Blum, 1952; Megyeri, 1962; Kamaev & Vykovskii, 1963; Miles & Falconer, 1969; Hajdu & Koss, 1970). All have been women of fertile age, 22 to 49 years old. In most cases, the clinical history has failed to reveal any relationship to the menstrual cycle. The most common symptoms have been lumbar pains and haematuria, which are common to many diseases of the urinary tract. Thus, the diagnosis is very difficult to make preoperatively. In particular, when radiological examinations indicate evidence of an expansive process, as has frequently been the case, an erroneus diagnosis of carcinoma is easily made. In the cases published, the diagnosis was made after histological examination of surgically removed kidneys in 6 patients and by post mortem examination in the remaining 2 cases.
CASE REPORT The patient was a 23-year-old unmarried woman. Menstruation had been normal, and she had never been pregnant. Four years prior to admission, she had a urinary
tract infection and later at least two attacks of acute pyelonephritis. One year before the actual admission, she was again noted to be tender to palpation in the region of the right kidney, and bacteriological culture of the urine showed the presence of Escherichia coli. She was treated with antibiotics, but gradually developed increasing discomfort with constant pain in the right lumbar region. There was no relationship between the pains and the menstrual cycle. She had periods of dysuria, but no haematuria was noted. On admission, she was in good general condition. There was no fever, BP 140/90, hgb 13.4%, WBCC 7400, ESR 5mm. Serum urea was 43mg%, and serum creatinin 0.87%. There was no growth of bacteria from the urine, neither on ordinary media nor on Lowenstein’s medium. IVP, retrograde pyelography and renal angiography gave evidence of an expansive process peripherally in the middle part of the right kidney (Figs. 1-2) The right kidney was explored by retroperitoneal ac-
Fig. 1 . Intravenous pyelography. Impression of the lower part of the renal pelvis by an expansive process in the lateral part of the right kidney. Furthermore, a pyelogenic cyst is visible in the upper lateral part of the kidney. Scand J Urol Nrphrol I I
190
T . Gauperaa and H . Stalsberg
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Melbourne on 10/29/14 For personal use only.
cess. At its lateral margin, a spherical fluctuating, protruding mass about 3 cm in diameter was found. On puncture it yielded a viscous yellow pus, from which E. coli was grown on bacteriological culture. A frozen section from the abscess wall showed chronic inflammation. On the
Fig. 2. Renal angiography. Expansive process in the middle, lateral part of the right kidney.
examination of paraffin sections, however, groups of closely packed epithelial-like cells with abundant light cytoplasm raised the suspicion of a clear cell carcinoma, and a nephrectomy was performed. The patient made an uneventful recovery and has been well and without symptoms or signs of urinary tract infections on subsequent controts . On gross examination of the nephrectomy specimen, the kidney was of normal size. On the cut surface, there was a rounded lesion 2 cm in diameter in the cortical zone, and extending through the renal capsule into the perinephric fat. The lesion was soft and necrotic centrally and was surrounded by a 6 mm wide homogenous whitish zone. On microscopic examination, a peripheral zone of dense collagenous tissue surrounding masses of light cells with abundant cytoplasm was observed. The cells were lipid macrophages, and there was no further evidence of carcinoma. One of the sections from the fibrous area showed several branching cavities lined by a regular columnar epithelium which, in part, rested on a cellular strona of endometrial type (Fig. 3). Surrounding these structures were circular bands of smooth muscle. Turnbull stain revealed the presence of substantial amounts of hemosiderin in adjacent areas, although in the immediate vicinity of the endometrioid structures, only a few scattered hemosiderin granules were seen in the cytoplasm of the epithelial cells. Moderate amounts of PAS-positive material were present in the cavities of the endometrioid structures and as small globules in the apical cytoplasm of the epithelial cells.
Fig. 3. Endometrioid structure in fibrotic area of the renal cortex. Hematoxylin and eosin. (X80). Scund J Urol Nephrol I I
Renal endometriosis
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Melbourne on 10/29/14 For personal use only.
DISCUSSION The patient is believed to represent a case of renal endometriosis in association with a localizect chronic pyelonephritis of the xanthogranulomatous type. Although deposition of hemosiderin was seen in adjacent areas, only tiny amounts could be demonstrated in the immediate vicinity of the endometrioid tissue. Thus, we cannot prove that the deposition of hemosiderin was caused by functioning endometrial tissue, and the endometrioid structures observed have probably not bled to any significant degree. From the histological structure, however, we feel justified to make the diagnosis of renal endometriosis. The clinical history and the radiological signs in our patient were in good agreement with those of previously reported cases. Among those, 4 had significant haematuria, 2 had lumbar pains related to their menstruations, and 4 had lumbar pains with no relation to the menstrual cycle. Endometriosis of the ovary was found in 2 patients. Changes on IVP or retrograde pyelography or both indicating an expansive process in the kidney were found in 6 patients. In our patient, however, symptoms and signs may at least partly have been due to the inflammatory process rather than to the endometriosis per se. The association of renal endometriosis with advanced stages of chronic pyelonefritis was also noted in three of the cases reported previously (Fruhling & Blum, 1951; Fruhling et al., 1952; Megyeri, 1962). Blum & Fruhling (1953) strongly advocated the view that the endometrioid structures developed through metaplasia of renal tissue that was disturbed by the process of chronic inflammation. However, in the remaining cases of reported renal endometriosis, no inflammatory
191
changes were described. This probably indicates that endometriosis may appear as a primary lesion of the kidney. Possibly, such a lesion may predispose to bacterial infection by the obstruction of urinary flow. Strands of smooth muscle surrounding the endometrioid structures have been described in all cases reported. Thus, the Miillerian duct derivatives appearing in renal endometriosis are not restricted to endometrial tissues. This observation speaks against the theory of a metastatic origin of renal endometriosis, but is of no help in deciding whether the endometrial tissue appears early in life as a developmental anomaly or later by metaplasia of normally developed renal tissue.
REFERENCES Blum, E. & Fruhling, L. 1953. L’endometriose renale,
nouvelle entite anatomo-clinique. Symptomes et pathogenie. J Chir 69, 19-37. Fruhling, L. & Blurn, E. 1951. Endornetriose renale. Contribution a I’etude de I’origine mttaplasique de I’endometriose.J Urot Nephrd 57, 151-162. Fruhling, L., Hurter, E. & Blum, E. 1952. A propos d’une nouvelle observation dendometriome renal par metaplasie du parenchyme renal. J Cynec Obsrer 51, 27 1-275.
Hajdu, S. I . , & Koss, L. G. 1970. Endometriosis of the kidney.Am J Obsrer Gynec 106, 314-315. Kamaev, M. F., & Vygovskii, Y. P. 1963. Endometriosis of the kidney pelvis. Urol Nefrol28, 5G.57. Marshall, V. F. 1943. The occurrence of endometrial tissue in the kidney. Case report and discussion.J Urol 50, 652456.
Maslow, L. S. & Learner, A. 1950. Endometriosis of kidney. J Urol64, 564-566. Megyeri, L. 1962. Adenomyosis renum. M a g y Sebeszei 1.5, 187-190.
Miles, H. B. &Falconer, K. W. 1969. Renal endometriosis associated with hematuria. J Urol 102, 291-293.
RENAL ENDOMETRIOSIS A case report Tore Gauperaa and Helge Stalsberg From the Departments of Surgery and Pathology, University of Tromsd, Tromsd, Norway
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Melbourne on 10/29/14 For personal use only.
(Submitted for publication March 21, 1976)
Abstract. In a 23-year-old woman with lumbar pain, an expansive process in the right kidney was demonstrated by I.V.P., retrograde pyelography and renal angiography. The histological examination subsequent to nephrectomy showed endometriosis in association with localized xanthogranulomatous pyelonephritis. Renal endometriosis has been described only eight times previously in the literature. The current case is discussed and compared with previous reports.
Endometriosis of the kidney is a rare condition, and only 8 cases have been reported in the literature (Marshall, 1943; Maslow & Learner, 1950; Fruhling & Blum, 1951; Fruhling, Hurter & Blum, 1952; Megyeri, 1962; Kamaev & Vykovskii, 1963; Miles & Falconer, 1969; Hajdu & Koss, 1970). All have been women of fertile age, 22 to 49 years old. In most cases, the clinical history has failed to reveal any relationship to the menstrual cycle. The most common symptoms have been lumbar pains and haematuria, which are common to many diseases of the urinary tract. Thus, the diagnosis is very difficult to make preoperatively. In particular, when radiological examinations indicate evidence of an expansive process, as has frequently been the case, an erroneus diagnosis of carcinoma is easily made. In the cases published, the diagnosis was made after histological examination of surgically removed kidneys in 6 patients and by post mortem examination in the remaining 2 cases.
CASE REPORT The patient was a 23-year-old unmarried woman. Menstruation had been normal, and she had never been pregnant. Four years prior to admission, she had a urinary
tract infection and later at least two attacks of acute pyelonephritis. One year before the actual admission, she was again noted to be tender to palpation in the region of the right kidney, and bacteriological culture of the urine showed the presence of Escherichia coli. She was treated with antibiotics, but gradually developed increasing discomfort with constant pain in the right lumbar region. There was no relationship between the pains and the menstrual cycle. She had periods of dysuria, but no haematuria was noted. On admission, she was in good general condition. There was no fever, BP 140/90, hgb 13.4%, WBCC 7400, ESR 5mm. Serum urea was 43mg%, and serum creatinin 0.87%. There was no growth of bacteria from the urine, neither on ordinary media nor on Lowenstein’s medium. IVP, retrograde pyelography and renal angiography gave evidence of an expansive process peripherally in the middle part of the right kidney (Figs. 1-2) The right kidney was explored by retroperitoneal ac-
Fig. 1 . Intravenous pyelography. Impression of the lower part of the renal pelvis by an expansive process in the lateral part of the right kidney. Furthermore, a pyelogenic cyst is visible in the upper lateral part of the kidney. Scand J Urol Nrphrol I I
190
T . Gauperaa and H . Stalsberg
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Melbourne on 10/29/14 For personal use only.
cess. At its lateral margin, a spherical fluctuating, protruding mass about 3 cm in diameter was found. On puncture it yielded a viscous yellow pus, from which E. coli was grown on bacteriological culture. A frozen section from the abscess wall showed chronic inflammation. On the
Fig. 2. Renal angiography. Expansive process in the middle, lateral part of the right kidney.
examination of paraffin sections, however, groups of closely packed epithelial-like cells with abundant light cytoplasm raised the suspicion of a clear cell carcinoma, and a nephrectomy was performed. The patient made an uneventful recovery and has been well and without symptoms or signs of urinary tract infections on subsequent controts . On gross examination of the nephrectomy specimen, the kidney was of normal size. On the cut surface, there was a rounded lesion 2 cm in diameter in the cortical zone, and extending through the renal capsule into the perinephric fat. The lesion was soft and necrotic centrally and was surrounded by a 6 mm wide homogenous whitish zone. On microscopic examination, a peripheral zone of dense collagenous tissue surrounding masses of light cells with abundant cytoplasm was observed. The cells were lipid macrophages, and there was no further evidence of carcinoma. One of the sections from the fibrous area showed several branching cavities lined by a regular columnar epithelium which, in part, rested on a cellular strona of endometrial type (Fig. 3). Surrounding these structures were circular bands of smooth muscle. Turnbull stain revealed the presence of substantial amounts of hemosiderin in adjacent areas, although in the immediate vicinity of the endometrioid structures, only a few scattered hemosiderin granules were seen in the cytoplasm of the epithelial cells. Moderate amounts of PAS-positive material were present in the cavities of the endometrioid structures and as small globules in the apical cytoplasm of the epithelial cells.
Fig. 3. Endometrioid structure in fibrotic area of the renal cortex. Hematoxylin and eosin. (X80). Scund J Urol Nephrol I I
Renal endometriosis
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Melbourne on 10/29/14 For personal use only.
DISCUSSION The patient is believed to represent a case of renal endometriosis in association with a localizect chronic pyelonephritis of the xanthogranulomatous type. Although deposition of hemosiderin was seen in adjacent areas, only tiny amounts could be demonstrated in the immediate vicinity of the endometrioid tissue. Thus, we cannot prove that the deposition of hemosiderin was caused by functioning endometrial tissue, and the endometrioid structures observed have probably not bled to any significant degree. From the histological structure, however, we feel justified to make the diagnosis of renal endometriosis. The clinical history and the radiological signs in our patient were in good agreement with those of previously reported cases. Among those, 4 had significant haematuria, 2 had lumbar pains related to their menstruations, and 4 had lumbar pains with no relation to the menstrual cycle. Endometriosis of the ovary was found in 2 patients. Changes on IVP or retrograde pyelography or both indicating an expansive process in the kidney were found in 6 patients. In our patient, however, symptoms and signs may at least partly have been due to the inflammatory process rather than to the endometriosis per se. The association of renal endometriosis with advanced stages of chronic pyelonefritis was also noted in three of the cases reported previously (Fruhling & Blum, 1951; Fruhling et al., 1952; Megyeri, 1962). Blum & Fruhling (1953) strongly advocated the view that the endometrioid structures developed through metaplasia of renal tissue that was disturbed by the process of chronic inflammation. However, in the remaining cases of reported renal endometriosis, no inflammatory
191
changes were described. This probably indicates that endometriosis may appear as a primary lesion of the kidney. Possibly, such a lesion may predispose to bacterial infection by the obstruction of urinary flow. Strands of smooth muscle surrounding the endometrioid structures have been described in all cases reported. Thus, the Miillerian duct derivatives appearing in renal endometriosis are not restricted to endometrial tissues. This observation speaks against the theory of a metastatic origin of renal endometriosis, but is of no help in deciding whether the endometrial tissue appears early in life as a developmental anomaly or later by metaplasia of normally developed renal tissue.
REFERENCES Blum, E. & Fruhling, L. 1953. L’endometriose renale,
nouvelle entite anatomo-clinique. Symptomes et pathogenie. J Chir 69, 19-37. Fruhling, L. & Blurn, E. 1951. Endornetriose renale. Contribution a I’etude de I’origine mttaplasique de I’endometriose.J Urot Nephrd 57, 151-162. Fruhling, L., Hurter, E. & Blum, E. 1952. A propos d’une nouvelle observation dendometriome renal par metaplasie du parenchyme renal. J Cynec Obsrer 51, 27 1-275.
Hajdu, S. I . , & Koss, L. G. 1970. Endometriosis of the kidney.Am J Obsrer Gynec 106, 314-315. Kamaev, M. F., & Vygovskii, Y. P. 1963. Endometriosis of the kidney pelvis. Urol Nefrol28, 5G.57. Marshall, V. F. 1943. The occurrence of endometrial tissue in the kidney. Case report and discussion.J Urol 50, 652456.
Maslow, L. S. & Learner, A. 1950. Endometriosis of kidney. J Urol64, 564-566. Megyeri, L. 1962. Adenomyosis renum. M a g y Sebeszei 1.5, 187-190.
Miles, H. B. &Falconer, K. W. 1969. Renal endometriosis associated with hematuria. J Urol 102, 291-293.
