Spontaneous

Rupture

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SIDNEY

of a Calyceal

ULREICH,1

DAVID

A. LUND,

Numerous reports have described the complications associated with calyceal diverticula: stones [1], milk of calcium [2], and infection with sympathetic pleural effusion [3]. A case of rupture of renal cysts into the pyelocalyceal system simulating calyceal diverticula has also been reported [4]. To our knowledge, this is the first demonstration of spontaneous rupture of a calyceal diverticulum

during

excretory Case

calyceal tended

diventiculum

kidney

extravasation

and,

in this

from

and

the

ureter

subsequent

films,

upper

pole

calyx

was minimally typical

changes

persisted of 0.2

or manipulative

procedures

had

been

of

contrast

relating

appeared

to ureteral

during

this

obstruction

examination,

had cleared.

Discussion

A calyceal diverticulum was first described in 1941 [5] and subsequently redescnibed and discussed in numerous papers under a variety of descriptive terms. Several theories of pathogenesis of calyceal diverticula have been reviewed by Middleton and Pfister [1]. It has been proposed that these diverticula arise as residuals of the rupture of a simple senous cyst into the collecting systern; that they are due to progressive dilatation of a calyx which otherwise retains its narrow neck; and that they result from fibrosing infundibular stenosis secondary to stone formation in the calyx. Middleton and Pfister [1] have proposed a congenital hypothesis. They suggest that one of the ureteral bud branches may fail to influence the formation of a renal vesicle and instead continue to grow out into the renal parenchyma, generating further branching and later consolidating into a cyst cavity. Review of the early films of the urogram in our case shows findings which typify a calyceal diverticulum: an eccentric location, a narrow communication between the diverticulum and the adjacent calyx, and early opac-

of

disof

distal right ureteral obstruction were present. The left renal drainage system and the bladder appeared normal. A 40 mm film clearly demonstrated subcapsular extravasation of contrast (fig. 2). There was no concomitant change in the symptom pattern. Intermittent right flank pain days but was relieved by the passage

Urography

J. JACOBSON

No surgical

and all findings

Report

1). The right

JAMES

during

performed in the interval. The calyceal diverticulum was again demonstrated but was smaller, measuring 2.6 x 1 .8 cm. No

urography.

originating

(fig.

AND

the calculus.

A 26-year-old white female had a 1 day history of right lower quadrant and flank pain. There was moderate tenderness in the right flank. Urinalysis showed microscopic hematuria but no pyuria. Preliminary film of the abdomen showed a 0.2 cm calcification in the region of the distal right ureter. Intravenous urography was performed without compression using 100 ml diatnizoate meglumine. A 5 mm film demonstrated a 3.0 x 3.2 cm the right

Diverticulum

for the next 2 x 0.2 x 0.1 cm

calculus. Analysis showed it to be composed of a nucleus of apatite (5%) and a body of calcium oxalate monohydrate (95%). Intravenous urography was repeated the day after passage of

Fig. 1-5 urogram

mm film of intravenous demonstrating calyceal di-

verticulum originating from upper pole calyx of right kidney. Note moderate right ureterectasis. Although the right psoas margin is obscured, this

finding was not consistent in other films and may be related to splinting rather than edema.

Received October 27, 1977; accepted after revision March 17, 1978. ‘ All authors: Department of Radiology, New Britain General Hospital, Am J Rontg#{149}nol 131 :337-338, August 1978 C 1978 American Roentgen Ray Society

New Britain,

337

Connecticut

06050. Address

reprint

requests

0361 -803X/78/08-0337

to 5. Ulreich.

$00.00

CASE

338

REPORTS ification

with

contrast.

mented,

that

the

episode ulum

may have and

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pothesize

initially

then

migrated

that

the

diverticulum

and

alter

the

apparently

formed into

its

of no clinical

this

in the calyceal the

distal

ureter. caused

diuresis from pressure in

subsequent

of the

not

for

obstruction

with the increased

course

though

responsible

partial

calculus combined agent resulted in not

It is possible,

calculus

rupture.

patient’s

the the The

recovery

docuclinical

diverticWe by

hythis

contrast calyceal event

did

and

was

consequence. REFERENCES

1 . Middleton

AW, Pfisten RC: Stone-containing pyelocaliceal embryogenic, anatomic, radiologic and clinical charactenistics.J Urol 111 :2-6, 1974 diverticulum:

2. Rosenberg

MA: Milk of calcium

in a renal calyceal

divertic-

ulum. Case report and review of literature. Am J Roentgenol 101 :714-718, 1967 3. Polsky MS, Weber CH, Ball TP: Infected pyelocaliceal diverticulum and sympathetic pleural effusion. J Urol 114:301-

303, 4.

1975

McLaughlin cysts

5. Prather

Fig.

2.-Tomogram

demonstrating calyceal

of right

subcapsular

diverticulum.

kidney 40 mm extravasation of

after injection contrast from

into

AP, Pfister RC: Spontaneous rupture the pyelocalyceal system.J UroI 113:2-7, GC: Calyceal diverticulum.J Urol 45:55-61,

of renal 1975 1941