International Urology and Nephrology 7 (2), pp. 109--114 (1975)
Spontaneous Rupture of the Renal Collecting System G. H6LTL, P. P . FIGDOR D e p a r t m e n t of Urology, University Medical School Vienna, Austria (Received July 27, 1974)
Three cases of spontaneous rupture of the collecting system of the kidney are reported on. Organ-saving surgery was feasible in two of them. The etiology a n d treatment of spontaneous ruptures of the renal pelvis are discussed.
In recent years a few cases of rupture of the urinary collecting system have been reported on, some of them following trauma to the kidney. Abeshouse [I] described 64 cases o f rupture o f the renal pelvis without involvement of the renal parenchyma. In 31 of them rupture was due to trauma. The primary cause is mainly congenital hydronephrosis, but inflammatory processes of the renal pelvis or urinary obstruction may also be responsible factors. In their presence even indirect injury to the kidney may cause rupture, for instance when the renal pelvis is pressed against the transverse process of one or more vertebrae or against the costal arch. In 26 of the cases referred to above rupture was spontaneous. Ruptures of this kind are generally associated with infected hydronephrosis. In two cases described by Smulewicz et al. [15] rupture was due to an increase in intrapelvic pressure resulting from calculous obstruction of the ureter. Trapnell [16] described 8 cases of spontaneous rupture of the renal pelvis or of the ureter. In a case of a juvenile patient described by Davidson [4] a small ureteral calculus, in another case reported on by Rous et al. [14] a hypernephroma of the lower renal pole was responsible for spontaneous pelvic rupture. We describe here three cases of spontaneous rupture of the renal collecting system. In two of them organ-saving surgery was feasible. Case 1. F. H., male, aged 60 years, was admitted with acute left flank pain brought on by heavy physical strain. There was slight left costovertebral tenderness but no palpable mass. Urinalysis was normal. On the right side there was good excretion of contrast medium, on the left side excretion was delayed and there were distinct signs of retention as a result o f a bean-sized stone at the pelvic-ureterm junction (Fig. 1). Retrograde pyelography showed dilatation of the collecting system and the site o f the concrement was marked by a large filling defect. Only the lower and middle calyces and the upper catyceal neck were visualized, the cranial calyceal system was not identifiable with certainty. The contrast medium formed a deposit in the upper area of the kidney. On surgical exposure of the left kidney the infundibular stone was located. There was, moreover, a large cyst at the upper renal pole, adjacent to the renal 2
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HOltl, Figdor: Rupture of the renal collecting system
pelvis over a large area and ruptured at one point into the pelvic cavity. In many places the pelvic wall was extremely thin owing to pressure atrophy. In consequence of the extensive changes complete rlephrectomy was inevitable. The postoperative course was uneventful. The concrement was an urate stone. The patient was placed on a preventive regimen. In this case increased intrapelvic pressure was due to calculous obstruction. This resulted in a rupture into the cyst and in an excessive pressure within the cystic lumen.
Fig. 1. Case 1. I. v. urogram Case 2. P. L., male, aged 68 years, consulted us for left groin pain. He had epididymitis five years earlier. Palpation revealed no abnormality and the rectal finding was in conformity with age. The urine was normal. There was good excretion on both sides but in the area of the left kidney numerous large deposits of contrast medium were seen (Fig. 2a, b). Cultures on L6wenstein's medium for TB were negative. The left kidney was exposed, the lower pole was resected, two cysts found at the upper pole were removed. On resection of the lower pole the communication between the renal cyst and the collecting system was located. The microscopic finding of the renal surgical specimen was consistent with nonspecific chronic pyelonephritis. Intravenous urography one year after surgery showed good excretion on both sides with no evidence of retention. Here too, as in the former case, distension of the renal pelvis in consequence of calculous obstruction had resulted in its rupture into a cyst. International Urology and Nephrology 7, 1975
H6ltl, Figdor: Rupture of the renal collecting system
111
Fig, 2. Case 2. 10 min (a) and 60 min (b) u r o g r a m s
Fig. 3. Case 3. (a) I. v. u r o g r a m , (b) R e t r o g r a d e pyel0gram 2*
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Hb'ltl, Figdor: Rupture of the renal collecting system
Case 3. R. E., female, aged 41 years, was subjected to radium therapy foi carcinoma of the uterine cervix. Two years later weakness, chills and high temperatures made hospitalization necessary. On admission there was right flank tenderness. Excretion urography revealed an extreme retention on the right side and a non-functioning left kidney (Fig. 3a). Blood urea nitrogen was 61.5 ml per 100 rag, serum creatinine 4.2 mg per 100 ml. An ureteral catheter could be easily passed up on the left side, obstruction was met at 2 cm at the right. On that side the pelveocalyceal system was considerably dilated as shown indistinctly by retrograde urography (Fig. 3b). Attempts at complete filling failed because of violent pain. In view of the patient's intractable distress an operation was performed on the same day. The right kidney which was still functioning to some extent was exposed in order to produce a fistula to divert urine. We found an excessively enlarged organ of tumour-like appearance. After its mobilization, the fluctuating area of the tumour-suspect region was incised, whereupon urine rushed out under high pressure while the kidney itself turned out to be very small. It was surrounded by a cavity filled with urine. Nephrostomy resulted in a marked improvement of renal function. Blood urea nitrogen dropped to 31.5 mg per 100 ml, serum creatinine to 1.4 ml per 100 ml, endogenous creatinine clearance 142 ml/min. In this case, a spontaneous rupture had occurred between the pelveocalyceal system and the indurated renal adipose capsule.
Discussion
Urinary passage obstruction may produce excessive pressure within the collecting system. Kiil and Aukland [9, 10], in animal experiments, noted intrapelvic values as high as 110 cm H20. It is therefore obvious that under these conditions even a slight injury or any other factor leading to an additional increase in pressure may produce a rupture. The ruptures are referred to as spontaneous if no previous trauma is demonstrable. The spontaneous ruptures fall basically into two groups, i.e. 1. rupture of a previously affected kidney, 2. rupture of an apparently normal kidney [17]. According to Valtonen [17], practically all spontaneous ruptures belong to Group 1, since the renal pelvis never ruptures in the absence of some pre-existing abnormality. In a number of his cases no clinical symptoms had been present and no abnormality was demonstrable until morphologic evidence provided by surgery was obtained. Smulewicz et al. [15], Campbell and Harrison [2] and Miller and Kaufman [12] support this view and advocate biopsy in every case of spontaneous rupture when no gross abnormalities are demonstrable. Campbell and Harrison [2] point to the involvement of polyarteriitis nodosa in many cases of spontaneous rupture. The ruptures generally occur at the weakest point of the urinary collecting system, i.e. at the fornix. However, pressure atrophy produced by a cyst may make the pelvic wall vulnerable to rupture at any point, as it did in two of the presInternational Urology and 2',Iephrology 7, 1975
HOltl, Figdor: Rupture of the renal collecting system
113
ent cases. In the presence of peripelvic fibrosis the urine may force its way through the renal parenchyma and collect subcapsularly [15]. However, the rupture need not produce an acute clinical syndrome: the symptoms may be confined to minor persistent pain and the rupture may remain undetected until the patient is operated on. Harrow [7], in radiographic studies including excretion urography, found extrapelvic extravasation of contrast medium in 51 cases but only 2 of them required surgical intervention. In all the other cases relief of obstruction resulted in an absorption of urinary extravasate and closure of the defect. In the two cases operated on the large urinary extravasate itself seemed to be responsible for the excessive intrapelvic pressure by exerting a continued compression on the ureteric junction even after restoration of urinary passage, thus keeping the defect of rupture patent. In cases of acute abdomen associated with gross retroperitoneal oedema the possibility of spontaneous rupture of the renal pelvis should be always taken into consideration [11]. Cywes et al. [3] and Moncada et al. [13] reported on ascites in children due to spontaneous rupture into the peritoneaI cavity of a dilated collecting system. Harrow [6, 7] and Hinman jr. [81 noted extravasation of contrast medium in a number of cases where excretion urography had been performed because of ureteral obstruction. To facilitate early diagnosis of spontaneous ruptures Davidson [4] advocates intravenous urography in every case of renal colic. In the present cases spontaneous rupture was detected by chance, in the framework of the routine investigations, there having been no history of acute trauma or of other acute events. Rupture at the typical site, i.e. at the fornix, occurred only in Case 3. In the two other cases calculous obstruction was responsible for the increased intrapelvic pressure. However, in both cases there were large renal cysts forming extensive contact with the renal pelvis and causing pressure atrophy of its wall. As a result, rupture took place within the atrophied area instead of the fornix and the cyst filled with urine. In many cases rupture of the renal pelvis is detected by accident. Consequently treatment may not be necessary at all. Even major extravasates during intravenous urography or retrograde urography in case of obstruction hardly ever require surgical therapy. Ureteral catheterization and broad-spectrum antibiotics will prove adequate in the majority of cases, although the hazard of peripelvic fibrosis must be always taken into account [5]. Treatment depends on the presence of clinical symptoms and signs, in particular perinephritic or peritoneal manifestations. Septic complications necessitate drainage of the kidney and urinary diversion by nephrostomy. Nephrectomy is scarcely ever indicated.
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H6Itl, Figdor: Rupture of the renal collecting system
References 1. Abeshouse, B. S. : Rupture of the kidney pelvis. Surg. Gynec. Obst. 60, 710 (1935). 2. Campbell, M. F., Harrison, J. H.: Urology. W. B. Saunders, Philadelphia 1970, p. 793. 3. Cywes, S., Wynne, J. M., Louw, J. H. : Urinary ascites in the newborn with a report of two cases. Y. ped. Surg. 3, 350 (1968). 4. Davidson, A. I. G. : Rupture of renal pelvis and ureter. J. roy. Soc. Surg. (Edinb.) 16, 100 (1971). 5. Ginsberg, S. A. : Spontaneous urinary extravasation in association with renal colic. J. Urol. 94, 192 (1965). 6. Harrow, B. R.: Spontaneous urinary extravasation associated with renal colic causing a perinephritic abscess. Amer. J. Roentgenol. 98, 47 (1966). 7. Harrow, B. R.: Unusual renal peripelvic extravasation requiring operative drainage. J. Urol. 102, 564 (1969). 8. Hinman, F. jr.: Peripelvic extravasation during intravenous urography, evidence for an additional route for backflow after ureteral obstruction. J. UroL 85, 385 (1961). 9. Kiil, F., Aukland, K.: Effect of high ureteral pressure on urine concentration during water diuresis. Scand. J. Chir. Lab. lnvest. 13, 268 (1961). 10. Kiil, F., Aukland, K. : Renal concentration mechanism and haemodynamics at increased ureteral pressure during osmotic and saline diuresis. Scand. Y. Chir. Lab. Invest. 13, 276 (1961). 11. Main, J. M.: Spontaneous rupture of the renal pelvis in the only functioning kidney. Brit. J. Surg. 54, 1033 (1967). 12. Miller, J. B., Kaufman, J. J.: Spontaneous rupture of the kidney by tumour. Brit. J. Urol. 35, 137 (1963). 13. Moncada, R., Wang, J. J., Love, L., Bush, I. : Neonatal ascites associated with urinary outlet obstruction (urine ascites). Radiology 90, 1165 (1968). 14. Rous, S. N., Vitenson, J. It., Nagamatsu, G. R. : Spontaneous rupture of the renal collecting system caused by unsuspected hypernephroma presenting as ureteral calculus disease, or. UroL 106, 512 (1971). 15. Smulewicz, J. J., Dorfmann, J., Cagan, S., Seery, W. H. : Spontaneous rupture of the collecting system of the kidney: An evaluation. J. UroL 104, 507 (1970). 16. Trapnell, J. E. : Spontaneous rupture of the renal pelvis and ureter. Brit. or. Surg. 56, 33 (1969). 17 Valtonen, E. J.: Spontaneous rupture of an apparently normal kidney: some criticism concerning this diagnosis. Brit. J. Urol. 38, 484 (1966).
International Urology and Nephrology 7, 1975
Spontaneous Rupture of the Renal Collecting System G. H6LTL, P. P . FIGDOR D e p a r t m e n t of Urology, University Medical School Vienna, Austria (Received July 27, 1974)
Three cases of spontaneous rupture of the collecting system of the kidney are reported on. Organ-saving surgery was feasible in two of them. The etiology a n d treatment of spontaneous ruptures of the renal pelvis are discussed.
In recent years a few cases of rupture of the urinary collecting system have been reported on, some of them following trauma to the kidney. Abeshouse [I] described 64 cases o f rupture o f the renal pelvis without involvement of the renal parenchyma. In 31 of them rupture was due to trauma. The primary cause is mainly congenital hydronephrosis, but inflammatory processes of the renal pelvis or urinary obstruction may also be responsible factors. In their presence even indirect injury to the kidney may cause rupture, for instance when the renal pelvis is pressed against the transverse process of one or more vertebrae or against the costal arch. In 26 of the cases referred to above rupture was spontaneous. Ruptures of this kind are generally associated with infected hydronephrosis. In two cases described by Smulewicz et al. [15] rupture was due to an increase in intrapelvic pressure resulting from calculous obstruction of the ureter. Trapnell [16] described 8 cases of spontaneous rupture of the renal pelvis or of the ureter. In a case of a juvenile patient described by Davidson [4] a small ureteral calculus, in another case reported on by Rous et al. [14] a hypernephroma of the lower renal pole was responsible for spontaneous pelvic rupture. We describe here three cases of spontaneous rupture of the renal collecting system. In two of them organ-saving surgery was feasible. Case 1. F. H., male, aged 60 years, was admitted with acute left flank pain brought on by heavy physical strain. There was slight left costovertebral tenderness but no palpable mass. Urinalysis was normal. On the right side there was good excretion of contrast medium, on the left side excretion was delayed and there were distinct signs of retention as a result o f a bean-sized stone at the pelvic-ureterm junction (Fig. 1). Retrograde pyelography showed dilatation of the collecting system and the site o f the concrement was marked by a large filling defect. Only the lower and middle calyces and the upper catyceal neck were visualized, the cranial calyceal system was not identifiable with certainty. The contrast medium formed a deposit in the upper area of the kidney. On surgical exposure of the left kidney the infundibular stone was located. There was, moreover, a large cyst at the upper renal pole, adjacent to the renal 2
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HOltl, Figdor: Rupture of the renal collecting system
pelvis over a large area and ruptured at one point into the pelvic cavity. In many places the pelvic wall was extremely thin owing to pressure atrophy. In consequence of the extensive changes complete rlephrectomy was inevitable. The postoperative course was uneventful. The concrement was an urate stone. The patient was placed on a preventive regimen. In this case increased intrapelvic pressure was due to calculous obstruction. This resulted in a rupture into the cyst and in an excessive pressure within the cystic lumen.
Fig. 1. Case 1. I. v. urogram Case 2. P. L., male, aged 68 years, consulted us for left groin pain. He had epididymitis five years earlier. Palpation revealed no abnormality and the rectal finding was in conformity with age. The urine was normal. There was good excretion on both sides but in the area of the left kidney numerous large deposits of contrast medium were seen (Fig. 2a, b). Cultures on L6wenstein's medium for TB were negative. The left kidney was exposed, the lower pole was resected, two cysts found at the upper pole were removed. On resection of the lower pole the communication between the renal cyst and the collecting system was located. The microscopic finding of the renal surgical specimen was consistent with nonspecific chronic pyelonephritis. Intravenous urography one year after surgery showed good excretion on both sides with no evidence of retention. Here too, as in the former case, distension of the renal pelvis in consequence of calculous obstruction had resulted in its rupture into a cyst. International Urology and Nephrology 7, 1975
H6ltl, Figdor: Rupture of the renal collecting system
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Fig, 2. Case 2. 10 min (a) and 60 min (b) u r o g r a m s
Fig. 3. Case 3. (a) I. v. u r o g r a m , (b) R e t r o g r a d e pyel0gram 2*
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Hb'ltl, Figdor: Rupture of the renal collecting system
Case 3. R. E., female, aged 41 years, was subjected to radium therapy foi carcinoma of the uterine cervix. Two years later weakness, chills and high temperatures made hospitalization necessary. On admission there was right flank tenderness. Excretion urography revealed an extreme retention on the right side and a non-functioning left kidney (Fig. 3a). Blood urea nitrogen was 61.5 ml per 100 rag, serum creatinine 4.2 mg per 100 ml. An ureteral catheter could be easily passed up on the left side, obstruction was met at 2 cm at the right. On that side the pelveocalyceal system was considerably dilated as shown indistinctly by retrograde urography (Fig. 3b). Attempts at complete filling failed because of violent pain. In view of the patient's intractable distress an operation was performed on the same day. The right kidney which was still functioning to some extent was exposed in order to produce a fistula to divert urine. We found an excessively enlarged organ of tumour-like appearance. After its mobilization, the fluctuating area of the tumour-suspect region was incised, whereupon urine rushed out under high pressure while the kidney itself turned out to be very small. It was surrounded by a cavity filled with urine. Nephrostomy resulted in a marked improvement of renal function. Blood urea nitrogen dropped to 31.5 mg per 100 ml, serum creatinine to 1.4 ml per 100 ml, endogenous creatinine clearance 142 ml/min. In this case, a spontaneous rupture had occurred between the pelveocalyceal system and the indurated renal adipose capsule.
Discussion
Urinary passage obstruction may produce excessive pressure within the collecting system. Kiil and Aukland [9, 10], in animal experiments, noted intrapelvic values as high as 110 cm H20. It is therefore obvious that under these conditions even a slight injury or any other factor leading to an additional increase in pressure may produce a rupture. The ruptures are referred to as spontaneous if no previous trauma is demonstrable. The spontaneous ruptures fall basically into two groups, i.e. 1. rupture of a previously affected kidney, 2. rupture of an apparently normal kidney [17]. According to Valtonen [17], practically all spontaneous ruptures belong to Group 1, since the renal pelvis never ruptures in the absence of some pre-existing abnormality. In a number of his cases no clinical symptoms had been present and no abnormality was demonstrable until morphologic evidence provided by surgery was obtained. Smulewicz et al. [15], Campbell and Harrison [2] and Miller and Kaufman [12] support this view and advocate biopsy in every case of spontaneous rupture when no gross abnormalities are demonstrable. Campbell and Harrison [2] point to the involvement of polyarteriitis nodosa in many cases of spontaneous rupture. The ruptures generally occur at the weakest point of the urinary collecting system, i.e. at the fornix. However, pressure atrophy produced by a cyst may make the pelvic wall vulnerable to rupture at any point, as it did in two of the presInternational Urology and 2',Iephrology 7, 1975
HOltl, Figdor: Rupture of the renal collecting system
113
ent cases. In the presence of peripelvic fibrosis the urine may force its way through the renal parenchyma and collect subcapsularly [15]. However, the rupture need not produce an acute clinical syndrome: the symptoms may be confined to minor persistent pain and the rupture may remain undetected until the patient is operated on. Harrow [7], in radiographic studies including excretion urography, found extrapelvic extravasation of contrast medium in 51 cases but only 2 of them required surgical intervention. In all the other cases relief of obstruction resulted in an absorption of urinary extravasate and closure of the defect. In the two cases operated on the large urinary extravasate itself seemed to be responsible for the excessive intrapelvic pressure by exerting a continued compression on the ureteric junction even after restoration of urinary passage, thus keeping the defect of rupture patent. In cases of acute abdomen associated with gross retroperitoneal oedema the possibility of spontaneous rupture of the renal pelvis should be always taken into consideration [11]. Cywes et al. [3] and Moncada et al. [13] reported on ascites in children due to spontaneous rupture into the peritoneaI cavity of a dilated collecting system. Harrow [6, 7] and Hinman jr. [81 noted extravasation of contrast medium in a number of cases where excretion urography had been performed because of ureteral obstruction. To facilitate early diagnosis of spontaneous ruptures Davidson [4] advocates intravenous urography in every case of renal colic. In the present cases spontaneous rupture was detected by chance, in the framework of the routine investigations, there having been no history of acute trauma or of other acute events. Rupture at the typical site, i.e. at the fornix, occurred only in Case 3. In the two other cases calculous obstruction was responsible for the increased intrapelvic pressure. However, in both cases there were large renal cysts forming extensive contact with the renal pelvis and causing pressure atrophy of its wall. As a result, rupture took place within the atrophied area instead of the fornix and the cyst filled with urine. In many cases rupture of the renal pelvis is detected by accident. Consequently treatment may not be necessary at all. Even major extravasates during intravenous urography or retrograde urography in case of obstruction hardly ever require surgical therapy. Ureteral catheterization and broad-spectrum antibiotics will prove adequate in the majority of cases, although the hazard of peripelvic fibrosis must be always taken into account [5]. Treatment depends on the presence of clinical symptoms and signs, in particular perinephritic or peritoneal manifestations. Septic complications necessitate drainage of the kidney and urinary diversion by nephrostomy. Nephrectomy is scarcely ever indicated.
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H6Itl, Figdor: Rupture of the renal collecting system
References 1. Abeshouse, B. S. : Rupture of the kidney pelvis. Surg. Gynec. Obst. 60, 710 (1935). 2. Campbell, M. F., Harrison, J. H.: Urology. W. B. Saunders, Philadelphia 1970, p. 793. 3. Cywes, S., Wynne, J. M., Louw, J. H. : Urinary ascites in the newborn with a report of two cases. Y. ped. Surg. 3, 350 (1968). 4. Davidson, A. I. G. : Rupture of renal pelvis and ureter. J. roy. Soc. Surg. (Edinb.) 16, 100 (1971). 5. Ginsberg, S. A. : Spontaneous urinary extravasation in association with renal colic. J. Urol. 94, 192 (1965). 6. Harrow, B. R.: Spontaneous urinary extravasation associated with renal colic causing a perinephritic abscess. Amer. J. Roentgenol. 98, 47 (1966). 7. Harrow, B. R.: Unusual renal peripelvic extravasation requiring operative drainage. J. Urol. 102, 564 (1969). 8. Hinman, F. jr.: Peripelvic extravasation during intravenous urography, evidence for an additional route for backflow after ureteral obstruction. J. UroL 85, 385 (1961). 9. Kiil, F., Aukland, K.: Effect of high ureteral pressure on urine concentration during water diuresis. Scand. J. Chir. Lab. lnvest. 13, 268 (1961). 10. Kiil, F., Aukland, K. : Renal concentration mechanism and haemodynamics at increased ureteral pressure during osmotic and saline diuresis. Scand. Y. Chir. Lab. Invest. 13, 276 (1961). 11. Main, J. M.: Spontaneous rupture of the renal pelvis in the only functioning kidney. Brit. J. Surg. 54, 1033 (1967). 12. Miller, J. B., Kaufman, J. J.: Spontaneous rupture of the kidney by tumour. Brit. J. Urol. 35, 137 (1963). 13. Moncada, R., Wang, J. J., Love, L., Bush, I. : Neonatal ascites associated with urinary outlet obstruction (urine ascites). Radiology 90, 1165 (1968). 14. Rous, S. N., Vitenson, J. It., Nagamatsu, G. R. : Spontaneous rupture of the renal collecting system caused by unsuspected hypernephroma presenting as ureteral calculus disease, or. UroL 106, 512 (1971). 15. Smulewicz, J. J., Dorfmann, J., Cagan, S., Seery, W. H. : Spontaneous rupture of the collecting system of the kidney: An evaluation. J. UroL 104, 507 (1970). 16. Trapnell, J. E. : Spontaneous rupture of the renal pelvis and ureter. Brit. or. Surg. 56, 33 (1969). 17 Valtonen, E. J.: Spontaneous rupture of an apparently normal kidney: some criticism concerning this diagnosis. Brit. J. Urol. 38, 484 (1966).
International Urology and Nephrology 7, 1975
