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Open Access
Stoicescu,
1:12http://dx.doi.org/10.4172/scientificreports.571
Case Report Open Access
Open Access Scientific ReportsScientific Reports
Open Access
Volume 1 • Issue 12 • 2012
Keywords: Hydronephrosis; Lack of kidney function
IntroductionThe main reason for this case presentation was to
discover the real
cause of the urographic lack of kidney function, which was
detected in a young patient and to avoid the nephrectomy in order
to save the kidney. In the first instance, when the patient was
consulted, there was no clue of what the final diagnose would
be.
Patient and Methods
AbstractObjectives: The main reason for this case presentation
was to discover the real cause of the urographic lack
of kidney function that was detected in a young patient and to
avoid the nephrectomy, in order to save the patient's kidney.
Methods: A clinical case of a young patient aged 19 is
presented, who initially goes to the family doctor, as he felt a
pain in the right lumbar area while he was making sudden moves or
while playing football. The objective examination ascertained
Giordano maneuver positive, vertebral and muscular sensitive points
on the right side. After the usual laboratory tests were performed,
following information was ascertained: ESR=18 mm/1 h- 36 mm/2 h,
fibrinogen=240 mg%, urea=40 mg/dl, creatinine=13 mg/dl, the
urinalysis examination was normal, urinary sediment: rare flat
epithelial cells, rare leukocytes, culture of urine - no germs were
developed. An abdominal ultrasound was required, which marked out
the following dimensions of the right kidney: longitudinal
diameter=132 mm, cortical=20 mm, homogeneous medullary and
surprisingly a grade III hydronephrosis, left kidney was normal, in
rest all the other abdominal organs was within normal ultrasound
limits.
Results: After these laboratory investigations an unexpected
diagnosis of grade III right kidney hydronephrosis ascertained
degree I chronic renal failure. The patient was quickly
hospitalized within the Urology Department. An intravenous
urography with contrast substance was performed, which marked out
of the urography lack of big kidney function. In addition, a MRI
native abdominal examination was performed which ascertained the
following: at the right kidney level a massive pyelocaliceal
expansion, with cortical thickening. On the MRCP sequences a
pyeloureteral expansion was observed, without visualising the
ureters. So it was concluded that it was right hydronephrosis by
high urethral obstruction.
Cause of hydronephrosis could be: urethral stone, nephroblastoma
(Wilms tumor), high urothelial pyelocaliceal tumors, TB
pyonephrosis, the pyeloureteral junction syndrome and a congenital
malformation of the right kidney.
Finally, the cause of hydronephrosis was not found and this
patient was sent to Urological Surgery Department for nephrectomy.
The urological surgeon makes a classical surgery and he discovered
a vascular congenital anomaly i.e. the right renal vein was
strangling the right kidney in the middle area and an accessory
branch of it strangled the ureters in initial area. A pyeloplasty
was performed and the right kidney was saved.
Conclusion: Not every kidney diagnosed with urographic lack of
kidney function should be removed. If the renal scintigraphy does
not also indicate a lack of kidney function, namely if it still has
a present function, we can try to save it.
Avoiding Nephrectomy in an Unexpected Diagnosis in Case of
Urography Lack of Kidney FunctionManuela Stoicescu* Department of
of Medical Disciplines, University of Oradea, Romania
g/dl, Ht=38, 7%, N=60%, E=2%, B=3%, L=34%, M=4%, PLT=234000/mm3,
Blood glucose=94 mg/dl, Urea=40 mg/dl, creatinine=1.3 mg/dl,
Creatinine clearance=105 ml/min, Densities in separate
urination=1024. The urinalysis examination was within normal value
limits, the urinary sediment: rare flat epithelial cells, rare
leukocytes, culture of urine - no germs were developed. An
abdominal ultrasound (Figure 1) was required, which marked out the
dimensions of the right kidney which was as follows: longitudinal
diameter=132 mm, cortical=20 mm, homogeneous medullary and
surprisingly a grade III hydronephrosis, left kidney dimensions
were as follows: longitudinal
A clinical case of a young patient aged 19 is presented, which
initially goes to the family doctor, as he felt a pain in the right
lumbar area while he was making sudden moves or while playing
football. The pain that he was feeling had a pressure like nature,
medium intensity, with duration of about 10 minutes, without
irradiation, which ceased spontaneously. Within the objective
examination is ascertained: 1.The Giordano maneuver positive on the
right 2.The vertebral and muscular sensitive points on the right
side, 3.Uretheric insensitive points, 4.BP=120/80 mmHg, 5.Otherwise
the objective examination was within normal limits. After the usual
laboratory tests were performed, following information was
ascertained: ESR=18 mm/1h-36 mm/2h, Fibrinogen=240 mg%,
WBC=5100/mm3, RBC=4.000000/mm3, Hb=12
*Corresponding author: Dr. Manuela Stoicescu, PhD, Consultant
Internal Medicine, Faculty of Medicine and Pharmacy, Assistant
Professor, Department of Medical Disciplines, University of Oradea,
Romania, E-mail: [email protected]
Received November 12, 2012; Published November 22, 2012
Citation: Stoicescu M (2012) Avoiding Nephrectomy in an
Unexpected Diagnosis in Case of Urography Lack of Kidney Function.
1:571 doi:10.4172/scientificreports.571
Copyright: © 2012 Stoicescu M. This is an open-access article
distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source
are credited.
http://dx.doi.org/10.4172/scientificreports.571http://dx.doi.org/10.4172/scientificreports.571
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Citation: Stoicescu M (2012) Avoiding Nephrectomy in an
Unexpected Diagnosis in Case of Urography Lack of Kidney Function.
1:571 doi:10.4172/scientificreports.571
Page 2 of 3
Volume 1 • Issue 12 • 2012
renal failure. The patient was quickly committed in the
Urolology Department. After the repeated abdominal ultrasound and
laboratory tests confirmed the same results, an intravenous
urography with contrast substance was performed (Figure 2a), which
marked out a urographic lack of right kidney function, comparative
with a normal intravenous urography (Figure 2b). Of course, the
biggest problem was now the cause of the urographic lack of kidney
function.
In addition, a MRI native abdominal examination was performed
(Figure 3) (the patient’s state did not allow the contrast
substance to be administered) the result of which was: at the right
kidney level a massive pyelocaliceal expansion, with cortical
thickening, and also a pyeloureteral expansion was observed,
without visualising the urether. No abdominal adenopathywas
revealed. No free fluid was found in the peritoneal cavity. The
left kidney aspect with normal signal and the other abdominal
organs had a normal aspect. Conclusion: Right hydronephrosis caused
by a high ureteral obstruction.
DiscussionsOf course, at the time being the most important
question was:
what was the cause of the right kidney hydronephrosis,
respectively the urographic lack of kidney function?
1. Urethral stone, although this has not been marked out neither
by the ultrasound, MRI- scan and urography, nor indirectly by
ureter dilation detection because this was not at all visualized on
the entire route.
diameter=107 mm, cortical=21 mm, homogeneous medullary, in rest
all the other abdominal organs was within normal ultrasound
limits.
Summary of the Results
Figure 1: Hydronephrosis grade III-right kidney.
Figure 2a: Urography lack of big right kidney function.
Figure 2b: Normal intravenous urography.
Figure 3: Abdominal MRI - Right hydronephrosis by high urethral
obstruction.After these laboratory investigations an unexpected
diagnosis of
grade III right kidney hydronephrosis ascertained 1st degree
chronic
http://dx.doi.org/10.4172/scientificreports.571http://dx.doi.org/10.4172/scientificreports.571
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Citation: Stoicescu M (2012) Avoiding Nephrectomy in an
Unexpected Diagnosis in Case of Urography Lack of Kidney Function.
1:571 doi:10.4172/scientificreports.571
Page 3 of 3
Volume 1 • Issue 12 • 2012
2. Nephroblastoma (Wilms tumor) can represent 10% of the
urographic lack of kidney function through the complete obstruction
of the urinary tracts (basinet, ureter) or the complete destruction
of the renal parenchyma and its replacement with tumor tissue, but
the ultrasound examination and the MRI- scan did not mark out
anything in this direction nor did the urography highlight any
space replacing formation (lacunars images).
3. High urothelial pyelocaliceal tumors, but by performing
intravenous urography no lacunars images were marked out, that
could be suggestive in this meaning.
4. TB pyonephrosis can also determine, in rare cases, the
urographic lack of kidney function, but in this case, the patient
did not have any chills, fever, the laboratory test has marked out
a slightly elevated ESR, but the fibrinogen was normal without
leukocytosis, neutrophilia, and most important without
lymphocytosis. The urinalysis and the urinary sediment were within
the normal limits and also the urinalysis was negative. Because it
is well known that Koch bacillus does not develop in normal culture
medium so an insemination on a specific Lowenstein Jensen culture
was performed, but the result was negative. The intra dermal
reaction at tuberculin was negative as well. It is being mentioned
that the history of the patient did not present any tuberculosis
family contact. Rarely, the neglected, untreated pulmonary
tuberculosis, can spread through blood to affect the kidney, but
was not confirmed in the present case.
5. The pyeloureteral junction syndrome could have been another
possible cause of hydronephrosis and of the urography lack of
kidney function. But it is known, that this is a congenital
disorder, which theoretically could have been overlooked until this
age, if the patient has never been before examined, but until the
present the patient did not have any lower or high urinary
infections history (acute pyelonephritis) which should have
appeared on a pyeloureteral junction syndrome congenital basis.
6. A congenital malformation of the right kidney could have been
possible.
A renal scintigraphy would have been ideal, but this could not
be performed. The renal scintigraphy has its important role in the
diagnosis, in the quantitative assessment of the pre-surgical renal
function, for patients that have a nephrectomy indication. Not
every kidney that shows an urographic lack of kidney function must
be removed, it might still have a present function, and must be
tried to be saved. The truth is, that after this conclusion, the
cause of hydronephrosis was not found and this patient was
committed in the Urologic Department, was sent
to Urological Surgery Department for intention to nephrectomy.
The urological surgeon, has thought of saving the kidney and
decided to perform a laparoscopic surgery, but the laparoscopic
surgery result was surprising, confusing even for the urological
surgeon, which initially decided to perform a laparoscopic surgery,
but in the end was forced to make a classical surgery because he
observed laparoscopic a vascular congenital anomaly, namely the
right renal vein was strangling the right kidney in the middle
area, being very edematous-swollen. Moreover, another branch of it
strangled the ureter in initial area. This required an
intraoperative, classical way surgery of this unexpected venous
vascular malformation and also a pyeloplasty has been performed in
order to resolve the hydronephrosis, thus being able to save the
right kidney. The histopathological examination result (Figure 4)
has later shown: macroscopy-3/2 cm bassinet and microscopy with
minimal lymphocytic inflammatory.
Conclusions1. We should never hurry to indicate nephrectomy in
case of
detecting a urographic lack of kidney function.
2. Not every urographic lack of kidney function must be removed
if the renal scintigraphy does not indicate a lack of kidney
function, namely if it still has a present function, we can try to
save it.
3. The preoperative quantitative evaluation for patients who
require a “nephrectomy” is compulsory, because surprises may appear
any time, just like in the clinical case of the 19 year patient
that was presented.
Figure 4: Minimal lymphocytic inflammatory infiltrations.
http://dx.doi.org/10.4172/scientificreports.571http://dx.doi.org/10.4172/scientificreports.571
TitleCorresponding authorAbstractKeywordsIntroductionPatient and
Methods Summary of the Results DiscussionsConclusions Figure 1
Figure 2a Figure 2b Figure 3 Figure 4