Challenges in the diagnosis of calyceal diverticulum: A report of two cases and review of the literature

Prolonged postoperative urine leakage due to a calyceal diverticulum mimicking a renal cyst: A case report and literature review

Background

The calyceal diverticulum is a rare cystic cavity that communicates with the collecting system via a narrow neck or infundibulum. In clinical practice, part of the calyceal diverticula is difficult to differentiate from simple renal cysts even after contrast-enhanced CT. To date, there have been few kinds of literature works on the diagnosis and treatment of calyceal diverticulum combined with renal pelvis dilatation, especially concerning the treatment of prolonged postoperative urine leakage.

Case description

A 53-year-old woman with calyceal diverticulum and renal pelvis dilatation mimicking a simple renal cyst suffered urine leakage after receiving laparoscopic unroofing of the renal cyst. A persistent urine leakage was observed immediately after surgery, with about 200 ml of drainage fluid per day. We first attempted to place a double-J ureteral stent and indwell a catheter. After failing that, conservative treatment was performed. The core idea of the conservative treatment is retaining the drainage tube for more than 1 month, then clamping the drainage tube for 1 week, and finally removing the drainage tube. By 3 weeks of follow-up, the urine leakage disappeared, and the CT scan showed hydronephrosis of the right kidney without perirenal exudation and the lower pole cyst of the right kidney shrank significantly.

Conclusion

This case, we reported here, is to attract the attention of clinicians. Renal cysts should exclude the possibility of the calyceal diverticulum. If urine leakage is inevitable after surgical treatment, our conservative treatment strategy is also an alternative method.

A case report of renal calyceal diverticulum with hypertension in children and review of literature

Background

Renal calyx diverticulum refers to a cystic lesion covered with the transitional epithelium in the renal parenchyma. Although there is no clear evidence that calyx diverticulum can cause hypertension, there exists a close association between the two, and there are few related reports. Herein, we reported the case of a child with renal calyx diverticulum complicated with hypertension and summarized the diagnosis and treatment.

Case presentation

Physical examination of the patient, an 11-year-old child, revealed a left renal cyst with hypertension (155/116 mmHg). There were no related symptoms. Routine urine and blood biochemical examinations showed no abnormalities. Imaging revealed left renal cyst compression causing the hypertension. She underwent renal cyst fluid aspiration and injection of a sclerosing agent into the capsule, but her blood pressure increased again 3 days postoperatively. Color Doppler ultrasonography showed that the size of the left renal cyst was the same as that preoperatively. To further confirm the diagnosis, cystoscopic retrograde ureteropyelography was performed to confirm the diagnosis of renal calyx diverticulum. Subsequently, renal calyceal diverticulum resection and calyx neck enlargement were performed. The operation went smoothly and the blood pressure returned to normal postoperatively. No abnormalities were noted at the 7-month postoperative follow-up.

Conclusion

There exists an association between renal calyx diverticulum and hypertension. Therefore, hypertension can be considered a surgical indication for renal calyx diverticulum. Moreover, renal calyceal diverticulum in children can be easily misdiagnosed as a renal cyst. Therefore, it is important to be vigilant to prevent a series of complications, such as postoperative urine leakage, in such cases.

Confirmation of an internal hydatid bladder fistula using postoperative methylene blue retrograde injection via urinary catheter: a case report

Abdominal hydatidosis resulting in an internal hydatid bladder fistula postoperatively is quite rare and might have serious consequences without timely treatment. A 74-year-old Tibetan woman presented with abdominal distension and was diagnosed with hydatid disease. Cyst contents were removed, and the pericyst was partially resected without contraindication. Furthermore, no internal urinary fistula was found before or during the operation, and the presence of an internal fistula was indicated by methylene blue retrograde injection via urinary catheter after the operation. The use of postoperative methylene blue retrograde injection via urinary catheter is recommended to identify internal hydatid bladder fistula formation.

A Case Report of Calyceal Diverticulum: Differential Diagnosis for Organ-Preserving Operations

Calyceal diverticula and epidermal cysts are extremely rare kidney lesions with unknown etiology and pathogenesis. They have non-specific clinical and radiological picture. Despite the benign nature, sometimes these disorders mimic malignant tumors leading to unjustified nephrectomy. We present a clinical and morphological observation of a multicystic lesion in a 76-year-old patient's right kidney filled with keratinized masses and imitating a malignant solid tumor. The detailed gross, histological and immunohistochemical (desmin, cytokeratin 7, uroplakin and p63) analyses of the kidney tissue excluded the malignant nature of the lesion. The final differential diagnosis was between an epidermal cyst and calyceal diverticulum with pronounced squamous cell metaplasia of urothelium. The upper pole localization of the lesion, its connection with the pelvicalyceal system through the unobstructed isthmus, the presence of urothelial lining and smooth muscle cells in its wall let us diagnose a calyceal diverticulum type I. Knowledge of the key clinical and morphological features of epidermal cysts and diverticula of the pelvicalyceal system will help the practicing physicians suspect the benign nature of such lesions and perform organ-preserving operations.

Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cysts: What we learned and a review of the literature

PURPOSE

To avoid Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cyst (diameter > 70 mm), we present two cases of iatrogenic ureteral injury and discuss their clinical courses and final outcomes.

PATIENTS AND METHODS

Two male patients (47 years old and 74 years old) with large left simple renal cysts underwent a retroperitoneal laparoscopic operation to treat the cysts. In the first patient, the left proximal ureter was partially transected (Grade 3) during the operation. The injury was identified intraoperatively. The transection was managed with a primary ureteroureterostomy (end to end) along with a double J ureteral stent. In the second patient, the left proximalureter was partially transected (Grade 4). However, the injury was unrecognized postoperatively for two days. After recognition of the complication, the injury was managed with an early primary ureteroureterostomy, which followed a failed attempt to place ureteral stent endoscopically.

RESULTS

In the first patient, a postoperative urinary leakage developed and lasted for 13 days. During long term follow-up of the first patient after the urine leak resolved, there were no reports of pain in the lumbar region or other discomfort. No recurrence of the renal cyst occurred, which was confirmed with an ultrasound at one year postoperatively. In the second patient a ureteral fistula and severe perirenal infection occurred and lasted for 86 days. The patient ultimately underwent a left nephrectomy after conservative management for this surgical complication failed. This patient developed a chronic wound infection that lasted for 3.14 months following the nephrectomy. During follow-up post nephrectomy, the patient developed stage 3B moderate chronic kidney disease (CKD) (GFR = 30 -44 ml/min).

CONCLUSIONS

For single large (diameter > 70 mm) renal cysts located at the lower pole of the kidney, it is recommended to not completely dissect out and mobilize the entire renal cyst for cyst decortication in order to avoid injuring the ureter. Iatrogenic ureteral injury increases the risk of readmission and serious life-threatening complications. The immediate diagnosis and proper management ureteric injury can reduce complications and long term sequalae.

A rare case of a cystic renal mass with heterotopic ossification and a mini literature review

INTRODUCTION

It is a challenge to make accurate pre-surgical diagnosis for renal tumors. This study is to report the findings, management, and outcome of one rare case of ossification in a cystic renal mass. We present and discuss the pathological characteristics, radiologic features, and treatment alternatives of the patient.

PATIENTS AND METHODS

A 38 years old female patient had intermittent epigastric pain and microscopic hematuria for two months. Computerized tomography (CT) scan and Magnetic Resonance imaging (MRI) showed a mass with rough edge and dense calcification in the upper pole of the right kidney and normal left kidney. Pre-operative diagnosis is cystic nephroma or cystic renal mass (Bosniak III type, Bosniak renal cyst classification). GFR was within normal limits for age and no other significant laboratory aberrations were noted. Patient underwent a right retroperitoneal laparoscopic partial nephrectomy (margin status was negative). A mini literature review was performed to highlight the principals of diagnosis and treatment of cystic renal mass with heterotopic ossification.

RESULTS

The entire renal mass was successfully removed from upper pole of the right kidney by laparoscopic nephron sparing surgery. The size of renal mass is 38×35×30 mm3 with thick and hard capsular wall. The cystic cavity contains yellow lipid-like substances without stone. Histological examination revealed renal cyst in which the cyst wall reveals fibrosis and no obvious lining epithelium. The additional unique feature includes the presence of dense calcification and ossification in the renal mass. Localization tissue of yellow bone marrow was detected. No complications occurred in 9 months after surgery during follow-up.

CONCLUSIONS

Cystic renal mass with heterotopic ossification is a rare case of non-malignant renal tumor. Whether surgery is needed depends to whether patients have symptoms. For symptom renal tumors, laparoscopic nephron sparing surgical procedure is recommended. Furthermore, complete surgical resection of the lesion is needed when the mass is suspected to be malignant. An accurate histologic diagnosis is key in its diagnosis.