P. Vedamurthy Reddy1, G. Ravi Shankar2, DVS Rambabu3
Department of Urology and Renal Transplantation,
Narayana Medical College and Hospital, Nellore,1
Department of Urology, Bollineni Hospitals, Rajahmandry,2
Department of Urology, SVIMS, Tirupati,3
Andhra Pradesh, India.
Corresponding Author:
Dr. Vedamurthy Reddy Pogula
Email: pglreddy@yahoo.co.in
48uep6bbphidvals|477 48uep6bbph|2000F98CTab_Articles|Fulltext Congenital pelviureteric junction obstruction can present clinically at any time of life. In neonates and infants it presents as a palpable flank mass. Older children and adults present with intermittent abdominal or flank pain, nausea, vomiting, hematuria or hypertension. Here we present a case of congenital pelviureteric junction obstruction misdiagnosed as pseudocyst of pancreas.
Case report
A 30 year old unmarried male was referred to us by a general surgeon with a diagnosis of recurrent pseudocyst of pancreas. The case had been operated by the same surgeon around 11 years ago. The patient was suffering from unrelieved left upper abdominal pain. On abdominal examination a left upper
paramedian scar was noted. A 12×10 cm mass was palpable in the left lumbar and hypochondriac regions. The mass was bimanually palpable and ballottable, suggesting a left renal origin.
A prior ultrasound abdomen of the patient showed a pseudocyst of pancreas. Contrast enhanced computed tomography (CECT) of abdomen was performed with oral and intravenous contrast administration (Figure 1). It revealed gross left hydronephrosis with thinned out renal parenchyma. The pancreas and gastrointestinal tract were normal. In light of these findings a left pelviureteric junction obstruction was suspected. A technitium 99m diethyltriamine penta acetic acid (DTPA) renogram was performed which revealed hydronephrotic, nonfunctioning left kidney due to pelviureteric junction obstruction. The right kidney was normal. A decision was taken to perform a left simple nephrectomy.
The left kidney was approached through the 11th rib flank incision. On exploration the anterior wall of the kidney was attached to posterior wall of the stomach. On separating the adhesions a prolene suture was found. The communication between the kidney and the stomach was completely dismantled. Gastric wall edges were freshened and closed in two layers using absorbable suture material. The pelviureteric junction was narrow suggesting obstruction. The ureter was not dilated, and the renal parenchyma was thin. A simple nephrectomy was performed, followed by an uneventful postoperative period.
Discussion
Renoalimentary fistulae comprise less than 1% of fistulae between the urinary and intestinal tract, the vast majority of which are colovesical fistulae. Hippocrates is credited for the first reported case of renoalimentary fistula in 460 BC. Renoalimentary fistulae began to be recognized more commonly in the mid 1800s and predominantly due to renal tuberculosis (TB). A distant second cause was pyelonephritis due to infection with other organisms.[1] With the exception of pyelonephritis in conjunction with stone disease, infectious causes of renoalimentary fistula diminished.
Most renoalimentary fistulae are iatrogenic, secondary to percutaneous nephrostomy tube placement,[2] percutaneous radiofrequency ablation,[3] or laparoscopic cryoablation. Trauma, foreign body ingestion, malignancy (particularly colon, renal, and transitional cell carcinoma), and inflammatory processes (usually secondary to stones,[4] infection, or diverticular disease) have also been implicated in some cases.
The clinical presentation of a patient with a renoalimentary fistula varies. The patient may present with just abdominal pain and fever. In many cases, the presence of fecaluria, pneumaturia, biliuria, recurrent urinary tract infection, or watery diarrhea may be noted. Evidence of sepsis with fever and leukocytosis is common. The presence of peritoneal signs demands immediate surgical exploration. Renoalimentary fistulae may be diagnosed with the aid of either renal or alimentary imaging studies. Complete imaging and endoscopy of the gastrointestinal tract are necessary in cases of spontaneous renoalimentary fistulae in order to rule out gastrointestinal malignancy as an etiology.
Antibiotic therapy is instituted to assist in the treatment of concomitant infection, but surgical intervention remains the definitive treatment for renoalimentary fistulae. The choice of surgical therapy largely depends on the etiology of the fistulae and the segment of bowel involved. Surgical therapy involves resection of the bowel segment, reanastomosis, and resection of the fistula tract to the kidney. If renal function is severely compromised, a nephrectomy may be more efficacious than attempts at repairing the urinary tract component of the fistula.[5]
Successful percutaneous fulguration of the fistula tract has been reported.[6] In rare cases of renoalimentary fistula following radiofrequency ablation or cryoablation, conservative measures have been successful.[7] This presentation highlights the importance of history, clinical examination and proper radiological evaluation before undertaking any surgical intervention, and emphasizes the importance of precise intraoperative assessment and management.
References
- Arthur GW, Morris DG. Reno-alimentary fistulae. Br J Surg. 1966;53:396–402.
- LeRoy AJ, Williams HJ Jr, Bender CE, Segura JW, Patterson DE, Benson RC. Colon perforation following percutaneous nephrostomy and renal calculus removal. Radiology. 1985;155:83–5.
- de Arruda HO, Goldman S, Andreoni C, Maia RS, Szejnfeld J, Ortiz V. Renoduodenal fistula after renal tumor ablation with radiofrequency. Surg Laparosc Endosc Percutan Tech. 2006;16:342–3.
- Cline KL, Lang EK. Renal gastric fistula caused by staghorn calculus. J Urol. 2005;174:1107.
- Milling MA, Santer GJ. Renogastric fistula. Br J Urol. 1978;50:423.
- Kim SC, Weiser AC, Nadler RB. Nephroenteric fistula treated with fulguration of the fistulous tract. J Endourol. 2000;14:443–5.
- Vanderbrink BA, Rastinehad A, Caplin D, Ost MC, Lobko I, Lee BR. Successful conservative management of colorectal fistula after percutaneous cryoablation of renal-cell carcinoma. J Endourol. 2007;21:726–9.
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