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|Year : 1981 | Volume
| Issue : 4 | Page : 243-4
Giant pelvi-ureteric diverticulum presenting as ascites : (a case report).
Desai MB, Kamdar MS, Patel MG, Desai SB, Deshpande RB, Pinto AC, Bapat RD, Kinare SG
|How to cite this article:|
Desai M B, Kamdar M S, Patel M G, Desai S B, Deshpande R B, Pinto A C, Bapat R D, Kinare S G. Giant pelvi-ureteric diverticulum presenting as ascites : (a case report). J Postgrad Med 1981;27:243
|How to cite this URL:|
Desai M B, Kamdar M S, Patel M G, Desai S B, Deshpande R B, Pinto A C, Bapat R D, Kinare S G. Giant pelvi-ureteric diverticulum presenting as ascites : (a case report). J Postgrad Med [serial online] 1981 [cited 2020 Apr 8];27:243. Available from: http://www.jpgmonline.com/text.asp?1981/27/4/243/5620
Congenital diverticuli have been described from all parts of the urinary system but diverticuli from the pelvis and ureter are uncommon. We are reporting here a giant pelvi-ureteric diverticulum which had clinically presented as ascites.
A 20 year old male patient was admitted in a medical ward with progressive asymptomatic distension of the abdomen from childhood [Fig. 1].
On examination, no abnormality was detected except for a dull note over a markedly distended abdomen with a resonant note in the right flank. A clinical diagnosis of encysted ascites was made. The routine haematological and biochemical investigations were normal. A routine urine examination showed no abnormality and urine was sterile. Repeated diagnostic abdominal paracenteses revealed a clear sterile fluid with a protein content ranging from 0.2 to 1.2 gm%. A barium study of the gastro-intestinal tract showed the small bowel pushed to the right side. An ultrasound revealed a large cystic mass in the abdomen and the left kidney was not visualised. This was confirmed by an intravenous urogram which showed no excretion of dye on the left side. The right kidney was normal and below the right kidney a second calyceal system was seen. At this stage, the patient was transferred to a surgical ward. An ascending pyelography was attempted but the left ureter could not be cannulated.
A tentative diagnosis of hydronephrosis of the left kidney was made. Forty-eight hours prior to surgery the swelling was drained off 3 litres of fluid by an antegrade puncture through a left paraspinal approach.
An antegrade pyelography revealed a large cyst with a narrow pelvi-ureteric junction through which the dye did not enter the ureter [Fig. 2].
An angiogram showed a normal right kidney and a smaller pelvi-calyceal system below it. This was supplied by a separate vessel which was catheterised. With this a diagnosis of fused kidney with hydronephrosis was made.
Exploratory laparotomy was done. On opening the abdomen a huge sac filled with fluid was seen extending from the costal margin to the pelvis with the left colon stretched over it [Fig. 3].
The mildly hydronephrotic left kidney was rotated and pushed to the right side below the right kidney. The colon was separated and left nephrectomy with excision of hydronephroticsac was done. Post-operative recovery was uneventful.
On subjecting the specimen to gross pathological examination, it showed a large tense cystic mass with kidney attached to it in one area [Fig 4]. On opening it, the cyst contained 7 litres of clear colourless fluid. The inner lining of the cyst was smooth to granular. The cyst showed two small communications with the calyces with the openings partially obliterated. The calyces were moderately dilated with moderate atrophy of the renal parenchyma. The cyst also communicated with ureter. The ureteric opening was patent though partially obliterated. Rest of the ureter was normal. The histopathology of the cyst showed thick fibromuscular wall lined by flattened epithelial cells. The renal parenchyma was partially atrophied. The renal artery and ureter were normal. Thus a final diagnosis of giant diverticulum of pelvi-ureteric junction was made.
Though some cases of diverticuli of ureter have been reported till now, on scrutinizing only a few were true diverticuli. Such cases are usually reported in pediatric age group. Culp in 1947 and McGraw and Culp in 1952 have report ed similar cases of diverticuli from the upper end of ureter containing 1.5 to 2 litres of fluid. Diverticulum of this size from pelvis has not been reported. These patients present a diagnostic problem but only rarely a correct pre-operative diagnosis can be made. Saving the kidney is theoretically possible if a correct preoperative diagnosis is made but practically it is not feasible.
We are grateful to the Dean, Seth G.S. Medical College and K.E.M. Hospital, Bombay, for permission to use the hospital retards and to the Radiology Department of the K.E.M. Hospital for their help and co-operation.
|1.||Culp, O. S.: Ureteral diverticulum: Classification of literature and report of an authentic case. J. Urol. 58: 309-321. 1947. |
|2.||McGraw, A. B. and Culp, O. 5.: Diverticulum of ureter: Report of another authentic case. J. Urol. 67: 262-265, 1952. |