|Year : 1984 | Volume
| Issue : 4 | Page : 241-3
Vesicopyelostomy in a pelvic kidney with uretero-pelvic junction obstruction and multiple renal calculi (a case report).
AK Goel, SS Vaidyanathan, MS Rao, CS Rao, PP Nath, TK Sen, BB Suryaprakash
A K Goel
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Goel A K, Vaidyanathan S S, Rao M S, Rao C S, Nath P P, Sen T K, Suryaprakash B B. Vesicopyelostomy in a pelvic kidney with uretero-pelvic junction obstruction and multiple renal calculi (a case report). J Postgrad Med 1984;30:241-3
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Goel A K, Vaidyanathan S S, Rao M S, Rao C S, Nath P P, Sen T K, Suryaprakash B B. Vesicopyelostomy in a pelvic kidney with uretero-pelvic junction obstruction and multiple renal calculi (a case report). J Postgrad Med [serial online] 1984 [cited 2023 Jun 9 ];30:241-3
Available from: https://www.jpgmonline.com/text.asp?1984/30/4/241/5436
Vesicopyelostomy has been performed for post-transplant donor ureteral necrosis,,, and in cases of renal pelvic or ureteral carcinoma along with autotransplantation. Encouraged by a previous use of this procedure in a solitary functioning pelvic kidney with ureteropelvic junction obstruction, we performed this surgical procedure in another case of pelvic kidney with such obstruction and multiple renal calculi.
A forty year male was admitted with history of a gradually increasing left lower abdominal mass.. He had been suffering from episodic left lower abdominal pain with radiation to groin for over fifteen years. During one such episode, he was catheterised elsewhere when the palpable suprapubic mass was suspected to be a distended urinary bladder. Only a small quantity of urine was recovered and there was no reduction in the size of this mass.
He was normotensive. A globular, non-tender lump, 20 cm in diameter, was felt in the suprapubic region, predominantly to the left of the midline. A well-defined lower border could be palpated. It was not bimanually palpable during an otherwise normal rectal examination.
His blood urea was 30 mg%, and the serum creatinine, 1.3 mg%. Urine culture showed bacterial growth of no significance. Hemogram, 24-hour urinary excretion and serum values of calcium, uric acid, and phosphorus were normal. Radiograph of the KUB region showed small radio-opaque shadows, shifting in relation to one another in subsequent urographic exposures. Intravenous urography revealed normally functioning orthotopic right kidney with a lower polar cyst. On a one hour delayed film, faint opacification of the pelvic mass was observed suggestive of a hydronephrotic left pelvic kidney [Fig. 1]. A renal scan (99mTC DTPA) showed uptake in the right lumbar area with photon deficient area in the region of the lower pole but no uptake over the left lumbar area. Percutaneous transfemoral aortography showed single right renal artery at the orthotopic level. Multiple ectopic vessels were directly arising from the aorta and the, common iliac artery and supplying the pelvic mass [Fig. 2]. A bull, tip left ureteropyelography revealed an undilated ureter displaced medially by the mass. A dilated pelvicalyceal system was faintly visualised due to contrast dilution, thus confirming the diagnosis of ureteropelvic junction obstruction .
Realising that the multiple renal vessels coursing over the dilated pelvis of a malrotated ectopic kidney could hamper satisfactory performance of pyeloplasty in this case, vesicopyelostomy was planned which, in addition to promoting free drainage, could facilitate spontaneous passage of any recurrent renal calculi in future. The pelvic kidney was approached extraperitoneally by a modified Gibson incision dividing both abdominal recti in their lower part. The kidney was found to be discoid in shape with extrarenal calyces and massive hydronephrosis. The cortical thickness in the middle and lower pole was 1.5 to 2.0 cm. Six stones were removed. from the huge renal pelvis which was then trimmed. A 6 x 1.5 cm disc of bladder wall was excised at the dome. Renal pelvis was then anastomosed to the dome of the bladder by a continuous interlocking suture of 3/0 chromic catgut reinforced by a second layer of interrupted horizontal mattress sutures [Figs. 3A] and [Figs. 3B]. The left ureter was not disturbed. The bladder was drained by a 22 Fr. suprapubic Foley catheter brought out through a separate stab wound. The wound was closed in layers around a retropubic penrose drain. The post-operative period was uneventful. The drain was removed on the fifth post-operative day and the catheter on the fourteenth post-operative day. Cystography performed two weeks later revealed vesicopelvic reflux. After double voiding, near total emptying of the refluxed contrast was observed [Figs. 4A] and [Figs. 4B]. Excretory urography done three months later showed better visualisation of the pelvic kidney [Fig. 5]. Urine culture continued to be sterile.
Anastomosis of the pelvis of a hydronephrotic pelvic kidney with the urinary bladder provides free drainage of urine. This may be preferable to performing a pyeloplasty especially in stone formers as in this patient who belongs to an endemic region for metabolic urolithiasis. The wider anastomosis made possible by vesicopyelostomy would perhaps not only allow spontaneous passage of recurrent renal calculi into the bladder, but also extend the scope of endoscopic manipulation through the wider anastomosis thus achieved. Further, the factors like malrotation of the pelvicalyceal system and multiple aberrant arteries supplying a pelvic kidney which would hamper performance of a satisfactory pyeloplasty are circumvented by this procedure.
A drawback of this operation could be the possible detrimental effect of vesicopelvic reflux upon renal function. In an experimental study using a canine model, it was possible to preserve excellent renal function for a year following vesicopyelostomy. There was no impairment of inulin clearance or transport maximum of paraaminohippuric acid. No histological abnormalities of glomeruli, tubules or interstitium were noticed in the animals in whom vesicopyelostomy had been performed. These experimental findings were corroborated in a clinical study where good function was maintained in a renal allotransplant with vesicopyelostomy over nine years.
If diseases such as genito-urinary tuberculosis or chronic cystitis which result in reduced bladder capacity occur in these patients, they may lead to renal damage at a relatively early stage because of infection in presence of vesicopelvic reflux and transmission of high intravesical pressure to the now proximate renal collecting system. Similarly, these patients could develop renal back-pressure effects early when bladder outlet obstruction or prostatic hypertrophy occurs at a later date. Thus, these patients require a close, almost life-long follow-up and alertness towards appropriate and timely intervention whenever a threat to renal function (even of subtle nature as judged by sensitive radionucleide tests) is detected.
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