SPONTANEOUS RUPTURE OF THE KIDNEY PELVIS

By HENRY CLARKE, F.R.C.S.

Sirrgron, Luton and Dunstable Hospiial, Luton

Two types of acute rupture of the kidney occur ; that involving the parenchyma, and frequently the pelvis also, i n which the picture is mainly one of hzemorrhage ; and the rarer type involving the pelvis only, in which the picture is mainly one of extravasation of urine. This case falls into the latter group.

Chronic rupture also occurs in which the perforation is gradual and usually presents as a perirenal abscess or fistula.

In a review of the literature I have been unable to find any case reported of a rupture of the kidney pelvis, due to growth, without involvement of the kidney parenchyma. Abeshouse (1935), in a very full review, collected sixty-four cases of rupture of the kidney pelvis without involvement of the parenchyma but was unable to find any due to growth. Beard (1946) collected forty-two cases of spontaneous rupture of the kidney due to various causes, including growth, but does not specify whether the parenchyma was involved. However none of the cases reported in his references was similar to this case. Frumkin and Meigher (1953) collected eight cases of spontaneous rupture of kidney tumours but in all of them there was involvement of the parenchyma. It would seem that the case here reported must be a very rare condition.

Case Report.-Mrs R. M., a housewife, aged 30, was admitted to the Luton and Dunstable Hospital as an emergency under my care on 8th December 1953.

History.-Two days previously, just after getting into bed, she had been seized with a sudden, severe, intermittent pain in the right hypochondrium, like a knife stab. It spread over the abdomen and settled in the right iliac fossa. She vomited and lost her appetite and her bowels had been loose and frequent since the onset.

Over the last nine months she had often been worried with epigastric pain five to six hours after food, which was relieved by stomach powder and belching. She also had heartburn and had lost eight pounds in the last five months. She had had no pain in the renal angle or centre of her abdomen and no increased frequency or other genito-urinary symptoms. Her periods were regular. She suffered from asthma but otherwise had no cardiovascular or nervous symptoms.

Past Histor.v.-Three and a half years ago she had a nervous breakdown, for which she had shock treatment, and nine months ago she had functional tachycardia.

On Examination.-She was nervous and pale. Her temperature was 100.4" F., her pulse 128, her respirations 24, and her blood-pressure 165/85 mm. Hg. Her tongue was furred. The abdomen was slightly distended and was tender and rigid down the right side and especially i n the right iliac fossa but not in the renal angle ; it moved well with respiration. There was a marked release and Rovsing's sign but no hyperzsthesia. Bowel sounds were normal and there was no obturator or psoas spasm. On vaginal examination she was tender in the posterior and right lateral fornix, and on rectal examination to the right and especially posteriorly. No other abnormality was found in the pelvis. No abnormality of the heart, lungs, or nervous system was found and the urine contained no abnormal constituents. A centrifuged deposit was not examined.

Diagnosis of acute appendicitis with peritonitis was made and immediate operation advised. Operation revealed an extensive retroperitoneal extravasation of urine with some blood clot. This involved

the whole of the right side of the abdomen and spread forwards to appear in the lower end of the paramedian incision and downwards into the pelvis and into the right half of the broad ligament and round the right fallopian tube, to such an extent that at first it was thought she might have some affection of it . Further examination revealed a large right renal swelling, and as there was a normal kidney to palpation on the opposite side a right nephrectomy was done approaching the kidney transperitoneally by mobilising the right colon. There was a large pelvic hydronephrosis, and it was thought that this had undergone spontaneous rupture. On examination of the specimen afterwards a tiny perforation was found on the anterior wall of the pelvis which exuded blood-stained urine, and on opening the pelvis a large papilliferous growth (Fig. I ) .

On Pathological €x-an~ination.-The kidney was normal in appearance from without except that the renal pelvis was much dilated. There was a huge tumour arising from all parts of the epithelium of the pelvis and projecting into it . The tumour was soft and appeared from its gross characters t o be benign. The obstruction

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to the pelvi-ureteric junction had caused a dilatation of the calyces and flattening of the renal papillz, but otherwise the kidney was normal in appearance. Microscopic examination showed the typical histological appearance of a benign papilloma arising from the epithelium of the renal pelvis (Fig. 2). The possibility of nialignancy cannot be completely excluded, but in the regions examined there was no evidence of carcinoma and there was no sign o f infiltration into the fibromuscular wall o f the renal pelvis or of spread into the kidney. The kidney itself did

FIG. 1

rl(,. 2

Fig. I.-Photograph of specimen \honing large papilloma. hydronephrosis. a n d normal kidney. Fig. 2.-Photomicrogriiph shon ing papillary nature of tumour with few niitosec and absence

of intill-ration. I 21.5.

not show any pathological condition other than tubular degenerative changes and slight fibrosis associated with the early stages of hydronephrosis.

Pvo~ress was uneventful and she was discharged on the eleventh post-operative day (19th December 1953). O n direct questioning after operation she admitted that she had had hzmaturia for one day six months ago and also said that about half an hour before the onset of pain she had been squeezed in the loin when picked up by her husband but had not noticed anything at that time. Intravenous pyelogram and cystoscopy after operation showed no abnormality. The remaining portion of the right ureter was removed threc months later and showed no abnormality on pathological and microscopic examination.

DISCUSSION

Rupture of the kidney pelvis is usually caused by trauma but, as Larks (1942) pointed out, if the kidney is diseased the trauma may be so slight that it is not recognised by the patient or the surgeon ; even muscular activity may be sufficient. In this case the squeeze which the patient received when her husband picked her up may have caused the rupture, but it was not until after she had gone to bed, half an hour later, that the pain started. Whether or not this slight trauma was the final cause of the rupture, there must have been some predisposing weakness of the pelvis, produced either by thrombosis or hamorrhage in the pedicle of the papilloma or even a small area of malignant change. In this case the trauma was so slight that the patient did not mention it until questioned after the operation. I think, therefore, the designation of spontaneous is justified.

Spontaneous rupture of the kidney frequently presents as an abdominal emergency and is often diagnosed before operation as acute appendicitis (Walker, 1933). This case was no

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exception, but there are certain features which should have raised a doubt had their significance been realised at the time : firstly, the absence of midline abdominal pain ; secondly, the pain was all in the right side of the abdomen, although not in the renal angle; thirdly, the extreme tenderness posteriorly on rectal examination. This posterior tenderness has not been described previously but surely must be due to downward extension of the retroperitoneal extravasation and, if found, must be strong presumptive evidence of a spontaneous rupture of the kidney, especially if there are abdominal signs to support the diagnosis.

Although some early malignant change cannot be excluded, the tumour had none of the features of a malignant growth, such as infiltration, frequent mitoses, etc., and, because of its large size without such changes, must have been essentially benign. Such a large benign papilloma of the renal pelvis is unusual, especially in a woman of only 30 years.

Finally, despite its apparently benign nature, the prognosis must be guarded, because such extensive extravasation as occurred in this case must carry the risk of retroperitoneal implantation. Moreover, papillomata of the urinary tract are notorious for recurring, so a very careful follow-up, with regular cystoscopy, will have to be done.

SUMMARY

A case of spontaneous rupture of the kidney pelvis due to a large benign papilloma is presented. A search of the literature revealed no report of a similar case. Certain features of the symptoms and signs are discussed, especially the significance of tenderness posteriorly on rectal examination.

I would like to express my thanks to Dr Cuthbert Dukes for his report on the specimen and his very helpful advice, and to his staff for their excellent photographs : also to Dr Bradley Watson for his pathological report.

REFERENCES

AFESHOUSE, B. S. (1935). Surg. Cynec. Obstet.. 60, 710. BEARD, D. E. (1946). Sth. nied. J., 39, 780. FRUMKIN. J., and MEIGHER, s. (1953). LARKS. G. ( 1942). Brit. J. Surg., 29, 354. WALKER, R. M. (1933). Brit. J. Urol., 5, 159.

Ann. Srrrg., 138, 275.