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Giant hydronephrosis mimicking progressive malignancy
© Schrader et al; licensee BioMed Central Ltd. 2003
Received: 01 July 2003
Accepted: 18 October 2003
Published: 18 October 2003
Cases of giant hydronephroses are rare and usually contain no more than 1–2 litres of fluid in the collecting system. We report a remarkable case of giant hydronephrosis mimicking a progressive malignant abdominal tumour.
A 78-year-old cachectic woman presented with an enormous abdominal tumour, which, according to the patient, had slowly increased in diameter. Medical history was unremarkable except for a hysterectomy >30 years before. A CT scan revealed a giant cystic tumour filling almost the entire abdominal cavity. It was analysed by two independent radiologists who suspected a tumour originating from the right kidney and additionally a cystic ovarian neoplasm. Subsequently, a diagnostic and therapeutic laparotomy was performed: the tumour presented as a cystic, 35 × 30 × 25 cm expansive structure adhesive to adjacent organs without definite signs of invasive growth. The right renal hilar vessels could finally be identified at its basis. After extirpation another tumourous structure emerged in the pelvis originating from the genital organs and was also resected. The histopathological examination revealed a >15 kg hydronephrotic right kidney, lacking hardly any residual renal cortex parenchyma. The second specimen was identified as an ovary with regressive changes and a large partially calcified cyst. There was no evidence of malignant growth.
Although both clinical symptoms and the enormous size of the tumour indicated malignant growth, it turned out to be a giant hydronephrosis. Presumably, a chronic obstruction of the distal ureter had caused this extraordinary hydronephrosis. As demonstrated in our case, an accurate diagnosis of giant hydronephrosis remains challenging due to the atrophy of the renal parenchyma associated with chronic obstruction. Therefore, any abdominal cystic mass even in the absence of other evident pathologies should include the differential diagnosis of a possible hydronephrosis. Diagnostic accuracy might be increased by a combination of endourological techniques such as retrograde pyelography and modern imaging modalities.
Cases of giant hydronephroses are rare and usually contain up to 2 litres of fluid in the collecting system [1, 2]. Giant hydronephrosis is thought to develop gradually over a long time period, although rapid exacerbations of the condition have been reported . Patients always present with abdominal enlargement and most of them are asymptomatic . However, complications include compression of surrounding structures including the contralateral ureter, intestine, veins, infections, renal insufficiency, malignant change and rupture of the kidney [4–6]. Even though the use of multiple diganostic instruments such as ultrasonography, excretory, antegrade and retrograde urography, as well as CT technology has facilitated the diagnosis of hydronephrosis in the last decades, accurate diagnosis of giant hydronephrosis in individual cases remains challenging [7, 8]. An extensive list of alternate diagnoses has been reported including ovarian cyst, retroperitoneal haematoma, hepatobiliary cysts, mesenteric cysts, pseudomyxoma, renal tumour, retroperitoneal tumours, ascites and splenomegaly .
We report a remarkable case of giant hydronephrosis on the basis of a benign ovarial tumour mimicking a progressive malignant abdominal neoplasm.
A 78-year-old cachectic woman called on her general practitioner with a slight chronic neuropathy. Indipendent of that, she presented with an enormous abdominal tumour. According to the patient, her abdominal girth had slowly increased in diameter over the last months, maybe years, which she ascribed to hyperalimentation. She negated any general symptoms like fatigue, weight loss or gain, fever, or any kind of urinary dysfunction. Medical history was unremarkable except for an abdominal hysterectomy without ovariectomy more than 30 years before due to a hysteromyoma.
Although both clinical symptoms and the enormous size of the tumour had indicated malignant growth, it turned out to be a giant hydronephrosis. Presumably, a chronic obstruction of the ureter had led to extensive progressive hydronephrosis with consecutive loss of renal parenchyma and function.
As demonstrated here, an accurate diagnosis of giant hydronephrosis remains challenging [7, 8]. Due to the atrophy of the renal parenchyma associated with chronic obstruction, the diagnostic accuracy even of modern imaging modalities is limited since functioning renal parenchyma with adequate contrast enhancement might be absent . Therefore, any abdominal/retroperitoneal cystic mass even in the absence of other evident pathologies should include the differential diagnosis of a possible hydronephrosis. Regarding the case presented here, a preoperative cystoscopy in combination with a retrograde illustration of the ureter could have been useful to complete diagnosis. In general, diagnostic accuracy might be increased by a combination of endourological techniques (such as retrograde pyelography) and modern imaging modalities, e.g. magnet resonance imaging.
We thank the patient for giving consent to publication of this case report.
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