CASE 16896 Published on 22.07.2020
0

An uncommon cause of urinary obstruction.

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Daniel Hynes, MB BCh BAO, Bertrand Janne d’Othée, MD, MPH, MBA.

University of Massachusetts Medical School – Baystate

Springfield, MA (USA)

Connected authors
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Bertrand Janne d'Othee Professor of Radiology United States
Patient

71 years, male

Categories
Area of Interest Interventional non-vascular, Kidney, Urinary Tract / Bladder ; Imaging Technique CT, Fluoroscopy, Percutaneous
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Clinical History

A 71-year-old man presented with fever, tachycardia, hypoxia, elevated white blood cell count, lactic acidosis and sepsis. Non-contrast CT demonstrated right-sided hydronephrosis with suspicion of obstructive uropathy and infected urolithiasis. Patient is not a surgical candidate given his respiratory status, morbid obesity, type 2 diabetes mellitus and hypertension. Percutaneous nephrostomy is requested.

Imaging Findings

Antegrade percutaneous nephrostogram was obtained via an enlarged lower pole calyx of the right kidney (Figure 1). (1A-B) Initial injections show significantly enlargement of lower third calyces, but the renal pelvis, ureteropelvic junction (UPJ) and proximal ureter are not opacified. On later rotational views (1C), some contrast is seen passing into a non-distended ureter. The renal pelvis remains non- well visualized or opacified.

Pre-contrast CT images in axial (Figure 2A) and coronal (2B) planes do not show an obstructive radiodense stone. The pigtail of the percutaneous nephrostomy tube is in an enlarged lower pole calyx and not in the renal pelvis. Axial (2C) and coronal (2D) images 10 minutes after intravenous contrast show contrast filling enlarged calyces in the right kidney (contrast in the lower pole calyx presumably already excreted into the nephrostomy tube bag). The renal pelvis is not opacified due to extrinsic compression by a large parapelvic cyst(s).

Discussion

Background Parapelvic (or peripelvic) cysts are relatively uncommon, often found by chance, comprising 1-2% of all renal cysts and observed in >1% of routine autopsies [1-3]. A commonly held pathophysiologic explanation is the dilatation of lymphatic structures obstructed by adjacent chronic inflammation [1-3], although embryonic remnants have also been invoked [1]. They do not communicate with the renal collecting system [2]. They are structurally similar to simple renal cysts [3] and morphologically can be simple or multiloculated, single or multiple [1].

Clinical Perspective Although usually asymptomatic, they can be associated with lumbar pain (98% of symptomatic cases), infection (9%), haematuria (5%) [1-3], or less commonly stones, vascular compression, renin-associated hypertension and spontaneous haemorrhage [1-2].

Imaging Perspective Parapelvic cysts are central in location and can misleadingly suggest hydronephrosis on ultrasound evaluation. Both intravenous pyelograms and antegrade percutaneous nephrostograms can show stretching and extrinsic compression of calyces similar to that seen with renal sinus lipomatosis [1-2]. Definite differential diagnosis relies on computed tomography with intravenous contrast, which fills the renal calyces and pelvis but not the cyst(s), the latter compressing the former in symptomatic cases [2]. Stones can be found within the parapelvic cysts themselves [2].

Outcome Unlike simple renal cortical cysts, sclerotherapy is contraindicated for the management of parapelvic cysts due to the risk of retroperitoneal extravasation, perirenal inflammation with associated pain, fever, and ureteropelvic junction obstruction [2, 4]. Surgical approach has evolved from open marsupialization to laparoscopy (renal-sparing cyst excision, unroofing, decortication, or ablation). Less invasive treatment options include antegrade percutaneous nephroscopy or retrograde ureteroscopy (rigid or flexible) [2-3, 5]. In retrograde ureteroscopy, the scope guides the incision (1 cm) into the cyst wall, examines its cavity (+/- stone removal and/or incision of septa if present), and guides internal drainage leaving an internal ureteral stent in place for 1-2 months. This results in complete cyst disappearance in 33-79% of cases and >50% diameter reduction of cysts in 62-14%, with cyst recurrence in 0-4% [2-3]. Percutaneous cyst ablation has results similar to laparoscopy [2].

Take-Home Message / Teaching Points During percutaneous antegrade nephrostogram, the discrepancy between enlarged calyces and a thin, barely or non-visible renal pelvis (“vanishing pelvis”) combined with the difficulty in advancing the wire into the renal pelvis in the absence of a visible obstructing filling defect are key hints to the diagnosis. These observations should prompt the interventionalist to obtain a contrast-enhanced CT scan with an excretory phase.

Differential Diagnosis List
Obstructive parapelvic cyst.
Ureteropelvic junction (UPJ) obstruction.
Extrinsic compression of the renal pelvis.
Obstructive urolithiasis, tumour, blood clot.
Final Diagnosis
Obstructive parapelvic cyst.
Case information
URL: https://eurorad.org/case/16896
DOI: 10.35100/eurorad/case.16896
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Antegrade percutaneous nephrostogram via first-pass needle access into a lower pole calyx of the right kidney. (1A-1B) Initial injections show significant enlargement of all calyces. The renal pelvis and proximal ureter however are not initially visible. The accessed calyx appears to be posterolateral based on general orientation and position of the ultrasound probe, but the exact location of the renal hilum cannot be determined with certainty due to patient's obesity and limited ultrasonographic access win
Play Video
Antegrade percutaneous nephrostogram via first-pass needle access into a lower pole calyx of the right kidney. (1A-1B) Initial injections show significant enlargement of all calyces. The renal pelvis and proximal ureter however are not initially visible. The accessed calyx appears to be posterolateral based on general orientation and position of the ultrasound probe, but the exact location of the renal hilum cannot be determined with certainty due to patient's obesity and limited ultrasonographic access window. Clear urine sample showed no microbial growth on subsequent cultures. On later rotational views (B), some contrast is seen passing into a small, non-distended ureter. The renal pelvis is not well visualized or opacified. A 0.018" guidewire was passed and coiled in the accessed calyceal group, but could not be advanced more centrally into the renal pelvis.
Antegrade percutaneous nephrostogram via first-pass needle access into a lower pole calyx of the right kidney. (1A-1B) Initial injections show significant enlargement of all calyces. The renal pelvis and proximal ureter however are not initially visible. The accessed calyx appears to be posterolateral based on general orientation and position of the ultrasound probe, but the exact location of the renal hilum cannot be determined with certainty due to patient's obesity and limited ultrasonographic access win
Antegrade percutaneous nephrostogram via first-pass needle access into a lower pole calyx of the right kidney. (1A-1B) Initial injections show significant enlargement of all calyces. The renal pelvis and proximal ureter however are not initially visible. The accessed calyx appears to be posterolateral based on general orientation and position of the ultrasound probe, but the exact location of the renal hilum cannot be determined with certainty due to patient's obesity and limited ultrasonographic access window. Clear urine sample showed no microbial growth on subsequent cultures. On later rotational views (B), some contrast is seen passing into a small, non-distended ureter. The renal pelvis is not well visualized or opacified. A 0.018" guidewire was passed and coiled in the accessed calyceal group, but could not be advanced more centrally into the renal pelvis.
Antegrade percutaneous nephrostogram via first-pass needle access into a lower pole calyx of the right kidney. (1A-1B) Initial injections show significant enlargement of all calyces. The renal pelvis and proximal ureter however are not initially visible. The accessed calyx appears to be posterolateral based on general orientation and position of the ultrasound probe, but the exact location of the renal hilum cannot be determined with certainty due to patient's obesity and limited ultrasonographic access win
Play Video
Antegrade percutaneous nephrostogram via first-pass needle access into a lower pole calyx of the right kidney. (1A-1B) Initial injections show significant enlargement of all calyces. The renal pelvis and proximal ureter however are not initially visible. The accessed calyx appears to be posterolateral based on general orientation and position of the ultrasound probe, but the exact location of the renal hilum cannot be determined with certainty due to patient's obesity and limited ultrasonographic access window. Clear urine sample showed no microbial growth on subsequent cultures. On later rotational views (B), some contrast is seen passing into a small, non-distended ureter. The renal pelvis is not well visualized or opacified. A 0.018" guidewire was passed and coiled in the accessed calyceal group, but could not be advanced more centrally into the renal pelvis.
Figure 2

Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous
Play Video
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous injection of iodinated contrast show contrast filling of enlarged calyces in the mid and upper thirds of the right kidney (contrast in the lower pole calyx presumably has already been excreted into the nephrostomy tube bag). The renal pelvis is not opacified due to extrinsic compression by a large parapelvic cyst(s).
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous
Play Video
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous injection of iodinated contrast show contrast filling of enlarged calyces in the mid and upper thirds of the right kidney (contrast in the lower pole calyx presumably has already been excreted into the nephrostomy tube bag). The renal pelvis is not opacified due to extrinsic compression by a large parapelvic cyst(s).
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous
Play Video
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous injection of iodinated contrast show contrast filling of enlarged calyces in the mid and upper thirds of the right kidney (contrast in the lower pole calyx presumably has already been excreted into the nephrostomy tube bag). The renal pelvis is not opacified due to extrinsic compression by a large parapelvic cyst(s).
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous
Play Video
Computed tomographic images in axial and coronal planes (Figure 2). Pre-contrast images in axial (2A) and coronal (2B) planes shows the pigtail of the percutaneous nephrostomy tube in an enlarged lower pole calyx, not in the renal pelvis. A small (<1 cm) radiodense intra-calyceal stone is adjacent to the pigtail, but no obstructive urolithiasis is seen, particularly in the renal pelvis, ureteropelvic junction or proximal ureter. Axial (2C) and coronal (2D) images obtained 10 minutes after intravenous injection of iodinated contrast show contrast filling of enlarged calyces in the mid and upper thirds of the right kidney (contrast in the lower pole calyx presumably has already been excreted into the nephrostomy tube bag). The renal pelvis is not opacified due to extrinsic compression by a large parapelvic cyst(s).