Материал: Oxford American Handbook of Urology ( PDFDrive )
332 CHAPTER 7 Miscellaneous urological diseases of kidney
Cystic renal disease: simple cysts
Simple cysts are single or multiple renal masses ranging from a few to many centimeters in diameter that do not communicate with any part of the nephron or the renal pelvis. They are mainly confined to the renal cortex, are filled with clear fluid, and contain a membrane composed of a single layer of flattened cuboidal epithelium. They can be unilateral or bilateral and often affect the lower pole of the kidney.
In comparison, parapelvic cysts are simple parenchymal cysts located adjacent to the renal pelvis or hilum.
The prevalence of simple cysts increases with age. The precise prevalence depends on the method of diagnosis. On CT, 20% of adults have renal cysts by age 40 years and 30% by the age of 60. At postmortem, 50% of subjects aged >50 have simple cysts. Most reports show no gender predilection.
Cysts do not usually increase in size with age, but may increase in number.
Etiology
Both congenital and acquired causes have been suggested. Chronic dialysis is associated with the formation of new simple cysts.
Presentation
Simple cysts are most commonly diagnosed following a renal ultrasound or CT (less commonly after IVP) done for other purposes, and, as such, they represent an incidental finding. Very large cysts may present as an abdominal mass or cause dull flank or back pain.
The great majority of simple renal cysts are asymptomatic. Acute, severe flank pain may follow bleeding into a cyst (causing sudden distension of the wall).
Rupture (spontaneous or following renal trauma) is rare. Rupture into the pelvicalyceal system can produce hematuria.
Infected cysts (rare) present with flank pain and fever. Very occasionally, large cysts can cause obstruction and hydronephrosis.
Differential diagnosis
-Renal cell carcinoma
-Early autosomal dominant polycystic kidney disease (ADPKD)—diffuse, multiple, or bilateral cysts; presence of hepatic cysts
-Complex renal cysts (i.e., those which contain blood, pus, or calcification)
Investigation
Renal ultrasound
Simple cysts are round or spherical, have a smooth and distinct outline, and are anechoic (no echoes within the cyst—i.e., sound waves are transmitted through the cyst). Evidence of calcification, septation, irregular margins, or clusters of cysts requires further investigation (CT 9 aspiration, MRI). In the absence of these features no further investigation is required.
CYSTIC RENAL DISEASE: SIMPLE CYSTS 333
CT (see Table 7.1)
Simple cysts are seen as round, smooth-walled lesions with homogenous fluid in the cavity (with a typical density of –10 to +20 Hounsfield units), and with no enhancement after contrast (enhancement implies that the mass contains vascular tissue or communicates with the collecting system, i.e., that it is not a simple cyst).
Hyperdense cysts have a density of 20–90 Hounsfield units, do not enhance with contrast media, and are <3 cm in diameter.
Treatment
A simple cyst (round or spherical, smooth wall, distinct outline, and no internal echoes) requires no further investigation, no treatment, and no follow-up. In the rare situation where the cyst is thought to be the cause of symptoms (e.g., back or flank pain), treatment options include percutaneous aspiration ± injection of sclerosing agent or surgical excision of the cyst wall. In the rare event of cyst infection, percutaneous drainage and antibiotics are indicated.
Cysts with features on ultrasound suggesting possible malignancy (calcification, septation, irregular margins) should be investigated by CT with contrast.
Table 7.1 Bosniak classification of CT appearance of simple and complex cysts
Type |
Description |
Approx. % of |
Treatment |
|
|
such cysts that |
|
|
|
are malignant* |
|
|
|
|
|
I |
Simple benign cyst with |
None |
None; no follow-up |
|
no smooth margins, no |
|
required |
|
contrast enhancement, |
|
|
|
no septation, no |
|
|
|
calcification |
|
|
II |
Smooth margins; thin |
10% |
Observation—repeat |
|
septae; minimal |
|
ultrasound looking for |
|
calcification; no |
|
increase in size or |
|
contrast enhancement |
|
development of |
|
Includes high-density |
|
malignant features |
|
(hyperdense) cysts |
|
|
III |
Irregular margins; |
40–50% |
Surgical exploration 9 |
|
moderate calcification; |
|
partial nephrectomy |
|
thick septation (septae |
|
|
|
>1mm thick) |
|
|
IV |
Cystic malignant lesion; |
90% |
Radical nephrectomy |
|
irregular margins and/ |
|
|
|
or solid enhancing |
|
|
|
elements |
|
|
|
|
|
|
* From Siegel et al. (1997). Study relating CTs of cysts where pathological identification had been performed. AJR Am J Roentgenol 169:813–818.
334 CHAPTER 7 Miscellaneous urological diseases of kidney
Cystic renal disease: calyceal diverticulum
A calyceal diverticulum is an outpocketing from the pelvicalyceal system, with which it communicates by way of a narrow neck. It is lined by a smooth layer of transitional epithelium and is covered by a thin layer of renal cortex.
The etiology of calyceal diverticula is unknown. They are usually asymptomatic and are discovered incidentally on an IVP. Symptoms may result from the development of a stone or infection within the diverticulum, presumably caused by urinary stasis.
Stones that form within the calyceal diverticulum may be treated by flexible ureteroscopy and laser lithotripsy or, if large, by percutaneous nephrolithotomy (PCNL) (if percutaneous access is possible). Extracorporeal shock wave lithotripsy (ESWL) may result in stone fragmentation, but it may be difficult for the stone fragments to get out of the diverticulum and they may simply reform into a larger stone.
Endoscopic dilatation or incision of the neck of the diverticulum may be attempted at the time of stone surgery to prevent recurrence, and this technique can also be employed if the diverticulum is thought to be the cause of recurrent urinary infection.
Open surgery has been used to remove stones and to de-roof calyceal diverticula.
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336 CHAPTER 7 Miscellaneous urological diseases of kidney
Cystic renal disease: medullary sponge kidney (MSK)
Definition
MSK is a cystic condition of the kidneys characterized by dilatation of the distal collecting ducts associated with the formation of multiple cysts and diverticula within the medulla of the kidney.
Prevalence
Prevalence is difficult to know, as MSK may be asymptomatic (diagnosed on an IVP done for other reasons or at postmortem). It is estimated to affect between 1 in 5000 and 1 in 20,000 people in the general population, and 1 in 200 in those undergoing IVP (a select population). In 75% of cases both kidneys are affected.
Pathology
The renal medulla resembles a sponge in cross-section because of dilated collecting ducts in the renal papillae and the development of numerous small cysts. This is associated with urinary stasis and the formation of small calculi within the cysts.
It has a reported familial inheritance and is associated with other malformations (hemihypertrophy).
Presentation
The majority of patients are asymptomatic. When symptoms do occur, they include ureteric colic, renal stone disease (calcium oxalate ± calcium phosphate), UTI, and hematuria (microscopic or macroscopic). Up to 50% have hypercalciuria due to renal calcium leak or increased gastrointestinal calcium absorption.
Renal function is normal, unless obstruction occurs (secondary to renal pelvis or ureteric stones).
Differential diagnosis
This includes other causes of nephrocalcinosis (deposition of calcium in the renal medulla) (e.g., TB, healed papillary necrosis).
Investigation
Intravenous pyelogram (IVP)
The characteristic radiological features of MSK, as seen on IVP, are dilatation of the distal portion of the collecting ducts with numerous associated cysts and diverticula (the dilated ducts are said to give the appearance of bristles on a brush). The collecting ducts may become filled with calcifications, giving an appearance described as a bouquet of flowers or bunches of grapes.
Biochemistry
Levels of 24-hour urinary calcium may be elevated (hypercalciuria). Detection of hypercalciuria requires further investigation to exclude other causes (i.e., raised serum parathyroid hormone levels [PTH] indicate hyperparathyroidism).