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AN UNUSUAL PRESENTATION OF HUGE PARAPELVIC CYST

case report
 
MUHAMMAD SHAFIQ UL AZAM, FARHINA IKRAM, SIBTAIN RAZA, SHAFQAT UL ISLAM, SYED MEHMOOD, HAJI HAROON
 
Karachi X-rays & CT Scan / Ultrasound centre Karachi

INTRODUCTION
  CT scans must not be taken too quickly after injection of contrast
material before it can enter the dilated, and often obstructed, renal
Parapelvic cysts are spherical fluid filled masses that originate from pelvis. When contrast agent does enter the collecting system, in
the supine position it is possible for only the dependent part of the
renal parenchyma or renal sinus and may cause compression of the
collecting system to be opacified and thus the unopacified part can
collecting system. Incidence is 1.5% at autopsy and 4-6% of all renal
be confused with a parapelvic cyst. However, in such cases a
cysts. Its etiology may be obstructive lymphatic channel,
horizontal urine-contrast level would identify this unopacified part
posttraumatic extravasation of urine/blood, mesonephric/wolffian body as belonging to the collecting system. This problem is not
remnant, duplication anomaly or outpouchings of renal pelvis. These encountered, however, on the multidetector row CT scanner
are most common in 5th-6th decade. Parapelvic cysts are almost because of the capability of multiplanar reformation.
always asymptomatic but may cause pain from obstructive caliectasis
Although surgical proof was not obtained in most of the studies,
or may cause renal vascular hypertension from renal artery
the CT criteria which used were identical to those shown to be
compression. Incidentally diagnosed on IVP or ultrasound examination, virtually pathognomonic for cysts of the renal parenchyma (3).
however CT scan can be done to see its extension and effect on
surrounding structures. CT and sonography provide rapid, accurate, non invasive
evaluation of renal masses identified on excretory urography. To
 
accurately characterize a mass as a simple benign cyst by CT, the
CASE HISTORY a) Coronal reformatted CT images showing huge parapelvic cyst displacing right lesion must meet strict criteria (3).In addition to the well known
kidney superiorly and inferior vena cava inferiorly and laterally (curved arrow)
  causes of hemorrhage or infection within a cyst, other cause for
high-density renal cysts, (i.e., that of contrast material artifactually
A 62 years old male, presented with complains at right lumbar pain
raising the attenuation value temporarily). When this is suspected,
associated with vomiting and fever for last 15 days. Laboratory reports
a repeat CT examination after a short delay can be diagnostic, and
including complete blood count and liver function tests showed normal
it may not be necessary to resort to more invasive procedures for
values. The only abnormal investigations were raised ESR, 45, while
further clarification. However, the presence of calcification,
Serum creatinine was 1.4 mg/dl.
particularly if diffuse in distribution, or fresh hemorrhage can lead
to CT numbers higher than those of normal renal parenchyma. The
Ultrasound done out side our institute showed large hypoechoic area
rapid change from high to relatively low attenuation values in the
at right side of the abdomen and was diagnosed as Liver abscess and
mass in some of the cases reported would be highly unusual for a
referred to us for ultrasound guided aspiration of the abscess. On
lesion with a malignant etiology (6). Although it is conceivable that
ultrasound performed at our institute, no liver abscess was found
this appearance could have been secondary to simultaneous
instead a large extra hepatic cystic structure was noted in right side of
hemorrhage or infection in bilateral parapelvic cysts, the lack of a
abdomen lying inferior to the liver with gross displacement of the right
history of puncture, trauma, bleeding disturbance, or fever
kidney. The origin of this huge cystic lesion could not be defined on
combined with the known extravasation noted after retrograde
the ultrasound.
pyelography makes these much less likely as explanations for the
We performed his Contrast enhanced CT Abdomen on 16 detector row transient increase in attenuation of the cysts.
CT which revealed a huge right parapelvic cyst with significant
b) Axial contrast enhanced CT images showing huge parapelvic cyst on right side Parapelvic cysts may be single or multiple and while they are
superior displacement of right kidney. The parapelvic cyst also causing with another left renal cortical cyst
usually less than 5 cm in diameter, an occasional one may attain
significant compression on the right pelviureteric junction and upper
larger dimensions (7, 8, 9). A lymphatic tissue or embryologic rest
ureter resulting in moderate hydronephrosis. Another small cortical
origin is believed by some to be the source for parapelvic cysts (7,
cyst was seen at the upper pole of right kidney. The large parapelvic
8).
cyst measured 15x17x15 cm in maximum craniocaudal,
anteroposterior and transverse dimensions respectively extending
 In summary, parapelvic cysts can be diagnosed on both
from right hypochondric region to iliac crest level. The unusual aspect
ultrasonography and CT scan which are both accurate and non
of this parapelvic cyst is the effect on IVC, which is showing significant
invasive examinations. But CT scan is more valuable as it
lateral and inferior displacement, these changes were better
differentiates renal sinus lipomatosis and hydronephrosis. In
demonstrated on reconstructed coronal and sagittal images. A cortical
addition to this, it gives more information about complications like
cyst was found at upper pole of left kidney, measuring about 5x6 cms
infection, hemorrhage, thrombus formation and extension of the
causing no displacement or pressure on adjacent structures. Rest of
cyst that causes displacement of adjacent viscera specially vessels
the abdominal viscerae and vessels were normal.
which help in surgical planning.

The patient underwent surgery because of the patient’s symptoms.  


Per-operative findings confirmed the diagnosis given on CT. Excision of
the cyst was performed followed by marsupialization. The post
operative course was uneventful and the patient had no complaints on
a subsequent short term follow up visit at the physician’s clinic.

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