Department of Urology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel.
Department of Urology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel.
Urology. 2019 Nov;133:240. doi: 10.1016/j.urology.2019.08.024. Epub 2019 Aug 26.
To present a rare case of "huge" hydronephrosis causing distortion of large vessels and formation of a thrombus in the inferior vena cava. Multidisciplinary treatment was applied with particular focus on pyeloplasty utilizing a robot-assisted laparoscopic approach.
A 20-month-old male presented to the emergency room severely ill with abdominal pain, nausea, vomiting, and fever and was subsequently transferred to the intensive care unit, in septic shock. An abdominal ultrasound revealed a large multilobular cystic structure in the right hemiabdomen, which was initially interpreted as an infected mesenteric cyst. CT scan revealed a huge hydronephrotic kidney crossing the midline, causing a mass effect that compressed and distorted the vena cava laterally, in addition to a thrombus between the hepatic vein and right renal vein. Intravenous Ceftriaxone and Amikacin, as well as anticoagulation therapy with low molecular weight heparin (Enoxaparin) were initiated. A nephrostomy tube was inserted that drained 900 mL of purulent urine. A full hematology investigation including protein C, S, and antithrombin III was carried out, excluding factor V Leiden and prothrombin mutation. All values were in the normal range. Dimercaptosuccinic Acid (DMSA) scan showed 30% function on the affected kidney and Voiding Cystourethrogram (VCUG) excluded any bladder pathology or reflux. Subcutaneous Enoxaparin was continued for 3 months, maintaining antifactor Xa in the therapeutic range (0.7-1 IU/mL). Ultrasound Doppler of the vena cava showed full resolution of the thrombus. Robot-assisted laparoscopic pyeloplasty was performed and significant reduction of the renal pelvis was carried out, taking care to preserve the calyces. Postoperative ultrasound 4 months after surgery showed a complete resolution of the hydronephrosis.
Giant hydronephrosis is a rare finding. Distortion of adjacent veins and formation of thrombosis should be kept in mind, as they are life threatening. A multidisciplinary collaboration is mandatory to ensure optimal treatment.
介绍一例罕见的“巨大”肾盂积水导致下腔静脉大血管扭曲并形成血栓的病例。采用多学科治疗方法，特别注重利用机器人辅助腹腔镜肾盂成形术。
一名 20 个月大的男性因腹痛、恶心、呕吐和发热急诊就诊，随后转入重症监护病房，出现感染性休克。腹部超声显示右半腹部有一个大的多房囊性结构，最初被解释为感染性肠系膜囊肿。CT 扫描显示一个巨大的肾盂积水性肾脏穿过中线，产生压迫和侧向扭曲腔静脉的肿块效应，肝静脉和右肾静脉之间有血栓。开始静脉注射头孢曲松和阿米卡星，并给予低分子肝素（依诺肝素）抗凝治疗。插入肾造瘘管，引流 900ml 脓性尿液。进行了全面的血液学检查，包括蛋白 C、S 和抗凝血酶 III，排除了因子 V Leiden 和凝血酶原突变。所有值均在正常范围内。二巯丁二酸（DMSA）扫描显示受影响肾脏的功能为 30%，排空性膀胱尿道造影（VCUG）排除了任何膀胱病理或反流。继续皮下注射依诺肝素 3 个月，维持抗因子 Xa 在治疗范围内（0.7-1IU/ml）。腔静脉超声多普勒显示血栓完全溶解。进行机器人辅助腹腔镜肾盂成形术，并进行了显著的肾盂缩小，同时注意保留肾盏。术后 4 个月的超声检查显示肾盂积水完全缓解。
巨大肾盂积水是一种罕见的发现。应注意相邻静脉的扭曲和血栓形成，因为它们有生命危险。需要多学科合作，以确保最佳治疗。
