0022-5347 /79/1212-0228$02.
00/0
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Clinicopathologi cal Conference
NON-FUNCTIONING KIDNEY
HARPER D. PEARSE,* JOHN M. BARRY,* DONALD C. HOUGHTONt
From the Division of Urology and Department of Pathology, University of Oregon Health Sciences Center, Portland, Oregon
PRESENTATION OF CASE§
Dr. Harper D. Pearse. R. H., 60-68-10, a 64-year-old black
man, had been evaluated in another state in September 1976,
with a 3-month history of gross, painless hematuria. Cystos-
copy revealed a solitary papillary bladder tumor adjacent to
the left ureteral orifice. The tumor was resected and patholog-
ically showed a grade I to II transitional cell carcinoma
without invasion. An excretory urogram (IVP) before resec-
tion of the bladder tumor was reported to have been normal,
although incomplete filling was noted on the left side. The
patient was referred to us since he was moving to Oregon.
We first saw the patient in April 1977, 6 months after the
bladder tumor resection. At that time the patient did not have
subjective urinary symptoms and physical examination re-
vealed no pertinent findings. Laboratory evaluation included
a normal chest film, urinalysis, hemogram and renal function
studies. An IVP showed a normal right collecting system and
ureter and non-function on the left side. Cystoscopy revealed
scarring over the left hemitrigone and obliteration of the left
ureteral orifice, making a left pyeloureterogram impossible.
Recurrent bladder tumor was not noted. Cytology showed no
malignant cells. IBtrasound documented the presence of a left
kidney and suggested a compact collecting system. A renal
scan revealed minimal perfusion on the left side.
The clinical diagnosis at this time was non-function of the
left kidney secondary to endoscopic obliteration of the left
ureteral orifice at the time of the bladder tumor resection.
After our diagnostic studies the original IVPs arrived. Non-
function of the left kidney was noted on these pre-resection x-
rays rather than incomplete visualization, as had been re-
ported previously. The possibility of an upper tract tumor with
obstruction progressing to non-function was now considered
more strongly. Renal exploration was done on July 8, 1977.
DIFFERENTIAL DIAGNOSIS
Dr. John M. Barry. From the available evidence can we
assure this man that he does not have a transitional cell
carcinoma of the renal pelvis or ureter without removing the
kidney? In any case non-function of a kidney may be of pre-
renal, renal or post-renal causes. The kidney may have been
infarcted with an embolus, a clot at an arteriosclerotic steno-
sis, trauma with an intimal tear or aortic thrombosis. There
is no history of myocardial infarction, atrial arrhythmia or
prior embolic episodes. There is no history of sudden onset of
hypertension or severe arteriosclerosis. We have no history of
an acceleration-deceleration injury that would result in an
* Associate Professor of Surgery, Division of Urology University
of Oregon Health Sciences Center. ' reasonable. The possibility of a totally obstructing calculus of
! Assistant Professor of Pathology, University of Oregon Health
Sciences Center.
:j: Professor and Chairman, Division of Urology, University of
Oregon Health Sciences Center.
§ Case presented '.3-t Urol?IP'. Grand Rounds on August 22, 1977.
Reques~s for reprmts: D1V1s1on of Urology, University of Oregon
Health Sciences Center, Portland, Oregon 97201.
228
Vol. 121, February
Printed in U.S.A.
AND CLARENCE V. HODGES+
intimal tear of the renal artery with thrombosis, dissection
and infarction. The femoral pulses are normal and the patient,
therefore, does not have aortic thrombosis.
Renal causes of unilateral non-function include agenesis,
dysplasia and chronic infection. Agenesis can be eliminated
immediately because a left kidney was demonstrated on an
ultrasound examination of the retroperitoneum.
The possibility of renal dysplasia cannot be eliminated on
the basis of the available information. Chronic infection is
unlikely because there is no history of recurrent left pyelone-
phritis and the urinalysis was normal. Tuberculosis is un-
likely because the chest x-ray was normal, there were no
cystoscopic findings consistent with bladder tuberculosis and
the right upper urinary tract shows no evidence of destruction
of renal parenchyma, scarring or obstruction of the collecting
system. The renal cause of non-function of greatest concern is
that of a tumor. The most common metastatic tumors to the
kidney are from the lung and stomach. Our patient has no
gastrointestinal symptoms or recent weight loss and the chest
x-ray is clear. Angiomyolipoma is unlikely because there is no
mass associated with the left kidney, there are no stigmas of
tuberous sclerosis and the patient is a man. Renal angiomyoli-
pomas that are not associated with tuberous sclerosis usually
are single, unilateral, have a male-to-female ratio of 1:4 and
usually present with flank pain and hematuria. 1 Adenocarci-
noma is unlikely because, in addition to enlargement of the
renal shadow on ultrasound examination, the kidney tends to
retain function on an IVP. Sarcomas are extremely rare and,
again, present as a mass on ultrasound examination. Transi-
tional cell carcinoma of the renal pelvis or ureter is a strong
possibility in this man because he has had a prior transitional
cell carcinoma of the bladder around the left ureteral orifice
and, although there is no history of phenacetin abuse or
exposure to industrial amines, he has a 50-pack year history
of cigarette smoking, which has been associated with urothe-
lial cancers. 2• 3 Transitional cell carcinoma of the renal pelvis
is 4 times more common in men than in women and is
associated with bladder and ureteral transitional cell carcino-
mas in at least 10 per cent of the cases at the time of diagnosis.
Ureteral carcinoma is a rare lesion that occurs twice as often
in men as in women, more commonly in the lower third of the
ureter and in association with bladder carcinoma 25 per cent
of the time. 3• 4
Post-renal causes of renal non-function include calculus
disease, stricture and carcinoma of the urothelium, which we
have just completed discussing under renal causes of non-
function. A simple distal ureteral stricture secondary to resec-
tion of the previous bladder tumor with subsequent scarring is
the renal pelvis or ureter cannot be eliminated but it usually
is associated with hydronephrosis and no large hydronephrosis
was developed on ultrasound examination. A ureteropelvic
junct~on obstruction ~w~~g to a ~ongenital or acquired stric-
ture IS a remote poss1b1hty, agam because of the absence of
hydronephrosis.
 NON-FUNCTIONING KIDNEY 229
We come back to the basic question and I would have to junction must be exposed adequately to ensure removal of a
suggest that a nephroureterectomy with a cuff of bladder proper cuff of bladder (fig. 2, B). 5 If proper visualization
would be the best diagnostic and therapeutic maneuyer in this cannot be obtained the bladder can be opened and the cuff can
man because of the high association of transitional cell carci- be removed intravesically. Figure 3, A shows the nephroure-
noma of the upper urinary tract in a patient who has had a terectomy specimen.
prior bladder cancer and the fact that we simply have no fool- DISCUSSION OF PATHOLOGY
proof means of ruling out this malignancy in this particular
case. Dr. Donald C. Houghton. The surgical specimen consisted

FINDINGS AT SURGICAL EXPLORATION

Doctor Pearse. The patient was placed in a modified flank

position so that the torso formed a 45-degree angle with a
flexed operating table rather than the usual 90-degree angle
(fig. 1). Depending on the relationship of the kidney to the
lower ribs the incision is made either in the 10th or 11th
intercostal space from the lateral border of the erector spinae
muscle to the midline just above the symphysis pubis. An
incision over the 11th rib was used in this patient. Posteriorly,
the costovertebral ligament was cut in the superior aspect of
the lower rib, allowing this rib to hinge downward and the
superior rib to hinge upward. This exposed the pleura and
diaphragm fibers. The diaphragm fibers were then cut to
allow the pleural cavity to be retracted superiorly. Palpation
revealed a large, firm mass occupying the entire renal pelvis.
The decision was made at this point to perform an en bloc
complete nephroureterectomy. The incision was then extended
to the symphysis medially and the anterior rectus sheath was
incised, allowing the rectus muscle to be retracted medially.
With blunt dissection the retroperitoneal fat surrounding the
kidney and ureter was elevated superiorly over the aorta. The
left renal artery was isolated, ligated and divided between
ligatures at its origin from the aorta. The left renal vein was
ligated and divided in a similar manner. The perirenal fat and
fascia were then freed from the abdominal surface of the
diaphragm. Medially, adrenal vessels required division be-
tween hemostatic clips. The peritoneum was dissected off the
perirenal fat and fascia. The kidney was elevated along with
the ureter and its surrounding fat and the entire retroperito-
neal space was dissected, including all lymphatic tissue along
the great vessels. The kidney, surrounding fat and fascia with
lymph nodes were lifted out of the wound, attached only by
the ureter (fig. 2, A). Removal of the distal ureter and a cuff of
bladder was accomplished extravesically. The ureterovesical Fm. 1. Position of patient for supracostal incision

Fm. 2. A, kidney, surrounding fat and nodal tissue lifted out of wound, attached only by ureter. B, proper exposure of ureterovesical
junction permits removal of cuff of bladder. Simply tenting-up of bladder by traction on ureter does not permit adequate removal.5
230 CLINICOPATHOLOGICAL CONFERENCE

Fm. 3. A, left nephroureterectomy specimen. B, photograph of surgical specimen after coronal sectioning. Tumor protrudes from opened
renal pelvis. Its papillary structure is evident. Arrow extends from dilated intrarenal pelvis to site of origin of ureter, route effectively
obstructed by tumor. Kidney is hydronephrotic as indicated by caliceal dilatation, papillary blunting and parenchymal thinning.

of the left kidney, ureter and bladder cuff. A block of the renal
hilar and periaortic lymph node-bearing fibroadipose tissue
also was received. The kidney was 11 cm. long and weighed
160 gm. Its surface was irregularly scarred.
Distending the renal pelvis was a papillary tumor, measur-
ing 4 cm. in diameter (fig. 3, B). It arose with a broad base
from the mucosa on the inferior wall of the pelvis. The tumor
was impacted into the pelvic infundibulum and the kidney
was hydronephrotic. The calices were dilated, the renal pa-
pillae were blunted and the medullary pyramids were
shortened and fibrotic.
Microscopically, the pelvic tumor was a low grade papillary
transitional cell carcinoma without muscle invasion (fig. 4).
Its frond-like papillations consisted of fibrovascular stalks
covered by transitional epithelium, varying from 5 to 15 cell
layers in thickness. The transitional cells displayed minor
variations in size and shape. They had moderate amounts of
cytoplasm and well defined cell borders. Nuclei were round or
oval, differing only slightly in size except for occasional large
hyperchromatic forms. Chromatin was coarse, clumped and
marginated. Multinucleate cells were not identified. Up to 4
mitotic figures per high power field were found in some sites.
Abnormal figures were not seen. There was no evidence of
extension of the tumor into the underlying stroma and no
other urothelial tumors were identified in the specimen.
The renal parenchymal changes were typical of chronic
urinary obstruction and chronic pyelonephritis. The medulla
was compressed and the normal architecture was effaced and
replaced by dense fibrous scar and patchy infiltrates of mono- Fm. 4. Photomicrograph of tumor papilla. Thickened transi-
tional epithelium covers fibrovascular stalk. Cells have generally
nuclear inflammatory cells. The renal cortex was thin and uniform orientation and size. Nuclear pleomorphism is mild. H & E,
distorted by confluent irregular scars, tubular atrophy and reduced from x 135.
 NON-FUNCTIONING KIDNEY
infiltrates of inflammatory cells. Most glomeruli were sclerotic
or collapsed. The walls of most arteries were thickened and
their lumina were narrowed to a moderate degree by intimal
fibrosis and medial hypertrophy.
None of the 16 lymph nodes found in the hilar and periaortic
fat contained tumor.
ANATOMIC DIAGNOSES
Papillary transitional cell carcinoma, grade I to II, left renal
pelvis.
Chronic hydronephrosis.
Chronic pyelonephritis.
COMMENT
Dr. Clarence V. Hodges. Renal non-function always de-
mands investigation and clarification of the cause. The urolog-
ical maxim that the presence of a bladder tumor requires
accurate delineation of the upper urinary tracts to rule out the
presence of a primary urothelial tumor is well illustrated in
this case. The diagnosis of renal pelvic tumor was delayed by
the misdiagnosis of incomplete filling when it should have
231
been non-function. A more common mistake is the acceptance
of inadequate visualization as probably normal. It is fortunate
that, as in most cases with seeding from primary renal or
ureteral tumors, the tumor was low grade and low stage so
that the delay of 6 months had not resulted in an inoperable
tumor.
REFERENCES
1. Walker, D. E., Barry, J. M. and Hodges, C. V.: Angiomyoli-
poma: diagnosis and treatment. J. Urol., 116: 712, 1976.
2. Smart, J. G.: Renal and ureteric tumours in association with
bladder tumours. Brit. J. Urol., 36: 380, 1964.
3. Baker, R. and Maxted, W.: Tumors of the renal pelvis, ureter,
and urinary bladder. In: Urology. Edited by L. Karafin and A.
R. Kendall. Hagerstown, Maryland: Harper & Row, chapt. 7,
pp. 1-81, 1977.
4. Strong, D. W. and Pearse, H. D.: Recurrent urothelial tumors
following surgery for transitional cell carcinoma of the upper
urinary tract. Cancer, 38: 2178, 1976.
5. Strong, D. W., Pearse, H. D., Tank, E. S., Jr. and Hodges, C.
V.: The ureteral stump after nephroureterectomy. J. Urol.,
115: 654, 1976.