Loin Pain and Haematuria Syndrome (LPHS) Complicating Symptomatic Nephroptosis (SN), Cured with Renal Sympathetic Denervation and Nephropexy (RSD&N) Surgery: Case Report

Abstract

Introduction and Objective: To report a case demonstrating the link of LPHS with SN is that is based on IVU7 sign and retrograde pyelography. Renal Sympathetic denervation and Nephropexy (RSD & N) Surgery has proved curable for the condition. Patient and Methods: The reported case in which IVU with erect film shows the IVU7 sign is measure of renal pedicle stretch. Retrograde Pyelography (RGP) showed the internal renal damage while all ancillary imaging were normal. The surgery of RSD & N was used for treatment of the condition. Results: An IVU with erect film and RGP detected the diagnosis and the renal pathology while no other imaging could. Comparing IVU supine and erect revealed the IVU7 sign which is a measure of renal pedicle stretch causing artery stenosis and ischaemia. The findings on RGP show erosion of renal papillae and leakage of contrast medium into renal veins which is the sie of hamaturia. The surgery of RSD & N cured the condition. Conclusion: An IVU with erect film and RGP clinched the diagnosis and revealed the renal pathology while no other imaging could. It should be essential diagnostic investigation in every LPHS case. The surgery of RSD & N cured the condition. Ahmed N Ghanem1*, Khalid A Ghanem2, Nisha Pindoria3 and Salma A Ghanem4 1Consultant Urologist Surgeon, Egypt 2Mansoura University Hospital, Egypt 3North Middlesex University Hospital, London 4Barts & the Royal London NHS Trust, London Ahmed N Ghanem, et al., Annals of Clinical Case Reports Urology Remedy Publications LLC., | http://anncaserep.com/ 2018 | Volume 3 | Article 1552 2 Figure 1: This shows a supine compared to IVY erect film demonstrating right nephroptosis. Figure 2: It shows renal pedicle mapped on a supine IVU film (Horizontal) and erect film (Vertical) limbs of 7 where the renal pedicle is stretched to 3 times its normal length, causing stenosis and ischemia. Figure 3: It shows retrograde pyelography showing erosion of renal papillae and contrast extravasations into renal veins of right kidney where haematuria occurs in an opposite direction. is caused by pedicle stretch causing renal ischaemia as shown on IVU7 sign (Figure 2). The internal renal damage causing pain and haematuria is best shown on RGP (Figure 3). Unfortunately no other investigation including CT and MRI is capable of revealing the pathology of LPHS complicating SN. Upright IVU is currently undone and has not been reported previously in LPHS. Retrograde pyelography findings have not previously been documented in either condition (Figure 3). The use of IVU started early in the 20th century while clinical evidence on the genuineness of SN pain dated back to the 15th century. Loin pain hematuria syndrome was reported in 1967 while Dietl’s crisis is known for centuries [5]. Organic reno-vascular complications demonstrated on conventional arteriography of SN and LPHS are of advanced cases. In view of the new evidence presented here and previously [1,2], the authorities should reconsider SN with link to LPHS and bring it back to current textbooks. References 1. Ghanem AN. Features and complications of nephroptosis causing the loin pain and hematuria syndrome. A preliminary report. Saudi Med J. 2002;23(2):197-205. 2. Ghanem S, Ghanem AN. Prospective Observational Study on Loin Pain Hematuria Syndrome Complicating Symptomatic Nephroptosis and the Results of Renal Sympathetic denervation and Nephropexy Surgery. J J Nephro Urol. 2016;3(1):024. 3. Burford CE. Nephroptosis with coexisting renal lesions. J Urol. 1946;55:220-224. 4. Hoenig DM, Hemal AK, Shalhav AL, Clayman RV. Nephroptosis: A “disparaged” condition revisited. Urology. 1999;54(4):590-6. 5. Little PJ, Sloper JS, de Wardner HE. A syndrome of loin pain haematuria associated with disease of the peripheral renal arteries. Q J Med. 1967;36(142):253-9.