V08_No_4_Final_New.pdf


Answer to Clinical Pathology Case

323Urology Journal   Vol 8   No 4   Autumn 2011

An Unusual Presentation of an Uncommon Renal
Disease
Farzaneh Sharifiaghdas,* Hossein Kilani, Seyed Amin Mirsadeghi

Urol J. 2011;8:323-4.
www.uj.unrc.ir

Brief History
A 59-year-old man with a history 
of right nephrolithotomy for 
staghorn stone presented with 
right flank pain and recurrent 
pyelonephritis. He was planned for 
right simple nephrectomy because 

of suspicious xanthogranulomatous 
pyelonephritis.

Quiz
1. Do you agree with the approach 
chosen for the diagnosis or do you 
recommend other imaging studies 

Post-chemotherapy computed tomography scan with contrast 2 months after the operation showing multiple hepatic metastases.

Urology and Nephrology Research
Center, Shahid Labbafinejad 

Medical Center, Shahid Beheshti 
University of Medical Sciences, 

Tehran, Iran

Corresponding Author:
Farzaneh Sharifi Aghdas, MD

Department of Urology, Shahid 
Labbafinejad Medical Center, 

9th Boustan St., Pasdaran Ave., 
16666-94516, Tehran, Iran
Tel/Fax: +98 21 2258 8016 

E-mail: fsharifiaghdas@yahoo.com



Answer to Clinical Pathology Case

324 Urology Journal   Vol 8   No 4   Autumn 2011

or procedures?

2. What do you think the final pathology report 
of the specimen might be?

The Recommended Approach
In this patient, the ultrasonography revealed 
pyonephrosis. Therefore, the first step is adequate 
kidney drainage via nephrostomy tube or double-J 
stents insertion. The next step is to determine the 
location and etiology of obstruction. Currently, 
the most appropriate radiologic modality for the 
diagnosis of obstruction is computed tomography 
scan. Ureteroscopy can be complementary to 
radiologic evaluation to evaluate intramural and 
mural pathologies.

In case of urinary tract obstruction, in addition 
to common etiologies, like stone and benign 
strictures, one should also be suspicious of 
external pressure and obstruction due to 
neoplastic lesions. Therefore, evaluation with 
other imaging studies, such as retrograde 
pyelography or nephrostography and urine 
cytology might be indicated. Retrograde 
pyelography or nephrostography not only can 
demonstrate intra-calyceal and intra-pelvic lesions 
perfectly, but also is able to diagnose the presence 
and level of obstruction in poor functioning 
kidneys because nuclear scans, such as diethylene 

triamine pentaacetic acid, are ineffective in this 
situation.

Operative Findings
During operation, severe adhesion of the Gerota 
fascia and renal capsule to surrounding tissues, 
including the psoas, diaphragm muscles, and 
peritoneum, was noted. There was a yellow, 
fibrotic mass over the hilum, which had engulfed 
the whole of the renal pelvis and main vessels 
and had resulted in severe obstruction. This 
mass, which has firmly adhered to the posterior 
abdominal wall, was removed with renal 
specimen.

Final Pathology Report
High-grade urothelial carcinoma of the pelvis 
with invasion into the renal parenchyma and 
perirenal fat was reported. Surgical margins were 
positive for tumor and pyelocalyceal carcinoma 
in situ was also present. Pathologic stage was pT3 
Nx Mx.

Short-term Follow-up
Back to the patient, he was referred to an 
oncologist for adjuvant chemotherapy, but in 
spite of chemotherapy, he developed hepatic 
metastases (Figure).