Case Reports

Giant Hydronephrosis Mimicking An Ovarian Cyst

BM Subnis*, Girish D Bakhshi**, Waqar Ahmed Ansari*** , Benazir N Palekar+, Siddharth Sarangi+, Tushar Bhagwat+, Sachin Giri+

Abstract
Gross Hydronephrosis in a rare presentation usually containing 1-2 litres of fluid. Here we present a case of a 17 yrs old unmarried female, who presented to us with gradual distension of abdomen since the last 7-8 yrs, without any other symptom. Ultrasonography of the abdomen showed a large right side ovarian cyst measuring 20 x 25 cm2. Hormonal studies were normal. On exploratory laparotomy, gross hydronephrosis of right kidney containing approximately 7 litres of fluid was found. Nephrectomy was done as treatment for gross hydronephrosis.

Introduction
Unilateral gross hydronephrosis usually
presents with painless mass in the abdomen and rarely with complications associated with them i.e. compression of surrounding structures, including the contralateral ureter, intestine, veins, infection, renal insufficiency and rupture of the kidney. Cases of giant hydronephrosis are rare usually contain 2 litres of fluid.1,2 Often, these masses are detected incidentally during ultrasound examination of abdomen for some other reason. Gross hydronephrosis presenting as a large mass occupying the whole abdomen and pelvis, with generalized distension of abdomen, mimicking as large ovarian cyst is very rare. Here, we present a 17 yrs old unmarried female who presented with gross distension of abdomen, over last 7-8 yrs without any other symptom. Sonology of the abdomen showed a large right sided ovarian cyst measuring 20 x 25 cm.2 Exploratory laparotomy was done and gross hydronephrosis of right kidney occupying whole of the abdomen, containing about 7 litres of fluid was found. Bilateral ovaries were normal. Right nephrectomy was done for the treatment of the same.

Case Report

A 17 year old female presented with chief complaints of gradual distension of abdomen since last 7-8 years without any other complaint. There was no c/o weight loss, loss of appetite, any urinary or bowel complaint. There was no history of any menstrual complaints. On examination, vitals were normal. Per abdominal examination revealed gross distension of abdomen due to cystic swelling, occupying the whole of the abdomen and pelvis (Fig. 1). Getting below or above the mass was not possible. There was also evidence of fluid thrill within the mass i.e. it was possible to detect it in the left flank by tapping it in right flank. Ultrasound of the abdomen was done to find out the cause of this cystic swelling. It showed a large right ovarian cyst measuring around 20 cm x 25 cm. Ovarian tumour markers were normal.

Looking at the U.S.G. report, plan for exploratory laparotomy and right oophorectomy was made. Exploratory laparotomy by midline incision was done. On exploration, cyst had occupied the whole of the abdomen, and on further dissection, it was confirmed as grossly hydronephrotic kidney (Fig. 2). Right Nephrectomy was done. Both ovaries and the left kidney were normal (Fig. 3). Post operative course was uneventful and patient was discharged on 10th post operative day after suture removal.

Fig. 1 : Photograph of abdomen showing generalised distension.	Fig. 2 : Intraoperative photograph showing gross hydronephrosis.	Fig. 3 : Photograph showing normal bilateral ovaries.

Discussion

Gross hydronephrosis, also termed as Giant hydronephrosis, is rare. Gross hydronephrosis mimicking ovarian cyst clinically as well as on ultrasound is a rare presentation. Ectopic hydronephrotic kidney presenting as an ovarian cyst is well known.3 The diagnostic criteria for giant hydronephrosis include the presence of more than 1 litre of fluid, radiologically a mass occupying half of the abdomen or crossing the midline and with a height extending 5 vertebral bodies.4 Patients always present with abdominal enlargement and most of them are asymptomatic. Common differential diagnosis includes ovarian cyst, mesenteric cyst, pseudocyst of pancreas, loculated peritoneal collection associated with tuberculosis, and pseudomyxoma. Complications associated with giant hydronephrosis are compression of surrounding structures, including the contralated ureter, intestine, veins or rupture of the kidney and infection. As far as treatment of giant hydronephrosis is concerned, nephrectomy is the treatment of choice.5

References

1. Chiang PH, Chen MT, Chou YH, Chiang CP, Huang CH, Chien CH. Giant hydronephrosis; report of 4 cases with review of literature. J Formos Med Assoc 1990; 89 : 811-17.
2. Stirling WC. Massive hydronephrosis complicated by hydroureter. Report of 3 cases. J Urol 1939; 42 : 520-33.
3. Eur J Obstet Gynecol Reprod Biol 2001; 1997 (2) : 239-40.
4. Reyna PR, Castaneda SJ, Himarano. Giant hydronephrosis – a case report. Rev Mex Urol 1997; 57 : 24-6.
5. Hemal AK, Wadhwa SN, Kumar M, Gupta NP. Transperitoneal and retroperitoneal laparoscopic nephrectomy for giant hydronephrosis. J Urol 1999; 162 : 35-9.