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Renal calyceal diverticula are cystic cavities lined with transitional epithelial cells within the renal parenchyma, communicating with the renal pelvis or calyx through narrow channels. The diverticula have no secretory function, but urine can reflux into the diverticula. This disease was first described by Rayer in 1841 and can be multiple, located in any part of the kidney, but the superior renal calyx is more likely to be affected.
First, Etiology
The etiology of renal calyceal diverticula is still unclear, and the incidence is similar in children and adults, suggesting an embryological etiology. In the early stages of embryogenesis, some third and fourth segment branches of the ureters form, and then they degenerate in an orderly manner. If they persist as a separate branch, they may form renal calyceal diverticula.
Second, Pathogenesis
There are congenital or acquired differences according to the mechanism of occurrence. Most of the diseases found in childhood are congenital diseases, and in 1976, Kottasz and Hamvas proposed the congenital vasocentric theory (congenital Vasocentric theory). Some authors argue that it is acquired later. Some patients may develop renal calyceal diverticula after acute upper urinary tract infection, suggesting that the diverticula may be formed by the rupture of small localized cortical abscesses into the collecting system, or due to increased intravesical pressure and urine reflux in childhood. Amar reported that in children with vesicoureteral reflux, the incidence of renal pelvis and calyceal diverticula is significantly increased, among 32 children with renal pelvis and calyceal diverticula, 23 had reflux, suggesting that the formation of diverticula may be the result of renal calyx reflux. Other causes include calculus obstruction, infection at the calyceal site, renal injury, spasticity or dysfunction of the sphincters surrounding the renal calyx.
There are two common types of renal papillary diverticula. Type I diverticula are the most common, often located within the cup of the renal pelvis, connected to the minor renal calyx, mostly located at one pole of the kidney, with the upper pole of the kidney being the most common. They are usually small, ranging from 1mm to several centimeters. Occasionally, they can be large diverticula. This type of diverticulum often has no symptoms during long-term follow-up. Type II diverticula are connected to the pelvis or adjacent large renal calyces, mostly located in the central part of the kidney, with larger shape and often have clinical symptoms.
The incidence of calculi in the diverticulum is 9.5% to 39%, and they can be milk of calcium stones. Mangin et al. found 43 cases with calculi in 80 patients with 90 diverticula. When the diverticulum becomes secondary infected or has calculi, symptoms such as lumbar pain, gross hematuria, pyuria, fever, frequent urination, urgency, and dysuria may occur. The closure of the diverticulum channel can cause acute infection and renal abscess. The abscess at the upper pole of the kidney often leads to symptomatic pleural effusion. Infection can also lead to yellow granulomatous pyelonephritis.
Most simple renal papillary diverticula have no clinical symptoms and are only incidentally found during intravenous pyelography. When the diverticulum becomes secondary infected or has calculi, symptoms such as lumbar pain, gross hematuria, pyuria, fever, frequent urination, urgency, and dysuria may occur. There are few symptoms of urinary tract infection in patients without calculi. The severity of symptoms is not related to the size of the diverticulum. Some small renal papillary diverticula can also cause significant lumbar pain, which may be related to increased pressure at the junction of the renal papilla or poor drainage. Since the renal papillary diverticulum channel is very narrow, calculi rarely pass through the neck of the diverticulum into the renal pelvis. If calculi are excreted, renal colic may occur. When a diverticulum is associated with calculi, the renal parenchyma on the surface often forms scars or atrophy, and scar formation often leads to closure of the diverticulum channel.
At this time, the calculus is located in the lumen of the renal parenchyma, completely separated from the collecting system. The closure of the diverticular channel can cause acute infection and renal abscess. The abscess at the upper pole of the kidney often leads to symptomatic pleural effusion. Infection can also lead to yellow granulomatous pyelonephritis. Ulreich et al. reported a case where a patient's renal papillary diverticulum spontaneously ruptured during intravenous pyelography, and there have been no literature reports of rupture due to trauma. Theoretically, larger diverticula can experience traumatic rupture. Wulfsohu et al. reported a case where a patient's hypertension returned to normal after nephrectomy due to renal papillary diverticulum, and the relationship between hypertension and renal papillary diverticulum is still unclear at present.
Eat light, easy-to-digest food, fresh vegetables and moderate fruits, and drink water appropriately. Pay attention to a balanced diet and nutrition.
Avoid overeating and eating unclean food. Avoid seafood, beef, mutton, spicy and刺激性food, alcohol, and all things that cause heat: five-spice powder, coffee, coriander, etc. Avoid eating all tonics, tonics, and easily overheating food such as chili, wisdom, chocolate, etc.
1. Urinalysis:Patients with concurrent infection may have microscopic hematuria, leukocytes, and in severe cases, gross hematuria. Urine bacterial culture and drug sensitivity test should be performed.
2. Blood routine:When the infection is severe, the total number and classification of white blood cells can increase.
Secretory urography is often used in diagnosis, and its delayed image can usually show the accumulation of contrast agent in the diverticula. In addition, retrograde urography, CT, and MRI can also be helpful sometimes.
1. What foods are good for the body for renal calyceal diverticula:Eat light, easy-to-digest food, fresh vegetables and moderate fruits, and drink water appropriately. Pay attention to a balanced diet and nutrition.
2. What foods should not be eaten for renal calyceal diverticula:Avoid overeating and eating unclean food. Avoid seafood, beef, mutton, spicy and刺激性food, alcohol, and all things that cause heat: five-spice powder, coffee, coriander, etc. Avoid eating all tonics, tonics, and easily overheating food such as chili, wisdom, chocolate, etc.
(The above information is for reference only, please consult a doctor for details.)
This condition rarely requires surgery. Gauthier et al. followed up 3 patients who did not need surgery for 14, 18, and 60 months, respectively, and no significant symptoms occurred. For those with significant symptoms, different methods can be chosen according to different situations.
1. Extracorporeal shock wave lithotripsy (ESWL) is an attempt by some scholars to treat calculi in the renal calyceal diverticula with symptoms using ESWL, and the efficacy obtained varies greatly. The stone clearance rate after the sole use of ESWL ranges from 4% to 58%. Due to the narrow diverticular channel and small urinary flow impact, the excretion of stone fragments is hindered. Streem and Yost selected 19 patients with renal calyceal diverticula with a stone diameter less than 1.5 cm and showed diverticular channels in renal pelvis urography for ESWL. The stone clearance rate was 58% (11 cases), and 12 cases (86%) of patients with lumbago before碎石disposal had symptoms disappear or significantly improve. 9 cases with concurrent infection before碎石disposal, 6 cases (67%) still had recurrent infection after treatment. Jones et al. performed ESWL on 26 patients with diverticular calculi without selection, and the stone clearance rate was only 4% (1/26), 36% (9/26) of symptoms disappeared. Although the stone clearance rate of ESWL for treating diverticular calculi is low, 70% to 80% of patients have symptom relief after treatment, so under certain conditions, ESWL can be an appropriate method for treating diverticula. Due to few complications and being non-invasive, ESWL should be the first choice for treating upper and middle group renal calyceal diverticular calculi, especially for making recurrent pain disappear. If symptoms still exist after ESWL, if the renal calyceal diverticular calculi are still the same as before ESWL after 3 months of observation, surgery should be considered.
2. For patients with recurrent infections, complete removal of stones is quite important in percutaneous cystoscopic nephrolithotomy (PCN). Besides extracorporeal shock wave lithotripsy (ESWL), PCN is a treatment method with minimal damage. Hulbert first applied PCN to treat 10 cases of renal papillary diverticulum stones in 1986 and achieved success. Hulbert believed that the best method is to puncture the diverticulum directly under imaging guidance, expand the renal parenchyma to form a channel, and damage the diverticulum wall and its epithelium, so that the diverticulum will be completely occluded after the renal造瘘管 is removed. Using this method to treat 7 cases, 5 cases of diverticulum occlusion were achieved. If the renal parenchyma on the surface of the diverticulum is thick, it is necessary to dilate the diverticulum channel. A renal造瘘管 is placed for 3 to 4 weeks to keep the diverticulum channel open, preventing stricture or recurrence of stones. When the renal parenchyma on the surface of the diverticulum is thin, it is advisable to excise the top of the diverticulum and electrocoagulate the neck and inner wall of the diverticulum to promote granulation tissue growth and closure of the diverticulum cavity. The stone clearance rate using PCN technology is much higher than that of ESWL, with most scholars reporting a clearance rate greater than 80%. Bellman et al. reported that the stone clearance rate reached as high as 95% (18/19), and more than 80% of patients' infections and other symptoms were cured. Many authors did not mention the serious complications caused by puncture and dilation of the diverticulum. PCN technology is relatively easy or safe for treating posterior renal diverticula, while treating anterior renal diverticula may cause renal parenchymal injury and severe hemorrhage. The upper renal papillary diverticula require puncture through the intercostal route, which is prone to injury to the pleura. Kriegmair et al. reported that in 13 cases, 2 cases experienced massive hemorrhage during surgery and underwent open surgery. Therefore, for the treatment of renal papillary diverticulum stones with PCN technology, it is necessary to have rich experience in percutaneous renal endoscopic technology. The indications for PCN are: ① able to puncture the ipsilateral renal papillary pelvis with a short renal parenchymal route to reach the stone; ② intercostal puncture, which can ensure no pleural injury. If the above conditions are not met, surgical treatment should be performed at the beginning.
3. Laparoscopic surgery In recent years, laparoscopic techniques have been used to treat complex renal sinus diverticula. In these case reports, diverticula are often located in front of the kidney or at the lower pole and protrude above the renal surface. The operation involves resecting the top of the diverticulum and closing the diverticulum opening, and electrocoagulating the diverticulum wall. An important step in the operation is to preoperatively insert a ureteral catheter into the renal pelvis, inject methylene blue through the catheter, and observe the leakage from the collecting system to the diverticulum to close the leakage during surgery. If the channel still exists, leakage may occur after surgery. So far, all reported cases have achieved good results with no complications. In addition to surgery, ESWL and PCN, laparoscopy provides a good way to treat renal sinus diverticula.
4. Most scholars still agree to use open surgery to treat renal diverticula. Especially for patients who need to remove the stones inside the diverticula thoroughly. There are many surgical methods, including diverticulectomy, partial nephrectomy, renal wedge resection, and nephrectomy. For larger renal diverticula at the poles and obvious damage to the renal parenchyma, partial or partial nephrectomy can be performed. If the renal sinus diverticulum cannot be excluded due to tumors or large renal sinus diverticula, causing severe damage to renal function, nephrectomy should be performed. Wuhsohn advocates diverticulectomy, which is relatively simple. After identifying the top of the diverticulum, it is excised, the incision margin is sutured continuously with absorbable suture to stop bleeding, the opening of the diverticulum and the cyst wall are electrocoagulated, and the neck of the diverticulum is closed. For those who are difficult to see the opening position of the diverticulum during surgery, preoperative ureteral catheterization should be performed, and methylene blue injection during surgery can help find the opening of the diverticulum. The cyst cavity is packed with pedicle renal perinephric fat or omentum. If the opening of the renal sinus diverticulum channel is not found during surgery, it is necessary to ensure that the ureteropelvic junction and pelviureteral drainage is unobstructed to prevent urinary leakage or diverticulum recurrence after surgery. This operation is less damaging to the renal parenchyma and is relatively safe and effective. Attention should be paid to anti-reflux surgery for those with vesicoureteral reflux.
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