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Journal of the Anatomical Society of India

Laterally Rotated Kidney - A Rare Congenital Anomaly

Author(s): Ingole I.V., Ghosh S.K

Vol. 54, No. 1 (2005-01 - 2005-03)

Mahatma Gandhi Institute of Medical Sciences, Sevagram, M.S.

Abstract:

Anomalies of the urinary system form a significant portion of the congenital malformations as a whole. Anomalies of kidney have been frequently reported. Anomalies of structure and position of kidney along with variations of renal vessels are the most frequently reported. Rotational anomalies form a rare entity that is not cited in most of the embryology textbooks.

A case of unilateral laterally rotated kidney is being reported here. The anomaly was detected in a 55yrs old female patient investigated for urinary symptoms. IVP was done which showed the left kidney to be normally placed with its hilum facing medially. Right kidney was smaller than normal. It was placed at a lower lumbar level with its hilum facing laterally.

Although a number of theories have been put forward to explain the anomalies of rotation, they seem to be purely speculative. Rotational anomaly though comparatively rare assumes great importance in view of the present day surgical

procedures like percutaneous nephrectomy etc.

Key Words: Kidney, aberrant renal nessels.

Introduction:

Congenital anomalies of urinary system are relatively common contributing 3% of live births (Williams et al, 1995). Anomalies of kidney form a significant percentage of them. Anomalies of structure and position are the most frequently encountered (Das

S. & Amar A, 1984). Morphological variations ofkidneys and their vessels are generally well known. Renal agenesis (Limkakeng & Retik1972), pelvic kidney (Palmer B.1933, Ogden H.1940), horseshoe kidney (Anson B., Pick J., & Cauldwell E. 1942, Kolln

C. P. et al 1972) and aberrant renal arteries (Jeidell H. 1911,Nathan H.1963, Olsson D. &Wholey M.1964, Jeffery R. 1972). Embryological basis for these variations has also been well established (Gray & Skandalakis1972). Rotational anomalies of kidney are a rare entity (Das S. &Amar A.1984, Nathan H. Glezer I.1984) and have been cited in very few of the embryology textbooks. Very few cases of rotational anomalies of kidney seem to have been reported and are available in the existing literature. Anomaly in the present case showing hilum facing laterally has been reported very infrequently as shown by the existing literature (Nathan H. Glezer I.1984).Though rare this type of anomaly has wide implications in the context of advanced surgical procedures and diagnostic evaluation of kidney donors.

Case report

Fifty-five years old female was investigated for urinary symptoms. Preliminary investigations revealed microscopic haematuria. Subsequently radiological investigations (X-ray KUB& IVP) were done.

Observations:

IVP showed excretion of dye by both the kidneys. Both the kidney shadows were clearly seen. Ureter, pelvis of the ureter and major and minor calyces on both the sides could be clearly visualized.

Left kidney was slightly bigger in size than normal; its shadow measuring 13.5cms x 6.5cms. It's upper pole was at the level of 11 th thoracic vertebra and lower pole at the level of upper border of 3 rd lumbar vertebra. Hilum of the left kidney was at the level of lower border of 1st lumbar vertebra and it was facing medially (Fig. 1& 2). Left ureter was normal except a slight kinking in the upper part (Fig.1) .The kinking seemed to be due to peristalsis as it was not seen in the later exposures. Pelvis of the ureter, major and minor calyces were normal (Fig.1&2).

Right kidney was smaller than the normal size, it's shadow measuring 11.5cms x 4cms. It was placed at a lower level than the left kidney. Its upper pole was at the level of 2nd lumbar vertebra and lower pole at the level of 5 th lumbar vertebra. Its hilum was facing completely laterally and was at the level between 3rd and 4 th lumbar vertebra. Pelvis of the ureter was extra renal. Upper major calyx was significantly elongated and extra renal. Ureter descended lateral to the lower pole of the kidney (Fig.1 & 2).

Discussion & Conclusion:

The present case shows right kidney slightly smaller in size than normal, lying at a lower lumbar level and seems to have undergone reverse rotation so that it's hilum is facing completely laterally. There has also been an incomplete ascent associated with rotational anomaly.

Missing Image

Fig.1: Laterally rotated kidney

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Fig.2: Laterally rotated kidney

Anomalies of renal rotation are associated with renal ectopia and the fusional abnormalities but may be exhibited by the kidneys, which are otherwise normally placed.

Normally the developing metanephros rotates from dorsomedial to more lateral position relative to the collecting system. Four types of rotational anomalies have been identified (Braash W.1931, Weyrauch 1939). In non-rotation the renal pelvis presents itself ventrally in relation to the kidney mass. In incomplete rotation it presents itself ventromedially. In the more rare reverse and excessive rotation the renal pelvis presents itself in a position depending upon the number of degrees through which rotation has occurred (Hollinshead W. 1971). This process occurs during the ascent of kidney, which occurs between 38 to 49 days of development. Renal rotation takes place before definitive vascularization (Pollack H., & McClennan B.2000). Rotational anomalies are often caused by or related to aberrant renal vessels. (Braash W.1931, Olsson D. &Wholey M.1964, Nathan H& Glezer 1984). Whether truly rotation occurs in the sense of involving twisting of kidney around it's longitudinal axis or is a case of differential growth of the lateral lip of the hilum (Priman J.1929) is not known.

Though the association of malrotation of kidney and anomalies of renal vessels has frequently been quoted, Das & Amar (1984) in the management of their 27 patients of ureteropelvic junction obstruction with associated renal anomalies observed only one case of malrotation. In the present case as the anomaly was detected on IVP, the status of renal vessels of the right unascended and malrotated kidney could not be commented upon.

Although a number of theories have been proposed to explain the anomalies of rotation, at the moment they are purely speculative. The embryological basis of rotational anomalies is still unknown (Pollack H. & McClennan B. 2000). Rotational anomaly though rare, has important implications from surgical point of view, as it may be mistaken for some more serious condition on IVP. It may erroneously be attributed to displacement by para vertebral mass. Pelvis and calyces may look peculiar though normal. Commonly lower pole causes deviation of the course of the crossing ureter. Usually such deviation is anterior and lateral sometimes creating an impression that lower pole mass is present. It assumes a great importance in the context of present day surgical procedures like percutaneous nephrectomy and preoperative diagnostic evaluation of the kidney donors etc.

References:

  1. Anson B. J., Pick J. W. & Cauldwell E. (1942): The anatomy of the commoner renal anomalies; Ectopic and horseshoe kidneys. Journal of Urology .47: 112.
  2. Braash W. F. (1931): Anomalous renal rotation and associated anomalies. Journal of Urology. 25: 9.
  3. Das S. & Amar A. (1984): Ureteropelvic junction obstruction with associated renal anomalies. Journal of Urology , 131: 872-878.
  4. Gray S. W. & Skandalakis J. E.: Embryology for Surgeons, in: The kidney and ureter. W.B. Saunders Co. Philadelphia, pp. 443-518 (1972).
  5. Hollinshead W. H.: Anatomy for Surgeons, in: The kidneys, ureter and suprarenal glands. 2nd Ed.: Harper & Row publishers, New York, Vol. 2, Chapt 10, (518-573) (1971).
  6. Jeffery R F. (1972): Unusual origins of renal arteries. Radiology . 102: 309.
  7. Jeidell H (1911): A note of the source and character of the early blood vessels of the kidney. Anatomical Record . 5: 47.
  8. Kolln C. P, Boatman D. L., Schmidt J. D. & Flocks R. H. (1972): Horseshoe kidney: A review of 105 patients. Journal of Urology . 107:203.
  9. Limkakeng A. D. & Retik A.B. (1972): Unilateral renal agenesis with hypoplastic ureter. Journal of Urology .108: 149-152.
  10. Nathan H. (1963). Aberrant renal artery producing developmental anomaly of kidney associated with unusual course of gonadal (ovarian) vessels. Journal of Urology . 89: 570.
  11. Nathan Hilel & Ilya Glezer. (1984). Right and left accessory renal arteries arising from a common trunk associated with unrotated kidneys. Journal of Urology . 132: 7-9.
  12. Ogden H. D. & Maltry E. (1940): Pelvic single kidney: Report of an additional case. Journal of Urology . 44:13.
  13. Olsson D. & Wholey M. (1964): Vascular abnormalities in gross anomalies of kidney. Acta Radiologica . 2 :420.
  14. Palmer B. M. (1933): Congenital pelvic kidney. American Journal of Surgery. 22: 220.
  15. Pollack H.M.& Mc Clennan B. L.: Clinical Urography, in: Congenital anomalies of the urinary tract. 2 nd ed, W. B. Saunders Co. Philadelphia, Vol. 1,Chapt 17. Pp.661-911 (2000).
  16. Priman J. (1929): A consideration of normal and abnormal positions of the hilum of the kidney. Anatomical Record . 42:355.
  17. Weyrauch H. M. Jr. (1939): Anomalies of renal rotation: Surgery, Gynecology & Obstetrics . 69:183.
  18. Williams P.L.; Bannister L.H.; Berry M.M.; Collins P.; Dyson M.; Dussek J. E.; Ferguson M. W. J. Gray's Anatomy, in: Embryology and development, Urinary system, 38th edn. Churchill Livingstone, London. Pp.199-204 (1995).

Laterally Rotated Kidney - A Rare Congenital Anomaly : Ingole I.V., Ghosh S.K

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