Page kidney in an adolescent with recent onset of hypertension and slightly decreased renal function: answer

Due to the presence of pelvicaliectasis on the right kidney and decreased right renal function with impaired drainage, the most likely diagnosis was ureteropelvic junction (UPJ) obstruction. This could be due to intrinsic narrowing at the UPJ or to extrinsic compression, for example, from a crossing vessel. The absence of hematuria and typical back pain made a diagnosis of kidney stone unlikely.

It was then decided to perform surgery to repair the UPJ obstruction. For several days before a planned procedure, the patient complained of severe right-sided costovertebral pain. He underwent exploratory laparoscopy to repair the UPJ obstruction. At laparoscopic exploration, when the retroperitoneum was entered, densely fibrotic scar tissue and hematoma were revealed. It was decided to convert to an open procedure because the hilum of the kidney could not be seen. Once Gerota’s fascia was entered, the kidney was noted to be black. The renal vein was identified and found to be collapsed. Upon dissection of the artery, an inadvertent capsulotomy was made, and while the hematoma extruded from the wound, the kidney returned to its normal pink color. The subcapsular hematoma encompassed the whole kidney, and its retroperitoneal component was from under the liver to the iliac vessels on the same side. Further exploration revealed a forniceal rupture, which was subsequently repaired. This patient appears to have had a Dietl crisis, with a large rupture of the lower-pole-collecting system on the right side. In addition, a lower-pole-crossing vessel causing a high-grade UPJ obstruction was also repaired. The pyeloplasty was performed uneventfully. The histologic analysis of the right kidney’s biopsy tissue, submitted intraoperatively for frozen evaluation, revealed focal mild−acute and chronic interstitial nephritis and fibrosis consistent with obstructive nephropathy. The patient was discharged on postoperative day 2. The combination of hypertension and finding of subcapsular hematoma of the right kidney confirmed the diagnosis of Page kidney.