Image of the Day 7 : Renal Mass

When we are doing round in one calm morning, we reach to one male patient who presented with first episode of hematuria and urinary tract infection. A verse that i will never forget from my specialist is, “ While urinary tract infection is commonly associated with hematuria, it usually needs further evaluation in man."  In today’s Image of the Day i will briefly illustrate the importance of further evaluation for a patient who presented with hematuria.

This 25 years old man who works as an army presented with first episode hematuria for three days duration associated with urinary tract infection sign and symptoms such as low grade fever, burning sensation on micturation, left flank discomfort and urgency. There was no history of passing out sandy stone on micturation, obstructive symptoms, terminal dribbling, nocturia or constitutive symptoms.

On examination, patient is a thin built man, not cachexic and appears healthy. VItal signs are stable. Per abdomen, it was soft and non distended, tenderness over suprapubic area but no guarding, no mass palpable, hernia orifices intact, renal punch positive, present of bowel sound and multiple small firm left inguinal lymph node. Examination of testis reveals no varicocele or hernia and per rectal demonstrate no palpable mass.

Blood parameters are normal and Urine FEME seggestive of urinary tract infection and patient was started on IV unasyn.

However bedside USG reveals ? left kidney hydronephrosis with an acoustic shadows which was initially thought to be stone and formal KUB USG was taken

KUB USG shows a mass which is measuring about 11X5 cm at the inferior pole of the kidney with mixed echogenicity and poorly differentiated cortical-medullary junction.  Otherwise, right kidney and urinary bladder were normal.

A CT scan was then done which shows lobulated heterogenously enhancing left renal mass measuring 10.7 X 7.8 CM with no evidence of thrombus in IVC or renal vein and no sign of metastasize.

To appreciate the mass further, the patient may need MRI or CT angiography study. In well establish center, nuclear imaging studies will help to differentiate between true kidney mass and pseudo mass. Above investigation will also help to determine further step of treatment. IVU may or may not be needed as CT scan and MRI are more superior than it. The next step for this patient would be left nephrectomy and the further management would be depends on further histopathlogy examination.