|Year : 2014 | Volume
| Issue : 2 | Page : 133-135
Symptomatic calyceal diverticulum: A case report
R. B. Nerli1, Nikhil A. Patil1, S. M. Abhijith1, M. B. Hiremath2
1 Department of Urology, KLES Kidney Foundation, KLE University's Jawaharlal Nehru Medical College, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka, India
2 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Web Publication||20-May-2014|
R. B. Nerli
Department of Urology, KLES Kidney Foundation, KLE University's Jawaharlal Nehru Medical College, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Calyceal diverticula are rare and unusual lesions in children. We report a case of symptomatic lesion in a 13-year-old male child presenting with pain and recurrent episodes of infection.
Keywords: Calyceal diverticulum, hematuria, infection, symptomatic lesion
|How to cite this article:|
Nerli RB, Patil NA, Abhijith SM, Hiremath MB. Symptomatic calyceal diverticulum: A case report. J Sci Soc 2014;41:133-5
| Introduction|| |
A calyceal diverticulum is a cystic cavity within the kidney that is lined by transitional epithelium and communicates with a calyx or less commonly with the renal pelvis through a narrow isthmus. , Calyceal diverticulum was first described by Rayer in 1841.  The upper calyx is the one that is most affected (70%). , They arise frequently from the posterior aspect of the kidney and are usually unilateral.  Most cysts are small <1 cm; however, larger ones are occasionally detected. 
Calyceal diverticula are usually asymptomatic; however, they can become problematic at times.  These diverticula are known to be associated with flank pain, hematuria, recurrent urinary tract infections (UTIs), and calculus formation. We report a case of symptomatic calyceal diverticula in a child.
| Case report|| |
A 13-year-old male child presented with history of right flank pain and recurrent episodes of fever with chills. Physical examination revealed no significant findings. Urine examination revealed pyuria and bacteriuria. Ultrasonography examination revealed a right-sided upper polar cystic lesion, 2.5 cm in size. Intravenous urogram revealed the cystic lesion communicating with the collecting system. Computed tomography confirmed the cystic lesion [Figure 1]. Voiding cystourethrogram revealed no reflux. Under antibiotic cover, retrograde urethrogram was done, which showed contrast filling the cystic lesion [Figure 2], but the exact position of the diverticular opening was not identified. Flexible ureteroscopy was done using an 8 Fr flexible ureteroscope. The upper calyx was well visualized, but the mouth of diverticulum could not be identified. In view of recurrent episodes of UTI, the child was surgically explored and the diverticulum was excised along with a portion of surrounding renal parenchyma. Postoperatively, the child had an uneventful recovery.
|Figure 1: Computed tomogram showing right upper pole calyceal diverticulum|
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|Figure 2: Retrograde pyelogram showing gradually filling calyceal diverticulum|
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| Discussion|| |
Calyceal diverticulum is an unusual, rare lesion of uncertain etiology, in which an urine-filled cavity lined with nonsecreting transitional epithelium, is connected to the renal calyx or the pelvis by a narrow or stenotic isthmus.  The incidence is about 0.21%-0.45% based on accidental findings on intravenous urogram ,,, and characteristically appears as a contrast-filled cystic cavity. Opacification and washout of contrast from the diverticulum may be delayed because of a slow exchange of urine between the collecting system and the diverticulum.  Sometimes the diverticulum may fail to opacify due to occlusion of the neck from infection. Urographically, two varieties of diverticulum are described. Type I is situated at the upper pole and communicates with the calyceal cup, usually at the fornix. These lesions have a bulbous shape with a narrow connecting infundibulum. Type II diverticula communicate with the renal pelvis and may become large enough to produce mass effect. The neck is short and not easily identified. 
Most calyceal diverticula are asymptomatic. Recurrent UTIs will be identified in 25% of the patients and poor drainage can result in sepsis, abscess formation, and eventual parenchymal damage.  Calculi can occur in 9.5%-50% of these diverticula.  These calculi are retained due to the small caliber of the diverticular necks. Asymptomatic diverticula can be managed expectantly. Indications for intervention include pain, recurrent UTIs, stones, compression, and damage of surrounding parenchyma.
Treatment includes invasive, open surgical techniques such as unroofing and marsupialization procedures, diverticulectomy or partial nephrectomy. The operative goals are obliteration of the diverticulum and communicating channel and, if present, complete clearance of calculi. Other surgical procedures include percutaneous ablation, laparoscopic marsupialization/ablation, and ureteroscopic infundibuloplasty with possible lithotripsy. 
Estrada et al.,  reviewed their series of calyceal diverticula in 22 children with a mean age of 5.4 ± 3.1 years. A total of 10 children presented with febrile UTI, 2 had hematuria, 2 had abdominal pain, 1 had flank pain, and 8 were asymptomatic. The mean diameter was 2.2 ± 1.7 cm. Two children (9%) had concomitant ipsilateral calyceal diverticula and vesico ureteric reflux. A total of 10 children were treated at a mean age of 3.0 ± 2.3 years. Treatment modalities included percutaneous ablation, open marsupialization/ablation, partial nephrectomy, and laparoscopic marsupialization/ablation. There were no recurrences during the follow-up period. The authors concluded that calyceal diverticula are rare in children. Most are stable and asymptomatic. Approximately, 20% have symptomatic enlargement warranting surgical intervention. Overall, approximately 43% require surgical intervention.
| Conclusion|| |
Calyceal diverticula are rare and unusual lesions in children. If symptomatic, these lesions are a source of morbidity requiring surgical intervention.
| Acknowledgment|| |
KLES Kidney Foundation, Belgaum.
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[Figure 1], [Figure 2]