Skill and talent
Subepithelial pelvic hematoma
Hematoma pélvico subepitelial
J.J. Aguilar-García
, B. Vargas-Serrano
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UGC de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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(A) Phase without contrast: the primary interpolar tumor is not clearly visible. (B) Nephrographic phase: a solid lesion (arrowhead) shows uptake in the interpolar region of the right kidney. (C) Excretory phase: right calyces, pelvis, and proximal ureter without evidence of hydronephrosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O.A. Raheem, R.G. Casey, E. Elmusharaf, D.J. Galvin, T.E.D. McDermott, R. Grainger, T.H. Lynch" "autores" => array:7 [ 0 => array:2 [ "nombre" => "O.A." "apellidos" => "Raheem" ] 1 => array:2 [ "nombre" => "R.G." "apellidos" => "Casey" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Elmusharaf" ] 3 => array:2 [ "nombre" => "D.J." "apellidos" => "Galvin" ] 4 => array:2 [ "nombre" => "T.E.D." "apellidos" => "McDermott" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Grainger" ] 6 => array:2 [ "nombre" => "T.H." 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"apellidos" => "Ersay" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480612002021" "doi" => "10.1016/j.acuro.2012.02.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480612002021?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578613000164?idApp=UINPBA00004N" "url" => "/21735786/0000003600000010/v1_201304251958/S2173578613000164/v1_201304251958/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Skill and talent</span>" "titulo" => "Subepithelial pelvic hematoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "620" "paginaFinal" => "623" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.J. Aguilar-García, B. Vargas-Serrano" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.J." "apellidos" => "Aguilar-García" "email" => array:1 [ 0 => "jjag96@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Vargas-Serrano" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "UGC de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hematoma pélvico subepitelial" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1724 "Ancho" => 801 "Tamanyo" => 174031 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) Baseline CT showing a rounded high-attenuation lesion in the left renal sinus; (b) in the nephrographic phase with contrast, the lesion is not enhanced, showing an attenuation similar to that of the muscle and (c) in the excretory phase, it produces an extrinsic compression on the collecting systems and the renal pelvis, without obstructive effect.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The subepithelial pelvic hematoma is a rare entity that clinically simulates a renal or pelvic malignancy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1948, Antopol and Goldman first described a series of 7 cases characterized by hematuria and filling defect in the renal pelvis by urographic study, secondary to subepithelial hematoma of the renal pelvis, which gave them a tumoral aspect.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This condition is not specific of the kidney; the esophageal intramural hematoma simulating a gastric cancer with esophageal extension has also been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The diagnosis of this entity is based on imaging tests. The knowledge of this rare benign pseudotoumoral lesion can prevent an unnecessary surgery.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, in the published literature, the difficulty of this preoperative diagnosis is pointed out, which in most cases has led to nephrectomy,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> establishing the definitive diagnosis by means of the pathological examination.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Casuistry</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present a 43-year-old female patient who came to the Emergency Department with pain in the left flank radiating to the inguinal region, of 24<span class="elsevierStyleHsp" style=""></span>h of evolution, without fever or urinary symptoms. On examination, she had positive left fist percussion, referring a physical effort as the only significant history. The hemogram, the coagulation study, and the serum biochemistry were normal. Abundant scaly cells were detected in urine and several red blood cells per field.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnostic technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">Among the complementary examinations, ultrasound and computed tomography (CT) were performed urgently without and with intravenous contrast. The ultrasound showed an enlarged left kidney, associated with an oval image in the renal sinus, not vascularized in Doppler mode (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The basal phase CT showed a high-attenuation round lesion in the left renal sinus that did not enhance after contrast, showing in excretory phase an extrinsic compression on the renal pelvis, without obstructive effect (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The findings were considered of probable hemorrhagic etiology.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">To rule out any underlying injury, we performed a magnetic resonance imaging (MRI) 8 days after the previous scans. Weighted axial sequences were performed in T1, T2, thick-cut basal URO-RMI, and after intravenous furosemide, dynamic study in coronal gradient echo T1 with fat suppression, and image subtraction dynamic study in T1-gradient coronal echo section with fat suppression, and images of subtraction of the dynamic study which showed a lesion with well-defined margins, indicative of subacute hematoma that compressed the collecting systems and left renal pelvis, without ectasia (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The image of subtraction of the dynamic study showed complete absence of contrast uptake of the lesion; therefore, it excluded the existence of an underlying vascularized lesion.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">We kept watchful waiting with conservative treatment (rest, analgesia, and antibiotherapy), with the patient being discharged 3 days later. In a subsequent ultrasound scan, at 3 months, the complete resolution of the lesion became evident. The patient remains asymptomatic 3 years after the episode.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The subepithelial pelvic hematoma is a rare lesion that can simulate a neoplastic process, which may lead to an unnecessary nephrectomy. Many of the reported cases, before the emergence of the most recent diagnostic techniques, have been diagnosed after the extraction of the surgical specimen.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There is an increased incidence of bleeding in anticoagulated patients ranging from 4 to 24%,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> with the urinary tract bleeding complications being the most frequent, documented in up to 40% of the patients receiving long-term anticoagulant therapy.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The location of the bleeding can be intrarenal (also called pseudotumor), subcapsular, perinephric, pararenal, intraluminal, and rarely intramural on the wall of the renal pelvis, the ureter, and the urinary bladder.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> The patient whom we present did not have any type of anticoagulant therapy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Traumatic events, congenital malformations, diabetes, hypertension, renal colics, or drug abuse<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> have been described as precipitating factors. From a clinical point of view, the most frequent is gross hematuria and flank pain, providing no significant data to the medical history.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the histological study, changes secondary to a large subepithelial hemorrhage and the subsequent elevation of the overlying epithelium, which results in the pseudotoumoral aspect in radiological examinations,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> are noticeable. The microscopic examination shows an area of submucosal hemorrhage and hematoma in organization, characterized by fibrinoid material containing extravasated fibroblasts and erythrocytes. The transitional epithelium may present focal ulcerations<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> with inflammatory reaction of particular interest to the lamina propria. The hemorrhagic extension can affect the entire pelvis, the major calyces, and even the proximal ureter.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In imaging tests, urography shows a ureteropelvic junction syndrome and a defect concentration of the contrast,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> this image is nonspecific, so the differential diagnosis should be performed with other entities such as renal vein thrombosis, submucosal pyelic edema, vascular impressions, cystic pyeloureteritis, and mainly, with an upper urinary tract tumor. The ultrasound may show mural thickening of the renal pelvis and/or ureter but, however, it cannot distinguish the hemorrhage of the edema or fluid collection.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is therefore necessary to extend the radiological study by CT with and without contrast. The CT without contrast shows a lesion of the pelvic and/or ureteral wall with high-attenuation values because of the blood remnants that will allow to determine its chronological evolution.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,11</span></a> The lesion does not enhance with contrast,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,11,12</span></a> unlike a neoplastic lesion. Repeating an imaging test (CT without contrast) several weeks after the acute process is indicated to confirm the resolution of the subepithelial hemorrhage.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The MRI has a high negative predictive value to exclude urothelial neoplasms, especially in the upper urinary tract.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It can provide data for the lesion characterization as hematoma, assess the urinary tract by URO-MRI sequences in T2 or T1 sequences in the elimination phase of the contrast using MIP postprocessing. The possibility of performing subtraction sequences in the dynamic study enables us to rule out the existence of underlying hypervascularized lesions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In its evolution, the subepithelial hemorrhage may compress the renal pelvis or have a break to the collecting system that is accompanied by blood clots.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, the evolution is usually rapid, favorable, with spontaneous resolution in a few weeks, and the hematuria and the anomalies described in imaging disappear.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a> In short, only the knowledge and a high index of suspicion of an Antopol–Goldman lesion can avoid an unnecessary nephrectomy, especially in patients with a non-uptake of renal mass and that originates an extrinsic compression of the collecting system.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres102021" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec89186" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres102020" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec89187" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Casuistry" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnostic technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Comment" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-26" "fechaAceptado" => "2012-07-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec89186" "palabras" => array:4 [ 0 => "Antopol–Goldman lesion" 1 => "Subepithelial pelvic hematoma" 2 => "Kindey" 3 => "Pseudotumor" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec89187" "palabras" => array:4 [ 0 => "Lesión de Antopol–Goldman" 1 => "Hematoma pélvico subepitelial" 2 => "Riñón" 3 => "Pseudotumor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Subepithelial pelvic hematoma (Antopol–Goldman lesion) is a rare condition that clinically simulates a renal or pelvic neoplasm, whose final diagnosis is established in most of the cases by the pathologist after the nephrectomy. To avoid this, imaging tests and high diagnostic suspicion are essential.</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The case of a 43-year-old female patient is presented. She had no background of interest and she came due to experiencing an acute pain in the left renal fossa after a physical effort. This patient was studied by Ultrasonography, Computed Tomography (CT), and evolutively with magnetic resonance (MR).</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The X-ray studies showed a lesion in the left renal sinus with characteristics suggestive of subepithelial renal pelvis hematoma, without data suggesting underlying lesion. The treatment of the patient was conservative, confirming the disappearance of the lesion in the follow-up studies.</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Knowledge of the X-ray findings of the Antopol–Goldman lesion in different imaging tests and an elevated index of suspicion are crucial in the management of patients affected by this uncommon condition. These make it possible to avoid an unnecessary nephrectomy.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El hematoma pélvico subepitelial (lesión de Antopol Goldman) es una rara entidad que clínicamente simula una neoplasia renal o pélvica, cuyo diagnóstico definitivo se establece en la mayoría de las ocasiones por el anatomopatólogo tras la nefrectomía. Para evitar ésta, son esenciales las pruebas de imagen y una alta sospecha diagnóstica.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se presenta una paciente de 43 años sin antecedentes de interés que acudió con un cuadro de dolor agudo en la fosa renal izquierda tras un esfuerzo físico y que fue estudiada mediante Ecografía, Tomografía Computarizada (TC) y evolutivamente con Resonancia Magnética (RM).</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las exploraciones radiológicas mostraron una lesión en el seno renal izquierdo con características sugestivas de hematoma subepitelial de la pelvis renal, sin datos que sugiriesen una lesión subyacente. El tratamiento de la paciente fue conservador, confirmándose en exploraciones de seguimiento la desaparición de la lesión.</p> <span class="elsevierStyleSectionTitle">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El conocimiento de los hallazgos radiológicos de la lesión de Antopol Goldman en las distintas pruebas de imagen, y un índice de sospecha elevado, son cruciales en el manejo de los pacientes afectos por esta infrecuente entidad, pudiendo evitar una nefrectomía innecesaria.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Aguilar-García JJ, Vargas-Serrano B. Hematoma pelvic subepitelial. Actas Urol Esp. 2012;36:620–3.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 691 "Ancho" => 800 "Tamanyo" => 111409 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of the left kidney showing an oval image in the renal sinus, hypoecogenic, with internal echoes, subsequent reinforcing, and not vascularized in Doppler mode.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1724 "Ancho" => 801 "Tamanyo" => 174031 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) Baseline CT showing a rounded high-attenuation lesion in the left renal sinus; (b) in the nephrographic phase with contrast, the lesion is not enhanced, showing an attenuation similar to that of the muscle and (c) in the excretory phase, it produces an extrinsic compression on the collecting systems and the renal pelvis, without obstructive effect.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 616 "Ancho" => 999 "Tamanyo" => 94135 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(a) MRI, T1 axial sequence, showing a lesion with well-defined margins, and hyperintense periphery, indicative of subacute hematoma and (b) axial T2 sequence with discretely hypointense lesion displacing the renal hilar vessels and subcentimeter renal cysts.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subepithelial pelvic hematoma (Antopol–Goldman lesion) simulating renal neoplasm: report of a case and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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