Discussion

Nephroptotic scrotal kidney

The term “nephroptosis” was first used in 1885 (4); it was purely a diagnosis of exclusion after ruling out other causes of abdominal pain (2). In this regard, the accuracy of diagnosing nephroptosis in the pre-imaging era is questionable, given the fact that the first ever attempt to visualize the upper urinary tract using contrast material took place in 1905 and it was not until the 1930s that IVU became available for public use (5). Furthermore, the condition itself signifies a degree of kidney hypermobility, but whether this represents the extreme of a normal anatomical variant is yet to be explored. Before the adoption of nephropexy, nephrectomy had long been considered the standard treatment for nephroptosis but was discontinued due to its excessive mortality rate (1,2). After being popularized by Hahn in 1881, it is interesting to note that nephropexy fell out of fashion in the late twentieth century mainly due to the persistence of symptoms postoperatively (2). However, there seems to have been a surge in articles mentioning nephropexy in the literature over the past two decades, due to the increased uptake of radionucleotide scans and the evolution of minimally invasive surgery (1,2). In this patient, the kidney appears to have slowly migrated caudally over the years, remaining symptomless until it finally became lodged within the scrotal sac, causing symptoms. This has resulted in significant elongation and stretching of its supplying vessels, although this elongation does not seem to have resulted in any ischemic insult as one might expect. Moreover, it is reasonable here to assume that gravitational force exerts constant downward pull on the kidney, suspended by means of its hilar vessels, and this in turn causes the vessels to stretch even further. This effect might be potentiated by intrinsic soft tissue laxity in the perinephric and retroperitoneal region.

Learning points

• The report captures an interesting and unique pictorial case.
• The risks versus benefits of any intervention must be discussed with the patient against their background performance status.
• Complex cases require a multidisciplinary approach.

References

View the original case report for a complete list of references.

Our appreciation is extended to Elmuiz A. Hsabo and Seshikanth Middela, Department of Radiology, and Jonathan Tuck, Department of Radiology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, U.K., and Ikenna Anderson Aneke, Wythenshawe Hospital and The Christie, Manchester University NHS Foundation Trust, Manchester, U.K., for contributing this case. Case was originally published in BJR|case reports.