|Year : 2015 | Volume
| Issue : 3 | Page : 56-58
Right psoas muscle hydatid cyst causing giant hydronephrosis
Sunder Goyal1, Snigdha Goyal2, Isha Saini3
1 Department of Surgery, Kalpana Chawla Government Medical College, Karnal, Haryana, India
2 Department of Pathology, Dr. Ram Manohar Lohia Postgraduate Institute of Medical Sciences, New Delhi, India
3 Honorary Research Fellow, Kalpana Chawla Government Medical College, Karnal, Haryana, India
|Date of Web Publication||8-Oct-2015|
Dr. Sunder Goyal
Department of Surgery, Kalpana Chawla Goverment Medical College, Karnal, Haryana - 132 001
Source of Support: None, Conflict of Interest: None
Hydatid disease is a common disease in sheep and cattle raising countries and affects most of the body organs. But hydatid cyst of psoas muscle with pressure on ureter, and thus causing hydronephrosis is uncommon and only few cases have been reported so far in literature. Here, we present a rare case with right giant hydronephrosis as a result of ureter compression by psoas hydatid cyst.
Keywords: Giant hydronephrosis, hydatid cyst, psoas muscle
|How to cite this article:|
Goyal S, Goyal S, Saini I. Right psoas muscle hydatid cyst causing giant hydronephrosis. Sifa Med J 2015;2:56-8
| Introduction|| |
Hydatid disease is endemic in Middle East as well as in India.  Primary cyst may localize anywhere in body, but commonly they are found in the liver (55-70%) and lung (20-30%). Location in muscular tissue is about 2-3% of all cases.  Hydatid cyst located at psoas muscle obstructing the ureter, resulting in giant hydronephrosis is very rare and few cases have been reported in literature. Giant hydronephrosis can be defined as the presence of more than 1,000 ml of fluid in the collecting system.  The main causes of giant hydronephrosis can be congenital pelvi-ureteric junction obstruction; ureterovesical junction obstruction; obstructive megaureter; ureteric atresia; obstructive ectopic ureter with or without a duplex system; impacted ureteric stone; blind ending ureteric bud; and rarely, compression of ureter by a psoas muscle hydatid cyst. , Hereby, we report a rare case of right psoas muscle hydatid cyst causing giant hydronephrosis due to chronic obstruction of right ureter.
| Case Report|| |
A 65-year-old male patient was admitted with a complaint of mass in the right flank. He gave history of the feeling of heaviness and dragging pain in the abdomen and in the right flank with no other relevant medical history. The physical examination revealed a ballotable mass in right flank. All blood reports were within normal parameters. Contrast-enhanced computed tomography (CECT) abdomen [Figure 1] and [Figure 2] revealed hydatid cyst of right psoas muscle, which was compressing the right ureter resulting in massive hydronephrosis of right kidney. On nuclear scanning, right kidney was found nonfunctioning. Percutaneous nephrostomy was done and more than 1,100 cc of urine drained in the bag. Patient was put on oral albendazole (10 mg/kg body weight) for 4 weeks. After 4 weeks, laparotomy was done. Operative findings revealed a retroperitoneal cyst in the right psoas region of size about 8 × 6 cm firm in consistency, along with hydronephrotic right kidney. Right nephrectomy was done. Povidine iodine (Betadine lotion 5%) was used as scolicidal agent. As the cyst was adherent with surrounding structure; marsupialization of cyst was done. A large bore tube drain was placed in the residual cyst cavity and removed at the 8 th postoperative day when there was no drainage. Postoperative stay was uneventful and the patient was discharged on 10 th day after surgery with continuous albendazole therapy for 6 months. There was no recurrence of hydatid disease after 6 months of follow-up.
|Figure 1: CECT showing hydatid cyst of psoas muscle and liver along with hydronephrosis of right kidney. CECT = Contrast-enhanced computed tomography|
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| Discussion|| |
Hydatid disease is a zoonotic infection caused by Echinococcus granulosus and rarely by Echinococcus multilocularis. The disease is often manifested by slow-growing cystic masses. Single organ hydatid cyst disease is common, but simultaneous involvement of multiple organs is quiet rare. Intraperitoneal and retroperitoneal cysts develop secondary to spontaneous or iatrogenic rupture of hepatic, splenic, or mesenteric cystand can be located anywhere in the peritoneum. Primary peritoneal involvement is extremely rare.  In our case, it was a case of isolated hydatid cyst of right psoas muscle.
When hydatid cyst is located in the muscle tissue, the diagnosis may be difficult and delayed due to asymptomatic nature. When huge enlarged cyst compresses the adjacent organs like ureter, kidney, or vertebra; then it becomes symptomatic as compression of ureter can result in gross hydronephrosis as in our case.
Cystic or complex retroperitoneal tumors, cold or pyogenic abscess of psoas muscle are considered in differential diagnosis. 
Various serological tests like immunoelectrophoresis, enzyme-linked immunosorbent assay (ELISA), latex agglutination, and indirect hemagglutination (IHA) are carried out for the diagnosis, screening, and postoperative follow-up for recurrence; but these tests are often negative because the capsule isolates the parasite from the host's immune system. Ultrasonography and CT is used for diagnosis. Recently, magnetic resonance imaging (MRI) is used to diagnose soft tissue hydatid disease.
Clinical suspicion of hydatid disease is very important for diagnosis. Correct preoperative diagnosis is very important as if scolicidal precautions are not taken during surgery, dissemination and seedling cannot be avoided. Scolicidal agents like normal saline (3%), povidine iodine (5%), or rarely formalin should always be used during surgery to decrease the incidence of dissemination and postoperative recurrence. Medical therapy with mebendazole or albendazole is used as prophylaxis in preoperative period and postoperatively to prevent recurrences. Preoperative medical therapy should be started at least 4 days prior to hydatid disease surgery and should be continued for at least a month or preferably several months postoperatively. Extraperitoneal approach is preferred in order to avoid intraperitoneal dissemination.
Most of the time, total cystectomy is not possible in muscular hydatid disease, because disease is diffusely spread in muscle.  A few authors recommend irrigation of residual cyst cavity with scolicidal agents via drain tube for several weeks following surgery, while other authors do not advice postoperative irrigation. ,
As all the patients with giant hydronephrosis do not have similar anatomical configuration and functional status of renal units; therefore, treatment has to be individualized. Ideally, percutaneous nephrostomy should be done as initial procedure in all the patients (as done in our case) and then, based upon overall functional status, removal of diseased kidney or reconstruction of the unit is done. 
Partial cystectomy of hydatid cyst, simple nephrectomy combined with medical therapy was done in our case.
| Conclusion|| |
Giant hydronephrosis due to compression of ureter by psoas muscle hydatid cyst may mimic cystic retroperitoneal disease growing to enormous size. Accurate diagnosis of giant hydronephrosis remains challenging due to the atrophy of the renal parenchyma associated with chronic obstruction, thus resulting in loss of contrast enhancement. In the endemic countries, the possible diagnosis of a giant hydronephrosis due to retroperitoneal hydatid cyst (compressing on the right ureter) should always be kept in mind.
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[Figure 1], [Figure 2]