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Modified Whitaker Test: a Novel Diagnostic for Nephroptosis Ralph Grauer ‍ ‍ , Mikel Gray, Noah Schenkman

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Modified Whitaker Test: a Novel Diagnostic for Nephroptosis Ralph Grauer ‍ ‍ , Mikel Gray, Noah Schenkman Novel diagnostic procedure BMJ Case Rep: first published as 10.1136/bcr-2020-235108 on 27 April 2020. Downloaded from Case report Modified Whitaker test: a novel diagnostic for nephroptosis Ralph Grauer , Mikel Gray, Noah Schenkman Department of Urology, SUMMARY The relationship between positive imaging University of Virginia, A 77-year -old woman presented with right flank pain studies and clinically significant disease is weak Charlottesville, Virginia, USA radiating to the ipsilateral groin and associated nausea, owing to the prevalence of asymptomatic nephro- consistent with renal colic. In the emergency department, ptosis; therefore, the use of a study that correlates Correspondence to ptosis and symptoms is critical. In this report, we Mr Ralph Grauer; a non-contr ast CT scan revealed severe right-sided rg3db@ virginia. edu hydronephrosis but failed to demonstrate a calculus or examine the novel utility of a dynamic Whitaker ureteropelvic obstruction. The patient improved with test in the diagnosis of nephroptosis compared Accepted 13 April 2020 fluids and followed up with a community urologist. Initial with previous diagnostic modalities. The Whitaker work-up with cystoscopy and ureteroscopy, voiding test is an anterograde urodynamic study used to cystourethrogram and diuretic renography failed to determine the presence of mechanical obstruction, deduce a diagnosis. At our hospital, we used a modified during which the renal pelvis is percutaneously dynamic (supine and upright) Whitaker test in a novel accessed and infused with saline or contrast. Pres- sure monitors in the renal pelvis and the bladder fashion to diagnose nephroptosis, a rare hypermobility 3 condition of the kidney. are used to determine abnormalities. During the work- up of this case, we modified the Whitaker test to be performed both supine and in reverse Tren- delenburg position to provoke and document posi- BACKGROUND tionally dependent obstruction. Nephroptosis is defined as descent of the kidney ≥5 cm or two or more vertebral bodies when the patient moves from a supine to an upright position.1 CASE PRESENtatION The condition is thought to be due to a deficiency A- 77- year old woman presented to her local emer- in the support of the inferior renal fasciae and other gency department with progressive right flank pain http://casereports.bmj.com/ perinephric structures. Hypermobility of the kidney and associated severe nausea of 1.5 days duration. has been documented in up to 20% of intravenous The pain radiated to the right groin and was wors- urograms of young adult women not experiencing ened by movement. Initial vital signs were within symptoms; but a small, unknown proportion will normal limits and a comprehensive metabolic panel, experience symptoms from stretching or kinking complete blood count and urinalysis were unre- of vessels, nerves or ureteral involvement during markable. An abdominal CT scan demonstrated ptosis.2 A classic presentation (Dietl’s crisis) is char- severe right hydronephrosis of right kidney with perinephric stranding; no dilation of the ureter or acterised by acute abdominal pain and vomiting urinary calculi was seen. She improved with intra- when the patient is upright that is rapidly alleviated venous hydration and antiemetics and was advised when the patient moves to a recumbent or knee- on September 28, 2021 by guest. Protected copyright. to follow- up with a urologist. One week later, she chest position.2 The pain is localised to the flank was seen by a community urologist who performed with occasional radiation to groin, mimicking renal a technetium-99m mercaptoacetyltriglycine diuretic colic, and may be accompanied by nausea and renography scan, which revealed delayed clearance emesis, intermittent haematuria and palpable flank and excretion of radionucleotide without clear mass. evidence of obstruction (post- Lasix T1/2= 11 min). Nephroptosis typically affects women (10:1 ratio A voiding cystourethrogram was also obtained that compared with men) aged 20–40. Due to the rarity revealed no vesicoureteral reflux or abnormalities of the condition and asymptomatic predominance, of the lower urinary tract. the true prevalence remains unknown. Nephro- Five weeks following initial presentation, the © BMJ Publishing Group ptosis is a diagnosis of exclusion; supine and community urologist performed a cystoscopy with Limited 2020. Re- use upright duplex ultrasound, intravenous urograms right retrograde urogram and attempted ureteros- permitted under CC BY- NC. No and radionuclide scans are commonly obtained if commercial re-use . See rights copy. A tortuous ureter was noted and the renal and permissions. Published there is clinical suspicion. Diagnosis is suggested pelvis was not visualised; a double-J stent was by BMJ. by sufficient renal descent between supine and placed and she was referred to our urologic service. upright positioning, development of obstruction She presented to the University of Virginia To cite: Grauer R, Gray M, Schenkman N. BMJ Case when upright but not supine or imaging suggesting urology clinic 7 weeks after initial presentation. Rep 2020;13:e235108. kinking of ureteropelvic junction or proximal With the stent in place, she reported nearly constant doi:10.1136/bcr-2020- ureter. Nephroptosis is typically treated with renal pain that limited her ability to complete daily 5- mile 235108 fixation via nephropexy. walks. The intensity of pain was exacerbated with Grauer R, et al. BMJ Case Rep 2020;13:e235108. doi:10.1136/bcr-2020-235108 1 Novel diagnostic procedure BMJ Case Rep: first published as 10.1136/bcr-2020-235108 on 27 April 2020. Downloaded from Figure 1 Coronal, anteroposterior fluoroscopic imaging obtained during dynamic Whitaker test. (A) Imaging obtained while the patient is supine; contrast is visualised in the pelvis and throughout the right ureter. No apparent narrowing of ureteropelvic junction or ureterovesicular junction. (B) Imaging obtained while the patient is in 45° of reverse Trendelenburg position; contrast is accumulating in renal pelvis without flow into the ureter. movement, but it was not affected by hydration. One week later, fashion.1 Dynamic imaging (supine and upright), which correlates she underwent right ureteroscopy with ureteral stent removal symptoms to functional obstruction, remains the cornerstone in and placement of a right percutaneous nephrostomy tube that the diagnosis of nephroptosis. Our literature review revealed the alleviated her pain. She was scheduled for a Whitaker test. common use of upright and supine ultrasonography, diuretic The patient returned in 2 weeks for a Whitaker test of the renography and intravenous urography in diagnosis; although right renal pelvis and ureter, facilitated by the nephrostomy its use has been posited, the Whitaker test has not been docu- tube still in place. She was placed in supine position and dilute mented in the diagnosis of nephroptosis.4 Supine and upright http://casereports.bmj.com/ contrast was infused at a rate of 8 mL/min. Once 60 mL of intravenous urograms have historically been the standard diag- contrast was infused into the renal pelvis, the patient reported nostic tool; however, diuretic renography and dynamic ultraso- mild flank discomfort and fullness. The differential pressure nography are complementary modalities that have been playing between renal pelvis and bladder was 15 cm of water, below an increasing role in diagnosis. Diuretic renography is favoured the 20–22 cm of water cut- off for a diagnosis of obstruction.3 as it can document renal obstruction via radiotracer excretion, The patient was then placed in a reverse Trendelenburg position decreased renal perfusion and/or changes in renal function.5 (45°) with continued perfusion of 8 mL/min. At this point, the Nevertheless, diuretic renography has been found to be less sensi- differential pressure rose to 24 cm of water and she reported tive than supine and upright ultrasound for diagnosing nephro- intense flank pain (figure 1). This dynamic study demonstrated ptosis.6 Dynamic colour Doppler with estimation of renal artery positional- dependent obstruction via differential pressures and resistive index (peak systolic velocity–end diastolic velocity/peak on September 28, 2021 by guest. Protected copyright. fluoroscopic imaging, supporting a diagnosis of symptomatic nephroptosis. The patient elected to undergo laparoscopic nephropexy, in which the right kidney is sutured and well approximated to the lateral abdominal wall. The nephrostomy tube was removed intraoperatively. Postoperative course was uneventful and the patient was discharged on postoperative day 1. OUTCOME AND FOLLOW-UP Two- month follow- up evaluation revealed a well-healed oper- ative incision. She reported occasional lower back pain when walking longer distances, but flank pain had resolved. She denied any haematuria, dysuria or voiding complaints. One year following surgery, renal ultrasound showed complete resolution of right- sided hydronephrosis (figure 2). Discussion Nephroptosis is a condition in which the kidney has increased Figure 2 Sagittal abdominal ultrasound of right kidney at 1- year post- mobility that may mimic renal colic in a position- dependent op demonstrating complete resolution of hydronephrosis. 2 Grauer R, et al. BMJ Case Rep 2020;13:e235108. doi:10.1136/bcr-2020-235108 Novel diagnostic procedure BMJ Case Rep: first published as 10.1136/bcr-2020-235108 on 27 April 2020. Downloaded from systolic velocity) has shown promise as a rapid and non- invasive
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