T.T. Ibiyeye1, A.A. Abolarinwa2 and R.I. Osuoji2
- Department of Surgery, Federal Medical Center, Lokoja, Kogi State, Nigeria.
- Department of Surgery, College of Medicine, Lagos State University, Ikeja, Lagos State, Nigeria.
Background: Wilms’ tumour is one of the most common solid abdominal tumours in children in sub-Saharan Africa. Most cases present with an asymptomatic abdominal mass. We report a 2 year old male child who presented with acute urinary retention of 6 hours duration. He had a left flank mass and ascites, with a piece of necrotic tissue protruding from the urethral meatus. The urinary retention was relieved by manual removal of the necrotic tissue and passage of a Foley’s urethral catheter. Abdominal ultrasound and computed tomographic scan revealed bilateral Wilms’ tumour. The child commenced neoadjuvant chemotherapy and he has made significant improvement.
Conclusion: This is a rare mode of presentation of bilateral Wilms’ tumour which presented with a diagnostic dilemma. The need to palpate the abdomen of children who come to the hospital, cannot be over-emphasized.
Keywords: Bilateral Wilms’, Tumour; Necroturia, Acute urinary retention.
Dr. A.A. Abolarinwa
College of Medicine,
Lagos State University,
Ikeja, Lagos State,
Wilms’ tumour is the most common solid abdominal tumour in children in sub-Sahara Africa. 1,2,3 It accounts for 6% of malignancy in children in USA,4,5 and is seen frequently in children less than 5 years,4 with 90% of Wilms’ tumour diagnosed before the age of 7.1,5 The peak incidence is between the ages of 2-5.4 Most patients present with an asymptomatic abdominal mass.1,5 Other modes of presentation may include hematuria, fever, weight loss, and abdominal pain.1,5 Presentation may however be unusual like this index case, requiring a high index of suspicion for diagnosis. To our knowledge, there is no previous reported case of this nature.
A 2 year old male child was referred to our facility on account of inability to pass urine of 6 hours duration with associated straining, painful abdominal swelling, and protrusion of a fleshy mass from the urethral meatus, which became more prominent with straining. There was no history of abdominal or perineal trauma, no history of insertion of a foreign body into the urethra, no previous history of hematuria and fever. The child however had a 3 months history of progressive abdominal distention.
Examination revealed a male child in obvious distress. A 4cm long, fleshy necrotic mass was seen protruding through the urethral meatus, with bleeding from the tip of the mass (Fig. 1) The abdomen was distended with a tender suprapubic swelling. There was a palpable mass in the left flank which was firm, non tender, not ballotable and did not cross the midline. There was ascites.
The fleshy material was manually extracted and sent for histology. (Fig. 2) The child was catheterized, and 250mls of clear urine was drained. Laboratory investigations revealed a packed cell volume of 20% and microscopic hematuria. His renal function tests were normal. He had an abdominal ultrasound scan which showed bilateral solid renal masses with a dilated right pelvicalyceal system. An abdominal CT scan showed bilateral renal masses compressing the adjacent small bowel and colon, a right intra-pelvic tumour with moderate hydrocalycosis (Fig. 3)
The histology of the extracted tissue was confirmed to be necrosis. His chest x-ray result was normal.
A clinical diagnosis of bilateral Wilms’ tumour was made. He commenced neo-adjuvant chemotherapy using the SIOP protocol for the management of nephroblastoma. A significant response was noted following the commencement of chemotherapy as there was resolution of the ascites and a clinical reduction in the size of the mass, which became barely palpable after the first course was given.