Crossed and Non-fused Renal Ectopia of Inferior type

G. J. Jorwekar*, K. N. Dandekar*, R. K. Shinde*, P. K. Baviskar**

Abstract
Crossed ectopia of the kidney occurs when the kidney is located on the side opposite
from which its ureter inserts into bladder. Ninety per cent of crossed ectopic kidneys
are fused to their ipsilateral mates. We present a case of eight year old female child
who was found to have left crossed non-fused renal ectopia of inferior type.

Introduction

T he reported incidence of crossed

renal ectopia is 1:2000 to 1:7000
autopsies. It was first described by
Pannorius in 1654. Crossed ectopic
kidneys are fused to their ipsilateral
mate in more than 90% of cases.
Crossed ectopia without fusion is rare (1
in 75,000 autopsies) as compared to the
fused crossed ectopia. Most patients
have concomitant urinary pathology
which makes the kidney susceptible to
infection and obstruction which
ultimately dictate its management.
Case Report
An 8 year old female child presented with
intermittent abdominal pain in right lumbar and
iliac region since one year. Per abdomen
examination revealed single palpable lump in
right lumbar and iliac region. Ultrasonography of
abdomen showed 12.3 x 5.4 cm sized single
reniform lesion with multiple cystic components
close to the lower pole of right kidney with empty
left renal fossa. Intravenous urography showed
crossed renal ectopia with gross hydronephrosis
with calculus (Fig. 1). Computed tomography of
abdomen and pelvis showed gross hydronephrotic Fig. 1 : IVU shows crossed ectopia with calculus
crossed ectopic kidney in right lumbar region with gross hydronephrosis
(Fig. 2). Patient was subjected to renal isotope kidney in view of poor function and obstructive
scan (DTPA scan), showed non-function of left changes leading to chronic symptomatic
crossed ectopic kidney and normal function of presentation. Intra-operatively, severely
right kidney. Further workup did not show any hydronephrotic, non-fused, crossed ectopic
associated anomalies. Diagnosis of crossed non- kidney with papery thin parenchyma was found
fused ectopia with poor-function was made. infero-medial to the normal right kidney and
Decision was taken to explore crossed ectopic ureter crossing to the opposite side (Fig. 3).
*Asst. Prof., **Prof. and Head, Dept. of Surgery, Nephrectomy was carried out in view of severe
Rural Medical College and Hospital, Loni. hydronephrosis leading to papery thin

Bombay Hospital Journal, Vol. 53, Special Issue, 2011 541

 solitary crossed ectopia and bilaterally
crossed ectopia.2 In crossed ectopia,
both kidneys are found same side of
midline of the body and usually ectopic
kidney lie inferior to the contra lateral
kidney. Ninety per cent of crossed
ectopic kidneys are fused to their
ipsilateral mates. Crossed ectopia
without fusion occur more commonly in
males in the ratio of 2:1. Left to right
crossed ectopia is 3 times more
Fig. 2 : CT scan shows crossed ectopic kidney
with gross hydronephrosis common than right to left.3 The
symptoms are varied and vague with
pain, dysuria, haematuria and urinary
infection. Mass in abdomen is noted in
one third of patients, hydronephrotic
transformation and renal calculi have
been discovered in conjugation with
abdominal mass as was found in the
present patient. Renal
Ultrasonography, intravenous
urography (IVU), renal scintigraphy,
renal angiography, cystoscopy,
Fig. 3 : Intraoperative photograph shows retrograde pyelography and computed
severely hydronephrotic kidney with papery tomography (CT) provide valuable aid in
thin parenchyma
the diagnosis.4 Good results were
parenchyma, calculus formation, chronic observed from nephrectomy performed
symptoms and DTPA scan findings. Patient had
on children for hydronephrotic
uneventful post operative recovery. Patient is
routinely following in surgical outpatient transformation of the ectopic kidney
department and is free from any complication. and is widely used in the management
Discussion of hydronephrotic crossed ectopia with
non-function.5 Highest incidence of
Renal ectopia occurs when the
associated anomalies occur in children
kidney fails to migrate to the lumbar
with solitary renal ectopia and involves
region during embryonic development
both skeletal system and genital
and does not rotate about its axis.1
organs. 6 Occurrence of associated
When kidney is located on the side
anomalies is low in crossed ectopia
opposite from which its ureter inserts
excluding solitary crossed ectopia.
into the bladder, the condition is known
Anomalies of genital organs like vagina
as crossed ectopia. Crossed ectopia is
or uterus are seen in 40% patients with
classified by McDonald and McClellan
solitary crossed ectopia.7
into 4 types as, crossed ectopia with
fusion, crossed ectopia without fusion, Conclusion

542 Bombay Hospital Journal, Vol. 53, Special Issue, 2011

 Surgeon should always keep in 1. Marshal FF, Freedman MT. Crossed renal
mind possibility of developmental renal ectopia. J Urol 1975; 119:188-91.

and associated anomalies in children 2. McDonald JH, McClellan DS. Crossed renal
ectopia. Am J Surg 1957; 93:995.
whenever clinical findings doesn’t
3. Winram RG, Ward-Mcquaid JN. Crossed
dictate diagnosis of chronic abdomen.
ectopia without fusion. Can Med Ass J 1959;
References
81(6):481-483.
4. Boyan N, Kubat H, Uzum A. Crossed renal

VITAMIN D AND BONE HEALTH IN CHILDREN

What is the definition of vitamin D deficiency in clinical practice? This has been hotly debated given
the current interest in the potential extraskeletal benefits of vitamin D. It has been recommended
that serum concentrations of greater than 50 nmol/L or even 80 nmol/L should be regarded as
vitamin D sufficiency.
There is currently no standard definition of an optimal concentration of vitamin D and that
concentreations below 25 nmol/L should indicate deficiency. Even at this value vitamin D deficiency
is still prevalent in children worldwide.
However, Winzenberg and colleagues’ review suggests that adequate vitamin D status is needed
throughout childhood and adolescence. This is unlikely to be achieved by vitamin D supplementation
alone and advice on sensible sun exposure and more extensive food fortification needs to be
considered.
NICK SHAW, BMJ 2011; 342:239-240

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