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Image of the Day 7: Renal Mass Muhamad Na’im B. Ab Razak (MD USM)When we are doing round in one calm morning, we reach to one male patient who presentedwith first episode of hematuria and urinary tract infection. A verse that i will never forgetfrom my specialist is, “ While urinary tract infection is commonly associated withhematuria, it usually needs further evaluation in man." In today’s Image of the Day iwill briefly illustrate the importance of further evaluation for a patient who presented withhematuria.This 25 years old man who works as an army presented with first episode hematuria for threedays duration associated with urinary tract infection sign and symptoms such as low gradefever, burning sensation on micturation, left flank discomfort and urgency. There was nohistory of passing out sandy stone on micturation, obstructive symptoms, terminal dribbling,nocturia or constitutive symptoms.On examination, patient is a thin built man, not cachexic and appears healthy. VItal signs arestable. Per abdomen, it was soft and non distended, tenderness over suprapubic area but noguarding, no mass palpable, hernia orifices intact, renal punch positive, present of bowelsound and multiple small firm left inguinal lymph node. Examination of testis reveals novaricocele or hernia and per rectal demonstrate no palpable mass.Blood parameters are normal and Urine FEME seggestive of urinary tract infection andpatient was started on IV unasyn.However bedside USG reveals ? left kidney hydronephrosis with an acoustic shadows whichwas initially thought to be stone and formal KUB USG was takenKUB USG shows a mass which is measuring about 11X5 cm at the inferior pole of the kidneywith mixed echogenicity and poorly differentiated cortical-medullary junction. Otherwise,right kidney and urinary bladder were normal.
A CT scan was then done which shows lobulated heterogenously enhancing left renal massmeasuring 10.7 X 7.8 CM with no evidence of thrombus in IVC or renal vein and no sign ofmetastasize.
To appreciate the mass further, the patient may need MRI or CT angiography study. In wellestablish center, nuclear imaging studies will help to differentiate between true kidney massand pseudo mass. Above investigation will also help to determine further step of treatment.IVU may or may not be needed as CT scan and MRI are more superior than it. The next stepfor this patient would be left nephrectomy and the further management would be depends onfurther histopathlogy examination.