Calyceal Diverticula and Megacalycosis Urographic Diagnosis Complications and Treatment

Background: Calyceal diverticulae and megacalycosis are rare congenital anomalies. The majorities are asymptomatic but they can present with complications. Objective: The objective of this study is to describe the clinical presentations, complications, urographic diagnosis of calyceal diverticulae, megacalycosis, and their treatment. Methods: A descriptive study carried out over 8 years period from March 2012 to December 2019. In three big hospital of Aden province, we collect 15 patients aged from seven to 41 years (mean 13.5 years), our patients were 9 female (60%) and 6 male (40%). They diagnosed incidentally with calyceal diverticulae and megacalycosis by contrasted urography, describing the clinical manifestations, localization, complications, and type of treatment. Results: Sixty percent of patients with calyceal diverticulae and megacalycosis were women and (40%) were men. Clinical manifestations including, dull aching flank and abdominal pain in (40%), acute renal colic (20%), recurrent urinary tract infection (33%), and abdominal pain with a fever of unknown origin in (7%). Calyceal diverticula and megacalycosis were


Introduction
Calyceal diverticula and megacalycosis are rare congenital anomalies. Calyceal diverticulae present as a cystic cavity of the renal calyceal system which communicates with it through a narrow fornical cannel, while megacalycosis is unilateral dilatation of the renal calyces in the presence of normal undilated renal pelvis and ureter. It results from abnormal budding of the ureteric bud with subsequent lack of parenchymal induction and resultant cystic cavity formation. Megacalycosis is a rare congenital malformation, characterized by homogenous dilatation of the renal calyces with non-obstructive and non-progressive evolution [1] [2]. Calyceal diverticulae were seen in 0.05% of patients out of 12,000 of examined excretory urography. In the majority of cases are asymptomatic, and incidentally diagnosed during imaging study but clinically can result in a variety of complications [3] [4]. Upright or right lateral decubitus plain abdominal radiography shows the half-moon shape of milky calcium appearance which is the pathogenic feature [5]. Ultrasound is the first investigation but is inconclusive because it resembles a simple cyst [6] [7]. The diagnosis is made by intravenous urography and computerized tomographic urography in complex cysts [8]. Stones in the pelvicalyceal diverticula occurred in up to 50% of patients and recurrent urinary tract infections in 25% of patients [9]. Historically open surgical procedures include excision, marsupialization, diverticulectomy or partial nephrectomy.
Extracorporeal Shock wave Lithotripsy (SWL) is considered as the first line for treatment [10]. Percutaneous extraction and diverticulum fulguration with canal dilatation provide a good immediate success rate, and low morbidity, it is now accepted as the standard treatment [11]. The diagnosis of calyceal diverticula is a challenge, especially in children. They can result in various complications and diagnostic difficulties.
The objective of this study is to describe the diagnosis of calyceal diverticulae and megacalycosis and their treatment. Inclusion: We included those patients who attended these three Hospitals in Aden Governorate and diagnosed with calyceal diverticulae or megacalycosis.

Methods
Exclusion: The patients who had the acquired types, and those diagnosed as simple or complex renal cysts were excluded from the study.
Statistic: Statistics method carried out with frequencies and percentages, and confection of tables carried out manually using a summary measure. Data was processing and analyzed using Social Science Statistics software.
Ethical Approval and Consent for patients were not applicable, and patients' identifiers and organ exposure for patients are not involved.

Results
Of the total 15 patients included in our study nine patients (60%) with calyceal diverticulae and megacalycosis were women's and six patients (40%) were men.
The clinical manifestations (Table 1)

Discussion
Calyceal diverticula and megacalycosis are rare congenital anomalies; both represent dilatation of the collecting system but differ in their pathological and radiological features. Two types of calyceal diverticula are recognized. Type I: Calyceal diverticula is the most common, is related to a minor calyx [12]. Type II: It is an extremely rare renal anomaly; it communicates with the renal pelvis or major calyx. It is larger, and symptomatic in the majority of patients. Characterized by non-obstructive dilatation of calyces, the renal pelvis is not dilated, and the ureteropelvic junction is normal and conserved renal function [13]. Calyceal diverticula in the majority are asymptomatic. One-third to one-half of patients present with flank pain, urinary tract infection, and/or hematuria, and stones formation [14]. The calyceal diverticulae were bilateral in 53% and unilateral in 47% of patients, Calyceal diverticulae were commonly unilateral and less frequent bilaterally described by Jain et al. 2004 [15]. It is two times more often found in the right kidney than in the left one, and solitary calyceal diverticulae occurs in 90% of patients described by Surendrababu [16]. They should differentiated simple renal cysts, renal cortical abscess, papillary necrosis, and early stage of adult dominant polycystic kidney disease [17]. Clinical presentations and urographic findings are consistent with reported [18] by Stunnell et al. 2010.
Megacalycosis is a rare congenital anomaly, mostly asymptomatic and discovered incidentally or by their complications. The renal pelvis, infundibulum, and ureter are not dilated [19]. Calyces in calyceal diverticulae present as a semilunar configuration rather than the triangular or conical form. Kaviani [24].
Different treatment modalities like percutaneous nephrolitottomy and flexible uretero-renoscopy. Urolithiasis was described by Baso et al. 2015 [25]. Recent study by Laura McGarry concludes that Laparoscopic ablation is the optimal treatment and has significantly higher success rates than the ureteroscopic approach [26]. Carcinoma in a calyceal diverticulum is largely uncommon but some cases were reported [27] this goes with our study no malignancy reported.

Conclusion
Calyceal diverticulae are rare congenital anomalies and megacalycosis is an extremely rare anomaly. The most common clinical manifestation is abdominal and flank pain in 60% followed by urinary tract infection. Urinary stones were the most common complications, 73% of patients treated conservatively and only 27 of patients need intervention.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.