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AJR 2001; 176:1601-1602
© American Roentgen Ray Society

Another Route for Escape

Sergin Akpek

School of Medicine Gazi University Besevler 06510, Ankara, Turkey

I read with interest the perspective by Dr. Gore et al. [1] entitled "The Great Escape: Interfascial Decompression Planes of the Retroperitoneum." This article deals with the same important anatomic descriptions and clinical problem about the perinephric spaces and their potential extensions as does another important pictorial essay by Aizenstein et al. [2]. As stated in both of the articles, anterior interfascial and inferior retroperitoneal extensions to contralateral perirenal space and into the pelvis are well-known clinical situations and supported by cadaveric studies [3]. The debate is about the superior extension. The studies by Gore and Aizenstein et al. explained the trans-diaphragmatic spread of perinepric disease only on the basis of lymphatic communications between the mediastinum and retroperitoneum. Although it occurs rarely, according to my knowledge and experience direct trans-diaphragmatic extension of perirenal fluid collection to the mediastinum through the aortic and esophageal hiatus does occur, and this can be explained with potential interfascial communications between these compartments [4, 5]. I hope my contribution makes this well-written perspective complete.

References

  1. Gore RM, Balfe DM, Aizenstein RI, Silverman PM. The great escape: interfascial decompression planes of the retroperitoneum. AJR 2000;175:363 -370[Free Full Text]
  2. Aizenstein RI, Wilbur AC, O'Neal HK. Interfascial and perinephric pathways in the spread of retroperitoneal diseases: refined concepts based on CT observations. AJR 1997;168:639 -643[Free Full Text]
  3. Kunin M. Bridging septa of the perinephric space: anatomic, pathologic and diagnostic considerations. Radiology 1986;158:361 -365[Abstract/Free Full Text]
  4. Baron RL, Stark DD, McClennan BL, et al. Intrathoracic extension of retroperitoneal urine collections. AJR 1981;137:37 -41[Abstract/Free Full Text]
  5. Akpek S, Ilgit ET, Araç M, et al. Bilateral perirenal urinoma with mediastinal extension. Abdom Imaging 1995;20:267 -269[Medline]

Reply

Richard M. Gore

Evanston Hospital Evanston, IL 60201

We thank Dr. Akpek for his interest in our review and certainly agree that the diaphragm can provide several pathways of escape for retroperitoneal disease: lymphatic and less commonly through the aortic and esophageal hiatus. Akpek et al. [1] described a patient with adult polycystic kidney disease with perirenal fluid collections using the retromesenteric plane and aortic hiatus for decompression. Baron et al. [2] described five patients with retroperitoneal urinomas, three of whom rapidly developed pleural fluid collections and two acute mediastinal widenings that cleared rapidly with surgical drainage of the retroperitoneal collections. The interfascial planes were recruited in these cases as well. These findings lend credence to the concept that the chest and abdominal cavities are part of a continuum, in which the diaphragm is a significant but by no means complete barrier to the spread of disease.

References

  1. Akpek S, Ilgit ET, Araç M, et al. Bilateral perirenal urinoma with mediastinal extension. Abdom Imaging 1995;20:267 -269.
  2. Baron RL, Stark DD, McClennan BL, et al. Intrathoracic extension of retroperitoneal urine collections. AJR 1981;137:37 -41

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