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A 45-year-old man was hospitalized because of an 8-month history of progressive abdominal distension and intermittent attacks of nausea. Physical examination revealed a grossly distended abdomen with a palpable mass in the right flank region. Radiography of the kidneys, ureter, and bladder showed a radiopaque nodule over the left paraspinal region, suggestive of a ureteral stone (Figure, A). Computed tomography of the abdomen revealed a huge cystic lobulated mass in the right kidney that almost filled the entire abdominal cavity. A stone (1.3 cm) in the right upper aspect of the ureter was causing marked hydronephrosis of the right kidney, resulting in a paper-thin cortex with lack of right renal function (Figures, B and C). Right nephrectomy was performed, and approximately 5000 mL was drained from the pelvic cavity. The patient had an uneventful recovery postoperatively.
It has long been appreciated that the clinical presentation of urolithiasis is flank pain or colic. However, urolithiasis also can present asymptomatically and result in a rare condition termed giant hydronephrosis, defined as the presence of more than 1 L of fluid in the collecting system. The most common cause of giant hydronephrosis is obstruction of the ureteropelvic junction, followed by stones, trauma, and tumors. We suggest that giant hydronephrosis be considered in the differential diagnosis of intra-abdominal cystic masses. Early recognition using sophisticated imaging studies along with an increased awareness of urolithiasis, even an asymptomatic stone, is essential and may expedite appropriate management so that catastrophic morbidity can be avoided.