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Urology - Abdominal mass, newborn/child, urologic considerations
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1. BASICS
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Description
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Abdominal masses in newborns and children were traditionally identified during physical examination as palpable swellings within the abdomen. However, advances in prenatal ultrasonography have significantly changed the clinical presentation, with many abnormalities now detected before birth.
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Most abdominal masses identified in neonates and children do not require surgical intervention. Among lesions that require surgery, approximately 87% are benign, according to the original source.
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Nearly two-thirds of abdominal masses in infants arise from the kidneys. Other important anatomical sources include the gastrointestinal tract, accounting for approximately 12% of cases, the female reproductive system at 10%, and the retroperitoneum at 9%.
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Epidemiology
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Incidence
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The reported incidence of abdominal masses in newborns is approximately 1 per 1,000 live births. This estimate reflects the original source and may differ from contemporary epidemiological data.
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Prevalence
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The prevalence of abdominal masses in newborns and children varies according to the underlying disease, age at presentation, anatomical origin, and pathological characteristics.
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Risk Factors
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Genetic Factors
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Genetic predisposition to abdominal masses in children depends largely on the underlying disease. Several pediatric tumors and hereditary renal disorders are associated with specific chromosomal abnormalities, gene mutations, or inherited syndromes.
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Neuroblastoma
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Neuroblastoma is associated with several genetic abnormalities that may influence tumor development, biological behavior, and prognosis.
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Important alterations include deletion of chromosome 1p, loss of genetic material on chromosome 11q, and gain of chromosome 17q. These abnormalities may correlate with more aggressive tumor characteristics.
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Amplification of the MYCN oncogene, historically referred to as N-MYC, is an important marker of aggressive disease and is incorporated into neuroblastoma risk assessment.
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Autosomal Recessive Polycystic Kidney Disease
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Autosomal recessive polycystic kidney disease (ARPKD) is a hereditary renal disorder most commonly associated with pathogenic variants in the PKHD1 gene, located on chromosome 6.
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The disorder causes abnormal development of renal collecting ducts and is associated with congenital hepatic fibrosis. The severity of renal involvement varies, with some affected newborns presenting with markedly enlarged kidneys and respiratory compromise.
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Rhabdomyosarcoma
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Rhabdomyosarcoma (RMS) may be associated with inherited cancer predisposition syndromes and acquired chromosomal abnormalities.
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Mutations involving the TP53 tumor suppressor gene can occur in individuals with Li–Fraumeni syndrome, which increases susceptibility to several malignancies, including rhabdomyosarcoma.
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Alveolar rhabdomyosarcoma is commonly associated with characteristic chromosomal translocations involving chromosomes 1 and 13 or chromosomes 2 and 13. These rearrangements may produce PAX7::FOXO1 or PAX3::FOXO1 fusion genes.
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Embryonal rhabdomyosarcoma frequently demonstrates loss of heterozygosity involving chromosome 11p15.5, suggesting an important role for abnormalities in this region in tumor development.
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Wilms Tumor
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Wilms tumor, also known as nephroblastoma, is associated with several genetic abnormalities and congenital syndromes.
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Alterations involving the WT1 gene on chromosome 11p13 are associated with Denys–Drash syndrome and WAGR syndrome. WAGR is characterized by Wilms tumor, aniridia, genitourinary abnormalities, and developmental or intellectual disability.
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Abnormalities involving the chromosome 11p15 region, historically designated WT2, are associated with Beckwith–Wiedemann syndrome, a congenital overgrowth disorder that increases the risk of Wilms tumor.
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Inactivation of the WTX gene, now commonly known as AMER1, located on chromosome Xq11.1, has been identified in a substantial proportion of Wilms tumors, approaching one-third in some studies.
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Familial susceptibility loci historically designated FWT1 on chromosome 17q and FWT2 on chromosome 19q have also been described.
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Loss of heterozygosity involving chromosomes 1p and 16q has been associated with an increased risk of tumor recurrence and adverse outcomes in certain groups of patients with Wilms tumor.
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Pathophysiology
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The pathophysiology of abdominal masses in newborns and children depends on the underlying disease and the organ from which the mass originates.
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These masses may arise from congenital malformations, urinary tract obstruction, cystic renal abnormalities, vascular disorders, hemorrhage, infections, or benign and malignant neoplasms.
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The biological behavior and clinical manifestations of each condition are determined by its anatomical origin, developmental characteristics, and underlying pathological process.
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Associated Conditions
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Associated clinical conditions vary according to the underlying diagnosis.
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Renal masses may be accompanied by urinary tract obstruction, impaired renal function, hypertension, or urinary tract infection. Malignant tumors may be associated with systemic symptoms, metastatic disease, or specific genetic syndromes.
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Congenital abnormalities may also involve multiple organ systems, particularly when the abdominal mass forms part of a recognized hereditary or developmental disorder.
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General Prevention
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There are no universally applicable preventive measures for abdominal masses in newborns and children because many result from congenital, developmental, or hereditary abnormalities.
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Prenatal screening, early recognition, and appropriate postnatal evaluation are important for identifying potentially significant conditions and reducing complications.
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2. DIAGNOSIS
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Clinical History
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A detailed prenatal and postnatal history is essential when evaluating a newborn or child with an abdominal mass.
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The history should establish when the abnormality was first identified, whether it was detected during pregnancy or after birth, how rapidly it has enlarged, and whether associated systemic, urinary, or gastrointestinal symptoms are present.
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Prenatal Ultrasound Findings
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Prenatal ultrasonography provides valuable information about fetal abdominal and urinary tract abnormalities.
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Oligohydramnios, or reduced amniotic fluid volume, may be associated with severe fetal urinary tract abnormalities that reduce fetal urine production or drainage. Important causes include posterior urethral valves (PUV), severe bilateral ureteropelvic junction (UPJ) obstruction, urethral atresia, severe cystic renal dysplasia, and bilateral renal agenesis.
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Polycystic kidney disease and multicystic dysplastic kidney may also be associated with abnormal amniotic fluid volume, particularly when renal involvement is bilateral and severe.
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Polyhydramnios, characterized by excessive amniotic fluid, may be associated with high gastrointestinal obstruction because impaired fetal swallowing or intestinal passage interferes with normal amniotic fluid regulation.
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Postnatal History
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The postnatal history should document the circumstances surrounding the initial discovery of the abdominal mass, its duration, and the rate at which it has changed in size.
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Rapid enlargement may raise concern for hemorrhage, infection, obstruction, or malignancy, whereas a stable mass may be associated with certain congenital or benign conditions.
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Constitutional and Associated Symptoms
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Systemic symptoms such as fever, pain, weight loss, and anorexia may suggest infection, inflammation, or malignancy.
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Urinary symptoms, including urinary tract infection, dysuria, and hematuria, may indicate renal or lower urinary tract pathology.
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Gastrointestinal symptoms such as melena, bilious vomiting, and abdominal discomfort may suggest an intestinal or other gastrointestinal origin.
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Bilious vomiting in a newborn is particularly concerning because it may indicate intestinal obstruction requiring urgent evaluation.
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Physical Examination
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A comprehensive physical examination should be performed to determine the anatomical location and characteristics of the abdominal mass.
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Abdominal Examination
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The examiner should assess the size and location of the mass and determine whether it appears solid or cystic.
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The presence or absence of tenderness should be documented. The surface and consistency of the mass should also be evaluated to determine whether it is smooth, irregular, indurated, or soft.
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Mobility is another important characteristic. A fixed mass may suggest a retroperitoneal origin or invasion of surrounding tissues, whereas a mobile mass may arise from more freely movable intra-abdominal structures.
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Abdominal auscultation, percussion, and transillumination may provide additional information about the nature of the lesion and its relationship to surrounding organs.
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Additional Examination and Assessment
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Additional examination should be guided by the suspected anatomical origin of the mass.
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Nasogastric decompression may be required when intestinal obstruction or significant gastrointestinal distension is suspected.
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Bladder catheterization using an appropriately sized urinary catheter may be necessary when significant urinary retention or lower urinary tract obstruction is present.
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Rectal examination or examination of the vaginal introitus may be indicated in selected cases to identify pelvic masses, genital tract obstruction, or associated congenital abnormalities. Such examinations should be performed only when clinically justified.
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3. DIAGNOSTIC TESTS AND INTERPRETATION
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Laboratory Investigations
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Laboratory investigations should be individualized according to the child’s clinical presentation, suspected diagnosis, and associated abnormalities.
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Complete Blood Count
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A complete blood count (CBC) may reveal anemia, neutropenia, thrombocytopenia, or leukocytosis.
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Anemia, neutropenia, or thrombocytopenia may suggest bone marrow involvement in children with malignant disease, although these findings are not specific.
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Leukocytosis may indicate infection or an inflammatory process, particularly when associated with urinary tract obstruction or systemic illness.
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Renal Function and Electrolytes
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Blood urea nitrogen (BUN), serum creatinine, and electrolyte measurements are important for assessing renal function and detecting biochemical abnormalities.
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Elevated BUN or creatinine concentrations may indicate renal impairment, urinary tract obstruction, dehydration, or other disturbances affecting renal perfusion and function.
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Urinalysis
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Urinalysis may identify hematuria, proteinuria, or evidence of urinary tract infection.
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Hematuria can occur in Wilms tumor, renal vein thrombosis, and ureteropelvic junction obstruction, particularly when associated with trauma.
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Urinary Catecholamine Metabolites
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Measurement of urinary catecholamine metabolites is useful when neuroblastoma or pheochromocytoma is suspected.
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Elevated urinary homovanillic acid (HVA) and vanillylmandelic acid (VMA) concentrations may support the diagnosis of neuroblastoma or another catecholamine-producing tumor.
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Depending on patient age and laboratory protocols, testing may use a timed urine collection or a spot urine sample normalized to creatinine.
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Serum Tumor Markers
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Serum beta-human chorionic gonadotropin (β-hCG) and alpha-fetoprotein (AFP) may assist in evaluating certain pediatric tumors, particularly germ cell tumors and some hepatic malignancies.
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AFP may be elevated in yolk sac tumors and hepatoblastoma, whereas β-hCG may be elevated in certain germ cell tumors.
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AFP concentrations are physiologically elevated during early infancy, so results must be interpreted using age-appropriate reference ranges.
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Imaging Investigations
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Imaging is essential for identifying the origin, extent, internal architecture, and relationship of an abdominal mass to adjacent organs.
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Plain Abdominal Radiography
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Plain abdominal radiographs may help identify intestinal obstruction, ileus, abnormal bowel gas distribution, and calcifications.
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Air–fluid levels on appropriate radiographic views and absence of gas within the rectum may support a diagnosis of intestinal obstruction.
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Intra-abdominal calcifications may be associated with neuroblastoma, teratoma, hepatoblastoma, meconium peritonitis, urinary calculi, or biliary stones.
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Abdominal Ultrasonography
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Ultrasonography is generally the primary imaging modality for evaluating abdominal masses in newborns and children.
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It can identify the anatomical location and size of the mass, determine its organ of origin, and evaluate its internal architecture.
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Ultrasonography can also distinguish cystic from solid lesions and assess vascularity using Doppler techniques.
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Important advantages include its noninvasive nature, relatively low cost, lack of ionizing radiation, and minimal need for sedation.
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Computed Tomography
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Computed tomography (CT) may be performed when ultrasonography identifies a solid mass or when additional anatomical detail is required.
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CT provides detailed information about the size, extent, composition, and relationship of a lesion to surrounding structures.
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It may be particularly useful in older children and in selected cases of suspected malignancy.
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However, children are more sensitive to the potential long-term effects of ionizing radiation. CT should therefore be performed only when clinically justified, using pediatric dose-reduction protocols. Sedation may also be required in younger patients.
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Magnetic Resonance Imaging
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Magnetic resonance imaging (MRI) provides excellent soft-tissue contrast and detailed anatomical information without exposing the child to ionizing radiation.
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MRI is especially useful for evaluating vascular involvement, defining tumor extension, and characterizing masses arising from the adrenal glands or retroperitoneum.
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Advanced MRI techniques may also provide functional and quantitative information about certain lesions.
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The principal limitations include examination duration, availability, and the possible need for sedation or general anesthesia in infants and young children.
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Radionuclide Imaging
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Radionuclide investigations are used selectively to assess organ function and identify specific abnormalities.
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Renal nuclear medicine studies may evaluate differential renal function, urinary drainage, obstruction, renal scarring, or selected inflammatory conditions.
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Hepatobiliary scintigraphy may assist in the evaluation of biliary tract abnormalities, including certain cases involving choledochal cysts.
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Liver and spleen nuclear medicine studies have historically been used to investigate focal hepatic abnormalities and splenic enlargement, although modern ultrasound, CT, and MRI have replaced many of these applications.
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Voiding Cystourethrography
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Voiding cystourethrography (VCUG) is useful for assessing selected abnormalities involving the lower urinary tract.
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It may be performed when vesicoureteral reflux, posterior urethral valves, or other structural abnormalities of the bladder and urethra are suspected.
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Diagnostic Procedures and Surgery
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No single diagnostic surgical procedure is appropriate for every pediatric abdominal mass.
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The need for biopsy, endoscopy, drainage, or surgical exploration depends on the suspected pathology, radiological findings, and the child’s clinical condition.
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Pathological Findings
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Histopathological findings vary according to the disease and anatomical origin of the abdominal mass.
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Some conditions are diagnosed primarily through clinical and imaging findings, whereas others require tissue sampling or surgical excision to establish a definitive diagnosis.
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4. DIFFERENTIAL DIAGNOSIS
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Hydronephrosis
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Hydronephrosis is one of the most common causes of abdominal masses in newborns.
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It results from dilation of the renal collecting system, usually due to urinary tract obstruction or impaired urinary drainage.
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Ureteropelvic Junction Obstruction
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Ureteropelvic junction (UPJ) obstruction is the most common cause of a hydronephrotic abdominal mass in newborns.
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The obstruction interferes with urine drainage from the renal pelvis into the ureter, causing progressive dilation of the collecting system.
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Other causes of hydronephrosis include ureterovesical junction (UVJ) obstruction, posterior urethral valves, vesicoureteral reflux, primary megaureter, and ureterocele.
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Although hydronephrosis is frequently detected prenatally, fewer than 15% of affected neonates were reported in the original source to present with a palpable abdominal mass.
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Children presenting later may develop urinary tract infections, flank pain, or hematuria, particularly following trauma.
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Multicystic Dysplastic Kidney
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Multicystic dysplastic kidney (MCDK) is another common cause of neonatal abdominal masses.
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Together, UPJ obstruction and MCDK were reported to account for approximately 40% of neonatal abdominal masses in the original source.
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MCDK usually presents as a unilateral flank mass and has historically been reported more frequently in boys and on the left side.
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Ultrasonography typically demonstrates multiple cysts of varying sizes that do not communicate with one another, with little or no identifiable normal renal parenchyma.
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When functional imaging is necessary, radionuclide renal scanning generally demonstrates absent or minimal function in the affected kidney.
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Multilocular Cystic Nephroma
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Multilocular cystic nephroma is a cystic renal neoplasm that may resemble other complex cystic renal lesions.
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The differential diagnosis includes benign cystic lesions and cystic renal malignancies, including cystic Wilms tumor.
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The disease demonstrates a characteristic age distribution, with one group occurring in young boys, often younger than five years, and another predominantly affecting adult women.
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Definitive diagnosis may require surgical excision and histopathological examination because imaging alone may not reliably distinguish all complex cystic renal tumors.
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Renal Vein Thrombosis
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Renal vein thrombosis is an important vascular cause of renal enlargement and hematuria during the neonatal period.
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It occurs predominantly in newborns and young infants and has been reported more frequently in males.
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The classical clinical features include a palpable flank mass, hematuria, and thrombocytopenia.
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Predisposing conditions include dehydration, maternal diabetes, neonatal sepsis, diarrhea, and disorders associated with increased thrombotic risk, including sickle cell disease.
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Doppler ultrasonography is commonly used to evaluate renal vascular flow and identify evidence of thrombosis.
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Autosomal Recessive Polycystic Kidney Disease
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Autosomal recessive polycystic kidney disease commonly presents during the neonatal period with bilaterally enlarged kidneys.
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Severely affected infants may develop respiratory failure because markedly enlarged kidneys and reduced amniotic fluid can impair pulmonary development.
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The original source describes high mortality among severely affected newborns, with historical survival estimates of approximately 86% at one year and 67% at 15 years among survivors of the immediate neonatal period.
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These figures should be interpreted as historical estimates because prognosis varies considerably with disease severity and advances in neonatal and renal care.
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Congenital Mesoblastic Nephroma
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Congenital mesoblastic nephroma is the most common renal neoplasm of early infancy and is frequently identified during prenatal ultrasonography.
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The average age at diagnosis in the original source was approximately 3.5 months.
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The tumor typically presents as a solid renal mass in a newborn or young infant.
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Surgical excision is the principal treatment and is usually curative, particularly for localized disease that can be completely removed.
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Wilms Tumor
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Wilms tumor, or nephroblastoma, is the most common malignant renal neoplasm in children and an important cause of pediatric abdominal masses.
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It usually presents as a smooth, painless, and nontender unilateral abdominal mass.
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The median age at diagnosis is approximately 3.5 years, and around 80% of cases occur in children younger than five years.
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Presentation during the first six months of life or after ten years of age is relatively uncommon.
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Wilms tumor occurs more frequently in children with certain congenital syndromes, including WAGR, Beckwith–Wiedemann, and Denys–Drash syndromes.
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Treatment generally involves a combination of surgery and chemotherapy, with radiotherapy used when indicated by disease stage, histology, and treatment protocol.
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Survival rates exceed 90% in many children with favorable-histology disease, although outcomes are less favorable in certain high-risk or anaplastic tumors.
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Neuroblastoma
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Neuroblastoma is one of the most important malignant causes of abdominal masses in infants and young children.
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It is a common solid tumor of the neonatal period and frequently originates from the adrenal medulla or sympathetic nervous system.
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Approximately half of neuroblastoma cases are diagnosed before two years of age, although the exact proportion varies among populations.
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An abdominal neuroblastoma often presents as a firm, irregular, relatively fixed mass that may extend across the abdominal midline.
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Affected children may exhibit fever, malaise, weight loss, pain, and general ill appearance, particularly when the disease is advanced.
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This presentation may contrast with Wilms tumor, in which children are often relatively well despite having a large abdominal mass.
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Most neuroblastomas produce catecholamines or their metabolites, with elevated urinary HVA or VMA detectable in a substantial majority of cases.
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Adrenal Hemorrhage
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Adrenal hemorrhage is an important non-neoplastic cause of an adrenal or upper abdominal mass in newborns.
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The original source reports an incidence of approximately 1–2% among healthy infants, although estimates vary according to the population and method of detection.
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Risk factors include birth trauma, high birth weight, perinatal asphyxia, sepsis, and coagulation disorders.
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Most cases are managed conservatively with clinical observation and appropriate supportive care.
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Surgical intervention is rarely required, although follow-up imaging may be necessary to confirm resolution and distinguish hemorrhage from an underlying adrenal tumor.
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Genital Tract Masses
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Hydrocolpos and Hydrometrocolpos
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Hydrocolpos refers to abnormal distension of the vagina caused by the accumulation of fluid or secretions.
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Hydrometrocolpos involves distension of both the uterus and vagina.
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These conditions arise from obstruction of the vaginal outflow tract, which may result from vaginal atresia, vaginal stenosis, imperforate hymen, or congenital cloacal abnormalities.
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Patients may present with a midline pelvic or lower abdominal mass.
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Ultrasonography typically identifies a fluid-filled pelvic structure located between the urinary bladder and rectum.
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Ovarian Cysts
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Ovarian cysts are an important cause of abdominal cystic masses in female fetuses and newborns.
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The original source reports an occurrence of approximately one case per 3,000 girls, although reported frequencies vary.
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Ovarian cysts are among the most common cystic abdominal lesions identified in female fetuses.
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They may present as large, mobile masses in the central abdomen or pelvis.
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The relative frequency of ovarian cysts and tumors varies by age, with the original source describing approximately 17% of cases from birth through four years, 28% between five and nine years, and 55% between nine and eighteen years.
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The likelihood of malignancy depends on the patient’s age and the lesion’s imaging characteristics. Although the historical source describes a high malignancy proportion among prepubertal ovarian tumors, this should not be applied to all pediatric ovarian cysts, most of which are benign.
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Teratoma is an important ovarian germ cell tumor that should be considered in the differential diagnosis.
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Genitourinary Rhabdomyosarcoma
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Rhabdomyosarcoma is a malignant mesenchymal tumor that may arise from several structures within the genitourinary system.
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Approximately 15–20% of rhabdomyosarcomas involve genitourinary sites, including the urinary bladder, prostate, paratesticular tissues, vulva, vagina, and uterus.
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The two major histological categories described in the original source are embryonal and alveolar rhabdomyosarcoma.
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Embryonal rhabdomyosarcoma is the more common form, particularly in younger children.
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Alveolar rhabdomyosarcoma has historically been associated with a less favorable prognosis, especially when specific FOXO1 gene fusions are present.
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Gastrointestinal Masses
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Gastrointestinal abnormalities account for approximately 12% of neonatal abdominal masses according to the original source.
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Important causes include intestinal duplication cysts, hypertrophic pyloric stenosis, meconium-related cysts, omental cysts, and mesenteric cysts.
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Intestinal Duplication Cysts
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Intestinal duplication cysts are congenital abnormalities that develop along the gastrointestinal tract.
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They may contain fluid and present as cystic abdominal masses.
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The ileum is the most common location, followed by the esophagus and duodenum.
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Hypertrophic Pyloric Stenosis
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Hypertrophic pyloric stenosis results from thickening of the pyloric muscle, producing gastric outlet obstruction.
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Affected infants typically present with progressive nonbilious vomiting and may have a palpable, firm, olive-shaped mass in the upper abdomen.
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Other Gastrointestinal Cysts
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Additional cystic abdominal lesions include meconium cysts, omental cysts, mesenteric cysts, and other congenital intestinal cystic abnormalities.
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The clinical presentation depends on the lesion’s size, location, and whether it causes bowel obstruction or compression of adjacent structures.
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Hepatobiliary Masses
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Primary liver tumors are important causes of solid abdominal masses in children.
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The original source describes primary hepatic tumors as the third most common category of solid abdominal masses in childhood, accounting for approximately 15% of cases in the population described.
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Benign Hepatic Lesions
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Benign liver lesions account for approximately one-third of pediatric hepatic tumors in the original source.
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Examples include hepatic hemangioendothelioma, mesenchymal hamartoma, hepatic adenoma, focal nodular hyperplasia, and congenital hepatic cysts.
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Malignant Hepatic Tumors
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Malignant lesions account for approximately two-thirds of primary pediatric hepatic tumors in the original source.
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Hepatoblastoma is the most common malignant liver tumor in young children and typically presents before five years of age.
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Hepatocellular carcinoma is more frequently encountered in older children and adolescents, including those between 12 and 15 years of age.
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Splenic Masses
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Splenic enlargement or focal splenic abnormalities may present as masses in the left upper abdomen.
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Potential causes include congenital splenic cysts and hematological disorders associated with splenomegaly.
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Important hematological conditions include hemoglobinopathies, thalassemia, and hereditary spherocytosis.
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Lymphoma
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Lymphoma is an important malignant cause of abdominal masses in older children, particularly boys older than five years.
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Non-Hodgkin lymphoma is a major category of childhood lymphoma and may involve abdominal lymph nodes or gastrointestinal structures.
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The original source reports that approximately one-third of non-Hodgkin lymphoma cases involve the abdomen.
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Abdominal lymphoma may present with pain, distension, a palpable mass, or intestinal complications such as intussusception.
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5. TREATMENT
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General Measures
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Initial management should focus on assessing and stabilizing the child’s clinical condition.
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Urgent attention may be required for respiratory compromise, dehydration, hemodynamic instability, urinary obstruction, intestinal obstruction, infection, or significant renal dysfunction.
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Definitive treatment depends on the underlying diagnosis, anatomical origin of the mass, associated complications, and whether the lesion is benign or malignant.
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Medication
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First-Line Treatment
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Neuroblastoma
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Management of neuroblastoma follows a risk-adapted multidisciplinary approach.
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Treatment may include chemotherapy, surgical resection, radiotherapy, immunotherapy, and hematopoietic stem cell transplantation, depending on the disease risk group.
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Risk classification incorporates factors such as age at diagnosis, disease stage, MYCN amplification, tumor histology, chromosomal abnormalities, and other biological features.
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The original source refers to the International Neuroblastoma Staging System (INSS), DNA ploidy, and Shimada histopathological classification. Contemporary treatment approaches also use updated risk classification and pretreatment staging systems.
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Rhabdomyosarcoma
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Chemotherapy is an essential component of treatment for most children with rhabdomyosarcoma.
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It is commonly combined with surgery, radiotherapy, or both, depending on tumor location, size, extent, histology, and treatment response.
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For bladder and prostate rhabdomyosarcoma, organ-preserving treatment strategies are preferred whenever oncologically appropriate.
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The original source emphasizes chemotherapy before radiotherapy or surgical resection in many cases, with exceptions for selected tumors suitable for immediate surgical removal.
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Wilms Tumor
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Treatment of Wilms tumor generally combines surgical management with chemotherapy, and radiotherapy is added for selected patients.
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The specific chemotherapy regimen depends on tumor stage, histology, molecular risk factors, and the treatment protocol used.
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North American treatment strategies have historically followed recommendations developed through the National Wilms Tumor Study Group (NWTSG) and subsequent cooperative studies.
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European approaches developed by the International Society of Paediatric Oncology (SIOP) commonly favor preoperative chemotherapy for many children with Wilms tumor.
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Second-Line Treatment
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There is no universal second-line treatment applicable to all pediatric abdominal masses.
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Management of recurrent, refractory, or progressive disease depends on the specific diagnosis and may require additional chemotherapy, surgery, radiotherapy, targeted treatment, or other specialized interventions.
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Surgery and Other Procedures
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Surgical management is determined by the underlying pathological process.
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Tumors may require biopsy, complete excision, partial organ resection, or more extensive oncological surgery.
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Obstructive abnormalities of the urinary tract may require procedures to restore adequate urine drainage and preserve renal function.
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Infectious complications may require drainage or surgical intervention when medical treatment alone is insufficient.
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The timing and extent of surgery should be individualized according to the patient’s condition, diagnosis, and expected benefits of intervention.
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6. ADDITIONAL TREATMENT
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Radiation Therapy
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Rhabdomyosarcoma
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Radiotherapy is an important component of multidisciplinary treatment for selected children with rhabdomyosarcoma.
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It may be combined with chemotherapy and surgical excision to achieve local tumor control and improve the likelihood of cure.
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The need for radiation depends on the tumor’s location, stage, histology, surgical margins, and response to systemic treatment.
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Wilms Tumor
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Radiotherapy may be required in children with more advanced Wilms tumor, selected cases of favorable-histology disease, or tumors containing focal or diffuse anaplasia.
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Treatment decisions depend on stage, histological findings, surgical results, and the specific treatment protocol.
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Additional Therapies
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Neuroblastoma
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High-risk neuroblastoma may require intensive multimodal treatment that includes high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation.
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Additional therapies may include anti-GD2 immunotherapy, radiotherapy, and maintenance treatment depending on the applicable clinical protocol.
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Treatment is coordinated by a multidisciplinary pediatric oncology team.
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Complementary and Alternative Therapies
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No specific complementary or alternative therapy is established as a replacement for evidence-based treatment of pediatric abdominal masses.
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Supportive interventions may be considered when appropriate, provided they do not interfere with conventional medical or surgical management.
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7. ONGOING CARE
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Prognosis
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The prognosis of an abdominal mass in a newborn or child depends on the underlying diagnosis.
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Benign congenital and cystic lesions often have favorable outcomes, particularly when renal function is preserved and significant obstruction is absent.
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Malignant tumors require individualized prognostic assessment based on disease stage, histological subtype, molecular characteristics, age at diagnosis, and response to treatment.
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Complications
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Potential complications depend on the disease process and the treatment administered.
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Renal abnormalities may result in urinary tract infection, hypertension, urinary obstruction, progressive renal impairment, or chronic kidney disease.
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Malignant tumors may cause local compression, metastatic spread, or systemic complications.
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Treatment-related complications may include surgical morbidity, chemotherapy toxicity, radiation-related effects, and long-term organ dysfunction.
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Follow-Up
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Patient Monitoring
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Follow-up schedules should be tailored to the specific disease and treatment received.
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Children with congenital renal abnormalities may require serial ultrasonography, renal function assessment, blood pressure monitoring, and evaluation for urinary tract infections.
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Patients treated for malignancy require structured surveillance for recurrence, treatment complications, and long-term effects on growth, development, and organ function.
⠀
Children with hereditary cancer predisposition syndromes may also require specialized surveillance programs.
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Patient Resources
⠀
Disease-specific patient and family educational resources should be provided where available.
⠀
Families may benefit from counseling regarding the diagnosis, expected clinical course, treatment options, possible complications, and long-term follow-up requirements.
⠀
8. REFERENCES
⠀
- Becker AM. Postnatal evaluation of infants with an abnormal antenatal renal sonogram. Current Opinion in Pediatrics. 2009;21:207–213.
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- Golden CB, Feusner JH. Malignant abdominal masses in children: Quick guide to evaluation and diagnosis. Pediatric Clinics of North America. 2002;49:1369–1392.
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- Miller RJ, Breech LL. Surgical correction of vaginal anomalies. Clinical Obstetrics and Gynecology. 2008;51:223–236.
⠀
Additional Reading
⠀
Isaacs H. Fetal and neonatal hepatic tumors. Journal of Pediatric Surgery. 2007;42:1797–1803.
⠀
Related Topics
⠀
Abdominal mass in newborns and children is closely related to several important pediatric urological and oncological conditions.
⠀
Relevant subjects include hydrocolpos and hydrometrocolpos, hydronephrosis and hydroureteronephrosis, multicystic dysplastic kidney, neuroblastoma, polycystic kidney disease, pediatric rhabdomyosarcoma, ureteropelvic junction obstruction, and Wilms tumor (nephroblastoma).
⠀
9. DIAGNOSTIC CODES
⠀
ICD-9
⠀
753.14: Polycystic kidney, autosomal recessive.
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789.3: Abdominal or pelvic swelling, mass, or lump.
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789.30: Abdominal or pelvic swelling, mass, or lump, unspecified site.
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ICD-10
⠀
C64.9: Malignant neoplasm of unspecified kidney, except renal pelvis.
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C74.90: Malignant neoplasm of unspecified part of unspecified adrenal gland.
⠀
Q61.19: Other polycystic kidney, infantile type.
⠀
These codes are reproduced from the original source. Their applicability and current validity should be verified against the coding system and edition used in the relevant healthcare setting.
⠀
10. CLINICAL AND SURGICAL PEARLS
⠀
Importance of Age at Presentation
⠀
The age at which an abdominal mass is identified provides valuable information for narrowing the differential diagnosis.
⠀
Congenital renal abnormalities and benign cystic lesions are particularly common during the neonatal period and early infancy.
⠀
As children become older, the relative likelihood of certain malignant abdominal tumors increases.
⠀
Consequently, age should always be considered alongside clinical findings, imaging characteristics, and associated symptoms.
⠀
Differentiating UPJ Obstruction From Multicystic Dysplastic Kidney
⠀
Ureteropelvic junction obstruction and multicystic dysplastic kidney are two important causes of neonatal abdominal masses.
⠀
Both conditions may produce an enlarged kidney or a cystic-appearing renal mass, but they differ in renal architecture and function.
⠀
A kidney affected by UPJ obstruction generally retains some degree of function, although urinary drainage may be impaired.
⠀
In contrast, a typical multicystic dysplastic kidney is nonfunctioning or has minimal residual function.
⠀
Ultrasonography is usually the primary investigation for distinguishing these conditions. When additional functional assessment is required, radionuclide renal scanning can help demonstrate preserved function in an obstructed kidney and absent function in MCDK.
⠀
Age-Related Patterns of Pediatric Malignancy
⠀
The types of malignant abdominal tumors encountered in children vary with age.
⠀
Neuroblastoma and hepatoblastoma are particularly important malignancies to consider in children younger than two years.
⠀
In older children, Wilms tumor, hepatocellular carcinoma, genitourinary malignancies, and germ cell tumors become increasingly relevant to the differential diagnosis.
⠀
However, age alone cannot establish or exclude a diagnosis, and each child requires evaluation based on clinical presentation and appropriate investigations.
⠀
Distinguishing Renal and Adrenal Masses
⠀
The anatomical origin of a mass provides important diagnostic information.
⠀
Renal masses such as Wilms tumor commonly arise within the kidney and may distort the renal collecting system.
⠀
Adrenal neuroblastoma may displace the kidney and can extend across the midline or encase adjacent vessels.
⠀
Ultrasonography, CT, or MRI can help distinguish these lesions by identifying their organ of origin, vascular relationships, and internal characteristics.
⠀
Recognizing Conditions Requiring Urgent Intervention
⠀
Not all pediatric abdominal masses require immediate surgery, but certain clinical findings demand urgent evaluation.
⠀
These include bilious vomiting suggestive of intestinal obstruction, respiratory compromise associated with massive abdominal distension, severe urinary obstruction, hemodynamic instability, significant hemorrhage, and suspected sepsis.
⠀
Prompt stabilization and multidisciplinary assessment are essential when these features are present.
⠀
Importance of Multidisciplinary Management
⠀
The evaluation and treatment of pediatric abdominal masses frequently require collaboration among pediatricians, pediatric urologists, pediatric surgeons, radiologists, nephrologists, pathologists, and pediatric oncologists.
⠀
A coordinated approach improves diagnostic accuracy, supports appropriate treatment selection, and helps minimize unnecessary procedures and long-term complications.
⠀
Note: This article is a paraphrased and reorganized version of the supplied educational material. Some epidemiological figures, genetic classifications, treatment protocols, and prognostic estimates reflect older literature. Selected terminology and clinical explanations have been updated for accuracy, but contemporary pediatric urology and oncology guidelines should be consulted for clinical decision-making.
- Published on
Urology - ABDOMINAL MASS IN ADULTS: UROLOGIC CONSIDERATIONS
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1. BASICS
⠀
Description
⠀
In adults, abdominal masses of urologic origin are most commonly located in the retroperitoneal space. These masses may arise from various anatomical structures and can represent either benign or malignant conditions.
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Renal masses may originate from benign or malignant lesions of the kidney, while adrenal masses may arise from primary adrenal pathology. Retroperitoneal lymphadenopathy can occur secondary to germ cell tumors or other metastatic malignancies. Additional causes of retroperitoneal masses include retroperitoneal fibrosis (RPF), hematomas, abscesses, lymphoceles, lymphoma, and urinary retention.
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Epidemiology
⠀
Incidence
⠀
Renal cell carcinoma (RCC) is an important cause of adult urologic masses. The original source reports approximately 55,000 new cases annually and notes an increasing incidence. Testicular cancer is reported to account for approximately 8,000 new cases per year. These figures reflect the source material and should not be interpreted as current incidence estimates.
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Prevalence
⠀
The prevalence of abdominal masses of urologic origin varies considerably according to the underlying disease, anatomical location, and pathological characteristics.
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Risk Factors
⠀
Several clinical factors may predispose individuals to developing abdominal masses of urologic origin. Malignancies involving the kidneys, adrenal glands, or testes are important considerations. A history of previous abdominal or pelvic surgery may contribute to lymphocele formation, whereas infections can result in abscesses or may be associated with retroperitoneal fibrosis.
⠀
Abdominal or retroperitoneal trauma may lead to hematoma or urinoma formation. In addition, significant urinary retention can produce a palpable lower abdominal mass due to bladder distension.
⠀
Genetic Factors
⠀
Certain hereditary genetic alterations and syndromes are associated with the development of renal lesions, particularly renal tumors.
⠀
These include von Hippel–Lindau (VHL) disease, hereditary papillary renal cell carcinoma, Birt–Hogg–Dubé syndrome, hereditary leiomyomatosis and renal cell cancer syndrome, and tuberous sclerosis complex.
⠀
Pathophysiology
⠀
A broad spectrum of urologic disorders can manifest as abdominal or retroperitoneal masses. The underlying pathology may involve neoplastic, obstructive, infectious, traumatic, cystic, or metastatic processes.
⠀
Primary Renal Neoplasms
⠀
Primary renal tumors may be either malignant or benign. Malignant renal neoplasms include renal cell carcinoma, renal sarcoma, adult Wilms tumor, urothelial carcinoma, and renal lymphoma.
⠀
Benign renal tumors include renal cortical adenoma, renal oncocytoma, angiomyolipoma (renal hamartoma), and renal fibroma. Although these lesions are nonmalignant, some may produce a detectable abdominal mass depending on their size and anatomical location.
⠀
Primary Adrenal Neoplasms
⠀
Adrenal masses may develop from several types of adrenal tumors. These include adrenocortical carcinoma, pheochromocytoma, and adrenal adenoma. Paragangliomas, which arise from extra-adrenal paraganglionic tissue, may also present as retroperitoneal masses.
⠀
Hydronephrosis
⠀
Hydronephrosis involves dilation of the renal collecting system resulting from impaired urinary drainage. When severe, the affected kidney may become sufficiently enlarged to produce a palpable abdominal or flank mass.
⠀
Germ Cell Tumors
⠀
Germ cell tumors may arise primarily from the testes or occur at extragonadal sites. Their histological components include seminoma, embryonal carcinoma, yolk sac tumor, teratoma, and choriocarcinoma.
⠀
Primary extragonadal germ cell tumors can develop within the abdomen, including retroperitoneal or intraperitoneal locations. Metastatic germ cell tumors frequently involve the retroperitoneal lymph nodes, resulting in lymphadenopathy that may appear as an abdominal mass.
⠀
Renal Abscess
⠀
Renal abscesses frequently develop following inadequately treated focal bacterial nephritis, also known as lobar nephronia. In selected cases, image-guided needle aspiration may be required to establish the diagnosis and identify the causative organism.
⠀
Renal tuberculosis can also lead to the formation of a cold abscess. Purulent material originating from the kidney may extend along the psoas muscle and track toward the groin. When this occurs, the resulting groin swelling may resemble an inguinal hernia and must be distinguished from it clinically.
⠀
Perinephric Abscess
⠀
Perinephric abscesses usually develop in association with pre-existing renal or urinary tract abnormalities. Predisposing conditions include renal or ureteric calculi, hydronephrosis, renal cystic disease, and infected renal carcinoma.
⠀
Retroperitoneal Hematoma
⠀
Retroperitoneal hematomas may result from renal rupture or ureteric avulsion following trauma. Blood accumulating within the retroperitoneal compartment can extend toward the ipsilateral iliac fossa, potentially presenting as an abdominal mass.
⠀
Renal Cysts
⠀
Renal cystic lesions may also present as abdominal masses, particularly when they are large. These lesions may be simple or complex, and their clinical significance depends on their imaging characteristics and underlying pathology.
⠀
Bladder-Related Masses
⠀
Abnormalities involving the urinary bladder can produce lower abdominal masses. Important causes include urinary retention with bladder distension, bladder tumors, urachal abnormalities, and bladder malignancy.
⠀
Metastatic Tumors
⠀
Secondary malignant deposits involving the kidneys or adrenal glands can also manifest as abdominal or retroperitoneal masses. Such lesions should be considered particularly in individuals with a known history of malignancy.
⠀
Associated Conditions
⠀
Several systemic and local disorders may accompany urologic abdominal masses.
⠀
Hydronephrosis and renal insufficiency may occur as a result of urinary tract obstruction, particularly when caused by malignant disease. Retroperitoneal fibrosis may be associated with inflammatory involvement of the aorta, including aortitis and abdominal aortic aneurysm.
⠀
Renal cell carcinoma may also be associated with Stauffer syndrome, a paraneoplastic condition characterized by hepatic dysfunction in the absence of liver metastases.
⠀
General Prevention
⠀
No specific general preventive measures are described, as the underlying causes of adult urologic abdominal masses are diverse.
⠀
2. DIAGNOSIS
⠀
Clinical History
⠀
A detailed clinical history is essential when evaluating an adult patient with an abdominal mass. Particular attention should be given to constitutional symptoms, infectious features, previous trauma, and any history suggestive of urologic malignancy.
⠀
Constitutional Symptoms
⠀
Unintentional weight loss, cachexia, and night sweats may suggest an underlying malignant process or chronic infectious disease. These symptoms should raise suspicion for systemic pathology, particularly when associated with an unexplained abdominal mass.
⠀
Infectious Symptoms
⠀
Intermittent high-grade or spiking fever accompanied by flank pain may indicate an infectious process, such as a renal or perinephric abscess. The presence of systemic inflammatory symptoms further supports an infectious etiology.
⠀
History of Trauma
⠀
A recent history of abdominal, flank, or pelvic trauma should prompt consideration of renal or ureteric injury with associated hematoma or urinoma formation. Hematuria may be present but is not always observed.
⠀
History of Testicular Mass
⠀
A previous or current testicular mass is clinically important because testicular germ cell tumors may metastasize to the retroperitoneal lymph nodes and present as an abdominal mass.
⠀
Classical Presentation of Renal Cell Carcinoma
⠀
The classical triad of renal cell carcinoma consists of hematuria, flank pain, and a palpable abdominal mass. However, this combination is relatively uncommon in contemporary clinical practice, as many renal tumors are detected incidentally during imaging performed for unrelated reasons.
⠀
Physical Examination
⠀
A comprehensive abdominal and urologic examination is required to identify the mass, determine its likely origin, and detect associated clinical abnormalities.
⠀
Assessment of Abdominal Masses
⠀
Physical examination can help distinguish masses originating from the abdominal wall, such as lipomas, hematomas, enlarged lymph nodes, and hernias, from deeper intra-abdominal or retroperitoneal lesions.
⠀
Any palpable abdominal mass should be assessed for its anatomical location, size, consistency, mobility, and tenderness. These findings may provide valuable clues regarding the underlying pathology.
⠀
Examination of the Umbilicus
⠀
The umbilical region should be inspected for abnormal mucoid discharge, which may suggest an underlying urachal abnormality.
⠀
Blood Pressure Assessment
⠀
Blood pressure should be measured because hypertension may accompany certain renal and adrenal disorders, including hormonally active adrenal tumors.
⠀
Lymph Node Examination
⠀
The presence of peripheral lymphadenopathy should be evaluated, as enlarged lymph nodes may indicate metastatic malignancy, lymphoma, or infectious disease.
⠀
Lower Limb Examination
⠀
The lower extremities should be examined for edema, which may occur as a result of venous or lymphatic obstruction caused by a large retroperitoneal mass.
⠀
Peripheral pulses should also be assessed, particularly when vascular pathology or retroperitoneal fibrosis is suspected.
⠀
Assessment for Varicocele
⠀
The scrotum should be examined for the presence of a varicocele. A new-onset varicocele, particularly one that is right-sided, nonreducible, or persists when supine, may warrant evaluation for retroperitoneal pathology. A renal mass causing renal venous obstruction is one possible explanation.
⠀
Scrotal Examination
⠀
A thorough scrotal examination is important to identify testicular masses or other abnormalities that may indicate a primary testicular malignancy with retroperitoneal metastasis.
⠀
3. DIAGNOSTIC TESTS AND INTERPRETATION
⠀
Laboratory Investigations
⠀
Laboratory studies are selected according to the suspected origin of the mass and associated clinical findings.
⠀
Complete Blood Count and Metabolic Profile
⠀
A complete blood count (CBC) and comprehensive metabolic panel should be obtained to assess hematological abnormalities, renal function, electrolyte disturbances, and other biochemical changes that may accompany malignancy, infection, or urinary obstruction.
⠀
Urinalysis and Urine Culture
⠀
Urinalysis and urine culture are important in evaluating possible urinary tract infection, hematuria, or other urinary abnormalities associated with renal and bladder pathology.
⠀
Adrenal Hormonal Evaluation
⠀
When an adrenal mass is suspected, appropriate hormonal or metabolic investigations should be performed to determine whether the lesion is hormonally active. The specific investigations depend on the clinical presentation and suspected adrenal pathology.
⠀
Tumor Markers
⠀
Serum tumor markers are particularly important when a testicular germ cell tumor is suspected. The principal markers are alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH).
⠀
AFP may be elevated in nonseminomatous germ cell tumors containing embryonal carcinoma or yolk sac tumor components, including some mixed germ cell tumors. However, AFP is not produced by pure seminoma or pure choriocarcinoma.
⠀
LDH may be elevated in patients with substantial tumor burden, including retroperitoneal involvement. Nevertheless, LDH is nonspecific and cannot independently establish the diagnosis of testicular cancer.
⠀
Pregnancy Testing
⠀
Pregnancy testing should be performed when clinically appropriate, especially before investigations or procedures that may expose a patient to ionizing radiation or potentially harmful medications.
⠀
Imaging Investigations
⠀
Radiological imaging plays a central role in identifying the anatomical origin, internal characteristics, extent, and possible complications of abdominal masses.
⠀
Ultrasonography
⠀
Ultrasonography is particularly useful for identifying cystic lesions and differentiating fluid-filled masses from solid structures. It is widely available and does not expose patients to ionizing radiation.
⠀
However, ultrasonography has limitations in evaluating certain calcified masses and small urinary calculi. Diagnostic accuracy may also vary according to operator experience and technical factors.
⠀
Computed Tomography (CT)
⠀
Computed tomography is valuable for detecting and characterizing solid abdominal masses, urinary calculi, and metastatic lesions. It provides detailed anatomical information and helps determine the relationship of a mass to adjacent organs and structures.
⠀
CT angiography may be performed when detailed evaluation of the renal vasculature is required.
⠀
PET-CT may have a role in selected circumstances involving suspected metastatic renal cell carcinoma, although it is not routinely recommended for the initial assessment or staging of RCC.
⠀
Magnetic Resonance Imaging (MRI)
⠀
Magnetic resonance imaging is useful for characterizing adrenal lesions and evaluating renal masses that remain indeterminate after other imaging investigations.
⠀
MRI may be an alternative when iodinated CT contrast cannot be administered, including in some patients with contrast allergies or renal impairment. Nevertheless, patients with significant renal dysfunction require careful consideration before receiving gadolinium-based contrast agents.
⠀
Iodine-131 Metaiodobenzylguanidine (MIBG) Imaging
⠀
Iodine-131 metaiodobenzylguanidine imaging is a specialized nuclear medicine investigation that may be used in the evaluation of pheochromocytoma and related catecholamine-producing tumors. Its application depends on the clinical indication and availability of other functional imaging modalities.
⠀
Intravenous Pyelography / Excretory Urography
⠀
Intravenous pyelography, also known as excretory urography, was historically used to evaluate the kidneys and urinary collecting system. However, it has largely been replaced by more advanced imaging techniques, particularly CT urography and MR urography.
⠀
Diagnostic Procedures and Surgery
⠀
Fine-Needle Aspiration and Core Biopsy
⠀
Fine-needle aspiration or core needle biopsy may be performed when tissue sampling is necessary to establish a definitive diagnosis.
⠀
For renal masses, the diagnostic performance of biopsy can be improved through the use of coaxial core needle techniques, which allow multiple tissue samples to be obtained through a single introducer needle.
⠀
The decision to perform a biopsy depends on the suspected pathology, imaging findings, potential risks, and whether the histological result is likely to influence clinical management.
⠀
Pathological Findings
⠀
The histopathological characteristics of an abdominal mass depend on its anatomical origin and underlying disease process.
⠀
Pathological findings may demonstrate benign or malignant neoplasia, inflammatory or infectious changes, cystic abnormalities, hemorrhage, or metastatic disease.
⠀
Definitive pathological assessment, when indicated, helps establish the diagnosis and guides subsequent treatment planning.
⠀
