Demonstration of intrinsic innervation of the guinea pig upper urinary tract using whole-mount preparation

AIMS: The morphology and functional importance of the autonomic nervous system in the upper urinary tract is still not completely understood. Previous histological studies investigating the innervation of the urinary tract have mainly used conventional sections in which the three-dimensional structure of the intramural innervation is difficult to achieve. In contrast, the whole-mount preparation technique is a suitable method for visualizing the distribution of the mesh-like neuronal networks within the urinary tract. METHODS: The distribution and regional variation of neurofilament (NF), tyrosine hydroxylase (TH), choline acetyltransferase (ChAT), and substance P-immunoreactive (SP-IR) neurons, as well as acetylcholinesterase (AChE) and nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d)-positive neurons were investigated using whole-mount preparations of the guinea pig upper urinary tract. RESULTS: Two distinct nervous plexuses were detected within the muscle layers containing NF, TH, ChAT, and SP-IR nerves. AChE-positive nerves were seen in all layers. Only moderate NADPH-d-positive innervation was found. Renal pelvis, upper and lower part of the ureter showed an overall increased innervation compared to the middle portion of the ureter. Ganglia were found at the pelviureteric border displaying NF and TH immunoreactivity. CONCLUSION: The whole-mount preparation technique provides an elegant method for assessing the three-dimensional architecture of ureteral innervation. The guinea pig upper urinary tract is richly supplied with adrenergic, cholinergic, nitrergic, and sensory nerves which suggest that the autonomous nervous system plays an important role in controlling ureteral motility and blood flow.     

Trans-pyeloureteric anastomosis in the management of pelviureteric junction obstruction

Background : The application of pyeloureteric anastomoses in the management of pelviureteric junction obstruction is described. Methods : Two patients, one requiring a ureterocystoplasty for bladder augmentation but with a coexistent contralateral pelviureteric junction (PUJ) obstruction and the other with gross hydronephrosis but an atretic ipsilateral ureter, underwent trans‐pyeloureteric anastomosis to relieve the obstruction. Results : Both patients demonstrated satisfactory drainage of the upper tracts on postoperative imaging. Conclusions : Transureteropyeloplasty represents a novel and valid technique of urinary tract reconstruction in complex cases of PUJ obstruction.     

Pelvi-ureteric junction obstruction by crossing renal vessels: clinical and imaging features

OBJECTIVE: To present the characteristic clinical and imaging findings of pelvi-ureteric junction (PUJ) obstruction caused by crossing renal vessels (CRV), as it presents particular features within the spectrum of congenital hydronephrosis. PATIENTS AND METHODS: Between April 1982 and December 2000, 384 children underwent surgery for PUJ obstruction. In 71 (18.5%; mean age 8.5 years, range 2 months to 14 years; 49 aged> 5 years), the obstruction was caused by CRV. The data collected from the medical records of these patients were analysed for their clinical presentation and imaging findings, i.e. ultrasonography (US), intravenous urography (IVU) and diuretic renography. RESULTS: The main presenting symptom was recurrent renal colic (pain, nausea, vomiting) in 59%, followed by urinary infection (UTI) in 20%, gross haematuria in 11% and an incidental diagnosis in 10%. By contrast, in the 313 children with intrinsic PUJ obstruction, renal colic was present in only 10.5%. Moreover, from 1991 to 2000, when the use of prenatal US became widespread, hydronephrosis was detected prenatally in 42 of 212 children (20%) with intrinsic PUJ obstruction, but in only two of 31 (6%) with obstruction by CRV. However, in 10 children with CRV operated on during this period, prenatal US had shown mild hydronephrosis (< 15 mm), which during the follow-up decreased until the children became symptomatic after 5-9 years (eight renal colic, two UTI). US during acute symptoms showed significant hydronephrosis (> 25 mm), and colour Doppler US of two patients directly showed the CRV. In all 71 children with CRV obstruction diuretic IVU and renography during the acute symptoms had an obstructive pattern, and in 24 renal colic was reproduced during the examination. The differential kidney function was < 40% in 11 children who presented with UTI; two required nephrectomy and in the remaining 69 an Anderson-Hynes pyeloplasty, after which none had an episode of renal colic or UTI during a mean (range) follow-up of 10.2 (2-20) years. CONCLUSIONS: PUJ obstruction by CRV should be suspected in older children presenting with recurrent renal colic and hydronephrosis. Good kidney function is expected in most of these children, despite their age, because the vascular obstruction is intermittent. Mild prenatal hydronephrosis that could decrease postnatally does not exclude the possibility of vascular obstruction, which may later become symptomatic. Imaging (US, diuretic IVU and renography) during an episode of pain is essential and colour Doppler US could help to establish the diagnosis in these cases. Knowing that a child has a CRV is important for choosing an open surgical approach rather than endoscopic pyelotomy, to avoid potential complications     

磁共振水成像在上尿路梗阻疾病诊断中的应用价值

目的：探讨磁共振水成像在上尿路梗阻所致肾积水病因诊断中的临床应用价值。方法：收集86例上尿路梗阻所致。肾积水患者，包括输尿管良性狭窄、输尿管肿瘤、尿路结石和先天性畸形疾病，通过对疾病治疗前影像学诊断结果的对比分析，并基于术中所见及术后病理结果证实，评价MRU在尿路梗阻性疾病病因诊断中的应用价值。结果：对于尿路梗阻性扩张，MRU能显示其梗阻部位和程度，定位准确率达100％（86／86）。其中76例解剖结构清晰，可对梗阻作出定性诊断，并经手术及病理结果证实，准确率为88.4％（76／86）。对先天性肾积水的定位定性诊断率达91.7％（33／36），明显高于B超及静脉肾盂造影（P〈0.05）。结论：MRU足无创伤性检查方法，不接触射线，不需碘对比剂，对尿路梗阻性疾病定位、定性诊断准确，是可以替代创伤性检查的可靠方法，对儿童及不能耐受传统静脉肾盂造影者可作为首选方法。     

Innervation of congenitally hydronephrotic and normal porcine upper urinary tract

OBJECTIVE: To investigate the intrinsic innervation of the upper urinary tract in congenitally hydronephrotic and normal Goettingen minipigs, using the whole-mount preparation technique. MATERIALS AND METHODS: Whole-mount preparations of hydronephrotic (two with bilateral ectopic ureters, one with left distal ureteric stenosis) and normal (three) porcine upper urinary tracts were examined by immunohistochemistry with tyrosine hydroxylase (TH) and neurofilament and by histochemical staining with NADPH-diaphorase and acetylcholinesterase. Staining results were evaluated using normal bright-field and confocal laser scanning microscopy. RESULTS: Neurofilament-, TH-immunoreactive and acetylcholinesterase-positive nerve fibres and neuronal networks were identified in the adventitial, muscle and subepithelial layers of the whole upper urinary tract. An NADPH-diaphorase-positive network was expressed in the subepithelial layer and less densely in the muscle layer. The general distribution of the identified neuronal networks was similar in hydronephrotic and normal upper urinary tracts, but the density of these neuronal networks was less in the former. The most striking observation was the absence or marked reduction of neuronal networks in the stenotic part of the ureter in the pig with left distal ureteric stenosis. CONCLUSION: Whole-mount preparations provide a method for assessing the three-dimensional topography of neuronal networks in the different layers of the porcine upper urinary tract. Although the macroscopic differences between the hydronephrotic and normal porcine upper urinary tracts were striking, changes in the innervation pattern were less obvious, except in distal ureteric stenosis.     

磁共振尿路水成像对诊断上尿路梗阻病变的价值

目的：探讨磁共振尿路水成像(MRU)对诊断上尿路梗阻病变的价值。方法：回顾分析了52例上尿路梗阻患者的MRU的临床资料。结果：52例患者经过MRU检查均能显示梗阻的部位，50例与手术后诊断或治疗后明确的诊断相符合，2例误诊。结论：MRU能准确地显示尿路梗阻病变的部位和大小，具有无创伤、无痛苦、无辐射、不需造影剂及多平面成像能力等特点，比临床上常用的B超、静脉肾盂造影、逆行肾盂造影等检查具有一定的优越性。     

Role of i.v. urography in patients with haematuria

OBJECTIVE: Traditionally, patients presenting with haematuria undergo a series of investigations, including urine cytology, cystoscopy, i.v. urography (IVU) and renal tract ultrasound (US). Studies have suggested that the omission of IVU as a routine investigation for painless haematuria does not dramatically reduce the detection rate of malignant conditions. In this large retrospective study we evaluated the impact of the omission of IVU on the diagnosis of renal tract malignancies and other non-malignant but significant conditions. MATERIAL AND METHODS: A retrospective analysis of all patients attending our haematuria clinic between January 2000 and August 2002 was carried out. The diagnostic yields of IVU and a US scan were compared and the significance of abnormalities missed by either modality was assessed with regard to the overall management of patients. Diagnoses were divided into those that were significant and potentially harmful [e.g. tumour, pelvi-ureteric junction (PUJ) obstruction, hydronephrosis] and those that were insignificant and harmless (e.g. simple cyst, non-obstructing calculus). Liddell's exact test for matched pairs was used to test for statistical significance and to give the relative risk of a positive result. RESULTS: A total of 1211 patients were included in the study. When cytology, cystoscopy and US were normal, IVU did not detect any additional malignant pathology. Performing IVU instead of a US scan would have resulted in 74 non-malignant conditions remaining undiagnosed. Similarly, US alone would have missed 64 non-malignant lesions. Six non-malignant but significant conditions, including PUJ obstruction (n = 5) and benign ureteric stricture with hydronephrosis (n = 1), were missed by US but detected by IVU. CONCLUSION: In this cohort of retrospectively studied patients attending a haematuria clinic, IVU could safely have been omitted without decreasing the overall detection of malignant pathologies. Nevertheless, significant non-malignant pathologies would have remained undiagnosed. The authors suggest that US combined with a MAG III renogram could be considered as a first-line investigation instead of IVU. This is likely to result in maximum detection of malignant and non-malignant conditions, while reducing the radiation exposure to the patient.     

磁共振尿路造影在上尿路梗阻诊断中的应用

目的　评估磁共振尿路造影技术在诊断上尿路梗阻性疾患中的价值。　方法　采用磁共振尿路造影术（ Ｍ Ｒ Ｕ） 诊断上尿路梗阻患者３５ 例。　结果　所有病例均清晰显示梗阻部位及尿路积水情况。　结论　 Ｍ Ｒ Ｕ 是一种无创性、无需造影剂的诊断上尿路梗阻的方法。     

DEMONSTRATION OF NEURONAL NETWORKS IN THE HUMAN UPPER URINARY TRACT USING CONFOCAL LASER SCANNING MICROSCOPY

PURPOSE: To our knowledge innervation of the upper urinary tract and its role in motility and sensation are not clearly understood. The whole mount preparation technique provides 3-dimensional (D) morphology of the innervation and its relationship of branching and interconnecting nerve fibers to each other and to the neighboring tissues. Confocal laser scanning microscopy provides dramatic optical advantages for detecting 3-D structures in thick specimens. We investigated the distribution and morphology of the neuronal structures in the human upper urinary tract using the whole mount preparation technique and confocal laser scanning microscopy. MATERIALS AND METHODS: Whole mount preparations of the human renal pelvis and ureter were stained by standard immunohistochemical method using various neuronal markers (protein gene product 9.5, neuron specific enolase and neurofilament). The 3-D architecture of the specimens was investigated with the help of confocal laser scanning microscopy. RESULTS: We detected 2 mesh-like neuronal networks or plexus in the human upper urinary tract. The first and more prominent plexus was located in the submucosa between the lamina propria and tunica muscularis, and the second neuronal network was found between the smooth muscle fibers of the ureteral wall. There were frequent interconnections between the 2 networks in the ureteral wall. CONCLUSIONS: To our knowledge our study shows for the first time that there are 2 well formed mesh-like neuronal plexus in the human upper urinary tract. Our findings suggest that the autonomic nervous system of the human upper urinary tract may have a significant role in the propagation, coordination and modulation of ureteropelvic peristalsis.     

磁共振尿路造影在上尿路梗阻诊断中的

目的 评估磁共振尿路造影技术在诊断上尿路梗阻性疾患中的价值。方法 采用磁共振尿中造影术（ＭＲＵ）诊断上尿路梗阻患者３５例。结果 所有病例均清晰显示梗阻部位及尿路积水情况。结论 ＭＲＵ是一种无创性、无需造影剂的诊断上尿路梗阻的方法。     

Ureteroscopic pyelolysis for pelviureteric junction obstruction

The development of endourological techniques for the treatment of upper urinary tract disease has concentrated mainly on the endoscopic treatment of upper urinary tract stones. The relief of pelviureteric junction obstruction (PUJ) by percutaneous pyelolysis has recently been reported and the use of the flexible uretero-pyeloscope has also been described. We describe the use of a rigid uretero-renoscopy to relieve strictures causing secondary pelviureteric junction obstruction in two cases.     

螺旋CT三维成像在上尿路梗阻诊断中的应用

目的　评价螺旋CT三维成像技术 (3D -sCT)在上尿路梗阻中的应用价值。　方法　对113例上尿路梗阻行肾输尿管 3D -sCT检查 ,用遮盖表面显示法和最大密度投影法进行处理 ,获得立体三维图像 ,并与手术结果对照。　结果　全部病例三维立体形态显示良好 ,可显示病变的部位、形态 ,可从不同的角度和位置观察与周围结构的关系。 88例手术后诊断与 3D -sCT诊断结果完全相符 ,2 4例上尿路结石经 3D -sCT确诊后行体外冲击波碎石 (ESWL)治愈 ,1例腹膜后转移癌压迫输尿管经 3D -sCT确诊后保守治疗。诊断正确率 10 0 % (113/113)。　结论　 3D -sCT可以准确反映上尿路梗阻的部位、病因、程度及与周围结构的关系 ,尤其适于IVU不显影及不能插管行逆行肾盂造影患者。     

Case report: Minimally invasive treatment of an unusual obstructive ectopic upper pole ureter

An 18-year old man presented with left loin pain and recurrent urinary tract infections. Ultrasound and IVU revealed a duplex left kidney with hydronephrosis of the upper pole moiety. F-15 Mag-3 renography confirmed obstruction of the upper pole moiety. Cysto-urethroscopy identified the site of ectopic insertion to be adjacent to the verumontanum in the prostatic fossa. Retrograde ureterography showed the level of obstruction and dilation of the stricture was carried out. Post operatively, the patient became asymptomatic and remains so at 5-year follow up. This is an unusual case of obstructive upper pole ureter with an ectopic insertion into the prostatic fossa. We also demonstrated that dilatation of a stricture at this site can achieve good long term outcome.     

MRU诊断上尿路梗阻性疾病的价值

目的 探讨磁共振尿路造影（MRU）诊断上尿路梗阻性疾病的意义。方法 59例上尿路梗阻性疾病患者接受检查，MRU为冠状位快速自旋回波T2加权像。结果 所有病例MRU尿路梗阻部位及扩张状况均显示良好，其中54例经手术或病理确诊，仅2例术前MRU误诊。结论 MRU作为一种非侵袭性、无辐射损伤和不需造影剂的新技术，对上尿路梗阻性疾病的定位及定性诊断具有特殊价值，是一种可供选择的有临床实用价值的尿路成像方法。     

尿LDH及其同工酶对上尿路梗阻病人肾功能的估价

为了了解尿乳酸脱氢酶（ＬＤＨ）及其同工酶对上尿路梗阻病人肾功能判定的意义，对３１例单侧上尿路梗阻病人，采用比色法测定ＬＤＨ活性，电泳法测定尿ＬＤＨ同工酶。结果：轻、中、重度肾积水组和对照组ＬＤＨ活性分别为２８．２±１７．３、６８．９±３１．７、２２６．１±６６．３、２６．１±１６２ＩＵ／Ｌ，轻度肾积水组与对照组比较无显著性差异，中、重度组之间差异有显著性。轻度组和对照组ＬＤＨ同工酶均正常，中度组３例异常，重度组均异常，且梗阻解除后ＬＤＨ_１、ＬＤＨ_２相对量增加，尤以ＬＤＨ_１增加更明显，ＬＤＨ_４、ＬＤＨ_５有所下降。结果认为：尿ＬＤＨ及其同工酶测定可反映肾实质损害程度，并能估价肾功能恢复情况，可能成为肾功能可复性判定的重要指标之一。     

Is antibiotic prophylaxis necessary in infants with obstructive hydronephrosis?

PURPOSE: We investigated the relationship between the level of obstruction of the upper urinary tract and the risk and onset of urinary tract infection in infants with severe obstructive hydronephrosis to determine the need for antibiotic prophylaxis. MATERIALS AND METHODS: A total of 105 patients were prenatally diagnosed with severe hydronephrosis (Society for Fetal Urology grade III or IV) due to upper urinary tract obstruction between 1994 and 2004. Of these patients 75 had ureteropelvic junction obstruction and 30 had lower ureteral obstruction. We retrospectively evaluated the clinical course and incidence of urinary tract infection during the first 12 months postnatally without antibiotic prophylaxis. RESULTS: The incidence of overall urinary tract infection during followup was 36.2% (38 of 105 patients), and it demonstrated a higher trend with lower ureteral obstruction than with ureteropelvic junction obstruction (50% vs 30.7%, p=0.063). Most cases of urinary tract infection (92.8%) occurred before age 6 months, with a mean age at onset of 2.6 months. Of 105 patients 77 (73.3%) underwent corrective surgery at a mean age of 3.8 months. The incidence of urinary tract infection before surgical correction was 33.8% at a mean age of 2.1 months. The incidence of urinary tract infection in surgical cases was significantly higher with lower ureteral obstruction than with ureteropelvic junction obstruction (54.2% vs 24.5%, p=0.011). CONCLUSIONS: Urinary tract infection in infants with severe obstructive hydronephrosis has a high incidence, occurs before age 6 months and is more common with lower ureteral obstruction than with ureteropelvic junction obstruction. These findings indicate that infants with severe hydronephrosis due to obstruction of the upper urinary tract should receive antibiotic prophylaxis.     

经膀胱镜输尿管双J管置入治疗小儿上尿路梗阻

目的探讨经膀胱镜留置输尿管双J管在小儿上尿路梗阻中的应用价值。方法回顾性分析2014年12月~2018年5月45例膀胱镜输尿管双J管置入治疗上尿路梗阻的资料,其中先天性肾积水20例,急性输尿管结石梗阻23例,肾盂离断成形术后积水复发2例。均经膀胱镜逆行置入F3、F4或F4.7双J管。结果2例先天性肾积水和3例急性输尿管结石梗阻未能置入输尿管双J管,其余40例留置双J管位置良好。先天性肾积水18例均于术后6个月取出双J管,8例随访3~4年积水未加重,10例因积水加重行腹腔镜肾盂离断成形术;急性输尿管结石梗阻20例于1~2周拔除输尿管双J管,二期输尿管镜钬激光碎石成功;肾盂离断成形术后积水复发2例均于术后6个月拔除输尿管双J管,1例随访1年5个月肾积水无再次加重,1例因肾积水再次加重于拔管后20天行腹腔镜肾盂离断成形术。结论输尿管双J管置入可有效缓解小儿上尿路梗阻,达到缓解肾脏压力的目的,可作为婴幼儿和儿童上尿路梗阻的一线治疗方案。     

多层螺旋CT泌尿系成像在上尿路梗阻诊断中的应用

目的 探讨多层螺旋CT泌尿系成像（MSCTU）在上尿路梗阻性疾病中的诊断价值。方法 对17例经B超或IVU检查显示上尿路梗阻患者行螺旋CT扫描，并行3D重建，将诊断结果与手术结果进行对照。结果 MSCTU诊断输尿管结核4例，肾盂输尿管连接部狭窄6例。输尿管末端狭窄2例，输尿管阴性结石3例。输尿管肿瘤1例，腔静脉后输尿管1例，均显示出梗阻部位及尿路扩张的形态。手术结果与MSCTU诊断相符。结论 SCTU是一种安全有效的非侵袭性的影像学检查方法，特别对患肾功能严重受损的上尿路梗阻性疾病患者具有特殊诊断价值。     

急性上尿路结石梗阻的影像学分析

目的：探讨超声、腹部平片（ＫＵＢ）、静脉尿路造影（ＩＶＵ）对急性输尿管结石梗阻的诊断价值。方法：回顾性分析３５２例急性输尿管结石梗阻患者的Ｂ超、利尿性Ｂ超、ＫＵＢ、ＩＶＵ的诊断结果。结果：对肾积水的诊断,常规Ｂ超诊断率８３．２％（２９３／３５２）,而５９例可疑病例利尿性Ｂ超的诊断率７９．７％（４７／５９）,利用常规Ｂ超加利尿Ｂ超检查,对梗阻性肾积水的诊断率９６．６％（３４０／３５２）;对输尿管结石     

Case report: Minimally invasive treatment of an unusual obstructive ectopic upper pole ureter

An 18-year old man presented with left loin pain and recurrent urinary tract infections. Ultrasound and IVU revealed a duplex left kidney with hydronephrosis of the upper pole moiety. F-15 Mag-3 renography confirmed obstruction of the upper pole moiety. Cysto-urethroscopy identified the site of ectopic insertion to be adjacent to the verumontanum in the prostatic fossa. Retrograde ureterography showed the level of obstruction and dilation of the stricture was carried out. Post operatively, the patient became asymptomatic and remains so at 5-year follow up. This is an unusual case of obstructive upper pole ureter with an ectopic insertion into the prostatic fossa. We also demonstrated that dilatation of a stricture at this site can achieve good long term outcome. This revised version was published online in August 2006 with corrections to the Cover Date.