Anatomical relationship between the intrarenal arteries and the kidney collecting system

The anatomical relationship between the intrarenal arteries and the renal collecting system was studied in 82, 3-dimensional endocasts. Some anatomical details that have importance for urologists were observed. The arterial supply related to the upper caliceal group arises from 2 arteries that encircle these calices (in 86.6% 1 trunk originated from the anterior division and 1 from the posterior division of the renal artery). The artery to the mid kidney courses horizontally in the mid renal pelvis in 64.6% of the cases while the arterial supply to the inferior pole (front and back) arises from the inferior segmental artery of the anterior division in 62.2%. The posterior segmental artery is related to the upper infundibulum or to the junction of the pelvis with the upper calix in 57.3% of the cases and to the middle posterior aspect of the renal pelvis in 42.7%.     

Ureteral duplication with lower pole ectopia to the epididymis

We report a unique case of a duplex ureter with ureteral ectopia. A 30-year-old man presented with a coliform infection of the epididymis and excretory urography revealed, in addition to a normal-appearing right renal collecting system, a second right ureter that arose from an inferior calix, penetrated the lower pole parenchyma and drained directly into the ipsilateral epididymis. The radiological evaluation and surgical management are discussed, and several embryological explanations for this anomaly are offered.     

Inferior pole collecting system anatomy: its probable role in extracorporeal shock wave lithotripsy.

In addition to the gravity-dependent position, we believe that other particular anatomical features may be important in the retention of stone debris in the lower calices after extracorporeal shock wave lithotripsy (ESWL). We analyzed the inferior pole collecting system anatomy in 146, 3-dimensional polyester resin corrosion endocasts of the pelviocaliceal system. The inferior pole was drained by multiple calices disposed in 2 rows in 56.8% of the cases and by 1 midline caliceal infundibulum in 43.2%. In 60.3% of the cases there was a lower infundibulum equal to or greater than 4 mm. in diameter and 39.7% had a lower infundibulum smaller than 4 mm. in diameter. In 74.0% of the cases an angle of greater than 90 degrees was formed between the lower infundibulum and the renal pelvis, and in 26.0% the angle was 90 degrees or smaller. We believe that the physician should consider these anatomical features when suggesting ESWL to treat calculi in the lower calices.     

Intrarenal access: 3-dimensional anatomical study.

In an attempt to determine the best route to puncture and access the kidney collecting system we studied 62, 3-dimensional polyester resin endocasts of the pelvicaliceal system together with the intrarenal vessels. A retrograde pyelogram was obtained, and the arterial and venous trees were injected with red and blue resins, respectively. When the resin was still in the gel state, the kidneys were positioned at 30 to 45 degrees and the collecting system was punctured under radioscopy. Since the resin is not opaque to x-ray the operator was not able to visualize the vessels while puncturing. After puncture, the needle was maintained in place, the contrast medium was removed and the pelvicaliceal system was filled with yellow resin. After the resin had set, the renal organic matter was corroded in acid and the endocast was obtained (with the needle in the original position). This type of preparation allowed us to examine the needle tract and the vessels damaged during the puncture. In the same kidney we punctured the superior pole, mid kidney and inferior pole. In some cases we also punctured the renal pelvis. We performed 104 punctures through an infundibulum, 39 through a fornix of a calix and 12 through the renal pelvis. Due to a high percentage of vascular lesions, intrarenal access through an infundibulum should be avoided. Also, renal pelvis puncture should be avoided. Regardless of the kidney region, puncture through a fornix of a calix was safe.     

Intrasinusal pyelocalicotomy with lower pole nephrotomy for removal of renal stones

A small renal sinus often limits exposure of the intrarenal pelvis and restrains the sinus approach for removal of renal stones. For 14 such cases, we used a lower pole nephrotomy combined with extended pyelolithotomy. Incision of the renal parenchyma through the intersegmental avascular plane greatly facilitated exposure of the intrarenal collecting system and enabled stone removal through the longitudinal incision of the collecting system. The indication for operative technique and results of the procedure are described.     

Two pelvises,one stone: A different approach for management of calculi in a duplex renal collecting system

Duplex renal collecting systems are a common congenital abnormality. Management of renal calculi in patients with this abnormality is complex. We describe a patient with a duplex collecting system presenting with a renal calculus. Initial flexible ureteroscopy failed to reach the collecting system containing the stone due to inability to visualize an additional ureteric orifice. The patient then underwent percutaneous puncture of the stone containing moiety, followed by antegrade stent insertion. This allowed for guidewire-assisted passage of a ureteroscope into the duplex collecting system, where the calculi were identified and fragmented.     

Mixed epithelial and stromal tumor of the kidney (MEST) simulating an upper tract TCC

We present a rare and interesting case of a mixed epithelial and stromal tumour (MEST) of the kidney. The case is unique as it involves a male patient with no history of hormonal therapy presenting with a filling defect in the renal collecting system and positive urine cytology. The patient was diagnosed with transitional cell carcinoma of the renal pelvis and subjected to nephroureterectomy, which revealed a solid tumour arising from the lower calyces and extending into the renal pelvis and upper ureter. Pathology revealed a MEST. The patient was disease-free at the 6-month follow-up.     

瞬时X线联合B超在复杂经皮肾镜取石术中的应用体会

目的:探讨瞬时X线联合B超引导经皮肾穿刺定位在较为复杂的经皮肾镜取石术(PCNL)中的应用价值。方法:回顾2012年3月~2013年10月我院收治的69例肾结石患者临床资料,其中肾脏轻度积水25例,肾脏旋转不良12例,肾脏无明显积水8例,完全鹿角形结石6例,重复肾6例,术中逆行造影及人工积水肾建立失败4例,肾结石术后瘢痕肾5例,肥胖患者2例,肾下垂患者1例。术中常规给予输尿管置管行逆行造影并建立人工积水肾,采用C型臂瞬时X线照相联合B超引导建立经皮肾穿刺通道。结果:69例患者均穿刺成功,建立F14~18通道,建立时间10~35min,术中X线暴露次数2~5次。其中肾脏轻度积水25例、肾脏无明显积水8例、完全鹿角形结石6例由间断瞬时X线定位为主,辅助B超定位以避开主要血管及领近器官或辅助建立多通道;肾脏旋转不良12例、重复肾6例、肾结石术后瘢痕肾5例、肥胖患者2例、肾下垂患者1例由B超定位为主,辅助瞬时X线定位以确保穿刺线通过肾盏穹窿部;术中逆行造影及人工积水肾建立失败4例,由B超定位穿刺针进入肾脏集合系统,经穿刺针推注造影剂显示肾盂肾盏,用第二穿刺针在瞬时X线定位下建立目标肾盏的穿刺通道。64例为Ⅰ期手术,5例行Ⅱ期手术,清石率为96.8%,无严重并发症发生。结论:对于较为复杂的PCNL,瞬时X线联合B超的定位技术能够结合两种定位方法的优势,建立安全、有效的穿刺通道,提高清石率,减少手术并发症的产生,同时减少患者及医生在手术中X线的暴露时间。     

The nonopacified kidney with Wilms' tumor

We reviewed 56 cases in which the preoperative diagnosis was Wilms' tumor at the Children's Hospital of Philadelphia (CHOP) during the three calendar years 1983 through 1985. Fifty-one had Wilms' tumor (38 operated on at CHOP; 13 were referrals for further treatment or consultation), three had renal cell carcinoma (RCC), and one each with metastatic mesoblastic nephroma and clear cell sarcoma. We reviewed these cases to determine the significance of the urographic finding of nonopacification of kidney with suspected Wilms' tumor, and what additional diagnostic studies are needed. Five Wilms' tumor patients (10%) and one RCC patient had nonopacification of the involved kidney on intravenous pyelography (IVP). Four Wilms' tumor patients had tumor extending into the collecting system: into the proximal ureter in one, obstructing the superior pole in another, and filling the renal pelvis in two, one of which also had tumor extending through the inferior vena cava and into the right atrium. One patient with Wilms' tumor and one with RCC had huge left-sided tumors that crossed the midline and appeared to replace completely the functioning renal parenchyma on that side. The most common cause of nonpacification of kidney by Wilms' tumor is collecting system blockage by tumor. Although extension into the renal pelvis is relatively uncommon in Wilms' tumor (five of 51 cases during the study period, 10%), when it occurs, nonopacification of IVP often results (four of five cases, 80%). Although renal vein involvement is more frequent (eight of 51 cases; 16%), nonopacification is unusual (one of eight cases, 13%; the tumor also had filled the collecting system).(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral complete renal duplication with total obstruction of both lower pole collecting systems

Sepsis and a flank mass developed in a twenty-two-year-old primagravida two days after a normal delivery. Urography showed normal upper pole collecting structures bilaterally. A spherical mass containing curvilinear calcification occupied the left lower pole, and a large inflammatory mass filled the right inferior renal fossa. Angiography and retrograde pyelography demonstrated marked bilateral lower pole hydronephrosis with complete obstruction of the water to each inferior duplicated collecting system.     

Segmental multicystic dysplasia and ureteropelvic junction obstruction in a nonduplicated kidney

A 2-month-old child presented for evaluation of prenatal hydronephrosis. Imaging studies were consistent with a right duplex system with a dysplastic, nonfunctioning upper pole and lower pole ureteropelvic junction obstruction. We proceeded with removal of the upper pole and pyeloplasty and were surprised to find a single collecting system with a cystic, dysplastic upper pole segment and the absence of an upper pole pelvis or ureter. The rare diagnosis of a segmental multicystic dysplastic kidney with ipsilateral ureteropelvic junction obstruction was made. We present a review of the case and of previous literature on this topic.     

Long-term outcome of the retained ureteral stump after lower pole heminephrectomy in duplex kidneys

OBJECTIVES: Duplication of the ureter and renal pelvis is the most common upper urinary tract anomaly in childhood. The anatomical and functional divisions between upper and lower moieties of duplex kidney are extremely variable. The underlying pathological condition associated with a lower moiety is usually massive vesicoureteral reflux (VUR) to the lower collecting system and only rare obstruction. The non-functioning upper moiety is usually associated with obstructive ectopic ureter (with or without ureterocele). Most lower pole heminephrectomies are carried out for non-functioning lower moieties. In most cases, the lower defunctionalised segment of the ureter is left in situ. Complete ureterectomy is usually performed if presence of VUR into the lower end of the corresponding ureter is shown. There is little information on the long-term outcome of residual ureteral 'stumps'. The purpose of our study was to review the long-term outcome of retained ureteral stumps in children undergoing heminephrectomy for non-functioning lower pole moieties in duplex kidneys. MATERIALS AND METHODS: The medical records of 19 patients who underwent 20 lower pole heminephrectomies for a non-functioning lower pole moiety of a duplex kidney between January 1990 and December 2000 were reviewed retrospectively. Median age at heminephrectomy was 4.5 years (range: 1 month to 12 years). Indications for heminephrectomy in the 20 renal units was reflux nephropathy in 16 (80%) and obstructive nephropathy in 4 (20%). All corresponding ureters were taken down as low as possible and transfixed through the heminephrectomy incision. Median follow-up was 8.5 years (range: 1-11 years). RESULTS: Eight (40%) showed VUR into the stump after lower pole heminephrectomy. Two of these underwent subureteral endoscopic correction of VUR with polytetrafluoroethylene paste and resection of the stump was carried out in remaining two patients for recurrent urinary tract infections (UTI). Remaining four of the eight patients demonstrated spontaneous resolution of VUR during follow-up. CONCLUSIONS: Our data suggest that the vast majority of patients with residual ureteral stumps after lower pole heminephrectomy do not require stump resection at long-term follow-up.     

Management of ureteroceles with pyelo-ureteral duplication in children. Report of 64 cases]

Sixty four cases of ureteroceles in a context of pyeloureteric duplication were reviewed. They were detected antenatally in 69% of cases. Upper pole nephroureterectomy was performed as first-line procedure in 32 cases. In 37.5% of cases, this procedure was followed by lower tract reconstruction, essentially because of symptomatic reflux in the inferior renal pelvis. Complete renal and vesical reconstruction was performed as the first-line procedure in 6 cases. An ureteropelvic anastomosis allowed preservation of the superior renal pelvis in 4 cases, including one case with secondary lower tract reconstruction. Intravesical reimplantation of the two ureters was performed in 8 cases. Primary endoscopic opening of the ureterocele was performed in 10 cases and complementary surgery was required in 7 cases. Other procedures were used more rarely: temporary ureterostomy, nephrostomy, resection of the protruding dome of a cecoureterocele. Current management is usually neonatal. The first step consists of prevention of infection. The therapeutic approach depends on the quality of the superior renal pelvis assessed by DMSA renal scintigraphy. Immediate complete reconstruction of the kidney and bladder is now rarely indicated. When the superior renal pelvis is not functional, resection should be considered with aspiration of the ureterocele. A complementary bladder procedure is required in some cases (40% in our series) to treat symptomatic reflux in the inferior renal pelvis. When the superior renal pelvis is functional, ureteropelvic anastomosis is a good solution, especially when the superior ureter is very large and poorly functional, but endoscopic opening of the ureterocele can also be proposed, which may need to be followed be intravesical reconstruction.     

Squamous cell carcinoma of the renal pelvis with stones and inferior vena cava infiltration. Case report

We report a rare case of a 50 year old man with renal squamous cell carcinoma (SCC) who first came to our attention with renal colic and fever not responding to antibiotic or analgesic treatment. He had a long history of kidney stones, but had not undergone any imaging in the last 5 years. Physical examination revealed tenderness and a palpable mass in the right flank and lumbar region. A whole body CT scan was performed, revealing an 11 cm mass in the right kidney infiltrating the inferior vena cava. There were areas of calcification within the mass and multiple stones within the renal pelvis. The tumor was considered unsuitable for resection according to radiological and clinical criteria. The mass was biopsied percutaneously under CT guidance and histological examination revealed squamous cell carcinoma of the renal pelvis. The patient was treated with neoadjuvant chemotherapy and embolization of the renal artery. He died one month after diagnosis. To our knowledge this is the second reported case in the world of renal SCC infiltrating the inferior vena cava and with kidney stones.     

Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation

BACKGROUND AND PURPOSE: New-generation flexible ureteroscopes allow the management of proximal ureteral and intrarenal pathology with high success rates, including complete removal of ureteral and renal calculi. One problem is that the irrigation pressures generated within the collecting system can be significantly elevated, as evidenced by pyelovenous and pyelolymphatic backflow seen during retrograde pyelography. We sought to determine if the ureteral access sheath (UAS) can offer protection from high intrarenal pressures attained during routine ureteroscopic stone surgery. PATIENTS AND METHODS: Five patients (average age 72.6 years) evaluated in the emergency department for obstructing calculi underwent percutaneous nephrostomy (PCN) tube placement to decompress their collecting systems. The indications for PCN tube placement were obstructive renal failure (N=1), urosepsis (N=2), and obstruction with uncontrolled pain and elevated white blood cell counts (N=2). Flexible ureteroscopy was subsequently performed with and without the aid of the UAS while pressures were measured via the nephrostomy tube connected to a pressure transducer. Pressures were recorded at baseline and in the distal, mid, and proximal ureter and renal pelvis, first without the UAS, and then with the UAS in place. RESULTS: The average baseline pressure within the collecting system was 13.6 mm Hg. The mean intrarenal pressure with the ureteroscope in the distal ureter without the UAS was 60 mm Hg and with the UAS was 15 mm Hg. With the ureteroscope in the midureter, the pressures were 65.6 and 17.5 mm Hg, respectively; with the ureteroscope in the proximal ureter 79.2 and 24 mm Hg, and with the ureteroscope in the renal pelvis 94.4 and 40.6 mm Hg, respectively. All differences at each location were statistically significant (P<0.008). Compared with baseline, all pressures measured without the UAS were significantly greater, but only pressures recorded in the proximal ureter and renal pelvis after UAS insertion were significantly higher (P<0.03). CONCLUSIONS: The irrigation pressures transmitted to the renal pelvis and subsequently to the parenchyma are significantly greater during routine URS without the use of the UAS. The access sheath is potentially protective against pyelovenous and pyelolymphatic backflow, with clinical implications for the ureteroscopic management of upper-tract transitional cell carcinoma, struvite stones, or calculi associated with urinary tract infection.     

Pediatric renal pelvic fullness: an ultrasonographic dilemma

PURPOSE: We conducted a prospective study to define normal renal pelvic size in children. MATERIALS AND METHODS: Institutional Review Board approved consent was obtained to perform renal ultrasound during excretory urography (IVP) scheduled for medical management. Mean patient age (17 females, 11 males) was 5.2 years. Renal ultrasound was conducted concurrent with 10-minute IVP. RESULTS: Fifty kidneys were imaged with 51 collecting systems. IVP defined 44 collecting systems as normal. Mean anteroposterior pelvic diameter on sonography for these 44 systems was 3.3 mm. One normal collecting system on IVP had a diameter greater than 10 mm on ultrasound (14 mm). No sonographic caliceal dilatation was seen in any kidney appearing normal on IVP. The 7 dilated systems on IVP had a mean ultrasound diameter of 17.1 mm. Two dilated collecting systems smaller than 10 mm in diameter on sonography had caliceal distention on ultrasound. CONCLUSIONS: Normal renal pelvis threshold diameter was 10 mm in asymptomatic children. We recommend further evaluation in children with caliceal dilatation and/or dilatation of the anteroposterior renal pelvis greater than 10 mm. Using these criteria, no system appearing abnormal on IVP would have been missed.     

Laparoskopische Nierenbeckenplastik bei komplizierter Doppelniere

Laparoscopic pyeloplasty has been established as an effective and minimally invasive technique for treating ureteropelvic junction obstruction. Only case reports are available describing the use of laparoscopic pyeloplasty in patients with duplicated collecting systems. We report the case of a patient presenting with a short stenotic connection between the hydronephrotic lower pole system and a solitary ureter coming from the upper pole. In this patient, a side-to-side anastomosis between the renal pelvis and the ureter was successfully performed. The present data demonstrate that laparoscopic pyeloplasty is an applicable tool even in patients with upper urinary tract anomalies such as duplicated collecting systems.     

Carbon dioxide-based nephroscopy during laparoscopic pyeloplasty provides suboptimal view when stones are located in the lower calices

Flexible nephroscopy while using carbon dioxide to insufflate the collecting system has been described as a "good trick" to remove caliceal stones during laparoscopic pyelolithotomy. We found this true only for those calices with undisturbed urine drain into the renal pelvis, while it provided suboptimal view of stones that were located in dependent lower pole calices. We describe how we dealt successfully with a group of lower pole caliceal stones during laparoscopic pyeloplasty.     

肾实质肾盂分层切口治疗复杂性肾鹿角状结石

目的 探讨肾实质肾盂分层切口治疗复杂性肾鹿角状结石的效果。方法 采用肾实质肾盂分层切口治疗复杂性肾鹿角状结石２４例,具体方法是作１２肋缘上切口,游离肾脏,分离肾窦内肾盂,用１－０合成可吸收缝线在肾中下１／３交界处于血管区从肾后唇向外侧缘作两排扣锁式缝合肾实质全层,切开肾实质,从肾上颈经肾盂输尿管交界处向肾下颈作一弧形切口,即可取出结石,直视下探查各肾,用４－０可吸收缝线缝合肾盂,１－０可吸收缝线间     

Surgical management of incomplete duplex kidney with both upper and lower moieties ureteropelvic junction obstruction: a case report with modified reconstructive method

An incomplete duplex kidney combined with ureteropelvic junction obstruction is a rare entity, and the surgical management strategy is highly individualized according to the anatomic variability. Currently, there is no literature report of the specific reconstructive method for the condition when obstruction occurs in both the upper and lower units of the duplex kidney. In this case report, a 60-year-old female with a right solitary kidney was admitted to our hospital. The patient suffered intermittent right flank pain and had an occasionally palpable abdominal mass for seven years. Computed tomography and intravenous pyelography revealed an incomplete duplex kidney with obstruction in both the upper and lower units with a proximal confluence. A specially designed reconstructive method, including an ureteropyelostomy between the upper pole ureter and lower pole pelvis, plus a dismembered pyeloplasty between the lower pole pelvis and common ureter, was used, with no intra- or postoperative complications. The patient remained symptom free at the 6-month, 1-year and 2-year follow-ups. A diuretic renal scan showed better drainage, and ultrasound revealed no significant hydronephrosis. Thus, our specially modified reconstructive strategy could be a method of choice when addressing particular anatomies, such as incomplete duplex kidneys with ureteropelvic junction obstruction in both upper and lower poles when the obstruction is close to the confluence of the two ureters.