Francisco J.B. Sampaio

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.

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%.

Ureteropelvic Junction Stenosis: Vascular Anatomical Background for Endopyelotomy

To help endourologists perform endopyelotomy safely and efficiently with a reduced risk of vascular complications, we analyzed the vascular relationships to the ureteropelvic junction in 146, 3-dimensional endocasts of the kidney collecting system together with the intrarenal arteries and veins. There was a close relationship between a prominent vessel (artery and/or vein) and the anterior surface of the ureteropelvic junction in 65.1% of the cases, including the inferior segmental artery with a tributary of the renal vein in 45.2% and an artery or vein in 19.9%. In the remaining 34.9% of the cases the anterior surface of the ureteropelvic junction was free of vessels. There was a direct relationship between a prominent vessel (artery and/or vein) and the posterior surface of the ureteropelvic junction in 6.2% of the cases, including an artery and vein in 2.1%, and just an artery in 1.4%. In all cases (3.5%) of an artery crossing at the posterior surface of the ureteropelvic junction, this vessel was the posterior segmental artery (retropelvic artery). In 2.7% of the cases the relationship of the prominent vessel was just with a posterior tributary of the renal vein, and in 20.5% a vessel crossed lower than 1.5 cm. above the posterior surface of the ureteropelvic junction. Among these latter cases the vessel was an artery (posterior segmental artery) in 6.8%. In the remaining 73.3% of the cases the posterior surface was free of vessels up to 1.5 cm. above the ureteropelvic junction. Due to the anatomical findings, we advise that posterior and posterolateral incisions at the ureteropelvic junction be avoided, and that deep incision alongside the ureteropelvic junction stenotic wall be done only laterally.

Anatomical relationship between the renal venous arrangement and the kidney collecting system.

The anatomical relationships between the renal venous arrangement and the pelviocaliceal system were studied in 52, 3-dimensional polyester resin corrosion endocasts. In 53.8% of the cases, there were 3 large venous trunks and in 28.8% there were 2 venous trunks joining to form the main renal vein. Intrarenal veins demonstrated free anastomoses that were disposed in 3 systems of longitudinal arcades (stellate, arcuate and interlobar veins). There were large venous collars around caliceal necks and also horizontal arches crossing over calices to link anterior and posterior veins. In 84.6% of the cases the upper caliceal group was encircled anteriorly and posteriorly by venous plexuses, which coursed parallel to the infundibulum. In 50.0% of the cases the lower caliceal group also was enriched by 2 venous plexuses. A close relationship existed between a large inferior tributary of the renal vein and the anterior aspect of the ureteropelvic junction in 40.4% of the cases. In 69.2% of the cases there was a posterior (retropelvic) vein: in 48.1% this vein had a close relationship to the junction of the pelvis with the upper calix and in 21.1% it crossed the middle posterior surface of the renal pelvis.

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.

A morphometric analysis of bulbar urethral strictures.

In a beautifully descriptive paper, authors from Rio de Janeiro and San Francisco report a quantitative and qualitative histological analysis of spongiosal tissue in patients with bulbar urethral strictures. They found that stricture formation was characterised by major alterations in extracellular matrix features.

Testicular Migration: Remodeling of Connective Tissue and Muscle Cells in Human Gubernaculum Testis

PURPOSE We present the main morphological modifications in the human gubernaculum during testicular migration in humans. MATERIALS AND METHODS We obtained 12 gubernacula from fresh, macroscopically normal human fetuses at 15 to 29 weeks of gestation. Collagen was evidenced using trichrome and Sirius red staining procedures, while Weigerts resorcinol-fuchsin and anti-human elastin antibody were used to reveal elastic system fibers. Smooth muscle cells were detected by anti-human smooth muscle alpha-actin antibody. RESULTS When the testes were still located in the abdomen at 15 to 16 weeks of gestation, collagen fibers were sparse and embedded in a loose extracellular matrix. The amount of fibers then gradually increased with age and at 28 weeks of gestation the gubernaculum was mostly collagenous in composition. Elastic fibers had a similar growth pattern, although they were located mainly at the distal end of the gubernaculum. Fibroblasts largely predominated over other cell types and decreased in number with gestational age, whereas smooth muscle cells were restricted to the walls of blood vessels. Striated muscle cells were detected at the scrotal end of the gubernaculum, where they were disposed as isolated and scattered bundles running in various directions. Like fibroblasts, their number also decreased with age. CONCLUSIONS During testicular migration gubernacular connective tissue undergoes extensive remodeling and ultimately becomes an essentially fibrous structure rich in collagen and elastic fibers. Such changes should decrease the size of the gubernaculum and, thus, contribute to other forces that cause the testes to move toward the scrotum. In fact, because of the lack of smooth muscle cells, and the amount and organization of striated muscle cells, active contraction of the gubernaculum is less likely to be an important factor in testicular descent.

EXTRACELLULAR MATRIX CHANGES IN URETHRAL STRICTURE DISEASE

PURPOSE Glycosaminoglycans (GAGs) and collagen are major components of the extracellular matrix and they have key roles in fibrotic diseases. Little is known about the molecular environment in urethral stricture and the majority of the studies available focused on collagen analysis. However, to our knowledge there are no data on GAG composition in urethral stricture disease. MATERIALS AND METHODS Bulbar urethral strictured segments were obtained from 10 patients 18 to 61 years old (mean age 41.8) who underwent end-to-end anastomotic urethroplasty. GAGs in dry tissue samples were extracted by papain digestion and cetylpyridinium chloride/ethanol precipitation. The concentration of total GAGs was assessed by hexuronic acid assay and expressed in microg. hexuronic acid per mg. dry tissue, while the proportion of sulfated GAGs was determined by agarose gel electrophoresis. The concentration of hyaluronic acid was determined by ion exchange chromatography and total tissue collagen was estimated as its hydroxyproline content. The control group consisted of 10 bulbar urethras obtained from fresh normal cadavers 22 to 53 years old (mean age 32.8). RESULTS Mean total GAG concentration plus or minus standard deviation in the stricture group was 1.09 +/- 0.13, which was significantly lower than in controls (p <0.05). While the predominant GAG in normal bulbar urethras was hyaluronic acid, dermatan sulfate predominated in strictured urethras (mean 44.1% +/- 8.4 and 45.6% +/- 7.7%, respectively). Hyaluronic acid decreased 49.9% and dermatan sulfate increased 68.3%. There were no significant changes in the concentration of heparan sulfate or chondroitin sulfate in normal and strictured bulbar urethras. Mean total collagen significantly increased 32.3% (p <0.05). CONCLUSIONS Composition changes in GAGs in strictured urethras could contribute to the noncompliant nature of urethral scar tissue and cause functional changes. These results may be useful for defining new targets for therapy for urethral stricture disease.

3-Dimensional and Radiological Pelviocaliceal Anatomy for Endourology

The renal collecting system was studied in 100, 3-dimensional corrosion casts and also in 40 casts with the corresponding pyelograms. Some anatomical details that have great importance for endourology were observed and discussed, including the presence of perpendicular minor calices draining into the surface of the collecting system (11 per cent of the cases), crossed calices in the mid kidney with consequent formation of a region that we termed the inter-pelviocaliceal region (17.1 per cent), position of the calices related to the lateral kidney margin (in 52.9 per cent the anterior and posterior calices were superimposed or alternately distributed), position of the calices related to the polar regions (superior pole with a midline caliceal infundibulum in 98.6 per cent and inferior pole with paired calices in 57.9 per cent) and to the mid kidney (with paired calices in 95.7 per cent), and bilateral symmetry of the casts (37.1 per cent). The urologist must appreciate these anatomical structures during operations on the collecting system.

Stromal and acinar components of the transition zone in normal and hyperplastic human prostate

Objective To analyse the histological components of the transition zone in both normal human prostate and benign prostatic hyperplasia (BPH), and to determine the volumetric density (Vv) of the different elements (connective tissue, smooth muscle cells, acini and total stroma).