The effects of intentional cryoablation and radio frequency ablation of renal tissue involving the collecting system in a porcine model.

PURPOSE: Ablative techniques for the treatment of urological malignancy are gaining acceptance and they are likely to become more widely used in clinical practice. Indications and limitations of the technologies are still evolving. In a porcine model we evaluated the safety and efficacy of cryotherapy and radio frequency ablation (RFA) of cortical and deep renal tissue. MATERIALS AND METHODS: In 11 swine argon gas based cryoablation or RFA of renal tissue adjacent to the collecting system was performed using a laparoscopic or percutaneous approach. Lesions created in renal units 30 days or 2 hours prior to harvest were termed chronic or acute. Using single or multiple 17 gauge cryoneedles or 3.0 mm cryoprobes and 2 freeze-thaw cycles (10-minute freeze and 5-minute thaw) 13 acute and 10 chronic cryolesions were made. Using a single 16 gauge umbrella-shaped RFA probe and 2 heating cycles to maximum impedance 13 acute and 4 chronic RFA lesions were made. Gross and microscopic tissue analysis was performed to assess lesion size and renal parenchymal, collecting system and arterial effects. Acute cryolesion size estimation by laparoscopic or transcutaneous ultrasound (US) was compared with pathological lesion size. RESULTS: Acute cryolesions on hematoxylin and eosin staining demonstrated uniform coagulative necrosis of renal parenchyma and chronic cryolesions demonstrated uniform necrosis with fibrous scar formation. Interlobar artery (adjacent to renal pyramid) preservation occurred in 7 of 13 acute and 5 of 9 chronic cryolesions. Urothelial architecture was preserved in 8 of 13 acute and 7 of 9 chronic cryolesions. Acute and chronic RFA lesions demonstrated indeterminate necrosis on hematoxylin and eosin staining, although triphenyl tetrazolium chloride staining of gross specimens confirmed necrosis most definitively in renal cortex. Interlobar artery preservation occurred in 6 of 13 acute and 3 of 4 chronic RFA lesions. Urothelial architecture was preserved in 1 of 13 acute and 2 of 4 chronic RFA lesions. Acute cryolesion dimensions measured by laparoscopic US equaled or underestimated lesion size measured grossly in all 6 cases. Lesion dimensions measured by transcutaneous US equaled or underestimated true lesion size in 3 of 6 cases. In 3 of 6 lesions transcutaneous US overestimated true lesion size by 20%, 76% and 260%, respectively. CONCLUSIONS: Renal cortical tissue can be effectively destroyed by cryoablation or RFA. However, treatment of deep parenchymal lesions with either modality may result in incomplete ablation. Cryosurgery but not RFA spares the collecting system in an acute setting. However, healing or regrowth of the urothelium may occur with time after RFA. Laparoscopic US is more accurate for cryolesion monitoring than transcutaneous US.

A nephron-sparing surgical procedure for Fraley's syndrome. A case report.

A 14.5-year-old girl with Fraley's syndrome, which caused left flank pain and massive haematuria with anaemia underwent left renal surgery. The infundibulum for the left upper calyx group was entrapped between the lower segmental renal artery and one branch of the renal vein. Despite other known surgical procedures, the surgeon explored the area around the entrapped infundibulum and resected the vein. Impression of the infundibulum disappeared, the dilatation of the upper calyces diminished, the pain was immediately relieved, and the haematuria stopped. In the two-year follow-up period the patient remained healthy, without haematuria or a subjective feeling of illness. The surgical treatment performed was successful, and it is also one of the most nephron-sparing procedures available.

Nephron sparing management of Fraley's syndrome with a pyelopyelostomy.

PURPOSE: We describe a new technique for nephron sparing management of functionally significant vascular compression of the upper pole infundibulocaliceal system (Fraley's syndrome). MATERIALS AND METHODS: Two patients evaluated for debilitating, narcotic dependent flank pain had significant upper pole infundibulocaliceal obstruction resulting from aberrant major arterial branches entering the hilum dorsally. Reconstructive surgery consisted of dismembered pyelopyelostomy with transposition of the crossing vessels in both patients. RESULTS: Pain relief was immediate and complete in both patients. Followup radiographic evaluation at 1 and 12 months, respectively, has also documented resolution of the obstruction. CONCLUSIONS: Vascular compression causing obstruction of the superior infundibulum can cause debilitating pain. Pathophysiologically operative intervention can be nephron sparing and gratifying for the surgeon and the patient.

Calices renales majores extrarenales.

In the material of 300 kidneys obtained from corpses of adults, extra-renal location of calices renales majores was observed in 3 of the organs. This developmental anomaly was accompanied with the variations of courses and division patterns of blood vessels within or in the vicinity of the renal hilus, whose characteristic feature was that they could cause the impairment of urinary outflow or urine retention.

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.

[Sinus-parenchyma border of the human kidney as the site of origin of intracanalicular and extravascular diffusion of fluids]. / Die Sinus-Parenchym-Grenze der menschlichen Niere als Entstehungsort intracanaliculärer und extravasaler Flüssigkeitsausbreitungen.

Injecting fluids into the kidney against the physiological direction of flow leads to a passage of liquid across the border-line between the renal sinus and the parenchyma. This event, caused by a sudden raising of pressure during the injection is called pyelorenal backflow. It can be divided into a number of subtypes, as there are: pyelocanalicular backflow, pyelosinous backflow, pyelovenous backflow, pyelolymphatic backflow. Among all these phenomena only the pyelocanalicular backflow can be interpreted as a genuine backflow in the fullest sense of the word, while the others never can happen before the fornix had been mutilated. In the case of pyelocanalicular backflow, the contents of the renal pelvis regurgitate into the Ducts of Bellini, but the fluid never goes beyond the collecting ducts in the pyramids. Neither a rupture of the tubuli, followed by an interstitial spreading up to under the capsule, nor a direct penetration into the medullary veins are possible, because the pressure necessary for it causes a rupture of the fornix earlier. This rupture happens step by step as an oblique dissection of the calyx from the papilla. The big calices at the poles show an increased tendency to rupture because they are attached along a line which is shaped like an "8" or like a clover leaf, and so do calices the angle of which is acute. Depending on whether a vein is torn simultaneously with the fornix or not, the contents of the pelvis transflow into the vein (pyelovenous backflow) or into the sinus (pyelosinous backflow). In spite of a previous pyelocanalicular backflow the pelvis is not relieved of pressure to such an extent that there could not occur an additional rupture of the fornix, nevertheless. The pyelosinous backflow leads to a sinus-extravasation which can ascend towards the parenchyma and descend towards the hilum. The ascending sinus-extravasation spreads out within the vascular canals of the kidney. These canals, strictly situated between cortex and medulla, enclose a pyramid (Canales peripyramidales) and contain the interlobar and arcuate bloodvessels. The space between the bloodvessels and the wall of a peripyramidal canal (perivascular space) is filled with connective tissue consisting of 3 components: tunica adventitia of the bloodvessels themselves and fibres originating from the inner capsule and the wall of the calyx. The ascending sinus-extravasation proceeds into the perivascular space by pushing off the bloodvessels from the medulla.(ABSTRACT TRUNCATED AT 400 WORDS)

[Arteriovenous-caliceal fistula following biopsy of a transplanted kidney. Treatment by selective arterial embolization]. / Fistule artério-veino-calicielle après biopsie d'un rein transplanté. Traitement par embolisation artérielle sélective.

This article reports a case of arteriocaliceal fistula following a kidney transplant biopsy. Hematuria and anuria were arrested by therapeutic embolic occlusion.

Vascular impressions on the renal-collecting system: diuretic cine-roentgenographic and angiographic study of 50 cases.

The vascular impressions on the renal pelvis and caliceal system may assume an important role in the study of some patients with hematuria and renal pain of unclear origin. 50 patients presenting vascular impressions on the calices and renal pelvis have been studied. In 12 patients (24%) the impressions were bilateral and in 38 (76%) unilateral: in 35 patients (70%) the right kidney was involved. In each patient the morphological pyelocaliceal variations have been studied with cine-roentgen-dynamic investigations and in 30 angiography was also performed. Interesting results have been obtained with cine-roentgenographic investigations during forced diuresis allowing differentiation between intrinsic and extrinsic lesions of the renal collecting structures, without resorting to more complex investigations such as angiography.

[Attempt at defining a pyelocaliceal system. Application to partial nephrectomy]. / Essai de systématisation pyelo-calicielle. Application à la néphrectomie partielle.

A comparative study of the pyelo-caliceal segmentation of the kidney and the arterial intra-parenchymal segmentation has been realised from the analysis of 60 plastic molds of the pyelo-caliceal system from which 42 were also molds of the arterial and venous systems (Fig. 8). These molds were obtained through injection with Rhodopas, then corrosion by hydrochloric acid. Their analytical study concludes to the existence of a pyelo-caliceal systematization and particularly of an intra-parenchymal arterial segmentation that corresponds to the pyelo-caliceal arborization.

Intrarenal access.

Corrosion casts were made of 27 human cadaveric kidneys. The anatomy so displayed suggests that to avoid intrarenal vascular damage, incisions for nephrolithotomy should be radial, peripheral and, wherever possible, posterior.