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Retrograde Ureteroscopy: Handbook of Endourology

Retrograde Ureteroscopy: Handbook of Endourology

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Retrograde Ureteroscopy: Handbook of Endourology

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Deskripsi

Retrograde Ureteroscopy: Handbook of Endourology contains five focused, review-oriented volumes that are ideal for students and clinicians looking for a comprehensive review rather than a whole course. Each volume is easily accessible through eBook format.

Topics covered review both the endourological diagnosis and treatment of prostate, urethral, urinary bladder, upper urinary tract, and renal pathology, with all chapters describing the most recent techniques, reviewing the latest results, and analyzing the most modern technologies.

In the past ten years, the field of endourology has expanded beyond the urinary tract to include all urologic, minimally-invasive surgical procedures. Recent advancements in robotic and laparoscopic bladder surgery make this one of the fastest moving fields in medicine. As current textbooks are too time-consuming for busy urologists or trainees who also need to learn other areas of urology, this collection provides a quick references with over 4000 images that are appropriate for fellows and those teaching in the field.

  • Offers review content for urologists in training and “refresher content for experts in endourology
  • Explores new surgical techniques and technology through review-level content and extensive images of pathologies
  • Includes over 500 images per volume that were taken from more than 4000 endourologic procedures performed annually at the editor’s hospital
Dirilis:
Apr 7, 2016
ISBN:
9780128026625
Format:
Buku

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Retrograde Ureteroscopy - Academic Press

Retrograde Ureteroscopy

Handbook of Endourology

Edited by

Petrişor A. Geavlete

Table of Contents

Cover

Title page

Copyright

Contributors

Preface

Acknowledgments

Chapter 1: History

Abstract

1.1. History

Chapter 2: Notions of Histology, Anatomy, and Physiology of the Upper Urinary Tract

Abstract

2.1. Generalities

2.2. Notions of upper urinary tract histology

2.3. Descriptive anatomy of the upper urinary tract

2.4. Endoscopic anatomy of the upper urinary tract

2.5. Upper urinary tract physiology

Chapter 3: Instruments

Abstract

3.1. Generalities

3.2. Rigid ureteroscopes

3.3. Semirigid ureteroscopes

3.4. Flexible ureteroscopes

3.5. Energy sources

3.6. Accessory instruments

3.7. Ureteral stents

Chapter 4: Diagnostic Ureteroscopy

Abstract

4.1. Generalities

4.2. Indications and contraindications

4.3. Diagnostic ureteroscopy technique

4.4. Incidents and complications

4.5. Results

Chapter 5: Indications and Limitations of Therapeutic Ureteroscopy

Abstract

5.1. Indications for therapeutic retrograde ureteroscopy

5.2. Limitations of rigid and semirigid ureteroscopy

5.3. Limitations of flexible ureteroscopy

Chapter 6: Retrograde Ureteroscopy in the Treatment of Upper Urinary Tract Lithiasis

Abstract

6.1. Generalities

6.2. Indications

6.3. Rigid and semirigid retrograde ureteroscopy technique

6.4. Flexible retrograde ureteroscopy technique

6.5. The results of retrograde ureteroscopy in the treatment of upper urinary tract lithiasis

6.6. Incidents and complications of retrograde ureteroscopy

6.7. Ureteroscopy in the treatment of particular situations of lithiasis

Chapter 7: Retrograde Ureteroscopy in the Treatment of Caliceal Diverticula

Abstract

7.1. Generalities

7.2. Indications of retrograde ureterorenoscopic approach for caliceal diverticula

7.3. Technique particularities

7.4. Results

7.5. Complications

Chapter 8: Retrograde Ureteroscopy for the Treatment of Upper Urinary Tract Tumors

Abstract

8.1. Generalities

8.2. Diagnosis and staging

8.3. Indications

8.4. Operatory technique particularities

8.5. Results

8.6. Adjuvant therapy

8.7. Controversies

8.8. Complications

8.9. Follow-up protocol

Chapter 9: Retrograde Ureteroscopy in the Treatment of Ureteral Stenoses

Abstract

9.1. History

9.2. Generalities

9.3. Indications

9.4. Instruments

9.5. Notions of operative technique

9.6. Particular situations

Chapter 10: Retrograde Ureteroscopy in the Treatment of Ureteropelvic Junction Stenosis

Abstract

10.1. Generalities

10.2. Indications

10.3. Retrograde endopyelotomy technique

10.4. Results

10.5. Complications

10.6. Follow-up

Chapter 11: Retrograde Ureteroscopy in the Treatment of Infundibular Stenosis

Abstract

11.1. Generalities

11.2. Indications

11.3. Techniques

11.4. Results

Chapter 12: Ureteroscopy in the Treatment of Iatrogenic Injuries

Abstract

12.1. Generalities

12.2. Classification

12.3. Diagnosis

12.4. Therapeutic options

Chapter 13: Ureteroscopy in Particular Situations

Abstract

13.1. Generalities

13.2. Ureteroscopy in children

13.3. Ureteroscopy in pregnancy

13.4. Ureteroscopy in patients with reno-ureteral abnormalities

Subject Index

Copyright

Academic Press is an imprint of Elsevier

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Copyright © 2016 Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Medical Disclaimer:

Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administrations, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

ISBN: 978-0-12-802403-4

For information on all Academic Press publications visit our website at https://www.elsevier.com/

Publisher: Mica Haley

Acquisition Editor: Tari Broderick

Editorial Project Manager: Jeff Rossetti

Production Project Manager: Julia Haynes

Designer: Maria Inês Cruz

Typeset by Thomson Digital

Contributors

Petrişor A. Geavlete (Editor), MD, PhD,      Professor of Urology, Academician (Corresponding member) Romanian Academy of Medical Sciences, Head and Chairman of Urological Department, Saint John Emergency Clinical Hospital, Bucharest, Romania

Emanuel Alexandrescu MD,      Saint John Emergency Clinical Hospital, Bucharest, Romania

Bogdan Geavlete MD, PhD,      Lecturer of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania

Dragoş Georgescu MD, PhD,      Associate Professor, Chief of Urological Department, Saint John Emergency Clinical Hospital, Bucharest, Romania

Victor Mirciulescu MD, PhD,      Researcher grade III, Saint John Emergency Clinical Hospital, Bucharest, Romania

Cristian Moldoveanu MD, PhD,      Saint John Emergency Clinical Hospital, Bucharest, Romania

Răzvan Mulţescu MD, PhD,      Saint John Emergency Clinical Hospital, Bucharest, Romania

Gheorghe Niţă MD, PhD,      Assistant-Professor of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania

Dorel Soroiu MD, PhD,      Saint John Emergency Clinical Hospital, Bucharest, Romania

Preface

This fourth book in the series Handbook of Endourology: Retrograde Ureteroscopy continues with the procedures designed for ureteral approach, being the first of two volumes dedicated to the upper urinary tract.

Within the pages of the handbook, the technological progress of the past decades becomes maybe even more evident. Miniaturization, development of lasers, special materials for flexible scopes, and image chips, etc., have allowed the continuous reshaping of this field.

This process is continuing, each year bringing new developments in the field, new endoscopes or instruments aiming to improve the efficacy and safety of the procedures, or the broadening of the indications. Today, the retrograde approach is seriously challenging the other minimally invasive options for upper urinary tract pathology treatment, percutaneous approach, and SWL.

This volume is based on a broad experience of more than 11,500 rigid and semirigid ureteroscopies and more than 2,500 procedures using flexible ureteroscopes performed in the last 25 years. All this experience has allowed us to apply retrograde ureteroscopy in almost all the situations that can be approached in this fashion, with all the challenges, particular situations and, why not, most of the complications that can be encountered. Today, all this experience, carefully recorded, can be passed on to the readers. As in the previous books, the theoretical notions are supported by more than 1500 images captured during personal interventions, in the previously mentioned situations.

At the beginning, retrograde approach of the upper urinary tract was performed only for diagnostic purposes or for treatment of stones. Now, selected cases of patients with other upper urinary tract conditions can be treated using these techniques.

The volume starts with the history of the procedures and the description of the various endoscopes (semirigid or flexible, conventional or digital), energy sources, ancillary instruments, and stents available for clinical use. It seems that the variety of these instruments developed for the upper urinary tract is even more diverse than those for the endourological approach of the lower urinary tract.

This volume continues with the description of diagnostic ureteroscopy and then presents, in detail, the therapeutic approach for upper urinary tract lithiasis; caliceal diverticulum; upper urinary tract tumors; ureteral, uretero-pelvic junction, and infundibular stenosis; iatrogenic lesions; and finally, the ureteroscopic approach in selected situations (pediatric cases, pregnant women, anomalous ureters, or kidneys).

The indications, technique, limitations, complications, and results are thoroughly described for each of these pathological entities.

Being one of the most experienced centers in the world in ureteroscopy, with a unanimous national and international recognition, we consider that this volume can guide the diagnostic and therapeutic conduct for any urologist, as well as for other specialists.

Ureteroscopy has presently become one of the most frequently used minimally invasive methods in urology. The impressive technology that is under constant evolution, as well as the experience of many renowned urology centers, recommend the publishing of this book.

Editor

Professor Petrişor Aurelian Geavlete, MD, PhD

Acknowledgments

Great appreciation for the wonderful support of Karl Storz Endoskope GmbH & Co. KG. Also, many thanks to the Olympus Medical System Europe GmbH and especially to Sanador Hospital for its major scientific contribution with regard to the publication of the handbook.

Chapter 1

History

Dragoş Georgescu

Răzvan Mulţescu

Petrişor A. Geavlete

Bogdan Geavlete

Abstract

Initially developed as an extension of cystoscopy, ureteroscopy has become a major technique for the diagnosis and treatment of upper urinary tract disorders. At the end of the 1970s, the method was limited to the management of only a small number of lesions of the distal ureter (Lyon et al., 1979; Perez-Castro Ellendt and Martinez-Pineiro, 1980); today the entire upper urinary tract can be approached for diagnosis and treatment by using retrograde ureteroscopy. This progress is a result of the development of rigid and flexible ureteroscopes and of adequate accessory instruments.

Keywords

ureteroscopy

ureteroscope

urinary tract

lithotripsy

history

1.1. History

Initially developed as an extension of cystoscopy, ureteroscopy has become a major technique for the diagnosis and treatment of upper urinary tract disorders. At the end of the 1970s, the method was limited to the management of only a small number of lesions of the distal ureter (Lyon et al., 1979; Perez-Castro Ellendt and Martinez-Pineiro, 1980); today the entire upper urinary tract can be approached for diagnosis and treatment by using retrograde ureteroscopy. This progress is a result of the development of rigid and flexible ureteroscopes and of adequate accessory instruments. The first endoscopic explorations were performed by Bozzini in 1806, using small caliber cannulas, the light source being a candle (Greene and Segura, 1979). It was only at the end of the nineteenth century that the first cystoscope with a warm light source was created by Nietze.

The first description of the retrograde endoscopic approach of the upper urinary tract came from Hugh H. Young (Fig. 1.1) who, in 1912, explored the dilated distal ureter of a patient with posterior urethral valves using a 9.5 F pediatric cystoscope (Young and McKay, 1929). This method had obvious limitations, making it necessary to develop specific instruments that allowed for the easy approach of the upper urinary tract, including the pyelocaliceal system. Significant advances occurred half a century later, leading to the appearance of modern rigid ureteroscopes. The most important role was the development by Hopkins in 1960 of cylindrical lens systems that allowed for a significant increase of light transmission along endoscopes. This made possible the appearance of low-caliber rigid ureteroscopes.

Figure 1.1   Hugh Hampton Young (1870–1945).

The pioneering period in the field of optical fibers started in 1854 when John Tyndall (Fig. 1.2), resuming one of Colladon’s experiments from 1841, demonstrated in London the possibility of guiding light through a curved jet of water, due to the phenomenon of total internal reflection. The first patent for the transmission of light through optical fibers was granted in 1972, legitimizing this scientific breakthrough that paved the way for the construction and development of flexible endoscopes.

Figure 1.2   John Tyndall (1820–1893).

The first flexible ureteroscopy was reported by Marshall in 1964 (Marshall, 1964). He used a 9 F instrument produced by American Cystoscopes Makers Inc., without a working channel and active deflection possibilities, being a purely diagnostic procedure. Takagi in 1966 and then Bush also reported the successful achievement of ureteropyeloscopies using flexible instruments with the same technical characteristics as that of Marshall. Without a proper irrigation system, they used forced diuresis in order to obtain a clearer image of the endoscopic field (Takagi et al., 1968).

Further technical advances allowed for the development of ureteroscopes and the improvement of accessory instruments necessary for the endoscopic procedures in the upper urinary tract (Fig. 1.3).

Figure 1.3   Landmarks in the development of ureteroscopy.

Rigid ureteroscopy entered current urological practice only at the end of the 1970s. Goodman (1977) and Lyon et al. (1978) achieved the assessment of women’s distal ureter using a pediatric cystoscope. However, the reduced length of the instrument did not allow for its routine use. Lyon et al. (1979), in cooperation with Richard Wolf Instruments (Rosemont, IL), developed a ureteroscope with a length of 23 cm that allowed for the approach of the distal ureter, both in women and in men. The diameter of the ureteroscope’s sheath ranged from 13 F to 16 F and allowed the use of telescopes with 0–70° lenses. This diameter facilitated the use of accessory instruments with dimensions of over 5 F. On the other hand, the relatively large diameter of the endoscope continued to create difficulties in approaching the ureteral orifice and the intramural ureter. Subsequently, Karl Storz Instruments (Culver City, CA) and Richard Wolf Instruments developed a ureteroscope with a length of 40 cm and a caliber of 9–11 F. The development of these endoscopes marked the beginning of the modern era of ureteroscopy.

Until the 1980s, the design of the ureteroscope underwent continuous development; a reduced diameter and working channels allowed for the use of accessory instruments. With the advances regarding optical fibers technology and with the appearance of reduced diameter working instruments, the diameter of modern ureteroscopes was reduced to 6.9–9.4 F, with an integral sheath and two working channels of 2.1–5.4 F. These miniature semi-rigid ureteroscopes use 5° telescopic lenses and have a length of 33 cm and 41 cm, respectively. The reduced caliber facilitated the access to the upper urinary tract, reducing the aggression on the ureter (Abdel-Razzak and Bagley, 1994).

Until 1981, the treatment of ureteral lithiasis was represented by surgical ureterolithotomy or by endoscopic manipulation of stones under cystoscopic control. The disadvantages of these methods were represented by the morbidity of open surgery, respectively by the reduced success rate of blind extraction of stones. The first endoscopic extraction of ureteral stones under ureteroscopic control was achieved by Das (1981). Initially, the technical and safety difficulties of the intervention prevented the widespread use of ureteroscopy, the major disadvantage being the dimensions of the instruments.

The development of ureteroscopes with a length of 50 cm allowed the retrograde approach up to the level of the pyelocaliceal system. This development was produced by Karl Storz Endoscopy, and was based on the research conducted together with Perez-Castro Ellendt and Martinez-Pineiro (Perez-Castro Ellendt and Martinez-Pineiro, 1982; Huffman et al., 1982). These represented the basis for the subsequent evolution and progress of ureteroscopes with different lengths (25–54 cm), optical systems, and diameters (9–16 F).

The technical difficulties in achieving a rigid ureteroscopic approach are determined by the need for ureteral dilation and by the impediments in advancing the instruments along the ureter, in overcoming the sinuosities, and the areas with a reduced caliber. The modalities for overcoming these impediments represented the object of many studies regarding how to facilitate advancing the rigid ureteroscope into the middle ureter, especially in men. The attempt to solve these problems, as well as the desire to retrogradely approach the entire upper urinary tract, led to the introduction of semirigid and flexible ureteroscopes into current practice (Marshall, 1964). Their use implied the progress of accessory instruments, with the development of extracting forceps, basket catheters, and lithotripsy probes with calibers of 1.9–2 F.

In the early 1980s, at Chicago University, Bagley, Huffman, and Lyon started the development of the flexible ureteroscope, adding three essential technical features: the working channel, the irrigation system, and active deflection (Bagley et al., 1987).

In 1990, flexible ureteroscopes had a 10 F diameter, a standard working channel of 3.6 F, and a unidirectional active deflection. Today, due to the miniaturization of optical fibers, the average dimensions of the instruments have been reduced to 7.5 F; the deflection system has also been enhanced, with the increase of amplitude and even the presence of two active areas.

With the technological development, the indications for the ureteroscopic approach have also been diversified. Thus, in 1982 Goodman described the retrograde ureteroscopic approach as a conservative method for treating upper urinary tract urothelial tumors (Goodman, 1984).

Together with the development of endoscopes, a similar evolution of the energy sources was recorded. The first attempt of intracorporeal lithotripsy belongs to Mulvaney (1953) who used a 0.8 kHz ultrasonic lithotripter. In 1955, Coates managed to obtain a partial fragmentation of stones using a 15 kHz device (Coates, 1956). In 1983, Huffman reported the use of ultrasonic lithotripsy during ureteroscopic interventions (Johnston et al., 2004).

The elecrohydraulic lithotripter was invented by Yutkin in 1955, at Kiev University. However, the political situation at that moment initially limited its use to within the East-European Bloc only (Grocela and Dretler, 1997). In 1985, Green and Lytton reported the use of electrohydraulic lithotripsy in the ureteroscopic treatment of ureteral lithiasis (Green and Lytton, 1985), while Begun, in 1988, used this method during flexible ureteroscopy.

Languetin et al. (1990) described the Swiss lithoclast, a pneumatic lithotripsy device whose development was based on the principles stated by Heurteloup in 1932 for bladder stones fragmentation (Johnston et al., 2004). The main disadvantage of this type of safe and efficient lithotripsy is the impossibility of using it on the increasingly popular flexible ureteroscopes. In 1994, Grasso and Loisides published the experimental results of a pneumatic lithotripter with nitinol flexible probes (Loisides et al., 1995; Grasso et al., 1994). Mulvaney and Beck (1968) attempted the lithotripsy of a bladder stone using a ruby laser. Initially used by Watson in 1984, pulsed-dye laser was the first type of laser that positioned itself as a source of energy for lithotripsy (Watson et al., 1997). Subsequently, other lasers were developed and used: Alexandrite, Nd:YAG, Ho:YAG, etc. The first description of the potential for using the Ho:YAG laser in urology belongs to Johnson, in 1992 (Johnston et al., 2004). The first results of this type of laser in intracorporeal lithotripsy were published in 1995, demonstrating its efficacy and safety (Erhard and Bagley, 1995; Matsuoka et al., 1995).

The development of accessory instruments was dictated by the features of the endoscopes and energy sources. In 1983, Huffman introduced the balloon dilation of the ureteral orifice. Honey (1998) published the first results of nitinol basket catheters, while in 2001, Dretler described a new instrument, the so-called stone cone or Dretler cone, designed to prevent the ascent of ureteral lithiasic fragments during lithotripsy (Dretler, 2001).

Two other historical landmarks that should not be overlooked are the first upper urinary tract photographic image obtained by Takagi in 1968, and the first video recording of the upper urinary tract by Takayasu in 1970 (Johnston et al., 2004) (Table 1.1).

Table 1.1

The Chronology of Ureteroscopy Development

1854 – John Tyndall demonstrates the total internal reflection phenomenon

1912 – Hugh H. Young performs the first ureteroscopy in a child with hydronephrosis secondary to posterior urethral valves

1927 – The first patent regarding optical fibers

1953 – The first attempt of intracorporeal lithotripsy using an ultrasonic lithotripter, performed by Mulvaney

1955 – Coates manages to obtain the partial intracorporeal ultrasonic fragmentation of a stone

1955 – The electrohydraulic lithotripter was invented by Yutkin

1959 – Nickel-titanium alloy (nitinol) was discovered

1960 – Hopkins develops the optical systems with cylindrical lenses

1964 – Marshal reports the first flexible ureteroscopy

1968 – Takagi obtains the first photographic image of the upper urinary tract

1968 – Mulvaney and Beck attempt lithotripsy of a bladder stone using a ruby laser

1970 – Takayasu makes the first video recording of the upper urinary tract

1979 – Lyon, in cooperation with Richard Wolf Instruments, develops a ureteroscope with a length of 23 cm that allows access to the distal ureter

1981 – Das achieves the first endoscopic extraction of ureteral stones under ureteroscopic control

1982 – The development of 50 cm length ureteroscopes produced by Karl Storz Endoscopy, based on the research conducted together with Perez-Castro Ellendt and Martinez-Pineiro, that allow the retrograde approach up to the level of the pyelocaliceal system

1983 – Huffman reports the use of ultrasonic lithotripsy during ureteroscopic interventions

1983 – Huffman introduces the balloon dilation of the ureteral orifice

1984 – Watson uses the pulsed-dye laser

1985 – The use of electrohydraulic lithotripsy in the ureteroscopic treatment of ureteral lithiasis by Green and Lytton

1987 – Bagley, Huffman, and Lyon start the development of the flexible ureteroscope in its modern form

1990 – Languetin describes the Swiss lithoclast

1992 – Johnson describes for the first time the possibility of using the Ho:YAG laser in urology

1994 – Grasso and Loisides publish the experimental results of a pneumatic lithotripter with nitinol flexible probes

1995 – Erhard publishes the first results of Ho:YAG intracorporeal lithotripsy

1998 – Honey publishes the first results of using nitinol basket catheters

2001 – Dretler describes a new instrument, the so-called stone cone, conceived to prevent the ascent of ureteral lithiasic fragments during lithotripsy

2006 – ACMI announces the release of the first digital flexible ureteroscope (ACMI DUR-D)

References

Abdel-Razzak OM, Bagley DH. Rigid ureteroscopes with fiberoptic imaging bundles: features and irrigating capacity. J. Endourol. 1994;8:411.

Bagley DH, Huffman JL, Lyon E. Flexible ureteropyeloscopy: diagnosis and treatment in the upper urinary tract. J. Urol. 1987;138:280–285.

Coates EC. The application of ultrasonic energy to urinary and biliary calculi. J. Urol. 1956;75:865.

Das S. Transurethral ureteroscopy and stone manipulation under direct vision. J. Urol. 1981;125:112.

Dretler SP. The stone cone: a new generation of basketry. J. Urol. 2001;165(5):1593–1596.

Erhard MJ, Bagley DH. Urologic applications of the holmium laser: preliminary experience. J. Endourol. 1995;9(5):383–386.

Goodman TM. Ureteroscopy with a pediatric cystoscope in adults. Urology. 1977;9:394.

Goodman TM. Ureteroscopy with rigid instruments in the management of distal ureteral disease. J. Urol. 1984;132(2):250–253.

Grasso M, Loisides P, Beaghler M, Bagley D. Treatment of urinary calculi in a porcine and canine model using the Browne Pneumatic Impactor. Urology. 1994;44(6):937–941.

Green DF, Lytton B. Early experience with direct vision electrohydraulic lithotripsy of ureteral calculi. J. Urol. 1985;133:767.

Greene LF, Segura JW. Transurethral Surgery. Philadelphia: WB Saunders Company; 1979.

Grocela JA, Dretler SP. Intracorporeal lithotripsy: instrumentation and development. Urol. Clin. North Am. 1997;24:13.

Honey RJ. Assessment of a new tipless nitinol stone basket and comparison with an existing flat-wire basket. J. Endourol. 1998;12(6):529–531.

Huffman JL, Bagley DH, Lyon ES. Treatment of distal ureteral calculi using rigid ureteroscope. Urology. 1982;20(6):574.

Johnston IIIrd RK, Low RK, Das S. The evolution and progress of ureteroscopy. Urol. Clin. N. Am. 2004;31:5–13.

Languetin JMP, Jichlinski, et al. The Swiss Lithoclast. J. Urol. 1990;143:179A.

Loisides P, Grasso M, Bagley DH. Mechanical impactor employing Nitinol probes to fragment human calculi: fragmentation efficiency with flexible endoscope deflection. J. Endourol. 1995;9(5):371–374.

Lyon ES, Kyker JS, Schoenberg HW. Transurethral ureteroscopy in women: a ready addition to the urological armamentarium. J. Urol. 1978;119(1):35–36.

Lyon ES, Banno JJ, Schoenberg HW. Transurethral ureteroscopy in men using juvenile cystoscopy equipment. J. Urol. 1979;122:152.

Marshall VF. Fiber optics in urology. J. Urol. 1964;91:110–114.

Matsuoka K, Iida S, Nakanami M, Koga H, Shimada A, Mihara T, Noda S. Holmium: yttrium-aluminum-garnet laser for endoscopic lithotripsy. Urology. 1995;45(6):947–952.

Mulvaney WD. Attempted disintegration of calculi by ultrasonic vibrations. J. Urol. 1953;70:704.

Mulvaney WP, Beck CW. The laser beam in urology. J. Urol. 1968;99:112–115.

Perez-Castro Ellendt E, Martinez-Pineiro JA. Transurethral ureteroscopy. A current urological procedure. Arch. Esp. Urol. 1980;33(5):445–460.

Perez-Castro Ellendt E, Martinez-Pineiro JA. Ureteral and renal endoscopy. Eur. Urol. 1982;8:117–120.

Takagi T, Go T, Takayasu H. A small-caliber fibrescope for the visualisation of the urinary tract, biliary tract, and spinal canal. Surgery. 1968;64:1033–1038.

Watson GM, Dretler SP, Parrish JA. The pulsed dye laser for fragmenting urinary calculi. J. Urol. 1997;138:195–198.

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Chapter 2

Notions of Histology, Anatomy, and Physiology of the Upper Urinary Tract

Răzvan Mulţescu

Dragoş Georgescu

Petrişor A. Geavlete

Bogdan Geavlete

Abstract

The upper urinary tract, composed of the pyelocaliceal system and the ureter, ensures the function of vector of the urine from the kidney to the urinary bladder through peristaltic contractions. Knowing the internal configuration of the upper urinary tract, as well as the topography and the relations of its composing segments, is essential for the proper integration of information provided by endoscopy and fluoroscopic monitoring. Also, adapting the ureteroscopic technique to the micro- and macroscopic anatomical particularities of this segment makes it possible to perform endoscopic interventions with maximum efficiency and safety.

Keywords

urinary tract

pyelocaliceal system

ureter

ureteroscope

endoscopy

urothelium

vascularization

2.1. Generalities

The upper urinary tract, composed of the pyelocaliceal system and the ureter, ensures the function of vector of the urine from the kidney to the urinary bladder through peristaltic contractions. Knowing the internal configuration of the upper urinary tract, as well as the topography and the relations of its composing segments, is essential for the proper integration of information provided by endoscopy and fluoroscopic monitoring. Also, adapting the ureteroscopic technique to the micro- and macroscopic anatomical particularities of this segment makes it possible to perform endoscopic interventions with maximum efficiency and safety.

2.2. Notions of upper urinary tract histology

The histological structure of the ureter, renal pelvis, and calyces has major implications in the ureteroscopic approach of the upper urinary tract. Lesions in these structures during endoscopic maneuvers are relatively frequent and require adequate knowledge of the histological particularities.

The ureteral wall consists of three layers:

• tunica adventitia

• tunica muscularis

• tunica mucosa

The adventitia, which is the outside layer, is made of elastic connective tissue.

The muscular layer consists of longitudinal and circular smooth muscle fibers. Its abundant vascularization could explain the important bleeding that occurs in case of ureteral perforations.

In the upper 2/3 of the ureter, there are two muscular layers: a superficial one (circular, thin) and a deep one (longitudinal, thick). In the inferior 1/3, a third, external muscular layer with longitudinal fibers is added. These layers are interconnected by muscle fibers exchanged between the adjacent layers. Due to this extensive interconnection, the individual muscle layers do not have a strictly spiral arrangement around the ureter (Gosling, 1970). The density of the muscle fibers in the proximal ureter is reduced. Consequently, the proximal ureteral wall is thinner than the distal one, implying an increased risk of ureteral perforation.

The muscle layer of the uretero-vesical junction consists mainly of longitudinal fibers. The lateral fibers of the external longitudinal layer head toward the ureteral orifice, while the medial ones are intertwined with those from the opposite side, forming the interureteral bar. In this way, the bladder trigone is delimited. The circular layer disappears and its fibers arrange themselves in the form of islands and mix with the fibers of the internal longitudinal layer, forming helicoidal systems. This disposition of the muscular fibers at the level of the uretero-vesical junction plays a very important role in the antireflux mechanism. There are significant structural differences between the structure of the ureteral muscular layer and the vesical one (Gilpin and Gosling, 1983).

The smooth musculature of the ureteral wall plays a major role in the transport of urine. Through peristaltic contractions, the urine is propelled in the form of successive, rhythmical jets with a frequency of 1–4 per minute.

The ureteral mucosa is disposed in longitudinal folds that, on the transversal section, give the ureteral lumen its characteristic stellate aspect. It consists of a pseudostratified epithelium (polymorphic type covering epithelium, urothelium, or transitional epithelium) located on a dense corium, consisting of fibro-elastic connective tissue arranged irregularly. The epithelium is separated from the corium by a basement membrane.

The transitional epithelium represents a particular form of stratified epithelium whose cells present a high degree of plasticity. It has the ability to display its cells on several layers according to the extent of the surface that it must cover at a given moment. Classically, the urothelium has three cellular layers: basal, intermediate, and superficial.

In fact, all the cells of this epithelium reach the basal membrane, while the free surface is reached only by a part of the cells, which have a bulging and vesicular apical pole. The luminal cells of the urothelium are characterized by the presence of a specialized apical membrane, being attached to the ones situated toward the ureteral lumen through a junctional complex. Pluristratified nuclei are observed in hematoxylin-eosin staining. The first layer of cubic-prismatic cells from the basal membrane belongs to the basal or germinating layer. The cells have a polymorphic aspect (polyhedral or fusiform, piriform or tennis racket cells), with a poorly represented intercellular junction that allows them to slide. This layer of cells becomes unapparent after the epithelium’s distension.

A layer consisting of flattened cells can be observed on the surface. Each of them may cover one or several cells of the underlying layer (umbrella cells). They contain one to two round nuclei, while the cytoplasm presents, at the level of the free surface under the apical plasma membrane, a condensation (the cuticle) that has the role of sealing the mucosa.

One of the most important features of the urothelium is the increased size of the intercellular compartment.

In the normal upper urinary tract, there are no histological differences between the uretero-pelvic junction and the rest of the upper urinary tract. In case of obstruction, there is an increase in the amount of collagen around the muscle fibers and in the proportion of longitudinal muscle fibers, but with an overall decrease in the amount of muscle tissue.

The pyelocaliceal system has a similar histological structure with the ureter.

The mucosal layer is well defined and thick. The muscularis is relatively thin, composed of oblique fibers separated by connective tissue, without presenting the distinct layers from the ureteral level. In the small calyces, deep longitudinal muscle fibers are described that are inserted at the base of the papillae. Circular muscle fibers, whose contraction has a role in the expulsion of urine from the papillary ducts, also exist at this level.

All calyces and a part of the renal pelvis are surrounded by the renal parenchyma and the renal sinus fat. The adventitia from the distal part of the renal pelvis is continued by the renal capsule.

2.3. Descriptive anatomy of the upper urinary tract

2.3.1. The Pyelocaliceal System

The pyelocaliceal system consists of the renal pelvis and calyces. The urine from the collecting ducts (which cross the renal pyramids to open into the papillae) is collected in the small calyces (minor or secondary). At the renal level, there are 8–18 pyramids, but only 7–13 minor calyces, some of the latter having more than one papilla. These calyces converge to form the major calyces, which in turn open into the renal pelvis through the caliceal infundibula. The renal pelvis continues on to the ureter via the uretero-pelvic junction, which is situated at the level of the L1 vertebra.

According to the architecture of the pyelocaliceal system, Sampaio proposed the following classification (Sampaio, 2007):

1. Group A – the pyelocaliceal system has two main caliceal groups (upper and lower), the mediorenal area being dependent on one of these.

a. Subgroup A1 – the mediorenal area is drained by secondary calyces, which are dependent on the upper or lower caliceal groups or even on both simultaneously.

b. Subgroup A2 – the mediorenal area is drained by crossed calyces, some toward the upper caliceal group and others toward the lower one, with a space being delimited between them and the renal pelvis, called the inter-pyelocaliceal space.

2. Group B – the mediorenal area is drained independent of the upper and lower caliceal groups.

a. Subgroup B1 – the mediorenal area is drained by a major caliceal group independent of the upper or lower calyx.

b. Subgroup B2 – the mediorenal area is drained by 1–4 secondary calyces that open directly into the renal pelvis.

Another classification, proposed by Graves, describes four types of pyelocaliceal systems; two primary and two secondary. Thus, for type A, the upper and lower caliceal infundibula are arranged in the shape of the letter Y, merging into an elongated renal pelvis. In type B, the lower calyx continues to the upper one, both merging with the renal pelvis at a 90° angle in the shape of the letter T. Type C presents a balloon-type renal pelvis, the calyces being short and thick. Type D presents a small, round renal pelvis and prominent calyces with long infundibula. Types A and C are considered to be primary, while types B and D are secondary, probably being intermediate forms.

In 1901, Brodel described a model of a pyelocaliceal system, having the anterior calyces in a position medial to the posterior ones (Brodel, 1901). Subsequently, Hodson also described a model, which mirrors the previously described one having the posterior calyces in a medial position and the anterior ones in a lateralized position (Hodson, 1972). This controversy ended in 1984 when Kaye and Reinke, after computed tomography observations, demonstrated that the Brodel-type kidney is found more often on the right side (69%), while the Hodson type is more frequent on the left side (79%) (Kaye and Reinke, 1984).

However, in vivo, due to the anterior rotation of the renal hilum, the anterior calyces are situated more laterally than the posterior ones in 74% of cases (Shnorhavorian and Anderson, 2004).

The renal pelvis can be intrasinusal or extrasinusal, having relations anteriorly with the renal vein and four segmental arteries, branches of the renal artery, and posteriorly with the fifth segmental artery.

2.3.1.1. Vascularization

The pyelocaliceal system’s vascularization is ensured by branches of the superior ureteral artery and of the renal artery. Knowing the distribution of the terminal branches of these arterial sources is essential during intrarenal endoscopic interventions in order to choose the site for safely performing incisions or resections, as well as for evaluating the possibility of different complications.

Sampaio studied the relations between the pyelocaliceal system and the intrarenal arteries and veins, describing a model with very important endoscopic implications (Sampaio and Mandarim-de-Lacerda, 1988; Sampaio, 2007).

The upper pole arteries have their origins in the anterior branch of the antero-superior segmental artery. The upper caliceal group has close relations, both on the anterior and on the posterior sides, with segmental or interlobular arteries in 86% of cases, as well as with veins anastomosed into plexuses in 84.6% of cases.

For the mediorenal area, the arteries originate from the anterior branch of the renal artery, keeping a horizontal trajectory at the level of the renal pelvis, in its middle part. The middle calyces have anterior relations with a segmental or infundibular artery in 65% of cases and with a vein in 75% of cases. Posteriorly, at least one middle calyx has close relations with the middle branch of the posterior segmental artery (the retro-pyelic artery), and in 21% of cases with a venous branch tributary to the renal vein.

The arterial sources of the lower pole originate from the anterior branch (62.2%) or posterior branch (37.8%) of the renal artery. The lower calyces present, in all cases, anterior relations with a branch of the inferior or antero-inferior segmental artery, as well as with an intrarenal vein. In 32% of cases, this caliceal group has posterior relations with a branch of the posterior segmental artery, and in 21% of cases with a high caliber branch of the renal vein. Also, Sampaio described a venous ring around the lower secondary caliceal infundibula in an important percentage

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