pvca.pptx

Pelvicalyseal sysyiem anatomy

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3. KIDNEYS Each adult kidney, which is approximately 11 cm long, 6 cm wide and 3 cm thick, It lies in the retroperitoneal space underneath the diaphragmatic muscle in the paravertebral (costovertebral) gutter and extends from the 12lh thoracic vertebra to the third lumbar vertebra ,with its long axis parallel to the psoas muscle and the lordotic curvature of the lumbar vertebrae (Grunberger,1997 ). As a result, the upper pole of the kidney, which is closely related lo the adrenal gland, is more posterior and nearer to the median plane than in the lower pole

4. right kidney is approxi­mately 1.5 cm lower than its counterpart. The anatomic axis of the kidney is rotated to 30° posterior to the coronal plane of the body ( Grunberger , 1997). Because of the relation of the anatomic renal axis to the coronal plane, a patient is positioned prone and tilted 30° upward on the operative side so that the posterior calices project vertically upward in preparation for a calyceal puncture (spine back) (Coleman 1987).

5. Diaphragmatic fibers separate the inferior margin of the parietal pleura ( costodiaphragmatic recess) from the upper half of the posterior surface of the left kidney and the upper third of the posterior surface of the right kidney. puncture of the renal collecting system above the 12th rib can, therefore, lead to pneumothorax and hydrothorax (Kaye, 1982).

6. The kidneys are approximately 2.5 cm lower in the standing position and move downward during inspiration and upward during expiration. Cranial displacement during inspiration and caudal displacement during expiration of the extracorporeal segment of a percuteneously inserted needle therefore confirms its presence within the kidney however the renal movements during respiration are either restricted or lost in patients who have had previous retroperitoneal surgery (Grunberger1997).

7. CALYCEALSYSTEM In 1901, Brödel

8. Hodson Hodson also pointed out that the Brödel type of arrangement was infrequent ( Hodson , 1972).

9. Kaye and Reinke also studied CT scans of the kidneys and observed that right kidneys fre­quently showed a Brödel type of calyceal arrangement, whereas left kidneys frequently showed a Hodson type of distribution (Kaye and Reinke , 1984).

10. Anterior view of a pelviocalyceal endocast from a left kidney, obtained according to the injection–corrosion technique. (B) Schematic of the endocast shown in A. This shows the essential elements of the kidney collecting system. cc, compound calyx; sc , single calyx; mc, minor calyx; Mc, major calyx; f, calyceal fornix; i , infundibulum; P, renal pelvis (Renal Anatomy Applied to Urology, Endourology , and Interventional Radiology, Sampaio FJB, Uflacker R, eds., Thieme , 1993 (reprinted with permission))

11. View of the two morphologic types of pelviocalyceal systems that compose Group A. (A) Type A-I: anterior view of a left pelviocalyceal endocast shows the kidney midzone drained by calyces dependent on the superior (S) and inferior (I) calyceal groups. (B) Type A-II: anterior view of a right pelviocalyceal cast shows the kidney midzone drained by crossed calyces, dependent simultaneously on the superior (S) and inferior (I) calyceal group. This endocast shows the interpelviocalyceal space (IPC)

12. View of the two morphologic types of pelviocalyceal systems that compose Group B. (A) Type B-I: anterior view of a left pelviocalyceal endocast shows the kidney midzone drained by a hilar major calyx (M), independently of the superior (S) and inferior (I) major calyces. (B) Type B-II: anterior view of a left pelviocalyceal endocast shows the kidney midzone drained by minor calyces (M) entering directly into the renal pelvis, independently of both the superior (S) and inferior (I) calyceal groups

13. Anterior view of two left pelviocalyceal endocasts , one showing a long and thin superior calyceal infundibulum (arrow) (A) and the other a short and thick superior and inferior calyceal infundibula (arrows) (B)

14. Pelvi-calyceal Parameters Influencing Surgical Choices However, it has been argued that, as the pelvicalyceal structures are dynamic, the diameter or other measurements of any particular structure within the collecting system might also change during peristalsis [ 22 ].

15. perpendicular minor calyces

16. Thus, this anatomic detail must be considered in cases of stones that do not alter renal function and can appear as if they are in the renal pelvis or a major calyx. complementary radiologic study with lateral and oblique films must be performed to determine accurately the position and extent of the stones

17. When a stone is located in a perpendicular minor calyx (Figure 6.19), its removal presents additional difficulties for both extracorporeal shock-wave lithotripsy (ESWL) and percutaneous nephrolithotripsy (PCNL).

18. Regarding percutaneous removal, direct access into the calyx containing the stone is easy; nevertheless, it involves a puncture without consideration of the arterial and venous anatomic relationships to the collecting system, which carries a high risk of injuring a vascular structure [12]. Therefore, in cases of stone in such calyces, safe access, techniques, and instruments should be used.

19. Crossed calyces (A) Anterior view of a retrograde pyelogram shows the radiographic image of the interpelviocalyceal (IPC) region (arrow). (B) Anterior view of the corresponding 3D endocast . The arrow points to the calyx which is draining into the inferior calyceal group in the ventral position (87.7% of the endocasts of the IPC space). S, superior calyceal group; I, inferior calyceal group

20. In 17.2% of the endocasts , the kidney midzone (hilar) was drained simultaneously by crossed calyces, one draining into the superior calyceal group and the other into the inferior calyceal group. On the pyelograms, the crossed calyces (laterally) and the renal pelvis (medially) outlined a radiotransparent region that we termed the interpelviocalyceal region (Figure 6.20A). In the 3D endocasts , that same region appeared as a space (Figure 6.20B) [9, 11, 12].

21. The interpelviocalyceal space may have different shapes: lozenge-like (the most common), long and narrow, and even small and round, depending on the shape of the calyces and the shape of the renal pelvis (Figure 6.21). Regardless of the form assumed by the interpelviocalyceal space, it is the result of crossed calyces in the mid kidney. When the crossed calyces were in the mid kidney, the calyx draining into the inferior calyceal group was in the ventral position in 87.5% of the endocasts [9, 11, 12] In some cases, even when radiographically the calyx draining into the inferior group was apparently in the dorsal position, we verified its ventral posi - tion on the endocast (Figure 6.22). This constant spatial arrangement is noteworthy for endourologic maneuvers. If the intention is to access the renal pelvis via a crossed calyx or to access a crossed calyx via the renal pelvis,

22. it is useful to remember that the calyx draining into the inferior calyceal group is almost always in the ventral position. It is also worthy of remark that detection of an interpelviocalyceal region on the pyelograms is an indirect sign of crossed calyces in the kidney midzone .

23. Position of the calyces relative to the lateral kidney margin In 39 of the 140 endocasts (27.8%), the anterior calyces had a more lateral (peripheral) position than the posterior calyces (Figure 6.23). In 27 endocasts (19.3%), the posterior calyces were in a more lateral position than the anterior calyces (Figure 6.24).

24. Position of the calyces relative to the lateral margin of the kidney. (A) Anterior view of a right pelviocalyceal endocast , which shows the anterior calyces have a more lateral (peripheral) position than the posterior calyces (arrows). This means that the posterior calyces are located medially. (B) Schematic of the endocast shown in A. This shows the peripheral calyces in the anterior plane and the medial calyces (arrows) in the posterior plane

25. Position of the calyces relative to the lateral margin of the kidney. (A) Anterior view of a right pelviocalyceal endocast . This shows that the posterior calyces (arrows) have a more lateral (peripheral) position than the anterior calyces. (B) Schematic of the endocast shown in A. This shows the peripheral calyces in the posterior plane (arrows) and the medial calyces in the anterior plane

26. In the majority of the endocasts (74; 52.9%), the anterior and posterior calyces had varied positions: superimposed or alternately distributed (in one region the most lateral were the anterior calyces, and in another, the posterior calyces) (Figure 6.25)

27. Position of the calyces relative to the lateral margin of the kidney. (A) Anterior view of a right pelviocalyceal endocast and (B) schematic of this endocast . The calyces in the anterior plane (arrows) are located alternately relative to the lateral margin of the kidney, i.e. in one region they are more lateral and in another they are more medial.

28. ????? Since the first choice of access to the collecting system is through a posterior calyx, much effort has been made to determine preoperatively which calyces are anterior and which posterior. To solve this problem quickly and inexpensively, during endourologic procedures, with the patient in the prone position, room air should be injected into the collecting system and this will rise to the more posterior portions of the collecting system, determining which calyces are located posteriorly (radiolucent contrast).

29. Learning moments

30. Schematic drawing of the morphology of the pelvicalyceal system, classifi ed according to Sampaio into type A ( A1 and A2 ) and type B ( B1 and B2 ). S superior calyceal group, M middle calyceal group, I inferior calyceal group (see text) (© Cracco )

31. Anatomic relationship of intrarenal vessels (arteries and veins) with the kidney collecting system: importance for puncture intrarenal access

32. Superior pole Puncture is most dangerous through the upper pole infundibulum because this region is surrounded almost completely by large vessels Infundibular arteries and veins course parallel to the anterior and posterior aspects of the upper pole infundibulum.

33. (A) Posterior view of a retrograde pyelogram from a left kidney. Puncture performed through the upper infundibulum has injured an infundibular vein (curved arrow). Note the contrast in the retropelvic vein (short arrows). (B) Posterior view of the corresponding endocast reveals the site of the lesion (arrow). Arrowheads show the needle tracts. A, renal artery; V, renal vein; u, ureter

34. The most serious vascular accident in upper infundibulum puncture is lesion of the posterior segmental artery ( retropelvic artery).

35. Middle kidney Intrarenal access through the mid kidney infundibulum caused arterial lesion in 23% of the kidneys studied. The middle branch of the posterior segmental artery was injured more often than any other vessel.

36. Inferior pole The posterior aspect of the lower pole infundibulum is widely presumed by endourologists and interventional radiologists to be free of arteries. a safe region through which to gain access to the collecting system and to place a nephrostomy tube.

37. In about 38% of the kidneys examined, however, an infundibular artery was found in this region

38. Puncture through the lower pole infundibulum risks injury to a venous arcade (Figure 6.32). A venous lesion usually heals spontaneously, but consequent hemorrhage may be problematic during the procedure

39. The analysis of the caliceal cavities of 30 pairs of Kidneys shows a dichotomous distribution of two types: cranio-caudal for the major calices, ventro -dorsal for the minor ones. The dichotomous organization does not result from the initial division of the ureteral bud: but it should depend upon the renal arteries growth commanding a new caliceal pattern during the morphogenesis of the Kidney.