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Pluripotent stem cell-derived kidney organoids offer a promising solution to renal failure, yet current organoid protocols often lead to off-target cells and phenotypic alterations, preventing maturity. Here, various dynamic hydrogel architectures are created, conferring a controlled and biomimetic environment for organoid encapsulation. How hydrogel stiffness and stress relaxation affect renal phenotype and undesired fibrotic markers are investigated. The authors observe that stiff hydrogel encapsulation leads to an absence of certain renal cell types and signs of an epithelial-mesenchymal transition (EMT), whereas encapsulation in soft, stress-relaxing hydrogels leads to all major renal segments, fewer fibrosis or EMT associated proteins, apical proximal tubule polarization, and primary cilia formation, representing a significant improvement over current approaches to culture kidney organoids. The findings show that engineering hydrogel mechanics and dynamics have a decided benefit for organoid culture. These structure-property-function relationships can enable the rational design of materials, bringing us closer to functional engraftments and disease-modeling applications.

The significance of intrarenal reflux as a risk factor for renal scarring and hypertension has been discussed. Fluoroscopic detection of intrarenal reflux depends on the equipment, the training of the radiologists and the timing of spot film acquisition. To evaluate the prevalence of intrarenal reflux and its association with age, gender, grade of vesico-uretero-renal reflux and the renal segments affected. We retrospectively analysed 1,166 voiding cysturethrographies. Patients’ ages ranged from 1 day old to 19 years old. Vesico-uretero-renal reflux was detected in 209 female and 164 male patients using a standardised technique with digital pulsed fluoroscopy. The point in time and grade of reflux were documented with spot films. All radiographs showing reflux were assessed for the occurrence of intrarenal reflux. Intrarenal reflux was detected in 41 of 373 (11%) patients with vesico-uretero-renal reflux. Unilateral intrarenal reflux was found in 30 patients and bilateral in 11. The left kidney was more frequently affected than the right (31 versus 21). Only patients younger than 9 years of age were affected (mean age: 1.6 years, median: 0.8 years). Intrarenal reflux was independent of gender and was most frequently observed in grade IV reflux (59.6%) and less often in grade V (23.1%) and grade III (17.3%). Intrarenal reflux in this study was detected in 11% of patients with vesico-uretero-renal reflux, predominantly with reflux grade IV and in patients younger than 4 years old.

The formation of the caudal vena cava is a complex process involving development, regression, and anastomosis. In mammals, the normal caudal vena cava runs to the right side of the abdominal aorta, while duplication of the caudal vena cava has been identified as a congenital abnormality in both companion animals and humans. The present study demonstrates that Slc:Hartley guinea pigs frequently possess asymptomatic duplicated caudal vena cava. The prevalence was 30% and 24% for males and females, respectively, with no sex-related differences. In accordance with Saad et al. (2012)’s criteria, duplicated caudal vena cava were classified into two distinct variations. The dominant variation was a complete duplication without iliac anastomosis where the left caudal vena cava continued from the left common iliac vein and joined the left renal vein; the left renal vein ran to the right to join the right caudal vena cava. The alternative variation was an incomplete duplication where the left caudal vena cava joined the right infrarenal caudal vena cava at a more cranial point than in normal cases; the renal segment was unchanged. Iliac anastomosis was not found in any cases. Duplicated caudal vena cava neither affected the body weight nor the kidney weight. In conclusion, Slc:Hartley guinea pigs frequently possess asymptomatic duplicated caudal vena cava in the absence of iliac anastomosis and appear to be a novel and useful animal model for duplicated caudal vena cava in animals and humans.

Objective To study the arterial segments of ovine kidney, present a proportional volume analysis of each kidney arterial segment, and analyze arterial injuries caused by simulated partial nephrectomy of cranial pole. Materials and Methods Forty-eight ovine kidneys injected with polyester resin into the renal arteries and collecting system were used in this study. Eighteen kidneys were used to study the arterial segments and the proportional volume of each renal segment. Other 30 kidneys were submitted to superior pole resection at a distance of 1.0cm, 0.5cm, or exactly at the cranial hilar edge, just before the resin hardening. These endocasts were used to evaluate the arterial injuries caused by these different resection planes. Results Ovine renal artery divided into two (ventral and dorsal) or three segmental arteries. Dorsal segment presented higher proportional volume than ventral segment. For kidneys with three segments, the third segment was on the caudal region (caudo-ventral or caudo-dorsal segment) and presented the lowest proportional volume. None of the resected kidneys (at 1.0, 0.5 or at the cranial hilar edge) presented injury of arterial branches that irrigate non-resected region. Conclusion The segmental distribution of renal artery, the proportional volume of each segment and arterial injuries after cranial pole resection in ovine kidneys are different from what is observed in human kidneys. Meanwhile, ovine kidneys show a primary segmental division on anterior and posterior, as in humans, but different from swine. These anatomical characteristics should be considered when using ovine as animal models for renal experimental and/or training procedures.

Summary Purpose Inferior vena cava (IVC) agenesis is an uncommon congenital vascular anomaly stemming from aberrant development during embryogenesis. It results from the failure of one or more of the supracardinal veins, subcardinal veins, vitelline veins or postcardinal veins to connect. The symptomatology resulting from this vascular malformation can be either absent or extremely rich and varied. Methods Thoracoabdominal-pelvic CT scan projections following iodine-based contrast product injection were analyzed and a three-dimensional model of vascularization constructed. Results Herein, an asymptomatic case of IVC agenesis with absence of the suprarenal and renal segments, with azygos continuation, presenting an accessory hepatorenal vein is reported. The presence of this type of accessory vein has never been described in the literature to date. The etiology of this case of IVC agenesis is explored in depth. We also analyzed the morphometric parameters of the IVC remnant segments and the azygos vein in order to quantify the dilatation of the collateral venous pathway overdeveloped to handle blood return. Conclusion Using the findings from this case and those reported in the literature, we provide general recommendations that should be taken into account before managing a patient, symptomatic or asymptomatic, admitted to the hospital with IVC agenesis.

Os avanços cirúrgicos para as nefrosegmentectomias indicam a necessidade de cada vez mais os pesquisadores procurarem identificar os segmentos anatomocirúrgicos arteriais renais de mamíferos de uma maneira geral, uma vez que fornecem bases anatômicas necessárias às intervenções cirúrgicas renais, tanto terapeuticamente, quanto experimentalmente. Assim, nesta oportunidade, propôs-se investigar os segmentos anatomocirúrgicos dos rins de Oryctolagus cuniculus no que se refere à distribuição arterial, cuja finalidade é identificar, elencar, quantificar e denominar tais segmentos. Para a realização desta investigação científica, foram utilizados 30 pares de rins de coelhos da raça Gigante (Oryctolagus cuniculus), sendo 17 machos e 13 fêmeas, com idade de 60 a 90 dias, procedentes da Faval Agropecuária Centro Equestre LTDA, Três Marias, Minas Gerais. Os rins foram retirados, de cada animal, mantidos aos pares e unidos por suas artérias e veias aos tratos, respectivamente, da porção abdominal da aorta e veia cava caudal. As artérias renais foram dissecadas e canuladas para injeção de solução corada de resina vinílica. A seguir as peças foram submetidas à corrosão em solução aquosa de ácido sulfúrico a 30% por um período de 72 horas para obtenção dos modelos arteriais, a partir dos quais, foram confeccionados desenhos esquemáticos da distribuição das artérias renais, obtendo-se o seguinte: 1) as artérias renais direita e esquerda mostraram—se sempre únicas quanto à origem e bifurcaram-se em todos os casos em artérias setoriais dorsal e ventral, bifurcação ocorrida no nível pré-hilar em todos os casos; 2) as artérias segmentares são ramos originados a partir da divisão terminal das artérias setoriais, onde encontrou-se um número de três a sete artérias segmentares dorsalmente e ventralmente para os rins direito e esquerdo; 3) diante da distribuição das artérias setoriais nas faces do rim de coelhos, verificou-se a existência de dois setores renais tanto à direita quanto à esquerda, os setores dorsal e ventral, vascularizados, respectivamente, por ramos originados das artérias setoriais dorsal e ventral; 4) para os rins direitos e esquerdos, as artérias setoriais dorsal e ventral destinam-se à maior parte da respectiva face do órgão, alcançando ainda porções da oposta, e em alguns casos destinam-se exclusivamente para as suas respectivas faces do órgão; 5) para o rim direito, no setor dorsal observou-se um número máximo, mínimo e médio, respectivamente, de 7, 3 e 5,5 segmentos anatomocirúrgicos arteriais, com maior ocorrência de 6; 6) no setor ventral do rim direito foi constatado um número máximo, mínimo e médio, respectivamente, de 7, 3 e 4,9 segmentos anatomocirúrgicos arteriais, com maior ocorrência de 5; 7) um número máximo, mínimo e médio, respectivamente, de 7, 3 e 5,1 segmentos anatomocirúrgicos arteriais, com maior ocorrência de 5, foram encontrados nos setores dorsal e ventral do rim esquerdo; 8) a simetria bilateral da segmentação anatomocirúrgíca arterial renal foi encontrada em um caso (3,3 %). The surgical progresses for the nephrosegmentectomy indicate the need of more research to try to identify the anatomicosurgical renal arterial segments of mammals in general, once they supply necessary anatomical bases to the renal surgical interventions, as much as therapeutically as experimentally. In this study, was investigated the anatomicosurgical segments of the kidneys of Oryctolagus cuniculus in what refers to the arterial distribution, whose purpose is to identify, elucidate, to quantify and to denominate such segments. For the accomplishment of this scientific investigation, 30 pairs of kidneys from rabbits of the Gigantic race (Oryctolagus cuniculus) were used, being 17 males and 13 females, with age from 60 to 90 days, coming from Faval Fanning Equestrian Center LTDA, Três Marias City, Minas Gerais State. The kidneys were removed from each animal, in pairs, united buy their arteries and veins to tracts, respectively, of the abdominal portion of the aorta and caudal vena cava. The renal arteries were dissected and canulated for injection of a vinyl resin colour solution. To follow the respective parts they were submitted to corrosion in an aqueous solution of 30% sulphuric acid for a period of 72 hours in order to obtain the arterial models starting from the ones which, schematic drawings of the distribution of the renal arteries were made, being obtained the following: 1) the right and left renal arteries were always single as for the origin and bifurcated in all of the cases in dorsal and ventral sectorial arteries, and that bifurcation happened at pre- hilar level in all of the cases; 2) the segmented arteries are branches originated from the terminal division of the sectorial arteries, where was found a number from three to seven dorsal and ventral segmented arteries for the right and left kidneys; 3) due to the distribution of the sectorial arteries in the surface of the kidney of rabbits, the existence of two renal sections were verified such as to the right as for the left, the dorsal and ventral sections, irrigated, respectively, from branches of the dorsal and ventral sectorial arteries; 4) for the right and left kidneys, the dorsal and ventral sectorial arteries are designated to most of the respective surface of the organ, still reaching portions of the opposite arteries, and in some cases are designated exclusively to the respective surface of the organ; 5) for the right kidney, in the dorsal section, a maximum, minimum and medium number was observed, respectively, of 7, 3 and 5.5 anatomicosurgical arterial segments, with larger occurrence of 6; 6) in the ventral section of the right kidney a maximum, minimum and medium number was verified, respectively, of 7, 3 and 4.9 anatomicosurgical arterial segments, with larger occurrence of 5 segments; 7) a maximum, minimum and medium number, respectively, of 7, 3 and 5.1 anatomicosurgical arterial segments, with larger occurrence of 5, were found in the dorsal and ventral sections of the left kidney; 8) a bilateral symmetry of the anatomicosurgical arterial segment was found in a case (3,3%). Dissertação (Mestrado)

An increasing number of observations have called the general scheme of five renal segments into question: anatomists, radiologists, and surgeons have reported discrepancies between Graves's scheme and morphological observations. The aims of the present study are: (1) to assess the correspondence between a virtual and a real vascular cast of the kidney; (2) to analyze the arterial anatomy with reference to the renal segments. Fifteen kidneys were injected with acrylic resins to obtain vascular casts, which were also analyzed by computed tomography. A mean of 6.3 (range 4-8) avascular fissures was found, indicating a mean of 7.3 segments (range 5-9). In the superior and middle territories there was a single segment in 4 (26.7%) and 8 (53.3%) cases, respectively, and there were two segments in 11 (73.3%) and in 7 (46.7%) cases, respectively. In the inferior territory there was a single segment in two cases (13.3%), two segments in nine (60%), and three segments in four (26.7%). A mean segmental volume of 550.5 mm3 was calculated; the posterior (1,030.1 mm3 , 28.9%) and inferior (450.3 mm3 , 24.2%) segments were the largest. More third order branches were identified in the inferior segments than in the other segments (three branches of the inferior segmental artery in 26.6%). According to these data the inferior segment occupies the inferior pole, extending both anteriorly and posteriorly. In conclusion, the high correspondence between a virtual and a real vascular cast permits more segments to be identified than those described by Graves, and the volume of each segment can be calculated. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

Aim To investigate the effectiveness and benefits of using 3D planning and virtual surgery in the management of patients with localized renal carcinoma undergoing laparoscopic surgery. Materials and methods A retrospective analysis was performed on 558 patients with renal cell carcinoma (RCC) who underwent surgical treatment at the Clinic of Urology, I.M. Sechenov First MSMU from January 2012 to May 2017. Of them, 244 (43.7%) and 314 (56.3%) patients underwent laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN), respectively. In addition to the standard diagnostic work-up, 248 (44.4%) patients underwent multispiral computed tomography (MSCT) for 3D modeling and virtual surgery using the 3D modeling program Amira. Matched pairs of patients with and without 3D planning were selected based on similarity of urologists experience in performing the operation, the size and location of the tumor (relative to the renal segment, anterior and posterior surfaces), and the surgical approach. As a result, two homogeneous subgroups of patients were chosen comprising those who underwent LRN (22 pairs of patients) and LPN (53 pairs of patients). Results Patients with RCC who underwent LPN with 3D planning had a significant advantage over patients without virtual planning: by warm ischemia time 12.0+/-6.4 min (p=0.010), operative time 113.4+/-39.4 min (p=0.0001), blood loss 102.8+/-98.2 ml (p=0.001). Among patients with RCC who underwent LRN, the subgroup with 3D planning also had an advantage: operative time was 135.2+/-27 and 202.9+/-55.5 min (p=0.0001), blood loss was 143.2+/-137,4 and 472,0+/-395,4 ml (p=0,014), and regarding the rate of intraoperative (p=0,017) and postoperative (p=0,017) complications. Conclusion The use of computer-assisted 3D planning and virtual operations improves immediate results of surgery in RCC patients undergoing organ-sparing and organ-removing laparoscopic surgery.

Background and objectives A detailed understanding of surgical anatomy is an essential requisite to maximize perioperative and functional outcomes of partial nephrectomy. The objectives of this study were 1) to validate the Graves classification and 2) to verify the real absence of collateral arterial blood-supply between different renal segments. Material and methods The study was performed on 15 normal kidneys sampled from 8 un-embalmed cadavers. Kidneys with the surrounding perirenal fat tissue were removed en bloc with the abdominal segment of the aorta. The renal artery was injected with acrylic and radiopaque resins with the specimen suspended in water. A computed tomography examination of the injected kidneys was performed in order to analyse the branches located deeply. After the imaging acquisition, the specimens were treated with sodium hydroxide for removal of the parenchyma to obtain the vascular casts. Results Ten casts (66.6%) showed the classical subdivision of the main artery in a single posterior and anterior branch. Concerning the distribution of the segmental or second order arteries, only 2 (13%) casts showed a pattern similar to that described by Graves characterized by 4 segmental (second order) branches coming from the anterior renal artery (apical, superior, middle and inferior). In the remaining 13 kidneys (87%) a different arterial vascular network was detected. In 10 (80%) casts a single renal segment resulted vascularised by two or more different branches coming from an artery destined to another segment (multiple vascularisation). In details, multiple vascularisation was observed in 3 (20%) apical segments, in 5 (33%) superior segments, in 6 (40%) middle segments, in 7 (47%) inferior segments, and in 2 (13%) posterior segments. Conclusions This study demonstrates that in the human kidneys the arterial vasculature is frequently different from the classical Graves description. Moreover, in a significant percentage of cases, a single renal segment receives two or more branches coming from an artery destined to another segment. This article is protected by copyright. All rights reserved.

Bilateral deep vein thrombosis (DVT) should prompt investigation for pro-thrombotic conditions and the exclusion of vascular compromise due to intrinsic and extrinsic factors. The authors present the case of a 47-year-old man admitted with bilateral DVT and diagnosed with inferior vena cava (IVC) infra-renal segment agenesis, and discuss the management of this rare condition. LEARNING POINTS Bilateral deep vein thrombosis in young and otherwise healthy individuals should prompt investigation of the aetiology and risk factors in case life-long treatment and anticoagulation therapy is required. Although rare, anatomical variations and congenital malformations should be considered even in adult patients. Rare medical cases should prompt a multidisciplinary approach to investigation and treatment, as prognosis will depend on both therapeutic procedures and anticipation of complications. Keywords: Deep venous thrombosis, absence of inferior vena cava, inferior vena cava anomalies INTRODUCTION Congenital malformation and agenesis of the inferior vena cava (IVC) are extremely rare vascular anomalies, being present in only 0.0005–1% of the general population[1]. The absence of the infra-renal segment of IVC seems to be the rarest anomaly[2,3], with KILT syndrome (kidney anomaly, IVC anomaly and leg thrombosis) also beingvery uncommon[1]. Frequently, these are incidental findings on imaging studies but have been reported during abdominal surgery or when difficulties arise during femoral catheterization.

Background In a cadaveric model with healthy kidneys, it has recently been highlighted that a single renal segment could be supplied by one or more arterial branches originating from an artery supplying another segment. Objective To demonstrate occurrences of anatomical variations of renal vascularization and to analyze vascularization of renal tumors. Design, setting, and participants This prospective monocentric study included all patients treated for a renal tumor between May 2015 and June 2017 by laparoscopic partial nephrectomy after superselective tumor embolization in a hybrid operating room. Intervention Three-dimensional renal and tumoral arteriography with cone-beam computed tomography scan was performed, coupled with preoperative cross-sectional imaging. This procedure provided an accurate vascular anatomical mapping of the kidney and allowed further analysis of tumor vascularization. Outcome measurements and statistical analysis Relation between anatomical variations of the vascularization and perioperative data was assessed. A χ2 test or Fisher’s test was used for qualitative variables, and a Student t test was used for quantitative variables. Results and limitations Out of the 60 patients included, only 25 (42%) presented a standard vascular subdivision. In 26 patients (43%), tumors were supplied by more than one branch and in 20 patients (33%), there was a branch supplying the tumor from another segment. In these cases of multiple or multi-segmental tumor vascularization, tumor size, operative duration, and duration of embolization were significantly higher than in the case of standard vascularization. These complex tumors were more often located at the upper pole of the kidney or at the junction of the anterior and posterior vascular territories of the kidney. Limitations of this study include the low number of patients and its monocentricity. Conclusions This study confirms that renal vascularization frequently differs from Graves’ reference model and that tumor vascularization can depend on several segmental branches. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy. Patient summary We studied renal and tumor vascularization using three-dimensional preoperative arteriography data on tumor kidneys. We have shown that there is great variability in renal vascularization and that tumors can be vascularized branches that originate from an artery leading to another segment. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy.

Kidney transplantation is now a mainstream therapy for end-stage renal disease. However, with approximately 96,000 people on the waiting list and only one-fourth of these patients achieving transplantation, there is a dire need for alternatives for those with failing organs. In order to decrease the harmful consequences of dialysis along with the overall healthcare costs it incurs, active investigation is ongoing in search of alternative solutions to organ transplantation. Implantable tissue-engineered renal cellular constructs are one such feasible approach to replacing lost renal functionality. Here, described for the first time, is the microdissection of murine kidneys for isolation of living corticomedullary renal segments. These segments are capable of rapid incorporation within scaffold-free endothelial-fibroblast constructs which may enable rapid connection with host vasculature once implanted. Adult mouse kidneys were procured from living donors, followed by stereoscope microdissection to obtain renal segments 200 - 300 µm in diameter. Multiple renal constructs were fabricated using primary renal segments harvested from only one kidney. This method demonstrates a procedure which could salvage functional renal tissue from organs that would otherwise be discarded.

Introduction Duplication of the upper urinary tract is one of the most common congenital urological anomalies. In patients with critically decreased or lost function of one of the renal segments, heminephrureterectomy is usually the treatment of choice. Until recently, this was an open surgery; in cases of complete removal of the ureter, an additional incision in the iliac region was required. Currently, heminephrureterectomy is increasingly performed laparoscopically. We report the experience in laparoscopic heminephrureterectomy (LHNUE) in 10 clinics in Russia and Belarus. Some of them have already used this technique for 10 years. Aim The study aimed to to improve the treatment results in children with urodynamic dysfunction due to duplicated upper urinary tract. Materials and methods We retrospectively analyzed medical records of 111 children treated from 2007 to 2016. There were 26 (23.4%) boys and 85 (76.6%) girls with mean age 44.6 months (from 2 to 170) at the time of surgery. All children included in the study had complete duplex kidneys, including 51 (45.9%) right-sided and 60 (54.1%) left-sided. All the children underwent LHNUE for a critical decrease or absence of function of the upper or lower segment of the duplex kidney caused by the following pathology: obstruction of the ureterovesical junction with the development of the megaureter of the upper ureteral segment in 57 (51.4%) patients; ureterocele in 28 (25.2%); extra-vesical ectopic ureter with urinary incontinence in 10 (9.0%) girls; high-grade UVR in 16 (14.4%) patients. Results There were no conversions in this series of patients. The mean operative time was 135 minutes (60-240 min.). All children included in the study were followed for 1 to 9 years after surgery. Complications occurred in 17 (15.3%) patients, of whom 12 (10.8%) required repeat surgery. In one patient with the loss of lower pole function, the treatment result was considered unsatisfactory. Conclusion LHNUE for duplex kidney is performed by a few clinics and is still at the stage of development and accumulation of experience. Nevertheless, LHNUE, though an effective treatment modality, carries the risk of reducing or losing the function of the retained segment.

To propose a novel system based on segmental renal anatomy for objectively reporting location of clinical T1 masses for nephron-sparing surgery. The kidney was subdivided into 12 standard segments, based on the computed tomography images. In 103 patients (105 cT1 tumours), three blinded radiologists (A, B, and C) prospectively reported segmental tumour location, size, and tumour-feeding arteries. Baseline, peri-operative, and post-operative data of 98 patients who underwent partial nephrectomy (PN) were prospectively collected, and the correlation between segmental tumour location and peri-operative data was evaluated. Kappa statistics were used to measure the inter-observer agreements. Tumour location could be assigned to the defined renal segment in all cases. Median tumour size was 2.8 cm (range 0.6–5.8). Inter-observer concordance was as follows: A versus B 0.82 (95 % CI 0.74–0.90); A versus C 0.89 (95 % CI 0.83–0.95); and B versus C 0.84 (95 % CI 0.76–0.92). First, second, third, and fourth segments were involved by the tumour in 23, 39, 17, and 21 % of cases, respectively. Number of segments involved by the tumour correlated with tumour size (p = 0.007), number of tumour-feeding arteries (p = 0.001), estimated blood loss during PN (p = 0.03), and trended towards higher post-operative complication rate (p = 0.07). Tumour-feeding arteries were identifiable in 80 patients (76 %). Kidney segmentation (KS) system is an objective and reproducible radiologic method of universally reporting tumour location according to 12 renal segments. By adding descriptive information on tumour characteristics in candidates for nephron-sparing surgery, this novel KS system could serve as an adjunct to current nephrometry systems.

Objectives We present the management with partial nephrectomy and interposition of the greater omentum in case of urinary fistulas in renal allograft. Material and methods We present a patient with necrosis at the inferior pole of the renal graft that affected calyceal system but with pyeloureteral vascularization preserved. The patient's condition was satisfactorily managed with a partial nephrectomy of the necrotic renal segment and primary suturing of the collecting system with interposition of the greater omentum. We reviewed the cases published to date of partial nephrectomy in renal allograft, and examined their outcomes by analyzing the patient presentation, diagnostic tools, and surgical techniques used. Results There are few cases in the current literature that describe conservative surgical management of urinary fistulas caused by segmental necrosis after renal transplantation. Surgical approach using partial nephrectomy in these cases produces favorable outcomes in our experience and reported cases. Conclusions Despite its obvious surgical complexity, this nephron-sparing management is feasible and should be implemented in cases where the prior renal function and the quantity of healthy parenchyma indicate a favorable subsequent evolution for the renal graft.

BACKGROUND: The aim of the study was to examine whether parametric clearance images (PAR) enhance diagnostic potential of a dynamic renal scintigraphy with detection of local dysfunction of kidneys, on a model of kidneys after treatment with extracorporeal shock wave lithotripsy (ESWL), MATERIAL AND METHODS: Kidneys after ESWL were accepted as a proper model for the implementation of this objective because of the previously proven damaging effect of a shock wave on renal parenchyma and known region of ESWL application. Forty patients (23 males and 17 females) at the age of 37 to 70 years (mean value 54) with untreated earlier single, one-sided nephrolithiasis, currently treated with ESWL, underwent a study. A dynamic renal 99mTc-EC scintigraphy was performed three times: before ESWL, a week and a month after this therapeutic intervention. PAR images generated with use of an in-house developed software were compared with summation (SUM) of images obtained from radiopharmaceutical uptake phase and quantitative global function parameters (GFP) of each kidney, like split function, MTT — mean transit time and PTT — parenchymal transit time. RESULTS: PAR and SUM images of all 40 kidneys before ESWL were normal. PAR images revealed local or diffused defects a week and a month after therapeutic intervention in statistically significantly larger numbers of kidneys than SUM images (19 vs. 6, p = 0.002 and 16 vs. 5, p = 0.003, respectively). A week after ESWL, when defects in PAR images were observed in about a half of all renal segments (29/57 — 51%) all GFP values were significantly worse than in kidneys without defects. A month after ESWL defects in PAR images could be observed in ab. 1/3 (17/48 — 35%) of segments and were less extensive, whereas GFP values did not differ significantly from values in kidneys without clearance function impairment in the PAR images. CONCLUSIONS: PAR images enhance diagnostic potential of a dynamic renal scintigraphy with detection of local function defects. These images allow to detect more local renal function defects than SUM images.

Congenital vascular anomalies are although rare but may cause serious complications. Vascular pathologies are best demonstrated by contrast enhanced computed tomography, with the advent of multidetector computed tomography and applying multiplanar reformation techniques. However, ultrasound color Doppler and catheter angiography are accessory imaging modalities utilized to rule out vascular anomalies. We present here a case series of 2 patients aged 19 years and 54 years, diagnosed with congenital vascular anomalies (agenesis of inferior vena cava and hypo plastic infra renal segment of inferior vena cava). The development of inferior vena cava (IVC) includes early embryogenesis stages including formation, confluence and involution of three primary longitudinal venous systems. Agenesis of inferior vena cava or hypoplasia of segment of inferior vena cava leads to formation of collaterals to maintain the venous flow. Contrast enhanced computed tomography with multiplanar reformation provides ulterior spatial and contrast resolution in cases of recognized vascular abnormalities. Inferior vena cava obstruction due to thrombosis or congenital vascular anomaly leads to extensive collateralization accompanied by varicose veins. In our case series, we found contrast enhanced computed tomography as an ulterior modality in setting ultimate diagnosis with accuracy and maximum detail.

An original model of nephrogenic hypertension in rats was used for histochemical mapping of NADPH diaphorase (NO synthase) in various renal segments to examine the effect of hypotensive drugs furosemide, bendazol, and clonidine on the time course of nitroxide production in the kidneys. In various nephron segments, these drugs modulated NO synthesis in different ways. Clonidine induced a stable up-regulation of NO synthesis, which can maintain active vasodilation and gradually diminish the rennin production. Bendazol also enhanced NO synthase activity in renal glomeruli and collecting tubules, but this effect was less pronounced and short lasting. During the first week after injection of bendazol, insignificant elevation of NO synthase activity was observed in the proximal nephron segments. Furosemide exerted the least effect on NO production in kidneys.

It is well known that a prolonged ureteral obstruction leads to function loss of the congested kidney. Determining whether kidney stones cause any obstruction by non-contrast multislice CT is crucial for deciding about the timing of treatment. In our study we evaluated by Non-Contrast Multislice Computed Tomography (NCMSCT) detectable reliable changes of the density of the renal parenchyma in rats with artificial hydronephrosis. We made total or partial obstruction to left ureters of Spraque-Dawley rats, and applied sham operation to control groups. Using NCMSCT we measured the renal average parenchyma densities in the first, third and thirteenth days of operation. There was no significant difference between the parenchyma density of partial obstructed group and control group. However the parenchyma density in totally obsructed kidneys has significantly decreased compared to the contralateral kidneys and control group. In this group the duration of the obstruction correlated with significantly decreased parenchyma density. The average density values of the upper, middle and lower renal segments were similar. We assume that our results can be useful in the evaluation of the consequences of the ureteral obstruction. The decrease of the parenchyma density evaluated in NCMSCT could be an important indicator of the renal parenchymal damages. Hidronefrotik bobrek parankim dansitesinin kontrastsiz cok kesitli bilgisayarli tomografi kullanilarak degerlendirilmesi Uzun suren ureteral obstruksiyonun bobrek fonksiyon kaybina neden oldugu iyi bilinmektedir. Uriner sistem tasina bagli herhangi bir obstruksiyonun kontrastsiz cok kesitli bilgisayarli tomografi (KCKBT) ile belirlenmesi tedavi zamanlamasi hakkinda karar vermek acisindan cok onemlidir. Calismamizda deneysel hidronefroz olusturulan ratlarda renal parankim dansitesinde meydana gelen degisiklikler KCKBT ile degerlendirildi. Bu calismada sol ureterlerinde total veya parsiyel obstruksiyon olusturulmus Spraque-Dawley ratlarin bobrek parankim dansiteleri deneyin 1.,3. ve 30. gunlerinde KCKBT ile degerlendirilerek, sham ve kontrol grubu ratlarin bobrek parankim dansiteleri ile karsilastirildi. Parsiyel ureteral obstruksiyon olusturulmus ratlarin bobrek parankim dansiteleri ile kontrol grubunun bobrek parankim dansiteleri arasinda anlamli bir fark olmadigi saptandi. Bununla birlikte total ureteral obstruksiyon olusturulmus ratlarin bobrek parankim dansitelerinin karsi taraf bobrekleri ve kontrol grubu ile karsilastirildiginda anlamli olarak azaldigi saptandi. Elde edilen bu bulgularin insanlarda ureter obstruksiyonun sonuclarinin degerlendirilmesinde yararli olabilecegini dusunmekteyiz. KCKBT degerlendirilmesinde renal parankim dansitesinin azalmasi renal parankimal hasarin bir gostergesi olabilir. J. Exp. Clin. Med., 2012; 29:215-220

OBJECTIVE To examine the hypothesis that the distribution of nephrocalcinosis in patients with severe hypocitraturia should be symmetric. PATIENTS AND METHODS Patients with profound hypocitraturia defined as a 24-h urine citrate < 50 mg at the time of initial presentation were identified from the metabolic stone clinic database at our academic medical center. Two independent blinded reviewers evaluated all of the abdominal radiographs for the segmental distribution of macroscopic nephrocalcinosis. RESULTS A total of 44 patients met study criteria, with an equal distribution of males and females and a mean age of 55.4 ± 13.7 years. Mean urinary citrate was 28 ± 11 mg/day. Nephrocalcinosis was present in at least one renal segment in 22 patients (50%). Of the 22 patients with nephrocalcinosis, 9 patients (41%) had unilateral nephrocalcinosis and 13 patients (59%) had bilateral nephrocalcinosis. Of the 35 kidneys with nephrocalcinosis, 14 kidneys (40%) had nephrocalcinosis in only one renal segment, 13 kidneys (37%) had nephrocalcinosis in two segments and eight kidneys (23%) had nephrocalcinosis involving all three segments. CONCLUSIONS Despite the systemic nature of severe hypocitraturia, nephrocalcinosis is frequently asymmetric and focal in nature. This suggests that local factors intrinsic to the renal medullary interstitium, such as vascular injury, must play a role in the formation of nephrocalcinosis. Further study to elucidate these intrinsic local factors may further improve the treatment and prevention of urinary stone disease.

OBJECTIVE To determine which and how many segmental arteries supply a single renal lobule especially at and near the segmental border, as no data are available on the arterial supply to a single renal lobule (a pyramid and its covering cortex) at the border between renal segments. MATERIALS AND METHODS We studied semi-serial sections (100 µm intervals; haematoxylin and eosin staining) of 26 kidneys obtained from 13 mid-term human fetuses (20–30 weeks gestation). Eleven fetuses were used for horizontal sections and two for sagittal sections. Section to section, we first traced the renal pyramids using a pen to understand the lobular configuration. RESULTS Fusion of the medullary pyramids was usually evident along the segmental borders, except for the border between the upper and middle segments. This fusion often accompanied a pair of arcuate arteries, each of which arose from a different renal segment, but shared a common corticomedullary junction to supply a single lobule. The incidence of fusion was high along the anterior border of the posterior segment as well as the border between the apical and upper segments. When the lower segmental artery entered the parenchyma distant from the renal hilus, fusion of pyramids occurred along the border between the posterior and lower segments in association with double arcuate arteries. CONCLUSIONS A single lobule is most likely to be shared by double segments at or near the segmental border. This morphology seems to be a result of lobule fusion during development and growth. Thus, in adults, a dual segmental supply to a single lobule seems to be more frequent than in fetuses.

In a retrospective analysis of 42 paediatric blunt renal injuries the indications for conservative and surgical treatment were evaluated. The type of injury (contusion, laceration, fragmentation, pedicle injury), associated injuries, the diagnostic procedures, the therapy and its results were analysed. All 18 contusions were treated conservatively. For the 24 severe injuries there was a surgery rate of 66% (16/24), a renal loss rate of 16% (4/24); the other organs could be saved by the operation. With primarily conservative treatment we had to operate in one case only due to recurrent haematuria; the renal loss rate was 0%. The following criteria are defined as indications for surgical treatment: (1) deteriorating vital signs, (2) pedicle injury, (3) large devitalized renal segments, (4) large extravasations of contrast medium ("Page kidney").

To present a systematic study and a proportional analysis of the arterial segments of the pig kidney.Sixty-one three-dimensional endocasts of the arterial segments of pig kidneys were studied. Each segment was injected with a resin of a different color. Cavalieri's principle was used to calculate the volume of each renal segment, and these results were compared with the results from the point-counting planimetry method used on photographs of pig-kidney surfaces.Two to five renal segments were observed. Division into two segments, a cranial and a caudal, was the most common (42.62%). The renal volume ranged from 101 to 173 cm(3) (mean 130.85 cm(3)). The cranial segment was present in 39 of the 57 casts (68.42%). It presented the greatest median value of proportional area (50.00%) and also the greatest maximum value of proportional area, accounting for as much as 74.04% of the total kidney area. The ventral segment, which was found in 20 of the 57 casts (35.09%), presented the lowest median value of proportional area (13.87%) and showed the most variation in area (coefficient of variation 72.89%). There was no significant statistical difference between the segmental areas as evaluated by Cavalieri's principle and by the point-counting planimetry method.The distribution and size of the renal-arterial segments in pigs are not similar to those of the human kidneys. Therefore, this information must be taken into account by practitioners of urologic training or ablation using pigs as the animal model, as the structure of the porcine arterial segments cannot be transposed to humans.

We hypothesized that the left renal vein pressure difference (ΔP) before and after the ligation can serve as an objective indicator for free of reconstruction after resection of a retroperitoneal tumor with renal segment of inferior vena cava and right kidney. After established a model of left renal vein compression, 45 miniature pigs were operated on experimental procedures including renal segment of inferior vena cava resection, right nephrectomy and left renal vein ligation. The ΔPs of left renal vein before and after the ligation were measured. Safe ΔP variation without causing acute kidney injury was calculated using regression analysis. In human the safety range of ΔP before and after ligation of the left renal vein was calculated by diuretic response test. The safety range of ΔP in animals or human was 0–11.9 or 0–17.5 cm H2O, respectively. The renal function changed dramatically (p

Objectives A circumcaval ureter is a rare congenital anomaly usually associated with upper urinary tract stasis and an "S" or "fishhook" deformity of the ureter, in which the ureter itself passes behind the inferior vena cava. Aim of this paper was to debate novel issues concerning the embryologic anomaly of the inferior vena cava which may lead to the ureter obstruction and hydronephrosis. Methods Search of published literature and meeting abstracts. Results A circumcaval ureter results from the posterior cardinal vein persisting as the renal segment of the inferior vena cava during development. Normally, the inferior vena cava develops from the vitelline vein, subcardinal and sacrocardinal veins, which must undergo sequential development, anastomosis and regression to become the inferior vena cava. Normally, the right vitelline vein forms the pre-renal or hepatic segment of the inferior vena cava, the right subcardinal vein forms the renal segment and the right sacrocardinal vein forms the post-renal vena cava. Typically, the circumcaval ureter aetiology is assumed to be abnormal embryologic development of the vena cava as a result of atrophy failure of the right posterior cardinal vein in the lumbar portion. Whether the renal segment of inferior vena cava is formed from the right posterior cardinal vein that lies ventral to the ureter, then the ureter will develop in a "circumcaval" position. Conclusions Although this embryologic anomaly is commonly known to urologists as circumcaval or retrocaval ureter – terms that are anatomically descriptive but misleading in regards to development – it is not the result of an abnormality in ureteral development but rather an anomaly in the development of the inferior vena cava. The term preureteral vena cava may thus emphasize that the circumcaval ureter results from altered vascular, rather than ureteral development.

Background/Purpose Congenital anomalies of the inferior vena cava (IVC) are infrequent conditions. Most are asymptomatic and incidentally discovered. However, their recognition may sometimes have relevant clinical and therapeutic implications. The purpose of this report is to emphasize the importance of accurate identification and to assess the utility of three-dimensional contrast-enhanced magnetic resonance angiography (3D contrast-enhanced MRA) in their evaluation. Methods We retrospectively evaluated the 3D contrast-enhanced MRA of 21 patients in whom an IVC anomaly was found. Results Five of these anomalies concerned the hepatic and prerenal segments, seven were located in the renal segment, and finally, the last nine concerned the postrenal segment. Conclusion IVC anomalies are uncommon conditions which may sometimes have important clinical implications. 3D contrast-enhanced MRA is a good method not only to identify them, but also to depict them accurately and safely.

Objectives To review our experience with the management of high-grade (grade IV and V) renal injuries to clarify the role of conservative management. Methods From 1991 to 2003, 79 consecutive patients (age range 2 to 14 years) with renal injuries were treated in an urban level I pediatric trauma center. Twenty children were identified as having high-grade renal injury (grade IV, 10 children and grade V, 10 children). The mechanism of injury was blunt trauma in 17 patients (85%) and penetrating trauma in 3 (15%). Results Of the 10 patients with grade IV injury, 8 (80%) were successfully treated conservatively with bedrest and catheter drainage. Two patients with persistent urine leaks required ureteral stenting, and one subsequently required open operative repair. The initial radiographic findings in both patients demonstrated complete renal fracture with retained vasculature to both renal segments. All 10 patients with grade V injury required open operative management and only 3 (30%) achieved long-term renal salvage. Conclusions Most children with grade IV renal injury can be treated conservatively. Patients with complete renal fracture or significant urinary extravasation on initial radiographic imaging may be less likely to undergo spontaneous resolution. Patients with a persistent urinary leak can be successfully treated with internal drainage. Grade V injuries are associated with an increased risk of requiring open operative intervention, and the renal preservation rates are low.

Renal units were created in vivo by transplanting isolated renal segments on three-dimensional, biodegradable polymer scaffolds. Renal segments, freshly isolated from rat kidneys, were seeded on polymer scaffolds and subcutaneously implanted in athymic mice for two and four weeks. Three-dimensional renal reconstructs were formed with glomeruli and tubules, showing a possibility of reconstituting renal structures by transplanting renal segments.

Ectopic ureter is one of the most common urinary tract anomalies. We, herein, present a case of a giant ureter with ectopic orifice, mimicking pelvic organ prolapse, which is the first in the literature. A 59-year-old female patient presenting with frequently recurrent urinary tract infection had grade 3 pelvic organ prolapse. On examination, the organ producing the appearance of prolapse was found to be a right ureter of giant size and was obstructed by a large stone at the distal segment. The proximal end of the ureter ended blindly. After exploration, the stone was removed, the ureter was detached from the urethra, and the lumen was tied off and cut 5 cm proximally. At 6 months postoperatively, the patient is being followed up without any clinical problems. In such cases with nonfunctioning renal segment draining proximally, the chance of cure can be obtained without a need for a comprehensive intervention such as total abdominal ureterectomy.

INTRODUCTION: Classically each kidney is supplied by a single renal artery. In its course renal artery divides into anterior and posterior division, both of these division further divide into segmental arteries that are apical, upper, middle, lower and posterior. Segmental arteries are representing an end artery and they form independent renal segments. In their course they are closely related with collecting system. So, a thorough in depth knowledge of the variations in segmental arteries is a basic requirement for surgeons. AIM: To observe and investigate the anatomical variations in arterial pattern of upper segmental renal artery and its relations with collecting system of ducts in human kidneys. MATERIALS AND METHODS: Fifty human kidneys of both sexes were observed and studied by corrosion cast method. Different colour coded cast material (butyl butyrate) like red for artery and black for collecting ducts were used. 20% solution of butyl butyrate in acetone was injected into renal artery and ureter of the kidneys. After polymerization (24 hours) these kidneys were kept immersed in a bath of concentrated KOH solution at 50(0)C for 24-48 hours for corrosion to obtain the endocasts. These endocasts were cleaned and washed under running tap water and photographed. RESULTS: In present study upper segmental artery was found in 49 (98%) kidneys. It was absent in 1 (2%) kidney. We observed four types of variations in arterial pattern of upper segmental artery namely Upper Segmental Artery Type-1 (USAT1), Upper Segmental Artery Type-2 (USAT2), Upper Segmental Artery Type-3 (USAT3), Upper Segmental Artery Type-4 (USAT4) and they were found in 20 (40%), 14 (28%), 10 (20%), 5 (10%) kidneys respectively. We also observed two different variations in the anatomical relations between upper segmental artery and collecting system namely Upper Segmental Artery Group -1 (USAG1) and Upper Segmental Artery Group-2 (USAG2). USAG1 was found in 40 (80%) kidneys and USAG2 in 9 (18%) kidneys respectively. CONCLUSION: Anatomical knowledge of these variations is very important and useful for the uro-surgeons for best outcome and minimal complications in and during nephrectomies, removal of calculi, surgery of renal tumors or other various intrarenal surgeries.

Background Males of the order Squamata have similar structure to the seminal vesicles of mammals called Renal Sexual Segment (RSS). The RSS regions are hypertrophied kidney ducts, androgen-dependent, responsible for providing secretions (complex of glycogen, mucopolysaccharides, mucoproteins and lipids) that nourishes and keeps the sperm during copulation [1,3], acting accessorily on reproductive cycle, once when mixed with sperm, and nutrient function, also act as activating agent of sperm transferred to the cloaca in the female during intercourse [2,3]. Valverde (personal communication, April 6, 2010) tested the crude extract of the renal sexual segment Crotalus durissus in bovine semen and the results showed a significant increase in sperm motility and vigor of the samples, but this activity was lost over time storage of the extract. The promising data in this study aimed to evaluate the effect of the addition of crude extract of the RSS from C. durissus on spermatic kinematics of thawed dog semen.

Introduction A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. Aim In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. Materials and Methods Following cystoscopy and ureteral catheter insertion the patient was placed in 600 modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. Results The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. Conclusions Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment.

Objectives To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments. Patients and methods All patients treated conservatively who presented between 1990 and 1999 with major renal laceration (grade 4 and 5) were retrospectively reviewed to determine whether urinary extravasation and devitalized segments adversely affected the outcome. For each patient the data collected included the initial emergency department evaluation, findings on computed tomography, associated injuries, duration of hospital stay, transfusion requirements, complications and follow-up imaging. Results Of 20 patients who sustained blunt trauma resulting in a major renal laceration (five grade 5 and 15 grade 4) with urinary extravasation, 11 had coexisting devitalized segments. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P

Summary In more than 20% of subjects, at least one kidney is found to be supplied by more than one artery arising from the aorta. This aberrant renovascular anatomy has been reported in the literature to occur in up to 80% of patients who suffer from essential hypertension. Predominant numbers of the so-called ‘accessory' vessels are longer and narrower than the segmental arteries arising in the main renal artery. As a result (in accordance with Poiseuille's law of fluid flow), the renal segments supplied by these ‘accessory' vessels may have lower levels of blood pressure than the remainder of the parenchyma, thereby increasing the renin secretion. This hypothesis could be significant in terms of finding a causal treatment for a disorder induced by such a mechanism. We first review the literature in which the frequency of these vascular anomalies in normotensive and hypertensive patients is described, and then advance a hypothesis explaining the frequent incidence of essential hypertension in these subjects, as well as the ramifications of this phenomenon.

The development of a peripheral aneurysm of the renal artery as a result of an ESWL is a rarely described complication. We discuss in the presented case the diagnosis and successful endovascular treatment of a complicated aneurysm of a renal segment artery with complete preservation of the renal parenchyma.

OBJECTIVES: The management of malignant tumours invading the inferior vena cava (IVC) generally requires a high-risk surgery with low long-term benefits. Surgical treatment with resection and/or embolectomy of the IVC may, however, be beneficial in selected patients. We describe our experience with regard to patient selection, operative technique and outcomes through a standardized and simplified approach. METHODS: Between 1996 and 2012, 37 patients underwent extended resection of malignant tumours invading the IVC. Tumour infiltration was located at the hepatic and suprahepatic segment in 23 patients (62%), the renal segment in 6 (16%), and the infrarenal segment in 8 (24%). Fourteen patients (38%) had right heart involvement, of whom 5 had a tumour thrombus located in the pulmonary arteries (PA). RESULTS: All the patients underwent a median laparotomy. A sternotomy with full liver mobilization was performed for tumours involving the PA, or the retrohepatic or supradiaphragmatic IVC. Cardiopulmonary bypass was performed in 15 patients (41%), with deep hypothermic circulatory arrest (DHCA) in 5 (14%). The 30-day mortality rate was 5.4%. The 1-, 5- and 10-year survival rates were 68.1, 45.7 and 40%, respectively, with a median survival of 18 months. Incomplete resection (R1 or R2) was the only parameter found to have a significant negative effect on survival (P= 0.003). CONCLUSIONS: Radical resection of malignant tumours invading the IVC is feasible in carefully selected patients and may require CPB with or without DHCA. Morbidity and mortality are low and the survival rates acceptable, particularly in patients with complete resection of the tumour.

To determine the safety and feasibility of Endoloop-assisted laparoscopic partial nephrectomy in a large-animal model.Twelve female Yucatan mini-pigs underwent either left (N = 6) or right (N = 6) transperitoneal laparoscopic lower-pole nephrectomy following cinching of a 1-0 Vicryl suture loop (Endoloop) proximal to the resected lower pole until ischemic discoloration was achieved. The ischemic lower pole was excised with Endo-scissors and the lower pole removed using a laparoscopic bag. Follow-up involved evaluation under anesthesia with retrograde pyelography and intravenous urography and subsequent sacrifice for pathologic evaluation at 3 (N = 4), 14 (N = 4), or 60 (N = 4) days.All procedures were completed successfully. In two cases, the Endoloop slipped off the retained parenchyma. Both problems were corrected immediately with no sequelae. At sacrifice, all upper-pole renal segments functioned, as shown by urography, and no urinomas or abscesses were found. In one animal, there was moderate hydronephrosis presumably secondary to ureteral scarring, and in another, mild extravasation was demonstrated on the retrograde pyelogram.We were able to perform laparoscopic partial nephrectomy with the Endoloop safely and effectively in the current model. Modification of the Endoloop to allow more controlled pressure application may allow clinical application of this method for polar laparoscopic partial nephrectomy.

ObjectiveControversy surrounds the treatment of chronic aortic dissection. Open surgical and endovascular experiences include mixed populations treated with evolving strategies and limited follow-up. We establish a standard against which endovascular repair can be compared by assessing outcomes after open repair of chronic distal aortic dissections anatomically suitable to stent-grafting.MethodsFrom 2000 to 2008, 169 patients underwent open repair of the descending thoracic artery only (n = 88) or thoracoabdominal (n = 81) chronic aortic dissection (elective in 98, urgent/emergency in 71). Chart review and 3-dimensional assessment of computed tomography were performed. Poor outcome included all-cause mortality or vascular reintervention.ResultsThirty-day mortality was 8% (n = 14). Serious complications included neurologic (n = 12 [spinal cord n = 4, 2.4%]), respiratory (n = 32), and renal failure (n = 1 descending thoracic artery only vs 17 thoracoabdominal, P

Background The hypothesis that fenoldopam mesylate, by increasing renal flow, could reduce renal damage in patients undergoing cardiac surgery with cardiopulmonary bypass has gained great interest. The aim of the current study was to quantify the relationship of the increase of the renal blood flow as a function of the fenoldopam dose in these patients and to evaluate renal flow distribution within the renal parenchyma using Doppler. Methods Twenty-five patients admitted to cardiac surgery have been enrolled. We used the Doppler technique to measure renal blood flow at the level of the renal, segmental, interlobar, and interlobular arteries. We calculated both the resistive and pulsatility indexes in all the renal segments. Moreover, we calculated echographically all the variables of preload, afterload, and cardiac index. Measurements were performed at baseline and after the infusion of fenoldopam mesylate at the doses of 0.05, 0.1, 0.2, and 0.3 μg·kg −1 ·min −1 . Results Fenoldopam infusion at doses more than 0.1 μg·kg −1 ·min −1 significantly increases blood flow in all renal compartments, thus improving the resistive and pulsatility indexes starting at a dose of 0.1 μg·kg −1 ·min −1 . The highest renal flow increase is observed with 0.3 μg·kg −1 ·min −1 . Fenoldopam seems to increase the renal flow directed to the most external kidney areas. Systemic hemodynamically significant changes are observed only in patients receiving doses more than 0.1 μg·kg −1 ·min −1 . Conclusions In hemodynamically stable patients undergoing cardiac surgery with preserved renal function, fenoldopam shows a pharmacodynamic dose-dependent profile: it significantly increases renal flow and reduces the resistances of the renal circulation starting at a dose of 0.1 μg·kg −1 ·min −1 .

Objective The purpose of this study was to evaluate the effect of 0.1 μg/kg/min of fenoldopam mesylate on renal flow and central hemodynamics measured by echocardiography in hemodynamically stable patients with preserved renal function undergoing cardiac surgery. Design Experimental observational study. Setting Single-institutional community hospital study. Participants Thirty patients undergoing cardiac surgery. Intervention Fenoldopam mesylate infusion (0.1 μg/kg/min) in patients undergoing cardiopulmonary bypass. Measurements and Main Results Doppler measurements of renal blood flow and echocardiographic hemodynamic determinations after Doppler echocardiography measured flux velocities of the main, segmental, and interlobar and interlobular right renal arteries. The authors calculated the resistive index of all the renal segments studied. Moreover, the authors measured the flux of the main renal artery and its diameter as well as the main hemodynamic variables. All the measurements were performed in the intensive care unit setting at baseline and 20 minutes after the infusion of 0.1 μg/kg/min of fenoldopam mesylate. Fenoldopam mesylate infusion significantly increased blood flow in all renal compartments, thus improving the resistive index. The study showed that fenoldopam mesylate infusion does not induce any significant change of the heart rate or arterial pressure, cardiac output, preload, or wall stress. Conclusions In hemodynamically stable cardiac surgery patients with preserved renal function, an infusion of 0.1 μg/kg/min of fenoldopam mesylate has no influence on systemic hemodynamics while increasing renal blood flow.

A 46-year-old Japanese man was diagnosed with a left renal pelvic carcinoma and a contralateral hypoplastic kidney. The tumor was adjacent to the renal pelvis and was considered too difficult to completely resect in situ. The patient was treated by ex vivo partial nephrectomy of the left kidney followed by autotransplantation of the remaining renal segment. A pathologic evaluation revealed a transitional cell carcinoma, G2, pT3. Graft function recovered satisfactorily postautotransplantation and no significant complications developed during the postoperative period. The patient is alive and doing well 12 months postoperatively with no evidence of tumor recurrence.

We have identified 2 relatively young patients with significant hypertension, an elongated single aberrant renal artery supplying blood to a renal segment, and evidence for localization of the elevated plasma renin activity to the side and vein draining the affected kidney. Furosemide-induced diuresis and acute oral captopril stimulated the renal vein/contralateral renin ratios to 4.3:1 and 6.5:1 in patients 1 and 2, respectively. These renal vein ratios are significantly higher than normal (>3:1 under similar conditions). Partial resection of the portion of the kidney affected by the aberrant tortuous artery led to a marked reduction in blood pressure in patient 1. Patient 2, not an operative candidate, responded satisfactorily to use of a converting enzyme inhibitor, which helped to confirm the dependency of the blood pressure on the abnormal flow relationship existing within that aberrant artery and the kidney. We believe these 2 patients are representative of a small but distinct subgroup within the larger number of patients with elongated single or multiple renal aberrant arteries. Each aberrant artery had no focal stenosis, although a decrease in flow relative to the tissue perfusion demands was apparent from the marked activation of the renin-angiotensin system in the venous system draining that artery. The increased length of such vessels may contribute to their decreased flow, although their average diameter may reside just above such a critical value for a normal length vessel. This new syndrome, involving more than one component of the flow/resistance relationship, has been overlooked when renin-dependent forms of hypertension are considered.

An eight-year-old, male castrated basset hound presenting with a three-month history of lethargy was examined. Diagnostic tests including radiography and ultrasonography showed a right-sided renal mass. A 99mTc diethylenetriamine penta-acetic acid scan demonstrated that this kidney was non-functional. At surgery, invasion of the caudal vena cava was found, and the renal segment of the vena cava and the right kidney were resected. The left renal vein was anastomosed to the more proximal vena cava using a polytetrafluoroethylene graft, and the dog recovered well. Two days postsurgery, the dog suffered an acute episode of aspiration pneumonia and was euthanased. The renal mass was diagnosed as lymphoma on histopathology.

Was studied 18 pairs of White-lipped peccaries kidneys (Tayassu pecari), that has your renal arteries injected whit Vinilit dissolved in P.A. acetone e colored, following submitted to acid corrosion. The vascular molds like this obtained propose that: a) the renal arteries, always single, to divide firstly in setorial renal branches, being these cranial, dorsal, dorsocranial, dorsocaudal, ventral, ventrocranial, ventrocaudal and caudal; b) the segmentary renal arteries, originating from second division of the renal arteries, in agreement with your topographical disposition, consists of: cranial, mediocranial, middle, mediocaudal, caudal, dorsal and ventral; c) independent of the modality in which to introduce, the renal segments are separated amongst themselves by paucivasculars areas.

Objectives. Laparoscopic partial nephrectomy (LPN) has generally been reserved for small exophytic lesions because of the limited hemostatic capabilities when excising large segments of renal parenchyma. To overcome this problem, we investigated a technique of laparoscopic reversible, regional hypoperfusion using a cable-tie to minimize blood loss and optimize exposure. Methods. Ten domestic pigs underwent LPN after securing a cable-tie around one pole of the kidney and tightening it until the distal parenchymal surface blanched completely. Eight large amputations involving the collecting system and eight smaller amputations excluding the collecting system were performed using laparoscopic scissors. Fibrin glue was applied to seal the cut surface prior to cable-tie removal. Four pigs (4 large and 4 small amputations) were killed immediately and methylene blue was injected retrograde into the ureter to identify collecting system leaks. The remaining 6 pigs (4 large and 4 small amputations) were killed 4 weeks later and retrograde urograms were performed to assess collecting system integrity. Results. Median cable-tie ischemia time was 15 minutes (range 7 to 48) and median blood loss was 30 mL (range 10 to 300). In each case, hemostasis was attained with fibrin glue. In the survival group, all 4 small amputations healed with a fibrotic scar. In the large amputation group, 1 animal died from urinary extravasation on postoperative day 4. The collecting systems of the remaining 3 pigs sealed completely. Conclusions. In the porcine model, cable-tie-assisted LPN provides an almost bloodless surgical field that facilitates rapid resection of large renal segments and hemostasis during a short ischemic period. We anticipate that this technique will broaden the clinical application of LPN.

We report a case of a previously healthy forty-year-old man with bilateral renalartery stenosis secondary to bilateral medial fibrous dysplasia. He was additionally found to have a dissecting aneurysm of the left upper renal artery branch with resultant infarction of the upper and middle pole renal segments. We believe renal infarction secondary to medial fibrous dysplasia with occlusion of the renal artery associated with a dissecting aneurysm has not been reported, and we report the first such case. A multimodality treatment approach was utilized.

Objectives: To determine if prenatal identification of significant renal duplication anomalies affects the management of the patient or the clinical outcome. Methods: This is a retrospective review of 79 consecutive children with severe hydronephrosis involving a duplex renal collecting system, identified by either prenatal ultrasound (asymptomatic), or symptoms, most often urinary tract infection, but also including abdominal mass, hematuria, or incontinence. An individualized combination of voiding cystourethrogram, ultrasound, intravenous urogram, and nuclear renal scan was used to assess anatomy and function. Ablation of the involved segment was carried out if no or extremely poor function was identified; a definitive reconstructive procedure was elected in the face of easily measureable function. Outcome was determined clinically and by repeat imaging. Results: There was no difference in the rate of renal segment salvage between the prenatally and clinically diagnosed groups. Of the cases analyzed, 20/79 were prenatally identified, of which 13/20 (65%) were reconstructed; 59/79 were identified on clinical grounds, of which 34/59 (58%) were reconstructed. One patient in the prenatal salvage group underwent removal of the affected kidney 5 years later. Another, in the clinical salvage group, underwent a successful secondary procedure for closure of a ureteral fistula. All others have shown improved function, drainage, or both in follow-up. No secondary procedures have been required for the ablation group to date. Follow-up ranges from 4 months to 12 years. Conclusions: Prenatal identification of significant duplex system hydronephrosis does not improve the rate of renal segment salvage, as determined by standard radiographic means, compared to later identification on clinical grounds. The decision for reconstruction versus ablation in significant duplex system hydronephrosis can be made on the basis of function alone.