A morphometric study of the pelvi-ureteric junction and review of the pathogenesis of upper ureteric obstruction

Is the pelviureteric junction an anatomical entity?

OBJECTIVE

The concept of the pelviureteric junction has existed for more than a century and yet there is no clear anatomical definition of this junction. This systematic review addresses the question of whether the human pelviureteric junction is a discrete anatomical entity.

METHODS

A systematic literature review was undertaken to investigate the normal gross and microscopic anatomy of the pelviureteric junction using the electronic databases MEDLINE, PubMed, Cochrane Library and Google Scholar.

RESULTS

In most individuals there is a gradual transition between the renal pelvis and ureter with no external features indicating the presence of a discrete pelviureteric 'junction'. Internally, however, luminal mucosal folds are prominent in this region. There is no consensus on the arrangement of muscle fibers at the pelviureteric junction (which may be age-dependent) although some studies suggest a focal thickening in the muscle wall consistent with physiological observations suggesting a high pressure zone capable of regulating urine flow. Studies of innervation have shown no evidence of specialization at this site.

CONCLUSIONS

There is some evidence that a pelviureteric region can be delineated anatomically and physiologically. However, although it may be a useful clinical concept, there is no sound anatomical basis for an actual pelviureteric junction.

The kidney in congenital ureteropelvic junction obstruction: a spectrum from normal to nephrectomy

PURPOSE

Our recent studies of renal histology in congenital ureteropelvic obstruction cases prompted us to review the literature in this regard, focusing on issues of development, normal variation, clinicopathological correlations and pathogenesis.

MATERIALS AND METHODS

The period from 1971 to 2006 was analyzed, including all relevant articles, which were critically reviewed.

RESULTS

There have been many studies encompassing the entity of ureteropelvic junction obstruction that include clinical findings, radiographic imaging, pathological examination of ureteropelvic junction obstruction per se and renal biopsies during pyeloplasty procedures. We synthesized this information in a cohesive review with a proposed classification.

CONCLUSIONS

Congenital ureteropelvic junction obstruction is a spectrum that ranges from the radiological demonstration of apparent physiological ureteropelvic junction obstruction to a disordered ureteropelvic junction, characterized by smooth muscle hypertrophy and fibrosis associated with renal parenchymal changes that may necessitate pyeloplasty or nephrectomy. However, renal biopsies in patients in whom pyeloplasty is done show in most of them relatively well maintained parenchyma, in which overt changes are mainly glomerular. More subtle alterations have been described that relate to shifts in proximal-to-distal tubular ratios. Extreme thinning of the renal parenchyma can occur with only limited tubulointerstitial injury. Recently ureteropelvic junction obstruction was described in a series of genetically altered animals and placed in a more global context, ie CAKUT (congenital abnormalities of the kidney and urinary tract).

Anatomic and physiologic considerations in ureteroscopy

The successful and safe implementation of ureteroscopic techniques depends on considerations of anatomy and physiology. Combining knowledge of the drainage system of the kidney with its vascular supply, predictive patterns of incisions can be applied within the collecting system to safely avoid vascular injury. In addition, awareness of the variation in normal and pathologic anatomy and physiology is key to effective interventions. An appreciation of the impact of ureteroscopy on normal anatomy and physiology can prevent complications and promote improved therapeutic outcomes.

Physiology and evaluation of ureteropelvic junction obstruction

Ureteropelvic junction (UPJ) obstruction is not a single anatomic entity but rather a set of processes with multiple causes. In the obstructed system, histologic changes are apparent that have implications for healing. The role of crossing vessels In UPJ obstruction and its treatment is of growing interest. Various methods are available to assess the functional characteristics of the UPJ, of which the diuretic renogram, Whitaker perfusion test, and Doppler ultrasound resistive index may be the most useful. The treatment must be individualized according to the patient's symptoms, the status of renal function, and the potential complications of intervention.

Three-D muscular arrangement at the ureteropelvic junction and its changes in congenital hydronephrosis: a stereo-morphometric study

Ureteral walls were obtained from twelve autopsies without urological diseases and from surgical material of twelve patients operated for congenital hydronephrosis. The specimens were submitted to computer-assisted analysis of 3-D muscular architecture at the ureteropelvic junction (UPJ). Serial histologic sections in parallel with the wall were prepared. A geometric model was introduced to simplify the muscular layer, replacing bundles with vectors of corresponding size and direction. The vector distribution visualized that normally, the ureteral muscles change their arrangement with age, from a circular pattern in neonates to an oblique mesh in adults. In addition, longitudinal muscles emerged at the age of two years in the subepithelial layer. In patients with congenital hydronephrosis, not only were such growth-related changes ambiguous or lacking, but there also were various abnormalities; segmental muscular hypoplasia, disarrangement of bundles or lack of longitudinal fibers. These were considered to closely correlate with the urinary obstruction in patients with this disease.