Lower Infundibulum Research Articles

Factors and nomograms determining the effectiveness of extracorporeal shock wave lithotripsy in children with urolithiasis: a literature review

Extracorporeal shock wave lithotripsy (ESWL) is currently the priority method for treating urolithiasis in children. Due to the lack of extended indications for the application of this technique, an active search has been made over the past 30 years to define factors predicting ESWL outcome, to create objective preoperative planning tools, to increase ESWL effectiveness and to reduce the number of anesthetics and unnecessary surgical interventions. Search for the information on predictive factors of ESWL successful intervention and on modern statistical tools predicting lithotripsy effectiveness in children with urolithiasis was made in foreign and domestic sources, like MEDLINE, eLIBRARY, CyberLeninka. The literature analysis has showed that the following factors predispose positive ESWL outcomes: age before six years, smaller calculi size, and shorter skin-to-stone distance. Stone location in the lower calyx group, multiple concrements, and their high density has a negative impact at complete fragment detachment after ESWL. The probability of complete detachment of stone fragments from the lower calyx group decreases under the following anatomic features of kidney collecting system: number of draining calyces is more than one, calyx neck diameter is less than 4 mm, acute angle between the lower infundibulum and renal pelvis. Body mass index and prestenting have a controversial effect at successful ESWL too. Nomograms and scoring systems based on predicting factors are widely used in both adult and pediatric practice. The two most commonly used nomograms in pediatric urology are Onal and Dogan nomograms developed in 2012 and 2015 in Turkey. These nomograms include the following parameters: patient's sex and age, history of ipsilateral surgical interventions as well as stone localization, number and size. Thus, predicting ESWL outcomes using preoperative planning allows to choose the most appropriate treatment modality for a particular patient considering his/her individual anatomical and physiological characteristics and characteristics of the calculi.

Kidney collecting system anatomy applied to endourology - a narrative review.

To evaluate the surgical anatomy of the kidney collecting system through a narrative review of the literature, highlighting its importance during diagnosis and its approach during surgical procedures for the treatment of renal stones. We carried out a review about the anatomy of the kidney collecting system. We analyzed papers published in the past 40 years in the databases Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials and opinions of specialists. Renal collecting system could be divided in four groups: A1 - kidney midzone (KM), drained by minor calyx that are dependent on the superior or the inferior caliceal groups; A2 - KM drained by crossed calyx, one draining into the superior caliceal group and another draining into the inferior caliceal group; B1 - KM drained by a major caliceal group independent of both the superior and inferior groups; and B2 - KM drained by minor calyx entering directly into the renal pelvis. Some details and anatomic variations of the collecting system are related to clinical and radiological aspects, particularly perpendicular calyces, interpyelocalyx space, position of calyces in relation to renal border, classification of the renal collecting system, infundibular diameter and the angle between the lower infundibulum and renal pelvis. The knowledge of intra-renal collecting system divisions and variations as the angle between the renal pelvis and lower infundibula, position of the calices in relationship with renal edge and the diameter and position of the calyces are important for the planning of minimally invasive renal surgeries.

Diagnostic Accuracy of GATA6 Immunostaining in Sebaceous Tumors of the Skin

The accurate diagnosis of skin adnexal neoplasms is sometimes challenging but is necessary because medical management and follow-up may differ between tumors. GATA6 transcription factor has been identified as a new marker of the upper folliculosebaceous compartment (lower infundibulum, junctional zone and isthmus, and upper sebaceous gland) in the human skin. We aimed to determine the diagnostic accuracy of GATA6 immunostaining to diagnose sebaceous tumors compared with that to diagnose other adnexal and nonadnexal cutaneous neoplasms. We conducted a retrospective, evaluator-nonblinded study comparing the reference standard (diagnosis by an expert dermatopathologist) with GATA6 immunostaining to identify sebaceous tumors in a cohort containing 234 different tumors. The GATA6 expression score was significatively higher in sebaceous than that in nonsebaceous tumors. In addition, tumors originating from the upper hair follicle showed positive results for GATA6 staining; however, they showed lower GATA6 expression scores. Detection of sebaceous tumors using GATA6 positivity had a sensitivity of 95.7% (95% CI, 85.8-99.2), specificity of 80.8% (95% CI, 74.5-85.8), positive predictive value of 55.6% (95% CI, 44.7-65.9), and negative predictive value of 98.7% (95% CI, 95.4-99.8). GATA6 showed similar sensitivity to adipophilin, the reference marker; however, the specificity of GATA6 was higher, as observed in a cohort of 106 tumors enriched in squamous cell carcinomas with clear-cell histology. In addition, GATA6 positivity was assessed in 39 sebaceous carcinomas and compared with epithelial membrane antigen (EMA), CK7, and androgen receptor (AR) staining results. Although CK7 staining displayed lower diagnostic performances, GATA6 staining showed comparable results as EMA and AR. Finally, we found GATA6 expression in skin metastases of gastrointestinal origin, whereas GATA6 was absent in metastases originating from breast or lung cancers. Overall, our work identified GATA6 immunostaining as a new diagnostic tool for sebaceous tumors.

Lower pole anatomy of horseshoe kidney and complete ureteral duplication: Anatomic and radiologic study applied to endourology

ABSTRACTPurpose:To analyze the 3-dimensional intrarenal anatomy of horseshoe kidneys (HK) and kidney with complete ureteral duplication (CUD), in polyester resin endocasts of the collecting system and in patients submitted to 3D computerized tomography scan (CT-scan).Materials and Methods:We analyzed seven 3-dimensional polyester resin endocasts of the kidney collecting system obtained from 6 fresh adult cadavers (4 with unilateral CUD and 2 with horseshoe kidney) and CT-scan reconstruction images of kidneys from 24 patients: 6 patients with HK, 8 with CUD and 10 patients without renal anomalies that were used as controls. We analyzed the spatial distribution of the calices, the infundibula diameters, the angle between the lower infundibulum and the renal pelvis (LIP) and the angle between the lower infundibulum and the inferior minor calyces (LIICA). Measurements of the width and length of the inferior infundibulum and the infundibula of the minor calyces, as well as the angles (LIP and LIICA) were made with the aid of the LibreOffice 6.3 software. The data were analyzed with the IBM® SPSS® Statistics.Results:There was no statistical difference in the inferior pole measurements between the groups with anomalies and the control group, both in polyester resin endocasts and CT-scan reconstruction images for LIP. When we compared the LIP in the CT-scan between HK versus CUD (p= 0.003), and HK versus the control group (p= 0.035), we observed statistical difference.Conclusions:The knowledge of spatial anatomy of lower pole is of utmost importance during endourologic procedures in patients with kidney anomalies. In the present study we observed that horseshoe kidneys had more restrictive anatomic factors in lower pole than the complete ureteral duplication.

Lower pole anatomy of horseshoe kidney and complete ureteral duplication: Anatomic and radiologic study applied to endourology.

To analyze the 3-dimensional intrarenal anatomy of horseshoe kidneys (HK) and kidney with complete ureteral duplication (CUD), in polyester resin endocasts of the collecting system and in patients submitted to 3D computerized tomography scan (CT-scan). We analyzed seven 3-dimensional polyester resin endocasts of the kidney collecting system obtained from 6 fresh adult cadavers (4 with unilateral CUD and 2 with horseshoe kidney) and CT-scan reconstruction images of kidneys from 24 patients: 6 patients with HK, 8 with CUD and 10 patients without renal anomalies that were used as controls. We analyzed the spatial distribution of the calices, the infundibula diameters, the angle between the lower infundibulum and the renal pelvis (LIP) and the angle between the lower infundibulum and the inferior minor calyces (LIICA). Measurements of the width and length of the inferior infundibulum and the infundibula of the minor calyces, as well as the angles (LIP and LIICA) were made with the aid of the LibreOffice 6.3 software. The data were analyzed with the IBM® SPSS® Statistics. There was no statistical difference in the inferior pole measurements between the groups with anomalies and the control group, both in polyester resin endocasts and CT-scan reconstruction images for LIP. When we compared the LIP in the CT-scan between HK versus CUD (p= 0.003), and HK versus the control group (p= 0.035), we observed statistical difference. The knowledge of spatial anatomy of lower pole is of utmost importance during endourologic procedures in patients with kidney anomalies. In the present study we observed that horseshoe kidneys had more restrictive anatomic factors in lower pole than the complete ureteral duplication.

The anatomy of the renal lower calyceal group influence on the risk of residual stones in the Urolithiasis treatment

Background. There are various data in the literature regarding the boundary values of the width and length of the neck, as well as the angle between the pelvis and infundibulum. These parameters distinguish between patients with high and low risk of residual fragments.Objectives. The purpose of this study is to examine the lower calyceal group anatomy of patients without kidney stones and to compare the obtained results with previously published one. Materials and methods. Retrospective stage: Computed tomography (CT) scan of the abdomen was obtained in 120 patients (which was performed on them from March 2018 to 2019). CT scans of 100 patients (200 kidneys) were included in analysis after exclusion of inappropriate data. The infundibulopelvic angle was measured using the two most common methods by Sampaio and by Elbahnasy. Also, the length and width of the lower infundibulum were measured. All results were divided into four groups depending on the Sampaio classification of pyelocaliceal system (PCS). Results. The average value of the infundibulopelvic angle according to the Elbahnasy’s method is 74.1±15.1, and according to the Sampaio method is 101.8±20.1. When measured by the Elbahnasy method, an angle of more than 90 ° is more likely to occur with A1 structure variant, and less than 90 ° is more likely to occur in the PCS corresponding to the A2 variant. The average length of the lower infundibulum is 20.7±2.8 mm. The higher value of the lower infundibulum width was in group A1. Conclusion. In our study, all parameters were out of risk of both the low success of the operation and the development of kidney stone indicated in previously published studies. This fact can confirm the influence of the anatomy of the lower calyceal group on the development of kidney stones.

Morphological details of pelvicaliceal system and lower infundibulum in human kidneys

Morphological details of pelvicaliceal system and lower infundibulum in human kidneys

Influence of the renal lower pole anatomy and mid-renal-zone classification in successful approach to the calices during flexible ureteroscopy.

The aim of this paper is to analyze if the anatomy type of the collector system (CS) limits the accessibility of flexible ureteroscopy (FUR) in the lower pole. We analyzed the pyelographies of 51 patients submitted to FUR and divided the CS into four groups: A1-kidney midzone (KM) drained by minor calices (Mc) that are dependent on the superior or on the inferior caliceal groups; A2-KM drained by crossed calices; B1-KM drained by a major caliceal group independent both of the superior and inferior groups, and B2-KM drained by Mc entering directly into the renal pelvis. We studied the number of calices, the angle between the lower infundibulum and renal pelvis, and the angle between the lower infundibulum and the inferior Mc. With the use of a flexible ureteroscope, the access attempt was made to all of lower pole calices. Averages were statistically compared using the ANOVA and Unpaired T test (p < 0.05). We found 14 kidneys of A1 (27.45 %); 4 of A2 (7.84 %); 17 of B1 (33.33 %); and 16 of B2 (31.37 %). The LIP was >90° in 31 kidneys (60.78 %) and between 61° and 90° in 20 kidneys (39.22 %). We did not find angles smaller than 60°. The group A1 presented 48 Mc and the UF was able to access 42 (87.5 %); the group A2 had 11 Mc and the UF was able to access 7 (63.64 %); the group B1 had 48 Mc and the UF was able to access 41 (85.42 %) and in group B2 we observed 41 Mc and the UF could access 35 (85.36 %). There was no statistical difference in the accessibility between the groups (p = 0.2610). Collecting system with kidney midzone drained by crossed calices presented the lower accessibility rate during FUR.

Lower pole anatomy and mid-renal-zone classification applied to flexible ureteroscopy: experimental study using human three-dimensional endocasts.

The aim of this study was to analyze the anatomy of the inferior pole collecting system and the mid-renal-zone classification in human endocasts applied to flexible ureteroscopy. 170 three-dimensional polyester resin endocasts of the kidney collecting system were obtained from 85 adult cadavers. We divided the endocasts into four groups: A1--kidney midzone (KM), drained by minor calices (mc) that are dependent on the superior or the inferior caliceal groups; A2--KM drained by crossed calices; B1--KM drained by a major caliceal group independent of both the superior and inferior groups; and B2--KM drained by mc entering directly into the renal pelvis. We studied the number of calices, the angle between the lower infundibulum and renal pelvis and the angle between the lower infundibulum and the inferior mc (LIICA). Means were statistically compared using ANOVA and the unpaired T test (p < 0.05). We found 57 (33.53 %) endocasts of group A1; 23 (13.53 %) of group A2; 59 (34.71 %) of group B1; and 31 (18.23 %) of group B2. The inferior pole was drained by four or more calices in 84 cases (49.41 %), distributed into groups as follows: A1 = 35 cases (41.67 %); A2 = 18 (21.43 %); B1 = 22 (26.19 %); and B2 = 9 (10.71 %). Perpendicular mc were observed in 15 cases (8.82 %). We did not observe statistical differences between the LIICA in the groups studied. Collector systems with kidney midzone drained by minor calices that are dependent on the superior or on the inferior caliceal groups presented at least two restrictive anatomical features. The mid-renal-zone classification was predictive of anatomical risk factors for lower pole ureteroscopy difficulties.

Evaluation of perifollicular inflammation of donor area during hair transplantation in androgenetic alopecia and its comparison with controls

Background:Mild perifollicular inflammation is seen in both androgenetic alopecia (AGA) cases and normal controls, whereas moderate or dense inflammation with concentric layers of collagen, is seen in AGA cases but only in very few normal controls, and may lessen the response to topical minoxidil. Moderate or dense lymphocytic inflammation and perifollicular fibrosis have poor hair growth following transplantation.Aim:The purpose of the study is to evaluate the perifollicular lymphocytic inflammation and fibrosis in AGA patients during follicular unit hair transplantation (FUT) and its comparison in normal controls.Materials and Methods:A total of 21 male patients with AGA and 7 matched controls participated in the study. Histopathological analysis of biopsy specimens from donor strip of patients during the hair transplantation and two 4 mm punch biopsies on controls were performed. Morphometric analysis was performed and perifollicular fibrosis was scored based on the width of the condensed collagen at the lower infundibulum and isthmus from 0 to 3. Perifollicular infiltrate was also scored 0-3 and a total score of 3 or more out of 6 was considered significant.Results:Nearly 76% of AGA patients had perifollicular fibrosis more than 50 μm at ×200 magnification. Almost 33.33% patients had moderate/dense perifollicular lymphocytic infiltrate whereas none of the controls had it. Total score in AGA cases was significantly higher than controls (P = 0.012) using Chi-square test. Out of 21 patients, 13 had a score of 3 or more and were followed-up with monthly treatment with intralesional steroids using a dermaroller.Conclusion:Histopathological evaluation of the donor area is a must during hair transplantation to evaluate the extent of perifollicular inflammation and achieve better results by following it up with treatment directed to decrease the inflammation.

The impact of radiological anatomy in clearance of lower caliceal stones after shock wave lithotripsy

The goal of this study was to determine the factors affecting stone clearance after extracorporeal shock wave lithotripsy (ESWL) for lower caliceal stones. Lower pole stone clearance was investigated in 128 (80 males, 48 females) patients treated with ESWL during 1998-2003 in our clinic. Renal anatomy was determined on standard intravenous urogram. The lower infundibulopelvic angle (LIPA) was measured as the angle between the vertical pelvis axis and the vertical axis of lower infundibulum (Sampaio's method). The mean age of the patients was 42.8 +/- 12.4 (19-77) years. The mean stone diameter and burden were found to be 1.28 +/- 0.58 (0.5-3.5) cm and 1.2 +/- 1 (0-7) cm(2) respectively. The stone-free rate was 62.5% and ESWL was unsuccessful in 16 (12.5%) patients. Thirty-two (25%) patients had residual fragments < or =4 mm retained in lower calices after lithotripsy. The stone clearance was found to be unrelated to stone burden and diameter (P = 0.17 and P = 0.14, respectively). However, there was a significant difference between mean lower pole infundibulum length (P = 0.001), infundibulum width (P = 0.001) and LIPA (P = 0.0001) between stone-free patients and patients with residual fragments. Multivariate logistic regression analysis accepting stone-free as the favourable result also confirmed that LIPA, lower pole infundibulum length and width were factors that significantly affected the outcome. Lower pole anatomy has a significant influence on clearance of fragments after ESWL.

Factors affecting the success rate of extracorporeal shock wave lithotripsy for renal calculi in children

The aim of the study was to analyse factors affecting the success rate of extracorporeal shock wave lithotripsy (ESWL) in children with renal calculi. We performed a retrospective analysis reviewing records of 85 (40 female, 45 male) children (89 renal units) subjected to ESWL for treatment of renal calculi during 1990-2005 in our department. As 4 patients had bilateral calculi and 19 children (21 renal units) had renal stones at more than one different site, each location was analysed separately for convenience. The mean age of the patients was 10.3+/-4.6 (2-16) years. The stone-free rates for renal pelvis, lower, middle and upper caliceal calculi were 70, 62, 50 and 73%, respectively. A higher rate (33%) of insignificant fragments (< or = 4 mm) was noted for lower pole calculi. Increased stone diameter (P=0.0001) and burden (P=0.04) were found as the most significant factors that adversely affect the stone-free rate for pelvis renalis calculi, whereas an acutely oriented infundibulum and/or a long lower infundibulum (P=0.005) were unfavourable factors for clearance of lower caliceal stones. The stone-free rate in children with multiple calculi was 48%, while 29% of the renal units had retained fragments. ESWL is a good initial option for treatment of most of the renal calculi < 2 cm except in the presence of unfavourable lower caliceal anatomy. Increased stone burden, multiple stones, staghorn calculi, narrow lower infundibulopelvic angle and long lower infundibulum are factors that adversely affect the clearance rate.

Acne Keloidalis Is a Form of Primary Scarring Alopecia

To better define the pathogenesis of acne keloidalis (AK). Prospective, blinded study of histologic material collected from 10 patients with clinically typical AK. Outpatient dermatology clinic of a military tertiary care medical center. Ten male volunteers 18 years or older with early AK lesions (1- to 4-mm firm papules on the lower occipital/nuchal region). Biopsy specimens from small, early lesions and from clinically uninvolved skin, studied histologically with transverse sectioning. Three separate 4-mm punch biopsy specimens of the scalp (lesional, perilesional, and "normal" scalp) were obtained from each volunteer. The specimens were processed using transverse sectioning. The primary variables for data analysis were the presence or absence of the following histologic features: premature loss of the inner root sheath; eccentric placement of shaft, with thinning of the outer root sheath; lamellar fibroplasia surrounding the follicle; loss of sebaceous glands; evidence of follicular destruction or scarring; inflammation; and intrafollicular or perifollicular microorganisms. The number and type of hairs were also recorded. The most common findings in the 19 histologically abnormal specimens were perifollicular, chronic (lymphocytic and plasmacytic) inflammation, most intense at the level of the isthmus and lower infundibulum; lamellar fibroplasia, most marked at the level of the isthmus; complete disappearance of sebaceous glands, associated with inflamed or destroyed follicles; thinning of the follicular epithelium, most marked at the level of the isthmus; and total epithelial destruction (superficial and deep), with residual "naked" hair fragments. Even some "normal" specimens contained true follicular scars, demonstrating that normal-appearing scalp skin had previously been affected by the disease. Acne keloidalis is a primary form of scarring alopecia, and many of the histologic findings closely resemble those found in certain other forms of cicatricial alopecia. Extensive subclinical disease may be present in patients with AK and can account for some of the permanent hair loss. Overgrowth of microorganisms does not appear to play an important role in the pathogenesis of the disease. There is no etiologic relationship between AK and pseudofolliculitis barbae. Therapies found to be useful in other forms of inflammatory scarring alopecia are useful in the treatment of early AK.

Immunohistochemical observation of cytokeratins in keratinous cysts including plantar epidermoid cyst.

Sixteen cases of epidermal cyst (EC) (6 cases of conventional EC and 10 cases of plantar epidermoid cyst (PEC)) and 9 cases of trichilemmal cyst (TC) were examined by an immunohistochemical technique using various antibodies against cytokeratins and human papilloma virus (HPV) in order to clarify their histogenesis. There was no difference in immunoreactivities between EC and PEC with or without HPV infection. In TC, the inner layers of the cyst wall were stained with the antibody E3 (CK17), and the outermost layer was stained with the antibodies 4.1.18 (CK8) and 170.2.14 (CK19). In PEC and EC, however, the cyst wall didn't react with these antibodies, and differentiation-specific cytokeratins were expressed in the inner layer. These results confirmed that the immunoreactivities of PEC and EC were identical to those of normal epidermis or infundibulum, and that those of TC were similar to the outer root sheath between the lower infundibulum and isthmus. Although PEC has been recently reported to originate from eccrine ducts, there was a significant difference in immunoreactivities between PEC and eccrine ducts. Furthermore, on the basis of the fact that sole skin has no hair follicles, PEC was speculated to originate from epidermal implantation.

Limitations of extracorporeal shockwave lithotripsy for lower caliceal stones: anatomic insight.

In addition to gravity-dependent position, we suppose that other particular anatomic features may be important in the retention of stone debris in lower calices after extracorporeal shockwave lithotripsy (SWL). We analyzed the inferior-pole collecting system anatomy in 146 three-dimensional polyester resin corrosion endocasts of the pelviocaliceal system. In 74% of the cases, there was an angle of greater than 90 degrees formed between the lower infundibulum and the renal pelvis, and in 26%, the angle was 90 degrees or less. In 60%, there was a lower infundibulum 4 mm or larger in diameter. The inferior pole was drained by multiple calices disposed in two rows in 57% of the cases and by one midline caliceal infundibulum in 43%. We believe that the physician must appreciate these anatomic features when considering SWL to treat calculi located in lower calices.