Changes in lower urinary tract function after minimally invasive nerve-sparing for complete excision of endometriosis: An observational study.

OBJECTIVES: The objective of this paper is to evaluate changes in lower urinary tract symptoms (LUTS), severity of pain and urodynamic parameters after minimally invasive nerve-sparing surgery for patients with endometriosis. METHODS: We analyzed 143 patients undergoing minimally invasive nerve-sparing surgery for endometriosis excision (laparoscopy/robot-assisted). The endometriosis was confirmed by preoperative clinical evaluation, magnetic resonance imaging (MRI) showing at least one lesion deeper than 5 mm, and histological confirmation after laparoscopy. We evaluated three points prior and after surgery: LUTS parameters according to the International Urogynecological Association; urodynamic measures of storage and voiding and the severity of the dyspareunia, dyschezia and dysmenorrhea assessed on a self-reported 11-point numeric rating scale. The Wilcoxon signed rank and McNemar tests were used for statistical analyses (p < 0.05). RESULTS: We observed significant improvements in LUTS after the surgery with postoperative symptom-free probabilities in urgency (64.5%), daytime frequency (38.5%), and dysuria (87.1%). However, slow stream prevalence increased significantly postsurgery (p = 0.022), with a 20.5% risk of asymptomatic patients developing this symptom. Urodynamic responses varied; for instance, maximum cystometric capacity improved significantly (p = 0.004), while postvoiding residual worsened (p = 0.006). Significant worsening in postvoiding residual occurred in women with normal preoperative values (p = 0.002), with a 17.7% risk of normal values becoming abnormal. Compliance or maximum cystometric capacity not considered normal preoperatively showed significant improvements (p < 0.001), but the risk of normal values becoming abnormal after surgery was 14.5%. CONCLUSION: The minimally invasive nerve-sparing surgery for endometriosis excision shows improvement in lower urinary tract symptoms, urodynamics parameters and severity of pain. The majority of patients became asymptomatic in the postoperative period. When compared to the benefits of the patients' surgical treatment, particularly when considering the reduction of pain, the risks of the lower urinary tract treatment seem to be acceptable. The surgical intervention seems to be a safe alternative in patients with endometriosis, although studies with larger samples are needed to confirm these findings.

Is the learning curve of the urology resident for conventional radical prostatectomy similar to that of staff initiating robot-assisted radical prostatectomy?

INTRODUCTION: The superiority of the functional results of robot-assisted radical prostatectomyis still controversial. Despite this, it is known that minimally invasive surgery obtains better results when analyzing blood loss, blood transfusion and length of stay, for example. Several studies have analyzed the impact of the resident physician's involvement on the results of urological surgeries. The simple learning curve for robot-assisted radical prostate surgery is estimated to be around 10 to 12 cases. Learning curve data for robotic surgeons is heterogeneous, making it difficult to analyze. Rare studies compare the results of a radical prostatectomy of an inexperienced surgeon starting his training in open surgery, with the results of the same surgeon, a few years later, starting training in robotic surgery. OBJECTIVE: to analyze the results of open radical prostatectomy surgeries (ORP) performed by urology residents, comparing them to the results of robot-assisted radical prostatectomy (RARP), performed by these same surgeons, after completing their training in urology. MATERIALS AND METHODS: a retrospective analysis of the cases of only 3 surgeons was performed. 50 patients underwent ORP (group A). The surgeons who operated on the ORP patients were in the 3rd and final year of the urology residency program and beginners in ORP surgery, but with at least 4 years of experience in open surgery. The same surgeons, already trained urologists, began their training in robotic surgery and performed 56 RARP surgeries (group B). For the comparative analysis, data were collected on age, number of lymph nodes removed, surgery time, hospitalization time, drain volume, drain permanence time, indwelling bladdercateter (IBC) permanence time, positive surgical margin, biochemical recurrence, risk classification (ISUP), intra and postoperative complications, urinary incontinence (UI) and erectile dysfunction (ED). The console used was the Da Vinci Si, from Intuitive®. For statistical analysis, the Shapiro-Wilk test verified that the data did not follow normality, the Levene test guaranteed homogeneity, and the Mann-Whitney test performed the comparative analysis of the quantitative data. For the analysis of qualitative data, the Chi-square test was used for nominal variables and the Mann-Whitney U test for ordinal variables. Additionally, the Friedman test analyzed whether there was an improvement in the perception of UI or ED over the months, for each group individually (without comparing them), and the post-hoc Durbin-Conover test, for the results with statistically significant difference. We used a p-value < 0.05, and the Jamovi® program (Version 2.0). RESULTS: there was no statistically significant difference between the groups for age, number of lymph nodes removed, positive surgical margin, biochemical recurrence, risk classification and urinary incontinence. Additionally, we observed that the surgical time was longer in group B. On the other hand, the length of stay, drain volume, drain time, IBC time, complication rate and levels of erectile dysfunction in the third and sixth months were higher in group A, when compared to group B. We also observed that there was no evolutionary improvement in ED over the months in both groups, and that there was a perception of improvement in UI from the 1st to the 3rd month in group A, and from the 1st to the 6th month, and from the 3rd to the 12th month, in group B. CONCLUSION: the learning curve of RARP is equivalent to the curve of ORP. In general, the results for the robotic group were better, however, the functional results were similar between the groups, with a slight tendency of advantage for the robotic arm.

Experimental Model Exposed to Bisphenol and Submitted to a High-Fat Diet and Related Morphologic Testicular Parameters Alterations Analysis.

PURPOSE: To evaluate the morphological and stereological parameters of the testicles in mice exposed to bisphenol S and/or high-fat diet-induced obesity. MATERIAL AND METHODS: Forty adult male C57BL/6 mice were fed a standard diet (SC) or high-fat diet (HF) for a total of 12 weeks. The sample was randomly divided into 4 experimental groups with 10 mices as follows: a) SC - animals fed a standard diet; b) SC-B - animals fed a standard diet and administration of BPS (25 µg/kg of body mass/day) in drinking water; c) HF: animals fed a high-fat diet; d) HF-B - animals fed a high-fat diet and administration of BPS (25 µg/Kg of body mass/day) in drinking water. BPS administration lasted 12 weeks, following exposure to the SC and HF diets. BPS was diluted in absolute ethanol (0.1%) and added to drinking water (concentration of 25 µg/kg body weight/day). The animals were euthanized, and the testes were processed and stained with hematoxylin and eosin (H&E) for morphometric and stereological parameters, including density of seminiferous tubules per area, length density and total length of seminiferous tubules, height of the tunica albuginea and the diameter of the seminiferous tubules. The images were captured with an Olympus BX51 microscope and Olympus DP70 camera. The stereological analysis was done with the Image Pro and Image J programs. Means were statistically compared using ANOVA and the Holm-Sidak post-test (p<0.05). RESULTS: The seminiferous tubule density per area reduced in all groups when compared with SC samples (p<0.001): HF (40%), SC-B 3(2%), and HF-B (36%). Length density was reduced significantly (p<0.001) in all groups when compared with SC group: HF (40%), SC-B (32%), and HF-B (36%). The seminiferous tubule total length was reduced (p<0.001) when compared to f HF (28%) and SC-B (26%) groups. The tubule diameter increased significantly (p<0.001) only when we compared the SC group with SC (54%) an SC-B (25%) groups and the tunica thickness increased significantly only in HF group (117%) when compared with SC-B (20%) and HF-B 31%. CONCLUSION: Animals exposed to bisphenol S and/or high-fat diet-induced obesity presented important structural alterations in testicular morphology.

Preliminary results of a new surgical technique: bladder mucosal graft harvested with holmium:YAG (HO:YAG) laser. A new option in bulbar replacement urethroplasty?

OBJECTIVE: To describe the technique of transurethral harvesting of bladder mucosal graft using the Holmium:YAG (Ho-YAG) laser and describe the preliminary results from 7 cases where this graft was used for urethroplasty. MATERIALS AND METHODS: We performed a single-stage dorsal onlay urethroplasty using bladder mucosal graft in 7 patients with anterior urethral stricture. Transurethral harvesting was performed with the Ho-YAG laser. We performed a prospective and descriptive analysis with uroflowmetry performed at 30, 90 and 180 days after surgery and applied the PROM translated into Portuguese before and 6 months after urethroplasty. RESULTS: Seven patients were included, 2 (28.5%) with penile urethral stricture, and 5 (71.5%) with bulbar urethral stricture. Mean stricture length was 50mm (range 35-60mm). Stricture etiology was trauma in 3 (42.9%) patients, iatrogenic in 1 (14.3%) patient, and idiopathic in 3 (42.9%) patients. Two patients (28.6%) had previously undergone ventral buccal mucosa urethroplasty. Mean bladder mucosal graft length was 52.86mm (± 13.801), and mean harvest time was 46.43min (± 14.639). Dorsal onlay urethroplasty using bladder mucosa was successfully completed in 5 patients (71.4%). Two patients (28.6%) couldn't have the procedure completed using bladder mucosa, one due to thermal damage of the graft during harvesting, and one due to insufficient graft length. In both cases the procedure was completed using buccal mucosa. Two patients (28.6%) experienced minor hematuria between the twelfth and eighteenth postoperative day, but neither required hospitalization and/or additional procedures. All patients achieved normalization of peak flow, and this was maintained throughout the follow-up period. Mean peak flow was 17.8 ml/s (± 3.271) at 30 days, 20.6 ml/s (± 5.413) at 90 days, and 19.6 ml/s (± 8.019) 180 days. Mean IPSS score decreased from 19.3 to 5.4. Similar improvements were also seen in the ICIQ-MLUTS Score (a mean drop from 3.8 to 2.0) and Peeling's Voiding Picture Score (a mean drop from 4.0 to 2.2). Quality of Life improved post urethroplasty, with increases in EQ-5D (from 0.6371 to 0.7285) and EQ-VAS (from 58.0 to 84.0). CONCLUSION: Transurethral harvesting of bladder mucosa using the Holmium laser (Ho-YAG) is feasible and reproducible. Our preliminary experience suggests that bladder mucosa grafts achieve comparable results to other grafts when used for dorsal onlay urethroplasty. Further research is needed to confirm these results.

Low-intensity extracorporeal shockwave therapy in the treatment of erectile dysfunction - a narrative review.

OBJECTIVES: To provide an overview of low-intensity extracorporeal shockwave therapy (LIEST) for erectile dysfunction (ED), pointing out which concepts are already consolidated and which paths we still need to advance. MATERIALS AND METHODS: We performed a narrative review of the literature on the role of shockwave therapies in erectile dysfunction, selecting publications in PUBMED, including only relevant clinical trials, systematic reviews and meta-analyses. RESULTS: We found 11 studies (7 clinical trials, 3 systematic review and 1 meta-analysis) that evaluated the use of LIEST for the treatment of erectile dysfunction. One clinical trial evaluated the applicability in Peyronie's Disease and one other clinical trial evaluated the applicability after radical prostatectomy. CONCLUSIONS: The literature presents little scientific evidence but suggests good results with the use of LIEST for ED. Despite a real optimism since it is a treatment modality capable of acting on the pathophysiology of ED, we must remain cautious, until a larger volume of higher quality studies allows us to establish which patient profile, type of energy and application protocol will achieve clinically satisfactory results.

ASTRA - An alternative approach for the posterior urethra.

INTRODUCTION: Access represents one of the main challenges in performing posterior urethroplasty (1, 2). Several approaches and tactics have been previously described (3). This video demonstrates the Anterior Sagittal Transrectal Approach (ASTRA), which allows better visualization of the deep perineum (4). MATERIALS AND METHODS: Our patient was a 65-year-old man with post radical prostatectomy vesicourethral anastomotic stenosis. He failed repeated endoscopic interventions, eventually developing urinary retention and requiring a cystostomy. We offered a vesicourethral anastomotic repair through ASTRA. The patient was placed in the jackknife position and methylene blue instilled through the cystostomy. To optimize access to the bladder neck, an incision of the anterior border of the rectum is performed. Anastomosis is carried out with six 4-0 PDS sutures. These are tied using a parachute technique, after insertion of a 16F Foley. RESULTS: The patient was discharged after 72 hours, and the Foley catheter was removed after 4 weeks. There were no access-related complications. Retrograde urethrogram 3 months after surgery confirmed patency of the anastomosis. Upon review 5 months after surgery the patient had urinary incontinence requiring 5 pads/day and was considered for an artificial urinary sphincter. DISCUSSION: In our series of 92 patients who have undergone reconstructive procedure through ASTRA there have been no cases of fecal incontinence. Two patients with prior history of radiotherapy developed rectourethral fistulas. Urinary incontinence was observed in those patients with stenosis after radical prostatectomy. CONCLUSION: This video presents a step-by-step description of ASTRA, an approach that provides excellent visualization to the posterior urethra, representing an alternative access for repair of complex posterior urethral stenosis.

Dynamic cystoscopy to optimize preoperative assessment of bladder endometriosis.

PURPOSE: Bladder endometriosis (BE) accounts for 84% of cases of urinary tract involvement. The use of cystoscopy for preoperative evaluation is limited. The aim of this study was to evaluate the accuracy of preoperative dynamic cystoscopy (DC) in patients undergoing surgery for deep endometriosis and to describe the main findings and their impact on surgical planning. MATERIALS AND METHODS: This cross-sectional observational study was conducted from January 2011 to March 2022. DC findings were divided into two groups according to the depth of involvement. To estimate sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), laparoscopic findings of bladder involvement and histopathological report were used as the gold standard. RESULTS: We included 157 patients in this study. 41 had abnormalities in DC. Of these, 39 had abnormalities that were confirmed intraoperatively. The sensitivity and specificity of the test were 58.21% and 97.78%, respectively. PPV was 95.12%, and NPV was 75.86%. The presence of any lesions in the DC had a diagnostic odds ratio (OR) of 61.28 for BE. Patients with BE type 2 had a higher rate of partial cystectomy than those with BE type 1 lesions (OR 9.72 CI 95% 1.9-49.1) Conclusion: DC appears to be a highly specific test with lower sensitivity. DC abnormalities are associated with a higher ratio of bladder surgery for the treatment of deep endometriosis, and BE type 2 seems to be associated with a greater ratio (9.72) of partial cystectomy.

Testicular arteries anatomy applied to fowler-sthephens surgery in high undescended testis - a narrative review.

OBJECTIVES: In this review we will describe the testicular vessels anatomy and the implications of these vessels in surgical treatment of high undescended testis. MATERIAL AND METHODS: We performed a narrative review of the literature about the role of the testicular arteries anatomy in the treatment of high undescended testis. We also studied two human testes to illustrate the testicular vascularization. RESULTS: Each testis is irrigated by three arteries: testicular artery (internal spermatic artery), a branch of the right aorta; deferential artery (vasal artery), a branch of the inferior vesicle artery that originates from the anterior trunk of internal iliac artery and cremasteric artery (external spermatic artery), a branch of the inferior epigastric artery. There are important communications among the three arteries with visible anastomotic channels between the testicular and deferential arteries. CONCLUSIONS: Laparoscopic transection of the testicular vessels by dividing the spermatic vessels (Fowler-Stephens surgery) is safe in patients with high abdominal testis due to the great collateral vascular supply between testicular, vasal and cremasteric arteries; also, two-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach.

Endoscopic Holmium Laser harvesting of bladder mucosal graft for substitution urethroplasty.

INTRODUCTION: Tissue transfer has been used in urethral reconstruction for decades, and several grafts have been described (1, 2). The ideal graft would have optimal tissue characteristics and lead to minimal morbidity at the donor site. Urethroplasty using bladder mucosa was first described by Memmelaar in 1947 (3). The main limitation in using bladder mucosal grafts has been the invasiveness of open harvesting (4). We describe an endoscopic technique using Holmium:YAG laser to harvest bladder mucosal graft for substitution urethroplasty. METHODOLOGY: A 33-year-old male with no history of urethral instrumentation, trauma, or infection presented with obstructive lower urinary tract symptoms. On retrograde urethrogram a 6cm bulbar urethral stricture was identified. Several options were discussed, and the patient opted for a one-sided onlay dorsal urethroplasty (5) using a bladder mucosal graft. Equipment used to harvest the graft included an 18.5Fr continuous flow laser endoscope with a Kuntz working element (RZ) and a 60W Holmium Laser (Quanta) with 550µm laser fiber. The procedure was started by making a perineal incision, urethral mobilization and incision of the stricture segment. The laser endoscope was then introduced via the perineum. Settings of 0.5J, 30 Hz, and long pulse were used and a 7 x 2.5cm graft was harvested from the posterior bladder wall. Hemostasis of the harvest site was performed. The bladder mucosal graft was thinned in similar fashion to a buccal mucosal graft and sutured as per previously described techniques. CONCLUSION: Endoscopic Holmium Laser harvesting of bladder mucosal graft is feasible and may allow this graft to become an alternative to buccal mucosa. Further studies are required to define its role in urethral reconstruction.

The role of intra-abdominal pressure in human testicular migration.

OBJECTIVES: This review aims to study the role of the abdominal wall in testicular migration process during the human fetal period. MATERIALS AND METHODS: We performed a descriptive review of the literature about the role of the abdominal wall in testicular migration during the human fetal period. RESULTS: The rise in intra-abdominal pressure is a supporting factor for testicular migration. This process has two phases: the abdominal and the inguinal-scrotal stages. The passage of the testis through the inguinal canal occurs very quickly between 21 and 25 WPC. Bilateral cryptorchidism in Prune Belly syndrome is explained by the impaired contraction of the muscles of the abdominal wall; mechanical obstruction due to bladder distention and structural alteration of the inguinal canal, which hampers the passage of the testis during the inguinoscrotal stage of testicular migration. Abdominal wall defects as gastroschisis and omphaloceles are associated with undescended testes in around 30 to 40% of the cases. CONCLUSIONS: Abdominal pressure wound is an auxiliary force in testicular migration. Patients with abdominal wall defects are associated with undescendend testis in more than 30% of the cases probably due to mechanical factors; the Prune Belly Syndrome has anatomical changes in the anterior abdominal wall that hinder the increase of intra-abdominal pressure which could be the cause of cryptorchidism in this syndrome.

Findings regarding non-sexual penile fracture in a referral emergency hospital.

PURPOSE: To describe penile fracture (PF) findings with non-sexual etiology in a referral emergency hospital, with emphasis on demographic data, clinical and intraoperative findings and long-term outcomes. MATERIALS AND METHODS: Patients with PF of non-sexual cause operated at our institution from January 2014 to January 2019 were submitted to surgical treatment and monitored for at least three months after surgery. Etiology of trauma, epidemiological and clinical presentation data, time to intervention and operative findings were reviewed retrospectively. The evaluation of postoperative erectile function was carried out by filling out the International Index of Erection Function - 5 (IIEF-5). The tool used to assess urinary function was the International Prostate Symptom Score (IPSS) questionnaire. RESULTS: Of a total of 149 patients submitted to surgical treatment for PF, 18 (12%) reported non-sexual etiology. Twelve (66.6%) cases were due to penile manipulation through the act of bending the penis during morning erection, three (16.6%) when rolling over in bed with erect penis, one (5.5%) when embracing the wife during erection, one (5.5%) to laying on the partner with erect penis and the other (5.5%) when sitting on the toilet with an erection. Operative findings were unilateral corpus cavernosum injury in all cases. Only one (5.5%) patient had a partial urethral lesion. Follow-up time varied from 3 to 18 months (mean, 10.1 months). Three (16.6%) patients developed erectile dysfunction six months after surgery. However, all of them responded to treatment with IPDE-5 and reported improvement of erection, with no need for medication, on reevaluation after 18 months. One (5.5%) patient developed penile curvature < 30 degrees. Thirteen (72.2%) patients developed penile nodules. No patient presented voiding complaints during follow-up. CONCLUSIONS: PF is a rare urologic emergency, especially with the non-sexual etiology. However, PF should always be considered when the clinical presentation is suggestive, regardless of the etiology. Penile manipulation and roll over in bed were the most common non-sexual causes. These cases are related to low-energy traumas, usually leading to unilateral rupture of corpus cavernosum. Urethral involvement is uncommon but may be present. Early treatment has good long-term clinical outcome, especially when performed in specialized centers with extensive experience in FP.

Anatomic study of verumontanum during endoscopic surgeries in patients with benign prostatic hyperplasia.

INTRODUCTION AND OBJECTIVE: To evaluate changes in verumontanum anatomy in patients with benign prostatic hyperplasia (BPH) who used 5-alpha reductase inhibitors (5-ARIs) and to propose an anatomical classification of the verumontanum. MATERIALS AND METHODS: We studied 86 patients with BPH and 7 patients without the disease (age under 40 years-old who underwent kidney or ureteral lithotripsy). Of the patients with BPH, 34 (mean age=67.26) had 5-ARIs use and 52 (mean age=62.69) did not use the drug. During surgeries, photographs of the seminal colliculus were taken and later, with the aid of software (Image J), the length (longitudinal diameter) and width (transverse diameter) of the verumontanum were measured in all patients. During the procedure, we evaluated the different types of verumontanum. For statistical analysis, the R-Project software was used. RESULTS: In the group of patients with BPH who were taking medication (group 1), the mean measures of length and width of the verumontanum were 4.69mm and 2.94mm respectively. In the group of patients with BPH who did not use the drug (group 2), the mean diameters were 4.54mm and 3.20mm respectively. In the control group (group 3), the average length and width were 5.63mm and 4.11mm respectively. There was an increase in longitudinal and transverse measurements of the control group with an increase in body mass index (BMI) (p=0.0001 and p=0.035 respectively). In addition, there was a reduction in transverse diameter in the group of BPH using 5-ARI with increased prostate volume (p=0.010). We found five different verumontanum types: "volcano" (51.61%), "lighthouse" (24.73%), "whale tail" (12.90%), "hood" (5.38%) and "castle door" (5.38%), which we propose as an anatomical classification. CONCLUSION: Veromontanum has smaller measurements in patients with BPH regardless of treatment. In the control group, there was an increase in verumontanum diameters with an increase in BMI. The volcano type of verumontanum was the most frequent regardless of groups and BMI.

Penile refracture: a preliminary report.

OBJECTIVE: To report our institutional experience with penile refracture, including demographic data, recurrence time, etiology and operative findings in the first and second episodes. MATERIALS AND METHODS: Between January 1982 and September 2017, 281 patients underwent surgical treatment for penile fracture (PF) at our institution. Demographic data, clinical presentation, besides operative findings and follow-up of patients with relapsed PF were retrospectively assessed by reviewing medical records. RESULTS: Of a total of 281 cases of PF operated at our institution, 3 (1.06%) patients experienced two episodes of trauma. Age ranged from 38 - 40 years (mean: 39.3). The recurrence time varied from 45 to 1560 days (mean: 705). Two patients presented the new fracture episode at the same site of the previous lesion, while in the other case the lesion was observed at another site. CONCLUSION: Recurrent FP is an extremely rare entity. The risk factors for its occurrence are still unknown. Although the lesion of the corpus cavernosum ipsilateral to the scar tissue of the prior FP is more common, contralateral rupture may be present. Nevertheless, prospective studies with larger samples should be conducted.

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

PURPOSE: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.

PURPUSE: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.