Pedículo Renal: Análisis de sus Variantes / Renal Pedicle: Analysis of their Variants

Testut & Latarjet (1980), Bouchet & Cuilleret (1986), Latarjet & Liard (2005) y Rouvière & Delmas (2005) describen las relaciones intrínsecas del pedículo renal (PR) a partir de dos planos coronales, siendo la PER el elemento que limita entre ambos. Trivedi et al. (2011) demostró relaciones entre los elementos del PR que no coinciden con las descripciones aportadas por dichos autores.Conocer las posibles variantes en las relaciones intrínsecas del PR es de suma importancia en prácticas quirúrgicas como el trasplante renal (García de Jalón Martínez et al., 2003; Batista Hernández et al., 2010). Por lo tanto, el objetivo del presente trabajo fue analizar las variables relaciones entre los elementos que conforman el PR en la región yuxtahiliar del riñón. Se estudiaron 23 PR, formolizados al 10 % y provistos por el Equipo de Disección de la Segunda Cátedra de Anatomía de la Universidad de Buenos Aires. Se clasificaron los PR en dos grupos. En el Grupo I, las afluentes de origen de la vena renal (AOVR) se hallaban en el mismo plano coronal. En el grupo II, las AOVR se encontraban en diferentes planos coronales. Cada grupo fue subdividido en distintos patrones. Los patrones I y II, de mayor incidencia, fueron asociados al grupo I y los patrones III, IV y V al grupo II. En el patrón I, las AOVR eran anteriores a la pelvis renal (PER) y posteriores a la arteria prepiélica (APP). En el patrón II, las AOVR eran anteriores a la PER y a la APP. Los patrones I y II conforman el grupo I y presentaron mayor número de incidencia en nuestra investigación. Existen también variantes que inciden con menor frecuencia que dichos patrones, estas comprenden el grupo II de la clasificación planteada en el presente trabajo.

SUMMARY: Testut & Latarjet (1980), Bouchet & Cuilleret (1986), Latarjet & Liard (2005) y Rouvière & Delmas (2005) describe the intrinsic relationships of the renal pedicle (PR) from two coronal planes, the renal pelvis (PER) being the element that limits between both. Trivedi et al. (2011) showed relationships between the elements of the RP that do not coincide with the descriptions provided by these authors. Knowing the possible variants in the intrinsic relationships of the RP is of the utmost importance in surgical practices such as renal transplantation (García de Jalón Martínez et al., 2003). Therefore, the objective of this study is to analyze the variable relationships between the elements that make up the RP in the juxtahilar region of the kidney. 23 RP were studied, formalized at 10 % and provided by the Dissection Team of the Second Chair of Anatomy of the University of Buenos Aires. PRs were classified into two groups. In Group I, the tributaries of origin of the renal vein (RVOA) were in the same coronal plane. In group II, the AOVRs were in different coronal planes. Each group was subdivided into different patterns. Patterns I and II, with the highest incidence, were associated with group I and patterns III, IV and V with group II. In pattern I, the VROA were anterior to the renal pelvis (PER) and posterior to the prepelvic artery (PPA). In pattern II, AOVRs were prior to PER and APP. Patterns I and II make up group I and presented a higher number of incidence in our investigation. There are also variants that occur less frequently than these patterns, these comprise group II of the classification proposed in this work.

Cadaveric study of arterial renal anatomy and its surgical implications in partial nephrectomy.

PURPOSE: Partial nephrectomy is gaining, nowadays, more interest in oncologic kidney surgery. This type of surgery requires the good knowledge of vascular renal anatomy to make it safe and to guarantee good functional and oncological outcomes. This paper exposes the clinical implication of the arterial renal anatomy in nephron-sparing surgery. METHODS: This is a cadaveric study of 71 human kidneys performed at Charles Nicolle mortuary. The right and left kidneys with surrounding tissues were removed en bloc with the adjacent part of the aorta and inferior vena cava, cleared and studied. Colored resin was injected in each artery, vein, and urinary ducts, with a specific color code for each structure. Corrosion technique was used to eliminate the surrounding tissue, leaving only the colored resin matrix. The Ternon anatomic classification of the inferior polar artery, based on its emergence point was used. RESULTS: Multiple renal arteries were noted in 9.85% of casts. Anterior and posterior division of main renal artery was found in 95.7% of cases. Posterior segmental artery crossed posteriorly the upper caliceal infundibulum and the renal pelvis in 93% of cases. The upper renal pole was vascularized by an apical segmental artery in 16.9% of cases and a superior polar artery in one case (1.4%). The mid pole of the kidney was supplied by a unique anterior branch and a single posterior branch in 40% of cases. Inferior polar artery was found in 52 casts (73.23%). Type I of Ternon was found in 6 casts (11.53%), Type II in 25 cases (48.07%), Type III in 19 cases (36.53%), Type IV in 2 cases (3.84%), and type V in 13 casts (25%). CONCLUSION: Renal vascular anatomy presents large variations. Good knowledge of the segmental arterial anatomy of the kidney is a primordial to a safe partial nephrectomy. Good preoperative vascular mapping can be of great help for the surgeon.

Anatomical variations of the renal artery: a computerized tomographic angiogram study in living kidney donors at a Nigerian Kidney Transplant Center.

BACKGROUND: Understanding of the renal vascular anatomy is key to a safe and successful donor nephrectomy, which ultimately impacts on the renal graft function and survival in kidney transplant recipients. OBJECTIVE: To report the various anatomical configurations of the renal artery identified in living kidney donors in a Nigerian kidney transplant institution. MATERIALS AND METHODS: The computerized tomography angiograms of 100 consecutive living kidney donors were prospectively reviewed over an 18-month period. Anatomical variations of the renal arteries including accessory arteries and early divisions were noted. Duration of surgery and ischemic time were recorded intra-operatively. Data analysis was carried out using IBM SPSS version 20. RESULTS: There were variations in renal artery configuration in 50 (50%) cases, 32% were accessory renal arteries while 18% were early branches of the renal artery. The classical bilateral solitary renal arteries were found in 50 (50%) of potential donors. There was statistically significant longer operating and ischemic time in donors with multiple renal arteries as compared with solitary arteries (p<0.05). CONCLUSION: There are a wide variety of renal artery configurations seen in potential kidney donors. The classical solitary renal artery remains the commonest and most favourable configuration for donor nephrectomy and transplantation.

Safe exposure of the left renal vein during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: anatomical variations and pitfalls.

PURPOSE: The left renal vein is technically difficult to expose during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma despite being an important landmark for posterior dissection. We hereby propose a novel technique to safely expose the left renal vein while avoiding the associated anatomical pitfalls. METHODS: The anatomy of the left renal artery and vein was analyzed using multidetector computed tomography. We initially exposed the left renal vein on the left posterior side of the superior mesenteric artery followed by exposure toward the left kidney. We retrospectively examined the perioperative results of this technique in 33 patients who underwent laparoscopic distal pancreatectomy. RESULTS: 15.7% of the patients had an accessory left renal artery coursing cranial to the vein. In 43.1%, the left renal arterial branch ventrally traversed the vein at the renal hilum, thereby posing a risk for arterial injury. The location of the left renal vein varies cranial (17.6%) or caudal (82.4%) to the pancreas. The left renal vein was exposed without any vascular injury using this technique. The median operative time was 259 min, blood loss was 18 mL, and R0 resection rate was 97.0%. CONCLUSIONS: The initial exposure of the left renal vein should, therefore, be on the left posterior side of the superior mesenteric artery.

Assessment of renal vascular anatomy on multi-detector computed tomography in living renal donors.

BACKGROUND: Prospective renal donors are a select population of healthy individuals who have been thoroughly screened for significant comorbidities before they undergo multi-detector computed tomography angiography and urography (MDCT). PURPOSE: The aim of this study is to describe the anatomy of potential living renal donor subjects using MDCT over a 2-year period. The primary objective is to identify the renal arterial anatomy variations, with a secondary objective of identifying venous and collecting system/ureteric variations. MATERIALS AND METHODS: A prospective study was performed of prospective living kidney transplant donors at a national kidney transplant centre. Study inclusion criteria were all potential kidney donors who underwent MDCT during the living-donor assessment process over a 2-year period. RESULTS: Our cohort included 160 potential living donors who had MDCT; mean age was 45.6 years (range, 21-71). Two renal arteries were identified on the left in 40 subjects (25%) and on the right in 42 subjects (26.3%). A total of 3 or more renal arteries were identified on the left in 7 subjects (4.4%) and on the right in 7 subjects (4.4%). On the left, the distances between multiple arteries ranged from 1 mm to 43 mm, and on the right, they were 1 mm to 84 mm. CONCLUSIONS: Conventionally described anatomy was only seen on the left side in 70.6% and 69.4% on the right side of subjects. Single renal arteries are seen in 54.4% showing that conventional anatomy has a relatively low incidence.

Artéria renal tripla em porco-espinho (Sphiggurus villosus): relato de caso / Triple renal artery in porcupine (Sphiggurus villosus): case report

O interesse pelo estudo de animais silvestres vem crescendo consideravelmente nos últimos anos, seja em decorrência do risco de extinção ou visando o controle de doenças, especialmente as zoonoses. A ordem Rodentia apresenta o maior número de espécies da classe Mammalia. Apesar de ampla distribuição e importância, dados sobre sua anatomia vascular renal são escassos na literatura. O objetivo deste artigo é relatar o aparecimento de variação numérica na artéria renal esquerda em Sphiggurusvillosus com enfoque nas possibilidades de implicações clínico-cirúrgicas, como, anastomoses cirúrgicas, estudos imaginológicos, nefrectomias e planejamento pré-operatório para redução de riscos e complicações como hemorragia. O cadáver foi devidamente formolizado no Laboratório de Ensino e Pesquisa em Morfologia de Animais Domésticos e Selvagens e posteriormente dissecado. O rim esquerdo apresentou três artérias renais, uma cranial, uma intermediaria e outra caudal, ambas posicionadas em nível de L2 emergindo de forma impar lateralmente da aorta abdominal. A primeira artéria, mais cranial, apresentou 10,52 mm de comprimento e se dirigiu diretamente para o hilo renal, emitindo ramo para adrenal, diafragma e musculatura sublombar. A segunda artéria, intermediária, mediu 7,77 mm, emitiu ramo cranial e caudal para o hilo renal e ramo ureteral. A terceira artéria, caudal, mediu 10,11 mm e se dirigiu para o hilo renal. A veia renal esquerda era única e apresentou 9,25 mm de comprimento, posicionada em nível de L1. Este é o primeiro relato de artéria renal tripla em mamífero silvestre.

Interest in the study of wild animals has grown considerably in recent years, either due to the risk of extinction or to control diseases, especially zoonoses. The order Rodentia has the largest number of species in the Mammalia class. Despite its wide distribution and importance, data on its renal vascular anatomy are scarce in the literature. The aim of this paper is to report the appearance of numerical variation in the left renal artery in porcupine focusing on the possibilities of clinical and surgical implications, such as surgical anastomoses, imaging studies, nephrectomies and preoperative planning to reduce risks and complications such as bleeding. The animal was duly formalized in the Laboratory of Teaching and Research in Morphology of Domestic and Wild Animals and subsequently dissected. The left kidney had three renal arteries, one cranial, one intermediate, and one caudal, both positioned at L2 level, emerging unevenly laterally from the abdominal aorta. The first more cranial artery was 10.52 mm long and directed directly into the renal hilum, emitting a branch to the adrenal, diaphragm and sub lumbar muscles. The second intermediate artery measured 7.77 mm, emitting a cranial and caudal branch to the renal hilum and ureteral branch. The third caudal artery measured 10.11 mm and headed straight for the renal hilum. The left renal vein was unique, measured 9.25 mm long, and positioned at L1 level. This is the first report of triple renal artery in wild mammals.

Artéria renal tripla em porco-espinho (Sphiggurus villosus): relato de caso / Triple renal artery in porcupine (Sphiggurus villosus): case report

O interesse pelo estudo de animais silvestres vem crescendo consideravelmente nos últimos anos, seja em decorrência do riscode extinção ou visando o controle de doenças, especialmente as zoonoses. A ordem Rodentia apresenta o maior número deespécies da classe Mammalia. Apesar de ampla distribuição e importância, dados sobre sua anatomia vascular renal são escassosna literatura. O objetivo deste artigo é relatar o aparecimento de variação numérica na artéria renal esquerda em Sphiggurusvillosus com enfoque nas possibilidades de implicações clínico-cirúrgicas, como, anastomoses cirúrgicas, estudos imaginológicos,nefrectomias e planejamento pré-operatório para redução de riscos e complicações como hemorragia. O cadáver foi devidamenteformolizado no Laboratório de Ensino e Pesquisa em Morfologia de Animais Domésticos e Selvagens e posteriormente dissecado.O rim esquerdo apresentou três artérias renais, uma cranial, uma intermediaria e outra caudal, ambas posicionadas em nível de L2emergindo de forma impar lateralmente da aorta abdominal. A primeira artéria, mais cranial, apresentou 10,52 mm de comprimentoe se dirigiu diretamente para o hilo renal, emitindo ramo para adrenal, diafragma e musculatura sublombar. A segunda artéria,intermediária, mediu 7,77 mm, emitiu ramo cranial e caudal para o hilo renal e ramo ureteral. A terceira artéria, caudal, mediu10,11 mm e se dirigiu para o hilo renal. A veia renal esquerda era única e apresentou 9,25 mm de comprimento, posicionada emnível de L1. Este é o primeiro relato de artéria renal tripla em mamífero silvestre.

Interest in the study of wild animals has grown considerably in recent years, either due to the risk of extinction or to control diseases,especially zoonoses. The order Rodentia has the largest number of species in the Mammalia class. Despite its wide distributionand importance, data on its renal vascular anatomy are scarce in the literature. The aim of this paper is to report the appearanceof numerical variation in the left renal artery in porcupine focusing on the possibilities of clinical and surgical implications, suchas surgical anastomoses, imaging studies, nephrectomies and preoperative planning to reduce risks and complications such asbleeding. The animal was duly formalized in the Laboratory of Teaching and Research in Morphology of Domestic and Wild Animalsand subsequently dissected. The left kidney had three renal arteries, one cranial, one intermediate, and one caudal, both positionedat L2 level, emerging unevenly laterally from the abdominal aorta. The first more cranial artery was 10.52 mm long and directeddirectly into the renal hilum, emitting a branch to the adrenal, diaphragm and sub lumbar muscles. The second intermediate arterymeasured 7.77 mm, emitting a cranial and caudal branch to the renal hilum and ureteral branch. The third caudal artery measured10.11 mm and headed straight for the renal hilum. The left renal vein was unique, measured 9.25 mm long, and positioned at L1level. This is the first report of triple renal artery in wild mammals.

An Ex Vivo Evaluation of Tomographic 3-D Ultrasound, B-Mode Ultrasound, CT And MR Imaging to Measure Artery Diameter, Length and Wall Volume.

Precise measurement of luminal diameter in arteries is important when planning interventional vascular procedures in patients. Measuring wall volume may be important in detecting early artery disease and in the assessment of treatments to prevent atherosclerosis. An ex vivo phantom using porcine arteries was used to evaluate the accuracy with which (i) B-mode ultrasound, (ii) 3-D tomographic ultrasound (tUS), (iii) computed tomography (CT) and (iv) magnetic resonance imaging (MRI) measured length, diameters and volume. The mean error in inner-to-inner diameter measurements by B mode, tUS, CT and MRI were 0.08 ± 0.26, -0.73 ± 0.96 mm, 0.09 ± 0.55 and 0.60 ± 1.01 mm, respectively. The mean error in outer-to-outer diameter measurements by B mode, tUS, CT and MRI were -1.33 ± 0.61, -1.03 ± 0.35, 0.02 ± 1.00 and -0.47 ± 1.32 mm, respectively. The mean error in volume measurements by B mode, tUS, CT and MRI were -0.54 ± 0.62, -0.06 ± 0.09, 0.01 ± 0.18 and -0.20 ± 0.32 cm3, respectively. Errors in length and diameters remain within clinically acceptable thresholds where MRI was the least accurate. tUS was the most accurate method of volume measurement.

Morphological assessment of cat kidneys using computed tomography.

There are numerous publications about feline renal imaging information; however, none have established reference values for kidney size using computed tomography (CT). This study aimed to determine renal size and shape as well as the morphology of renal-related structures in clinically normal cats (Felis catus) that underwent CT. Twenty-seven healthy cats underwent pre- and post-iodinated contrast-enhanced CT. Most cat (59%) kidneys were located at the same level. The average pre-contrast dimensions of the left kidney included a width of 2.46 ± 0.28 cm, a length of 3.52 ± 0.44 cm and a height 2.19 ± 0.31 cm, whereas those of the right kidneys were 2.45 ± 0.27 cm, 3.54 ± 0.46 cm and 2.05 ± 0.23 cm, respectively. After contrast enhancement, kidneys were slightly enlarged though not significantly. Additionally, renal length (LK or RK) was compared with second lumbar vertebra (L2) length and abdominal aorta diameter (AO). AO was significantly larger in male cats whereas L2 length appeared longer in male cats, but was not statistically different from the female cats. The LK/L2 and RK/L2 ratios were 2.29 ± 0.23 and 2.36 ± 0.20, respectively, and the LK/AO and RK/AO were 11.72 ± 1.37 and 12.05 ± 1.47, respectively. Renal vessels were examined. The renal vein was obviously larger than the renal artery, and paired renal veins were observed periodically. This study provides CT information about the feline kidney, which may help to establish reference values and information regarding renal structure prior to surgery in practice.

Renal fibromuscular dysplasia and hypertension. / Renal fibromuskulær dysplasi og hypertensjon.

Fibromuscular dysplasia affects the muscles of small and medium-sized arteries. The aetiology of the condition is unknown; it is most frequently seen in middle-aged women, but can affect both sexes at any age. Hypertension is the most common clinical manifestation when the renal arteries are affected. The diagnosis is made based on clinical suspicion and specific angiographic findings. The treatment is aimed at normalisation of blood pressure with the aid of drugs or through revacularisation.

Renal artery in tufted capuchin monkey: structure and morphometry / Artéria renal do macaco prego: estrutura e morfometria

The objective was to describe the structure of the renal artery in capuchin monkey at the level of the proximal and distal arterial segments. Morphometric analysis was performed referring to the thickness and quantification of tissue elements of the renal artery tunica media in both segments. Renal arteries of eight adult capuchin monkeys were collected for histological analysis of the two segments, being the proximal part branched from the abdominal aorta, and the distal part localized next to the renal hilus. The quantification of smooth muscle cells and connective elements was carried out in transversal sections of the two segments; for the tunica media, it was used the volume densities of smooth muscle cells, collagen and elastic fibers. Considering these volume densities obtained for each segment, it was verified that the proximal segment showed a marked myoconnective architecture, while the distal segment was characterized by a single muscular artery. Apparently, the mixed architecture of the proximal segment could be related to a blood flow control at the aortic emergence of the renal artery, which helped to guarantee a priority flow of enriched plasma into the kidney parenchyma.

O objetivo foi descrever a estrutura da artéria renal no macaco prego ao nível dos segmentos arteriais proximal e distal. Uma análise morfométrica foi realizada, tendo como parâmetros a espessura e a quantificação dos elementos constituintes da túnica média da parede vascular, nos dois segmentos. Foram coletadas as artérias renais de oito macacos pregos adultos para estudos histológicos dos dois segmentos, sendo o segmento proximal a parte originária da aorta abdominal e o segmento distal a parte arterial junto ao hilo renal. A quantificação de células musculares lisas e de elementos conjuntivos da matriz extracelular foi realizada em secções transversais dos dois segmentos, sendo empregadas para a túnica média as densidades de volumes (DV), dos componentes musculares e das fibras elásticas e colágenas. Tendo por base estas densidades de volumes obtidas para cada segmento arterial verificou-se que o segmento proximal apresentou estrutura mioconjuntiva marcante, enquanto que o segmento distal foi caracterizado como uma artéria muscular padrão. Aparentemente, a arquitetura mista do segmento proximal estaria relacionada com o controle de fluxo sanguíneo na emergência aórtica da artéria renal, garantindo um direcionamento prioritário de fluxo de plasma sanguíneo enriquecido para dentro do parênquima renal.

Anatomic and Radiologic Study of Renal Avascular Plane (Brödel's Line) and Its Potential Relevance on Percutaneous and Surgical Approaches to the Kidney.

OBJECTIVE: The aim of the present anatomic and radiologic study was to evaluate the location, extension, and characteristics of the Brödel's plane and eventually define its different patterns. MATERIALS AND METHODS: We evaluated 15 human normal kidneys sampled from unembalmed cadavers without clinical history or anatomical evidence of renal diseases. 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. A CT examination of the injected kidneys was performed. After the imaging acquisition, the specimens were treated with sodium hydroxide for removal of the parenchyma to obtain the vascular casts. All the CT images were elaborated using dedicated three-dimensional (3D) software with the aim to improve the possibility to identify the Brödel's plane. The avascular plane was identified directly on the vascular casts and confirmed on the corresponding 3D images. RESULTS: The avascular plane was located in all cases medially to the lateral convex border of the kidneys. The recorded mean distance was 2.04 cm (range 1.8-2.4 cm). Three patterns of distribution of the Brödel's line were identified. In five (33.3%) cases the avascular plane was extended from the apical to the inferior segment of the kidneys (type 1); in six (40%) from the superior to the inferior segment (type 2); and in four (26.7%) from the apical to the middle segment (type 3). Fourth and fifth order vessels crossing the Brödel's line were detected in all the analyzed cases. CONCLUSIONS: The renal avascular plane showed a different extension allowing us to cluster three different patterns. Preoperative identification of the Brödel's line patterns could help surgeons to minimize hemorrhagic complications during percutaneous and surgical procedures requiring an incision of the renal parenchyma such as traditional or robot-assisted nephrolithotomy or partial nephrectomy for endophytic renal tumors. Radiologic studies validated that the described patterns in the clinical practice are strongly needed.

Resultados del trasplante renal con donante vivo: análisis comparativo entre arteria renal única y múltiple / Outcome in Living Donor Kidney Transplant: Comparative Análisis of Single and Multiple Renal Arteries

Objetivos: Realizar un análisis comparativo de los resultados funcionales y complicaciones en trasplantados renales y sus respectivos donantes vivos con arteria renal única versus múltiple. Materiales y métodos: Trabajo retrospectivo analítico de una base de datos confeccionada prospectivamente de pacientes sometidos a trasplantes renales con donante vivo en nuestra institución entre mayo de 2010 y julio de 2014. Según el número de arterias presentes en la angiotomografía preoperatoria se confeccionaron dos grupos: grupo 1 (arteria renal única) y grupo 2 (arteria renal múltiple). Resultados: De los 91 pacientes incluidos, el 37% (n=34) presentaba arterias renales múltiples. Se realizó una nefrectomía laparoscópica al 63% (n=36) y el 41% (n=14) de los donantes del grupo 1 y el grupo 2, respectivamente (p=0,05). Tiempos promedio de isquemia total (grupo 1: 55,6 min; grupo 2: 56 min; p=0,931), de anastomosis (grupo 1: 29,6 min; grupo 2: 29,7 min; p=0,982) y de "cirugía de banco" (grupo 1: 23,5 min; grupo 2: 23,8 min; p=0,948). Transfusión de glóbulos rojos en los receptores (grupo 1: 7%; grupo 2: 14%; p=0,23). Porcentaje de hemodiálisis en la primera semana (grupo 1: 5,2%; grupo 2: 5,8%; p=1). No se hallaron diferencias significativas entre grupos a nivel de tasa de complicaciones y días de internación. Ambos grupos presentaron una sobrevida del injerto del 100% a los 35,6 meses de seguimiento promedio. Conclusiones: La presencia de multiplicidad arterial no debe ser considerada una contraindicación para el donante vivo, ya que el implante de estos injertos logra resultados funcionales similares a los injertos renales con arteria única, sin aumentar la morbilidad del procedimiento. (AU)

Objectives: TTo compare functional outcomes and complications in patients with a single artery versus multiple arteries undergoing living donor nephrectomy. Materials and methods: Retrospective analysis of a prospective collected database of living donor kidney transplantations performed at our institution between May 2010 and July 2014. According to the number of arteries present in preoperative angiotomography, two groups of patients were organized: group 1 (single artery) and group 2 (multiple arteries). Results: TNinety-one living donor kidney transplantations were performed during this period. A total of 34 patients (37%) had multiple renal arteries. Mean total ischemia time (single: 55.6 min; multiple: 56 min; p=0.931), anastomosis time (single: 29.6 min; multiple: 29.7 min; p=0.982), bench surgery time (single: 23.5 min; multiple: 23.8 min; p=0.948). Blood transfusion rate was 7% and 14% for group 1 and group 2, respectively (p=0.23). Three patients in group 1 (5.2%) and two patients in group 2 (5.8%) needed dialysis during the first postoperative week (p=1). Overall, recipient complication rate and hospital stay were similar between group 1 and 2. Both groups had a 100% graft survival with a mean follow-up of 35.6 months. Conclusions: The presence of multiple renal arteries should not be considered a contraindication for the living donor nephrectomy, since these grafts achieve similar functional results to single artery renal grafts, without increasing the morbidity of the procedure. (AU)

Dupla variação anatômica vascular em um único indivíduo: estudo morfométrico / Dual vascular anatomical variation in a single individual: morphometric study

INTRODUÇÃO: Variações anatômicas são pequenas diferenças morfológicas congênitas que aparecem nos diferentes sistemas orgânicos, as quais não acarretam prejuízo ou distúrbio funcional para o indivíduo. No que diz respeito aos vasos sanguíneos, alterações no desenvolvimento embriológico podem gerar duplicidade de vasos, agenesia ou ocasionar o surgimento de artérias e o desembocar de veias fora da descrição anatômica padrão. RELATO DE CASO: Foi observada dupla variação anatômica vascular em um indivíduo durante uma dissecação de rotina no Laboratório de Anatomia do Centro Universitário São Camilo. A artéria renal principal tinha origem na parte abdominal da artéria aorta seguindo até sua entrada no hilo renal, porém, em vez de um trajeto retilíneo a partir da aorta, a mesma possuía um trajeto descendente e bem angulado. A partir da artéria renal principal surgia uma artéria polar aberrante que entrava no polo inferior do rim direito. Em um nível mais inferior, na altura da bifurcação da aorta, originava-se outra artéria polar aberrante que entrava no hilo renal, seguindo um trajeto retilíneo até o polo inferior do rim direito. A artéria hepática comum originava-se no tronco celíaco seguindo até sua entrada na porta do fígado. A artéria mesentérica superior possuía origem no tronco celíaco. A artéria hepática direita originava-se na artéria mesentérica superior. CONCLUSÃO: O estudo das variações anatômicas constitui-se tarefa árdua em virtude das inúmeras expressões diferentes que ocorrem no corpo humano, porém, o conhecimento dessas variações é de extrema valia para a clínica e o planejamento cirúrgico, garantindo a precisão e evitando complicações pós-cirúrgicas ou diagnósticos errôneos.

INTRODUCTION: Anatomical variations are small congenital morphological differences that appear in different organ systems, which do not result in damage or functional disturbance for the individual. When it comes to blood vessels, alterations in embryological development may lead to the duplicity and the agenesis of vessels, or cause the emergence of arteries and the disembogue of vessels not according to the standard anatomical description. CASE REPORT: Dual anatomical variation in an individual was observed during a routine dissection in the Laboratory of Anatomy of the Centro Universitário São Camilo. The main renal artery originated in the abdominal part of the aorta artery, following its path until its entry in the renal hilum. However, instead of a rectilinear path from the aorta, it had a descending and well-angulated path. From the main renal artery, an aberrant polar artery emerged, that entered the inferior pole of the right kidney. At a lower level, on the same level as the bifurcation of the aorta, another aberrant polar artery emerged, which entered the renal hilum following a straight path to the inferior pole of the right kidney. The common hepatic artery was originated in the celiac trunk, following its path until its entrance in the porta hepatis. The superior mesenteric artery was originated in the celiac trunk. The right hepatic artery was originated in the superior mesenteric artery. CONCLUSION: The study of anatomical variations is an arduous task due to the innumerable different expressions that occur in the human body. However, the knowledge of these variations is extremely valuable for medicine and surgical planning,assuring accuracy and avoiding postoperative complications or erroneous diagnoses.

Factors influencing the operating time for single-port laparoscopic radical nephrectomy: focus on the anatomy and distribution of the renal artery and vein.

OBJECTIVE: It is considered that laparoscopic single-site surgery should be performed by specially trained surgeons because of the technical difficulty in using special instruments through limited access. We investigated suitable patients for single-port laparoscopic radical nephrectomy, focusing on the anatomy and distribution of the renal artery and vein. METHODS: This retrospective study was conducted in 52 consecutive patients who underwent single-port radical nephrectomy by the transperitoneal approach. In patients undergoing right nephrectomy, a 2-mm port was added for liver retraction. We retrospectively re-evaluated all of the recorded surgical videos and preoperative computed tomography images. The pneumoperitoneum time (PT) was used as an objective index of surgical difficulty. RESULTS: The PT was significantly shorter for right nephrectomy than left nephrectomy (94 vs. 123 min, P = 0.004). With left nephrectomy, dissection of the spleno-renal ligament to mobilize the spleen medially required additional time. Also, the left renal vein could only be divided after securing the adrenal, gonadal and lumbar veins. In patients whose renal artery was located cranial to the renal vein, PT tended to be longer than in the other patients (131 vs. 108 min, P = 0.070). In patients with a superior renal artery, the inferior renal vein invariably covered the artery and made it difficult to ligate the renal artery via the umbilical approach at the first procedure. CONCLUSIONS: These findings indicate that patients undergoing right nephrectomy in whom the renal artery is not located cranial to the renal vein are suitable for single-port laparoscopic radical nephrectomy.

The protective effect of human renal sinus fat on glomerular cells is reversed by the hepatokine fetuin-A.

Renal sinus fat (RSF) is a perivascular fat compartment located around renal arteries. In this in vitro and in vivo study we hypothesized that the hepatokine fetuin-A may impair renal function in non alcoholic fatty liver disease (NAFLD) by altering inflammatory signalling in RSF. To study effects of the crosstalk between fetuin-A, RSF and kidney, human renal sinus fat cells (RSFC) were isolated and cocultured with human endothelial cells (EC) or podocytes (PO). RSFC caused downregulation of proinflammatory and upregulation of regenerative factors in cocultured EC and PO, indicating a protective influence of RFSC. However, fetuin-A inverted these benign effects of RSFC from an anti- to a proinflammatory status. RSF was quantified by magnetic resonance imaging and liver fat content by 1H-MR spectroscopy in 449 individuals at risk for type 2 diabetes. Impaired renal function was determined via urinary albumin/creatinine-ratio (uACR). RSF did not correlate with uACR in subjects without NAFLD (n = 212, p = 0.94), but correlated positively in subjects with NAFLD (n = 105, p = 0.0005). Estimated glomerular filtration rate (eGRF) was inversely correlated with RSF, suggesting lower eGFR for subjects with higher RSF (r = 0.24, p < 0.0001). In conclusion, our data suggest that in the presence of NAFLD elevated fetuin-A levels may impair renal function by RSF-induced proinflammatory signalling in glomerular cells.

Anatomical variations of the renal arterial vasculature: An Australian perspective.

INTRODUCTION: Variations of the renal arteries have been studied and published across various population groups, but similar information for the ethnically diverse nation of Australia is lacking. This study describes the pattern of renal artery anomalies in a section of the Australian population based on computed tomography (CT) angiograms of the abdomen and cadaveric dissection. METHODS: The renal arterial vasculature of 594 kidneys from 300 subjects (28 cadavers, 272 CT) was studied. The number and pattern of renal arteries were categorised on the basis of laterality, point of origin and termination in the kidney (superior pole, hilum and inferior pole), symmetry and sex. RESULTS: Multiple renal arteries were discovered in 22% of subjects and 12.12% of kidneys. The most common pattern observed was the presence of one variant renal artery (93.1%), compared to the finding of two (5.6%) and three (1.4%) multiple arteries. The aorta was the most frequent site of origin for anomalous vessels, while the hilum was the predominant point of entry. No significant difference was established between left- and right-sided kidneys (13.8% vs. 12.5%; P = 0.627); however, unilateral distribution was more common than bilateral additional renal arteries (16.7% vs. 3.4%; P < 0.01), and variations among males were more than females (27.2% vs. 15.2%; P < 0.05). A higher rate of multiple renal arteries was noted in cadaveric dissections compared to CT images (46.4% vs. 19.5%; P < 0.01). CONCLUSION: These findings provide application of an evidence-based teaching tool that facilitates education regarding renal arterial variations in Australia.

Morphological characterization of the renal arteries in the pig: comparative analysis with the human / Caracterización morfológica de las arterias renales en el cerdo: análisis comparativo con el humano

In spite of its importance as an experimental model, information on therenal artery inpigs is scarce.The objective of this work was to determine the morphological characteristics of the renal artery (RA) and its branches in pigs. One hundred and twenty one (121) pairs of kidneys of pigs destined to slaughter by stunning were studied. The RA and its branches were perfused with polyester resin (Palatal 85 % t Styrene 15 %)and subjected to KOH infusion (potassium hydroxide) for total corrosion. Calibers were measured, and trajectories and relations with adjacent arterial structures were evaluated.Continuous variables were assessed with Student's t test,and discrete variables with Pearson's chi square test. The significance level used was p<0.05. The origin of the RA was symmetric in 57 specimens (50.4 %), with the right renal arterybeing more cranial in 55 % of the cases. Single renal arteries were seen in 98.4 %, without significant side differences (p=0.31).The caliber and length of the RA were 5.11mm (SD1.35) and 30.1mm (SD8.63), respectively. A pattern of RA expression that causes one cranial and one caudal polar branch (Type I) was observed in 97.1 % of the cases. The distribution of the RA in cranial and caudal polar branches was found to be higher than what is described in the literature, since these morphometric features have not been reported in prior studies.These findings contribute to a better knowledge in the field of the compared anatomy of the kidney, and allow for applying the pig model in procedural and hemodynamic applications.

A pesar de su importancia como un modelo experimental, la información sobre la arteria renal en los porcinos es escasa. El objetivo de este trabajo fue determinar las características morfológicas de la arteria renal (AR) y sus ramas en cerdos. Fueron estudiados 121 pares de riñones de cerdos destinados al sacrificio con método de aturdimiento. Las AR y sus ramas fueron perfundidas con resina poliéster (Palatal 85 % t Estireno 15 %) y sometidas a infusión de KOH (hidróxido de potasio) para corrosión total. Se midieron calibres, evaluaron trayectorias y relaciones con estructuras arteriales adyacentes. Se evaluó las variables continuas con el test de t student y las variables discretas con el test de chi cuadrado de Pearson. El nivel de significancia usado fue de p<0,05. El origen de la AR fue simétrico en 57 muestras (50,4 %), siendo la arteria renal derecha la más craneal en el 55 % de los casos. Se observó arterias renales únicas en el 98,4 %, sin diferencias significativas de lado (p=0,31). El calibre y la longitud de la AR fue 5,11 mm (SD 1,35) y 30,1 mm (SD 8,63) respectivamente. En el 97,1 % se observó un patrón de expresión de la AR que origina una rama polar craneal y una caudal (Tipo I). La distribución en ramas polares craneal y caudal de la AR es superior a lo descrito en la literatura, en tanto que las características morfométricas no han sido reportadas en estudios previos. Estos hallazgos contribuyen al mejor conocimiento en el campo de la anatomía comparada del riñón y permiten postular al modelo porcino en aplicaciones procedimentales y hemodinámicas.

Changes in Renal Anatomy After Fenestrated Endovascular Aneurysm Repair.

OBJECTIVE: To assess short- and long-term movement of renal arteries after fenestrated endovascular aortic repair (FEVAR). METHODS: Consecutive patients who underwent FEVAR at one institution with a custom-made device designed with fenestrations for the superior mesenteric (SMA) and renal arteries, a millimetric computed tomography angiography (CTA), and a minimum of 2 years' follow-up were included. Angulation between renal artery trunk and aorta, clock position of the origin of the renal arteries, distance between renal arteries and SMA, and target vessel occlusion were retrospectively collected and compared between the pre-operative, post-operative (<6 months), and last (>12 months) CTA. RESULTS: From October 2004 to January 2014, 100 patients met the inclusion criteria and 86% of imaging was available for accurate analysis. Median follow-up was 27.3 months (22.7-50.1). There were no renal occlusions. A significant change was found in the value of renal trunk angulation of both renal arteries on post-operative compared with pre-operative CTA (17° difference upward [7.5-29], p < .001), but no significant change thereafter (p = .5). Regarding renal clock positions (7.5° of change equivalent to 15 min of renal ostial movement): significant anterior change was found between post-operative and pre-operative CTA (15 min [0-30], p = .03 on the left and 15 min [15-30], p < .001 on the right), without significant change thereafter (15 min [0-30], p = .18 on the left and 15 min [0-15] on the right, p = .28). No changes were noted on the distance between renal and SMA ostia (difference of 1.65 mm [1-2.5], p = .63). CONCLUSION: The renal arteries demonstrate tolerance to permanent changes in angulation after FEVAR of approximately 17° upward trunk movement and of 15-30 min ostial movement without adverse consequences on patency after a median of more than 2 years' follow-up. The distance between the target vessels remained stable over time. These results may suggest accommodation to sizing errors and thus a compliance with off the shelf devices in favourable anatomies.