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| Revisiting the morphology of pelvicalyceal system in human cadaveric kidneys with a systematic review of literature |
Kusum Rajendra Gandhia,*( ),Sushama Chavanb
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aDepartment of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
bDepartment of Anatomy, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India |
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Abstract Objective: Renal collecting system macroscopically consists of minor calyx, major calyx, renal pelvis and ureter. Stone in renal collecting system is a common presentation in everyday urological practice. The prevalence of renal calculi ranges from 4% to 20% in different geographical distribution. Anatomical variation in renal collecting system plays a significant role in formation of calculi in its parts. The large extra renal pelvis leads to stagnation of urine for longer durations and formation of stones. The stone free rate after percutaneous nephrolithotomy and extra corporeal shock wave lithotomy is significantly related to anatomical factors, particularly the type of renal pelvis and dimensions (length and width) of lower infundibulum. Previous authors described the morphology of pelvicalyceal system in a highly variable manner and the available anatomical description of pelvicalyceal system is contradictory and incomplete. Hence an attempt has been made to provide the precise anatomy of pelvicalyceal system in adult human kidneys. Methods: We studied 196 formalin embalmed kidneys to note the number of infundibulum, major and minor calyces. The location and shape of pelvis were also studied. Results: The intra-renal pelvis was narrow and had funnel shaped appearance in 95 of total 196 (48.5%) specimens, and the extra-renal pelvis was dilated as balloon shaped in 43 of 196 (21.9%) specimens. In 41 (20.9%) specimens, the renal pelvis was having partially intra- and extra-renal in location. Bilateral symmetry was found in only 27.1% of 196 renal collecting systems. The length of lower infundibulum was more than 22 mm in 19 (9.7%) of 196 cases which directly affects the stone clearance rate during open and endoscopic surgeries on pelvicalyceal system. Conclusion: This study provides the accurate morphological details of the shape and dimensions of renal pelvicalyceal system to help the urologists and nephrologists.
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Received: 17 April 2018
Available online: 21 December 2018
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Corresponding Authors:
Kusum Rajendra Gandhi
E-mail: gandhikusum.r@gmail.com
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| Location of pelvis | Total number of specimens, n (%) | Number of specimens observed | | Right | Left | | Extra-hilar | 43 (21.9) | 20 | 23 | | Intra-hilar | 95 (48.5) | 47 | 48 | | Mixed | 41 (20.9) | 19 | 22 | | No pelvis | 17 (8.7) | 8 | 9 |
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Incidence of extra-hilar and intra-hilar pelvis of 196 renal collecting systems observed.
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Three shapes of pelvis depending upon the number of major calices joining to for pelvis. (A) Bicalyceal intra-renal pelvis; (B) Tricalyceal extra-renal pelvix; (C) Multicaliceal extra-renal pelvis.
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| Number of major calyces | Number of cases observed, n (Right and Left) | Percentage (%) | | 2 (bicalyceal) | 116 (57 and 59) | 59.2 | | 3 (tricalyceal) | 42 (22 and 20) | 21.4 | | 4 and more (multicalyceal) | 33 (16 and17) | 16.8 | | Unclassified (absence of well defined pelvis) | 5 (3 and 2) | 2.6 |
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Number of major calyces (shape of pelvis) in pelvi calyceal system of 196 specimens.
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Types of bicayceal pelvis depending upon the width of renal calices. (A) Bicalyceal intra-renal pelvis with equal dimensions; (B) Bicalyceal pelvis with wide upper calyx; (C) Bicalyceal renal pelvis with wide lower calyx.
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Types of tricalyceal pelvis depending upon the width of major calices. (A) Tricalyceal pelvis (equal dimensions of all three calyces); (B) Tricalyceal pelvis with wider middle calyx; (C) Tricalyceal pelvis with wider lower calyx.
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The infundibula of major calyx are directly continuous with ureter and there is absence of a well defined funnel shaped renal pelvis.
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Multicalyceal renal pelvis with urolithiasis.
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| Number of minor calyx | Number of cases observed | Percentage (%) | | 4 | 16 | 8.2 | | 5 | 17 | 8.7 | | 6 | 5 | 2.6 | | 7 | 84 | 42.9 | | 8 | 55 | 28.1 | | 9 | 11 | 5.6 | | 10 | 6 | 3.1 | | 11 | 2 | 1.0 |
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Number of minor calyces in pelvi calyceal system of 196 specimens observed.
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| Length and width of lower infundibula (mm) | Number of cases observed | Percentage (%) | | Length | | 5-10 | 32 | 16.3 | | 11-15 | 53 | 27.0 | | 16-21 | 92 | 46.9 | | 22-31 | 19 | 9.7 | | Width | | More than 4 mm | 33 | 16.8 | | Less than 4 mm | 163 | 83.2 |
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Length and width of lower infundibula observed in the kidneys of 196 specimens.
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Classification of renal pelvi-calyceal system.
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| Study | Number of specimens studied | Number of minor cases observed | | Hollinshead, 1985 [25] | - | 7-8 | | Harrison, 1972 [26] | - | 8-9 | | Kaye and Reinke, 1983 [27] | - | 4-12 | | Dyson, 1995 [28] | - | 7-8 | | Ningthoujam et al., 2005 [6] | 20 adult and 80 fetal kidneys
100 IVU | 6-12 | | Wadekar and Gangane, 2012 [3] | 100 | 5-11 | | Present study | 196 | 4-11 |
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Reported number of minor calices by authors in different population.
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| Study | Country | Number of specimens studied | Number of major calyces observed | Percentage (%) | | Fine and Keen [29] | Great Britain | 107 | 2 more than 3 | - | | Ningthoujam et al. [6] | India | 20 adult and 80 fetal kidneys
100 IVU | 2-3 | - | | Miller et al., 2013 [2] | United States | 100 | 3 more than 2 | - | | Wadekar et al., 2012 [3] | India | 100 | 2 and 3 | 2 in 60% and 3 in 40% | | Present study | India | 196 | 2-4 | 2 in 116 (59.2%)
3 in 75 (38.3%)
4 in 5 (2.5%) |
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Reported number of major calices by authors in different population.
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