Functional anatomy of the human ureterovesical junction

BACKGROUND: The valve function of the ureterovesical-junction (UVJ) is responsible for protection of the low pressure upper urinary tract from the refluxing of urine from the bladder. Controversy about the microanatomy of the human ureterovesical-junction persists. METHODS: Ten (3 male and 7 female) fresh cadaveric bladders (mean age 70 years old) were studied. The bladders were fixed within 24 hours postmortem, frozen, and serially sectioned. Acetyl- and butyryl- (nonspecific) cholinesterase activity were visualised as described by Karnovsky and Roots. The three-dimensional distribution of the different muscle groups participating in the formation of the UVJ was reconstructed. RESULTS: Three different muscle groups were identified: (1) the detrusor muscle and the deep trigone were mainly acetylcholinesterase-positive, (2) the inner and outer layer of the ureteric muscle were butyrylcholinesterase-positive and merged into a single longitudinal layer at the level of the UVJ and form the superficial trigone distally to the ureteric orifices, and (3) the muscularis mucosae is a discontinuous butyrylcholinesterase-positive layer in the bladder that is absent from the trigone. No evidence of any muscular connection was found between the ureter and bladder musculature. CONCLUSIONS: The anatomy of the UVJ as observed by us suggests the following model of the ureteric peristalsis. The urine bolus arrives in the ureteric lumen at the UVJ level. The ureter can only shorten its length, slides freely in its tunnel, and discharges the urine bolus in the bladder cavity. Ureteric constriction due to the peristalsis and thickening of the contracted portion of the ureter prevents the upstream leakage. Distal spreading of the ureteric "peristalsis" in the superficial trigone increases the submucosal ureteric length and prevents reflu

Anatomy of ureterovesical junction and distal ureter studied by endoluminal ultrasonography in vitro

PURPOSE: The emerging technique of endoluminal ultrasonography (ELUS) provides a new modality for endoscopic visualization of the urinary tract which needs to be further evaluated. We studied the normal anatomy of distal ureter and ureterovesical junction using ELUS. MATERIALS AND METHODS: An assessment of in vitro ELUS ureteric images undertaken at 1 mm. intervals from 8 fresh human cadaver pelvis blocs of bladder and distal ureter were compared with findings of serial histological sections of the same specimens (stained for cholinesterase isoenzymes) to assess the degree of correlation. Computer-assisted 3D reconstructions were made. RESULTS: The different components (ureteric, detrusor and periureteric tissue) of the UVJ could be identified on the basis of echogenicity and form, but differentiation between the respective muscle layers in the wall of the ureter or of the detrusor was not possible. Nevertheless, ureteric volume measurements and an assessment of transmural ureteric length and the angle of passage through the bladder wall were possible. CONCLUSIONS: ELUS is able to differentiate between the ureteric and detrusor muscle and the UVJ gross anatomy can be reconstructed. ELUS technology, however, fails to differentiate between individual muscular layers of the ureter or the detrusor. Further improvement in ELUS is mandator

Pharmacological modulation of ureteral peristalsis in a chronically instrumented conscious pig model. I: Effect of cholinergic stimulation and inhibition

PURPOSE: We evaluated in vivo the role of muscarinic receptors on ureteral peristaltic frequency and contraction force in a large animal model using pharmacological manipulation. MATERIALS AND METHODS: A total of 12 female pigs weighing a mean +/- SEM of 72 +/- 4 kg were chronically instrumented using an electronic pressure monitoring catheter in the right ureter. Furthermore, nephrostomy, arterial, venous and cystostomy catheters were placed. Ureteral peristalsis was repeatedly recorded before and after the administration of atropine and carbachol. RESULTS: Systemic and local effects of the 2 agents were observed. Compared with controls we recorded an increase in mean ureteral peristaltic frequency (2.0 +/- 0.3 versus 1.6 +/- 0.6 minutes-1, p 0.05). CONCLUSIONS: Smooth muscle motor activity at the mid and distal ureter is not modulated by muscarinic receptors. Peristaltic frequency is directly related to the pyelocaliceal load during a rate of diuresis not exceeding animal normal diuresis plus 0.25 ml per minute. Ureteral contraction force increases only in the mid ureter with increased diuresi

Effect of hormonal manipulation on antithrombin III activity in patients with prostatic carcinoma

In three groups of patients with advanced prostatic cancer the influence of three different forms of hormonal manipulation, i.e. estrogens, anti-androgens and bilateral orchidectomy, on the coagulation and fibrinolytic systems has been investigated. The groups, studied over a period of 35 days, were comparable as to age and stage of malignancy. A significant decrease in antithrombin III (AT-III) activity of 27% (range 7-46%) was found in patients on an initially high-dose estrogen (diethylstilbestrol) treatment regime. No changes in any of the monitored coagulation and fibrinolytic parameters were noted in the other treatment groups, including patients on maintenance estrogen therapy. The results of this study show that only high-dose estrogen therapy is accompanied by a selective decrease in AT-III activity. This may be an important etiological factor in the increased risk of thromboembolism in patients treated by this regime. The other means of hormonal manipulation studied, including low-dose estrogen treatment, did not influence the coagulation or fibrinolytic system

Randomized double-blind, placebo controlled safety study of a low molecular weight heparinoid in patients undergoing transurethral resection of the prostate

In preparation for an efficacy study, the effect of the low molecular weight heparinoid Org 10172 on postoperative blood loss was assessed in a randomized double-blind, placebo controlled study in patients undergoing transurethral resection of the prostate (TURP). Org 10172 and placebo were given twice daily as i.v. injection for three postoperative days starting one hour preoperatively. Three doses of Org 10172 (800, 1600, and 2400 anti-Xa units b.d.) were evaluated against placebo in three consecutive patient blocks respectively. Each block consisted of 20 patients, 15 receiving Org 10172 and 5 patients placebo. The study was discontinued after 9 patients of the third block had completed the protocol because of excessive urinary blood loss. Data analysis showed a dose-dependent increase in postoperative haemoglobin loss, this was not significant for the 800 anti-Xa units b.d. dosage but was significant in those patients treated with 1600 (p less than 0.05) and 2400 anti-Xa units b.d. (p less than 0.01). It was concluded that the heparinoid Org 10172 caused a dose dependent increase in urinary blood loss following TUR

Estrogen-induced deficiency and decrease in antithrombin III activity in patients with prostatic cancer

Plasma antithrombin III activity was studied in 22 patients with prostatic cancer who were on estrogen therapy. Normal plasma antithrombin III activity varies between 0.80 and 1.40 U. per ml. A loading dose of 15 mg. diethylstilbestrol daily resulted in a marked decrease in plasma antithrombin III activity (mean 0.24 U. per ml.). Patients with the lower end of normal range of pre-treatment plasma antithrombin III activity may suffer acquired antithrombin III deficiency and, thus, a concomitantly increased risk of thromboembolic complications as a result of estrogen treatment. Patients on maintenance therapy of approximately 1 mg. daily appear to have normal plasma antithrombin III levels. The results obtained suggest that plasma antithrombin III activity should be monitored before and during estrogen therapy in patients with prostatic cance

Treatment of localized prostatic carcinoma using the transrectal ultrasound guided transperineal implantation technique

Treatment of localized prostate cancer by ultrasonically guided transperineal 125I implantation, in contrast to open 125I implantation, may allow for ideal distribution of the seeds and may therefore lead to better treatment results. 46 patients with localized prostatic carcinoma (T1-T2, G1-G3, N0, M0) have been treated since 1985, using this new technique. The longest follow-up is 64 months (median 30 months). The irradiation implantation dose to the prostate was 160 Gy. Assessed by ultrasonography an average prostate volume reduction of 20% was achieved at 6 months, increasing to 24% at 12 months, 39% at 24 months and 56% at 48 months. To evaluate response of the primary tumor systematic ultrasonically guided needle biopsies from the previous malignant prostate areas were performed in all patients every 6 months during follow-up. Tumor-negative biopsies were obtained in 33% of patients at 12 months, 40% at 24 months, progressively increasing to 50% at 48 months. Three patients developed distant metastases, and 6 died, of whom 1 patient due to prostate cancer. Morbidity from implantation has been low and the erectile function was preserved in all patients at 12 months postimplantation. The high percentage of tumor-positive biopsies during follow-up indicates that this technique fails to cure a significant proportion of patient

Multichannel urethral pressure profiles: reproducibility and three-dimensional representation

Urethral pressure profilometry (UPP) is used to investigate the pressure distribution in the urethra. Single UPP is dependent on the orientation of the catheter during the study. To circumvent this problem, we developed a system for multichannel profilometry (MCUPP) that can be used in daily clinical practice. In the study reported in this article, 29 healthy female volunteers (mean age 34.6 years) underwent MCUPP. The mean time needed to make five pressure profiles ranged from 4 to 12 minutes (mean 7.6). The system is patient- and user-friendly. The volunteers scored the discomfort on a 1 to 10 scale, with 10 meaning no discomfort at all, rendering a mean score of 7.6. The Symmetry Index (SI) is a calculated variable expressing the asymmetry in the pressure profiles. An SI of 1 means a completely symmetrical pattern of pressure distribution. The mean SI for the whole group was 0.7 (range 0.407-0.930). The standard deviation was 0.109. Within-subject SI was highly reproducible (Greenhouse-Geisser epsilon = 0.98292