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Salvatore Rocca Rossetti

Managing Segmental
Renal Diseases

123
Managing Segmental Renal
Diseases
Salvatore Rocca Rossetti

Managing Segmental
Renal Diseases
Salvatore Rocca Rossetti
Urology Department
University of Turin
Turin
Italy

ISBN 978-3-319-49720-4    ISBN 978-3-319-49721-1 (eBook)

DOI 10.1007/978-3-319-49721-1

Library of Congress Control Number: 2017955681

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduc-
tion on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service
marks, etc. in this publication does not imply, even in the absence of a specific
statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of pub-
lication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with
regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

Segmental renal diseases or pathologies are those occurring

in a segment of an organ. A segment of the kidney, like those
in the lung or liver, is not just any portion of the organ but a
precise embryological and anatomically autonomous struc-
tural district with an equally autonomous function. Some
diseases affect the kidney, temporarily, in a segment, respect-
ing the rest of the organ; at this stage the pathology is seg-
mental and if its treatment is surgical, the operation consists
of a segmentectomy—that is, precise excision of the seg-
ment—leaving the rest of the kidney unscathed.
Study of the development of the kidney (embryology,
organogenesis, and final constitution) has made it possible to
establish a way to locate, reach, and remove each renal seg-
ment, i.e., renal lobe.
Segmental renal diseases and pathologies are not frequent,
in fact they are rather rarer than those that are diffuse in the
parenchyma or located in peripheral or nonsegmental areas
of the kidney. Consequently, kidney segmentectomies (lobec-
tomies) are indicated less frequently than other types of
conservative surgery.
From a surgical point of view there is an essential differ-
ence in the aggressiveness of the technique in the kidney:
endorenal in segmentectomies and extrarenal in tumorecto-
mies, partial nephrectomies, and renal resections. Renal seg-
mentectomies require a hilum–sinus approach; they are a
typical kind of endorenal surgery.

v
vi Preface

The content of this book focuses on the peculiar character-

istics of segmental renal diseases and pathologies, and
anatomo-surgical aspects of endorenal surgery for specific
segment removal in the kidney.

Turin, Italy Salvatore Rocca Rossetti

Acknowledgments

The author would like to thank his colleagues and friends

who agreed to contribute to this work with their opinions,
comments, or suggestions: Dr. C. Boccafoschi, Head of
Urological Private Department at Alessandria Clinic
(Alessandria), Italy; Dr. A. Dezan, Head of Urological Private
Department at Villa Maria Pia Hospital, Turin, Italy; Professor
G. Muto, Professor of Urology and Head of Urological
Department and Graduate Urological School at Campus
Medical University, Rome, Italy; Professor F. Porpiglia,
Professor of Urology and Head of Urologic Department and
Graduate Urological School at Turin University, S. Luigi
d’Orbassano, Italy; and Professor A. Volpe, Head of Urologic
Department and Graduate Urological School at East
Piedmont University, Novara, Italy.
A special thanks goes to A. Dezan who provided the ana-
tomic drawings.
The author is particularly grateful to Alessandra Born of
Springer for the continuous and valuable assistance with the
editorial tasks.

vii
Contents

Part I Pathologies and Diseases Representing

Indications for Segmentectomy

1 General Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Kidney Stones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3 Renal Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4 Cystic and Mainly Malformative Diseases

of the Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1 Cysts: Solitary, Typical,
Atypical, Complicated. . . . . . . . . . . . . . . . . . . . . . 28
4.2 Multilocular Cyst or Cystic Nephroma. . . . . . . . 28
4.3 Unilateral Segmentary Cystic
Disease of the Kidney. . . . . . . . . . . . . . . . . . . . . . 31
4.4 Cysts Associated with Renal Neoplasms . . . . . . 31
4.5 Multicystic Segmentary Dysplastic Disease. . . . 33
4.6 Medullary Cysts. . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.7 Cysts of Renal Sinus . . . . . . . . . . . . . . . . . . . . . . . 35

5 Other Potential Segmental Pathologies . . . . . . . . . . . 37

5.1 Renal Hyperplasia and Hypoplasia. . . . . . . . . . . 37
5.2 Special Infections and Inflammations. . . . . . . . . 37
5.3 Other Endorenal Pathologies: Hydrocalyx. . . . . 39
5.4 Calyceal Diverticulum. . . . . . . . . . . . . . . . . . . . . . 39
5.5 Megapolicalycosis. . . . . . . . . . . . . . . . . . . . . . . . . . 40

ix
x Contents

5.6 Infundibulo-Pelvic Dysgenesia

(and Fraley Syndrome). . . . . . . . . . . . . . . . . . . . . 40
5.7 Reno-Ureteric Segmentectomies. . . . . . . . . . . . . 41

Part II Surgical Management

6 Organisation of Kidney and Urinary Apparatus . . . 47

7 Surgical Anatomy of Urinary Segments

and Operative Surgical Aspects . . . . . . . . . . . . . . . . . 55
7.1 Renal Segments, Calycectomy,
Segmentectomy, Lobectomy. . . . . . . . . . . . . . . . . 55
7.2 Renal Sinus Access . . . . . . . . . . . . . . . . . . . . . . . . 60
7.3 Pathologic Situations Potentially
Requiring Endosinusal Access. . . . . . . . . . . . . . . 68
7.4 Renal Segmental Resection (Lobectomy,
Calycectomy, Segmentectomy). . . . . . . . . . . . . . . 69
7.5 Reconstructive Surgery of the
Intrarenal Collecting System . . . . . . . . . . . . . . . . 76
7.6 Calyceal Stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . 79
7.7 Pyelic, Pyelo-Calyceal Stenosis,
or Coarctation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
7.8 Calyceal Prolonged Stenosis. . . . . . . . . . . . . . . . . 82
7.9 Pelvis Ablation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7.10 Open, Laparoscopic, Robotic Surgery. . . . . . . . . 85

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Introduction

Some organs, such as the lungs, the kidneys, and the liver, are
made up of lobes, which in the lungs and liver are clearly visible,
but much less evident in the kidneys. The lungs and liver appear
to have a lobated structure from the outside and shelter the
internal functioning parenchymal segments. This function is
inherent to all organ systems and can work independently due
to the fact that it remains operative even when other parts of
the lobe or the organ have been removed or are n ­ onfunctioning
as a result of illness. The segments have their own vessels,
nerves, and aeration and secretion ducts, and as a result it is
possible, when necessary, to remove the segment without caus-
ing any damage to the rest of the lobe (lung, liver). This leaves
the organ sound and only deprived of the removed area.
In childhood, the kidney has an external lobated appear-
ance, whereas in adulthood it is commonly compact or con-
globate. In any case, the interior of its structure is composed
of lobes, each made up of a minor calyx that receives the apex
papillae of the pyramid surrounded by its own cortical
envelop, which together form the renal segment. It is also
possible to perform a lobectomy on the kidney, which is
known as a renal segment ablation.
Some pathologies and diseases are temporary in that they
represent just a stage in the process of an illness, others are
definitive, referring to malformations or an irreversible
pathologic situation with district localization, and are seg-
mentary. In these cases, if surgical therapy is deemed to be
necessary, segmentectomies or segmental resections are pos-
sible. In the kidney they are also called lobectomies or
calicectomies.

xi
xii Introduction

These situations are perhaps rare but it is important to

remember that rare does not mean nonexistent!
When and why those diseases or pathologies can be con-
sidered segmentary and thus necessitate renal segmentec-
tomy and intrarenal plastic surgery is the topic of this book.
Readers will notice that the bibliography following some
chapters occasionally appears old, as in the case of, for exam-
ple, phylogenesis and the anatomic surgery of intrarenal
operations and typical lobectomy techniques. For the section
on phylogenesis I decided to report the source from which all
the successive literature came, judging it inappropriate to
ignore it. For the intrarenal surgery and lobectomy proce-
dures I described in 1997, there are no significant notes or
findings other than those published at that time by the
Intrarenal Surgery Society, which are frequently cited in the
book.
To better understand the topic, the book is divided into:
Part I: Pathologies and Diseases Representing Indications
for Segmentectomy
Part II: Surgical Management
 Part I
Pathologies and Diseases
Representing Indications for
Segmentectomy
Chapter 1
General Remarks

This part of Urology covers two inter-linked issues: Firstly,

the study of pathologies and diseases that are located or
potentially located in a single part of the organ, thus leaving
the rest of it healthy and disease free; secondly, the study of
surgical peculiarities in the targeted removal of part of the
organ leaving the rest intact and functioning, known as seg-
mentectomy. The value of the relationship between these two
groups of study is clear if one wants to consider the patho-
logical, clinical, and therapeutic aspects of each field.
This pathology will explain why pathologic phenomena or
processes occur, and in some cases only temporarily, and
remain in the specific part of the organ in which they started.
Clinical results will demonstrate if and when it is necessary
to treat the disease or pathological processes in order to alle-
viate the issues or prevent them from getting worse.
Therapeutic indications, in our case surgical, are part of the
clinical discipline.
The surgical, segmentary treatment of the kidney consists
of removing one or more renal lobes according to the mani-
festation and extent of the disease. Since the surgical tech-
nique begins by identifying the calyx in which the pathologic
lobe opens, the lobectomy technique used is also called a
calicectomy.
It is well known that it is possible to remove the affected
part of the kidney through surgical procedures other than
those specified above. This occurs in the case of small or

© Springer International Publishing AG 2018 3

S. Rocca Rossetti, Managing Segmental Renal Diseases,
DOI 10.1007/978-3-319-49721-1_1
4 Chapter 1. General Remarks

medium-size tumors that are circumscribed and have no infil-

tration of the surrounding parenchyma. In this instance we
are speaking of partial renal resection.
It is thus timely to establish the difference between the
two kinds of procedures, both considered to be “nephron
sparing.” The difference lies in both the surgical technique
and in the obtainable results. The surgical anatomy of seg-
mentectomy is based on calyces, from which the name “caly-
cectomy” is derived (Figs. 1.1 and 1.2). The calyx heads the

Figure 1.1 Renal lobation

 Chapter 1. General Remarks 5

Figure 1.2 Renal lobes

segment or lobe that is to be removed; in order to reach the

calyx one needs to enter the renal sinus and, using the major
calyx as a guide, find the desired minor calyx. The calyx
amputation and the traction on it favors the segmental paren-
chymal delimitation that unloads in it and the consequent
ablation.
While segmentectomy starts with intrarenal access
(Figs. 1.3 and 1.4), partial nephrectomy starts from outside of
the kidney, where the parenchymal incision is made just
around the lesion that is to be removed, independent of
whether the lesion is cortical, medullary, or calyceal (Figs. 1.5
and 1.6).
As far as results are concerned, segmentectomy leaves the
rest of the kidney sound, missing only the removed lobe or
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