Review: Anatomic Background for Intrarenal Endourologic Surgery*

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Abstract
A serious and troublesome complication of endoscopic intrarenal operation is bleeding from an injured vessel. To diminish the risk of such injury, the operator must know and recall the spatial position of the intrarenal vascular structures and their anatomic relations with the collecting system. The analysis of 82 three-dimensional endocasts of the kidney collecting system together with the intrarenal arteries and 52 endocasts of the collecting system with the veins showed that the segmental and the interlobar branches of the renal artery as well as the major intrarenal tributaries of the renal vein are in close relation with the anterior and posterior surfaces of the major caliceal infundibula as well as of the necks of the minor calices. Considering that the circumference of an infundibulum is composed of four quadrants, the infundibular incision must be done in the superior or inferior quadrant, because in general, these areas are free of large vessels. Contrariwise, the posterior and, mainly, the anterior quadrants are often in contact with major vessels. From an anatomic standpoint, if more than one infundibular incision is necessary, we recommend the following sequence: the first incision in the superior quadrant, the second in the inferior quadrant, the third between the superior and posterior quadrants, the fourth between the inferior and posterior quadrants, and the fifth in the posterior quadrant. Anterior incisions must be always avoided.

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