Reni, ureteri, vescica e uretra

Secondo Gutierrez, il 40% delle condizioni patologiche dell'apparato urinario è dovuto a variazioni. Variazioni urologiche si riscontrano nel 10% delle variazioni vertebrali, nel 15% dei casi di meningocele o mielomeningocele, nel 25% dei casi di ano doppio, nel 42% delle duplicazioni del colon e nel 90% delle duplicazioni dei genitali (Cernak, 1989).

I reni talvolta si discostano dalla loro forma normale, risultando o più lunghi e stretti, oppure più corti e arrotondati.

La caratteristica lobulazione fetale può persistere nell'adulto (7%).

Occasionalmente un rene è molto piccolo, mentre l'altro risulta proporzionalmente ingrandito.

Sono documentati numerosi casi di assenza di un rene, più frequentemente il destro. L'assenza congenita di un rene ha una frequenza riportata dello 0,24% (6.500 autopsie); in un altro studio su 52.198 casi l'incidenza dell'agenesia è risultata di 1/1000, ossia lo 0,10%.

Il rene ectopico ha una frequenza riportata compresa fra 1:500 e 1:110; il rene ectopico toracico, 1:13.000 (rene solitario, 1:1.000; rene pelvico solitario, 1:22.000; un rene normale e uno pelvico, 1:3.000, ed ectopia renale crociata, 1:7.000.

Il rene unico è di norma ingrandito, ma non invariabilmente. Il rene sinistro è di solito più grande del destro.

Berengario da Carpi (1523) fu il primo a scrivere di reni fusi con configurazione a ferro di cavallo. Essi furono tuttavia descritti e illustrati per la prima volta da Botallo nel 1564. Quando è allungato, il rene può giacere, in parte, dietro l'esofago.

In media, nel maschio il rene destro misura 12,7 X 6,3 cm mentre il sinistro misura 13,2 X 6,4 cm. Nella femmina il destro misura 12,4 X 5,9 cm e il sinistro 12,8 X 6,1 cm. Questi dati provengono da studi radiologici. La presenza di un rene soprannumerario è rara. In un caso il rene destro era normale, mentre sul lato sinistro erano presenti due reni (uno superiore e uno inferiore) separati fra loro da una distanza di 3 cm. L'uretere del rene superiore si univa a quello del rene inferiore, cosicché nella vescica si aprivano soltanto due orifizi ureterali.

I due reni possono essere uniti per i loro poli superiori e inferiori o anche nella parte media degli organi. Essi incrociano anteriormente i grossi vasi e la colonna vertebrale. L'organo così congiunto ha di solito la forma di un ferro di cavallo, con la convessità rivolta in basso per la fusione delle estremità caudali dei due reni. Il rene a ferro di cavallo è stato riscontrato nello 0,21% di 6.500 autopsie in uno studio e nello 0,12% di 68.000 autopsie (1:850) in un altro. I dati cumulativi di 192 autori (202.777 autopsie e studi radiologici) indicano un totale di 378 reni a ferro di cavallo. L'incidenza è pertanto di circa 1:536, ossia lo 0,19%; l'84% dei casi nei maschi e circa il 17% nelle femmine. In uno studio su 2.424 casi sono stati trovati 15 reni a ferro di cavallo nei maschi e tre nelle femmine.

Talvolta due reni uniti si trovano nella regione lombare su un solo lato della colonna vertebrale, o più raramente nella cavità pelvica. Il rene pelvico è stato riscontrato nello 0,04% di 6.500 autopsie.

Sono stati descritti anche organi a forma di manubrio (dumbbell) o due reni discoidi uniti fra loro nel loro punto mediano.

I reni possono essere mobili, per la lassità della capsula areolare e adiposa. Queste condizioni si verificano molto più frequentemente a carico del rene destro. Il tessuto adiposo perirenale è continuo attraverso la linea mediana da un rene all'altro.

1. Anomalie di numero
2. Assenza di entrambi i reni
3. Assenza di un rene (rene solitario)
4. Rene doppio o multiplo (rene soprannumerario)
5. Unilaterale o bilaterale

Variazioni di dimensione

1. Rene ipoplasico.
2. Vera ipoplasia renale.
3. Aplasia renale.
4. Rene ipertrofico.
5. Lobulato.
6. Compensato.

Variazioni di forma.

1. Rene lungo.
2. Rene corto.
3. Rene largo.
4. Rene lobulato.
5. Rene cistico.
6. Unilaterale.
7. Bilaterale.
8. Rene policistico.
9. Unilaterale.
10. Bilaterale.
11. Rene fuso.

• Asimmetrico
• Rene a L.
• Rene sigmoide.
• Rene ad anello («en galette»).
• Rene «en masse».

Simmetrico (rene a ferro di cavallo).

• Con la concavità in alto.
• Con la concavità in basso.
• Con istmo fibroso.
• Con istmo costituito da vero parenchima renale.
• Con una, due, tre o quattro pelvi e ureteri.

Variazioni di posizione.

1. Rene mobile o fluttuante.
2. Rene ectopico.
3. Semplice unilaterale.
4. Semplice bilaterale.
5. Bilaterale con fusione (rene a ferro di cavallo).
6. Crociato con o senza fusione.
7. Ciascuna di queste variazioni di posizione può essere lombare, iliaca, pelvica o mediana.

Variazioni di rotazione.

1. Rotazione insufficiente.
2. Unilaterale.
3. Bilaterale.
4. Rotazione eccessiva.
5. Unilaterale.
6. Bilaterale.

L'apparato escretore del rene (calici, pelvi e uretere):

1. Calici
2. Assenti
3. Aberranti
4. Numero, dimensione o posizione inconsueti
5. Pelvi renale
6. Assente
7. Rudimentale
8. Doppia (bifida) o multipla
9. Unilaterale
10. Bilaterale
11. Idronefrosi (congenita)
12. Pelvi intrarenale
13. Unilaterale
14. Bilaterale
15. Pelvi extrarenale
16. Unilaterale
17. Bilaterale
18. Diverticolo della pelvi renale
19. Uretere
20. Variazioni di numero
21. Singolo (assenza di un uretere)
22. Doppio da un lato
23. Triplo
24. Quadruplo
25. Quintuplo
26. Sestuplo
27. Tutte le condizioni sopra elencate possono essere complete o incomplete. Possono ramificarsi.
28. Variazioni di forma, dimensione e posizione
29. Diverticolo dell'uretere
30. Semplice
31. Multiplo
32. Uretere imperforato
33. Stenosi dell'uretere
34. Pio-uretere
35. Idrouretere
36. Megalo-uretere
37. Dilatazione dell'uretere
38. Totale
39. Parziale
40. Orifizio ureterale del tipo a «buca da golf»
41. Uretere ectopico
42. Malposizionato nella vescica
43. In corrispondenza del fondo
44. In un diverticolo
45. In prossimità del collo vescicale, ecc.
46. Con orifizio extravescicale che si apre in
47. Un altro uretere
48. Uretra
49. Tratto genitale
50. Intestino
51. Uretere torto od occluso
52. Ureteri incrociati
53. Uretere con formazione di valvole
54. Ureterocele

Modificato da Gutierrez, 1936.

I calici minori possono variare di numero da sei a 14; il numero minore indica che alcuni calici minori accolgono gli apici di più piramidi. Le variazioni dei calici minori e della pelvi sono più marcate.

I calici maggiori possono estendersi verso il basso per un certo tratto oltre l'ilo e terminare unendosi a formare l'uretere senza andare incontro a un'evidente dilatazione. In tali casi la pelvi è assente; se i calici si dilatano, possono essere presenti una o due pelvi.

È stato riportato che l'agenesia renale unilaterale associata ad anomalie genitali si verifica nel 12% degli uomini e nel 40% delle donne. Le anomalie della vescichetta seminale sono poco comuni, ma quando si verificano, nel 68% di tali casi si riscontra anche un'agenesia renale unilaterale.

L'anefrogenesi bilaterale ha un'incidenza dello 0,0017%.

È stata segnalata la presenza di tessuto renale eterotopico nel cuore e nella ghiandola surrenale.

La variazione principale dell'uretere è una divisione più o meno completa in due. Di regola i due ureteri si uniscono poco al di sopra della vescica, cosicché esiste un solo orifizio vescicale. Quando la divisione è completa, vi sono due aperture separate nella vescica. In uno studio su 26.480 autopsie sono stati riscontrati 136 ureteri doppi o bifidi (0,5%).

In rari casi si possono trovare tre o quattro ureteri. Sono documentati diversi casi in cui un uretere soprannumerario, proveniente dalla parte superiore del rene, si apriva direttamente nell'uretra. È stato riportato inoltre che gli ureteri possono aprirsi nella vagina, nella vescichetta seminale o nell'uretra prostatica.

L'uretere destro è stato trovato passare dietro la vena cava inferiore (uretere postcavale o retrocavale), fra tale vaso e l'aorta.

Sono state segnalate vesciche urinarie di forma variabile (per esempio la vescica a clessidra). La vescica può essere sdoppiata. L'agenesia ha un'incidenza riportata di 1:600.000 (0,00017%).

L'uretra può essere sdoppiata.

Rene a ferro di cavallo

Rene - a ferro di cavallo

Rene a ferro di cavallo

Rene a ferro di cavallo con tre ureteri

Rene pelvico

Terzo rene soprannumerario

Duplicazione bilaterale dell'uretere

Tipi di uretra doppia

Uretere bifido incompleto unilaterale

Rene sigmoide

Ureteri bifidi bilaterali

Reni fusi

Reni fusi a ferro di cavallo

Reni a ferro di cavallo

Tipi di uretere triplice

Configurazioni della pelvi e dei calici

Rene a S congenito

Riferimenti dell’opera originale

Elenco riportato come compare nella fonte, senza normalizzazione dei formati bibliografici. Le voci non sono tradotte: un riferimento bibliografico si cita nella lingua in cui è pubblicato.

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