Urodynamics: Hydrodynamics of the Ureter and Renal Pelvis

URODYNAMICS

Hydrodynamics of the Ureter and Renal Pelvis

Saul Boyarsky

Division of Genitourinary Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri

Emil A. Tanagho

Division of Urology, University of California School of Medicine, San Francisco, California

Carl W. Gottschalk

Department of Medicine and Physiology, University of North Carolina, Chapel Hill, North Carolina

Paul D. Zimskind

Department of Urology, Jefferson Medical College, Philadelphia, Pennsylvania

Table of Contents

Cover image

Title page

Contributors

Copyright

List of Contributors

Preface

I: Ureteral Morphology as a Basis for Peristaltic Activity: Basic Principles

Chapter 1: Ureteral Embryology, Developmental Anatomy, and Myology

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Gross Anatomy

Microscopic Structure

Specific Features

Chapter 2: The Neurohistochemistry of Mammalian Ureter

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Materials and Methods

Results

Model of Innervation to the Ureter

Conclusions

Chapter 3: Some Biophysical Aspects of Ureter Smooth Muscle

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Summary

Chapter 4: A Comparison of Other Conduit Organs with the Ureter: Reaching toward a Clearer Concept of Ureteral Peristalsis

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Models

Conclusions

Chapter 5: The Renal Pelvis and Calyces

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Discussion

II: The Concept of Ureteral Peristaltic Function

Chapter 6: Cineradiographic Observations of Ureteral Functions in Man and Dog

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Discussion

Summary

Chapter 7: Ureteral Delivery and Efflux

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Methods

Results

Discussion

Summary

Chapter 8: Ureteral Peristaltic Pressure Methods

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Direct Observation

Examination of Ureteral Efflux

X-Ray Techniques

Electromanometry or Ureteral Peristaltic Pressure Method

Ureteral Perfusion

In Vitro Methods

Tissue Culture

Biochemical Assays

Histology and Histochemistry

Pharmacologic Methods

Electromyography

Preparations for Study of the Ureter

Chapter 9: Ureteral Peristaltic Activity

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Activity with Low Rates of Urine Flow

Normal Hydration

Retrograde Flow

Effect of Bladder Distention

Diuresis

Effect of Mechanical Stimulation

Effect of Mechanical Obstruction

Effect of Gravity

Conclusion

Chapter 10: The Isolated Ureter in Vitro

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Summary

Chapter 11: Correlation of Cineradiographic Image and Pressure Tracing of Ureteral Peristalsis

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Method

Results

Summary

Conclusion

Chapter 12: Electrophysiological Methods in the Study of Ureteral Dynamics

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Materials and Instruments

Methods

Discussion and Conclusions

Discussion

III: Bioengineering Aspects of Ureteral Function

Chapter 13: Ureteral Dimensions and Specifications for Bioengineering Modeling

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Chapter 14: Basic Engineering Principles of Ureteral Flow

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Analysis

Summary

Chapter 15: Peristaltic Pumping: A Bioengineering Model

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Simplifying Assumptions

Analysis

The Muscle Action

Numerical Procedure

Results

Conclusion

Appendix

Chapter 16: The Ureter as a Peristaltic Pump

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The Ureter as a Uniform Circular Collapsing Tube

The Ureter as a Traveling Sinusoidal Wave

The Ureter as a Traveling Wave of Arbitrary Shape

Comparison of the Theory with Experiments

Conclusions and Future Work

Chapter 17: Hydrodynamic Model of Ureteral Function

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Objectives

Previous Work

Data for the Human Ureter

Calculational Model of the Ureter

Results

Conclusions

Appendix

Chapter 18: A Systems Physiology Approach to Ureteral Modeling

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Discussion

IV: Factors Controlling Ureteral Peristalsis

Chapter 19: Neurophysiological Theory of Ureteral Function

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Chapter 20: Physiological Organization of Function with Reference to a Pacemaker

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Ionic Hypothesis for Electrical Activity

Propagation of Electrical Activity

Ionic Basis for Ureteral Electrical Activity

Propagation of Ureteral Electrical Activity

Pacemaker Activity

Excitation-Contraction Coupling

Summary

Chapter 21: The Ureteral Response to Bladder Filling

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Direct Observations of the Ureterovesical Orifice in Man

Observations of Ureteral Activity during Bladder Filling, Micturition, and Sustained Pressure

Summary

Chapter 22: The Relation of Ureteral Function to Urine Flow: Backflow Mechanisms

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Chapter 23: A Review of Intrarenal Hemodynamics and Hydrodynamics

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Pressure Profiles along the Renal Vasculature and the Uriniferous Tubules

The Nephron

The Effects of Ureteral Occlusion on Intrarenal Pressures

Reabsorption of Salt and Water by the Uriniferous Tubules

Summary

Chapter 24: Partial Ureteral Obstruction and Renal Function

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Glomerular Filtration Rate

Concentrating Ability

Complete Obstruction and Reabsorption Replacement

Summary

Chapter 25: Drugs, Hormones, and Endotoxin Effects: Speculations on the Molecular Biology of Ureteral Peristalsis

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Discussion

Discussion

V: Clinical Applications

Chapter 26: Diagnostic Methods for Ureteral Peristalsis: Critique and Limitations

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The History

Physical Examination

Direct Observation

Cystoscopic and Chromocystoscopic Observation

Radiologic Studies

Ureteral Pressure Recording

Chapter 27: Laboratory Models of Diseases Altering Ureteral Hydrodynamics

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Chapter 28: Peristalsis in the Diseased Ureter: A Brief Summary of Current Knowledge

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The Obstructed Ureter

Transected or Injured Ureter

Effects of Disuse and Overuse on the Ureteral Wall

The Bifid Ureter

Inflammatory Effects on Peristalsis

Ureteral Regeneration

Summary

Chapter 29: Factors Promoting Recovery of Function in the Diseased and Operated Ureter

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Discussion

Discussion

VI: Theory and Techniques of Hydrodynamic Measurements

Chapter 30: Modal Activity of Ureteral Peristalsis

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Method

Discussion

Results

Summary and Conclusions

ACKNOWLEDGMENT

Chapter 31: Ureteral Pressure Measurements

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Pressure

Measurement of Pressure

Interrelations between Pressure Measurements and Other Forms of Study

Chapter 32: Factors in the Development of Measurement Techniques for Transcutaneous Studies of Ureter Function

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Basic Concepts That Should Be Adhered to

The Feasibility of Implementing These Criteria

The Development of Transcutaneous Techniques

Phase I of Transcutaneous Ureter Function Measurements Development Sequence

Phase II of Transcutaneous Ureter Function Measurements Development Sequence

Phase III of Transcutaneous Ureter Function Measurements Development Sequence

Summary

Discussion

VII: Potential Adaptation of Available Instrumentation and Techniques Not Currently Used

Chapter 33: Real-Time Digital Computer System for Ureteral Physiology Investigation

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Experimental Procedure

Instrumentation

Data Flow

Computation and Results

Correlation Analysis and Discussion

Conclusion

Chapter 34: Electrical Measurement of Ureteral Flow

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Measurement of Ureteral Cross Sections

Physical Considerations and Sources of Error

Systems Considerations

Chapter 35: A Microminiaturized Piezojunction Pressure Sensor

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Chapter 36: Ureteral Plethysmography

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Technique

Results

Chapter 37: Information Theory and the Ureter: A Hydrodynamic Point of View

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Variation of Hydrodynamic Information

A Simple System for Peristaltic Pumping

Data Analyzing

Pressure Gradient and Secondary Flow in the Bolus

Chapter 38: Ureteral Pacemaker

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Chapter 39: Observations on the Ureter after Renal Autotransplantation

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Methods and Materials

Operative Technique

Follow-Up Studies

Results

Discussion

Summary

Chapter 40: Ileal Sleeve Procedure for the Decompensated Ureter

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Chapter 41: Ureteral Replacement by Ileum

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Chapter 42: The Silastic Ureter

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Chapter 43: Use of the Internal Ureteral Stent in Surgery of the Kidney and Ureter

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Method

Functions of the Internal Stent

Complications of Internal Stents

Panel Discussion

Summary and Evaluation

Subject Index

Contributors

RICHARD ABSHER, KENJI AITO, GORDON F. ANDERSON, DONALD W. BAKER, LLOYD BARR, WILLIAM F. BARRY, JR., JOHN A. BENJAMIN, SAUL BOYARSKY, WILLIAM H. BOYCE, E.M. BRIGGS, GEORGE BUGLIARELLO, C.E. CONSTANTINOU, R.L. DALE, DAVID M. DAVIS, O. DUARTE-ESCALANTE, CHRISTOPHER M. FREDERICKS, YUAN-CHENG B. FUNG, J.F. GLENN, WILLARD E. GOODWIN, CARL W. GOTTSCHALK, D.E. GOVAN, JAY H. HARRIS, FRANK HINMAN, JR., TIN-KAN HUNG, M.Y. JAFFRIN, PEREGRINA C. LABAY, WYLAND F. LEADBETTER, PAUL S. LYKOUDIS, JOSEPH M. MALIN, JR., RICHARD L. MALVIN, W.F. MELICK, FREDERICK H. MEYERS, PABLO A. MORALES, SIMON OSTRACH, JAMES M. PIERCE, JR., A.H. SHAPIRO, ARTHUR M. STERLING, EMIL A. TANAGHO, ERIC E. THERKELSEN, S.L. WEINBERG, ROBERT M. WEISS, J.J. WORTMAN, PAUL D. ZIMSKIND and NORMAN R. ZINNER

Copyright

COPYRIGHT © 1971, BY ACADEMIC PRESS, INC.

ALL RIGHTS RESERVED

NO PART OF THIS BOOK MAY BE REPRODUCED IN ANY FORM, BY PHOTOSTAT, MICROFILM, RETRIEVAL SYSTEM, OR ANY OTHER MEANS, WITHOUT WRITTEN PERMISSION FROM THE PUBLISHERS. RIGHTS FOR PRIVILEGED USE BY THE UNITED STATES GOVERNMENT FOR SPECIAL PURPOSES ARE RESERVED.

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PRINTED IN THE UNITED STATES OF AMERICA

List of Contributors

Numbers in parentheses indicate the pages on which the authors’ contributions begin.

RICHARD ABSHER,     (233 399 473), Department of Electrical Engineering, University of Vermont, Burlington, Vermont

KENJI AITO,     (497), Urological Department, Matsuyama Sekijuji Hospital, Matsuyama, Ehenie-Ken, Skikoku, Japan

GORDON F. ANDERSON,     (283), Department of Physiology and Pharmacology and Department of Urology, Wayne State University School of Medicine, Detroit, Michigan

DONALD W. BAKER,     (425), Bioengineering Program, University of Washington, Seattle, Washington

LLOYD BARR,     (49), Department of Physiology and Biophysics, Woman’s Medical College of Pennsylvania, Philadelphia, Pennsylvania

WILLIAM F. BARRY, JR.,     (133, 399), Department of Radiology, Duke University Medical Center, Durham, North Carolina

JOHN A. BENJAMIN,     (77), Division of Urology, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York

SAUL BOYARSKY,     (55, 99, 163, 317, 349, 399, 473, 497, 571), Division of Genitourinary Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri

WILLIAM H. BOYCE,     (513), Division of Urology, Department of Surgery, The Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina

E.M. BRIGGS,     (143, 455), Division of Urology, Department of Surgery, Stanford University School of Medicine, Stanford, California

GEORGE BUGLIARELLO,     (485), University of Illinois at Chicago Circle, Chicago, Illinois

C.E. CONSTANTINOU,     (143, 455), Division of Urology, Department of Surgery, Stanford University School of Medicine, Stanford, California

R.L. DALE,     (143, 455), Division of Urology, Department of Surgery, Stanford University School of Medicine, Stanford, California

DAVID M. DAVIS,     (363), Department of Urology, Jefferson Medical College, Philadelphia, Pennsylvania

O. DUARTE-ESCALANTE,     (29, 317), Division of Genitourinary Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri

CHRISTOPHER M. FREDERICKS,     (283), Department of Physiology and Pharmacology and Department of Urology, Wayne State University School of Medicine, Detroit, Michigan

YUAN-CHENG B. FUNG,     (177), Department of Engineering Science (Bioengineering), University of California at San Diego, La Jolla, California

J.F. GLENN,     (497), Division of Urology, Duke University Medical Center, Durham, North Carolina

WILLARD E. GOODWIN,     (507), Division of Urology, Department of Surgery, University of California Medical School and Wadsworth Veterans Administration Hospital Los Angeles, California, and Los Angeles County Harbor General Hospital, Torrance, California

CARL W. GOTTSCHALK,     (299, 571), Department of Medicine and Physiology, University of North Carolina, Chapel Hill, North Carolina

D.E. GOVAN,     (143, 455), Division of Urology, Department of Surgery, Stanford University School of Medicine, Stanford, California

JAY H. HARRIS,     (465), Department of Electrical Engineering, and Urodynamics Laboratory, Department of Urology, University of Washington, Seattle, Washington

FRANK HINMAN, JR.,     (353), Division of Urology, University of California School of Medicine, San Francisco, California

TIN-KAN HUNG,     (485), Biotechnology Committee, Carnegie-Mellon University, Pittsburgh, Pennsylvania

M.Y. JAFFRIN,     (217), Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts

PEREGINA C. LABAY,     (55, 99, 163, 317, 349, 497), Division of Genitourinary Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri

WYLAND F. LEADBETTER,     (503), The Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

PAUL S. LYKOUDIS,     (199), School of Aeronautics, Astronautics, and Engineering Sciences, Purdue University, West Lafayette, Indiana

JOSEPH M. MALIN, JR.,     (125), Department of Urology, Wayne State University School of Medicine, Detroit, Michigan

RICHARD L. MALVIN,     (309), Department of Physiology, University of Michigan, Ann Arbor, Michigan

W.F. MELICK,     (493), Division of Urology, Department of Surgery, St. Louis University School of Medicine, St. Louis, Missouri

FREDERICK H. MEYERS,     (119, 255, 479), Department of Pharmacology, University of California School of Medicine, San Francisco, California

PABLO A. MORALES,     (87), Department of Urology, New York University Medical Center, New York, New York

SIMON OSTRACH,     (167), Division of Fluid, Thermal, and Aerospace Sciences, Case Western Reserve University, Cleveland, Ohio

JAMES M. PIERCE, JR.,     (283), Department of Physiology and Pharmacology and Department of Urology, Wayne State University School of Medicine, Detroit, Michigan

A.H. SHAPIRO,     (217), Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts

ARTHUR M. STERLING,     (411), Urodynamics Laboratory, Department of Urology, University of Washington, Seattle, Washingto

EMIL A. TANAGHO,     (3, 119, 255, 479, 571), Division of Urology, University of California School of Medicine, San Francisco, California

ERIC E. THERKELSEN,     (465), Department of Electrical Engineering, and Urodynamics Laboratory, Department of Urology, University of Washington, Seattle, Washington

S.L. WEINBERG,     (217), *Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts

ROBERT M. WEISS,     (261), Section of Urology, Yale University School of Medicine, New Haven, Connecticut, and Department of Pharmacology, Columbia University, College of Physicians and Surgeons, New York, New York

J.J. WORTMAN,     (473), Research Triangle Institute, Research Triangle Park, North Carolina

PAUL D. ZIMSKIND,     (61, 293, 339, 509, 571), Department of Urology, Jefferson Medical College, Philadelphia, Pennsylvania

NORMAN R. ZINNER,     (411, 465), Urodynamics Laboratory, Department of Urology, University of Washington, Seattle, Washington

*Present address: Washington University, St. Louis, Missouri.

Preface

This volume summarizes the present status of urodynamics in progression from the known, to the untried, to the seemingly impossible. Too many precedents exist, notably in the cardiovascular system, for us to doubt that a bioengineering analysis of urinary physiology can be equally productive. This volume spans nearly five decades in the development of urodynamics, and includes as contributors such pioneers in ureteral physiology as Davis, Lapides, Benjamin, and Morales with the more advanced urodynamicists from the engineering community.

This book is an outgrowth of the proceedings and conclusions of an interdisciplinary workshop devoted to the hydrodynamics of the ureter and renal pelvis, a companion second workshop to one which dealt with the hydrodynamics of micturition, both sponsored by The National Research Council and National Academy of Sciences, Division of Medical Sciences, Committee on The Genitourinary System. Such workshops have introduced new concepts, new methodologies, and insights, and have dissolved language barriers in a very successful manner.

The workshop made it possible for representatives of some 30 active laboratories to meet. A continuum of discussion developed between the theoretical bioengineer, the research bioengineer, the research physiologist, the research surgeon, and the clinical urologist.

Acknowledgments are due to the members of the Committee of the Genitourinary System of the National Research Council, particularly to the Chairman and guiding light, Dr. William Boyce; also to Drs. Flocks, Glenn, Goodwin, Hinman, Kass, Lattimer, Leadbetter, Schlegel, Merrill, Del Regato, and Colonel Derby, Captain Hubbard, Colonel Lewis, Dr. Edwin Coyl and his staff, including Mrs. Jean Perrin, and to Mr. Harry Weil of the Center for Continuing Education of the University of Chicago.

Saul Boyarsky, Carl W. Gottschalk, Emil A. Tanagho and Paul D. Zimskind

I

Ureteral Morphology as a Basis for Peristaltic Activity: Basic Principles

Outline

Chapter 1: Ureteral Embryology, Developmental Anatomy, and Myology

Chapter 2: The Neurohistochemistry of Mammalian Ureter

Chapter 3: Some Biophysical Aspects of Ureter Smooth Muscle

Chapter 4: A Comparison of Other Conduit Organs with the Ureter: Reaching toward a Clearer Concept of Ureteral Peristalsis

Chapter 5: The Renal Pelvis and Calyces

Discussion

1

Ureteral Embryology, Developmental Anatomy, and Myology

EMIL A. TANAGHO,     DIVISION OF UROLOGY, UNIVERSITY OF CALIFORNIA SCHOOL OF MEDICINE, SAN FRANCISCO, CALIFORNIA

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This chapter discusses ureteral embryology, developmental anatomy, and myology. The developmental process of ureter starts as an outgrowth of the mesonephric duct at the end of the fourth week of embryonic life. The outpouching then grows cranially to meet and unite with the metanephric cap. The time of this meeting and union is important, as it determines future nephric development and ascent. The ureter neither begins at the renal pelvis nor ends at the bladder. The ureter is only a segment of one continuous unit that starts cranially at the cortical level of the kidney and ends caudally at the genital ducts in the male and at the vaginal vestibule in the female. The ureter achieves relative fixation at both ends. The most terminal part of the ureter has a purely longitudinal arrangement; this is probably because of a tremendous pulling force along a longitudinal axis, first during the period of the absorption of the mesonephric duct into the urogenital sinus and again during the expansion of the absorbed mesodermal tissue as the urogenital sinus grows and stretches.

The ureter starts its development as an outgrowth of the mesonephric duct at the end of the fourth week (5 mm stage) of embryonic life (Fig. 1). Close to its caudal end, where it bends before opening into the cloaca, the mesonephric duct develops a localized thickening with cell proliferation around its circumference. An outpouching on the dorsomedial aspect of this cellular proliferation indicates the first appearance of the ureteral bud. The outpouching then grows cranially to meet and unite with the metanephric cap (Fig. 2). The time of this meeting and union is important, as it determines future nephric development and ascent.

Fig. 1 Ureteral development from the mesonephric duct, demonstrating caudal and cranial migration and its relation to the pronephros and mesonephros.

Fig. 2 Division of the cloaca and the progressive absorption of the mesonephric duct into the urogenital sinus. This absorbed mesodermal tissue will form the trigone, and the ureteral bud and mesonephric duct will have separate orifices.

Changes occur simultaneously at both ends of the ureteral bud. As a result of the progressive shortening of the common nephric duct due to its absorption into the ventral segment of the cloaca, the caudal end of the ureteral bud gradually approaches the urogenital sinus (the urethrovesical anlage differentiating from the cloaca). Finally (seventh week, 14 mm stage), the ureteral bud achieves an independent opening into the urogenital sinus (Fig. 2). The accumulated absorbed tissue of the mesonephric duct expands and forms the trigone, maintaining direct continuity with the ureter exactly as the common nephric duct is continuous with the ureteral bud originally.

If more than one ureteral bud develops, the accessory is higher on the nephric duct and meets the urogenital sinus later than the original bud. It drains the upper pole, and its vesical opening is always lower than and medial to the original one. If the original and the accessory ureteral buds develop close together, they open into the bladder near one another and in the normal site. If the accessory bud is widely separated from the original one, however, it terminates farther away in an ectopic location (vesical neck, proximal urethra, vaginal vestibule, or seminal vesicles).

The cranial end of the ureteral bud expands and dilates during its cephalad migration. It starts to branch at the ninth week (11 mm) and by the fifth month, 10–12 successive generations are developed (Fig. 3). The process continues almost until birth, when approximately 20 such generations have appeared, leading to the development of about a million renal units in each kidney. The first and second branchings form the major and minor calyces. The third and fourth generations are absorbed into the minor calyces. The fifth to the tenth generations form the pyramids and the collecting tubules (ducts of Bellini). Further branching develops more tubules, and finally each connects with the differentiating S-shaped metanephric tubules which form the secretory portion of the kidney. Earlier bifurcation of the ureteral bud occurs at any level from the bladder to the renal pelvis and results in a bifid ureter.

Fig. 3 Cranial expansion of the ureteral bud to form the renal pelvis; its subsequent progressive division and subdivision to form the numerous renal tubules that connect to the glomeruli, establishing the continuity between metanephric and mesonephric elements.

The condensation of loose mesenchyme around the mesonephric tubular structures marks the start of the muscularization and can usually be noted as early as the 26 mm stage. Initially (late in the eighth week), the young mesenchymal cells have a circular orientation; later, longitudinally oriented fibers appear (Mehta, 1967). Although there is no definite evidence, it is possible that with ureteral lengthening, the circularly oriented mesenchymal fibers assume a partly oblique, or even longitudinal, orientation, while some retain their circular orientation. The abundance of circularly oriented fibers depends on the relative lengthening of each segment. The general arrangement, however, is an irregular helical pattern, as will be discussed below.

Gross Anatomy

The adult ureter is about 28–30 cm long and averages 3–5 mm in diameter. The ureter (in 85% of the cases) starts imperceptibly as the renal pelvis gradually tapers to the ureter proper (Fig. 4a). Occasionally, there is actually no pelvis because there has not been much dilatation at this end of the ureteral bud, and the calyces open directly into the ureter (Fig. 4c). The ureter then pursues a relaxed course with sufficient length to allow for a smooth curve over the psoas muscle and another curve in the pelvis before it turns medially and enters the vesical wall. In 15% of the cases, the pelvis is box-shaped and there is a relatively sharp transition between the pelvis and upper ureter (Fig. 4b).

Fig. 4 Three types of normal variation in the ureteropelvic junction. (a) Funnel-shaped, (b) box-shaped, and (c) lack of pelvic expansion.

It is clear from the embryologic development that the ureter neither begins at the renal pelvis nor ends at the bladder. The ureter is only a segment of one continuous unit that starts cranially at the cortical level of the kidney and ends caudally at the genital ducts in the male and at the vaginal vestibule in the female. The ureter achieves relative fixation at both ends. There is direct continuity between the renal pelvis and ureter at one end (Fig. 5) and between the ureter and trigone at the other (Fig. 6). Both the renal pelvis and the trigone influence the ureter’s main function as the conducting tube between the secretory nephric element and that periodically expulsive reservoir, the bladder. The ureter does not have a uniform diameter or thickness. There is one constant point of relative narrowing at the vesical end and a less frequent one at its pelvic origin. Occasionally there are other sites of relative narrowing, but these have no functional significance.

Fig. 5 Sagittal section of the human ureteropelvic junction. There is direct continuity between pelvic and ureteral musculature (×9 Trichrome).

Fig. 6 Sagittal section of the terminal ureter showing direct continuity between the ureter and the trigone (BL, bladder; IV, intravesical; UO, ureteral orifice) (×4 Trichrome).

Since the entire ureter lies in the retroperitoneum, it reflects any changes in intraabdominal pressure.

Microscopic Structure

The ureter, which is primarily a muscular tube, has three histologic coats.

(a) Adventitia: This forms a complete investment around the entire ureter (Fig. 7). The ureteral vascular supply comes from several segmental sources and runs longitudinally beneath the adventitia. In dissecting the ureter, one should stay outside the adventitia in order to preserve ureteral vascularity to a great extent. During peristaltic activity, the ureter slides up and down and changes in caliber, moving freely within the adventitia. This freedom of movement seems to be essential for proper ureteral function. Any interference with this mobility, whether localized (adhesions and bands) or extensive (retroperitoneal fibrosis), obstructs urine transport and often leads to stasis and dilatation.

Fig. 7 Cross section of the human midureter showing the loose adventitia and blood vessels surrounding the ureter (×7 Trichrome).

Proximally, the ureteral adventitia is continuous with the pelvic fascial sheath. At its distal end, the adventitia becomes thicker and more prominent as several well-developed muscle bundles appear. It becomes fibromuscular rather than a fibrous connective sheath and forms a sleeve around the terminal 1.5–2 inches of ureter; this sleeve is called Waldeyer’s sheath (Fig. 8). It is extremely valuable to the function of the terminal ureter and the ureterovesical junction and also forms the link between the mesodermal ureteral structure and the endodermal detrusor.

Fig. 8 Cross section of the human lower ureter. Note the fibromuscular Waldeyer’s sheath surrounding the ureter. Blood vessels are mainly outside the sheath.

(b) Mucosal lining: Like the lining of other urinary passages, the mucosal lining of the ureter is composed of transitional epithelium 4–6 layers thick. Besides providing a barrier against interstitial diffusion of urinary constituents, the ureteral epithelium lies over a relatively thick lamina propria which is composed of a loose mesh of fibrous bands that attach the basal epithelial cells to the muscle coat. Because of this thick yet loosely packed submucosa, the ureter can distend, easily stretching its epithelial lining, which assumes several longitudinal folds in the resting undistended state (Figs. 9a and b).

Fig. 9.(a) Cross section of a collapsed upper ureter. Note the mucosal folds filling the lumen.

Fig. 9.(b) Cross section of a distended upper ureter. Note the flattening of the ureteral mucosa and the diminished thickness of the submucosal layer (×7 Trichrome).

(c) Muscle: The ureter is a well-muscularized tube. The musculature of the renal pelvis continues imperceptibly into the upper ureter, establishing the continuity of the collecting duct. In the funnel-shaped ureteropelvic junction, there is no histologic delineation at the end of the renal pelvis and the beginning of the ureter except for a gradual variation in lumen caliber (Fig. 5). Approximately 50% of the pelvic musculature continues down the ureter, while the rest is continuous between the renal pelvis and the calyces (Fig. 10). There is a similar relationship between the musculature of the minor and major calyces (Fig. 11). Minor calyces are also quite muscular (Fig. 12).

Fig. 10 Sagittal section of the pelvicalyceal junction. Note the direct continuity of musculature (×4 Trichrome).

Fig. 11 Sagittal section of the calyceo—calyceal junction, showing muscular continuity (×4 Trichrome).

Fig. 12 Cross section of the minor calyx, showing abundant musculature (×9 Trichrome).

Embryologically, while the cranial end of the ureteral bud is expanding to start the formation of the renal pelvis, the rest of the tube is lengthening. The point of junction between the expanding pelvis and the lengthening ureter, however, is not undergoing much change. Early in its development, the mesenchymal cell arrangement has a circular orientation around this tubular structure, and the final arrangement depends on the degree and direction of growth either in a longitudinal or transverse axis. If it is the former (lengthening), the fibers will assume more longitudinal orientation (Fig. 13). If it is the latter (broadening), the fibers will retain most of their circular orientation. Growth in both directions, which is usually the case, will result in fibers with mixed orientation throughout the entire collecting-duct system, with a preponderance of one or the other orientation at certain locations (Fig. 14).

Fig. 13 Diagrammatic illustration of the muscle fiber arrangement that results from lengthening or broadening in a tube with circularly oriented fibers around it. (a) Circular orientation around a tube, (b) effect of broadening is exaggeration of circular orientation, (c) effect of lengthening is tendency toward longitudinal orientation.

Fig. 14 Orientation of muscle fibers as a result of a combination of broadening and lengthening. (a) Circular orientation around a tube, (b) effect of broadening in the upper half and lengthening in the lower half. Similar to events at the ureteropelvic junction.

The renal pelvis has a preponderance of circularly oriented fibers because its growth is more along a transverse axis than a longitudinal one (Fig. 15). The ureteropelvic junction has this arrangement to a lesser degree, but there are still more circular fibers than longitudinal ones. With little or no stretching at the level of the ureteropelvic junction, a box-shaped pelvis will result. If there is some stretching, the more common funnel-shaped pelvis will result. The ureter proper grows more in length than in breadth and therefore has an equal mixture of fiber orientation. The most terminal part of the ureter (the intravesical ureter) has a purely longitudinal arrangement; this is probably due to a tremendous pulling force along a longitudinal axis, first during the period of the absorption of the mesonephric duct into the urogenital sinus and again during the expansion of the absorbed mesodermal tissue as the urogenital sinus grows and stretches.

Fig. 15 Longitudinal section taken from the renal pelvis showing the abundance of circularly oriented fiber (×16 Trichrome).

Specific Features

The ureter has only one muscle coat rather than the layering seen in other smooth muscular tubes, such as the gut. We cannot speak of an inner longitudinal, middle circular, and outer longitudinal muscle layer of the ureter, as most histology books describe. There is only one muscle coat, and its fibers are interwoven in a mixture that is oriented in almost every direction (Fig. 16). Nevertheless, there is a partial tendency toward layering in the upper ureter, where the inner fibers tend to pursue a longitudinal course and the outer fibers have a more circular or oblique orientation (Fig. 17). As we approach the midureter, this layering gradually fades into a mixture without any tendency toward distinct layering. The mixture becomes definite in the distal ureter.

Fig. 16 Longitudinal section of the ureteral wall showing muscle fibers running in every direction.

Fig. 17 Cross section of the upper ureter showing a tendency toward layering. The inner muscle fibers are predominantly longitudinal; the outer fibers are mainly circular (×7 Trichrome).

We speak of circular and longitudinal fibers, but in reality the fibers are neither purely circular nor purely longitudinal. The result of the lengthening, stretching, and rotation of the developing ureteral bud is that the muscle fibers assume a spiral or, more aptly, helical orientation. Because the degree and direction of lengthening or expansion are not uniform, the helical arrangement is irregular. Each muscle bundle is one long irregular helix (Fig. 18). The combination of several of these muscle bundles constitutes the unique arrangement of ureteral musculature (Fig. 19), which superficially looks haphazard yet offers a balanced mixture of muscle fibers arranged in all degrees of obliquity, ranging from a purely longitudinal axis to a purely transverse axis. Longitudinally oriented fibers help to shorten the tube, while those along a transverse axis help to reduce its caliber; oblique fibers combine these two functions with rotation (Fig. 20). A helical arrangement is the most efficient way of providing the unique ureteral peristaltic wave which is needed for the transport of the thin watery fluid (urine) in one direction against certain resistance at its terminal end.

Fig. 18 Irregular helical arrangement of three separate muscle bundles.

Fig. 19 Combination of two muscle bundles (a) and three muscle bundles (b). Combination results in fibers running in every direction.

Fig. 20 Changes resulting from contraction of helically arranged muscle bundles.

As the terminal ureter approaches the ureteral hiatus, its helical loops become widely open, and in the intravesical ureter, the fibers assume a purely longitudinal orientation without any loss or reduction of the ureteral muscle mass. At the ureteral orifice, the ureter loses its lumen and continues uninterrupted into the trigone (Fig. 21). This specific arrangement, in which the ureter changes from a tubular to a sheetlike structure, offers an efficient, adaptable, sphincteric mechanism at the terminal ureter to guard against regurgitation of urine from the bladder to the ureter. When the trigone is stretched (with filling) or contracted (with voiding), it will inevitably pull on the longitudinally oriented muscle fibers along the intravesical ureter, bringing them toward one another and firmly including the ureteral lumen (Fig. 22).

Fig. 21 A female human bladder dissected from inside, exposing the terminal ureter and its direct continuity with the superficial trigone, as well as the continuity of Waldeyer’s sheath with the deep trigone. (From Tanagho and Pugh, 1963.)

Fig. 22 Trigonal functional control of the intravesical ureter as related to various phases of detrusor activity. With progressive bladder filling, trigonal stretch augments the degree of closure of the intravesical ureter. Active contraction during voiding firmly seals the intravesical ureter.

Grossly, the blood supply of the ureter is segmental, arising from adjacent blood vessels (renal, mesenteric, spermatic or ovarian, lumbar, and vesical). Almost four-fifths of the ureter receives its blood supply from above, while the terminal one-fifth receives the majority of its blood supply from below. There is of course an appreciable overlap, which must be considered in ureteral freeing, dissection, and transection.

We have noted the longitudinal course of the adventitial blood vessels. Perforating branches arise from the adventitial vascular trunks to pierce the ureteral wall in a perpendicular plane. Some of these traverse the ureteral wall without any branching and terminate in fine arborization supplying the mucosa and submucosa. Others branch throughout their passage in the muscle wall to provide the necessary blood supply.

Electron microscopy of the ureteral musculature reveals that, although there is no protoplasmic or myofibrillar continuity between ureteral smooth muscle fibers, there are either intercellular bridges (Bergman, 1958) or broad areas of contact between muscle cells (Notley, 1968). Either histologic feature can provide a structural pathway for the conduction of action currents from one muscle cell to another. This is consistent with electrophysiologic and pharmacologic studies.

REFERENCES

Aires de Sousa, L., Microangiographic aspects of the ureter. J. Urol. 1966; 95:179–183

Bergman, R. A. Intercellular bridges in ureteral smooth muscle. Bull. Johns Hopkins Hosp. 1958; 102:195–202.

Carando, M. Contributo allo studio dell’architettura della muscolatura ureterale. Arch. Ital. Urol. 1950; 24:137–146.

Fuchs, F. Die Hydromechanik der Niere. Z. Urol. Chir. 1931; 33:1–144.

Fuchs, F. Über das reflexbedingte Verhalten der oberen Harnwege und seine Bedeutung für die Ausscheidungsurographie. Z. Urol. Chir. 1932; 35:169–179.

Fuchs, F. Theorie der Harnwegefunktion. Z. Urol. Chir. 1933; 37:154–212.

Gould, D. W. The behavior of the intact ureter in dogs, rabbits and rats. J. Physiol. 1955; 129:436–447.

Kuntz, A. The Autonomic Nervous System,, 4th ed. Philadelphia: Lea and Febiger; 1953.

Lenaghan, D. Bifid ureters in children: an anatomical, physiological and clinical study. J. Urol. 1962; 87:808–817.

Mehta, H. J. The Ureter.. New York: Harper (Hoeber); 1967.

Meyer, R. Normal and abnormal development of the ureter in the human embryo–a mechanistic consideration. Anat. Rec. 1946; 96:355–371.

Mingledorff, W. E. Experimental studies of the blood supply of the distal ureter with reference to cutaneous uretrostomy. J. Urol. 1964; 92:424–428.

Murnaghan, G. F. Experimental investigation of the dynamics of the normal and dilated ureter. Brit. J. Urol. 1957; 29:403–409.

Murnaghan, G. F. Dynamics of the renal pelvis and ureter with reference to congenital hydronephrosis. Brit. J. Urol. 1958; 30:321–329.

Notley, R. C. Electron microscopy of the upper ureter and the pelvic—ureteric junction. Brit. J. Urol. 1968; 40:37–52.

Schneider, W. Die Muskulatur der oberen harnableitenden Wege. Z. Anat. Entwicklungsgesch. 1938; 109:187–196.

Tanagho, E. A., Pugh, R. C. The anatomy and function of the ureterovesical junction. Brit. J. Urol. 1963; 35:151–165.

2

The Neurohistochemistry of Mammalian Ureter

O. DUARTE-ESCALANTE,     DIVISION OF GENITOURINARY SURGERY, DEPARTMENT OF SURGERY, WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS, MISSOURI

Publisher Summary

This chapter discusses the neurohistochemistry of mammalian ureter. It presents histochemical evidence of balanced adrenergic and cholinergic mechanisms in each ureteral layer, the localization of one group of ganglion cells (adrenergic and cholinergic) at the ureterovesical junction and the presence of a few ganglion cells close to the pelviureteral junction. Adrenergic and cholinergic terminals exist in close anatomic proximity to these ganglion cells. A great number of sympathetic and parasympathetic fibers enter the ureteral wall with the blood vessels. Ganglion cells are consistently found in clusters in the lower ureteral segment and in a scattered distribution along the middle and upper segments. Some ganglion cells, generally in groups of 2–3, are occasionally located at the lower portion of the renal pelvis. These cells are more closely related to the blood vessels and the muscle surface than to the main nerve trunk itself.

The upper ureter receives sympathetic innervation from the spinal cord segments thoracic 10–12 and a parasympathetic component from the dorsal efferent nucleus of the vagus nerve [1–7]. The lower ureteral segment receives sympathetic innervation from the spinal cord segments lumbar 1 and 2 and a parasympathetic component from the spinal cord segments sacral 2 and 3. Ganglion cells were observed in the lower ureter as early as 1894 [1, 2, 8, 9].

The primary interests of this investigation were the intrinsic adrenergic and cholinergic innervation of the mammalian ureter. It was our purpose to find suggestion in their pattern of distribution as to the role, if any, they play in ureteral muscle and the epithelial layer. Furthermore, we have found epithelial cells in the uroepithelium which give a positive chromaffin reaction similar to that given by chromaffin cells described in the mammalian urinary system [10–12].

We shall present histochemical evidence of balanced adrenergic and cholinergic mechanisms in each ureteral layer, the localization of one group of ganglion cells (adrenergic and cholinergic) at the ureterovesical junction, and the presence of a few ganglion cells close to the pelviureteral junction. Adrenergic and cholinergic terminals exist in close anatomic proximity to these ganglion cells.

Materials and Methods

Histochemical procedures have been developed to identify both cholinergic and adrenergic fibers and cells. The material consisted of the ureters and small pieces of bladder from 140 animals, including rats (Sprague-Dawley strain), guinea pigs, rabbits, cats, adult mongrel dogs, normal cows, and small biopsies from nine human patients. The ureter was removed immediately after death. The rats and guinea pigs were sacrificed by decapitation with no anesthesia. Rabbits, cats, and dogs were anesthetized with 2% solution of nembutal (intravenous or intraperitoneal injection). The bovine material was obtained at a slaughter house and the human specimens were obtained during a surgical operation. The tissue was processed by different histochemical procedures to develop catecholamine fluorescence [13–15], cholinesterase enzyme activity [13, 16, 17], and chromaffin reaction [18–20].

Formaldehyde-Induced Fluorescence

Small pieces of ureter were quick-frozen, sectioned in a cryostat, dried on phosphorus pentoxide, and treated with formaldehyde gas of 70% relative humidity at 60–70°C for 45–60 min.

Acetylcholinesterase Enzyme Activity

The best procedure for demonstration of acetylcholinesterase activity proved to be a slight modification [13] of the original method of Karnovsky and Roots [26]. Small pieces of tissue were fixed for 2–3 hr in cold 10% formalin containing 1% CaCl2 and 0.88 M sucrose. The fixed tissue was washed in distilled water and quick-frozen. The cryostat sections were incubated at 37°C for 1–3 hr in a substrate solution containing acetyl-thiocholine and iso-OMPA (tetraisopropylpyrophosphoramide).

Combined Cholinesterase and Silver Reactions

To demonstrate the sites of acetylcholinesterase activity and the presence of noncholinergic structures at the same time, a combined procedure of cholinesterase stain followed by silver impregnation in the same histological section has been developed. First, the acetylcholinesterase reaction was developed. Then the best section was selected under a light microscope; only the sections with well-differentiated cholinesterase precipitate were subsequently treated overnight with a buffered 1% silver nitrate solution.

Chromaffin Reaction

The chromaffin reaction is given strongly by dihydric and poryhydric phenols and polyamines, and less strongly by other substances. The positive reaction suggests the presence of phenols which are usually, for practical purposes, the phenol group of catecholamines. To identify the chemical nature of the granules in the suspected chromaffin cells, several histochemical reactions were used: (a) The argentaffin reaction, the most commonly used to demonstrate the granules. It uses the phenolic property of substances to reduce ammoniacal silver solutions to metallic silver. A black precipitate is developed. Our material was treated in two ways: the classical Masson-Fontana procedure and developing the cholinesterase activity, impregnating the sections with 10% ammoniacal silver solution, and finally differentiating with potassium iodide and acetone. (b) The diazo reaction in acid solution of sulfanilic acid, sodium nitrite, and sodium hydroxide. The mixture was buffered at pH 5.0–5.4. The precipitate was brownish red to light yellow. (c) The Gibb’s dichloroquinone chlorimide reaction. Sections were treated with a solution of 2,6-dichloroquine chlorimide in Veronal buffer at pH 9.2. A gray or blackish precipitate was formed. (d) The dopamine-granule reaction. The tissue was fixed in a mixture of 5% potassium dichromate, 10% aqueous formalin, and 5% potassium chromate. A red or yellow-red precipitate was formed.

Microscopy

The sections treated with paraformaldehyde gas were studied under a Zeiss fluorescent microscope using a combination of a BG-12 excitation filter and a 470 μ barrier filter. The specific catecholamines developed a specific strong yellowish-green fluorescence that faded quickly under the ultraviolet (UV) exposure or treatment with sodium borohydride.

The sections prepared for acetylcholinesterase enzyme activity were studied under the phase-contrast microscope. The sites of enzyme activity are characterized by fine granular reddish-brown deposits.

Results

A great number of sympathetic and parasympathetic fibers enter the ureteral wall with the blood vessels (Fig. 1A). Ganglion cells are consistently found in clusters in the lower ureteral segment and in a scattered distribution along the middle and upper segments. Some ganglion cells (groups of 2–3) are occasionally located at the lower portion of the renal pelvis. These cells are more closely related to the blood vessels and the muscle surface than to the main nerve trunk itself.

Fig. 1 (A) Combined diagram of mammalian ureter in horizontal section and two frontal planes illustrating intrinsic organization of nerve fibers and cell elements. Nerves enter ureter with arteries (striped elements). Nerves contain both preganglionic (Chol., cholinergic) and postganglionic (Adren., adrenergic) nerve fibers. Both types of fiber intermingle in an irregular plexus of thick collateral branches (a) coursing adventitial layer (Adv.); the cholinergic fibers appear to synapse first with a group of ganglion cells [extrinsic ganglia (Ex. G.); 1, adrenergic; 2, cholinergic] in outer part of muscle layer. Secondary nerve branches (b), cholinergic and adrenergic, ramify regularly in muscle. Adrenergic fibers usually innervate blood vessels first, but collaterals are directed toward extrinsic ganglia. In inner part of muscle layer there is a tertiary collateral (c) from cholinergic and adrenergic fibers, making a delicate plexus; a synapse appears to be established with other ganglion cells [intrinsic ganglia (In. G.) 1, 2] in relation to the lamina propria (Lam. P.). Delicate collaterals (cholinergic and adrenergic) form a plexus (d) in deepest layer of epithelium. Entering epithelial layer, delicate cholinergic fibers are closer to some specific cholinergic cells, and delicate adrenergic branches (d) from c, d, or in g appear to end at the chromaffin cells (3). (B) Directions taken by adrenergic and cholinergic nerves entering each ureteral layer. Main adrenergic fibers from blood vessels appear to innervate smooth muscle, and through secondary collaterals the fibers appear to synapse with external adrenergic and cholinergic cells at different levels. Cholinergic fibers appear to synapse with cholinergic cells (2) first in adventitia and then with smooth muscle; another synapse appears to exist with cholinergic ganglia cells of different levels and adrenergic cells in outer and inner muscle layer. From inner adrenergic cells, or adrenergic fibers coursing between muscle and lamina propria, delicate adrenergic fibers extend toward the chromaffin cell in epithelial layer (3). From nerve terminals in epithelium and muscularis, sensory inputs can be processed in three ways: intrinsically in ureter by short reverberating circuits between cholinergic and adrenergic cells, centrally and segmentally by the spinal cord, and upward to various levels of central nervous system. (Circ, circular; Long., longitudinal; n.e., nerve ending.)

Upper Segment and Renal Pelvis

The ganglion cell is spheroid or ovoid and is 15–25 μ in diameter; it has a pale nucleus and three or four short cytoplasmic processes (Fig. 2A). These cells are arranged between the adventitia and outer muscularis layer. The larger cells show a high acetylcholinesterase activity, and the small cells develop a yellowish-green fluorescence of medium to high intensity. A small number of cells are located between the inner muscularis and the outer layers of the tunica epithelialis. These cells are small, predominantly developing a medium intensity of cholinergic activity. Other cells with adrenergic activity appear to have a direct connection with the nonfluorescent cells which are cholinergic by the cholinesterase reaction (Fig. 2B). Medium-sized cells (20 μ) with a cholinesterase activity are seen between the smooth muscle bundles; some of these cells show an intense chromaffin reaction. Topographically, one group of ganglion cells appears to be related to the adventitia and muscle, and a second group to the muscle and epithelium (Fig. 1A).

Fig. 2 Dog ureter preparation. (A) Upper ureter between muscle and adventitia. Combined cholinesterase-silver procedure plus treatment with paraformaldehyde gas. Bundle of cholinergic nerve fibers. Arrows 1 and 2 point to small brown varicosities along the fibers, which course along the surface of smooth muscle. Cholinergic cells (3) show a close relationship with cholinergic fibers. Adrenergic cell (4) sends off diffuse collaterals to muscle and shows two black-brownish granular structures on its surface (5). Cell 6 has a pale-greenish fluorescence and a small varicosed fiber which develops diffuse fluorescence. (B) Upper ureter between muscle and lamina propria. Arrow 1 points to small brown varicosities along the delicate fibers; 2 points out what appear to be nerve contacts with the surface of smooth muscle. Cholinergic cell (3) shows close relationship with cholinergic fibers. Adrenergic cell (4) sends off diffuse collaterals to muscle and shows two black-brownish granular structures on its surface (5). Cell 6 shows pale-greenish fluorescence and a varicosed fiber which develops diffuse fluorescence. (Fluorescent microscopy, ×280.)

In the adventitia, the main nerve trunks which surround the blood vessels are mostly cholinergic and give off branching trunks perpendicular to the longitudinal muscular fibers. These branching trunks develop multiple short collaterals which course up and down the ureter. A few of the nerve trunks develop green fluorescence and send off several short collaterals to the adventitia; these are in turn intermingled with the cholinergic collaterals. The collaterals accompanying the adventitial blood vessels are in close proximity to the cholinergic ganglion cells, which are observed to be surrounded by those processes. Other cholinergic collaterals appear to end at the surface of the small cells which fluoresce with a yellowish-green color (Fig. 2B).

The adrenergic fibers are derived from a large longitudinal trunk which courses and branches along the arteriolar ramifications that lie between the smooth muscle bundles. The ratio of adrenergic fibers to a bundle of smooth muscle fibers varies from 3:1 to 5:1. The branching of the fibers and the probable synaptic sites at the muscular surface do not appear to be so profuse as they are in the lower segment (Fig. 3A).

Fig. 3 (A) Dog lower ureteral segment. Paraformaldehyde treatment. Note the distribution of beaded fluorescent nerve fibers coursing around the blood vessels (b) and along the smooth muscular bundles (m). The serial sections give a ratio of 5–8 fluorescent rescent fibers per 2 muscular bundles. The fluorescent appearance of collagen fibers (c) is clearly distinguished. (Fluorescent microscopy, ×112.) (B) Dog lower ureteral segment. Acetylcholinesterase reaction. Note the profusion of delicate and coarse varicosed cholinergic fibers. Short (s) and long (1) fibers follow a linear direction (the direction of the muscular bundles). The sections give a ratio of 8–10 cholinergic fibers per 1 muscular bundle. A group of small cholinergic cells (cc) is surrounded by multibranched short fibers; artifacts (a) can be seen. (Phase microscopy, ×112.)

In the lamina propria, the cholinergic fibers form a delicate subepithelial plexus giving off short, slender fibers around the small vessels and delicate fibers which synapse with cholinergic fibers in the inner part of the muscularis layer.

In the epithelial layer, the cholinergic fibers are very delicate, short, and close to the tortuous arterial capillaries. The structures which appear to be the cholinergic endings are observed to be of three types: (1) slightly clubbed, (2) finely arborized, or (3) free (Fig. 4A). A few collateral fibers branch from the main epithelial fibers and synapse the cholinergic fibers from the upper and lower levels to form a plexus in this layer. These cholinergic fibers neither synapse with the straight adrenergic fibers reaching the epithelium, nor do they approach the chromaffin cells. One or two delicate adrenergic fibers are derived from the inner ganglion cells; they course the lamina propria, enter the inner plexuses, and end in the vicinity of the chromaffin cells (Fig. 4B). The subepithelial fibers synapse freely with the muscular plexus.

Fig. 4 (A) Dog upper uroepithelium. Acetylcholinesterase reaction. Arrows point to a brushlike (b) and a slightly clubbed (c) structure which appears to be the special cholinergic nerve terminal ending at the surface of epithelial cells. Those cells develop a high cholinergic enzymic activity. (Phase microscopy, ×665.) (B) Dog upper ureter. Paraformaldehyde treatment. Bundle of delicate adrenergic fibers entering epithelium (e) in front of epithelial cell which develops low to medium yellowish fluorescence (ch). Autofluorescence from epithelial layer masks specific catecholamine fluorescence in another fluorescent cell (x); 1p, lamina propria. (Fluorescent microscopy, ×112.)

The chromaffin cells, like those in the lower ureteral segment, show a positive silver reaction due to the presence of many small argentaffin granules, which also fluoresce intensively with a yellowish-green color under paraformaldehyde treatment (Fig. 5B). These are the cells which develop a positive argentaffin reaction for dopamine localization (Fig. 5A).

Fig. 5 Dog ureter. (A) Uroepithelium of lower segment. Dopamine reaction. Arrows point to epithelial cells with a fine and coarse granular substance located