Download Urinary system

Urinary system
for students of general medicine and dentistry
Miloš Grim
Institute of Anatomy, First Faculty of Medicine, Summer semester 2016/2017
Urinary system - systema urinarium
Kidney - ren, nephros
Renal pelvis - pelvis renalis
Ureter
Urinary bladder - vesica urinaria
Femal urethra - urethra feminina
Male urethra - urethra masculina
Development and congenital defects
Urinary system - organa urinaria
Homeostasis (electrolyte and water balance),
Excretion of metabolic products,
Production of urine - kidney
Transportation – pelvis, ureter, urethra
Accumulation – urinary bladder
Micturition
Endocrine functions (renin, erythropoetin)
Urinary tract of male is from prostate also part
of genital tract
Structure of urinary tract organs – transitional
epithelium (urothelium), smooth muscle layer,
adventitia
Kidney - ren (nephros) lateral + medial border, hilum, sinus,
anterior+posterior surface, superior + inferior extremity
Renculisation
Horseshoe kidney
Position of the kidney
in retroperitoneal space
of lumbar region
Syntopy of the kidney
Position of the kidney
Syntopy of the
kidney
n.subcostalis, n. iliohypogastricus, n. ilioinguinalis,
diaphragma, m. iliopsoas, m. quadratus lumborum,
m. transversus abdominis, recessus costodiaphragmaticus
Renal envelopes
Fibrous caspule, perinephric fat (capsula adiposa renis),
renal fascia, paranephric fat (corpus adiposum pararenale)
renal cortex, medulla, lobi renales (pyramids) 5-14, renal
papilla, cribirform area, opening of papillary ducts (120 – 770)
Renal pelvis (ampullar x ramificate type), major (2-3) and
minor (7-14) renal calices. Renal a., anterior r. (praepelvicus),
posterior r. (retropelvicus), segmental aa.
Renal arteries, renal vascular segments
A. renalis:
r. anterior, r. posterior, segmental aa., interlobar aa.
Segments:
superior, upper anterior, lower anterior, inferior, posterior
Intrarenal vessels
Uriniferous tubules:
nephron = glomerular
capsule + renal tubule
(proximal convoluted
tubule, renal loop of
Henle, distal convoluted
tubule)
glomerular filtration,
selective tubular
resorption
(countercurrent multiplier
and exchange system)
tubular secretion,
collecting duct
papillary duct
180 l primary urine – 1.8 l
definitive urine; 1 – 1,5
mio. of nephrons/kidney
Intrarenal vessels
arteries
segmental aa.
interlobar aa., arcuate aa.
cortical radiate aa.
afferent + efferent
glomerular aa.
intertubular capillary
plexuses x straight
medullar arterioles
veins
interlobar vv., arcuate vv.,
cortical radiate vv.
straight vv., stellate vv.
Cortical nephron
Juxtamedullary nephron
Blood supply of the kidney
Junqueira´s Basic Histology
Renal Cortex
Juxtaglomerular apparatus (JGA): dense macula
(chemosensitive area of distal tubule), juxtaglomerulal cells
of media of afferent a. producing renin, pole cushion
(extraglomerular mesangium). JGA - feedback device
regulating perfusion of glomerule by renin production.
Urinary filter: endothelium, basal lamina, podocytes
Glomerular capillaries
JGA
Renal pelvis,
calices
Branching x
ampullary type
Major + minor
calices
Muscular layer
(contraction
vaves),
mucous
membrane,
urothelium
X-ray of pelvis and ureter
Ureter
( 25-30 cm )
Parts:
abdominal
pelvic
intramural
3 constrictions
ureteric point
muscular layer
mucous
layer
Syntopy of pelvic portion of ureter in female and male
Urinary bladder
(vesica urinaria)
Apex, body, fundus,
neck, uvula,
trigon of bladder,
ureteric orifice,
internal urethral
orifice,
interureteric crest,
serous coat,
subserous layer,
muscular layer,
detrusor, trigonal
muscle,
submucousa,
mucosa,
Pelvic relationships
in the female
vesico-uterine pouch, recto-uterine pouch, pubovesical lig.,
retropubic space, vesico-vaginal septum, paracystium,
recto-vaginal septum
Syntopy of the urinary bladder in male
Recto-vesical pouch, pubo-vesical lig., pubo-prostatic lig.,
retropubic space, recto-vesical septum, paracystium
Female urethra
Fibromuscular tube
(4 cm)
internal orifice,
(filling, voiding,
accipiens, evacuans)
external orifice
Parts: intramural,
pelvic,
perineal,
external urtehral
sphincter,
urethral glands,
(para-urethral ducts)
Trigonum interampullare
Urinary bladder
frontal section of pelvis
at the level of prostate
Male urethra
(ca 20 cm)
(urinary + seminal duct)
Internal orifice,
Parts: intramural,
prostatic, membranous,
spongy, External orifice
seminal colliculus,
prostatic sinus,
internal urethral
sphincter, bulbourethral gland
external urtehral
sphincter,
urethral glands,
urethral lacunae,
navicular fossa
External urethral sphincter, Sphincter urethrovaginalis,
Compressor urethrae
Tractography is a 3D modeling technique used to visually neural
tracts is used to illustrate the course of muscle fibres using data
collected by diffusion tensor imaging (DTI). It uses special
techniques of magnetic resonance imaging (MRI), and computerbased image analysis. The results are presented in two- and
three-dimensional images.
Fiber tractography representing the urethral sphincter complex
from cranial (C) and posterior view (D).
External urethral sphincter
localisation – urogenital diaphragm
consists of slow striated muscle fibresproducing long
lasting contraction
innervated from nucleus of Onuff localised in spinal
segments S2-3. Axons arrive the muscle via inferior
hypogastric plexus
Urinary continence
The urethra lies on a supportive layer composed of the
endopelvic fascia and the anterior vaginal wall. This layer
gains structural stability through its lateral attachment to the
tendineus arch of pelvic fascia and levator ani muscle.
Pressure from above compresses the urethra against this
hammock-like supportive layer, compressing its lumen closed.
The stability of the suburethral layer depends on the intact
connection of the vaginal wall and endopelvic fascia to the
arcus tendineus fasciae pelvis and levator ani muscles.
the urethra is compressed against a hammock-like supportive
layer (J. DeLancey, 1994)
Urinary incontinence
also known as involuntary urination, is any leakage of urine. It
is a common and distressing problem. Surgical therapy:
tension-free vaginal tape, and bladder suspension
Magnetic resonance image of female pelvis in plane of urogenital
hiatus (level 2 according to DeLancey)
Anatomy of the pelvic outlet (scheme based on MRI)
Symphysis
Urogenital
hiatus
Urethra
Vagina
Anal canal
Puborectal
sling
(levator ani)
Tendinous arch
of levator ani
Tendinous arch
of pelvic fascia
Hammock
New surgical technique for treatment of stress urinary
incontinence: tension-free urethral suspension
Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jun;20(6):681-8. .
Anatomical relationship and fixation of tension-free vaginal tape Secur
Hubka P, Masata J, Nanka 0,Grim M, Martan A, Zvarova J
First Faculty of Medicine and General Teaching Hospital, Department of Gynaecology and
Obstetrics, Charles University in Prague, Apolinarska 18, 12000, Prague, Czech Republic.
[email protected]
The objective is to describe the anatomical localisation of tension-free
vaginal tape Secur (TVT-S) in the H-position regarding possible injury of
vessels and fixation site. METHODS: We placed TVT-S inserters bilaterally
in 14 embalmed and five fresh frozen female bodies. After dissection, we
measured distances from the obturator bundle (obturator nerve and
obturator vessels). RESULTS: In embalmed bodies, the mean distance of
TVT-S from the obturator bundle was 3.05 cm (standard deviation (SD) 1.18
cm) on the left, 3.07 cm (SD 1.17 cm) on the right. Perforation of the fascia
of obturator internus muscle occurred in 46.4%. In fresh frozen bodies,
results were fundamentally similar. Injury of variable vessels can occur.
CONCLUSION: There is a minimal risk of injury to the obturator bundle
during TVT-S; however, there is a significant risk of inserting the TVT-S
inserter into the obturator fossa. The position of TVT-S does not change
significantly after legs mal-positioning.
Development of urinary system
from intermediate mesoderm, urogenital sinus,
external genital primordia
3 stages of development:
pronephros
mesonephros
mesonephric duct (Wolffian), ureteral bud
metanephros,
5th embryonic week
Sadler T. W: Langman´s Medical
Embryology, 11th Edition 2010
NEPHROGENESIS: inductive interactions between
branching ureteric bud (signaling molecules Fgf2, Bmp7)
and mesenchyme of nephrogenic blastema (transcription
factors PAX2 and WT1 expression).
From the ureteric bud arise the urinary pathways. In
nephrogenic blastema the two cell lines are induced under
the influence of transcription factors Foxd1 and Six2.
Nephrogenic cells secrete VEGF, which is involved in the
formation of glomerular capillary loops.
The development of pelvis and calices renales.
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Migration of the kidneys from the pelvis to their definitive adult level.
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Migration defects of the kidney
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Common renal developmental anomalies.
Sources of illustrations used :
Gray´s Anatomy,
Sobotta: Atlas der Anatomie des Menschen
Grim, Druga: Regional anatomy. Galén, Prague 2012
Benninghoff, Drenckhahn: Anatomie I., II.
Carlson,B.M.: Human Embryology and Developmental Anatomy
Recommended Textbooks:
R. S. Snell: Clinical Anatomy. 7th Edition, Lippincott Williams &
Wilkins, 2004, pp. 478 – 562
or
K. L. Moore: Clinically oriented Anatomy, 3rd Edition, Williams &
Wilkins 1992, pp. 501 – 635
and
W. Kahle: Color Atlas/Text of Human Anatomy, Vol. 2 Internal
organs. Thieme, 4th English Edition, 1993
Langman´s Medical Embryology,11th Edition, 2010
Junqueira´s Basic Histology 12th Edition, 2010
Atlas
Gilroy, MacPherson, Schuenke, Schulte, Schumacher: Atlas of
Anatomy, 3rd edition, Thieme 2016