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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. Downloaded from: StudentConsult (on 19 February 2009 03:52 PM) Downloaded from: StudentConsult (on 19 February 2009 03:52 PM) Migration of the kidneys from the pelvis to their definitive adult level. Downloaded from: StudentConsult (on 19 February 2009 03:52 PM Migration defects of the kidney Downloaded from: StudentConsult (on 19 February 2009 03:52 PM) 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