Download Renal artery

Kidneys, Ureters and
Bladder
Ahmed Abdellatif, MD, PhD.
Objectives
Describe/demonstrate the anatomy of:
• Kidney, Ureters, & Bladder.
• Urethra (male & female).
• Clinical correlation.
KIDNEYS & SUPRARENALS
Anatomy of the Kidneys
- Retroperitoneal.
- Obliquely situated, long axis parallel to lateral
boarder of psaos major.
- Hilum faces forward & Medial & is posterior to; on
right side 2nd part of duodenum, & on left tail of
pancreas.
- Kidney measures 12X6X3 cm.
- Right kidney lower, why?
- Fibrous capsule gives shiny appearance to the
kidney.
- Perinephric fat (peri-renal fat)
- Renal fascia, surrounds the perinephric fat,
separates kidney from suprarenal glands.
KIDNEYS
Perinephric fat (peri-renal fat)
Outside renal capsule, & inside renal
fascia.
Stabilizes kidneys in place
What is nephro-ptosis (floating
kidney) ???
What is the relation of suprarenal
glands to the renal fascia??
KIDNEYS
Cortex
• Outer portion & renal columns.
• Contains renal corpuscles
Medulla
• Inner portion, 8-12 renal pyramids
contains loops of henle and collecting
tubules.
• Renal papilla is the apex of the
pyramid which fits into the minor
calyx (collecting tubules open here).
Major Calyces (Calyx) 2-3 & empty into
renal pelvis.
KIDNEYS
Renal Pelvis
• Funnel shaped, upper end of ureter.
• Most posterior in the hilum.
Ureter
• Fibro-muscular tube (25 cm= 10 in.) from
renal pelvis to bladder.
• Runs on anterior surface of psoas muscle
• Blood supply: renal a., aorta, gonadal, iliac.
• 3 narrow points;
– at pelvi-ureteric junction
– At crossing of pelvic brim.
– Entrance to UB, oblique with a slit like opening.
Ureter
•
•
•
•
•
Enter the pelvis over the bifurcation of
the common iliac artery.
Left: runs posterior to sigmoid colon.
Right may run next to appendix.
At level of ischial spine, turns anteriorly.
Male; ductus differens crosses the
ureter (Water goes under the bridge).
Female ureter;
–
–
–
–
–
Runs in base of broad lig.,
Crossed by the uterine artery,
Close to lateral cervical ligament
Ureter crosses lateral fornix.
AT RISK during hysterectomy ?????
Cases
• Mrs. Smith goes into postpartum hemorrhage that requires
hysterectomy to control the bleeding, after returning home a
couple of days later she starts to notice clear fluid soiling here
pads. Her doctor explained to her that she may need another
surgery to correct a fistula between her vagina and one of the
ureters.
• Following a hysterectomy to remove a tumor of the uterus, the
nurse alerts the doctor that Mrs. Smith’s urine bag is empty,
she tells the doctor there is no urine coming out !!!
Vascular & Nerve Supply of the Kidneys
Renal artery
• From the aorta
• Right a. is longer, & posterior to
IVC (significant ??).
• Gives Inf. Suprarenal artery.
•
What is the most anterior vessel in the
renal hilum???
Renal Vein  IVC
Lymphatics  para-aortic nodes.
Nerve Supply
Sympathetics, celiac, renal ganglia.
Parasympathetics from Vagus.
Renal arterial
Segments
• 5 segments based on branches
of the renal artery.
• Renal artery 
– Anterior Division 
Superior (apical), Ant.
Superior, Ant. Inferior &
Inferior segments.
– Posterior Division post.
Segment.
Quiz
Identify:
• Renal artery
• Renal pelvis
• Ureter
• Aorta
Quiz
1.________
2.________
3.________
4.________
5.________
6.________
7.________
8.________
Case
• Following Surgery to remove a huge
kidney stone, Mr. Smith suffered from
severe shortness of breath, clinical
examination and radiology revealed a
diagnosis of pneumo-thorax. Why?????
Posterior
Relation of the
Kidney
Rib 11
Rib 12
Renal Transplantation
• Where do you put the
transplanted kidney &
why?
Urinary Bladder
•
•
•
•
Pyramidal (3 sided) shape (ovoid when
distended).
Superior surface is covered with peritoneum. Full
bladder peels the peritoneum off the posterior
rectus sheath.
Apex points anterior above symphysis pubis.
Median Umbilical ligaments (Urachus) attaches to
apex.
Base, triangular, posterior,
–
–
•
•
No peritoneal covering (except top part in male),
anterior to rectum. In females anterior to cervix and
anterior vaginal wall.
Lowest part of base is trigone.
2 Infero-lateral walls.
Neck, inferior, urethra opens here.
Urinary Bladder
•
•
Inferolateral walls slope down & medially to
meet at the apex.
Retropubic space; fat & veins
–
–
•
•
Female; Pubovesical ligament.
Male; Puboprostatic & pubovescical ligaments
Median umbilical ligament, from apex 
the umbilicus (urachus).
Lateral umbilical ligaments, superior
surface  umbilicus (obliterated umbilical
arteries).
Case
Umbilical Ligaments
• Median umbilical lig.
• Medial umbilical lig.
• Lateral umbilical folds
Which one of these ligaments/fold is
responsible for urine coming out of the “belly
button” in the previous case?
Urinary Bladder
• Inferolateral walls
slope down &
medially to meet
at the apex.
• Retropubic
space; fat & veins.
• Relation of UB to
levator ani &
obturator internus
muscles.
Trigone
•
•
•
•
•
•
Triangular area at base of UB
Smooth wall; Structure & embryology different
from UB.
Least mobile part of the UB, Fixed with fibrous
tissue to pelvic fascia.
The two ureteric opening are connected at top
of trigone by the inter-ureteric ridge.
Ureteric openings are slit like, ureters enter UB
oblique.
Internal urethral sphincter;
–
–
Male, circular muscle fibers at the internal urethral
opening
Female, longitudinal muscle fibers NO internal
sphincter. Why??????
Posterior relation of bladder in
Male
• Seminal vesciles
• Ductus deferens & ampulla
• Ejaculatory ducts
– Embedded in the prostatic tissue
– These are the junction and union of the
ampulla of the ductus deferens on one
side and the tube of the seminal
vesicles on the other side
• Prostate
– Sits underneath bladder
Nerve supply of the Urinary Bladder
Parasympathetic
•
S 2-4  pelvic splanchnic nerves.
•
These enter the inferior hypogastric plexus and
pass through it to the bladder wall.
•
Motor to the detrusor,
•
Inhibitory to the internal sphincter.
Sympathetic
•
T 11-12 & L1-2 segments of the spinal cord 
superior hypogastric plexus.
•
Constriction in the internal sphincter
•
Inhibit the detrusor muscle.
Sensation
•
Distension and pain.
•
Via both the sympathetic and parasympathetic
nerves.
Control of Micturition
• Parasympathetic  Pee
• Sympathetic  STOP no
pee
Female Urethra
Female Urethra
– ~2 inches (4cm)
– Embedded in ant. Wall of
vagina.
– Opens in the vestibule
between the clitoris ant. and
the vaginal opening post.
– In urogenital diaphragm the
External urethral sphincter,
supplied by pudendal nerve.
Male Urethra
Male Urethra
• ~ 8 inches (20 cm)
• Parts:
?? Pre-prostatic part is the part at neck of
bladder ~ 1cm.
Prostatic; Crosses through the prostate gland.
– Openings:
•
•
•
(1) the ejaculatory ducts,
(2) Prostatic ducts,
(3) Prostatic utricle.
Membranous, 1- 2 cm, passing through
the external urethral sphincter.
– Narrowest part of the urethra.
– Located in the deep perineal pouch.
Male Urethra
• Spongy (penile),
•
•
•
•
•
•
•
Runs on ventral surface of the penis through
the corpus spongiosum.
About 15 cm in length
The ducts from the urethral gland (gland of
Littre) open here.
Bulbourethral glands (Cowper's gland)
located in the urogenital diaphragm & open
in the spongy urethra.
May be subdivided into two parts, the
bulbous and pendulous urethra.
The urethral lumen runs parallel to the penis
External Urethral meatus is a narrow
vertical slit-like opening  a spiral stream of
urine.
Congenital Anomalies
Hypospadius
• External urethral opening is
abnormally located on the
underside (ventral) of the penis,
even in the scrotum, or
sometimes perineum.
Epispadius
• Opening is located on the upper
side of penis.
Stricture/stenosis (narrowing) of
the external urethral meatus.
Congenital Anomalies
Phimosis
• Excessive narrowing of
the foreskin, where it
cannot be retracted
over glans penis.
• Can lead to back
pressure on bladder.
• Surgically corrected.