Ahmed Abdellatif, MD, PhD. 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. They are very nicely situated and organized b/c of their value to the body Placed in a perovertebral gutter with lots of fat to help them stay there and protect them Hilum – where you have blood vessels coming into an organ Point anteriorly Each have a vein, artery, and a third vessel that carries urine from the renal pelvis into the ureter Kidney tissue = covered by fibrous capsules= shiny appearance Lobulation postmortem appears in some species, but not humans Shiny shit = true fibrous renal capsule On top of this, have an intense dense layer of fat that covers and protects the kidneys in place Outside of the whole arrangement = renal fascia (an outer fascia) The fat has been dissected in this image

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?? Black shit around the kidneys  renal fat (know, because looks like the outer fat around the muscles) = perinephric fat - Very impt to stabilize and keep the kidney in place Nephro - Ptosis = dropping Too thin, space, kidneys drop with floating kidney (loss of perinephric fat) More sensitive to trauma Renal a and vein can kink up, as well as the ureter * impt These are extremely sensitive to the amount of blood flow Regulators of blood flow and pressure – they work as sensors If kinked  hypertension Ureters can get kinked too Hypernephrosis (water/urine gets backed up) if stays like this too long s

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. Have cortex, medulla, and tubes that collect what is being produced and carry it away (calyx system) Circles – calyces (we have about 12 of these minor ones)  collect into about 3 major calyces  go into the renal pelvis (like one big funnel, bends about 90degs, and then continues into ureter) Stars = bend and ureter Ureter comes all the way down the posterior abdominal wall, goes into pelvic region  goes all the way down the ischeal spine, makes a 90 deg angle goes into a urinary pouch = urinary bladder If have a stone  colicky type pain as the stone pushes down Pt starts feeling peristaltic movement of the muscles of the ureter as it tries to push on the stone  Extremely painful Urologist  put catheter in There are normally 3 narrow points of ureter At pelvic uretary juncture (between the stars) As it crosses the pelvic brim As it enters the urinary bladder * Do not misdiagnose these as a disease state

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. 3 natural constricting points on the pathway of the ureter

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 ????? Can see birufcation of common iliac a. Ureter is posterior to sigmoid Not that significant on the left side, but on the right side have the appendix If the appendix goes from the tip of the cecum and goes towards the pelvis, ureter and appendix run side to side These two are commonly misdiagnosed (appendicitis or renal colic) EXTREMELY important relationship: compare relationship of the ureter to the uterine a in female and vas deferens in male  REMEMBER: water goes under the bridge (water is urine and bridge is the structure) Men doesn’t really matter “ they think they are superior” In women the path that it takes to reach the urinary bladder, and this is very close to a ligament that holds the cervix in place, close to the later pouch of vagina (lateral fornix) and super close to uterine a. Worry about hemorrhage

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 !!! Tampon or pad filling with water Fistula This is a common scenario after hysterectomy More dangerous  if urine bag is empty  ligated both ureters on both sides Urine backs up, fills renal pelvis, backs up on kidneys - Fix this super quick

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. 17:38 The aorta is more to the left, and the IVC more to the right Gives some dissimilarities between the right and the left Because of gravity, you the a to be behind the vein because it is high in pressure and you want the least amount of pressure to obstruct the vein As for locations in the renal hilum: Veins are the most anterior structure Arteries are in the middle renal pelvis is the most posterior structure 80 – 120 is pressure in renal a.is the same as the pressure in the aorta Almost 0 in IVC - With each pulse of the renal a you could obstruct the renal vein

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. As renal a approaches renal hilum splits into anterior and posterior division Posterior – supplies most of the posterior side of the kidney Anterior – supplies the top, bottom and middle part of the kidney End up with 5 subdivisions Four from anterior and one from posterior Impt bc in some cases need to take out a segment of the kidney Have to follow the blood vessels and follow that particular supply that you want to take back. When done removing the segment still have a functional piece left

Quiz Identify: Renal artery Renal pelvis Ureter Aorta Ureter comes out of the renal pelvis

Quiz 1.________ 2.________ 3.________ 4.________ 5.________ 6.________ 7.________ 8.________ 1. Celiac trunk 2.SMA 3.Renal vein 4.Renal a 5. Suprarenal vein 6.Ureter 7.Suprarenal 8.Kidney Things that come off anterior or posterior from the aorta are usually one single branch Celiac trunk SMA IMA Median sacral a (there is one more we will get to) Things that come off to the sides of the aorta = usually double branches (they each have a left and a right branch off the aorta to supply the left and right side of the body) Lumbar a Suprarenal a Middle suprarenal a Inferior phrenic a Listen to this slide The two Gonadal a comes off aorta (he made a mistake - said right comes off the aorta, and the left comes off the renal a…that is wrong) On the left side - Gonadal veins and suprarenal veins drain into the renal vein On the right side the suprarenal vein drains directly into the IVC The gonaldal veins on the right side drain directly into IVC as well On the right side therefore, only receives blood directly from the kidney

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 Most approaches to operate on the kidneys is on the posterior side Circle – pleural fluid in here can accumulate  pneumothorax Pleura can form a recess here Sometimes you have to remove and break the 12th rib to do the surgery and can cause this if one breaks the pleura doing this  sucks air in  lung shrinks on that side  SOB Can be fixed easily with a chest tube Nerve under T 11 = intercostal; Nerve under T 12 = subcostal under that is L 1  iliohypogastric and ileoingunal So pt could complain of numbmess in pevlic/ingunal area

Renal Transplantation Where do you put the transplanted kidney & why? Put a transplanted kidney in the pelvis, not original location because this doesn’t have the renal fat, fascia, etc… to replicate the normal anatomy structure You are just transplanting a kidney Put iliac fossa where it can rest Common iliac a and external iliac a, pick an a and v to hook up to it and the attach ureter to it

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 = pyramidal shaped organ in the pelvis Sits behind the pubis symphysis Sits in front of the rectum in the male The superior surface is covered with peritoneum All other surfaces are not As the bladder fills with urine, it peels off the peritoneum from the posterior surface of the anterior abdominal wall and starts to rise up As the bladder empties, it goes back down where it belongs From the apex of the bladder there is a fibrous piece of tissue that runs from the apex all the way to the umbilicus = Urachus Median umbilical ligament – remnant of the urachus Neck is where the urethera joins and leads to the outside

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). Urinary bladder = pyramidal shaped organ in the pelvis Sits behind the pubis symphysis Sits in front of uterus and upper part of the vagina in the female

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? Median umbilical ligament – fibrous remnant of the urachus Urachus  was the connection of the yolk sac on the outside and the bladder - Some of this may remain open  If fills too much can pee out the umbilicus

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. The side walls of the bladder are very close to the levator ani & obturator internus muscles on either side Retropubic space (retrovesical space) Contains fat and venous plexuses Venous plexuses are responsible for the following: Bladder fills with urine, compresses on the venous plexus, and if you slow down the venous return from the penis get false erection, typically happens in the morning

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?????? All of the inside of the bladder is rough with the exception of the trigone Trigone comes from a different embryological origin It is a triangle and can consider opening at teach edge of the triangle: At the tops Right and left ureter opening At the bottom In males, muscular fibers are circular in nature to form a real internal sphincter for the bladder In Females , muscular fibers are longitudinal in nature, no real functional internal sphincter needed The reason you need a real functional sphincter in males: In male, prostatic urethra has openings for the ejaculatory ducts Ejaculation needs to get out about 25 cm and not up and into urine (which is like a cm) If the sphincter is not closed can get retrograde ejaculation - Function is to prevent this, not really control urine

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. Parasympathetic PEE - Help you empty the bladder Sympathetics  STOP, no pee Makes the sphincter tight so you don’t pee when you don’t need to Detrusor muscle Makes the wall of the bladder Parasympathetic  stimulates this to help you pee Sympathetics  relax this to stop you from peeing

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 has advantage b/c longer ureter Pudendal nerve (S2-4) controls this in females through external uretheral sphincter - Keeps it tight to avoid any problems

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. Urethra is sectioned in males Preprostatic - above the prostate, small section Prostatic – along the prostate Membranous – in the urogenital diaphragm (refers to the peroneal membrane) penile urethra – significantly longer than the other sections, in penis in corpus spongiosum

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. If someone crushes the pelvis (car accident) screws with ureogenital diaphragm Depends on where cut in ureter happened and where the urine is collecting If it is superior to membraneous urethra (unlikely)  collects inside of the pelvic cavity Can collect wihtin the diaphragm between the superficial and deep peroneal membranes Cut more commonly happens below the membraneous where the urethra is coming out of the urogenital diaphragm collects in subcutaneous area and collects underneath the skin in the thighs Spans the peroneum, anterior sides of the thigh

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. If have hypospadius – can have scrotum split and the uretheral opening in the perineum  resembles labium majorum in a female Stricture – has to push harder for it to empty

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. Phy-a-mo-sis Not a congenital anomaly of the urethra persay, but of the repous (the piece of skin that covers the glans of the penis)  can lead to difficult micturition (need to pee all the time) Opening to the glands becomes very tight, sometimes requiring surgery