THE KIDNEYS, URETERS, URINARY BLADDER AND URETHRA

The kidneys
The kidneys are a pair of bean-shaped organs

approximately 12 cm long, the right kidney is 0.5 in (12 mm) lower than the left because of the mass of the liver. They extend from vertebral level T12 to L3 when the body is in the erect position. The kidneys lie retroperitoneally on the posterior abdominal wall.

Relations
Posteriorlythe diaphragm (separating pleura), quadratus

lumborum, psoas, transversus abdominis, the 12th rib and three nervesthe subcostal (T12), iliohypogastric and ilioinguinal (L1). Anteriorlythe right kidney is related to the liver, the 2nd part of the duodenum and the ascending colon. In front of the left kidney lie the stomach, the pancreas and its vessels, the spleen, and the descending colon. Superiorly-The suprarenals sit on each side as a cap on the kidneys upper pole. The medial aspect of the kidney presents a deep vertical slit, the hilum, which transmits, from before backwards, the renal vein, renal artery, pelvis of the ureter and, usually, a subsidiary branch of the renal artery.

RELATIONS

Internal Structure
The kidney substance is divided into an outer cortex and an

inner medulla. Cortexcontains glomeruli, Bowman's capsules, and proximal and distal convoluted tubules. It forms renal columns, which extend between medullary pyramids. Medullaconsists of 10 to I8 striated pyramids and contains collecting ducts and loops of Henle. The apex of each pyramid ends as a papilla where collecting ducts open. Calycesthe minor calyces receive one or more papillae and unite to form major calyces, of which there are two to three per kidney. Renal pelvisthe dilated upper portion of the ureter that receives the major calyces.

RENAL FASCIA
The kidneys lie in an abundant fatty cushion (perinephric fat)

contained in the renal fascia Above, the renal fascia blends with the fascia over the diaphragm, leaving a separate compartment for the suprarenal Medially, the fascia blends with the sheaths of the aorta and inferior vena cava. Laterally it is continuous with the transversalis fascia. Inferiorly it remain relatively open tracking around the ureter into the pelvis. The kidney has, in fact, three capsules: 1.fascial (renal fascia); 2.fatty (perinephric fat); 3.truethe fibrous capsule which strips readily from the normal kidney surface but adheres firmly to an organ that has been inflamed.

 The renal artery are derived directly from the aorta.

Blood supply

The right renal artery passes behind the inferior vena cava.
The left renal vein passes in front of the aorta immediately below

the origin of the superior mesenteric artery, It receives the left gonadal vein, the left suprarenal vein, and the left inferior phrenic vein, and may receive a root of the hemiazygos vein before crossing anterior to the aorta to join the inferior vena cava.

 Lymphatic Drainage
The kidneys drain to the lumbar nodes. Innervation

Primarily sympathetic with postganglionic cell bodies

located in the renal plexus. Preganglionic sympathetic fibers are from splanchnic nerves. Pain afferents from the renal pelvis travel in splanchnic nerves.

APPLIED ANATOMY
1. Blood from a ruptured kidney or pus in a perinephric

abscess first distend the renal fascia, then force their way within the fascial compartment downwards into the pelvis. The midline attachment of the renal fascia prevents extravasation to the opposite side. 2. In hypermobility of the kidney (floating kidney), this organ can be moved up and down in its fascial compartment but not from side to side.

RENAL COLIC

The renal pelvis and the ureter send their afferent nerves into

the spinal cord at segments T11 and 12 and L1 and 2. In renal colic, strong peristaltic waves of contraction pass down the ureter in an attempt to pass the stone onward. The spasm causes an agonizing colicky pain, which is referred to the skin areas that are supplied by these segments of the spinal cord, namely, the flank, loin, and groin. When a stone enters the low part of the ureter, the pain is felt at a lower level and is often referred to the testis or the tip of the penis in the male and the labium majus in the female. Sometimes ureteral pain is referred along the femoral branch of the genitofemoral nerve (L1 and 2) so that pain is experienced in the front of the thigh.

TRANSPLANTED KIDNEYS
The iliac fossa on the posterior abdominal wall is used.

The iliac fossa in front of the iliacus muscle is approached retroperitoneally. The kidney is positioned and the vascular anastomosis constructed. The renal artery is anastomosed end to end to the internal iliac artery and the renal vein is anastomosed end to side to the external iliac vein. Ureterocystostomy is then performed by opening the bladder and providing a wide entrance of the ureter through the bladder wall

The ureter
The ureter is 10 in (25 cm) long and comprises the pelvis of the ureter

and its abdominal, pelvic and intravesical portions. The abdominal ureter lies on the medial edge of psoas major and then crosses into the pelvis at the bifurcation of the common iliac artery in front of the sacroiliac joint. Anteriorly, the right ureter is covered at its origin by the second part of the duodenum and then lies lateral to the inferior vena cava and behind the posterior peritoneum. It is crossed by the testicular (or ovarian), right colic, and ileocolic vessels. The left ureter is crossed by the testicular (or ovarian) and left colic vessels and then passes above the pelvic brim, behind the mesosigmoid and sigmoid colon to cross the common iliac artery immediately above its bifurcation.

 The pelvic ureter runs on the lateral wall of the pelvis in front of

the internal iliac artery to just in front of the ischial spine; it then turns forwards and medially to enter the bladder. In the male it lies above the seminal vesicle near its termination and is crossed superficially by the vas deferens. In the female, the ureter passes above the lateral fornix of the vagina 0.5 in (12 mm) lateral to the supravaginal portion of the cervix and lies below the broad ligament and uterine vessels The intravesical ureter passes obliquely through the wall of the bladder for 0.75 in (2 cm); the vesical muscle and obliquity of this course produce respectively a sphincteric and valve-like arrangement at the termination of this duct.

BLOOD SUPPLY
The ureter receives a rich segmental blood supply from

all available arteries along its course: the aorta, and the renal, testicular (or ovarian), internal iliac and inferior vesical arteries.

APPLIED ANATOMY
1. The ureter is readily identified in life by its thick

muscular wall which is seen to undergo worm-like (vermicular) writhing movements, particularly if gently stroked or squeezed. Ureteric Stones There are three sites of anatomic narrowing of the ureter where stones may be arrested, namely, the pelviureteral junction, the pelvic brim, and where the ureter enters the bladder.

CONGENITAL ANOMALIES OF THE KIDNEYS

Polycystic Kidney A hereditary disease, polycystic kidney

can be transmitted by either parent. It may by associated with congenital cysts of the liver, pancreas, and lung. Pelvic Kidney the kidney is arrested in some part of its normal ascent; it usually is found at the brim of the pelvis Such a kidney may present with no signs or symptoms and may function normally Horseshoe Kidney When the caudal ends of both kidneys fuse as they develop, the result is horseshoe kidney. The interconnecting bridge becomes trapped behind the inferior mesenteric artery so that the kidneys come to rest in the low lumbar region.

CONGENITAL ANOMALIES OF THE KIDNEYS

CONGENITAL ANOMALIES OF THE KIDNEYS

Unilateral Double Kidney The kidney on one side may be

double, with separate ureters and blood vessels. Supernumerary renal arteries are relatively common. They represent persistent foetal renal arteries, which grow in lower groups of calyces. The cause is a premature division of the ureteric bud near its termination. Congenital polycystic kidneys (which are nearly always bilateral) are believed to result from failure of metanephric tissue to link up with some of the metanephric duct collecting tubules; blind ducts therefore form which subsequently become distended with fluid.

CONGENITAL ANOMALIES OF THE KIDNEYS

The mesonephric duct may give off a double

metanephric bud so that two ureters may develop on one or both sides. These ureters may fuse into a single duct anywhere along their course or open separately into the bladder (where the upper ureter enters below the lower ureter).

The bladder

RELATIONS
Anteriorlythe pubic symphysis. Superiorly the bladder is covered by peritoneum with coils

of small intestine and sigmoid colon lying against it. In the female, the body of the uterus flops against its posterosuperior aspect. Posteriorlyin the male the rectum, the termination of the vasa deferentia and the seminal vesicles; in the female, the vagina and the supravaginal part of the cervix. Laterallythe levator ani and obturator internus. The neck of the bladder fuses with the prostate in the male; in the female it lies directly on the pelvic fascia surrounding the short urethra.

Blood supply and Lymph drainage

Blood is supplied from the superior and inferior vesical

branches of the internal iliac artery. The vesical veins form a plexus which drains into the internal iliac vein. Lymphatics drain alongside the vesical blood vessels to the iliac and then para-aortic nodes.

Nerve supply
Efferent parasympathetic fibres from S2 to S4 accompany the

vesical arteries to the bladder. They convey motor fibres to the muscles of the bladder wall and inhibitory fibres to its internal sphincter. Sympathetic efferent fibres are said to be inhibitory to the bladder muscles and motor to its sphincter, although they may be mainly vasomotor in function, so that normal filling and emptying of the bladder are probably controlled exclusively by its parasympathetic innervation. The external sphincter is made up of striated muscle. It is also concerned in the control of micturition and is supplied by the pudendal nerve (S2, 3, 4). Sensory fibres from the bladder, which are stimulated by distension, are conveyed in both the sympathetic and parasympathetic nerves, the latter pathway being the more important.

THE URETHRA
The male urethra The male urethra is 8 in (20 cm) long and is

divided into the prostatic, membranous and spongy parts. The prostatic urethra (1.25 in (3 cm) traverses the prostate. Its posterior wall bears a longitudinal elevation termed the urethral crest, on each side of which is a shallow depression, the prostatic sinus, into which the 1520 prostatic ducts empty. At about the middle of the crest is a prominence termed the colliculus seminalis (verumontanum) into which opens the prostatic utricle.

PROSTATIC URETHRA CONTD

Prostatic utricle is a blind tract,

about 5mm long, running downwards from the substance of the median lobe of the prostate. It is believed to represent the male equivalent of the vagina, a remnant of the paramesonephric duct. On either side of the orifice of the prostatic utricle open the ejaculatory ducts.

 The membranous urethra (0.75 in (2 cm)) pierces the

external sphincter urethrae (the voluntary sphincter of the bladder) and the fascial perineal membrane which covers the superficial aspect of the sphincter. The spongy urethra (6 in (15 cm)) traverses the corpus spongiosum of the penis. It first passes upwards and forwards to lie below the pubic symphysis and then in its flaccid state bends downwards and forwards.

THE FEMALE 1.5 in (4 cm) long; it traverses the URETHRA The female urethra is
sphincter urethrae and lies immediately in front of, indeed embedded in the wall of, the vagina. Its external meatus opens 1 in (2.5 cm) behind the clitoris. The sphincter urethrae in the female is a tenuous structure and vesical control appears to depend mainly on the intrinsic sphincter of condensed circular muscle fibres of the bladder.

APPLIED ANATOMYthe pubis is a common site 1. Where the urethra passes beneath
for it to be ruptured by a fall astride a sharp object, which crushes it against the edge of the symphysis. 2. The external orifice is the narrowest part of the urethra and a calculus may lodge there. Immediately within the meatus, the urethra dilates into a terminal fossa whose roof bears a mucosal fold (the lacuna magna) which may catch the tip of a catheter. Instruments should always be introduced into the urethra beak downwards for this reason.

 Urethral Infections The short length of the female urethra

predisposes to ascending infection; consequently, cystitis is more common in females than in males. Catheterization Because the female urethra is shorter, wider, and more dilatable, catheterization is much easier than in males. Moreover, the urethra is straight, and only minor resistance is felt as the catheter passes through the urethral sphincter.

 The following anatomic facts should be remembered before

Catheterization

passing a catheter or other instrument along the male urethra: The external orifice at the glans penis is the narrowest part of the entire urethra. Within the glans, the urethra dilates to form the fossa terminalis (navicular fossa). Near the posterior end of the fossa, a fold of mucous membrane projects into the lumen from the roof The membranous part of the urethra is narrow and fixed. The prostatic part of the urethra is the widest and most dilatable part of the urethra. By holding the penis upward, the S-shaped curve to the urethra is converted into a J-shaped curve.

Anatomy of the Procedure ofThe patient lies in a supine position. Catheterization 1.

2. With gentle traction, the penis is held erect at right angles

to the anterior abdominal wall. The lubricated catheter is passed through the narrow external urethral meatus. The catheter should pass easily along the penile urethra. On reaching the membranous part of the urethra, a slight resistance is felt because of the tone of the urethral sphincter and the surrounding rigid perineal membrane. 3. The penis is then lowered toward the thighs, and the catheter is gently pushed through the sphincter. 4. Passage of the catheter through the prostatic urethra and bladder neck should not present any difficulty.