Anatomy Flashcards
Superficial Inguinal lymph node dissection superior limit: lateral limit: medial limit: inferior limit:
-superior limit: external oblique fascia at level of spermatic cord -lateral limit: a sagittal plane through the anterior superior iliac spine (ASIS) -medial limit: sagittal plane through the ipsilateral pubic tubercle -inferior limit: transverse plane 20 cm inferior to the ASIS
Deep Inguinal Lymph Node Dissection
Nodes removed from the femoral triangle - DO NOT go lateral to the femeral artery (avoids injury to femoral nerve and profunda femoris artery) - NAVEL
Femoral Triangle
superior boundary -
medial boundary -
lateral boundary -
anterior surface -
Arrangement of structures in femoral triagle
Lateral boundary - sartorius
Superior boundary - inguinal ligament
Medial boundary - Adductor Longus
Anterior surface - fascia lata (superficial to facia lata are superficial inguinal lymph nodes)
NAVEL (from lateral to medial)
The node of Cloquet
the most cephalad node in the deep inguinal ring
When should you do a pelvic lymph node dissection in patients with penile cancer?
only if ipsilalteral inguinal nodes have cancer (>2 nodes).
penis lymphatics do not drain directly to the pelvic nodes. Inguinal lymph node mets must be present before cancer can reach the pelvid nodes. Also, does not spread to contraleteral pelvic nodes from ILN
name the anatomy
name the anatomy
name the anatomy
name the anatomy
What is the obturator reflex?
stimulation of the obturator nerve that causes sudden leg adduction
this can happen when you are resecting tumors of the lateral bladder wall
can prevent this by using neuromuscular blockade during surgery
progression fo cancer spread from penis through nodes
penis –> sentinel node –> superficial inguinal nodes –> deep inguinal nodes –> pelvic nodes –> distant metastasis
Metastasis from Testis Tumors:
Right testis –> ?
Left Testis –> ?
How to lymphatic metastases spread?
Right testis –> tumor spreads to the interaortocaval retroperitoneal nodes
Left testis –> tumor spreads to the left para-aortic retroperitoneal nodes
Lymphatic metastases can spread from RIGHT –> LEFT but they do NOT usually spread from LEFT –> RIGHT
When will testis tumor mets go to the inguinal nodes?
When would it go to the pelvic nodes?
May also get to INGUINAL NODES if tumor invades through tunica vaginalis or scrotum
PELVIC NODES if tumor invades into the epididymus or spermatic cord
Radical Pelvic Lymph Node dissection - Full Bilateral template
superior, lateral and inferior limit
Superior limit –> renal vessels
Lateral Limit –> ureters bilaterally
Inferior limit –> where ureters cross the common iliac arteries
What causes impaired ejaculation after RPLND?
Injury to post-ganglionic sympathetic nerves (T2-T4) and to the hypogastric plexus (sympathetic nerve plexus) near the origin of the IMA
-Can use modified RPLND template or nerve sparing surgery to avoid this if this is clinically possible
Superficial to deep, layers of the penis
1) Skin
2) Superficial (DARTOS) fascia
3. Areolar tissue
4. Deep (BUCKS) fascia
5. Tunica albuginea
6. Corpus cavernosum
Superficial to deep, layers of the scrotum
- Skin
- Dartos fascia and muscle
- External spermatic fascia
- Cremasteric fascia
- Internal spermatic fascia
- Tunica vaginalis
- Tunica albuginea
Layers of scrotum/spermatic cord derived from what abdominal wall layers?
Internal spermatic fascia –> transversalis fascia
Cremasteric fascia –> interal oblique muscle
External spermatic fascia –> external oblique muslce
what is unique about the cremasteric muscle
striated and innervated by the genital brance of the genitofemoral nerve to elevate the testis
what is the gubernaculum, what does it do? What does it become later in development?
paired organ, embryonic strucure that attaches to the caudal end of the gonads (Testis/ovaries) and assists in their descent
Testes eventually pulled through inguinal canal
In males it becomes a scrotal ligament (secures testis to inferior scrotum)
In females it becomes with ovarian ligament and the round ligament
Bell Clapper Deformity
Failure of the normal posterior anchoring of the gubernaculum, epididymus and testis.
Leaves testis free to swing and rotate within the tunica vaginalis of the scrutum like the gong (clapper) insude of a BELL
Layers of the testis
- Tunica vaginalis (parietal layer, cavity, visceral layer)
- Capsule (tunica albuginea)
- Seminiferous tubule
pathway of sperm from seminiferous tubule
seminiferous tubule –> straight tubule –> rete testis –> efferrent ductules –> head of epididymus –> body –> tail of epididymus –> vas deferens
Layers of the abdominal wall (1-8)
- skin
- subcutaneous tissue (fat)
- external oblique
- Internal oblique
- Fascia of both superficial and deep surfaces of the internal oblique muscle
- Transversus abdominis
- Transversalis fascia
- Peritoneum
What is Buck’s fascia? What does it cover? Where does it anchor?
aka deep fascia of the penis (immedietly superficial to the tunica albuginea)
covers:
- three erectile bodies of the penis (corpus spongiousum and two corpora cavernosa).
- On dorsal aspect , branches of the dorsal nerve, deep dorsal vein and paired dorsal arteries are contained in Buck’s.
- encloses ischiocavernosus, bulbospongiousus muscles
- Contains each crus of the corpora cavernosa and bulb of corpus spongiousum
- Adheres all these structures to the PUBIS, ISCHIUM, and UROGENITAL DIAPHRAGM
continuous with the EXTERNAL SPERMATIC FASCIA
splits to envelop corpus spongiosum
What is the verumontanum?
aka seminal colliculus
part of prostatic urethra where ejaculatory ducts (seminal vesicle + vas deferens) enter
important anatomic landmark - a distinct median elevation of urothelium
pathophys of calcium oxalate stone
form at calcium phosphate nidus concretion at renal papilla –> this erodes through urothelium in the renal papilla and forms a nidus for the calcium oxalate deposition when it is exposed to urine
what makes calcium oxalate stones worse?
- dehydration
- hypercalciuria
- hperoxaluria (e.g. crohn’s)
- hypernatrituria
- hypocitraturia
- hyperuricosuria
Causes of uric acid stones
- ACIDIC URINE
- Hyperuricosuria (gout)
- Insulin resistance, DM, Lesch-Nyhan syndrome
- Chemotherapy (lymphoma/leukemia)
Causes of struvite stones
- urease producing organisms (proteus, klebsiella, enterobacter, pseudomonas) –> ALKALINE URINE
Causes of calcium phosphate stones?
- underlying metabolic disorder (RTA, primary hyper PTH, medullary sponge kidney)
- ALKALINE URINE
Causes of cystine stones
AR problem with cystine transport
more soluble in very high pH (9.6), but can’t alkalinize it that high for tx.
Urethral anatomy
Penile blood flow
Distribution of penile blood supply
Blood supply in pelvis
label this
Arterial blood supply to the bladder
Bladder is supplied by the SUPERIOR and INFERIOR VESICAL arteries (branches of the ANTERIOR trunk of the INTERNAL ILIAC artery)
Venous supply to bladder and lymph drainage
bladder is drained from a plexus on the infero-lateral surface of the bladder –> end in INTERNAL ILIAC VEIN
Lymph –> EXTERNAL ILIAC NODES
Label me
Layers of the bladder
Layers of the bladder (deep to superficial)
- Mucosa (transitional epithelium + lamina propria)
- Submucosa
- Detrusor Muscle
- Adventitia and Perivesicular fat
Renal blood supply
Renal images
