Dunnick, 5th: Anatomy and Procedures Flashcards
The kidney is divided into an outer cortex and an inner medulla by the ____ at the base of each pyramid
Arcuate artery
Columns of cortical tissue sometimes descend between the medullary pyramids and are often referred to as a ____
Column of Bertin
Or septal cortex
Large column of Berthin is most common at the junction ofthe superior and middle thirds of the kidney.
The following make up the intrarenal collecting system, except:
a. Calyces
b. Infundibulum
c. Pelvis
d. Proximal ureter
e. All of the above are part of the intrarenal collecting system
d. Proximal ureter
It is the space around the collecting system and contains a variable amount of fat, along with branches of the renal artery, vein, and lymphatics
Renal sinus
The following structures are located within the anterior pararenal space, except:
a. Tail of the pancreas
b. D2-D4 of the duodenum
c. Ascending and descending colon
d. Hepatic and splenic arteries
a. Tail of the pancreas
The calyx is the cup-shaped portion of the intrarenal collecting system and the rim of the cup is the ____
Fornix
The long axes of the kidneys are deviated approximately ____ degrees from the spine, with the top of the kidneys closer to the spine
20
The perirenal space is defined by what fascia?
Gerota’s fascia
The following are part of the extraperitoneal space, except:
a. Space of Retzius
b. Rectovesical space
c. Presacral space
d. Perirectal space
e. All of the above are extraperitoneal spaces
b. Rectovesical space
Rectovesical space is intraperitoneal
RETROVESICAL SPACE is extraperitoneal
Which of the following statements are false:
a. The right adrenal lies above and anteromedial to the upper pole of the right kidney and best seen on axial immediately posterior to the inferior vena cava (IVC) just below the liver
b. The left adrenal is also above and anteromedial to the upper pole of the ipsilateral kidney and lies posterior to the pancreas
c. The right adrenal typically has an inverted Y appearance, whereas the left tends to resemble a three- pointed star
d. In patients with renal agenesis or ectopy, the ipsilateral adrenal gland has a linear shape
b. The left adrenal is also above and anteromedial to the upper pole of the ipsilateral kidney and lies posterior to the pancreas
The left adrenal is also anteromedial to the ipsilateral kidney but usually seen AT THE SAME LEVEL AS THE UPPER RENAL POLE and lies posterior to the pancreas
Adrenal gland
a. Normal weight
b. Normal width
a. 5g
b. 3-6 mm up to 1 cm
Arterial supply of the adrenal gland comes from what arteries?
a. Superior portion: Superior adrenal artery from inferior phrenic artery
b. Middle portion: Middle adrenal artery from aorta
c. Inferior portion: Inferior adrenal artery from renal artery
Which of the following is false regarding the drainage of the adrenal glands:
a. Each adrenal is drained by a single central vein (adrenal vein)
b. The right adrenal vein directly enters into the anterior aspect of IVC
c. Ocassionally, the right adrenal vein may join an accessory hepatic vein before entering the IVC
d. The left adrenal vein enters the inferior phrenic vein before joining the left renal vein
e. The right adrenal vein is shorter and has smaller caliber than the left
b. The right adrenal vein directly enters into the anterior aspect of the IVC
POSTERIOR aspect of the IVC
Narrowest portion of the ureter
Ureterovesical junction
The ureters enter the bladder obliquely and course submucosally for about ____ before terminating at the lateral margin of the trigone as ureteral orifice
2 cm
The predominant vessel supplying the distal ureter is ____
Inferior vesical artery
Proximal ureter: Renal artery
Mid ureter: Aorta, lumbar, gonadal and iliac arteries
Muscle of the urinary bladder
Detrusor muscle
Between the ureteric orifices is a muscular ridge, known as the ____, which forms the base of the trigone
Interureteric ridge
Venous drainage of urinary bladder
Primarily drains into hypogastric (internal iliac) veins
Auxiliary veins connect the vesical venous plexus to the hemorrhoidal veins that drain into the intervertebral venous plexus. This is the route of vesical venous drainage when the IVC is blocked.
Lymphatic drainage of the urinary bladder
External and iliac lymph nodes
Normal length of the prostatic urethra
3.5 cm
The prostatic urethra is approximately 3.5 em in length, passes through the prostate gland, and ends at the superior aspect of the urogenital diaphragm
A longitudinal ridge of smooth muscle extends from the bladder neck to the membranous urethra on the posterior wall of the posterior urethra. This longitudinal smooth muscle bundle swells just proximal to the membranous urethra to form a 1-cm-long ovoid mound on the urethral floor called ____
Verumontanum (colliculus)
A small depres- sion in the verumontanum is known as the UTRICLE
This the portion of the urethra which marks the change in epithelial lining from transitional epithelium to stratified columnar epithelium
Membranous urethra
Prostatic urethra: Transitional cells
Rest of the urethra: Stratified columnar cells
External meatus: Stratified squamous cells
This is the narrowest part of the urethra
Membranous urethra
SHORTEST AND NARROWEST SEGMENT
1 cm in length, passing through the urogenital diaphragm
Proximal landmark: Distal end of the verumontanum
Distal landmark: Tip of the cone of the bulbous urethra
What urethra will you find the following structures:
a. Opening of the prostatic and ejaculatory ducts
b. Cowper’s glands
c. Opening of the Cowper’s glands
d. Glands of Littre
a. Prostatic urethra
b. Membranous urethra
c. Bulbous urethra
d. Anterior urethra (Bulbous and penile urethra)
This is the widest and most inferior portion of the urethra
Bulbous urethra
The bulbous urethra begins at the inferior aspect of the urogenital diaphragm and extends to the angulated penoscrotal junction
Landmark that which divides the anterior urethra into bulbar and penile urethra
Penoscrotal junction
The distal 2 cm of the penile urethra is slightly dilated and known as the ____
Fossa navicularis
These glands secrete mucus during sexual stimulation
Glands of Littre and Cowper’s glands
A small, striated musculotendinous sling of the bulbocav- emous muscle extends from the anterior and lateral surfaces of the proximal bulbous urethra. This structure is known as the ____ and may circumferentially indent muscle contracts proximal bulbous urethra on dynamic retrograde urethrography.
Musculus compressor nuda
This finding, sometimes called “Cobb’s collar: should not be mis· taken for a true stricture.
Name the finding and specific structure this represents
Cobb’s collar
Musculus compressor nuda
It lies around the bladder neck and is the primary muscle of passive urinary continence
Internal sphincter
PASSIVE URINARY CONTINENCE
Bladder neck: INTERNAL sphincter
Below the verumontanum in the distal one third of the proximal urethra and surrounding membranous urethra: INTRINSIC spincter
ACTIVE URINARY CONTINENCE
Membranous urethra: EXTERNAL sphincter
Length of the female urethra
4 cm
Normal dimensions and weight of testis
4-5 x 3 x 2.5 (L x W x B)
10-14 g
Contents:
1. 250-400 LOBULES containing convoluted TUBULES > Spermatozoa + Sertoli cells
It is a tiny oval sessile body, lies at the upper e:nd of the testis adjacent to the head o f the epididymis
Appendix testis
(Hydatid of Morgagni)
A vestigial remnant of the mollerian duct
Name the pointed structure
Mediastinum testis
Tail of the epididymis is connected to what structure
Vas deferens
Total length: 35 to 45 cm
In the pelvis, the vas deferens follows the lateral pelvic wall, curving first superoposteriorly and then inferomedially. It crosses superficial to the external iliac vessels and the ureter.
As the vas deferens crosses the ureter, it becomes convoluted and dilated, increasing in diameter from 2 to 3 mm up to 1 cm, forming the ampulla of the vas deferens.
Name the pointed structure
Rete testis
The channels of the rete testes progress to the proximal end o f the mediastinum, where they again coalesce into a number of ducts that perforate the tunica albuginea and enter the head o of the epididymis, which is closely applied to the upper testis.
The more slender body of the epididymis runs along the posterolateral aspect of the testis, and the tail is continuous with the vas deferens. In essence, the epididymis is a long and very convoluted tubule.
The distal ampulla and excretory duct of the seminal vesicle on each side join to form an ____
Ejaculatory duct
Normal length and diameter of seminal vesicles
Length: 5 cm
Diameter: 2 cm
The posterior surface of the seminal vesicle lies on ____, which separates it from the rectum
Denonvilliers fascia
The prostate is also separated from the rectum by Denonvilliers fascia.
Normal weight of prostate gland
up to 20g
The glands in this zone can undergo hypertrophy and form fibro- adenomata, resulting in typical benign enlargement of the prostate, or BPH
Transitional zone
The transitional zone represents only 5% of prostatic volume and is found around the midprostatic urethra.
Identify the structures labeled 1 through 5
Identify the structures labeled 1-4
Identify
This zone occupies the superior and central portion of the gland, and is also subject to hypertrophy
Central zone
It comprises the bulk ofthe prostate gland and is the site where most carcinomas and infections occur
Peripheral zone
The peripheral zone occupies al- most the entire posterolateral portion of the prostate and the prostatic apex. cupping the central prostate like a baseball glove around a baseball. The prostate is covered by a :fibrous capsule.
Fascia of the penis from outside in
Dartos fascia > Buck fascia > Tunica albuginea
Upper normal limit of mean ovarian volume in:
a. Premenopausal women
b. Postmenopausal women
a. Up to 20 cc
b. Up to 10 cc
Arterial supply of the ovaries:
Venous drainage of the ovaries:
a. Arterial supply: Ovarian artery, adnexal branch of the uterine artery
b. Venous drainage: Ovarian vein
(L): Ovarian vein > Renal vein
(R) Ovarian vein > IVC
Normal length of the fallopian tube
10 cm
Identify the pointed structures
Arrow: Isthmus
Arrowhead: Ampulla
What imaging modality best depicts the uterus?
MRI (T2W sequence)
Width of the endometrium:
a. Premenopausal, proliferative phase
b. Premenopausal, secretory phase
c. Postmenopausal
a. 4-8 mm
b. 8-16 mm (double)
c. 4 mm
What phase of the menstrual cycle will you see the trilaminar appearance?
Proliferative phase
(Late)
Hyperechoic (uterine cavity) - Hypoechoic (inner functional layer) - Hyperechoic (outer basal layer)
Identify the pointed structure
Junctional zone of inner myometrium
What phase of the menstrual cycle?
Secretory phase
It consists o f a series of uriniferous tubules, each of which is associated with a group of blood vessels to form primitive glomeruli.
Mesonephros
Stages of kidney development:
1. PRONEPHROS (3rd week AOG): tubules > excretory duct > cloaca // pronephros involutes
2. MESONEPHROS: Uriniferous tubules + vessels = primitive glomeruli > mesonephric duct/wolffian duct > excretory duct > cloaca // mesonephric duct involutes but remnants persist
3. METANEPHROS (5th week AOG): Ureteral bud, metanephric blastema
Ureteral bud influences metanephric blastema > nephrons
Ureteral bud > Collecting system
https://www.youtube.com/watch?v=-qLog_tbMlU
https://www.youtube.com/watch?v=YELuuFhVF9U
The uriniferous tubules develop from a pair of laterally placed mesodermal structure known as the ____
Nephrogenic cord
This refers to the diverticulum in the mesonephric duct which eventually becomes the renal urinary collecting system
Ureteral bud
It serves as the precursor of the vas deferens, the seminal vesicles, and the ejajculatory ducts in males
Mesonephric duct
Identify the pointed structure
Compression device
A prominent bulge on the lateral border of the left kidney represents a normal variation because of molding by the adjacent spleen and has been called a ____
Dromedary hump
In older patients, the calyces and renal pelvis may be compressed by the accumulation of fat in the renal sinus. This condition, termed ____
Renal sinus lipomatosis
Complications of retrograde pyelography
a. The pyelocalyceal system may be overdistended, so that contrast escapes from small ruptures in the fornices into the renal sinus; this is known as ____
b.. If the contrast then opacifies the renal vein or lymphatics, it is known as ____
c. Contrast injected under high pressure into the collecting system may also flow retrograde into the renal tubular lumina, and this is known as ____
a. Pyelosinus backflow
b. Pyelovenous or pyelolymphatic backflow
c. Pyelotubular backflow
Identify the study
Ileal conduit study or LOOPOGRAM
To perform a loopogram, an appropriate Foley catheter (generally between a 20- and 26-French) is inserted into the stoma and the balloon is inflated to a volume of 5 to 8 mL within the stoma. Contrast material is then instilled through the Foley catheter by gravity infusion (preferred) or hand injection.
What study can demonstrate the following structures:
a. Anterior urethra
b. Posterior urethra
a. Retrograde urethrography
b. Voiding urethrography
Retrograde urethrography demonstrates the anterior urethra. Even if contrast is injected under sufficient pressure to traverse the posterior urethra the posterior portion will not distended because the sphincters are contracted. To demonstrate the porterior urethra, voiding urethrography should be performed.
To perform retrograde urethrography, the distal urethra should be occluded by a small Foley catheter. A 12- or 14-French Foley is inserted into the urethra until the deflated balloon just disappears inside the meatus; the balloon is inflated with 1 to 2 mL of saline so that it distends in the fossa navicularis (Fig. 3.7). Inflation should be performed slowly and carefully and terminated as soon as mild traction on the catheter does not remove it from the urethra. The catheter should be flushed to remove air bubbles before insertion into the meatus.
In females, retrograde urethrography is performed using this special catheter
Double-bubble catheter
Transvaginal probes usually operate within the ____ range
5- to 7.5-MHz
In scrotal ultrasonography, a high-frequency (____), short-focused transducer should be used.
7.5- to 12-MHz
What are the phases of a typical renal protocol?
a. Precontrast
b. Corticomedullary phase (15 to 30 seconds after injection)
c. Generalized nephrographic phase (60 to 90 seconds after injection)
d. Excretory phase (180 to 300 seconds after injection)
Two phases are typically omitted in assessment of renal masses for radiation dose reduction in some institutions:
1. Corticomedullary phase
2. Excretory phase
Phases of CT urography
a. Precontrast: low mA, 5- to 10-mm increments
b. General nephrographic phase (renal parenchyma): 90 to 120 seconds after contrast injection
c. Excretory phase: 8 to 12 minutes after contrast injection
These images will be reconstructed into three-dimensional (3D) maximum-intensity-projection (MIP) and/or volume-rendered images of the collecting system as well as into two-dimensional (2D) coronal images for the detection of urothelial abnormalities
To minimize radiation dose, a “split-bolus” technique may be used in which a second bolus is given ____ before excretory phase imaging in order to ‘“combine” nephrographic and excretory phases into one set of images.
90 seconds
Active oral and/or intravenous hydration to induce a sustained diuresis may help to fill the collecting system
Others have advocated the administration ofa short-acting diuretic (i.e., furosemide) for this purpose
Excretory MR urography is typically performed using a 3D gradient-echo sequence with fat suppression in the coronal plane (Fig. .3.19). Sequences are used for this purpose:
a. LAVA (liver acquisition with volume acceleration)
b. VIBB (volumetric interpolated breath-hold examination)
c. FAME (fast acquisition with multiphase EFGRE (enhanced fast gradient echo))
d. THRIVE (Tl-weighted high-resolution isotropic volume examination)
e. All of the above
e. AOTA
What zone of the prostate is affected?
Peripheral zone
Coils used for scrotal MRI
Circular surface coils
Scrotal MRI protocol
1. Axial T1W images
2. Axial, coronal and sagittal T2W images (SE or FSE)
3. 3 to 4 mm thick, small fields of view (14 to 16 cm)
4. If for testicular perfusion assessment, do it with contast and with fat saturation
Identify the pointed structure
Epididymis
Identify the pointed structure
Uterine veins
Contrast may enter uterine veins (Fig. 3.22) in patients who have uterine mural abnormalities (such as fibroids or adenomyosis), in patients with tubal occlusive disease in whom the endometrial contrast pressure is elevated, and even in normal patients.
Phase of contrast enhancement where the aortocaval attenuation difference is:
a. at least 30 HU
b. Between 10-30 HU
c. < 10 HU
a. Bolus phase
b. Non-equilibrium phase
c. Equilibrium phase
Give the timing of the three distinct phases of contrast enhancement of the kidneys that can be seen after a bolus of contrast medium has been administered by a mechanical injector:
a. Corticomedullary phase
b. Nephrographic phase
c. Excretory phase
a. 15 to 60 s
b. 80 to 120 s
c. > 120 s
The following are considered moderate idiosyncratic reaction, except:
a. Faintness
b. Generalized urticaria
c. Tachycardia
d. Facial edema
c. Tachycardia
Classificatons of idiosyncratic reactions:
1. Mild: minor effects, no treatment required
2. Moderate: transient and not life-threatening, treatment required
3. Severe: life-threatening, intensive therapy required
Large clinical trials have demonstrated significantly fewer ad.vuse reactions to the intravenous administration ofnonionic oon- trast media than coo:venti.onal ionic contrast media.
The only independent risk factors associated with a statistically important increased risk of reaction include the following, except:
a. History of prior contrast medium reaction
b. Asthma
c. Old age
d. History of allergy to food or drugs
c. Old age
In general, patients at greatest risk are in the older age groups and have significant pre-existing disease.
MUST KNOWS:
1. For severe reactions, the incidence appears to be slightly higher when larger doses ( > 20 g of iodine) are used.
2.
After intravenous injection of contrast medium, there is a rapid increase followed by a rapid decrease in plasma concentration of contrast. By how much of the decrease in contrast concentration due to excretion of the contrast by the kidneys represents the diagnostic opacification of the urinary tract during urography because it is during this period that glomerular filtration of the contrast medium is at its maximum? It is therefore within the first few moments after injection that the nephrogram, representing contrast within the renal tubules, is at its peak intensity.
12%
Although the majority (88%) of the rapid decline is due to equilibration of the contrast throughout the ECF.
The degree of opacification of the urinarytract is not a function of the concentration of the contrast medium in the urine alone, but it is the total amount of contrast (urinary contrast con- centration times the volume of urine produced) on which opacification depends. Thus, opacification depends on the total number ofiodine atoms in the path ofthe X-ray beam rather than on their concentration in the urine.
The following are included in the recommended protocol for treatment of contrast extravasation, except:
a. Elevation of affected extremity above the heart
b. Warm compress
c. Ice packs (15- to 60 min applications three times per day for 1-3 d)
d. Close observation for 2-4 h with release from department after physician evaluation of the patient if symptomatic
b. Warm compress
Acute renal dysfunction associated with contrast material is usually nonoliguric and in the typical case, the serum creatinine peaks in ____ days and returns to baseline values within ____ days
Peak: 3 to 5 days
Returns to baseline: 7 to 10 days
