L3 - Anatomy of the kidneys, ureters, urinary bladder Flashcards
Retroperitoneal space location
Anatomical space in abdominal cavity located posterior to the parietal peritoneum
Structures in retroperitoneal space
S = Suprarenal glands
A = Aorta/IVC
D = Duodenum (second and third segments [some also include the fourth segment]
P = Pancreas (only head, neck, and body are retroperitoneal)
U = Ureters
C = Colon (only the ascending and descending colons, as transverse and sigmoid retain mesocolon)
K = Kidneys
E = Esophagus
R = Rectum
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1) Kidneys
2) Ureters
3) Suprarenal glands
4) Muscles
5) Vessels arising from abdominal aorta
6) Spine and nerves (lumbar spinal nerves and autonomic nerves mostly)
Lymphatic drainage of posterior abdominal wall
1) Pre-aortic nodes (drains lymph from foregit to hindgut, liver, gallbladder, pancreas, spleen); efferent lymph forms intestinal trunk
2) Lateral aortic nodes (drains kidneys, suprarenal glands, testes, ovaries, uterus, deep vessels of abdominal wall, common illiac nodes); efferent lymphs form the right and left lumbar trunks
Kidney location
- Retroperitoneal on the posterior abdominal wall
- lies at the levels of T12 to L3
- Right kidney lower than left kidney due to position of the liver
Kidney coverings
INNER (Cortex)—
1) Fibrous capsule
2) Perirenal/perinephric fat (surrounds kidneys and their vessels)
3) Renal Fascia
4) Pararenal/paranephric fat
OUTER————
Structures that hold kidneys in position
1) Fibrous capsule of the kidneys
2) Perirenal fat
3) Renal Fascia
4) Pararenal fat
5) collagen bundles (from renal fascia)
6) Renal vessels
7) Ureter
**NO LIGAMENTS
Renal sinus
- Space within the kidneys
- Consist of renal pelvis, renal calices (major calyx and minor calyx)
What is the renal hilum
- the entrance to the renal sinus
- Vessels, nerves, ureter enter and exit the renal sinus via the renal hilum
- located at the level of transpyloric plane (~T12)
- *** Order of vessels from anterior to posterior: renal vein, renal artery, ureter
Internal structures and layers of kidneys
INNERMOST
1) Renal Pelvis
2) Major calyx
3) Minor calyx
4) Renal Papillae
5) Renal Pyramid, renal columns
6) Renal Medulla
7) Renal Cortex
OUTERMOST
OUTERMOST
What is the renal pelvis
- Flattened, funnel shaped expansion of the superior end of ureter
- apex of renal pelvis continuous with ureter
- receives two or three major calices
Major calyx
- continuous with renal pelvis
- devides into two or three minor calices
Definition of renal papillae
The apex of the renal pyramids, from which urine is excreted
Blood vasculature of the kidneys
ARTERIES
- Left and Right Renal arteries arises from abdominal aorta to supply kidneys
- Renal arteries arise at the level of IV disc between L1 and L2
- Right renal artery longer than left renal artery (due to location of abdominal aorta on the left)
- Each divides close to the hilum into five segmental arteries supplying renal segments
VEINS
- Left and Right Renal veins drains into the Inferior Vena Cava
- Drainage to IVC at level L2
- Right renal vein longer than left renal vein (due to IVC’s location on the right)
Lymphatic drainage of kidneys
- Renal lymphatic vessels follow the renal veins
- Drains into the lateral aortic lymph nodes (para-aortic or lumbar)
Nerve supply of kidneys
- Renal Nerve Plexus (both sympathetic and parasympathetic)
- sympathetic: Renal sympathetic plexus (T12)
- parasympathetic: Vagus Nerve (CNX)
(? different from Moore ?)
Location of Suprarenal Glands
- Superomedial aspect/superior poles of the kidneys
- Retroperitoneal on the posterior abdominal wall
Internal structure/layers of suprarenal glands
INNERMOST
1) Suprarenal medulla (developed from neural crest cells; releases catecholamines e.g. epinephrine and norepinephrine)
2) Suprarenal cortex (derived from mesoderm; releases corticosteroids and androgens)
Arteries of Suprarenal glands
Due to endocrine function of adrenal glands, abundant blood supply is necessary
- Superior suprarenal arteries from inferior phrenic artery
- Middle suprarenal arteries from abdominal aorta
- Inferior suprarenal arteries from renal arteries
Veins of suprarenal glands
- the shorter Right Suprarenal Vein drains into IVC
- the longer Left Suprarenal Vein, joined by inferior phrenic vein, enters the left renal vein, then IVC
Lymphatic drainage of suprarenal glands
Lateral aortic (para-aortic or lumbar) lymph nodes
Nerve supply of suprarenal glands
- Celiac plexus
- Preganglionic fibers from Abdominopelvic splanchnic nerves (T5-T9)
(? different from Moore ?)
Ureter location
- Begins at the renal pelvis (most posterior at the hilum) and ends at the urinary bladder
- Retroperitoneal on the posterior abdominal wall
Physiological narrowings of ureter
1) Ureteropelvic junction (where renal pelvis joins the ureter)
2) where ureter crosses the pelvic brim/external iliac artery
3) Ureterovesical junction (where ureter pierces the urinary bladder wall)
** These 3 narrowings are potential sites for ureteric calculus obstruction
Anatomical relations of ureter in male
Ductus deferens lies anterior to the ureter
Anatomical relations of ureter in female
- At the base of broad ligament and cardinal ligament, ureter passes below the Uterine artery
- important when doing hysterectomy or abdominopelvic surgery where they are liable to ligation
Ureteric entry of bladder
- Ureters obliquely insert into the bladder (angles of the trigone of the bladder), acting as a valve
Vasculature of ureter
Arteries
- branches of abdominal aorta
- renal arteries
- gonadal arteries (i.e. testicular/ovarian artery)
- iliac arteries
- vesical arteries
Veins
- renal veins
- gonadal veins
- iliac veins
- vesival veins
Lymphatic drainage of ureters
Lateral aortic (para-aortic or lumbar) lymph nodes
Nerve supply of ureter
1) Renal plexus
2) Testicular plexus
3) Hypogastric plexus
Reference of ureteric stone pain
Loin, scrotum, penis or labia majora
Bones of pelvis girdle
3 bones:
1) Left hip/pelvic bone (fused from left ilium, ischium, pubic)
2) Right hip/pelvic bone (fused from right ilium, ischium, pubis)
3) Sacrum (fused from 5 sacral vertebrae)
Hip bone structure
- consist of three bones (superior to inferior): ilium, ischium, pubis
- these bones unite by a triradiate cartilage, forming the acetabulum
- the acetabulum is a cup-like depression that articulates with the head of femur
Joints of pelvic girdle
1) Lumbosacral joint (lumbar vertebrae with sacrum)
2) Sacroiliac joints (sacrum with ilium)
3) Sacrococcygeal joint (posteriorly; sacrum with coccyx)
4) Pubic symphysis (anteriorly; left & right hip bones at pubis)
Pelvic Inlet or Pelvic Brim components
(Posterior, lateral to anterior)
1) Promontory and Ala of Sacrum
2) A right and left Linea Terminalis:
a) Arcuate line (inner surface of ilium)
b) Pecten pubis/pectineal line (oblique ridge of superio-lateral pubis)
c) Pubic Crest
Anterioposterior diameter of pelvic inlet
- Measured by pelvimetry
- from sacral promontroy to pubic crest
- >11.5cm
Pelvic outlet components
(Posterior, lateral to anterior)
1) Tip of coccyx
2) Inferior margin of sacrotuberous ligament
3) Ischial tuberosities (laterally)
4) Pubic arch
Important ligaments that stabalizes pelvic bone
1) Sacrospinous ligament (Sacrum to ischial spine)
2) Sacrotuberous ligament (Sarum to ischial tuberosities)
Muscular component of pelvic lateral wall
Obturator internus muscles
Muscular component of pelvic posteo-lateral wall
Piriformis muscles
Function of piriformis and obturator internus muscles
1) Forming the lateral pelvic wall
2) Lateral rotator of the hip joint
Obturator canal
A deficiency in the obturator internus muscles and the obturator membrane, with the function of:
1) Allowing passage of obturator VAN to pass from pelvis to thign, supply the adductors on the medial quadrant of the leg
Greater Pelvis/False pelvis boundary
Superiorly bounded by the pelvic girdles
Inferiorly bounded by the oblique plane of pelvic inlet
Lesser pelvis/true pelvis boundary
Superiorly bounded by the oblique plane of pelvic inlet
Inferiorly bounded by the pelvic floor/pelvic diaphragm
Key comparison of male and female pelves
(Male vs female)
Pelvic inlet: narroe vs wide
Pelvic outlet: smaller vs larger
Pubic arch/subpubic angle: Narrow (<70º) vs Wide (>80º)
Obturator foramen: round vs oval
Acetabulum: Large vs small
Major arteries supplying true pelvis of women
6 Main arteries:
1,2) Paired Internal iliac arteries
3,4) Paired ovarian arteries
5) Median sacral artery
6) Superior rectal artery
Major arteries supplying true pelvis of men
4 main arteries:
1,2) Paired Internal iliac arteries
3) Median sacral artery
4) Superior rectal artery
(** Testicular arteries do not enter true pelvis)
Branches of internal illiac artery
Anterior division (7-8 branches)
1) Umbilical
2) Obturator
3) Superior vesical
4) Internal pudental (supplies perineum)
5) Inferior gluteal
6) Middle rectal
7♂) Inferior vesical (give rise to prostatic artery and artery to ductus deferens)
7♀) Vaginal
8♀) Uterine
Posterior division (3 branches)
1) Iliolumbar
2) Lateral sacral
3) Superior gluteal
Autonomic Nervous structure of the true pelvis
Supplied by superior and inferior hypogastric plexes (T1-2, S2-4)
Pelvic Splanchnic Nerves
- arises in the pelvis from spinal nerves S2-S4
- conveys parasympathetic fibers to hypogastric plexus
Lumbar Splanchnic Nerves
- arises from L1-2
- supply sympathetic fibers to hypogastric plexus
Origin:
Coeliac plexus (T5-T11, CNX) —>
Superior Mesenteric plexus —>
Intermesenteric plexus (no vagal parasympathetic fibers; Lumbar splanchnic nerve L1 L2 from lumbar sympathetic trunk) —>
Inferior Mesenteric Plexus —>
Superior Hypogastric Plexus (lumbar splanchnic nerve)—>
Inferior Hypogastric Plexus (Sacral splanchnic nerve)
[[pelvic splanchnic nerves S2-4 run through to inferior mesenteric plexus]]
Structures in the true pelvic cavity
1) Urinary Bladder
2) Rectum
3) Anal Canal
4) female repriductive organs (uterus, ovaries, fallopian tubes, vagina)
5) male reproductive organs (prostate, seminal vesicle, ductus deferens)
6) Nerves (mainly hypogastric plexes)
7) Veseels (mainly branches of internal iliac artery)
8) lymphatics
Pelvic Floor
The pelvic floor is formed by a muscular structure known as the pelvic diaphragm (PD) which consist of:
1) Levator ani muscle
a) Puborectalis b) Pubococcygeus c) Iliococcygeus
2) Coccygeus muscle
Pelvic Diaphragm nerve supply
1) Sacral nerve 4 and 5
2) Branches of pudendal nerve
Action of pelvic disphargm
1) Supports and stablilizes the position of pelvic viscera
2) Act as a sphincter for anorectal junction and vagina
** Due to 1, damaged PD (e.g. women after parturition) would caused prolapsed of the pelvic viscera ie. pelvic organs (e.g. bladder, vagina, uterus, rectum) passing through into the perineum.
Perineal body (location, clinical relevance)
Location: Between pelvic diaphragm and irogenital diaphragm; posterior to vagina/prostate
Clinical relevance: damage to perineal body will cause prolapse of pelvic viscera
Peritoneal reflections (definition and examples)
Peritoneal reflections are infolding along the abdominal and pelvic cavities
a) Vesicouterine pouch (space between bladder and uterus in female)
b) Rectovesical pouch (space between bladder abd rectum in male)
Urogenital diaphragm (components and points of interest
Components:
1) Deep transverse perineal muscles (DTPM)
2) Perineal membrane (over the muscles)
3) Sphincter urethrae
Notes:
1. DPTM is incomplete and not entirely transverse.
- sphincter urethrae may not exist and it could be part of the urethra within.
- perineal membrane plays a major part of the support
Bladder wall layers
(internal to external)
1) Transitional epithelium (folded when relaxed, can be stretched)
2) Detrussor muscle (very thick)
3) outer serous peritoneal layer (superior surface only)
Support of the bladder
1) Urogenital diaphragm
2) Pelvic fascia
3) Medial umbilical ligament (umbilical artery)
4) Median umbilical ligament (urachus)
Trigone
- A triangular area at base of bladder
- between the internal urethral orifice and the two ureteric orifices
- smooth in lining
- most sensitive to pain and stretching
- upper border marked by ureteric ridge/fold
Ureteric ridge/fold location
between ureteric orifices on the urinary bladder
Sphincter vesicae
Aka Internal urethral sphincter
- Located at the neck of the urinary bladder
- smooth muscles; supplied by ANS (involuntary)
- fixed by pubovesical ligament (female) and puboprostatic ligament (male)
Sphincter urethrae
- aka External urethral sphincter
- Skeletal muscles; under voluntary control by somatic nervous system
Anatomical relationships of urinary bladder
Anterior: Pubic symphysis
Posterior: Uterus (female); Rectum (male)
Vasculature of urinary bladder
Arterial Supply:
1) Superior vescial artery (from internal illiac artery)
2) Inferior vesical artery (male) / vaginal artery (female)
Venous drainage:
Vesical venous plexus -> prostatic venous plexus -> internal iliac vein
Lymph drainage of urinary bladder
internal and external iliac nodes
Nerve supply of urinary bladder
ANS: Hypogastric plexus (T1-2, S2-4)
Transurethral cytoscopy
an invasive procedure that will allow you to view the internal features of the bladder, prostate, urethra, ureters and extract ureteral stone or perform other surgical procedures.
Suprapubic Aspiration
Distended bladder rises above the symphysis pubis and lifts the peritoneum away from the anterior abdominal wall. A needle can be punctured above the symphysis pubis to drain the bladder.
