This action might not be possible to undo. Are you sure you want to continue?
Anatomy of Kidney, Ureter and Bladder with Radiological Imaging
고려대학교 의과대학 영상의학교실
Gross Anatomy of the Kidney
1. General description The normal kidney in the adult male weighs approximately 150 g. On the average, it is slightly smaller in the female, weighing approximately 135 g. The normal kidney is typically 10 to 12 cm in vertical dimension, 5 to 7 cm in transverse width, and approximately 3 cm in anteroposterior thickness. These dimensions are related more to overall body size rather than to sex, with smaller individuals having generally smaller kidney mass than larger individuals. A thin but tough fibroelastic capsule encases the parenchyma and can be elevated from the parenchyma by hematoma. The kidneys are larger relative to body size in children, as are the adrenal glands, and, at birth, the kidneys are irregular in contour with multiple fetal lobations. These lobations typically disappear in the first years of life. By adulthood, the lateral surface of the kidney usually forms a smooth convexity with rounded upper and lower poles; however, it is neither unusual nor abnormal to see persistence of some degree of fetal lobation throughout adult life. Similarly, it is not unusual to see a focal bulge in the midlateral contour of the kidney on either side, referred to as a dromedary hump. This also is a normal variation, believed to be secondary to downward pressure from spleen or liver on the kidney during development, and occurs much more commonly on the left than the right side. On the medial surface of either kidney is a depression, the renal hilum. The renal hilum opens into the renal sinus, a space that forms the central portion of the kidney and is surrounded by the renal parenchyma. The urinary collecting structures and renal vessels occupy the renal sinus and exit the kidney via the hilum medially. Varying amounts of fat surround these structures within the renal sinus. The renal parenchyma is divided into cortex and medulla. The medulla is not contiguous but consists of multiple distinct conical segments, the renal pyramids. The rounded apex of each pyramid is the renal papilla, which points centrally into the renal sinus, where it is cupped by an individual minor calyx of the renal collecting system. Thus, the number of pyramids corresponds to the number of minor calyces. The base of each pyramid roughly parallels the 1
and it is separated from the liver by reflection of the peritoneum. The renal cortex covers the pyramids. Anatomic relations The upper pole of the left kidney typically lies at the level of the 12th thoracic vertebral body. The medial aspect of each kidney is rotated anteriorly on a longitudinal axis at an angle of about 30 degrees from the true coronal plane. A renal lobe is defined as a single medullary pyramid and its associated surrounding cortex. except for a small area of its upper pole. not only peripherally but also extending between the pyramids to the renal sinus. . The upper border of the left kidney. 2. being higher than the right. The extension of parietal peritoneum that bridges between the perirenal fascia covering the upper pole of the right kidney and the posterior aspect of the liver is called the hepatorenal ligament. The right kidney lies behind the liver. and its lower pole at the level of the 3rd lumbar vertebra. ligament. The kidneys do not lie in a simple coronal plane and the lower pole of the kidney is pushed slightly more anterior than the upper pole. with the renal vessels and pelvis exiting the hilum medially in a relatively anterior direction. which comes into direct contact with the liver's retroperitoneal bare spot. On the left. There is typically a peritoneal extension between the perirenal fascia covering the upper pole of the left kidney and the inferior splenic capsule.2 2009년 비뇨기과 저년차 전공의 연수강좌 external contour of the kidney. The duodenum is applied directly to the medial aspect and hilar structures of the right kidney. or lienorenal. The adrenal gland covers the superomedial aspect of the upper poles of both right and left kidneys. It is through these interpyramidal extensions of cortex the renal columns (of Bertin) that the renal vessels enter and leave the kidney parenchyma. called the splenorenal. usually extends to the upper border of the 11th rib. the retroperitoneal tail of the pancreas and the related splenic vessels are applied directly to the upper to middle portion and hilum of the kidney.
Inferiorly. It thins inferiorly and is contiguous with retroperitoneal fascia. Ureter and Bladder with Radiological Imaging 3 3. medially. Gerota's fascia extends across the midline and is contiguous with Gerota's fascia on the contralateral side. become fused on three sides around the kidney laterally. Gerota's fascia remains an open potential space. which extends into the pelvis and. Around and outside Gerota's fascia are variable amounts of retroperitoneal fat (the para renal or para nephric fat). containing the ureter and gonadal vessels on either side. The anterior and posterior leaves of Gerota's fascia. which extend anterior and posterior to the kidney.성득제：Anatomy of Kidney. also extends with the spermatic vessels and vas deferens into the scrotum. although the anterior and posterior leaves are generally fused and inseparable as they cross the great vessels. in males. . and superiorly. Gerota's fascia The kidneys and associated adrenal glands are surrounded by varying degrees of perirenal or perinephric fat. distinguished from the peri renal or peri nephric fat that is contained within Gerota's fascia and is immediately adjacent to the kidney. Gerota's fascia fuses and tapers to disappear over the inferior diaphragmatic surface. Medially. commonly called “Gerota's fascia”. and these together are loosely enclosed by the perirenal fascia. Superiorly.
early in their course. are all end arteries. 1) Renal arteries The right renal artery passes behind the inferior vena cava in its course and is considerably longer than the left renal artery. extend into the pelvis. which divide again and enter the renal parenchyma as interlobar arteries. In rare instances. such collections can and do. Gerota's fascia also serves to contain perinephric fluid collections. enters the kidney via the renal hilum medially. with five branches most commonly described. The main renal artery and each segmental artery. The first and most constant segmental division is a posterior branch. Four anterior segmental arterial branches can be described in most kidneys. and behind it lies the artery. classically described as a single artery and larger vein. . following the potential space where Gerota's fascia does not fuse inferiorly. the interlobular arteries. The renal vein lies most anteriorly. The main renal artery typically divides into four or more segmental vessels. These processes rarely cross the midline because of the fusion of Gerota's fascia over the great vessels medially. in turn. proceeding from superior to inferior: the apical. without anastomosis or collateral circulation. tend to remain within the fascial capsule formed by Gerota's fascia and can be safely and completely excised by removing the kidney within an intact surrounding Gerota's fascia as a single entity. the right renal artery may arch anteriorly over the inferior vena cava. the interlobar arteries branch into arcuate arteries. whether of pus (abscess). the renal pelvis. Renal malignancies. produce multiple radial arterial branches. Both normally lie anterior to the urinary collecting system that is. or blood (hematoma). The renal arteries and veins typically branch from the aorta and inferior vena cava at the level of the second lumbar vertebral body.4 2009년 비뇨기과 저년차 전공의 연수강좌 Gerota's fascia forms an important anatomic barrier around the kidney and tends to contain pathologic processes originating from the kidney. middle. 4. which usually exits the main renal artery before it enters the renal hilum and proceeds posteriorly to the renal pelvis to supply a large posterior segment of the kidney. The arcuate arteries. Vascular pedicle The renal vascular pedicle. however. At the base of each renal pyramid. upper. The remaining anterior division of the main renal artery typically branches as it enters the renal hilum. urine (urinoma). Very extensive and advanced inflammatory or malignant processes may eventually erode through Gerota's fascia and invade adjacent organs or the posterior body wall musculature. and occlusion of any of these vessels produces ischemia and infarction of the corresponding renal parenchyma that it supplies. The segmental arteries course through the renal sinus and branch further into lobar arteries. and lower anterior segmental arteries. as well as their multiple succeeding branch arteries. When very large. below the level of the anterior takeoff of the superior mesenteric artery. The latter course radially outward along the junction between the renal pyramid and the cortical columns of Bertin. which arc parallel to the renal contour along the corticomedullary junction.
성득제：Anatomy of Kidney. and may form large venous “collars” around the infundibula of many calyces. The most common variation is the occurrence of supernumerary renal arteries (two or more arteries to a single kidney. 3) Common anatomic variants of renal vessels Variations of the main renal artery and vein are common. especially at the level of the arcuate vessels. with up to five . none of which communicate. the renal parenchymal veins anastomose freely. usually without receiving other venous branches. the left renal vein typically receives the left adrenal vein superiorly. The left renal vein is generally three times the length of the right (6 to 10 cm) and must cross anterior to the aorta to reach the left lateral aspect of the inferior vena cava. The right renal vein is short (2 to 4 cm) and enters the right lateral aspect of the inferior vena cava directly. a lumbar vein posteriorly. present in 25% to 40% of kidneys. Lateral to the aorta. Ureter and Bladder with Radiological Imaging 5 2) Renal veins Unlike the renal arteries. and the left gonadal vein inferiorly.
6 2009년 비뇨기과 저년차 전공의 연수강좌 having been found). extending from a level as inferior as the common . Multiple renal veins are a less common entity and. the lymphatic trunks then drain primarily into the left lateral para-aortic lymph nodes. form the very first site of metastatic spread from the kidney. From the right kidney. representing a persistence of the embryologic state. to the inferior vena cava. rather than posteriorly. From the left kidney. On the left. the lymphatic trunks drain primarily into both interaortocaval and right paracaval lymph nodes. including nodes anterior and posterior to the aorta. from a level below the inferior mesenteric artery to the diaphragm. Some lymphatic channels from the left kidney may drain into retrocrural nodes and/or directly into the thoracic duct above the diaphragm. usually consist of duplicate renal veins draining the right kidney via the right renal hilum. and these. when present. including nodes anterior and posterior to the inferior vena cava. Drainage into the interaortocaval nodes does not generally occur from the left kidney except in advanced disease states. Lower pole supernumerary arteries on the right tend to cross anteriorly. the main renal vein may divide and send one limb anterior and one posterior to the aorta to reach the inferior vena cava (a so-called renal collar). 4) Renal lymphatics There are often two or more lymph nodes directly at the renal hilum associated with the renal vein. A supernumerary artery to the upper pole of the kidney is more common than an artery to the lower pole. when present. Only the retroaortic limb of the left renal vein may persist in unusual instances. Lower pole arteries on either side must cross anteriorly to the urinary collecting system and may be an extrinsic cause of ureteropelvic junction obstruction.
Renal papillae. also allowing bacterial reflux into the kidney in the presence of infected urine. although this is not common. Such compound papillae result in larger. The renal pelvis is continuous with the ureter and drains into it. The minor calyces are the first gross structures of the renal collecting system. calyces. the anterior calyces typically extend laterally in a coronal plane.성득제：Anatomy of Kidney. but 7 to 9 are present in the typical kidney. . which in turn coalesce in most individuals to form a single renal pelvis. The minor calyces narrow. creating a neck or infundibulum before joining other minor calyces to form usually two to three major calyces. Recognition of this anatomic configuration is important in radiographic interpretation and during percutaneous access to the renal collecting system. Ureter and Bladder with Radiological Imaging 7 iliac vessels on the right to the diaphragm. thus forming compound papillae. Each papilla is cupped by a corresponding minor calyx. some lymphatic channels from the right kidney may drain into retrocrural nodes or directly into the thoracic duct. There are typically two longitudinal rows of renal pyramids and corresponding minor calyces. compound calyces. which receives the urinary output from the collecting ducts. Again. extending anteriorly and posteriorly. This often occurs at the renal poles but can occur throughout the kidney. Renal parenchymal scarring secondary to infection is typically most severe overlying such compound papillae. roughly perpendicular to one another. The renal pelvis may be small and completely contained within the renal sinus or may be voluminous and almost entirely extrarenal. whereas the posterior calyces extend posteriorly in a sagittal plane. It is common that some renal pyramids fuse during development. the two joined at the anatomically indistinct ureteropelvic junction. some lymphatics from the right kidney may cross over from right to left and drain primarily into left lateral para-aortic lymph nodes near the left renal hilum. Because of the natural rotation of the kidney. 5. and renal pelvis The renal papillae may number as few as 4 or as many as 18. The compound papillae are of physiologic significance in that their configuration permits urinary reflux into the renal parenchyma with sufficient back pressure. In addition.
which together with the epithelium forms the mucosa. Anatomic relations The ureter is related posteriorly to the psoas muscle throughout its retroperitoneal course. with two distinct pyelocalyceal systems draining into a single ureter. depending on the location of the lesion. additional small arterial branches to the distal ureter may arise from the internal iliac artery or its branches. the urinary effluent does not passively drain but is actively propelled from renal pelvis to bladder by the peristaltic action of the ureteral muscle. renal pelvis. 3. General description In the adult. Gross Anatomy of the Ureter 1. Ureteral blood supply and lymphatic drainage In the retroperitoneum. Thus. After entering the pelvis. this muscle usually can be divided into an inner layer of longitudinally coursing muscle bundles and an outer layer of circular and oblique muscle. Rarely. The ureter and collecting system extending to the renal papillae are lined by a transitional cell epithelium. crossing the iliac vessels to enter the pelvis at approximately the bifurcation of the common iliac into internal and external iliac arteries. the lamina propria. abdominal aorta. A thin layer of adventitia immediately surrounds the ureter and contains an extensive plexus of ureteral blood vessels and lymphatics that course longitudinally with the ureter. The entire renal collecting system may be bifid. the ureter may receive branches from the renal artery. In the normal state. which may cause ureteral . whereas arterial branches within the pelvis approach the ureter from a lateral direction. The renal pelvis may be no wider than the ureter. especially the vesical and uterine arteries. or the ureter may also be duplicated over varying lengths extending from the kidney. 2. Beneath this epithelium is a layer of connective tissue.8 2009년 비뇨기과 저년차 전공의 연수강좌 1) Anatomic variations The bilateral collecting systems present in any single individual are often similar but are rarely identical and not uncommonly may be quite different even from one another. In the ureter. the ureter is generally 22 to 30 cm in total length. the primary sites of lymphatic drainage from ureteral lesions vary. the right ureter crosses behind the inferior vena cava in its course (the retrocaval ureter). varying with body size and habitus. identical to and contiguous with that of the bladder. and ureter. The venous and lymphatic drainage of the ureter generally parallels the arterial supply. gonadal artery. Smooth muscle covers the renal calyces. Note that arterial branches to the upper ureter approach from a medial direction. but also from the middle rectal and vaginal arteries. and common iliac artery.
5. The ureter is anatomically narrowest at this fixed point. and typically requires dilatation to allow retrograde passage of instruments. and the pelvic ureter extends from the iliac vessels to the bladder. There is no intrinsic change in the ureteral caliber at this location. this is thus a physiologic or functional rather than a fixed narrowing. and the lower (or distal or pelvic) ureter extends from the sacrum to the bladder. Gross Anatomy of the Bladder 1. the ureteropelvic junction is not found to restrict either retrograde or antegrade passage of appropriately sized catheters or endoscopes. the lamina propria forms a relatively . The ureter can also be divided into upper. the ureters are closely related to the uterine cervix and are crossed anteriorly by the uterine arteries. The gonadal vessels roughly parallel the ureter through much of its retroperitoneal extent. which roughly corresponds with the iliac vessels. where the renal pelvis tapers into the proximal ureter. Ureteral segmentation and nomenclature The ureter is often arbitrarily divided into segments for purposes of surgical or radiographic description. The second perceived region of narrowing occurs as the ureter crosses the iliac vessels. The upper ureter extends from the renal pelvis to the upper border of the sacrum. the middle ureter then extends to the lower border of the sacrum. There is a true physical restriction of the ureteral lumen at this point. This narrowing is due to the combination of extrinsic compression of the ureter by the iliac vessels and the necessary anterior angulation of the ureter as it crosses the iliac vessels to enter into the pelvis. Deep to this. owing to the discrepancy in size between the renal pelvis and the proximal ureter. Ureter and Bladder with Radiological Imaging 9 compression and obstruction. The abdominal ureter extends from renal pelvis to the iliac vessels. which appears smooth when the bladder is full but contracts into numerous folds when the bladder empties.성득제：Anatomy of Kidney. In the normal ureter. Midline retroperitoneal mass lesions. The third site of narrowing observed in the normal ureter is at the ureterovesical junction. Within the female pelvis. middle. 4. and lower segments. with three distinct narrowings classically described along its course. The first of these is the ureteropelvic junction. General description The internal surface of the bladder is lined with transitional epithelium. Normal variations in ureteral caliber The normal ureter is not of uniform caliber. usually for purposes of radiographic description. including massive lymphadenopathy or abdominal aortic aneurysm. this perceived narrowing at the ureteropelvic junction may be more apparent than real. obliquely crossing the ureter anteriorly from medial to lateral before entering the pelvis. and thus are at risk during hysterectomy. In many cases. In the normal ureter. will push the ureter laterally.
The median umbilical ligament is the remains of the partially obliterated urachus. With bladder filling. The median . interlacing bundles loosely arranged into inner longitudinal. Beneath this layer lies the smooth muscle of the bladder wall. As it passes through a hiatus in the detrusor (intramural ureter). 2. The ureter pierces the bladder wall obliquely. it is compressed and narrows considerably. The relatively large muscle fibers form branching. and a posteroinferior surface or base with the bladder neck at the lowest point. a fibromuscular sheath (of Waldeyer) extends longitudinally over the ureter and follows it to the trigone. and terminates at the ureteral orifice. and outer longitudinal layers. This is a common site in which ureteral stones become impacted. middle circular. Indeed. this arrangement is thought to result in passive occlusion of the ureter. travels 1. 3. extending from the urinary bladder to the umbilicus. Fibers from each ureter meet to form a triangular sheet of muscle that extends from the two ureteral orifices to the internal urethral meatus. The intravesical portion of the ureter lies immediately beneath the bladder urothelium and therefore is quite pliant. like a flap valve.10 2009년 비뇨기과 저년차 전공의 연수강좌 thick layer of fibroelastic connective tissue that allows considerable distention. The empty bladder is tetrahedral and is described as having a superior surface with an apex at the urachus. Two to 3 cm from the bladder. This layer is traversed by numerous blood vessels and contains smooth muscle fibers collected into a poorly defined muscularis mucosa.5 to 2 cm. Vesicoureteral reflux is thought to result from insufficient submucosal ureteral length and poor detrusor backing. reflux does not occur in fresh cadavers when the bladder is filled. Ureterovesical junction and the trigone The triangle of smooth urothelium between the two ureteral orifices and the internal urethral meatus is referred to as the trigone of the bladder. Anatomic relations When filled. two inferolateral surfaces. it is backed by a strong plate of detrusor muscle. the bladder has a capacity of approximately 500 ml and assumes an ovoid shape.
Clinical urography. REFERENCES 1. Anteroinferiorly and laterally. McAninch JW. Smith’s general urology. eds. Campbell’s urology. Anteriorly. the bladder has migrated to the confines of the deepened true pelvis.성득제：Anatomy of Kidney. The bladder neck. Harris RD. Connecticut: Appleton & Lange. eds. In infants. middle and inferior vesical arteries. With distention.41-80 4. Jr. Some anterior and lateral drainage may go through the obturator and internal iliac nodes. the peritoneum on the superior surface of the bladder is reflected over the uterus to form the vesicouterine pouch and then continues posteriorly over the uterus as the rectouterine pouch.218:659-663 5. Wein AJ. 2nd ed. Radiology 2001. located at the internal urethral meatus. Anatomy of the genitourinary tract. This potential space is called “space of Retzius”. The superior surface of the bladder is covered by peritoneum. In: Walsh PC. Thornton FJ. In female. 2000:147-257 2. In: Tanagho EA. ampullae of the vas deferentia. Kandiah SS. In: Walsh PC. the true pelvis is shallow and the bladder neck is level with the upper border of the symphysis. Bladder circulation The bladder is supplied with blood by the superior. Friedenberg RM. By puberty. Jr. In: Pollack HM. 8th ed. Tanagho EA. Brooks JD. Philadelphia: WB Saunders. Wein AJ. 8th ed. Helical CT evaluation of the perirenal space and its boundaries: a cadaveric study. Ureter and Bladder with Radiological Imaging 11 umbilical ligament anchors the bladder to the anterior abdominal wall. In the female. Kabalin JN. Surgical anatomy of the retroperitoneum. the uterine and vaginal arteries also send branches to the bladder. kidneys and ureters. Lee MJ. rests 3 to 4 cm behind the midpoint of the symphysis pubis. the bladder is cushioned from the pelvic side wall by retropubic and perivesical fat and loose connective tissue.3-40 3. The vagina and uterus intervene between the bladder and the rectum. Retik AB. Philadelphia: WB Saunders. Vaughan ED. 1995. which arise from the anterior trunk of the internal iliac artery. 2002. the peritoneum sweeps gently onto the anterior abdominal wall. The bulk of the lymphatic drainage passes to the external iliac lymph nodes. Anatomy of the lower urinary tract and male genitalia. Campbell’s urology. 14th ed. and by smaller branches from the obturator and inferior gluteal arteries. Philadelphia: WB Saunders.1-16 . The bladder base is related to the seminal vesicles. McClennan BL. Vaughan ED. eds. Monkhouse WS. the peritoneum passes to the level of the seminal vesicles and meets the peritoneum on the anterior rectum to form the rectovesical space. 2002. so that the base of the bladder and urethra rest on the anterior vaginal wall. Posteriorly. whereas portions of the bladder base and trigone may drain into the internal and common iliac groups. Retik AB. eds. The veins of the bladder coalesce into the vesicle plexus and drain into the internal iliac vein. and terminal ureter. It is firmly fixed by the pelvic fasciae and by its continuity with the prostate. 4. the bladder rises out of the true pelvis and separates the peritoneum from the anterior abdominal wall. Excretory Urography.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.