Anatomy of Retroperitoneal

Organs
Hariyono Winarto, M.D., Ph.D
Topography
• The retroperitoneum is a part
of the abdominal cavity;
surrounded anteriorly by the
parietal peritoneum and
posteriorly by the
transversalis fascia (Figure
1)(1).

Figure 1. Transverse section of the anterior abdominal wall

• It is a wide area from the pelvis to the
diaphragm and contains numerous
organs and structures; structures behind
the peritoneum are called
‘retroperitoneal’ (Figure 2)(2).
 Primary Secondary
retroperitoneal retroperitoneal
organs organs

Adrenal glands
ascending and Note:
descending colon
The secondary retroperitoneal organs
were initially intraperitoneal and became
duodenum retroperitoneal structures during
except the bulbus
kidneys
part (first half of embryologic development due to the
duodenum regression of peritoneal tissue lying on
the posterior wall of the abdominal cavity
(the mesentery of these structures fuse
ureter pancreas with the posterior abdominal wall

abdominal aorta

inferior vena cava

and their
branches
 • The peritoneal reflection between the round
ligament [ligamentum (lig) teres uteri]
(lateral) and infundibulopelvic ligament
How to (medial) is an easy way to enter the
retroperitoneum (Figure 3).
enter? • Gentle traction on the lateral parietal
peritoneal surface and cutting it either with
scissors or energy devices is an easy and safe
way of opening the retroperitoneum
Figure 3. Demonstration to enter the retroperitoneum between the Figure 4. Demonstration of opening retroperitoneum, right pelvic side wall
round ligament and infundibulopelvic ligament
Pelvic retroperitoneal vasculature
• A. Arteries
• Abdominal aorta
The abdominal aorta is divided into the right and left common iliac arteries at
the level of the L4-L5 vertebra, and the common iliac artery is divided into two
parts as the external and internal iliac artery at the pelvic brim. The ovarian
artery, median sacral artery, external iliac artery, internal iliac artery and its
branches are important structures of pelvic retroperitoneal vasculature (Figure
5).
• Ovarian artery
This is located on the anterolateral surface of the abdominal aorta, at the level
of the L2 vertebra, generally 2 cm below the level of the left renal vein.
• Median sacral artery: This is the continuation of the abdominal aorta on the anterior
surface of the sacrum and coccyx.
• Common iliac artery: The common iliac artery divides into the external and internal iliac
artery. It is the point where polar renal arteries mostly arise
• External iliac artery: This goes along the medial border of the psoas muscle to the level
of femoral ring, which is below the inguinal ligament. The genitofemoral nerve is found
on the lateral border of the external iliac artery
• Internal iliac artery: This runs infero-medially after the pelvic brim and is the major
vascular supply of the pelvic cavity. It has two trunks; posterior and anterior(
• Umbilical artery: This is the end artery of the internal iliac artery (anterior trunk). It goes
longitudinally to the abdominal wall and becomes the medial umbilical ligament.
• Uterine artery: The uterine artery arises from the anterior trunk and goes medially
through the broad ligament (lig. latum uteri)
• Figure 5. Paraaortic
region, aorta and
inferior vena cava
after paraaortic
lymphadenectomy
(surgical archive)
• Figure 6. Polar renal
artery arising from
the right common
iliac artery and also
abdominal aorta
(surgical archive)
• Figure 7. Uterine
artery, right pelvic
side wall (surgical
archive)
Veins
• Inferior vena cava → The inferior vena cava (IVC) begins just inferior to the L5 vertebra,
where the abdominal aorta has a bifurcation of common iliac arteries.
• Clinical tip: Renal vein and ovarian vein
• The left renal vein crosses over the abdominal aorta below the origin of the superior
mesenteric artery and drains into the vena cava inferior.
• External iliac vein: This is the continuation of the femoral vein above the inguinal
ligament and runs on the posterior side of the external iliac artery.
• Pubic vein: This is a vascular connection between the external iliac/inferior epigastric
and obturator vein, and hemorrhage of this vein is called corona mortis.
• Internal iliac vein: Corresponding branches of the internal iliac artery generally run with
their veins.
• Common iliac vein: This starts from the conjunction point of the internal and external
iliac veins and forms the inferior vena cava with its counterpart.
Ureter
• The ureter is a muscular structure, functioning in the transport of urine from the
kidney to the bladder. It is about 23-30 cm in length.
• The narrowest points of the ureter:
• The ureteropelvic junction
• Pelvic brim, where the ureters cross the common iliac vessels
• The ureterovesical junction, where the ureters enter the smooth muscle wall
of the bladder
• Anatomically, the ureter is divided into abdominal, pelvic, and intravesical parts.
Figure 10. Right ureter below the right ovarian vein medial to the ascending colon Figure 11. Vascularization of ureter from the kidney to the bladder
and lateral to inferior vena cava, and left ureter underneath the mesentery of (left side), while dissecting the ureter traction should be applied
descending colon, medial/ parallel to the inferior mesenteric vein and lateral to towards the side of blood vessels
aorta/ superior hypogastric plexus (surgical archive)
 Retropubic (Retzius) space

Paravesical space

Avascular Presacral (Retrorectal) space

spaces in
Pararectal space
the pelvis
Vesicovaginal (Vesicouterine) space

Rectovaginal space
• Avascular spaces
of the pelvis
 Retropubic Space
• Extraperitoneal space between the
bladder and the pubic bone that
generally contains fat.
• Anteriorly: Pubic symphysis,
• Posteriorly: Bladder,
• Superiorly: Parietal peritoneum
(anterior abdominal wall),
• Laterally: Arcus tendinous fascia
pelvis and ischial spines.
Paravesical (and paravaginal) space
• This is located within the lateral part
of the Retzius space anterior to the
cardinal ligament, bilaterally.
• Superiorly: Lateral umbilical folds
(peritoneal thickening of inferior
epigastric vessels),
• Inferiorly: Pubocervical fascia where
it enters into the tendinous structure
of levator ani muscle, iliococcygeus
muscle,
• Anteriorly: Superior pubic ramus,
arcuate line of the os ilium,
• Posteriorly: Endopelvic fascial sheath
that covers the internal iliac artery
and vein, cardinal ligament which
separates it from the anterior part of
pararectal space and uterine artery, -
Medially: Bladder pillars,
• Laterally: Pelvic side wall, obturator
internus and levator ani muscle.
Presacral (retrorectal) space
• The retrorectal space is between the
rectum and the sacral- coccygeal
part of spine.
• Superiorly: Peritoneal (parietal)
reflections,
• Anteriorly: Distal portion of the
sigmoid mesentery, posterior rectal
fascia, rectum,
• Posteriorly: Anterior longitudinal
ligament, sacral promontorium and
anterior part of the sacrum,
• Inferiorly: Levator ani and coccygeus
muscle,
• Laterally: Ureter, internal iliac vessels
and hypogastric nerves.

Pararectal space
• The pararectal space is
located lateral to the
rectum and retrorectal
space, and it is at the
posterior part of the
cardinal ligament. Its
boundaries are (Figure 19):
• Anteriorly: Cardinal
ligament,
• Medially: Rectal pillars,
uterosacral ligament,
ureter,
• Laterally: Internal iliac
artery,
• Posteriorly: Sacrum,
• Caudally: Puborectalis
muscle.
Vesicovaginal (Vesicouterine)
space
• The vesicovaginal,
vesicocervical, and
vesicouterine spaces are all
at the same longitudinal
axis and this area is also
known as the anterior cul-
de-sac.
• Anteriorly: Trigone of
bladder,
• Posteriorly: Vagina,
• Laterally: Bladder pillars,
pubocervical ligament,
• Inferiorly: Urogenital
diaphragm.
Rectovaginal space
• The rectovaginal space is
from the recto-uterine
peritoneal fold (pouch of
Douglas) to the level of the
perineal body.
• Anteriorly: Posterior wall of
the vagina,
• Posteriorly: Anterior wall of
the rectum,
• Laterally: Uterosacral
ligament, rectal pillars.
Reference
1. Selçuk İ, Ersak B, Tatar İ, Güngör T, Huri E. Basic clinical retroperitoneal anatomy for
pelvic surgeons. Journal of Turkish Society of Obstetric and Gynecology.
2018;15(4):259-269.
2. Morozov V, Rosati M, Campian E, Enzmann C, Soliman P, Lemos N et al. Intra and
Retroperitoneal Anatomy – Landmarks and Pearls of Dissection (Didactic)
[Internet]. National Harbor, MD: 42nd AAGL Global Congress on Minimally Invasive
Gynevology; 2013 [cited 18 September 2022].