You are on page 1of 129

Anatomy of the

Urinary Tract
Scope: Retroperitoneum,
Kidneys, Ureters, Bladder, &
Female Urethra

Genlinus D. Yusi, MD, FPUA, FPCS


Urology:
 Is the surgical subspecialty which
deals with diseases of male and
female urinary tract and the male
reproductive organs.
Course Outline:

 Urinary System
• Retroperitoneum & Adrenals
• Kidneys
• Ureters
• Bladder
• Urethra
Retroperitoneum
 Retro- means “behind”
 Bounded:
– Anteriorly: Peritoneal Sac
– Superiorly: Diaphragm
– Posteriorly: Contiguous with the
retroperitoneal portions of the pelvis.
– Posteriorly & Laterally: Abdominal Wall
Retroperitoneu
m
The Kidneys (L: renes)

 The kidneys are paired, reddish-


brown, bean-shaped, solid organs
that lie well protected deep within
the retroperitoneum on either
side of the spine.
Kidneys
The Kidneys
 One on each side of the
paravertebral column.
 Lower part of the ribs,
just peeking below the
floating ribs.

 Level of T12 to
L3.
The Kidneys
 The kidneys remove excess
water, salts, and the products of
protein metabolism from the
blood and maintain its pH.
 Then these are conveyed to the
urinary bladder through the
ureters.
Kidney Position

 Within the retroperitoneum


 Posterior to the peritoneum
 Lateral to the vertebral column
 Anterior to the Psoas muscles
 Inferior to the diaphragm
 Superior portions are protected by the
thoracic cage.
 The right kidney is lower.
Anterior Relations of the
Kidney
Kidney Position
Posterior
Within thetoretroperitoneum
the peritoneum
Kidney Position
Kidney Position

Lateral to the
vertebral Column

Anterior to the Psoas


muscle
Kidney Position
Superior portions are
protected by the thoracic
cage

Generally, the
right kidney is
lower because of
the presence of
the large right
liver lobe
Kidney Regions:

 Anterior surface
 Posterior surface
 Superior pole
 Middle region
 Inferior pole
 Lateral margins/borders (convex)
 Medial margins/borders (concave)
The Kidney

 Usually 10 (length) x 5 (width) x


2.5 cm (thick)
 150 gm in the male
 135 gm in the female
The Kidney’s Medial
Border
 Renal Hilum is a vertical cleft, an
indentation where the renal
artery enters, the renal vein
exits, and the renal pelvis exits.
 Renal Sinus is the space within
the kidney which contains these
structures
Kidney Color, reddish
brown
The Kidney’s Surface
Anatomy & Markings
 Normally impalpable, except in
thin individuals.
 They descend during inspiration
by 3 cm.
 The superior pole is superior to
the 12th rib.
 The Inferior pole is just above the
iliac crest.
Renal Fascia & Renal
Fat
Renal Capsule

Perirenal fat

Renal or Gerota’s fascia


Pararenal fat
Renal Capsule

 Is a tough fascia that encloses the


renal parenchyma.
 Contains most of the pain receptors
of the kidney.
 Acute stretching of the capsule is
the main cause of “renal colic”
 In chronic inflammatory conditions,
shields the renal parenchyma.
Renal Sinus
Major Renal Blood Supply

Gonadal veins
Points to Remember Regarding
the Major Blood Supply of the
Kidney
 Both renal arteries arise from the aorta,
both renal veins drain into the IVC. Both
arteries and veins arise/drain just
opposite each other.
 The kidneys consume 20% of the
heart’s cardiac output.
 The arteries generally lie posterior to
the vein within the renal hilum.
 The renal pelvis is generally infero-
posterior to the vessels.
Gonadal veins
Points to Remember Regarding
the Major Blood Supply of the
Kidney
Length
 The right renal artery is longer
than the left.
 The right renal vein is shorter
than the right
Gonadal veins
Points to Remember Regarding
the Major Blood Supply of the
Kidney
Crossings
 The right renal artery crosses the
IVC posteriorly.
 The left renal vein crosses the
aorta anteriorly.
Gonadal veins
Points to Remember Regarding
the Major Blood Supply of the
Kidney
Major branches:
 The renal artery branches into the anterior and
posterior segmental arteries.
 The anterior segmental artery further divides
into 4 additional segmental arteries:
– Apical - Middle
– Upper - Lower
 These 5 segmental branches are responsible for
dividing the kidney into segments.
LOBAR ARTERIES
Lymphatic
s of the
Right
Kidney

Interaortoca
val &
Paracaval
Lymphatic
s of the
Left Kidney

Para-aortic
Ultrasonography
IVP or IVU
Intra Venous Pyelogram
or
Intra Venous Urogram
Renal Conditions
 Renal Tumors
 Acute Renal Failure
– Temporary
 Chronic Renal Failure
– Permanent
– End-Stage Renal Disease (ESRD)
The Ureter
 Conveys urine produced in the kidney to the
bladder through peristaltic motion.
 Thick walled expandable muscular ducts with
a narrow lumen that carry urine from the
kidneys to the urinary bladder. Usually 25 cm
in length in adults
 Continuous with the renal pelvis.
 Completely retroperitoneal but adheres
closely to the parietal peritoneum.
 Descends anterior to the psoas.
Points to remember regarding the Ureter’s course

 From upper to
middle part, the
ureter runs lateral to
its corresponding
great vessel.
 The IVC is on the
RIGHT, the AORTA is
on the LEFT.
 Closely adherent to
the peritoneum
 At the lower ureter,
the ureter shifts from
lateral to medial, by
crossing the iliac
vessels anteriorly.
 The ureters then
course towards
the infero-
posterior bladder.
 The ureters enter
the bladder
through its
opening, the
bladder hiatus.
 The ureter ends
by opening into
the bladder lumen
through the
ureteral orifices.
The Ureter has three
points of narrowing
throughout its course
•Most common locations where
ureteral stones will lodge.
UPJ

Iliac Vessel
crossing

UVJ
The Ureter has multiple
blood supplies.

The ureters and the common iliac


arteries cross each other at this
point!

1. Point of narrowing.
2. Landmark in
surgical dissection.
Venous Drainage of the Ureter

Gonadal veins
Innervation of the
Ureters
 Derived from the adjacent
autonomic plexuses which
contain pain fibers.
 Afferent fibers from the ureters
enter the spinal cord via dorsal
roots T11, T12, & L1
Lymphatic Drainage of
the Kidneys & Ureters
 Generally follow the course of the
renal vein and drain into the lumbar
(lateral aortic) lymph nodes.
 Upper ureteral lymphatics join those of
the kidney.
 Middle ureteral lymphatics drain to the
common iliac nodes.
 Lower ureteral lymphatics drain to the
common, external or internal iliac
lymph nodes.
Urinary Stone Disease
 Nephrolithiasis
– Calyceal calculi
– Infundibular calculi
 Pelveolithiasis
 Ureterolithiasis
– Proximal third
– Middle third
– Distal third
P3

M3

D3
Congenital Renal &
Ureteral Anomalies
 Supernumerary Kidney
 Renal Ectopia
 Horseshoe Kidney
 Ureteral duplication
End of Kidneys &
Ureter
Start of the Urinary Bladder &
Prostate
Urinary Bladder (L. vesica)

 Hollow muscular vesicle for


storing urine.
 The bladder expels urine through
smooth muscle contraction.
Urinary Bladder
 In adults, the empty bladder is
impalpable, lying within the pelvis
minor.
 It lies posterior & slightly superior
to the pubis.
 There is a retropubic space
between the pubis & bladder.
Urinary Bladder
 In infants & children, the bladder
is more superior and is easily
palpable when full.
 In adults, only a very full bladder
in thin individuals can be
palpated.
Urinary Bladder
 The main characteristic of the bladder as
compared to other hollow organs is its
distensibility without increasing the
intraluminal pressure significantly.
 Bladder capacity is highly variable.
 Bladder lumen is loosely lined by a mucous
membrane in its entirety, except for a
triangular area at the base or fundus known
as the trigone where it is firmly attached.
Peritoneal Reflections
in the Female
 Is from the superior surface of the
bladder near its posterior border
to the uterus, at the junction of
the uterine body & cervix.
 The vesicouterine pouch of
peritoneum is between the
bladder & uterus.
 Normally empty
Peritoneal Reflections
in the Male
 Is from the superior surface of the
bladder, over the ductus deferens
& seminal vesicles.
 The bladder is relatively free
floating except for its neck where
it is attached firmly by the
puboprostatic ligaments.
Surface Regions of the
Bladder
 Superior surface
 2 Inferolateral surfaces
 Posterior surface
 Postero-inferior surface (fundus)
 Apex – Where the Median Umbilical
Ligament or Urachus is attached.
 Bladder neck – where the urine exits
into the urethra.
Median umbilical ligament

Apex
Differences in the
Bladder between Male
& Female
Male Female
 Between the bladder &  Between the bladder &
the rectum are the the rectum is the cervix
ampullae of the vas & & the superior part of
the seminal vesicles. the vagina.
 Bladder neck opens into  Bladder neck opens into
the prostatic lumen. the short female
 There is a bulge just urethra.
beneath the trigone  There is usually an
caused by the posterior extrinsic compression
lobe of the prostate. at the superior margin
caused by the
anteverted uterus.
Layers of the Bladder
(external to internal)

 Vesical fascia – loose connective


tissue
 Vesical venous plexus –
surrounded by fat.
 Detrusor muscle / layer
 Mucous membrane – lined by
transitional cell epithelium.
Structure of the
Bladder
 Detrusor muscle – comprises the wall of
the bladder
 3 layers:
– External & Internal layer of longitudinal fibers
– Middle layer of circular fibers
– Continuous with the bladder neck, forming the
internal sphincter, then continuous with the
prostatic stroma in men.
– In women, they are continuous with the muscle
layer of the urethra
Structure of the
Bladder
 Mucous membrane of the bladder
lumen is lined by transitional cell
epithelium, whose quality is
elasticity or stretchability.
 Ureteral/ureteric orifices/ostia &
the internal urethral orifice are
located at the three angles of the
trigone which is located at the
infero posterior portion of the
bladder lumen.
Anti-Reflux Mechanism
 The ureter enters the bladder wall
at an oblique angle.
 It tunnels through the muscle wall
for more than a cm before opening
into the bladder lumen.
 With increased intraluminal
pressure, the muscle wall will
compress the intravesical ureter to
prevent reflux.
Arterial supply of the
Bladder
 Main arteries branch from the
internal iliac artery:
• Superior vesical a. - branches out
after the gluteal a.
• Inferior vesical a. – continuation fo
the internal iliac a. In women, it
arises from the uterine arteries.
Venous Drainage of
the Bladder
 Like the arteries, which are all
derived from the internal iliac
arteries, the veins are all
tributaries of the internal iliac
veins.
Venous Drainage of
the Bladder (Male)
 Enveloping the base of the bladder & prostate,
including the seminal vesicles, ampulla of the vas,
and inferior ends of the ureters, are the vesical
venous plexus & the prostatic plexus.
 These go through the internal iliac veins through
the inferior vesical veins.
 There is also some drainage into the sacral veins
thus entering the vertebral venous plexus (aka
Batson’s plexus).
Venous Drainage of
the Bladder (Female)
 The vesical venous plexus which
envelops the proximal urethra
and bladder neck drains into the
vaginal venous plexus.
Lymphatic Drainage
 Superior bladder – External Iliac
lymph nodes.
 Inferior bladder – Internal Iliac
lymph nodes
Nerve Supply of the
Bladder
Parasympathetic
 From the Pelvic Splanchnic
Nerves (S2, S3, S4)
 Motor to the detrusor muscle in
inhibitory to the internal
sphincter.
Nerve Supply of the
Bladder
Sympathetic
 From T11, T12, L1, & L2 nerves.

 Inhibits detrusor muscle


contraction and stimulates
internal sphincter contraction.
Cystolithiasis on Plain KUB film

Normal Cystogram film


Female Urethra
 Short muscular tube, 4 cm long.
 The superior half is homologous to
the prostatic urethra.
 The inferior half is homologous to
the membranous urethra.
 It lies anterior to the vagina, starts
after the bladder neck and ends at
the external urethral orifice within
the vestibule of the vagina.
Female Urethra
 The inferior end is surrounded by
the sphincter urethrae muscle.
 There are paraurethral glands at
the superior portion, which are
homologous to the prostate
gland.
Female Urethra Blood
Supply
 From the internal pudendal &
vaginal arteries & veins.
Female Urethra
Innervation
 Pudendal nerves
 Pelvic splanchnic nerves
Female Urethra
Lymphatics
 Sacral lymph nodes
 Internal iliac lymph nodes
End of Urinary Tract
Next Attraction:
Male Genital System

geneyus@urologist.ph