Applied Anatomy of Urinary Tract

B3 - 3rd Session
By: Anatomy Teaching Assistant Batch 2015
NS LO SM ND DR YS RO TO GR MI PA AB
CASE 1 ND
Normal Kidney
Vascularization
 Nephroptosis
– Terjadi karena fascia renal
bagian inferior kurang
berfusi secara kuat sehingga
lack of support
– Glandula suprarenal berada
dalam kompartemen fascia
yang berbeda  tetap di
tempat
– Perbedaan dari ectopic
kidney  panjang ureter
normal! Nephroptosis . Ectopic kidney
 Glomerulonephritis

– Mekanisme imunologis memicu inflamasi dan proliferasi jaringan glomerular  kerusakan membrana basalis,
mesangium, endothelium kapiler.
– Sign&Symptoms: Hematuria, proteinuria, red blood cell (RBC) casts, hipertensi, edema, azotemia, retensi air dan garam
 Pyelonephritis

– Pyelonephritis is an inflammation of the kidney tissue, calyces, and renal pelvis. It is commonly caused by
bacterial infection that has spread up the urinary tract or travelled through the bloodstream to the kidneys.
– Manifestasi klinis: demam, nyeri costovertebral, mual dan muntah
 Polycystic kidney disease

– Merupakan renal cystic disease yang paling sering diwariskan.

– Terkait autosomal dominant
Kidney Transplantation
 Visceral referred pain
– Nyeri yang timbul karena obstruksi calculi
di referred ke area kutan yang diinervasi
oleh segmen medulla spinalis dan ganglion
sensoris yang sama dengan visceral afferent
fiber dari ureter, yaitu segmen T11-L2
– “From loin to groin”
– Nyeri dapat dirasakan hingga aspek
proksimal anterior dari regio femoral,
scrotum dan labia mayor karena proyeksi
via n. genitofemoralis (L1,L2)
Case 2 NS
Nephron
Bifid Renal Pelvis and Ureter
Ectopic
Pelvic Kidney
Pancake & Horseshoe
kidney
Retrocaval
Ureter
Abnormalities of Urachus
Bloodless line

Brödel’s line Sagittal Plane

(projected to
Brödel’s line Posterolateral
abdominal wall)
Case 3 SM
Inervation
of urinary
organs
 SYMPHATETIC

 The sympathetic innervation of the bladder originates in the lower thoracic and upper

lumbar spinal cord segments (T10-L2),

 The preganglionic axons running to sympathetic neurons in the inferior mesenteric
ganglion and the ganglia of the pelvic plexus.
 The postganglionic fibers from these ganglia travel in the hypogastric and pelvic
nerves to the bladder,
 increase in bladder pressure from the accumulation of urine-> Sympathetic activity ->
internal urethral sphincter close , innervate the blood vessels of the bladder, and in
males the smooth muscle fibers of the prostate gland-> inhibits the contraction of the
bladder wall musculature-> allowing the bladder to fill.
 At the same time, moderate distension of the bladder inhibits parasympathetic activity
(which would otherwise contract the bladder and allow the internal sphincter to open).
 PARASYMPATHETIC

 When the bladder is full, afferent activity conveying this

information centrally -> increases parasympathetic tone and decreases
sympathetic activity -> causing the internal sphincter muscle to relax
and the bladder to contract.
 In this circumstance, the urine is held in check by the voluntary
(somatic) motor innervation of the external urethral sphincter muscle
– The central governance of these events stems from the rostral pons, the relevant
pontine circuitry being referred to as the micturition center (micturition is also
“medicalese” for urination).
– five other central regions implicated in the coordination of urinary functions,
including :
1.locus coeruleus,
2. hypothalamus,
3. the septal nuclei, and
4. several cortical regions =paracentral lobule, the cingulate gyrus,
5. and the frontal lobes.
(the motor representation of perineal musculature in the medial part of the
primary motor cortex and the planning functions of the frontal lobes which are equally
pertinent to bodily functions (remembering to stop by the bathroom before going on a long
trip, for instance))
AUTONOM
 Nephrolithiasis
▪ Calculi terbentuk dari garam
inorganik atau organik atau material
lainnya, tergantung kelainan
metabolik yang diderita
▪ Staghorn calculi → mengisi pelvis
renalis dan minimal 2 calyx
▪ Tx: pyelolithotomy, ESWL, PCNL
Nephrolithiasis & Ureterolithiasis – cont.
Ureterolithiasis

▪ Batu biasanya tersumbat pada 3 penyempitan ureter

▪ Jika batu tajam / >3mm (lumen ureter normal) → distensi berlebih
ureter → severe intermittent pain
▪ Batu dapat mengobstruksi total ureter → hidronephrosis
▪ Tx: ureterolithotomy, ureteroscopy
Vesicolithiasis
▪ Penyebab tersering: gangguan voiding
▪ Tanda dan gejala: nyeri saat berkemih, UTI, hematuria, pelvic pain,
intermittent urinary stream
▪ Treatment:
▪ Cystolitholapaxy (menggunakan cystoscope)
▪ Cystolithotomy
 Lithotripsy (ESWL)

▪ Menggunakan sumber energi untuk generasi shock wave →

mekanisme coupling memindahkan energi dari luar ke dalam tubuh
→ modalitas fluoroscopy atau USG digunakan untuk identifikasi
posisi calculi → konvergensi sumber energi
▪ Untuk ukuran batu 4 mm – 2 cm
▪ Kontraindikasi : wanita hamil, aneurisme abdominal, gangguan
hemostasis
▪ Komplikasi : trauma, perdarahan intrarenal dan perirenal, edema
Ureteral Stenting
▪ Untuk mempertahankan patensi ureter
▪ Bersifat sementara
▪ Untuk mencegah cedera berlebih pada
ginjal (hidronefrosis) sampai prosedur
pengeluaran batu dapat dilakukan
 Ureteroscopy (URS)

– Ureteroscopy is also a powerful tool in the diagnosis, treatment,

and surveillance of transitional cell tumors of the upper tracts
– In addition, ureteroscopy can be employed to treat ureteral
stenosis/stricture and ureteropelvic junction obstruction.
In each setting, an energy source is delivered through the working
channel of the endoscope to fragment, ablate, and/or incise. Additional
accessories can also be passed through the standard 3.6F working
channel to remove stone fragments or to obtain biopsy
samples
 Percutaneous
Nephrolithotomy
(PCNL)

▪ Merupakan treatment of choice

untuk calculi besar (>2.5 cm)
pada renal dan ureter proximal
yang resisten terhadap ESWL
▪ Insersi tube di Brödel’s
Bloodless Line
▪ Mekanisme trauma:
▪ Blunt → kecelakaan, olahraga
▪ Penetrating → gunshot wound
▪ Hematuria (hallmark sign of
renal trauma), flank pain,
ecchymosis pada region flank
dan kuadran atas abdomen,
fraktur costae bawah, massa
terpalpasi, diffuse abdominal
tenderness, distensi abdomen
hingga shock
▪ Modalitas diagnostik → IVP
pyelogram, CT scan

Rupture Renal
grade I: contusion or non-enlarging subcapsular perirenal haematoma, and no laceration

grade II: superficial laceration <1 cm depth and does not involve the collecting system (no
evidence of urine extravasation), non-expanding perirenal haematoma confined to
retroperitoneum

grade III: laceration >1 cm without extension into the renal pelvis or collecting system (no
evidence of urine extravasation)

grade IV
laceration extends to renal pelvis or urinary extravasation
vascular: injury to main renal artery or vein with contained haemorrhage
segmental infarctions without associated lacerations
expanding subcapsular haematomas compressing the kidney

grade V
shattered kidney
avulsion of renal hilum: devascularisation of a kidney due to hilar injury
ureteropelvic avulsions
complete laceration or thrombus of the main renal artery or vein
Case 4 LO
 Urethrolithiasis

Stone in urethra

Tx → urethrolitotomy,
meatotomy
Rupture of Urethra in Male

ANTERIOR RUPTURE

POSTERIOR RUPTURE
 ▪ Etiologi : straddle injury, transurethral catetherization

Anterior ▪ Ruptured structure : Buck’s Fascia, urethra in bulb of penis

(mostly)

Rupture ▪ Temuan klinis : Butterfly hematoma

▪ Komplikasi : striktur urethra
Why
Butterfly
Hematome ?
 Posterior
Rupture

▪ Etiologi : Fracture of Pelvic Girdle

▪ Ruptured Structure : urethra pars
membranacea, Lig. Puboprostaticum,
symphysis pubis (fractured)
▪ Temuan klinis : Floating prostate,
meatal bleeding, retensi urin
▪ Komplikasi : stiktur urethra, ED,
inkontinensia urin (overflow)
Why floating prostate ?
Urethritis

▪ Inflammation of urehtra
▪ SS → pain when
micturition, urinary incontinence
 Balanitis & Balanopostitis

• Balanitis : Inflammation of glans

penis
• Balanopostitis : inflammation of
glans and prepuce
• Etiology : infection, poor hygiene
Cystocele
▪ Prolapse/ herniation of part
of vesica urinaria to the wall
of the vagina
▪ Complication : urgency
urinary incontinence, UTI,
and pressure sensation on
the wall of vagina
▪ Inflammation of
Urinary Bladder
▪ SS :
- Urinary Incontinence
(Urgency type)
- Dysuria
- Suprapubic Pain
- Pain referred to T11-
L2/L3 and S2-S4 (pelvic
pain line concept)

Cystitis
 Suprapubic
Cystotomy

- Indication : high risk of UTI, urethral rupture,

failure of urethral catheter

- Parietal peritoneum at supravesical fossa is

loosely attached to the superficial layer at this site
>> so V.U is able to distent to the abdominal
cavity

- Suprapubic extraperitoneal incision could be

made to access the V.U
Cystoscopy

▪ Cystoscopy = Cystourethroscopy

▪ General purpose : evaluation of urethra and urinary bladder

▪ Indications : hematuria,voiding symptoms, or bladder obstruction; for

surveillance in the
setting of malignant neoplasms; and for removal of genitourinary foreign
bodies

▪ 2 types of endoscopy : rigid and flexible

rigid >> often used in female
flexible >> often used in male
 Urinary Incontinence ?
Continence = ability to
retain voluntarily

Urinary incontinence =
involuntary loss of
urine
Type Of Urinary Incontinence

Mixed True Urgency

Urgency Overflow Stress

Stress Urinary Incontinence
The sensation of urge appeared first then
followed by urine loss

Urgency Urinary
Incontinence
Mixed Urinary Incontinence
True Urinary Incontinence = Continuous
Urinary Incontinence

Etiology = Fistula (look at the picture

number 1-3)

SS = urine loss day and night!

True Urinary
Incontinence
Overflow Urinary Incontinence
Summary of Urinary Incontinence
 Hypospadia
• Etiology : Failure of fusion of
urethral fold
• Clinical Feature : OUE appears on
ventral of penis
• Circumscision !
(CONTRAINDICATION)
• Management :
Urethroplasty
 Epispadia
• OUE located on dorsal penis
• Associated with exstrophy of the bladder and
cloacal exstrophy
Thankyou!