Anatomy of the Urinary Tract, Kidneys, Ureters, Adrenals

Lecture given:

Objectives

State the location of the kidneys within the abdominal cavity and in relation to bony landmarks

  • Kidneys are 12cm x 6cm x 3cm thick
  • Can extend from T12 to L3. The left can go up to T11 (right is lower due to liver)
  • Lie against the psoas major muscles
  • Oblique poles with the inferior more lateral than superior
  • Transpyloric plane passes through the upper right kidney hilum, and the lower part of the left

Name the connective tissue coverings of the kidney

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  • Kidneys are retroperitoneal structures
  • Renal fascia: anchored to the wall, almost continous with peritoneum. Partitions and surrounds adrenals from kidneys
  • Perirenal fascia (fat): mainly fat, very thick layer. Serves to protect the kidneys & adrenals in an adipose capsule
  • Renal capsule: thin fibrous capsule surrounding the kidneys
  • Pararenal fascia (fat): between the renal capsule and the psoas and quadratus lumborum muscles. Only a thin layer of fat
  • In people who lost fat around the kidneys, they will start to drop. Ureters will bend and fold, creating a kink
  • So, the kidneys are surrounded by renal capsule, which is surrounded by pararenal fat, which is surrounded by renal fascia, which is partially surrounded by pararenal fat, which is then surrounded by the rest of the retroperitoneal muscles stuff

List the anterior relations of the left and right kidneys

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  • Right kidney: liver, adrenal, 2nd part duodenum, hepatic flexure, ileum
  • Left kidney: tail of pancreas, adrenal, stomach, spleen, splenic flexure, jejunum

Name the structures in the hilum of the kidney and state their relationship to one another

  • Outer renal cortex enveloping the inner medullar, formed into pyramids, which are separated from one another by inward extensions of the cortex (renal columns)
  • Apex of each pyramid extends towards the renal sinus as renal papilla containing collecting ducts
  • Collecting ducts drain from the tip into a minor calyx (8-10 per kidney), which drain into 2-3 major calyces, which become the renal pelvis, which then leave as the ureter

Follow the intra-abdominal course of the ureters and propose possible concerns about their relationship to gonadal and intestinal vessels

  • From the kidney, ureter passes inferiorly, deep to the perioneum, along the psoas muscle, adjacent to the tips of the transverse processes of the lumbar vertebrae
  • Enters the pelvis by crossing the pelvic brim at where the common iliac artery divides (sacroiliac joint)
  • Then the ureter makes a 90 degree angle at the ischial spine and passes forwards to enter the bladder
  • concerns Ureters are crossed by gonadal vessels. The left ureter is also crossed by left colic vessels, the right ureter by the right colic, ileocolic and intestinal vessels

Describe the features of the suprarenal glands and state their location and functions

  • On top of the kidneys surrounded by perirenal fat and renal fascia
  • Comprised of cortex (steroid hormones) and medulla (epi and norepi)
  • Suprarenal arteries come from three sources:
    • inferior phrenic artery (from aorta)
    • Aorta (direct branch)
    • Renal artery
  • Veins unite to form a single suprarenal vein for each gland
    • Left enters the left renal vein
    • Right drains directly into IVC
  • Nerve supply via the coeliac plexus. Most are pre-ganglionic sympathetic fibres to th cells of the adrenal medulla

State the arterial supply, venous drainage and lymphatic drainage of the kidneys, ureters and suprarenal glands

  • Arteries: arise from the L2 level at the aorta. The right renal artery is loner than the left (because aorta is toward the left), and passes posterior to the IVC
    • Give branches to ureters, adrenals, and kidneys
  • Veins: empty into the IVC. Passes anterior to the arteries expect at the hilum, where they are usually posterior
    • L renal vein is longer than the right, and received drainage from the L supraenal v & L. gonadal vein
  • Ureters are always inferior to the blood vessels
  • Nutcracker Effect: The L. renal v is sandwiched between the sup. mesenteric artery and the aorta, both with thick muscular walls. It is possible for the weight of the sup mesenteric a to compress the L. renal v, blocking venous drainage from the L kidney, gonads and adrenal gland
  • Lymphatic drainage of the kidney is to paraaortic (lumbar) nodes

State the nerve supply to the kidneys, ureters and suprarenal glands, with particular reference to pain

  • Visceral pain is caused by either ischemia or distension, and are dull aching in nature, usually through sympathetic nervous system innervation
  • Kidneys are innervated from the superior and intermesenteric ganglia and aorticorenal plexus (T10-L1)
    • T 10: up to umbilicus
    • L 1: groin area (top of thigh)
    • Boxer region
  • Kidney stones often cause ureter pain
    • Innervation T12 - L2
    • T 12: right above pubis symphisus
    • L2: mid thigh-ish
    • "Loin to Groin" pain (to scrotum or labia majora) typical of kidney stones

Predict the most likely sites of obstruction of the ureters due to a urinary calculus

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  • Where there is a narrowing:
    • pelvis of ureter narrows
    • ureter crosses the pelvic brim
    • entering the bladder
    • leaving the bladder (mentioned in lecture, not notes)


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