L3 - Anatomy of the kidneys, ureters, urinary bladder

Question 1

Retroperitoneal space location

Answer 1

Anatomical space in abdominal cavity located posterior to the parietal peritoneum

Question 2

Structures in retroperitoneal space

Answer 2

S = Suprarenal glands

A = Aorta/IVC

D = Duodenum (second and third segments [some also include the fourth segment]

P = Pancreas (only head, neck, and body are retroperitoneal)

U = Ureters

C = Colon (only the ascending and descending colons, as transverse and sigmoid retain mesocolon)

K = Kidneys

E = Esophagus

R = Rectum

112 212 111

1) Kidneys
2) Ureters
3) Suprarenal glands
4) Muscles
5) Vessels arising from abdominal aorta
6) Spine and nerves (lumbar spinal nerves and autonomic nerves mostly)

Question 3

Lymphatic drainage of posterior abdominal wall

Answer 3

1) Pre-aortic nodes (drains lymph from foregit to hindgut, liver, gallbladder, pancreas, spleen); efferent lymph forms intestinal trunk
2) Lateral aortic nodes (drains kidneys, suprarenal glands, testes, ovaries, uterus, deep vessels of abdominal wall, common illiac nodes); efferent lymphs form the right and left lumbar trunks

Question 4

Kidney location

Answer 4

• Retroperitoneal on the posterior abdominal wall
• lies at the levels of T12 to L3
• Right kidney lower than left kidney due to position of the liver

Question 5

Kidney coverings

Answer 5

INNER (Cortex)—

1) Fibrous capsule
2) Perirenal/perinephric fat (surrounds kidneys and their vessels)
3) Renal Fascia
4) Pararenal/paranephric fat

OUTER————

Question 6

Structures that hold kidneys in position

Answer 6

1) Fibrous capsule of the kidneys
2) Perirenal fat
3) Renal Fascia
4) Pararenal fat
5) collagen bundles (from renal fascia)
6) Renal vessels
7) Ureter

**NO LIGAMENTS

Question 7

Renal sinus

Answer 7

• Space within the kidneys
• Consist of renal pelvis, renal calices (major calyx and minor calyx)

Question 8

What is the renal hilum

Answer 8

• the entrance to the renal sinus
• Vessels, nerves, ureter enter and exit the renal sinus via the renal hilum
• located at the level of transpyloric plane (~T12)
• *** Order of vessels from anterior to posterior: renal vein, renal artery, ureter

Question 9

Internal structures and layers of kidneys

Answer 9

INNERMOST

1) Renal Pelvis
2) Major calyx
3) Minor calyx
4) Renal Papillae
5) Renal Pyramid, renal columns
6) Renal Medulla
7) Renal Cortex

OUTERMOST

OUTERMOST

Question 10

What is the renal pelvis

Answer 10

• Flattened, funnel shaped expansion of the superior end of ureter
• apex of renal pelvis continuous with ureter
• receives two or three major calices

Question 11

Major calyx

Answer 11

• continuous with renal pelvis
• devides into two or three minor calices

Question 12

Definition of renal papillae

Answer 12

The apex of the renal pyramids, from which urine is excreted

Question 13

Blood vasculature of the kidneys

Answer 13

ARTERIES

• Left and Right Renal arteries arises from abdominal aorta to supply kidneys
• Renal arteries arise at the level of IV disc between L1 and L2
• Right renal artery longer than left renal artery (due to location of abdominal aorta on the left)
• Each divides close to the hilum into five segmental arteries supplying renal segments

VEINS

• Left and Right Renal veins drains into the Inferior Vena Cava
• Drainage to IVC at level L2
• Right renal vein longer than left renal vein (due to IVC’s location on the right)

Question 14

Lymphatic drainage of kidneys

Answer 14

• Renal lymphatic vessels follow the renal veins
• Drains into the lateral aortic lymph nodes (para-aortic or lumbar)

Question 15

Nerve supply of kidneys

Answer 15

• Renal Nerve Plexus (both sympathetic and parasympathetic)
• sympathetic: Renal sympathetic plexus (T12)
• parasympathetic: Vagus Nerve (CNX)

(? different from Moore ?)

Question 16

Location of Suprarenal Glands

Answer 16

• Superomedial aspect/superior poles of the kidneys
• Retroperitoneal on the posterior abdominal wall

Question 17

Internal structure/layers of suprarenal glands

Answer 17

INNERMOST

1) Suprarenal medulla (developed from neural crest cells; releases catecholamines e.g. epinephrine and norepinephrine)
2) Suprarenal cortex (derived from mesoderm; releases corticosteroids and androgens)

Question 18

Arteries of Suprarenal glands

Answer 18

Due to endocrine function of adrenal glands, abundant blood supply is necessary

• Superior suprarenal arteries from inferior phrenic artery
• Middle suprarenal arteries from abdominal aorta
• Inferior suprarenal arteries from renal arteries

Question 19

Veins of suprarenal glands

Answer 19

• the shorter Right Suprarenal Vein drains into IVC
• the longer Left Suprarenal Vein, joined by inferior phrenic vein, enters the left renal vein, then IVC

Question 20

Lymphatic drainage of suprarenal glands

Answer 20

Lateral aortic (para-aortic or lumbar) lymph nodes

Question 21

Nerve supply of suprarenal glands

Answer 21

• Celiac plexus
• Preganglionic fibers from Abdominopelvic splanchnic nerves (T5-T9)

(? different from Moore ?)

Question 22

Ureter location

Answer 22

• Begins at the renal pelvis (most posterior at the hilum) and ends at the urinary bladder
• Retroperitoneal on the posterior abdominal wall

Question 23

Physiological narrowings of ureter

Answer 23

1) Ureteropelvic junction (where renal pelvis joins the ureter)
2) where ureter crosses the pelvic brim/external iliac artery
3) Ureterovesical junction (where ureter pierces the urinary bladder wall)

** These 3 narrowings are potential sites for ureteric calculus obstruction

Question 24

Anatomical relations of ureter in male

Answer 24

Ductus deferens lies anterior to the ureter

Question 25

Anatomical relations of ureter in female

Answer 25

- At the base of broad ligament and cardinal ligament, ureter passes below the Uterine artery - important when doing hysterectomy or abdominopelvic surgery where they are liable to ligation

Question 26

Ureteric entry of bladder

Answer 26

- Ureters obliquely insert into the bladder (angles of the trigone of the bladder), acting as a valve

Question 27

Vasculature of ureter

Answer 27

**Arteries** - branches of abdominal aorta - renal arteries - gonadal arteries (i.e. testicular/ovarian artery) - iliac arteries - vesical arteries **Veins** - renal veins - gonadal veins - iliac veins - vesival veins

Question 28

Lymphatic drainage of ureters

Answer 28

Lateral aortic (para-aortic or lumbar) lymph nodes

Question 29

Nerve supply of ureter

Answer 29

1) Renal plexus 2) Testicular plexus 3) Hypogastric plexus

Question 30

Reference of ureteric stone pain

Answer 30

Loin, scrotum, penis or labia majora

Question 31

Bones of pelvis girdle

Answer 31

3 bones: 1) Left hip/pelvic bone (fused from left ilium, ischium, pubic) 2) Right hip/pelvic bone (fused from right ilium, ischium, pubis) 3) Sacrum (fused from 5 sacral vertebrae)

Question 32

Hip bone structure

Answer 32

- consist of three bones (superior to inferior): ilium, ischium, pubis - these bones unite by a triradiate cartilage, forming the acetabulum - the acetabulum is a cup-like depression that articulates with the head of femur

Question 33

Joints of pelvic girdle

Answer 33

1) Lumbosacral joint (lumbar vertebrae with sacrum) 2) Sacroiliac joints (sacrum with ilium) 3) Sacrococcygeal joint (posteriorly; sacrum with coccyx) 4) Pubic symphysis (anteriorly; left & right hip bones at pubis)

Question 34

Pelvic Inlet or Pelvic Brim components

Answer 34

(Posterior, lateral to anterior) 1) _Promontory and Ala of Sacrum_ 2) A right and left _Linea Terminalis:_ a) Arcuate line (inner surface of ilium) b) Pecten pubis/pectineal line (oblique ridge of superio-lateral pubis) c) Pubic Crest

Question 35

Anterioposterior diameter of pelvic inlet

Answer 35

- Measured by pelvimetry - from sacral promontroy to pubic crest - \>11.5cm

Question 36

Pelvic outlet components

Answer 36

(Posterior, lateral to anterior) 1) Tip of coccyx 2) Inferior margin of sacrotuberous ligament 3) Ischial tuberosities (laterally) 4) Pubic arch

Question 37

Important ligaments that stabalizes pelvic bone

Answer 37

1) Sacrospinous ligament (Sacrum to ischial spine) 2) Sacrotuberous ligament (Sarum to ischial tuberosities)

Question 38

Muscular component of pelvic lateral wall

Answer 38

Obturator internus muscles

Question 39

Muscular component of pelvic posteo-lateral wall

Answer 39

Piriformis muscles

Question 40

Function of piriformis and obturator internus muscles

Answer 40

1) Forming the lateral pelvic wall 2) Lateral rotator of the hip joint

Question 41

Obturator canal

Answer 41

A deficiency in the obturator internus muscles and the obturator membrane, with the function of: 1) Allowing passage of obturator VAN to pass from pelvis to thign, supply the adductors on the medial quadrant of the leg

Question 42

Greater Pelvis/False pelvis boundary

Answer 42

Superiorly bounded by the pelvic girdles Inferiorly bounded by the oblique plane of pelvic inlet

Question 43

Lesser pelvis/true pelvis boundary

Answer 43

Superiorly bounded by the oblique plane of pelvic inlet Inferiorly bounded by the pelvic floor/pelvic diaphragm

Question 44

Key comparison of male and female pelves

Answer 44

(Male vs female) Pelvic inlet: narroe vs wide Pelvic outlet: smaller vs larger Pubic arch/subpubic angle: Narrow (\<70º) vs Wide (\>80º) Obturator foramen: round vs oval Acetabulum: Large vs small

Question 45

Major arteries supplying true pelvis of women

Answer 45

6 Main arteries: 1,2) Paired **_Internal iliac arteries_** 3,4) Paired ovarian arteries 5) Median sacral artery 6) Superior rectal artery

Question 46

Major arteries supplying true pelvis of men

Answer 46

4 main arteries: 1,2) Paired Internal iliac arteries 3) Median sacral artery 4) Superior rectal artery (\*\* Testicular arteries do not enter true pelvis)

Question 47

Branches of internal illiac artery

Answer 47

Anterior division (7-8 branches) 1) Umbilical 2) Obturator 3) Superior vesical 4) Internal pudental (supplies perineum) 5) Inferior gluteal 6) Middle rectal 7♂) Inferior vesical (give rise to prostatic artery and artery to ductus deferens) 7♀) Vaginal 8♀) Uterine Posterior division (3 branches) 1) Iliolumbar 2) Lateral sacral 3) Superior gluteal

Question 48

Autonomic Nervous structure of the true pelvis

Answer 48

Supplied by superior and inferior hypogastric plexes (T1-2, S2-4) **_Pelvic Splanchnic Nerves_** - arises in the pelvis from spinal nerves S2-S4 - conveys parasympathetic fibers to hypogastric plexus **_Lumbar Splanchnic Nerves_** - arises from L1-2 - supply sympathetic fibers to hypogastric plexus ------------------------ **Origin:** Coeliac plexus (T5-T11, CNX) ---\> Superior Mesenteric plexus ---\> Intermesenteric plexus (no vagal parasympathetic fibers; Lumbar splanchnic nerve L1 L2 from lumbar sympathetic trunk) ---\> Inferior Mesenteric Plexus ---\> Superior Hypogastric Plexus (lumbar splanchnic nerve)---\> Inferior Hypogastric Plexus (Sacral splanchnic nerve) _[[pelvic splanchnic nerves S2-4 run through to inferior mesenteric plexus]]_ ------------------------

Question 49

Structures in the true pelvic cavity

Answer 49

1) Urinary Bladder 2) Rectum 3) Anal Canal 4) female repriductive organs (uterus, ovaries, fallopian tubes, vagina) 5) male reproductive organs (prostate, seminal vesicle, ductus deferens) 6) Nerves (mainly hypogastric plexes) 7) Veseels (mainly branches of internal iliac artery) 8) lymphatics

Question 50

Pelvic Floor

Answer 50

The pelvic floor is formed by a muscular structure known as the **pelvic diaphragm (PD)** which consist of: **1) Levator ani muscle** a) Puborectalis b) Pubococcygeus c) Iliococcygeus **2) Coccygeus muscle**

Question 51

Pelvic Diaphragm nerve supply

Answer 51

1) Sacral nerve 4 and 5 2) Branches of pudendal nerve

Question 52

Action of pelvic disphargm

Answer 52

1) Supports and stablilizes the position of pelvic viscera 2) Act as a sphincter for anorectal junction and vagina \*\* Due to 1, damaged PD (e.g. women after parturition) would caused prolapsed of the pelvic viscera ie. pelvic organs (e.g. bladder, vagina, uterus, rectum) passing through into the perineum.

Question 53

Perineal body (location, clinical relevance)

Answer 53

Location: Between pelvic diaphragm and irogenital diaphragm; posterior to vagina/prostate Clinical relevance: damage to perineal body will cause prolapse of pelvic viscera

Question 54

Peritoneal reflections (definition and examples)

Answer 54

Peritoneal reflections are infolding along the abdominal and pelvic cavities a) **Vesicouterine pouch** (space between bladder and uterus in female) b) **Rectovesical pouch** (space between bladder abd rectum in male)

Question 55

Urogenital diaphragm (components and points of interest

Answer 55

Components: 1) Deep transverse perineal muscles (DTPM) 2) Perineal membrane (over the muscles) 3) Sphincter urethrae Notes: 
1. DPTM is incomplete and not entirely transverse.
 2. sphincter urethrae may not exist and it could be part of the urethra within. 3. perineal membrane plays a major part of the support

Question 56

Bladder wall layers

Answer 56

(internal to external) 1) Transitional epithelium (folded when relaxed, can be stretched) 2) Detrussor muscle (very thick) 3) outer serous peritoneal layer (superior surface only)

Question 57

Support of the bladder

Answer 57

1) Urogenital diaphragm 2) Pelvic fascia 3) Medial umbilical ligament (umbilical artery) 4) Median umbilical ligament (urachus)

Question 58

Trigone

Answer 58

- A triangular area at base of bladder - between the internal urethral orifice and the two ureteric orifices - smooth in lining - most sensitive to pain and stretching - upper border marked by ureteric ridge/fold

Question 59

Ureteric ridge/fold location

Answer 59

between ureteric orifices on the urinary bladder

Question 60

Sphincter vesicae

Answer 60

Aka Internal urethral sphincter - Located at the neck of the urinary bladder - smooth muscles; supplied by ANS (involuntary) - fixed by pubovesical ligament (female) and puboprostatic ligament (male)

Question 61

Sphincter urethrae

Answer 61

- aka External urethral sphincter - Skeletal muscles; under voluntary control by somatic nervous system

Question 62

Anatomical relationships of urinary bladder

Answer 62

Anterior: Pubic symphysis Posterior: Uterus (female); Rectum (male)

Question 63

Vasculature of urinary bladder

Answer 63

**Arterial Supply:** 1) Superior vescial artery (from internal illiac artery) 2) Inferior vesical artery (male) / vaginal artery (female) **Venous drainage:** Vesical venous plexus -\> prostatic venous plexus -\> internal iliac vein

Question 64

Lymph drainage of urinary bladder

Answer 64

internal and external iliac nodes

Question 65

Nerve supply of urinary bladder

Answer 65

ANS: Hypogastric plexus (T1-2, S2-4)

Question 66

Transurethral cytoscopy

Answer 66

an invasive procedure that will allow you to view the internal features of the bladder, prostate, urethra, ureters and extract ureteral stone or perform other surgical procedures.

Question 67

Suprapubic Aspiration

Answer 67

Distended bladder rises above the symphysis pubis and lifts the peritoneum away from the anterior abdominal wall. A needle can be punctured above the symphysis pubis to drain the bladder.