Surgical, Radiologic, and Endoscopic Anatomy of the Kidney and Ureter

Question 1

The kidneys lie on the psoas muscles; thus the longitudinal axes of the kidneys are ___ with the upper poles more ___ and ____ than the inferior poles.

Therefore, during percutaneous renal access, the lower pole of the kidney lies ___ and ___ relative to the upper pole.

In addition, the medial aspect of each kidney is rotated ___ at an angle of approximately ___.

Answer 1

The kidneys lie on the psoas muscles; thus the longitudinal axes of the kidneys are oblique with the upper poles more medial and posterior than the inferior poles. Therefore, during percutaneous renal access, the lower pole of the kidney lies laterally and anteriorly relative to the upper pole. In addition, the medial aspect of each kidney is rotated anteriorly at an angle of approximately 30 degrees.

Question 2

the kidneys move inferiorly approximately ___ (____ body) during inspiration and during changing body position from ___ to the ___ position. Because of the inferior displacement of the right kidney by the liver, the right kidney sits ____ than the left kidney. Therefore the right kidney resides in the space between the top of the ____ to the ___, whereas the left kidney occupies a space between the ___ and the ___.

Answer 2

The exact position of the kidney within the retroperitoneum varies during different phases of respiration, body position, and presence of anatomic anomalies. For example, the kidneys move inferiorly approximately 3 cm (one vertebral body) during inspiration and during changing body position from supine to the erect position. Because of the inferior displacement of the right kidney by the liver, the right kidney sits 1 to 2 cm lower than the left kidney. Therefore the right kidney resides in the space between the top of the 1st lumbar vertebra to the bottom of the 3rd lumbar vertebra, whereas the left kidney occupies a space between the 12th thoracic vertebra and the 3rd lumbar vertebra.

Question 3

Each kidney measures ___ cm in length, ___ cm in width, and ___ cm in thickness. Each adult male kidney weighs approximately __; the kidney is __ g smaller in females. The kidneys are ___ in children and have more prominent ___, which generally disappear by the ___. In addition, the adult kidney’s lateral contour may have a focal renal parenchymal bulge known as a ___, which is more common on the ___ and has no pathologic significance. These dromedary humps are thought to be caused by the downward pressure from the __or the ___.

Answer 3

Each kidney measures 10 to 12 cm in length, 5.0 to 7.5 cm in width, and 2.5 to 3.0 cm in thickness. Each adult male kidney weighs approximately 125 to 170 g; the kidney is 10 to 15 g smaller in females. The kidneys are relatively larger in children and have more prominent fetal lobulations, which generally disappear by the first year of life. In addition, the adult kidney’s lateral contour may have a focal renal parenchymal bulge known as a dromedary hump, which is more common on the left side and has no pathologic significance. These dromedary humps are thought to be caused by the downward pressure from the liver or the spleen. T

Question 4

Superiorly, the kidneys are related to the inferior edge of the
___ and the __.

The right kidney is related to the __, and the left kidney is related to the ___ and ___

Furthermore, percutaneous access to the upper pole of the kidneys above the __ (____) is associated with increased risk for injuring pleura and even lungs.

More inferiorly, the kidneys are related to the ___ muscle medially and the ___ and __ of the ___ muscles laterally.

The ____ and vessels and the ___and ___nerves descend obliquely across the posterior surfaces of the kidneys .

Answer 4

Superiorly, the kidneys are related to the inferior edge of the
diaphragm and the ribs.

The right kidney is related to the 12th rib, and the left kidney is related to the 11th and 12th ribs

Furthermore, percutaneous access to the upper pole of the kidneys above the 11th rib (10th intercostal space) is associated with increased risk for injuring pleura and even lungs.

More inferiorly, the kidneys are related to the psoas major muscle medially and the quadratus lumborum and aponeurosis of the transversus abdominis muscles laterally.

The subcostal nerve and vessels and the iliohypogastric and ilioinguinal nerves descend obliquely across the posterior surfaces of the kidneys .

Question 5

The right kidney is related __ to the liver (intraperitoneal and retroperitoneal bare portions) and ___ to the adrenal gland.

Inferiorly, the right kidney is related to the ____ and ____ of the colon, and medially it is related to the ___ stage of the duodenum and ___ of the pancreas.

The _____ bridging the upper pole of the right kidney to the liver forms the ___ ligament.

The left kidney is related to the __ and ___ superiorly, ___ superomedially, ___ and ___ of the colon inferiorly, and___ of the pancreas with ___ vessels medially.

The parietal peritoneum bridging the upper pole of the left kidney to the spleen forms the ____ ligament.

Answer 5

The right kidney is related superiorly to the liver (intraperitoneal and retroperitoneal bare portions) and superomedially to the adrenal gland.

Inferiorly, the right kidney is related to the small intestine and hepatic flexure of the colon, and medially it is related to the second stage of the duodenum and head of the pancreas.

The parietal peritoneum bridging the upper pole of the right kidney to the liver forms the hepatorenal ligament.

The left kidney is related to the stomach and spleen superiorly, adrenal gland superomedially, jejunum and splenic flexure of the colon inferiorly, and tail of the pancreas with splenic vessels medially.

The parietal peritoneum bridging the upper pole of the left kidney to the spleen forms the splenorenal ligament.

Question 6

Each kidney and its vessels are surrounded by a ____ that extends into its ____, the ___, which is the entrance to a space within the kidney called the ___

Answer 6

Each kidney and its vessels are surrounded by a perinephric fat that extends into its hollow vertical cleft, the renal hilum, which is the entrance to a space within the kidney called the renal sinus.

Question 7

The ___ and ___, including the ___ surrounding them, are enclosed by a condensed, membranous layer of ___, which continues ___ to fuse with the ___.

This fascia extends ___ along the ___ as a ____.

The Gerota fascia encasing the ___, ___, and ____ is closed ____ and ___ and serves as an ___ to the spread of malignancy and a means of containing ___ collections.

Because it is open inferiorly, perinephric fluid collections can track ____ into the pelvis without violating the Gerota fascia.

Answer 7

The kidneys and adrenal glands, including the perirenal fat surrounding them, are enclosed by a condensed, membranous layer of renal (Gerota) fascia, which continues medially to fuse with the contralateral side.

This fascia extends inferomedially along the abdominal ureter as a periureteral fascia.

The Gerota fascia encasing the kidneys, adrenal glands, and abdominal ureters is closed superiorly and laterally and serves as an anatomic barrier to the spread of malignancy and a means of containing perinephric fluid collections.

Because it is open inferiorly, perinephric fluid collections can track inferiorly into the pelvis without violating the Gerota fascia.

Question 8

The Gerota fascia is further surrounded by a layer of condensed fat called the___, which is most obvious __ and represents the __ of the ___.

Superiorly, the Gerota fascia is continuous with the ____ on the inferior surface of the diaphragm, and inferiorly, the anterior and posterior layers of the Gerota fascia are ___.

The Gerota fascia is attached with the paranephric fat by ___. Therefore the kidneys are relatively kept fixed in position by these ___, the ___, and ___.

Answer 8

The Gerota fascia is further surrounded by a layer of condensed fat called the paranephric fat, which is most obvious posteriorly and represents the extraperitoneal fat of the lumbar region.

Superiorly, the Gerota fascia is continuous with the diaphragmatic fascia on the inferior surface of the diaphragm, and inferiorly, the anterior and posterior layers of the Gerota fascia are loosely attached.

The Gerota fascia is attached with the paranephric fat by collagen bundles. Therefore the kidneys are relatively kept fixed in position by these collagen bundles, the Gerota fascia, and paranephric fat.

Question 9

To access the kidneys, adrenals, or abdominal ureters, the ___ must be opened.

To access the kidneys transperitoneally, the colon must be mobilized from the ___, which is the ___ of ___ over the ascending and descending colon.

To access the right renal hilum, the ___ of the duodenum and ___ pancreas must be carefully mobilized using the ___ maneuver.

To access the left renal hilum, the tail of the pancreas together with the spleen and splenic vessels must be mobilized ____.

Answer 9

To access the kidneys, adrenals, or abdominal ureters, the Gerota fascia must be opened.

To access the kidneys transperitoneally, the colon must be mobilized from the white line of Toldt, which is the lateral reflection of posterior parietal peritoneum over the ascending and descending colon.

To access the right renal hilum, the second stage of the duodenum and head of pancreas must be carefully mobilized using the Kocher maneuver.

To access the left renal hilum, the tail of the pancreas together with the spleen and splenic vessels must be mobilized medially.

Question 10

Two distinct regions can be identified on the cut surface of a bisected kidney: the cortex, which is a ___ outer region, and the medulla, which is a __ inner region

The renal medulla is divided into___ striated, distinct, conically shaped areas that are frequently called___

The ___ forms the renal papilla, and each papilla is cupped by an___. The base of the pyramids is positioned at the ___.

Furthermore, these renal papillae could be inspected ___.

Answer 10

Two distinct regions can be identified on the cut surface of a bisected kidney: the cortex, which is a pale outer region, and the medulla, which is a darker inner region

The renal medulla is divided into 8 to 18 striated, distinct, conically shaped areas that are frequently called renal pyramids.

The apex of the pyramids forms the renal papilla, and each papilla is cupped by an individual minor calyx. The base of the pyramids is positioned at the corticomedullary boundary.

Furthermore, these renal papillae could be inspected endoscopically.

Question 11

The renal cortex is approximately ___ in thickness and covers the base of each renal pyramid peripherally and extends downward between the individual pyramids to form the ___ ___ arteries traverse these ____ from the renal sinus to the peripheral cortex and decrease/increase in diameter as they move peripherally.

Therefore percutaneous access to the collecting system is usually performed through a ___ into a calyx to avoid these ___ containing larger blood vessels.

The pyramids and their associated cortex form the __of the kidney.

Answer 11

The renal cortex is approximately 1 cm in thickness and covers the base of each renal pyramid peripherally and extends downward between the individual pyramids to form the Collumns of Bertin.

Interlobar arteries traverse these Collumns of Bertin from the renal sinus to the peripheral cortex and decrease in diameter as they move peripherally.

Therefore percutaneous access to the collecting system is usually performed through a renal pyramid into a calyx to avoid these collumns of Bertin containing larger blood vessels.

The pyramids and their associated cortex form the lobes of the kidney.

Question 12

The functional unit of the kidney is the nephron

Approximately
___ million nephrons are found in each adult kidney. The nephron consists of a ___, which is composed of a surrounded by ___ cells and the thin, fibrous ___.

The glomerulus filters the blood at a rate of ___ mL/min, the glomerular filtration rate, which is considered an __

The filtrate passes into the ___ and then into the ___, through the thin and thick limbs of the ___, to the ___adjacent to the glomerulus, and into the ___. It then enters the ___ and the ___. After absorption of approximately __ of this filtrate, the remaining part constitutes the urine, which drips from the collecting ducts into the ___, then to the ___, ___, and __.

Answer 12

The functional unit of the kidney is the nephron

Approximately
0.4 to 1.2 million nephrons are found in each adult kidney. The nephron consists of a glomerulus, which is composed of a surrounded by epithelial cells and the thin, fibrous Bowman capsule.

The glomerulus filters the blood at a rate of 125 mL/min, the glomerular filtration rate, which is considered an index of renal function.

The filtrate passes into the Bowman space and then into the proximal convoluted tubule, through the thin and thick limbs of the loop ofHenle, to the macula densa adjacent to the glomerulus, and into the distal convoluted tubule. It then enters the collecting tubules and the ducts of Bellini. After absorption of approximately 90% of this filtrate, the remaining part constitutes the urine, which drips from the collecting ducts into the calyces, then to the renal pelvis, ureter, and bladder.

Question 13

Three layers separate the filtered blood from the Bowman space: a __ layer of ___ cells, a thin glomerular ___, and a layer of ___ on the other side of that basement membrane. The proximal and distal convoluted tubules and the loop of Henle are lined by a ___ of ___ cells.

The cells lining the collecting ducts are ___ and are more resistant to damage than those of the renal tubules. The calyces, pelvis, ureters, bladder, and urethra are lined by ____, the urothelium, which may change and give rise to a transitional cell carcinoma of the urinary tract or urothelial carcinoma.

Answer 13

Three layers separate the filtered blood from the Bowman space: a single layer of endothelial cells, a thin glomerular basement membrane, and a layer of podocytes on the other side of that basement membrane. The proximal and distal convoluted tubules and the loop of Henle are lined by a single layer of cubical epithelial cells.

The cells lining the collecting ducts are cubical to columnar and are more resistant to damage than those of the renal tubules. The calyces, pelvis, ureters, bladder, and urethra are lined by transitional epithelium, the urothelium, which may change and give rise to a transitional cell carcinoma of the urinary tract or urothelial carcinoma.

Question 14

From anterior to posterior, the renal hilar structures are the__, ___, ___, and ___ —making the mnemonic ___

Answer 14

From anterior to posterior, the renal hilar structures are the renal vein (V), renal artery (A), renal pelvis (U for ureter), and posterior segmental artery (A)—making the mnemonic VAUA.

Question 15

Compared with renal size, cortical thickness, or parenchymal thickness,
___ correlates strongly with severity of pathologic changes in renal parenchyma, such as glomerular sclerosis, tubular atrophy, interstitial fibrosis, and inflammation

However, this correlation coefficient is still low with subsequent poor predictive value of renal echogenicity. Compared with renal parenchyma, the renal sinus appears ____
because of the presence of hilar adipose tissue, blood vessels, and lymphatics

On unenhanced computed tomography (CT), the renal parenchyma is homogeneous, with a density ranging from ___ Hounsfield units (HU) that increases up to ___ HU after intravenous contrast injection. After 20 to 30 seconds of contrast injection, the ___is reached, and the ____ appears after 30 to 70 seconds, when contrast accumulates in the renal cortex. The ____, after 80 to 120 seconds, equally enhances renal cortex and medulla and is considered to be the optimal phase for detection of ___. Finally, the ____, more than 3 minutes after contrast injection, shows the opacified pelvicalyceal system, ureter, and bladder

Answer 15

Compared with renal size, cortical thickness, or parenchymal thickness,
cortical echogenicity correlates strongly with severity of pathologic changes in renal parenchyma, such as glomerular sclerosis, tubular atrophy, interstitial fibrosis, and inflammation

However, this correlation coefficient is still low with subsequent poor predictive value of renal echogenicity. Compared with renal parenchyma, the renal sinus appears hyperechoic
because of the presence of hilar adipose tissue, blood vessels, and lymphatics

On unenhanced computed tomography (CT), the renal parenchyma is homogeneous, with a density ranging from 30 to 60 Hounsfield units (HU) that increases up to 80 to 120 HU after intravenous contrast injection. After 20 to 30 seconds of contrast injection, the arterial CT phase is reached, and the corticomedullary CT phase appears after 30 to 70 seconds, when contrast accumulates in the renal cortex. The nephrographic CT phase, after 80 to 120 seconds, equally enhances renal cortex and medulla and is considered to be the optimal phase for detection of renal neoplasms. Finally, the excretory CT phase, more than 3 minutes after contrast injection, shows the opacified pelvicalyceal system, ureter, and bladder

Question 16

Magnetic resonance imaging with T1 and T2 relaxation sequences provides information regarding __ and enhancement characteristics of tissues. T1-weighted sequences show the renal cortex ___ than the renal medulla, whereas the cortex is slightly less intense than the medulla on T2-weighted sequences. The renal pelvis containing fat appears ___ on T1- and T2-weighted sequences. After injection of contrast, the nephrographic and excretory phases start after _-_ seconds and ___ seconds of contrast injection, respectively

Answer 16

Magnetic resonance imaging with T1 and T2 relaxation sequences provides information regarding lipid or fat content and enhancement characteristics of tissues. T1-weighted sequences show the renal cortex much brighter than the renal medulla, whereas the cortex is slightly less intense than the medulla on T2-weighted sequences. The renal pelvis containing fat appears hyperintense on T1- and T2-weighted sequences. After injection of contrast, the nephrographic and excretory phases start after 60 to 90 and 120 seconds of contrast injection, respectively

Question 17

assessment of Cortico Medullary Differentiation by CT requires injection of a contrast agent because both compartments have the same density (__) . CMD decreases or disappears in patients with ____ and ___, with/without clear correlation with the level of serum creatinine

However, upon restorationof renal function, CMD has been shown to reappear by ___

Recently, imaging studies such as 3D CT and MRI have been used to calculate renal parenchymal volumes to assess ___.

Studies using customized imaging software have demonstrated a high correlation between measurements of ____ and ___ volumes and renal function

Answer 17

assessment of Cortico Medullary Differentiation by CT requires injection of a contrast agent because both compartments have the same density (~30 HU). CMD decreases or disappears in patients with chronic kidney disease and acute kidney injury, with/without clear correlation with the level of serum creatinine

However, upon restorationof renal function, CMD has been shown to reappear by MRI

Recently, imaging studies such as 3D CT and MRI have been used to calculate renal parenchymal volumes to assess functional parenchymal volume.

Studies using customized imaging software have demonstrated a high correlation between measurements of renal and cortical volumes and renal function

Question 18

Renal glomerular filtration correlate better with MR measurements of renal ___ than renal bipolar length.

Of all congenital anomalies encountered in newborns, ___ % affect the kidneys and ureters .

Radiologically, renal malrotation is identified because the renal pelvis appears to arise ___ instead of its medial origin from the kidney. Some calyces are located MEDIAL/LATERAL to the ___, a hallmark of rotational anomalies.

These renal calyces appear ___ with or without obstruction

Arrest or exaggeration of ___ of the kidneys gives rise to renal ectopia and is usually associated with malrotation.

Answer 18

Renal glomerular filtration correlate better with MR measurements of renal volume (r = 0.86) than renal bipolar length.

Of all congenital anomalies encountered in newborns, 20% to 30% affect the kidneys and ureters .

Radiologically, renal malrotation is identified because the renal pelvis appears to arise centrally instead of its medial origin from the kidney. Some calyces are located medial to the renal pelvis, a hallmark of rotational anomalies.

These renal calyces appear distorted with or without obstruction

Arrest or exaggeration of normal ascent of the kidneys gives rise to renal ectopia and is usually associated with malrotation

Question 19

A kidney may cross the midline and fuse with the opposite kidney (___).

The ureter from the ectopic lower kidney crosses the midline and usually inserts into the bladder in an ABNORMAL/NORMAL position.

The two kidneys may fuse by an isthmus at their lower pole, giving rise to the ____

It is usually positioned low in the abdomen because of its arrest by the origin of the ___ The isthmus may contain a___ or non-functional/functional renal parenchyma. This kidney is usually subjected to other anomalies, especially (give 5)

Answer 19

A kidney may cross the midline and fuse with the opposite kidney (crossed-fused ectopia).

The ureter from the ectopic lower kidney crosses the midline and usually inserts into the bladder in its NORMAL position.

The two kidneys may fuse by an isthmus at their lower pole, giving rise to the horseshoe kidney

It is usually positioned low in the abdomen because of its arrest by the origin of the inferior mesenteric artery. The isthmus may contain a fibrotic band or functional renal parenchyma. This kidney is usually subjected to other anomalies, especially ureteropelvic junction obstruction (UPJO), vascular anomalies, duplication anomalies, stone formation, and urinary tract infections.

Question 20

The renal pedicle classically consists of a single artery and a single vein that enter the kidney via the renal hilum

The renal arteries arise from the aorta at the level of the intervertebral disk between the L1 and L2 vertebrae,where the longer RIGHT/LEFT renal artery passes posterior to the i___ . Renal arteries give branches to the ___, ___ and ___

Answer 20

The renal pedicle classically consists of a single artery and a single vein that enter the kidney via the ___

The renal arteries arise from the ___ at the level of the intervertebral disk between the __ and __vertebrae,where the longer RIGHT renal artery passes ___ to the inferior vena cava (IVC). Renal arteries give branches to the adrenal glands, renal pelves, and proximal ureters.

Question 21

After entering the hilum, each artery divides into ___ segmental end arteries that __ significantly with other segmental arteries.

Therefore occlusion or injury to a segmental branch causes ___.

the area supplied by each segmental artery could be ___ surgically resected.

Answer 21

After entering the hilum, each artery divides into five segmental end arteries that do not anastomose significantly with other segmental arteries.

Therefore occlusion or injury to a segmental branch causes segmental renal infarction.

the area supplied by each segmental artery could be independently surgically resected.

Question 22

The anterior division supplies roughly the anterior __of the kidney, and the posterior division supplies the posterior __ of the kidney.

Typically, the anterior division divides into four anterior segmental branches: (4).

The posterior segmental artery represents the ___ and most ___, which separates from the renal artery before it enters the ____.

A small apical segmental branch may originate from this posterior branch, but it arises most commonly from the ___.

The posterior segmental artery from the posterior division passes ___ to the renal pelvis while the others pass ___ to the renal pelvis.

Answer 22

The anterior division supplies roughly the anterior two-thirds of the kidney, and the posterior division supplies the posterior one-third of the kidney.

Typically, the anterior division divides into four anterior segmental branches: apical, upper, middle, and lower. The posterior segmental artery represents the first and most constant branch, which separates from the renal artery before it enters the renal hilum.

A small apical segmental branch may originate from this posterior branch, but it arises most commonly from the anterior division.

The posterior segmental artery from the posterior division passes posterior to the renal pelvis while the others pass anterior to the renal pelvis.

Question 23

If the posterior segmental branch passes ___ to the ureter, UPJO may occur.

In __% of kidneys, anatomic variations in the renal vasculature have been reported.

___ arteries are the most common variation, with reports of up to five arteries, especially on the __ side. The main renal artery may manifest ___ after originating from the ___ and before entering the ___

These prehilar arterial branches should be detected in patients undergoing evaluation for donor nephrectomy. An accessory renal artery may arise from the __, between ___, and terminate in the kidney.

Rarely, it may also originate from the ___ or ___ artery.

Accessory renal arteries are seen in ___ of patients and are considered the sole arterial supply to a specific portion of the renal parenchyma, commonly the___ and occasionally the ___ pole of the kidney.

These accessory renal arteries may___ laparoscopic donor nephrectomy and result in ___ if they are injured during endopyelotomy for UPJO.

Multiple renal arteries that arise from the aorta or iliac arteries are frequently seen in __ and ___ kidneys. In approximately 5% of patients, the __ and ___ arteries pass anterior to the IVC.

Answer 23

If the posterior segmental branch passes anterior to the ureter, UPJO may occur.

In 25% to 40% of kidneys, anatomic variations in the renal vasculature have been reported.

Supernumerary renal arteries are the most common variation, with reports of up to five arteries, especially on the left side. The main renal artery may manifest early branching after originating from the abdominal aorta and before entering the renal hilum.

These prehilar arterial branches should be detected in patients undergoing evaluation for donor nephrectomy. An accessory renal artery may arise from the aorta, between T11 and L4, and terminate in the kidney.

Rarely, it may also originate from the iliac arteries or superior mesenteric artery.

Accessory renal arteries are seen in 25% to 28% of patients and are considered the sole arterial supply to a specific portion of the renal parenchyma, commonly the lower and occasionally the upper pole of the kidney.

These accessory renal arteries may contraindicate laparoscopic donor nephrectomy and result in severe bleeding if they are injured during endopyelotomy for UPJO.

Multiple renal arteries that arise from the aorta or iliac arteries are frequently seen in horseshoe and pelvic kidneys. In approximately 5% of patients, the main and accessory right renal arteries pass anterior to the IVC.

Question 24

There is a longitudinal avascular plane (__) between the
__ and ___ arteries just __ to the lateral aspect of the kidney through which incision results in ___

This plane may have various locations that necessitate its delineation before incision either by ___ or intraoperative ___ of ___

During percutaneous access into the kidney, anterior/posterior calyces alongthe line of Brodel are preferred. Furthermore, during anatrophic nephrolithotomy (___ procedure), an incision is made through this avascular plane.

Answer 24

There is a longitudinal avascular plane (line of Brodel) between the
posterior and anterior segmental arteries just posterior to the lateral aspect of the kidney through which incision results in significantly less blood loss.

This plane may have various locations that necessitate its delineation before incision either by preoperative angiography or intraoperative segmental arterial injection of methylene blue.

During percutaneous access into the kidney, posterior calyces alongthe line of Brodel are preferred. Furthermore, during anatrophic nephrolithotomy (Boyce procedure), an incision is made through this avascular plane.

Question 25

At the renal sinus, each segmental artery branches into lobar arteries,
which further subdivide in the renal parenchyma to form interlobar arteries .

These interlobar arteries progress peripherally within the cortical columns of Bertin to give the arcuate arteries at the base of the renal pyramids at the corticomedullary junction.

Note the close relationship of the interlobar arteries to the infundibuli of minor calyces.

Interlobular arteries branch off the arcuate arteries and move radially, where they eventually divide to form the afferent arterioles to the glomeruli.

Answer 25

At the renal sinus, each segmental artery branches into lobar arteries,
which further subdivide in the renal parenchyma to form interlobar arteries . These interlobar arteries progress peripherally within the cortical columns of Bertin to give the arcuate arteries at the base of the renal pyramids at the corticomedullary junction. Note the close relationship of the interlobar arteries to the infundibuli of minor calyces. Interlobular arteries branch off the arcuate arteries and move radially, where they eventually divide to form the afferent arterioles to the glomeruli.

Question 26

Each afferent arteriole supplies a glomerulus, one of approximately ___ glomeruli, where urinary filtrate leaves the arterial system and is collected in the ___. Blood returns from the glomerulus via the ____ and continues as either secondary ___ around the urinary tubules in the cortex or ___ into the ___ as the ___.

Answer 26

Each afferent arteriole supplies a glomerulus, one of approximately 2 million glomeruli, where urinary filtrate leaves the arterial system and is collected in the glomerular (Bowman) capsule. Blood returns from the glomerulus via the efferent arteriole and continues as either secondary capillary networks around the urinary tubules in the cortex or descends into the renal medulla as the vasa recta.

Question 27

The renal venous drainage ___ with the arterial supply, with the
exception that unlike the arterial supply, venous drainage has __ collateral communication through the venous collars around ___

Furthermore, the interlobular veins that drain the postglomerular capillaries also communicate freely with ___ through the ___ of ___ veins.

The interlobular veins progress through the ___, ___, ___, and ___ veins paralleling their corresponding arteries. __ to ___ segmental renal veins eventually unite to form the renal vein.

Occlusion of a segmental venous branch has ___ effect on venous outflow.

Answer 27

The renal venous drainage correlates closely with the arterial supply, with the
exception that unlike the arterial supply, venous drainage has extensive collateral communication through the venous collars around minor calyceal infundibula

Furthermore, the interlobular veins that drain the postglomerular capillaries also communicate freely with perinephric veins through the subcapsular venous plexus of stellate veins.

The interlobular veins progress through the arcuate, interlobar, lobar, and segmental veins paralleling their corresponding arteries. Three to five segmental renal veins eventually unite to form the renal vein.

Occlusion of a segmental venous branch has little effect on venous outflow.

Question 28

The right and left renal veins lie ___ to the right and left renal arteries and drain into the ___

Whereas the right renal vein is ___ cm long, the left renal vein is ___ cm.

The longer left renal vein receives the left ___ and the ___ vein.

The left renal vein also may receive a lumbar vein, which could be easily avulsed during surgical manipulation of the left renal vein

Answer 28

The right and left renal veins lie anterior to the right and left renal arteries and drain into the IVC.

Whereas the right renal vein is 2 to 4 cm long, the left renal vein is 6 to 10 cm.

The longer left renal vein receives the left suprarenal (adrenal) vein and the left gonadal (testicular or ovarian) vein.

The left renal vein also may receive a lumbar vein, which could be easily avulsed during surgical manipulation of the left renal vein

Question 29

The left renal vein traverses the acute angle between the ___ anteriorly and the __ posteriorly.

In thin adolescents, the left renal vein may get compressed between the superior mesenteric artery and aorta, causing ___

In approximately 15% of the patients,___ are seen and often are ___ when present on the left.

____ are more common on the right side, and the most common anomaly of the left renal venous system is the ___, reported in ___ of patients.

The ___ is less commonly seen than the circumaortic vein, in which the left renal vein bifurcates into _____ limbs, which encircle the abdominal aorta.

In the retroaortic renal vein, the single left renal vein courses posterior to the aorta and drains into the ____

Answer 29

The left renal vein traverses the acute angle between the superior mesenteric artery anteriorly and the aorta posteriorly.

In thin adolescents, the left renal vein may get compressed between the superior mesenteric artery and aorta, causing nutcracker syndrome.

In approximately 15% of the patients, supernumerary renal veins are seen and often are retroaortic when present on the left.

Accessory renal veins are more common on the right side, and the most common anomaly of the left renal venous system is the circumaortic renal vein, reported in 2% to 16% of patients.

The retroaortic renal vein is less commonly seen than the circumaortic vein, in which the left renal vein bifurcates into ventral and dorsal limbs, which encircle the abdominal aorta.

In the retroaortic renal vein, the single left renal vein courses posterior to the aorta and drains into the lower lumbar segment of the IVC

Question 30

___ clearly identifies renal arteries at their origin from the abdominal aorta (

___ is currently considered the gold standard to assess renal arteries, with 100% sensitivity for identification of renal arteries and veins.

Arterial branches down to the segmental branches could be identified, but vessels ___could be missed

Answer 30

Doppler ultrasonography clearly identifies renal arteries at their origin from the abdominal aorta (see eFig. 84.12). Computed tomography angiography (CTA) is currently considered the gold standard to assess renal arteries, with 100% sensitivity for identification of renal arteries and veins.

Arterial branches down to the segmental branches could be identified, but vessels smaller than 2 mm could be missed

Question 31

Interstitial fluid leaves the kidney by either a ___ or a ___

The arcuate lymphatic vessels drain into ___vessels through interlobar lymphatics.

As these lymphatics exit the ___, they join branches from the renal capsule, perinephric tissues, renal pelvis, and upper ureter, where they empty into lymph nodes associated with the ___

Afterward, the lymphatic drainage varies considerably between the two kidneys. Left lymphatic drainage primarily goes into the ___ (between the inferior mesenteric artery and diaphragm), with occasional additional drainage into the ___ or directly into the ___ above the diaphragm.

Right renal lymphatic drainage primarily goes into the right ___ and ____ nodes (between the common iliac vessels and diaphragm), with occasional additional drainage from the right kidney into the ___or the ___ lymph nodes.

Answer 31

Interstitial fluid leaves the kidney by either a superficial capsular or a deeper hilar network

The arcuate lymphatic vessels drain into hilar lymphatic vessels through interlobar lymphatics.

As these lymphatics exit the renal hilum, they join branches from the renal capsule, perinephric tissues, renal pelvis, and upper ureter, where they empty into lymph nodes associated with the renal vein.

Afterward, the lymphatic drainage varies considerably between the two kidneys. Left lymphatic drainage primarily goes into the left lateral para-aortic lymph nodes (between the inferior mesenteric artery and diaphragm), with occasional additional drainage into the retrocrural nodes or directly into the thoracic duct above the diaphragm.

Right renal lymphatic drainage primarily goes into the right interaortocaval and right paracaval lymph nodes (between the common iliac vessels and diaphragm), with occasional additional drainage from the right kidney into the retrocrural nodes or the left lateral para-aortic lymph nodes.

Question 32

The kidney can function ___ neurologic control, as evidenced by the successful function of transplanted kidneys

Sympathetic preganglionic nerves originate from the ___ segments, with contributions mainly from the ___ and a lesser contribution from the greater splanchnic, intermesenteric, and superior hypogastric plexuses.

Postganglionic sympathetic nerve fiber distribution generally follows the ___ throughout the cortex and the outer medulla. These postganglionic fibers travel to the kidney via the autonomic plexus surrounding the renal artery.

In addition, parasympathetic fibers from the___ travel with the sympathetic fibers to the autonomic plexus along the renal artery. The renal sympathetics cause ___, and the parasympathetics cause ___

Answer 32

The kidney can function well without neurologic control, as evidenced by the successful function of transplanted kidneys

Sympathetic preganglionic nerves originate from the T8-L1 segments, with contributions mainly from the celiac plexus and a lesser contribution from the greater splanchnic, intermesenteric, and superior hypogastric plexuses.

Postganglionic sympathetic nerve fiber distribution generally follows the arterial vessels throughout the cortex and the outer medulla. These postganglionic fibers travel to the kidney via the autonomic plexus surrounding the renal artery.

In addition, parasympathetic fibers from the vagus nerve travel with the sympathetic fibers to the autonomic plexus along the renal artery. The renal sympathetics cause vasoconstriction, and the parasympathetics cause vasodilation.

Question 33

A calyx may receive __ papilla.

Compound papillae are often found in the ___of the kidney. The ___ is usually drained by a single midline calyceal infundibulum, and the ___ is drained by either a single midline calyceal infundibulum or by paired calyces.

The hilar region is drained by anterior and posterior rows of ____.

The pelvicalyceal system may have the configuration of either a true pelvis or divided double calyceal pelvis. The true pelvis is the ___ in which the calyces drain directly through ____ into an elongated pelvis.

This pelvis may be completely imbedded within the renal sinus (___) or mostly outside it (___).

The renal pelvis is roughly pyramidal, with the base facing the parenchyma and the apex funneling down into the ureter. It usually has a capacity of___ ml of urine.

Answer 33

A calyx may receive 1-3 papilla.

Compound papillae are often found in the polar regions of the kidney. The upper pole is usually drained by a single midline calyceal infundibulum, and the lower pole is drained by either a single midline calyceal infundibulum or by paired calyces.

The hilar region is drained by anterior and posterior rows of paired calyces.

The pelvicalyceal system may have the configuration of either a true pelvis or divided double calyceal pelvis. The true pelvis is the classic type in which the calyces drain directly through elongated necks into an elongated pelvis.

This pelvis may be completely imbedded within the renal sinus (intrarenal pelvis) or mostly outside it (extrarenal pelvis).

The renal pelvis is roughly pyramidal, with the base facing the parenchyma and the apex funneling down into the ureter. It usually has a capacity of 3 to 10 mL of urine.

Question 34

In a divided (duplex) pelvis, it is divided at the __ into upper and lower portions and drains a __ number of calyces than a normal pelvis.

Its lower part is usually __and often drains the hilar and the lower pole calyces. there is __ between the upper and lower calyces. This usually becomes apparent during the __ of a CT urogram or on retrograde pyelography.

During percutaneous endoscopic evaluation of the kidney, the __ should be considered if upper or lower pole calyces cannot be accessed through a particular calyceal access.

Duplex systems are easier to recognize on __

Answer 34

In a divided (duplex) pelvis, it is divided at the hilum into upper and lower
portions and drains a higher number of calyces than a normal pelvis. Its lower part is usually shorter but larger and often drains the hilar and the lower pole calyces. there is no direct connection between the upper and lower calyces. This usually becomes apparent during the excretory phase of a CT urogram or on retrograde pyelography.

During percutaneous endoscopic evaluation of the kidney, the existence of a duplex pelvis should be considered if upper or lower pole calyces cannot be accessed through a particular calyceal access. Duplex systems are easier to recognize on retrograde nephroureteroscopy.

Question 35

After an iodinated contrast agent is injected for intravenous urography, nephrotomograms appear after ___ seconds that represent contrast material within the renal tubules.

Fifteen minutes after contrast injection, a panoramic radiograph of the whole urinary tract can be obtained; the bladder finally appears ___ minutes after contrast injection. Absence of contrast excretion ___ after intravenous contrast injection indicates a nonfunctioning kidney.

Currently, CT urography has replaced intravenous urography, and multidetector CT provides the ability to obtain thin (___) collimated data of the entire urinary tract during a short single breath-hold

Magnetic resonance urography (MRU) has two consecutive phases: a ___ phase and an ___phase. The ___ is ideally indicated for evaluation of the obstructed or dilated collecting system. The practicability of excretory MRU depends on renal function, and its quality could be improved by a low-dose ___.

The infundibula insert directly into the extrarenal pelvis, giving the impression of a ___ Receiving the tip of renal papilla, the renal calyx is a concave structure with two side projections, the ___, which surround the papilla of the renal medulla.

Each kidney contains an average of ___ although this number may vary considerably from ___ or even more.

___ represents a nonobstructive asymptomatic congenital dilation of some or all renal calyces, while the renal pelvis and ureter are normal.

___ represent a focal extrinsic dilation of a renal calyx that is connected to the calyceal fornix and projects into the renal ___. The renoureteral unit may show duplication anomalies, including a ___ and complete or incomplete ureteral duplication.

Answer 35

After an iodinated contrast agent is injected for intravenous urography, nephrotomograms appear after 60 to 90 seconds that represent contrast material within the renal tubules.

Fifteen minutes after contrast injection, a panoramic radiograph of the whole urinary tract can be obtained; the bladder finally appears 20 to 30 minutes after contrast injection. Absence of contrast excretion 24 hours after intravenous contrast injection indicates a nonfunctioning kidney.

Currently, CT urography has replaced intravenous urography, and multidetector CT provides the ability to obtain thin (<1 mm) collimated data of the entire urinary tract during a short single breath-hold

Magnetic resonance urography (MRU) has two consecutive phases: a static-fluid phase and an excretory phase. The static-fluid MRU is ideally indicated for evaluation of the obstructed or dilated collecting system. The practicability of excretory MRU depends on renal function, and its quality could be improved by a low-dose furosemide diuretic.

The infundibula insert directly into the extrarenal pelvis, giving the impression of a dilated pelvis. Receiving the tip of renal papilla, the renal calyx is a concave structure with two side projections, the fornices, which surround the papilla of the renal medulla.

Each kidney contains an average of 7 to 9 calyces, although this number may vary considerably from 4 to 19 or even more.

Megacalycosis represents a nonobstructive asymptomatic congenital dilation of some or all renal calyces, while the renal pelvis and ureter are normal.

Calyceal diverticula represent a focal extrinsic dilation of a renal calyx that is connected to the calyceal fornix and projects into the renal cortex, not into the medulla. The renoureteral unit may show duplication anomalies, including a bifid renal pelvis and complete or incomplete ureteral duplication.

Question 36

The ureters are bilateral muscular __ ducts with narrow lumens that carry urine from the kidneys to the urinary bladder

Each ureter runs inferiorly as a narrow continuation of its renal pelvis at the UPJ, passing over the __ at the bifurcation of the __

They then run along the lateral wall of the pelvis to enter the urinary bladder. In adults, the ureter is __ cm in length with a diameter of __; in neonates it measures __ long.

In the retroperitoneum, the ureter is situated just lateral to the tips of the __ vertebrae.

The ureter is arbitrarily divided into proximal (upper), middle (over the __), and distal (lower) segments. However, according to international anatomic terminology the ureter consists of abdominal (from __ vessels), pelvic (from __ to __), and __segments.

The abdominal parts of the ureters are __ to the retroperitoneum throughout their entire course and extend from the renal pelvis to the pelvic brim.

From the back, the surface anatomy of the ureter corresponds to a line joining a point __ lateral to the __ spinous process and the __.

Normally, three constrictions could be identified radiologically in each ureter: __

Answer 36

The ureters are bilateral muscular retroperitoneal ducts with narrow lumens that carry urine from the kidneys to the urinary bladder

Each ureter runs inferiorly as a narrow continuation of its renal pelvis at the UPJ, passing over the pelvic brim at the bifurcation of the common iliac artery.

They then run along the lateral wall of the pelvis to enter the urinary bladder. In adults, the ureter is 22 to 30 cm in length with a diameter of 1.5 to 6 mm; in neonates it measures 6.5 to 7.0 cm long.

In the retroperitoneum, the ureter is situated just lateral to the tips of the transverse processes of the lumbar vertebrae.

The ureter is arbitrarily divided into proximal (upper), middle (over the sacrum), and distal (lower) segments. However, according to international anatomic terminology the ureter consists of abdominal (from renal pelvis to iliac vessels), pelvic (from iliac vessels to the bladder), and intramural segments.

The abdominal parts of the ureters are adherent to the retroperitoneum throughout their entire course and extend from the renal pelvis to the pelvic brim.

From the back, the surface anatomy of the ureter corresponds to a line joining a point 5 cm lateral to the L1 spinous process and the posterior superior iliac spine.

Normally, three constrictions could be identified radiologically in each ureter: at its junction with the renal pelvis (UPJ), where it crosses the iliac vessels, and during its passage through the wall of the urinary bladder (intramural ureter) or ureterovesical junction

Question 37

Posteriorly, both ureters descend anterior to the ___ and then
cross the ventral surface of the ___ and enter the pelvis at the bifurcation of the common iliac vessels

The bifurcation of the common iliac vessels is used intraoperatively as a landmark to look for the ureter. The ___ runs on top of the psoas major muscle behind the ureter.

The right ureter begins behind the ___, where it is crossed by ___, which is called “___”

The left ureter is covered at its origin by the initial part of the ___. The ___ cross the left ureter after running parallel to it for a small distance. The ___ and its terminal branch, the ___,follow a ___ close to the left ureter.

Just above the entry to the pelvis, the ureter is still covered by peritoneum by virtue of the ___ This location at the pelvic brim
represents one of the most common areas of ___

Answer 37

Posteriorly, both ureters descend anterior to the psoas major muscle and then
cross the ventral surface of the transverse processes of the third to fifth lumbar vertebrae and enter the pelvis at the bifurcation of the common iliac vessels

The bifurcation of the common iliac vessels is used intraoperatively as a landmark to look for the ureter. The genitofemoral nerve runs on top of the psoas major muscle behind the ureter.

The right ureter begins behind the descending part of the duodenum, where it is crossed by the gonadal vessels (testicular or ovarian), which is called “water under the bridge.”

The left ureter is covered at its origin by the initial part of the jejunum. The gonadal vessels cross the left ureter after running parallel to it for a small distance. The inferior mesenteric artery and its terminal branch, the superior rectal artery,follow a curved course close to the left ureter.

Just above the entry to the pelvis, the ureter is still covered by peritoneum by virtue of the ureteral fold. This location at the pelvic brim
represents one of the most common areas of ureteral injury.

Question 38

The pelvic segment of the ureter is approximately ___ long—___

At the pelvic inlet, it crosses the ___near their bifurcation. This crossover point is usually at the bifurcation of the ___ into the___, making this a useful landmark for pelvic procedures.

The ureter then runs downward and laterally toward the
___ on the ___ along the anterior border of the ___, dorsally accompanied by the ___ and its visceral branches and the venous plexuses as well.

It is still closely related to the posterior parietal peritoneum. At the___, the ureter turns medially to descend in the ___ with branches of the hypogastric nerves.

At the lateral wall of the pelvis, this part of the ureter crosses the ___

Answer 38

The pelvic segment of the ureter is approximately 15 cm long—half of its total length.

At the pelvic inlet, it crosses the common iliac vessels near their bifurcation. This crossover point is usually at the bifurcation of the common iliac artery into the internal and external iliac arteries, making this a useful landmark for pelvic procedures.

The ureter then runs downward and laterally toward the
ischial spine on the lateral pelvic wall along the anterior border of the greater sciatic notch, dorsally accompanied by the internal iliac artery and its visceral branches and the venous plexuses as well. It is still closely related to the posterior parietal peritoneum. At the ischial spine, the ureter turns medially to descend in the endopelvic fascia with branches of the hypogastric nerves.

At the lateral wall of the pelvis, this part of the ureter crosses the obturator artery, vein, and nerve.

Question 39

In males, the vas deferens loops medially over this part while the ureter passes the ___ and the ___ just before it enters the bladder.

In females, the descending part of the pelvic segment of the ureter courses posterior to the ___ to form the posterior boundary of the ___.

The ureter then passes through the base of the ___ and swings in a convex curve to cross under the uterine vessels (“water under the bridge”) in a sagittal direction approximately 1.5 to 2 cm adjacent to the
supravaginal part of the uterine cervix.

The terminal ureter runs forward, accompanied by the ___ of the bladder and passes the ___ just before entering the bladder. This close proximity of the ureter to the uterine vessels is the cause of ureteral injuries during gynecologic procedures.

Answer 39

In males, the vas deferens loops medially over this part while the ureter passes the ampulla of the vas deferens and the seminal vesicles just before it enters the bladder.

In females, the descending part of the pelvic segment of the ureter courses posterior to the ovary to form the posterior boundary of the ovarian fossa.

The ureter then passes through the base of the broad ligament and swings in a convex curve to cross under the uterine vessels (“water under the bridge”) in a sagittal direction approximately 1.5 to 2 cm adjacent to the
supravaginal part of the uterine cervix.

The terminal ureter runs forward, accompanied by the neurovascular bundle of the bladder and passes the anterior vaginal fornix just before entering the bladder. This close proximity of the ureter to the uterine vessels is the cause of ureteral injuries during gynecologic
procedures.

Question 40

In the case of vaginal surgery, there is a high risk for injury, especially for the ___ that crosses the anterior vaginal fornix

Near the bladder, the terminal ureter is enveloped by a muscular layer, the___, and then pierces the bladder wall obliquely as the ___

The length of this intramural part of the ureter in adults is ___, and in neonates it is approximately ___ cm long.

The Waldeyer muscle bundles of the ureter coalesce with those of the ___ of the bladder wall.

Therefore reflux of urine from the bladder to the ureter is prevented during ___, such as during micturition.

When approached from the retrograde direction, the ureter courses ___ as it goes along the lateral pelvic wall.

Then, as it crosses the pelvic brim, it angulates ___ to continue as the proximal ureter.

Answer 40

In the case of vaginal surgery, there is a high risk for injury, especially for the left ureter that crosses the anterior vaginal fornix closer than the right ureter.

Near the bladder, the terminal ureter is enveloped by a muscular layer, the Waldeyer sheath, and then pierces the bladder wall obliquely as the intramural
segment.

The length of this intramural part of the ureter in adults is 1.2 to 2.5 cm, and in neonates it is approximately 0.5 to 0.8 cm long.

The Waldeyer muscle bundles of the ureter coalesce with those of the detrusor muscle of the bladder wall.

Therefore reflux of urine from the bladder to the ureter is prevented during increased intravesical pressure, such as during micturition.

When approached from the retrograde direction, the ureter courses anterolaterally as it goes along the lateral pelvic wall.

Then, as it crosses the pelvic brim, it angulates posteriorly to continue as the proximal ureter.

Question 41

The ureter could be delineated by ___ during expiration,because it may be kinked during inspiration as a result of downward movement of the kidney radiologists describe three segments of the ureter: a proximal portion extending from its origin down to the upper border of the ___ , a middle portion lying over the sacroiliac joint, and the remaining segment from the lower border of that joint to its entrance into the bladder, which represents the distal portion of the ureter.

The course of the ureter and its bilateral symmetry are subject to great variability. It may descend laterally away from the margin of the ___ or be displaced medial to the ___

The right ureter may run medially behind the vein at the level of ___ before it returns to its lateral position.

The entire length of the ureter is ___ in a single film of the excretory urography because of its peristaltic activity. Otherwise, ureteral atony or obstruction should be suspected

Similarly, crossing vessels may compress the ureter and

simulate areas of stricture. Therefore the diagnosis of a ureteral stricture ___ of excretory urography with the presence of ureteral dilatation proximal to the site of narrowing.

Answer 41

The ureter could be delineated by excretory urography during expiration,because it may be kinked during inspiration as a result of downward movement of the kidney radiologists describe three segments of the ureter: a proximal portion extending from its origin down to the upper border of the sacroiliac joint, a middle portion lying over the sacroiliac joint, and the remaining segment from the lower border of that joint to its entrance into the bladder, which represents the distal portion of the ureter.

The course of the ureter and its bilateral symmetry are subject to great variability. It may descend laterally away from the margin of the transverse processes or be displaced medial to the renal pedicle.

The right ureter may run medially behind the vein at the level of third lumbar vertebra before it returns to its lateral position.

The entire length of the ureter is rarely seen in a single film of the excretory urography because of its peristaltic activity. Otherwise, ureteral atony or obstruction should be suspected

Similarly, crossing vessels may compress the ureter and

simulate areas of stricture. Therefore the diagnosis of a ureteral stricture should not be based on a single film of excretory urography with the presence of ureteral dilatation proximal to the site of narrowing.

Question 42

Complete duplication results from the development of a ___, and the two ureters are

inserted into the bladder ___

The partial type results from redundant duplication of the single ureteric bud in which the ___ join together above the bladder to from a ___ draining into the bladder.

Complete ureteral duplication with a common or ectopic entry of the___ is less common than incomplete duplication. The ureter draining the upper segment of the kidney prevalently inserts in the bladder___ to the ureter draining the lower segment of the kidney (___).

These ectopic orifices are prone to ___ and/or ___

Answer 42

Complete duplication results from the development of a second ureteric bud, and the two ureters are

inserted into the bladder separately.

The partial type results from redundant duplication of the single ureteric bud in which the two ureters join together above the bladder to from a single stump draining into the bladder.

Complete ureteral duplication with a common or ectopic entry of the upper pole moiety is less common than incomplete duplication. The ureter draining the upper segment of the kidney prevalently inserts in the bladder inferior and medial to the ureter draining the lower segment of the kidney (Weigert-Meyer rule).

These ectopic orifices are prone to ureteroceles and/or vesicoureteral reflux.

Question 43

In elderly patients with atherosclerotic vessels, ureteral narrowing at the pelvic brim at its crossing to the common iliac vessels may produce a posterior indentation that may appear as an ___

Medial displacement of both pelvic ureteral segments may result from ___ , or it may appear after abdominoperineal surgery.

medial displacement and concavity of a single pelvic ureter may result from ___, or ___ of the hypogastric artery. Nevertheless, this may be a normal finding in adult women if only the ___ is affected because of the uterine tilt to the left.

In older men, benign prostatic hyperplasia may result in elevation of the bladder floor enough to cause the intramural segment of the ureter to curve superiorly, giving a characteristic ___ or___ appearance on excretory urography

Answer 43

In elderly patients with atherosclerotic vessels, ureteral narrowing at the pelvic brim at its crossing to the common iliac vessels may produce a posterior indentation that may appear as an extrinsic filling defect.

Medial displacement of both pelvic ureteral segments may result from retroperitoneal fibrosis or pelvic lipomatosis, or it may appear after abdominoperineal surgery.

medial displacement and concavity of a single pelvic ureter may result from enlarged hypogastric nodes, a bladder diverticulum, or aneurysmal dilation of the hypogastric artery. Nevertheless, this may be a normal finding in adult women if only the right ureter is affected because of the uterine tilt to the left.

In older men, benign prostatic hyperplasia may result in elevation of the bladder floor enough to cause the intramural segment of the ureter to curve superiorly, giving a characteristic “fish hook” or “hockey stick” appearance on excretory urography

Question 44

The abdominal portion of the ureter is supplied mainly by arterial branches medially from the ___

However, this segment may be uncommonly supplied by branches arising from the ___ or ___

These branches approach the ureters ___ and divide into ascending and descending branches, forming a longitudinal anastomosis on the ureteral wall. However, despite this anastomotic plexus, ___ is not uncommon if these small and delicate ureteral branches are disrupted.

Surgeons are trained to handle ureters gently to avoid unnecessary ___ and removing periureteral adventitial tissues containing the blood supply to minimize ureteral ischemia and subsequent stricture.

The mid-ureter is supplied by branches arising posteriorly from the ___ .

The blood supply to the distal ureter comes laterally from the ___ , a branch of the internal iliac artery. Therefore the blood supply of the ureter is medially in the ___ , posteriorly in the ___ , and laterally in the ___.

Therefore endoureterotomy should be performed ___ in the proximal ureter, ___ in the midportion, and ___ in the distal ureter.

Another important surgical caveat is to control the ___ before mobilizing the most distal aspect of the ureter as it enters the bladder.

Answer 44

The abdominal portion of the ureter is supplied mainly by arterial branches medially from the main renal arteries However, this segment may be uncommonly supplied by branches arising from the abdominal aorta or gonadal arteries. These branches approach the ureters medially and divide into ascending and descending branches, forming a longitudinal anastomosis on the ureteral wall. However, despite this anastomotic plexus, ureteral ischemia is not uncommon if these small and delicate ureteral branches are disrupted.

Surgeons are trained to handle ureters gently to avoid unnecessary lateral retraction and removing periureteral adventitial tissues containing the blood supply to minimize ureteral ischemia and subsequent stricture.

The mid-ureter is supplied by branches arising posteriorly from the common iliac arteries.

The blood supply to the distal ureter comes laterally from the superior vesical artery, a branch of the internal iliac artery. Therefore the blood supply of the ureter is medially in the proximal part, posteriorly in the midportion, and laterally in the distal portion.

Therefore endoureterotomy should be performed laterally in the proximal ureter, anteriorly in the midportion, and medially in the distal ureter.

Another important surgical caveat is to control the obliterated umbilical artery before mobilizing the most distal aspect of the ureter as it enters the bladder.

Question 45

Veins draining the abdominal part of the ureters drain into the __

Venous drainage of the mid- and distal ureters is into the ___.

The lymphatics of the ureter form plexuses within its muscular and adventitial layers. The lymphatics from the left abdominal ureter drain into the ___ lymph nodes, and the lymphatics from the right abdominal ureter drain into the right ____

Lymphatic vessels from the middle part usually drain into the ___ whereas lymphatics from its intrapelvic part drain into the common, external, and ___

Answer 45

Veins draining the abdominal part of the ureters drain into the renal and gonadal veins.

Venous drainage of the mid- and distal ureters is into the common and internal iliac veins.

The lymphatics of the ureter form plexuses within its muscular and adventitial layers. The lymphatics from the left abdominal ureter drain into the left para-aortic lymph nodes, and the lymphatics from the right abdominal ureter drain into the right paracaval and interaortocaval lymph nodes.

Lymphatic vessels from the middle part usually drain into the common iliac lymph nodes, whereas lymphatics from its intrapelvic part drain into the common, external, and internal iliac lymph nodes.

Question 46

The ureter receives a rich autonomic nerve supply that originates from the (3 answers) together with the __ and ___

The sympathetic supply to the ureter arises from the preganglionic fibers of the ___and___

Parasympathetic vagal fibers supply the upper part of the ureter via the ___ and the lower portion is supplied by the ___

Therefore afferent nerves from the upper portion of the ureter reach the spinal cord with the sympathetic fibers between ___ and those from the lower ureter travel via the pelvic plexus between ___

These fibers conduct afferent sensory stimuli from the ureters and have a minor, if any, role in the control of ___

Excised portions of the ureter continue to contract without nervous control and denervation of the lower portion of the ureter does ___

As mentioned earlier, the peristalsis of the ureter originates from ___ Thus the exact role of autonomic input of the ureters is unclear.

Distention of the renal capsule and the collecting system causes stimulation of renal pain fibers that carry signals through the sympathetic nerves, thus resulting in ___ referred pain in the ___ regions.

Answer 46

The ureter receives a rich autonomic nerve supply that originates from the celiac, aortorenal, and mesenteric ganglia, together with the superior and inferior hypogastric (pelvic) plexuses.

The sympathetic supply to the ureter arises from the preganglionic fibers of the 11th and 12th thoracic and 1st lumbar segments.

Parasympathetic vagal fibers supply the upper part of the ureter via the celiac plexus, and the lower portion is supplied by the sacral segments S2 to S4.

Therefore afferent nerves from the upper portion of the ureter reach the spinal cord with the sympathetic fibers between T11 and L1 and those from the lower ureter travel via the pelvic plexus between S2 and S4.

These fibers conduct afferent sensory stimuli from the ureters and have a minor, if any, role in the control of ureteral motility.

Excised portions of the ureter continue to contract without nervous control and denervation of the lower portion of the ureter does not result in reflux.

As mentioned earlier, the peristalsis of the ureter originates from pacemakers in the minor calyces. Thus the exact role of autonomic input of the ureters is unclear.

Distention of the renal capsule and the collecting system causes stimulation of renal pain fibers that carry signals through the sympathetic nerves, thus resulting in visceral-type referred pain in the flank, groin, or scrotal (labial) regions.

Question 47

The ureter consists of three distinct layers. The innermost is the ___, the middle muscular layer is the ___, and the outer layer is the ___.

The mucosa consists of ___, which has ___ of cells when the ureter is contracted. These cells encircle a large number of junctional complexes containing a consistent level of ___ that is responsible for the waterproof property of this layer.

The mucosa also contains many ___ that give the empty ureter a characteristic ___ outline.

Answer 47

The ureter consists of three distinct layers. The innermost is the mucosa, the middle muscular layer is the muscularis, and the outer layer is the adventitia.

The mucosa consists of transitional epithelium, which has four to six layers of cells when the ureter is contracted. These cells encircle a large number of junctional complexes containing a consistent level of keratin precursors that is responsible for the waterproof property of this layer.

The mucosa also contains many longitudinal folds that give the empty ureter a characteristic stellar outline.

Question 48

The muscular wall of the ureter consists of ___ separated by a ___ layer that may not be distinct from each other, especially in the abdominal segment of the ureter.

Mostly, these muscle fibers appear to be ___arranged by the light microscopy.

However, in the distal ureter, the innerspirals are ___ and the outer spirals are ___, thus appearing as inner ___ and ___ layers in cross section.

These smooth muscle layers are contiguous with the smooth muscle covering the ___, where the pacemaker is located to initiate the ___ to deliver urine.

The outermost layer, the ___, consists of a dense network of collagen and elastic fibers, including many blood vessels and ___

This layer is ___ with the capsule at the renal pelvis while it is thickened distally by a specialized muscle fibers and fibrous tissue to form the Waldeyer sheath.

In a normal kidney, the UPJ does not differ histologically from the renal pelvis. However, in an obstructed kidney, the ___ are significantly increased with more ___ around the muscle fibers in addition to attenuation of muscle bundles, leading to the physiologic obstruction known clinically as ___

Answer 48

The muscular wall of the ureter consists of two longitudinal layers separated by a middle circular layer that may not be distinct from each other, especially in the abdominal segment of the ureter.

Mostly, these muscle fibers appear to be spirally arranged by the light microscopy.

However, in the distal ureter, the innerspirals are steep and the outer spirals are horizontal, thus appearing as inner longitudinal and outer circular layers in cross section.

These smooth muscle layers are contiguous with the smooth muscle covering the minor renal calyces, where the pacemaker is located to initiate the rhythmic peristalsis to deliver urine.

The outermost layer, the adventitia, consists of a dense network of collagen and elastic fibers, including many blood vessels and unmyelinated nerve fibers among them.

This layer is continuous proximally with the capsule at the renal pelvis while it is thickened distally by a specialized muscle fibers and fibrous tissue to form the Waldeyer sheath.

In a normal kidney, the UPJ does not differ histologically from the renal pelvis. However, in an obstructed kidney, the longitudinal muscle fibers are significantly increased with more collagen deposits around the muscle fibers in addition to attenuation of muscle bundles, leading to the physiologic obstruction known clinically as UPJO.

Question 49

Once the cystoscope is inside the bladder neck, the trigone can be seen as a raised, smooth triangle.

The apex of that triangle is situated at the ___, and its base is formed by the___, extending between the two ureteric orifices. The interureteral ridge is more prominent in males than females, and the ureteric orifices are symmetrically located along it, approximately ___ from the midline.

The trigone is the ___ and is formed by an extension of the ___ over the ___

Therefore it appears cystoscopically to be ___ than the rest of the bladder.

The normal ureteric orifice may appear as a ___ that is prominent and obvious on endoscopy. However, it may look like a slit that can be identified with only meticulous examination. It is pushed out laterally during bladder filling and may vary in position and appearance.

The ureteric orifices are classified according to their position or configuration.
They are normally located at the___ (position A). However, they may be located at the ___ or at its ___ (position C) or in between positions A and C (___)

In terms of configuration, grade 0 indicates a normal ureteric orifice that looks like a___Grades 1, 2, and 3 describe __, ___ ,___ orifices, respectively.

The higher the grade of the orifice, the higher the tendency to be ____

Answer 49

Once the cystoscope is inside the bladder neck, the trigone can be seen as a raised, smooth triangle.

The apex of that triangle is situated at the bladder neck, and its base is formed by the interureteral ridge or Mercier bar, extending between the two ureteric orifices. The interureteral ridge is more prominent in males than females, and the ureteric orifices are symmetrically located along it, approximately 1 to 2 cm from the midline.

The trigone is the most vascular part of the bladder and is formed by an extension of the longitudinal muscle fibers of the ureters over the detrusor muscle.

Therefore it appears cystoscopically to be more deeply colored than the rest of the bladder.

The normal ureteric orifice may appear as a volcano or a horseshoe that is prominent and obvious on endoscopy. However, it may look like a slit that can be identified with only meticulous examination. It is pushed out laterally during bladder filling and may vary in position and appearance.

The ureteric orifices are classified according to their position or configuration.
They are normally located at the medial aspect of the trigone (position A). However, they may be located at the lateral wall of the bladder or at its junction with the trigone (position C) or in between positions A and C (position B)

In terms of configuration, grade 0 indicates a normal ureteric orifice that looks like a cone or a volcano. Grades 1, 2, and 3 describe stadium, horseshoe, and golf-hole orifices, respectively.

The higher the grade of the orifice, the higher the tendency to be laterally located and to reflux

Question 50

The intramural ureter represents the narrowest part of the ureter, with an average diameter of 3 to 4 mm.

The other ureteral narrowing areas at the pelvic brim and UPJ are identified endoscopically by being stenotic and relatively nondistensible.

The pulsating iliac vessels could be seen endoscopically as the ureters cross the pelvic brim and angulate posteriorly in the proximal portion.

The proximal ureter goes straight up to the UPJ; the ureter lies on the psoas major muscle, with the appearance of a typical stellate nondistended ureter.

The UPJ could be identified easily endoscopically during its frequent opening and closing. The UPJ merges into the wider and more dependent part of the renal
pelvis. The respiratory movement of the kidney could be seen by endoscopy after passing the relatively fixed UPJ. The kidneys lie on the diaphragm, and
thus they are affected by the respiratory movements. Therefore, during ureteroscopy, the tidal volume could be decreased to minimize renal excursions during respiration.

Moreover, the physiologic ureteral contractions
or peristalsis can be observed endoscopically. It is important to wait for the ureter to relax before pushing the ureteroscope to avoid mucosal trauma

The UPJ represents the apex of the funnel-shaped or conical normal renal
pelvis. An extrarenal pelvis is usually larger and has longer major calyceal
infundibula than an intrarenal pelvis. In the renal pelvis, the flexible
ureteroscope first faces the ostia of the major calyces, which look like circular
openings separated by carinae. Then the flexible ureteroscope enters a long
tubular infundibulum that branches into the minor calyces. These infundibula
usually connect the ostia of major calyces with their apex. For a flexible
ureteroscope to pass from the axis of the upper ureteral segment to the axis of
the lower infundibulum, it should deflected 140 (104 to 175) degrees at the
ureteroinfundibular angle (Bagley and Rittenberg, 1987).
A circular muscle layer extends around the base of the papilla to help expel
urine jets from papillary ducts. The renal papillae appear endoscopically as
protruding discs surrounded by calyceal fornices, paler in color than the pink
friable epithelium covering the papillae. Each papilla represents the apex of a
renal pyramid, receiving the papillary ducts of Bellini that drain the pyramids.
These ducts are minute openings that become more dilated and obvious with
distal obstruction (Andonian et al., 2008a, 2010a).
Segmental and interlobar branches of the renal artery, together with major
intrarenal tributaries of the renal vein, run in close relation with the anterior and
posterior surfaces of the major caliceal infundibula as well as the necks of minor
calices (Sampaio, 2009). Therefore, if infundibulotomy must be performed, it
should be performed in either the superior or inferior quadrants, which are free
of major vessels. Anatomically, the following sequence is recommended if morethan one infundibular incision is necessary: the first two incisions should be done, respectively, in the superior and inferior quadrants, the third incision between the superior and posterior quadrants, and the fourth between the inferior and posterior quadrants. Further incision would be performed in the posterior quadrant, avoiding anterior incisions as much as possible