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1

Describe the general structure of the kidney.

What is its peritoneal relation?

Size and shape.?

retroperitoneal organ

  • 120 - 200g
  • 10 - 12cm long, 5-6cm wide, 4cm thick

2 different types of structures:

  • urine formation: nephrons + uriniferous tubules
  • urine collection: renal calyces + renal pelvis

 

 

2

What are the functions of the kidney?

  • homeostasis of bodily fluids (amount, osmolarity, pH, ion concentration)
    ∽ 180l primary urine filtered out of the blood/day
  • excretion of metabolic end products (urine)
    1.5 - 2l final urine formed/day
  • endocrine function (renin-angiotensin, vit D3, erythropoietin) 

3

#1 - 5

 

#3 opens to #4.

Q image thumb

1) extremitas superior

2) extremitas inferior

3) hilum renale

4) sinus renalis

5) pyramidis renalis

4

#6 - 10

 

Another name for #8.

Q image thumb

6) capsula fibrosa

7) capsula adiposa

8) fascia renalis (= GEROTA)

9) medulla renalis

10) cortex renalis 

5

#11 - 13

Q image thumb

11) papilla renalis

12) columna renalis

13) lobus renalis 

6

What is a floating kidney?

What are other names?

loss of capsula adiposahypermobility of the kidney which descends into the pelvis

  • other names:
    nephroptosis, nephroptosia, renal ptosis, renal descensus, renal prolapse

7

Which structures can be found in the cortex?

radii medullares (= medullary rays) = continuation of medullary substance

cortex corticis = contains radii medullares 

labyrinthus corticis = area btw radii medullares

8

What are the projections of the kidney?

in fossa lumbalis

  • right: Th12 → L3
  • left: Th11 → L3
  • hilum: L2

⇒ left kidney moves (2-3 cm) during deep inspiration

9

What are the boundaries of the kidney?

  • laterally - medially
  • cranially
  • dorsally

laterally:

  • 6) m. transversus abdominis

medially:

  • 8) m. psoas major

cranially:

  • diaphragm
  • suprarenal gll.

dorsally:

  • 7) m. quadratus lumborum
  • n. subcostalis
  • n. iliohypogastricus
  • n. ilioinguinalis

A image thumb
10

What are the ventral boundaries of the kidney?

Differentiate btw right/left.

right:

  • 1) right lobe of the liver
  • 2) pars descendens duodeni
  • 3) flexura coli dextra
  • 4) loops of small intestine

left:

  • 6) stomach
  • 7) spleen
  • 9) pancreas
  • 10) flexura coli sinistra
  • 11) radix mesocolica
  • 12) loops of small intestine

A image thumb
11

What are the dorsal relations of the kidney clinically relevant?

contact to n. ilioinguinalis + n. iliohypogastricus explains why pain can spread up to the inguinal region in case of renal diseases

12

Explain the segmentation of the kidney.

5 segments

  • segm. superius
  • segm. anterius superius
  • segm. anterius inferius
  • segm. inferius
  • segm. posterius

 ⇒ correspond to the arterial supply via a. renalis

13

What is the microscopic unit of the kidney?

Describe it.

nephron

  • renal corpuscle 
  • glomerulus

forms together with renal tubule the uriniferous tubule

14

List some genetic abnormalities of the kidney.

  • additional kidneys
  • horseshoe kidney = fused kidneys
  • renal aplasia = one kidney is missing
  • renal hypoplasia = underdevelopment of one kidney

15

Explain the vasculature of the kidney

arterial supply:

  1. a. renalis dex./sin.
  2. type I r. principalis ant./post. 
    type II r. principalis ant./post./inf.
  3. aa. interlobulares
  4. aa. arcuatae
  5. aa. corticales radiatae (= aa. interlobulares)
  6. arteriolae afferentes

drainage: beginning at glomerulus

  1. arteriolae efferentes
  2. vasa recta/peritubular cap.
  3. vv. corticales radiatae
  4. vv. arcuatae interlobulares
  5. vv. renales
  6. IVC

16

What are clinically important abberations of the renal vasculature?

  • accessory renal aa.: persisting branches of aorta that didn't redevelop during fetal dev., esp. important in case of surgeries
  • abberant renal aa.: aa. don't enter through hilum, but through sup./inf. pole

17

What is important abt v. renalis sin.?

Why is it clinically important?

3 tributaries:

  • v. suprarenalis
  • v. testicularis/ovarica
  • v. phrenica inf.

​⇒ cancer in the left renal v. can cause reflux into v. testicularis → dilation of scrotum (= varicocele)

18

What innervates the kidneys?

sympathetic innervation via plexus renalis

19

What are calices renalis?

Differentiate.

drain urine from papilla renalis into pelvis renalis

  • major
  • minor

 

20

What are the 2 shapes of the pelvis renalis?

​type depends on calices renalis
volume: 3 - 8ml

  • branching: minor calices open consistently into major which eventually open into pelvis renalis
  • ampullary: minor and major calices open into pelvis renalis

21

What are the 2 ways for X-ray examinations to investigate the pelvis renalis?

  • urogram: iodid containing contrast material injected intravenously, eventually excreted by kidney
  • retrograde pyelogram: contrast material injected into ureters via a catheter

22

Which structures are connected by the ureter?

What are its 3 points of constriction?

pelvis renalis → urinary bladder

  1. exit from pelvis renalis
  2. crossing of a. iliaca communis/externa when entering the lesser pelvis
  3. wall of urinary bladder

23

Why are the points of constriction of the ureter clinically relevant?

 ⇒ renal colic = type of abdominal pain commonly caused by kidney stones, often wavelike in phases

24

What are the parts of the ureter?

  1. pars abdominalis in retroperitoneal space
  2. pars pelvica in lesser pelvis
  3. pars intramuralis in wall of urinary bladder

25

Explain the crossings of the ureter.

over - under - over - under

  1. over n. genitofemoralis
  2. under a./v. testicularis/ovarica
  3. over a. iliaca communis (left)/externa (right)
  4. under ductus deferens (male)/a. uterina (female)

A image thumb
26

What is important during a uterectomy?

a. uterina is close to ureter → injury/ligation of ureter can lead to loss of kidney

27

Which vessels supply and drain the ureter?

 

supply:

  • pars abdominalis: a. renalis, aorta abdominalis, a. testicularis/ovarica, a. iliaca communis
  • pars pelvica: a. iliaca interna, a. vesicalis inf. (in females also often a. uterina)

drainage:

→ v. testicularis → v. iliaca int. → plexus venosus vesicalis

 

 

28

Which structures form the bladder, vesica urinaria?

What is its peritoneal relation?

How much volume can it contain, when does usually the urge to void appear?

subperitoneal organ

  • apex, corpus, fundus
  • trigonum vesicae + 2 ostia ureteris (+ plica interureterica) + 1 ostium urethrae internum
  • in males: uvula vesicae

capacity = 500ml, urge to void at 300 ml

 

29

Which structures surround the urinary bladder?

 

  • paravesicular adipose tissue
  • anteriorly spatium retropubicum (RETZIUS)
  • posteriorly in males excavatio rectovesicalis
    in femaleexcavatio vesicouterina

additionally posteriorly located in males from medial to lateral (cf. picture):

  1. ductus deferens
  2. gl. vesiculosa
  3. ureter

A image thumb
30

Why is the spatium retropubicum clinically relevant?

distended urinary bladder can be punctuated superiorly to symphysis pubica → suprapubic catheter

31

Which structures attach to the vesica urinaria?

Differentiate btw genders.

  • both genders: lig. umbilicale medianum (obliterated urachus, connects to umbilicus)
  • males: ligg. puboprostatica (1 on each side)
  • females: ligg. pubovesicalia (1 on each side)

32

Explain the structure of the wall of the vesica urinaria?

from inside to outside

  1. mucosa
  2. m. detrusor vesicae
  3. tunica serosa (where overlied by peritoneum)

33

Which vessels supply/drain the vesica urinaria?

Innervation.

supply:

  • aa. vesicales sup./inf. (from a. iliaca int.)

drainage:

  • plexus venosus vesicalis → vv. vesicales → v. iliaca int.

innervation:

  • parasymp: plexus hypogastricus inf. → contract m. detrusor vesicae → micturition

34

Explain the macroscopical structure of the female urethra.

Supply/drainage/innervation?

Clinical relevance?

from ostium urethrea internum (bladder) to ostium urethrae externum

  • 3 - 5cm long
  • closed by m. sphincter urethrae ext.
  • supply/drainage/innervation are the same as for the bladder

 ⇒ cystitis (inflammation of the bladder) much more common in females due to short urethra

35

What is micturition?

Explain the process.

urination

closure of bladder/urethra by 

 

  • smooth m. sphincter urethrae int., innervated symphathetically
  • striated m. sphincter urethrae ext., innervated by n. pudendus → voluntary

micturition

  1. relaxation of pelvic diaphragm → lowering of bladder
  2. contraction of m. detrusor vesicae
  3. relaxation of m. sphincter urethrae int./ext.

36

What seperates cavitas pelvis from cavitas abdominalis?

How is it subdivided?

seperated by apertura pelvis superior demarcated by linea terminalis

subdivision in craniocaudal direction

  • cavitas peritonealis pelvis bounded by peritoneum inferiorly
  • spatium extraperitoneale pelvis bounded by pelvic diaphragm
  • regio urogenitalis (ant.) = spatium perinei sup./prof.
    regio analis (post.) = fossa ischioanalis
     

37

What are the contents of cavitas pelvis?

Differentiate btw male/female.

both:

  • vesica urinaria
  • ureters
  • rectum

male:

  • gll. vesiculosae
  • ductus deferentes
  • prostate

female:

  • uterus
  • vagina
  • ovaria
  • tubae uterinae

 

38

Where is plica rectovesicalis/rectouterina?

Which structures does it contain?

lat. folds bounding excavatio rectovesicalis/rectouterina (= DOUGLAS pouch)

⇒ contains plexus hypogastricus inf. (+ lig. rectouterium in females)

39

Explain the peritoneal relations in cavitas peritonealis of females.

2 pouches are formed instead of just 1 since peritoneum reflects on superior surface of vesica urinaria to cover uterus + adnexa → intraperitoneal → lig. latum

⇒ excavatio vesicouterina (ant.) + excavatio rectouterina (post.) = DOULGAS pouch

 

 

40

What are the parts of lig. latum?

What does it contain?

parts:

  • ​mesometrium attaches at uterus
  • mesosalpinx covers tuba uterina
  • mesovarium covers ovaries

add. contents:

  • a. ovarica
  • a. uterina
  • lig. ovarii proprium
  • lig. teres uteri
  • paracervical ganglion

for more information cf. ...genital system

41

Which structures are connected by parametrium?

 

 

8 ligg. (each side 4)

laterally: cervix + pelvis = paracervix

  • lig. cardinale (MACKENRODT)
  • continues caudally as paracolpium
  • contains branches of a./v. uterina

​ventrally: cervix + canalis inguinalis/bladder

  • lig. vesicouterinum
  • lig. teres uteris

​dorsally: cervix + sacrum

  • lig. sacrouterinum

 

 

42

Why is the Douglas pouch clinically relevant?

only seperated by thin tissue layers from post. wall of vagina 

→ Douglas abscesses can be removed 

→ uterus, ovaries, tubae uterinae can be examined via endoscopy

43

What is the name of the fascia that seperates prostate from rectum?

fascia rectoprostatica 

(= DENON-VILLIER)

44

Which mm. form the diaphragma pelvis?

What is their common function?

How do you call the opening that is formed by one of the 2 mm.?

Both are innervated by ... ?

m. levator ani + m. ischiococcygeus
 form hiatus levatorius for passage of urethra (+ vagina)

→ support pelvic/abdominal viscera + provide continence

both: innervated by plexus sacralis (S3/4)

45

#1 - 3

 

Origin, insertion, innervation.

Q image thumb

m. levator ani

  • ORIGIN: 
    • m. pubococcygeus/-rectalis: ramus sup.
    • m. iliococcygeus: arcus tendineus m. levatorius (fascia of m. obturator int.)
  • INSERTION:​​
    • ​m. pubo-/iliococcygeus: sacrum, coccyx
    • m. puborectalis forms sling around rectum
  • INNERVATION: 
    • plexus sacralis (S3/4)
    • m. puborectalis also by n. pudendus

46

#4

 

Origin, insertion, innervation

m. ischiococcygeus

  • ORIGIN: spina ischiadica, lig. sacrospinale
  • INSERTION: coccyx
  • INNERVATION: plexus sacralis (S3/4)

47

What might be the reason for pelvic floor insufficiency?

What are consequences?

multiple vaginal births 

→ descensus/prolapse of bladder (= cystocele), rectum (= rectocele)

incontinence

48

#1 - 5

Q image thumb

1) pubic bone

2) ischium

3) membrana obturatoria

4) m. obturator int.

5) membrana perinei

49

#6 - 10

Q image thumb

6) vesica urinaria

7) prostate

8) urethra - pars prostatica

9) urethra - pars intramuralis

10) urethra - pars membranacea

50

#11 - 15

Q image thumb

11) urethra - pars spongiosa

12) m. sphincter urethrae ext.

13) m. levator ani

14) fossa ischioanalis

15) peritoneum

51

#16 - 20

 

What is formed by #17?

Another 2 names for #20.

Q image thumb

16) corpus spongiosum

17) corpus cavernosum → crura of penis

18) m. ischiocavernosus

19) m. bulbospongiosus

20) fascia perinei profunda (= GALLAUDET), investing layer of perineal fascia

52

#21 - 25

 

Another 2 names for #22. What is it continuous with?

What does #25 partially form?

Q image thumb

21) skin

22) fascia perinei superficialis (= COLLES), membraneous layer of perineal fascia → continuous w/ fascia penis sup., tunica DARTOS

23) spatium superficiale perinei

24) spatium profundum perinei

25) m. transversus profundus (part of urogential diaphragm)

53

#26 - 29

Q image thumb

26) trigonum vesicae

27) ostium uteris

28) saccus subcutaneus perinei

29) paracystium

54

What are the contents of spatium profundum perinei?

Differentiate btw male/female.

male:

  • urethra
  • gll. bulbourethrales (COWPER)
  • m. transversus profundus

female:

  • vagina w/ urethra
  • smooth m. instead of m. transversus profundus

 

55

What are the contents of spatium superficiale perinei?

Differentiate btw male/female.

female:

  • gl. vestibularis maj. (BARTHOLIN)
  • gll. vestibulares min. ∽ correspond to Cowper's glands

both:

  • erectile tissues
  • canalis pudendalis (ALCOCK) containing:
    • n. pudendus
    • a. + v. pudenda int.

56

What are the contents of fossa ischioanalis?

 

  • canalis pudendalis (ALCOCK) containing
    • n. pudendus
    • a. + v. pudenda int.
  • a. + v + n. rectalis inf.

57

What are the boundaries of fossa ischioanalis?

  • base: skin
  • apex: m. levator ani, m. obturator int.
  • med: m. sphincter ani ext., m. levator ani
  • lat: tuber ischiadicum, m. obturator int.
  • ventr: COLLES fascia
  • dors: m. gluteus max., lig. sacrotuberale

 

58

Why is saccus subcutaneus perinei clinically relevant?

infections in this region can spread to ant. abdominal wall, scrotum/labiae majorae

59

Which n. innervates ALL perineal mm.?

n. pudendus

(= "shame" nerve)

60

What is a pudendal nerve block?

local anesthesia technique used in an obstretic procedure to anasthesize the perineum during labor

→ e.g. lidocaine injected through inner wall of vagina in direction of spina ischiadica

61

What is due to its location a common site for anal fistulas?

fossa ischioanalis

62

#1 - 5

Q image thumb

1) ischium

2) pubis

3) membrana obturatoria

4) m. obturator int.

5) membrana perinei

63

#6 - 10

 

Another name for #10.

Q image thumb

6) vagina

7) cervix

8) fornix lat.

9) vestibulum vaginae

10) ostium uteri (= ext. os)

64

#11 - 15

 

Another 2 names for #15

Q image thumb

11) m. levator ani

12) m. sphincter urethrae ext.

13) m. compressor urethrae

14) peritoneum

15) lig. cardinale (MACKENRODT), lig. cervicale lat.

65

#16 - 20

 

Which structure is formed by #18?

Q image thumb

16) labia min.

17) labia maj.

18) corpus spongiosum (both form bulbus vestibuli)

19) m. bulbospongiosus

20) corpus cavernosum clitoridis

66

#21 - 26

 

Another 2 names for #22, 23.

#24 is the remnant of which embryological structure?

Q image thumb

21) m. ischiocavernosus

22) fascia perinei profunda, investing layer of per. fascia (= GALLAUDET)

23) fascia perinei superficialis, membraneous layer of per. fascia (= COLLES)

24) lig. teres uteri (= remnant of gubernaculum)

25) spatium perinei profundum

26) spatium perinei superficiale

67

What is an episiotomy?

surgical incision of perineum/post. vag. wall to enlarge opening for baby during labor

OTHERWISE: perineal tear can rupture m. levator ani, m. sphincter ani int./ext.

68

Since in some books more add. mm. are considered part of m. sphincter urethrae ext., list them.

  • m. compressor urethrae = adjacent to original m. sphincter urethrae ext.
  • m. sphincter urethrovaginalis = adjacent to vagina