ANATOMY OF KIDNEY

ANATOMY OF KIDNEY

1. ANATOMY OF RETROPERITONEUM
IN RELATION TO KIDNEY

EMBRYOLOGY & ANATOMY OF
KIDNEY
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. HISTORY
Morgagni : retroperitoneal lipoma
1761
Emil Zuckerkandl- PRF
1883
Dimitrie Gerota: APF
1895
Meyers- Spaces
1972
3 Dept of Urology, GRH and KMC, Chennai.

4. BOUNDARIES
Posterior reflection of peritoneum
Abdominal wall
Extra peritoneal pelvic structures
Diaphragm
4 Dept of Urology, GRH and KMC, Chennai.

5. CONTENTS
•Kidneys
•ureters
•Adrenals
•pancreas,
•portions of the duodenum
ascending colon
•descending colon
•Mesentery
•arterial structures including
the aorta and its branches
•venous structures including
the inferior vena cava (IVC)
and its tributaries
•lymphatics, lymph nodes
•sympathetic trunk
•lumbosacral plexus
5 Dept of Urology, GRH and KMC, Chennai.

6. BODY SURFACE LANDMARKS
6 Dept of Urology, GRH and KMC, Chennai.

7. POSTERIOR ABDOMINAL WALL
•external oblique
•originates from ribs 5
through 12,
•inserting at the iliac crest
and ending in the midline at
the linea alba
•internal oblique
•originates from the
lumbodorsal fascia and the
iliac crest
•inserting at the lower 4 ribs
and linea alba
•The transversus abdominis muscle.
•Originates at Lumbodorsal
fascia, medial lip of iliac
crest, ribs 7–12
•Aponeurosis ending in linea
alba, pubic crest
•transversalis fascia
•which crosses the midline
anteriorly and fuses with
the lumbodorsal fascia
posteriorly
Flank Muscles
7 Dept of Urology, GRH and KMC, Chennai.

8. POSTERIOR ABDOMINAL WALL
•The psoas major muscle
•arises from the 12th thoracic vertebra to
the 5th lumbar vertebra
•attach to the lesser trochanter of the
femur
•The psoas minor muscle
•may be absent in some individuals
•originates at T12 and L1 and inserts at the
pelvic brim and iliopubic eminence.
•The iliacus muscle
•originates at the caudal aspect of the iliac
fossa and the lateral sacrum to
•insert at the lesser trochanter of the
femur.
•The quadratus lumborum
•lies posterior and medial to the psoas
muscle
•origin is at L5 and the iliac fossa
•attaches to the inferior border of the 12th
rib and the transverse processes of L1-L4.
•The erector spinae (sacrospinalis) is a large group
of back muscles that function to extend the
spine
8 Dept of Urology, GRH and KMC, Chennai.

9. SPINE
•Each vertebra has a
large weight-bearing
area called the
vertebral body
•The spinous process
projects
posteroinferiorly, and
the transverse
processes project
posterolaterally
9 Dept of Urology, GRH and KMC, Chennai.

10. RIBS
•The 10th rib
•articulates with the body of
the vertebra at its head and
the transverse process at its
neck.
•The 11th rib
•lacks a neck and does not
articulate with the
transverse process.
•The angle is less pronounced
than that of the upper ribs.
•The 12th rib
•has no angle and is shorter
than the other ribs.
•The 11th and 12th ribs
•no anterior connection with
the sternum and are often
referred to as floating ribs.
•These ribs are of clinical
significance during palpation
for the marking of a surgical
incision
10 Dept of Urology, GRH and KMC, Chennai.

11. RIBS
•The 12th rib has no angle and is
shorter than the other ribs.
•Its inferior border is
attached to the transverse
processes of L1 and L2 by
the costovertebral
(lumbocostal) ligament,
which can be incised to
allow for increased mobility
for greater exposure of the
upper retroperitoneum
during posterior approaches.
•Similar increased mobility
may be achieved by dividing
a thick, fibrous band known
as the intercostal ligament
found between other ribs.
11 Dept of Urology, GRH and KMC, Chennai.

12. RIBS
The intercostal vessels
and nerves
•between the
internal intercostal
and innermost
intercostal muscles
•within the costal
groove on the
caudal margin of the
superior rib
•Superior to inferior:
VAN
12 Dept of Urology, GRH and KMC, Chennai.

13. LUMBODORSAL FASCIA
13 Dept of Urology, GRH and KMC, Chennai.

14. LUMBODORSAL FASCIA
14 Dept of Urology, GRH and KMC, Chennai.

15. RETROPERITONEAL FASCIAE AND SPACES
•Derived from the mesoderm, the
primitive mesenchyme differentiates to
form
–a subcutaneous layer
–a body layer
–a retroperitoneal layer.
•The retroperitoneal layer forms three
strata in late fetal development:
–outer stratum-
•covers the epimysium of the abdominal wall
muscles and becomes the transversalis
fascia
–intermediate stratum-
•associated with the genitourinary organs
–inner stratum-
•associated with the gastrointestinal organs
15 Dept of Urology, GRH and KMC, Chennai.

16. TRANSVERSALIS FASCIA & PPRS
TRANSVERSALIS FASCIA
•The outer stratum forms the
transversalis fascia
•lies deep to the transversus
abdominis muscle and
superficial to the preperitoneal
fat and peritoneum.
•Posterior to the kidney, the
transversalis fascia remains
anterior to the fascia
surrounding the quadratus
lumborum and psoas muscle
•It may fuse medially with the
posterior lamina of Gerota
fascia, which is of clinical
significance during
retroperitoneal dissection
because this fascia must be
incised to allow access to the
renal hilum.
16 Dept of Urology, GRH and KMC, Chennai.

17. TRANSVERSALIS FASCIA & PPRS
POSTERIOR PARARENAL
SPACE
•This fusion creates the
medial boundary of
the posterior pararenal
space.
•The anterior boundary
-posterior lamina of
Gerota fascia
•Posterior and lateral
boundaries are formed
by the transversalis
fascia
17 Dept of Urology, GRH and KMC, Chennai.

18. GEROTA FASCIA & PERIRENAL SPACE
•Derived from the intermediate
stratum
•Embeds the genitourinary
organs
–Anterior lamina: fascia of Toldt
or prerenal fascia
–Posterior lamina: fascia of
Zuckerkandl or retrorenal
fascia, Thicker
•Help to form the boundaries of
the retroperitoneal spaces:
–the posterior pararenal space,
perirenal space, and anterior
pararenal space
18 Dept of Urology, GRH and KMC, Chennai.

19. GEROTA FASCIA & PERIRENAL SPACE
EXTENT:
•LATERAL- two layers merge laterally
to form the lateroconal fascia
•MEDIAL- Historically -no
communication
–in vivo cases and cadaveric injection
studies, there may be some
communication below the level of
the renal hilum
•CAUDAL- Previously-is closed
inferiorly by the fusion of Gerota
fascia.
–in vivo cases and cadaveric injection
studies -perirenal space has a
conelike shape that is open at its
inferior extent in the extraperitoneal
pelvis

19 Dept of Urology, GRH and KMC, Chennai.

20. GEROTA FASCIA & PERIRENAL SPACE
Clinical significance of boundaries:
•They function to contain perinephric fluid
collections, which include
–urine
•traumatic or iatrogenic urinary extravasation, obstructive
uropathy with calyceal rupture
–blood
•traumatic or iatrogenic perinephric hematoma, ruptured
aneurysm
–purulence
•perinephric abscess or infected urinoma.
20 Dept of Urology, GRH and KMC, Chennai.

21. GEROTA FASCIA & PERIRENAL SPACE
•CONTENTS:
–Adrenal
–Kidney
–Ureter
–perirenal fat-
finer and lighter
yellow
–renal vascular
pedicle
–gonadal vessels.
21 Dept of Urology, GRH and KMC, Chennai.

22. APRS AND INNER STRATUM
•BOUNDARIES
–Posteriorly: anterior
lamina of the renal
fascia
–Anteriorly: Posterior
layer of parietal
peritoneum
anteriorly.
22 Dept of Urology, GRH and KMC, Chennai.

23. APRS AND INNER STRATUM
•Clinical significance-
it can be developed
to gain access to the
kidney anteriorly
when followed
medially from the
white line of Toldt
23 Dept of Urology, GRH and KMC, Chennai.

24. APRS AND INNER STRATUM
•Contains the secondarily
retroperitoneal organs:
•These organs are
intraperitoneal at one
point during
embryogenesis
•they become
retroperitoneal
secondarily as they
attach to the posterior
abdominal wall when
the inner stratum fuses
with the primary dorsal
peritoneum.
24 Dept of Urology, GRH and KMC, Chennai.

25. APRS AND INNER STRATUM
•Contains the
secondarily
retroperitoneal
organs:
–ascending and
descending
colon,
–pancreas
–second and third
portions of the
duodenum.
25 Dept of Urology, GRH and KMC, Chennai.

26. ARTERIES
26 Dept of Urology, GRH and KMC, Chennai.

27. ARTERIES
27 Dept of Urology, GRH and KMC, Chennai.

28. ARTERIES
SMA:
•supplies the
•pancreas (inferior
pancreaticoduodenal
artery)
•small intestine
•large intestine
(ileocolic, right colic,
and middle colic
arteries)
•Marginal artery of
Drummond
28 Dept of Urology, GRH and KMC, Chennai.

29. ARTERIES
29 Dept of Urology, GRH and KMC, Chennai.

30. ARTERIES
•Paired lumbar arteries
arise posteriorly, adjacent
to the bodies of the upper
four lumbar vertebrae.
•They supply the posterior
body wall and spine.
•In some instances, a fifth
pair of lumbar arteries is
present, arising from the
middle sacral artery
30 Dept of Urology, GRH and KMC, Chennai.

31. ARTERIES
•Branches of the IMA are
the left colic, sigmoid, and
superior hemorrhoidal
(rectal) arteries
31 Dept of Urology, GRH and KMC, Chennai.

32. ARTERIES
32 Dept of Urology, GRH and KMC, Chennai.

33. VEINS
Middle sacral veins- sacral
colpopexy
ascending lumbar veins-
azygous, hemiazygous vein
Gonadal veins
Renal veins
Adrenal veins
33 Dept of Urology, GRH and KMC, Chennai.

34. LYMPHATIC SYSTEM
The lymphatic fluid from the pelvis and
lower extremities drains into
the internal iliac, external iliac, common
iliac, obturator, and sacral nodes.
drain cephalad toward the lumbar nodes
whose efferent lymphatics form the
lumbar trunks
34 Dept of Urology, GRH and KMC, Chennai.

35. LYMPHATIC SYSTEM
•The lumbar nodes are of considerable interest
to the urologist
–they provide the primary lymphatic drainage for
structures supplied by lateral aortic arterial
branches:
•kidneys, adrenals, ureters, and gonads
35 Dept of Urology, GRH and KMC, Chennai.

36. LYMPHATIC SYSTEM
For anatomic classification, three groups of
lumbar nodes can be defined:
•left lumbar (aortic),
•interaortocaval (interaorticovenous)
•right lumbar (caval) nodal groups.
36 Dept of Urology, GRH and KMC, Chennai.

37. LYMPHATIC SYSTEM
The left lumbar group includes
•Preaortic
•left para-aortic
•retroaortic nodes
The right lumbar group includes
•Precaval
•Right paracaval
•Retrocaval nodes
37 Dept of Urology, GRH and KMC, Chennai.

38. NERVES
•lumbosacral plexus from the anterior rami of
the lumbar and sacral nerves along with T12
38 Dept of Urology, GRH and KMC, Chennai.

39. NERVES
39 Dept of Urology, GRH and KMC, Chennai.

40. NERVES
40 Dept of Urology, GRH and KMC, Chennai.

41. DEVELOPMENT OF KIDNEY
41 Dept of Urology, GRH and KMC, Chennai.

42. EARLY EVENTS
•Mammals develop three sets of kidneys in the
course of intrauterine life.
•The embryonic kidneys are, in order of their
appearance
–Pronephros- regress completely in utero
–Mesonephros- regress partially
–Metanephros
•Embryologically, all three kidneys develop
from the intermediate mesoderm
42 Dept of Urology, GRH and KMC, Chennai.

43. PRONEPHROS
•Transitory, nonfunctional
kidney analogous to that
of primitive fish.
•Seen late in the 3
rd

week, completely
degenerates by 5
th

week.
•Starts at the cranial end
of the nephrogenic cord
in the thoracic region
and progresses caudally

43 Dept of Urology, GRH and KMC, Chennai.

44. PRONEPHROS
The significance of the pronephros:
•generation of the pronephric
duct that grows caudally within
the urogenital ridge.
•As the pronephric tubules
degenerate, the retained
pronephric duct becomes the
mesonephric duct as it grows
caudally into the domain of
mesonephric tubule
development
44 Dept of Urology, GRH and KMC, Chennai.

45. MESONEPHROS
•Serves as an excretory
organ for the embryo while
the definitive kidney, the
metanephros, begins its
development
•Begins formation at 4
weeks, start to degenerate
at about the fifth week,
completely by 4 months
•Approximately 40 pairs of
mesonephric tubules
45 Dept of Urology, GRH and KMC, Chennai.

46. MESONEPHROS
•Few elements that persist
into maturity as part of the
male reproductive tract
–some of the cranially located
mesonephric tubules
become the efferent ducts of
the testes.
–The paradidymis consists of
retained mesonephric
tubules near the head of the
epididymis.
46 Dept of Urology, GRH and KMC, Chennai.

47. MESONEPHROS
•In females, remnants of
cranial and caudal
mesonephric tubules
form small, nonfunctional
epithelial cysts residing
within the broad ligament
of the uterus, termed the
epoöphoron and
paroöphoron
47 Dept of Urology, GRH and KMC, Chennai.

48. METANEPHROS
•The definitive kidney, or
the metanephros, initially
forms in the sacral region
at about the 4 weeks’
gestation
48 Dept of Urology, GRH and KMC, Chennai.

49. METANEPHROS
•Key factors in
kidney
development
involve interplay
between secreted
signals and
transcription
factors both in the
ureteral bud and
the kidney
metanephric
mesenchyme
49 Dept of Urology, GRH and KMC, Chennai.

50. METANEPHROS
•The ureteral bud enters the
kidney mesenchyme and
makes the first t-type
branch.
•At the same time, the
ureteral bud induces the
condensation of
metanephric mesenchyme
cells to form a cap of
mesenchyme.
•Cap metanephric
mesenchyme cells contain
the progenitors/stem cells
of the nephrons
50 Dept of Urology, GRH and KMC, Chennai.

51. METANEPHROS
•The sequential and
reciprocal tissue
interactions between
the ureteral bud and
the metanephric
mesenchyme advance
kidney morphogenesis–
inducing nephrons
51 Dept of Urology, GRH and KMC, Chennai.

52. STAGE 1
•An internal cavity forms within the epithelializing
pretubular aggregate, at which point the
structure is called the epithelial renal vesicle
•The renal vesicles elongate to form a comma-
shaped body that is in turn converted to an S-
shaped body, one end of which establishes
connection with the distal tip of a ureteric
branch.
•Multipotential precursors residing within renal
vesicles ultimately give rise to all epithelial cell
types of the nephron
52 Dept of Urology, GRH and KMC, Chennai.

53. STAGE 1
53 Dept of Urology, GRH and KMC, Chennai.

54. STAGE 2
•Nephron segmentation into glomerular and tubular
domains is initiated by the sequential formation of two
clefts within the renal vesicle- upper and lower clefts
•Creation of a lower cleft, termed the vascular cleft,
precedes formation of a comma-shaped body.
•Generation of an upper cleft in the comma-shaped
body precedes formation of an S-shaped body.
•At this stage, the cup-shaped glomerular capsule is
recognized in the lowest limb of the S-shaped tubule.
54 Dept of Urology, GRH and KMC, Chennai.

55. STAGE 2
•The glomerular capillary tuft is formed via
recruitment and proliferation of endothelial
and mesangial cell precursors.
55 Dept of Urology, GRH and KMC, Chennai.

56. STAGE 2
•The rest of the S-shaped tubule develops into
the proximal convoluted tubule, the loop of
Henle, and the distal convoluted tubule
56 Dept of Urology, GRH and KMC, Chennai.

57. STAGE 3,4
•STAGE 3:
–Cup-shaped glomerular capsule matures into an
oval structure
•STAGE 4:
–round glomerulus that closely resembles the
mature renal corpuscle
57 Dept of Urology, GRH and KMC, Chennai.

58. •Older, more
differentiated
nephrons are located
in the inner part of
the kidney near the
juxtamedullary region
•Newer,less
differentiated
nephrons are found at
the periphery
58 Dept of Urology, GRH and KMC, Chennai.

59. COLLECTING SYSTEM
•Dichotomous branching of the ureteric bud and
subsequent fusion of the ampullae to form the
renal pelvis and calyces.
•infundibulam develops among the third, fourth,
or fifth generations of branches and their
subsequent expansions give rise to the calyces
59 Dept of Urology, GRH and KMC, Chennai.

60. MOLECULAR MECHANISM
Inductive interactions during early kidney
development.
•Glial cell line–derived neurotrophic factor (GDNF)
is secreted from the metanephric mesenchyme
•Activates the RET receptor tyrosine kinase in
the ureteric bud epithelium.
POSITIVE NEGATIVE
BMP4
FoxC
Pax2
Eya1
60 Dept of Urology, GRH and KMC, Chennai.

61. MUTATIONS
•Eya1-
–Homozygous mutation: failure of ureteric bud
outgrowth
–Haploinsufficiency: dominantly inherited disorder
called branchio-oto-renal syndrome
•FoxC1-
–homozygous mutants have duplex kidneys, in
which the upper ureter is dilated and connects
aberrantly to mesonephric duct derivatives in
males such as seminal vesicles and vas deferens
61 Dept of Urology, GRH and KMC, Chennai.

62. CAKUT
•Associated with mutations in transcription factors
–Hox11, Eya1, Pax2, Six1, Six2, Osr1, and Sall1
•Regulate the balance between differentiation and
maintenance of the nephron progenitors.
•Multiple gene pathways such as Wnt signaling are
also required for differentiation into the renal
vesicle.
•HNF1B and Notch signaling contribute to the
specification of the proximal tubules and terminal
nephron differentiation
62 Dept of Urology, GRH and KMC, Chennai.

63. CAKUT
63 Dept of Urology, GRH and KMC, Chennai.

64. TUBULOGENESIS
•Cell-cell interactions promote nephrogenesis.
•Three major cell types- thought to play a
critical role
–ureteric bud (UB) epithelial cells,
–condensing tubular mesenchymal cells
–stromal mesenchymal cells
64 Dept of Urology, GRH and KMC, Chennai.

65. TUBULOGENESIS
•At the UB tips, cells express unique markers such as
Emx2 and Pax2.
•The stromal cell lineage is marked by expression of
retinoic acid receptors (RAR) and BF2.
•Presence of Pax2, Wnt1, and Sall1 appears to be
important for continued branching morphogenesis of the
UB.
•Wnt4 is activated in the tubular mesenchymal cells by the
invading UB epithelial cells and stimulates the development
of polarized epithelium in an autocrine fashion.
•Finally, fibroblast growth factors (FGFs), such as FGF2,
along with leukocyteinhibitory factor (LIF), may be critical
as survival factors for the developing renal tubular
epithelial cells.
65 Dept of Urology, GRH and KMC, Chennai.

66. TUBULOGENESIS
66 Dept of Urology, GRH and KMC, Chennai.

67. RENAL VASCULAR DEVELOPMENT
•Not completely understood
•Angiogenic hypothesis
–derived exclusively from branches off the aorta
and other preexisting extrarenal vessels
•Vasculogenic hypothesis
–renal vessels may originate in situ, within the
embryonic metanephric mesenchyme from
vascular progenitor cells
67 Dept of Urology, GRH and KMC, Chennai.

68. CLINICAL CORRELATION- VASCULAR
ANAMOLIES
•As the kidneys migrate from their origin in the
pelvis cranially into the upper lumbar region, they
are vascularized by a succession of transient
aortic sprouts that arise at progressively higher
levels.
•These arteries do not elongate to follow the
ascending kidneys but instead degenerate and
are replaced by successive new arteries.
•The final pair of arteries forms in the upper
lumbar region and becomes the definitive renal
arteries
68 Dept of Urology, GRH and KMC, Chennai.

69. CLINICAL CORRELATION- VASCULAR
ANAMOLIES
•Occasionally, a more inferior pair of arteries
persists as accessory lower-pole arteries.
–These lower-pole arteries cross ventral to the ureter
and can cause intermittent UPJO requiring
repositioning of the ureter behind the accessory
lower-pole renal artery.
•The common variation in blood supply to the
kidney is a reflection of the continually changing
embryonic renal vasculature.
–This is reflected in that 25% of adult kidneys have two
or more renal arteries
69 Dept of Urology, GRH and KMC, Chennai.

70. ASCENT OF KIDNEYS
•The metanephros normally ascends from the sacral region to its
definitive lumbar location between the sixth and ninth weeks.
•Speculated that differential growth of the lumbar and sacral regions
of the embryo plays a major role
70 Dept of Urology, GRH and KMC, Chennai.

71. CLINICAL CORRELATION- ASCENT
ANAMOLIES
•Ectopic Kidney:
–When the kidney fails to ascend properly.
•Pelvic Kidney:
–If its ascent fails completely.
•Horseshoe Kidney
–The inferior poles of the kidneys fuse, that crosses ventral
to the aorta.
–During ascent, the fused lower pole is arrested by the
inferior mesenteric artery and thus does not reach its
normal site
•Cross-fused ectopy
–Kidney fuses to the contralateral one and ascends to the
opposite side

71 Dept of Urology, GRH and KMC, Chennai.

72. CLINICAL CORRELATION- MCDK
•characterized by nonfunctional renal tissue
without recognizable glomeruli.
•The malformed tissue consists of
noncommunicating cysts of various sizes with
dysplastic tubular epithelium.
•The etiology is not known but is thought to be
related to abnormal signaling between the
ureteral bud and the metanephric blastema
72 Dept of Urology, GRH and KMC, Chennai.

73. CLINICAL CORRELATION- MCDK
•Renal agenesis may be a nonrecognizable
form of multicystic dysplastic kidney in which
the involution occurs early in gestation before
the abnormal renal development can be
detected by prenatal sonogram
73 Dept of Urology, GRH and KMC, Chennai.

74. ANATOMY OF KIDNEY
74 Dept of Urology, GRH and KMC, Chennai.

75. SURFACE ANATOMY
•Paired ovoid, reddish-brown retroperitoneal
organs
•POSITION:
–Right- top of L1 to bottom of L3
–Left- T12 and L3
•Right sits 1 to 2 cm lower than the left
•SIZE: 10 to 12 cm in length, 5.0 to 7.5 cm in width,
and 2.5 to 3.0 cm in thickness
•WEIGHT: 125- 170g
–10 to 15 g smaller in females

75 Dept of Urology, GRH and KMC, Chennai.

76. AXIS OF THE KIDNEY
76 Dept of Urology, GRH and KMC, Chennai.

77. SURFACE ANATOMY
•Kidneys move inferiorly approximately 3 cm (1
vertebral body) during inspiration and during
changing body position from supine to the erect
position
•Dromedary hump
–Focal renal parenchymal bulge in lateral contour more
common on the left side
–Has no pathologic significance.
–Thought to be caused by the downward pressure from
the liver or the spleen

77 Dept of Urology, GRH and KMC, Chennai.

78. POSTERIOR RELATIONSHIP
•Rib fracture- renal injury
•Upper pole - diaphragm
78 Dept of Urology, GRH and KMC, Chennai.

79. POSTERIOR RELATIONSHIP
79 Dept of Urology, GRH and KMC, Chennai.

80. ANTERIOR RELATION
•Right kidney is related
–superiorly to the liver
–superomedially to the adrenal gland
–Inferiorly to the small intestine and hepatic flexure of the
colon
–medially it is related to 2
nd
part duodenum and head of the
pancreas
•To access the right renal hilum, 2
nd
part duodenum and
head of pancreas must be carefully mobilized using the
Kocher maneuver
•Hepatorenal ligament
–excessive downward traction of the right kidney may cause
capsular tear of the liver and may lead to excessive
intraoperative bleeding

80 Dept of Urology, GRH and KMC, Chennai.

81. ANTRIOR RELATION
•Left kidney is related to
–Superiorly to the stomach and spleen
–Superomedially to adrenal gland
–Inferiorly to jejunum and splenic flexure of the colon
–Medially to tail of the pancreas with splenic vessels
•To access the left renal hilum, the tail of the pancreas
together with the spleen and splenic vessels must be
mobilized medially.
•Splenorenal ligament
–If excessive downward pressure is applied to the left
kidney, splenic capsular tears may occur, leading to
hemorrhage from the spleen
81 Dept of Urology, GRH and KMC, Chennai.

82. ANTRIOR RELATION
82 Dept of Urology, GRH and KMC, Chennai.

83. RENAL FASCIA
•Renal fascia, Perinephric fat, Renal sinus
•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
83 Dept of Urology, GRH and KMC, Chennai.

84. GROSS ANATOMY
•Two distinct regions can be identified on the
cut surface of a bisected kidney:
–Cortex: which is a pale outer region
–Medulla: which is a darker inner region

84 Dept of Urology, GRH and KMC, Chennai.

85. GROSS ANATOMY
Renal medulla:
•Renal Pyramid- 8 to 18
striated, distinct,
conically shaped areas.
•The apex of the
pyramids forms the
renal papilla
•Each papilla is cupped
by an individual minor
calyx.
•The base of the
pyramids is positioned
at the corticomedullary
boundary.
85 Dept of Urology, GRH and KMC, Chennai.

86. GROSS ANATOMY
Renal cortex
•Approximately 1 cm
in thickness
•Covers the base of
each renal pyramid
peripherally
•Extends downward
between the
individual pyramids
to form the
columns of Bertin
86 Dept of Urology, GRH and KMC, Chennai.

87. MICROSCOPIC ANATOMY
•The functional unit of the kidney is the nephron
•Approximately 0.4 to 1.2 million nephrons are found in each adult
kidney
87 Dept of Urology, GRH and KMC, Chennai.

88. MICROSCOPIC ANATOMY
•PCT, DCT, loop of
Henle are lined by a
single layer of
cubical epithelial
cells.
•Collecting ducts are
lined by 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
88 Dept of Urology, GRH and KMC, Chennai.

89. ARTERIAL SUPPLY
•The renal arteries arise from the aorta at the
level of the intervertebral disk between the L1
and L2
•Renal arteries give branches to the adrenal
glands, renal pelves, and proximal ureters
89 Dept of Urology, GRH and KMC, Chennai.

90. ARTERIAL SUPPLY
•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.
•Nevertheless, the area
supplied by each
segmental artery could
be independently
surgically resected 90 Dept of Urology, GRH and KMC, Chennai.

91. ARTERIAL SUPPLY
•The renal artery
usually divides to
form anterior and
posterior divisions.
•The anterior division
supplies roughly the
anterior two-thirds of
the kidney
•Posterior division
supplies the posterior
one-third of the
kidney.
91 Dept of Urology, GRH and KMC, Chennai.

92. ARTERIAL SUPPLY
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.
•If the posterior segmental branch passes anterior to
the ureter, UPJO may occur.
92 Dept of Urology, GRH and KMC, Chennai.

93. ARTERIAL SUPPLY
•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.
93 Dept of Urology, GRH and KMC, Chennai.

94. ARTERIAL SUPPLY
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.
•Seen in 25% to 28% of patients.
•These accessory renal arteries may contraindicate
laparoscopic donor nephrectomy and result in
severe bleeding if they are injured during
endopyelotomy for UPJO.
94 Dept of Urology, GRH and KMC, Chennai.

95. ARTERIAL SUPPLY
An accessory renal artery
•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.
95 Dept of Urology, GRH and KMC, Chennai.

96. ARTERIAL SUPPLY
•Multiple renal arteries
–arise from the aorta or iliac arteries
–frequently seen in horseshoe and pelvic kidneys.
•In approximately 5% of patients, the main and
accessory right renal arteries pass anterior to
the IVC.
96 Dept of Urology, GRH and KMC, Chennai.

97. ARTERIAL SUPPLY
LINE OF BRODEL
•There is a longitudinal avascular plane between the posterior and
anterior segmental arteries just posterior to the lateral aspect of
the kidney
•Incision in this plane 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.
•Surgical implications.
–during percutaneous access into the kidney, posterior calyces along
the line of Brodel are preferred.
–during anatrophic nephrolithotomy (Boyce procedure), an incision is
made through this avascular plane.
97 Dept of Urology, GRH and KMC, Chennai.

98. ARTERIAL SUPPLY
98 Dept of Urology, GRH and KMC, Chennai.

99. ARTERIAL SUPPLY
•Intrarenal arterial anatomy
•Percutaneous access to the collecting system is usually
performed through a renal pyramid into a calyx to
avoid the columns of Bertin containing larger blood
vessels
99 Dept of Urology, GRH and KMC, Chennai.

100. VENOUS DRAINAGE
•The renal venous drainage correlates closely with the
arterial supply
•unlike the arterial supply, venous drainage has
extensive collateral communication through the
venous collars around minor calyceal infundibula
•Interlobular veins that drain the postglomerular
capillaries also communicate freely with perinephric
veins through the subcapsular venous plexus of stellate
veins
•Because the venous drainage communicates freely
forming extensive collateral venous drainage of the
kidney, occlusion of a segmental venous branch has
little effect on venous outflow
100 Dept of Urology, GRH and KMC, Chennai.

101. VENOUS DRAINAGE
The
interlobular
veins
Arcuate Interlobar Lobar
segmental
veins
Three to five
segmental
renal veins
eventually
unite to
form the
renal vein
101 Dept of Urology, GRH and KMC, Chennai.

102. VENOUS DRAINAGE
•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.
102 Dept of Urology, GRH and KMC, Chennai.

103. VENOUS DRAINAGE
The longer left renal vein
receives
•left suprarenal
(adrenal) vein
•left gonadal (testicular
or ovarian) vein.
•May receive a lumbar
vein, which could be
easily avulsed during
surgical manipulation
of the left renal vein
103 Dept of Urology, GRH and KMC, Chennai.

104. VENOUS DRAINAGE
•“Nutcracker phenomenon”
–compression of the left renal vein between the
aorta and superior mesenteric artery may account
for the varicocele in some boys

104 Dept of Urology, GRH and KMC, Chennai.

105. VENOUS DRAINAGE
•Supernumerary renal veins
–In approximately 15% of the patients
–often are retroaortic when present on the left.
•Accessory renal veins
–more common on the right side
•circumaortic renal vein
–most common anomaly of the left renal venous
system,
–reported in 2% to 16% of patients.
105 Dept of Urology, GRH and KMC, Chennai.

106. VENOUS DRAINAGE
•The retroaortic renal vein
–less commonly seen than the circumaortic vein
–left renal vein bifurcates into ventral and dorsal
limbs, which encircle the abdominal aorta.
•Retroaortic renal vein
–the single left renal vein courses posterior to the
aorta and drains into the lower lumbar segment of
the IVC.
106 Dept of Urology, GRH and KMC, Chennai.

107. LYMPHATIC DRAINAGE
•Interstitial fluid leaves the kidney by either a
superficial capsular or a deeper hilar network
•Renal lymphatics are embedded in the
periarterial loose connective tissue around the
renal arteries and are distributed primarily
along the interlobular and arcuate arteries in
the cortex.
107 Dept of Urology, GRH and KMC, Chennai.

108. LYMPHATIC DRAINAGE
•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
–upper ureter
•where they empty into lymph nodes associated
with the renal vein
108 Dept of Urology, GRH and KMC, Chennai.

109. LYMPHATIC DRAINAGE
109 Dept of Urology, GRH and KMC, Chennai.

110. LYMPHATIC DRAINAGE
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
110 Dept of Urology, GRH and KMC, Chennai.

111. LYMPHATIC DRAINAGE
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
111 Dept of Urology, GRH and KMC, Chennai.

112. LYMPHATIC DRAINAGE
112 Dept of Urology, GRH and KMC, Chennai.

113. INNERVATION
•The kidney can function well without neurologic
control, as evidenced by the successful function
of transplanted kidneys
•Sympathetic preganglionic nerves originate from
the T8 through L1 spinal segments, with
contributions
–mainly from the celiac plexus
–lesser contribution from the
•greater splanchnic
•Intermesenteric
•superior hypogastric plexuses
113 Dept of Urology, GRH and KMC, Chennai.

114. INNERVATION
•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.
114 Dept of Urology, GRH and KMC, Chennai.

115. INNERVATION
115 Dept of Urology, GRH and KMC, Chennai.

116. PELVICALYCEAL SYSTEM
•The upper pole: usually 3 calyces and less commonly 2
•Interpolar region: three or four calyces
•Lower pole: two or three calyces
•These calyces vary considerably not only in numbers
but also in size and shape because of the different
numbers of papillae they receive.
•A calyx may receive a single papilla, two, or even three.
•Compound papillae are often found in the polar
regions of the kidney.
116 Dept of Urology, GRH and KMC, Chennai.

117. PELVICALYCEAL SYSTEM
•The upper pole is usually
drained by a single midline
calyceal infundibulum
•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
117 Dept of Urology, GRH and KMC, Chennai.

118. PELVICALYCEAL SYSTEM
BRODELS HUDSON
Left Kidney
Anterior calyx-
Lateral(20 behind FP)
Posterio calyx-
medial(70 behind FP)
Anterior calyx-
Medial(70 behind FP)
Right kidney
Posterio calyx-
lateral(20 behind FP)
118 Dept of Urology, GRH and KMC, Chennai.

119. PELVICALYCEAL SYSTEM
•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).
119 Dept of Urology, GRH and KMC, Chennai.

120. PELVICALYCEAL SYSTEM
The renal pelvis
•Roughly pyramidal
–base facing the parenchyma
–apex funneling down into the ureter.
•It usually has a capacity of 3 to 10 mL of urine
120 Dept of Urology, GRH and KMC, Chennai.

121. PELVICALYCEAL SYSTEM
Divided (duplex) pelvis
•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.
•Therefore 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.
121 Dept of Urology, GRH and KMC, Chennai.

122. PELVICALYCEAL SYSTEM
•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.
•When a duplex system is suspected during
ureteroscopy, retrograde pyelography could be
performed to illustrate the anomalous
pelvicalyceal system
122 Dept of Urology, GRH and KMC, Chennai.

123. THANK YOU
123 Dept of Urology, GRH and KMC, Chennai.