EMBRYOLOGY AND ANATOMY OF KIDNEY

EMBRYOLOGY AND ANATOMY OF KIDNEY

1. EMBRYOLOGY AND 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. EMBRYOLOGY OF KIDNEY
3Dept of Urology, GRH and KMC, Chennai.

4. EMBRYOLOGY OF KIDNEY
•Develop from a common mesodermal ridge
(intermediate mesoderm) along the posterior
wall of the abdominal cavity.
–pronephros, (rudimentary and nonfunctional)
–mesonephros, (function for a short time during
the early fetalperiod)
–metanephros, (forms the permanent kidney)
4Dept of Urology, GRH and KMC, Chennai.

5. PRONEPHROS
•At 3
rd
week of gestation
•Develops as five to seven solid cell groups
•starts at the cranial end of the nephrogenic
cord and progresses caudally
•As each tubule matures it immediately begins
to degenerate along with the segment of the
nephric duct
5Dept of Urology, GRH and KMC, Chennai.

6. MESONEPHROS
•Around 24
th
day, mesonephricvesicles begin to form.
–Initially, several spherical mass of cells
–vesicle elongates, form an S-shaped tubule.
–The lateral end forms a budthat connects with the
nephric duct.
–The medial end lengthens and enlarges to form a cup-
shaped sac, which eventually wraps around a knot of
glomerular capillaries to form a renal corpuscle.
•The tuft of glomerular capillaries originating from a branch of
the dorsal aorta invades the developing glomerulus
6Dept of Urology, GRH and KMC, Chennai.

7. 7Dept of Urology, GRH and KMC, Chennai.

8. •Ducts fuse with the cloaca and begin to form a
lumen at the caudal end and progresses cranially
•This differentiation progresses caudally and
results in the formation of 40 to 42 pairs of
mesonephrictubules,
•At any time only 30 pair tubules present,because
degeneration start simultaneously
8Dept of Urology, GRH and KMC, Chennai.

9. –By the 4th month, the human mesonephros-completely
disappeared, except for a few elements that persist as
part of the reproductive tract.
–In males, some cranially located mesonephrictubules
become the efferent ductulesof the testes , epididymis
and vas deferens .
–In females, small, nonfunctionalmesosalpingealstructures
termed the epoöphoronand paroöphoron.
9Dept of Urology, GRH and KMC, Chennai.

10. 10Dept of Urology, GRH and KMC, Chennai.

11. 11Dept of Urology, GRH and KMC, Chennai.

12. METANEPHROS
•The definitive kidney
•Excretory units develop from metanephricmesoderm
•Ureteric bud forms from distal portion of the nephric duct as
sprouting buds
•Ureteric bud come in contact with the condensing blastemaof
metanephricmesenchyme = 28th day
•The ureteric bud penetrates the metanephricmesenchyme and
begins to divide dichotomously.
•As the ureteric bud divides and branches ,it gives metanephrosa
lobulated appearance
12Dept of Urology, GRH and KMC, Chennai.

13. •Mesenchymal-epithelial interaction --induce
formation of future nephrons
•Glomerulus, proximal tubule, loop of henle,
and distal tubule = derive from the
metanephricmesenchyme
•Collecting system, consisting of collecting
ducts, calyces, pelvis, and ureter, is formed
from the ureteric bud
13Dept of Urology, GRH and KMC, Chennai.

14. EXCRETORY SYSTEM
•Each newly formed collecting tubule is covered at its distal end by a
metanephrictissue cap.
•Cells of the tissue cap form small vesicles, the renal vesicles.
•Renal vesicles give rise to small S-shaped tubules.
•Capillaries grow into the pocket at one end of tubule and
differentiate into glomeruli.
•These tubules, together with their glomeruli, form nephrons, or
excretory units.
•The proximal end of each nephron forms Bowman’s capsule.
14Dept of Urology, GRH and KMC, Chennai.

15. •The distal end forms an open connection with one of the collecting
tubules, establishing a passageway from Bowman’s capsule to the
collecting unit.
•Continuous lengthening of the excretory tubule results in formation
of the proximal convoluted tubule, loop of Henle, and distal
convoluted tubule.
•At birth there are approximately 1 million of nephrons in each
kidney.
•Urine production begins early in gestation, soon after
differentiation of the glomerular capillaries, which start to form by
the 10th week.
•At birth the kidneys have a lobulated appearance, which disappears
during infancy as a result of further growth of the nephrons,
without increase in number.
15Dept of Urology, GRH and KMC, Chennai.

16. 16Dept of Urology, GRH and KMC, Chennai.

17. 17Dept of Urology, GRH and KMC, Chennai.

18. •Overall, these events are reiterated
throughout the growing kidney so that older,
more differentiated nephrons are located in
the inner part of the kidney near the
juxtamedullaryregion and newer, less
differentiated nephrons are found at the
periphery
18Dept of Urology, GRH and KMC, Chennai.

19. COLLECTING SYSTEM
•The dichotomous branching of the ureteric bud
determines the eventual pelvicalycealpatterns and
their corresponding renal lobules .
•By 20 to 22 weeks, ureteric bud branching is
completed.
•Thereafter, collecting duct development occurs by
extension of peripheral branch segments.
•
•The bud dilates, forming the primitive renal pelvis,
and splits into cranial and caudal portions (the future
major calyces).
19Dept of Urology, GRH and KMC, Chennai.

20. •Each calyx forms two new buds while penetrating the
metanephrictissue.
•These buds continue to subdivide until 12 or more
generations of tubules have formed.
•Meanwhile, at the periphery more tubules form until
the end of the fifth month.
•The tubules of the second order enlarge and absorb
those of the third and fourth generations, forming
the minor calyces of the renal pelvis.
•Collecting tubules of the fifth and successive
generations form the renal pyramid.
20Dept of Urology, GRH and KMC, Chennai.

21. 21Dept of Urology, GRH and KMC, Chennai.

22. 22Dept of Urology, GRH and KMC, Chennai.

23. •Between 22 and 24 weeks of fetalgestation the
peripheral (cortical) and central (medullary)
develops.
•Nephrogenesiscompleted before birth at 32-34
weeks of gestation.
•Postnatal maturation of kidney continue till 18-
24 month of age
23Dept of Urology, GRH and KMC, Chennai.

24. •Renal cortex
–70% of total kidney volume at birth,
–becomes organized as a relatively compact,
–circumferential rim of tissue surrounding the periphery of
the kidney.
•Renal medulla
–30% of total kidney volume at birth,
–modified cone shape with a broad base contiguous
with cortical tissue.
–The apex of the cone is formed by convergence of
collecting ductsin the inner medulla and is termed
the papilla.
24Dept of Urology, GRH and KMC, Chennai.

25. GENETICS
•WT1 is normally first expressed in the intermediate mesoderm prior
to kidney formation and is then expressed in the developing kidney,
gonad, and mesothelium
•The metanephrogenicmesenchyme secretes glial-derived
neurotrophicfactor (GDNF) to induce and direct the ureteric bud
•The ureteric bud secretes FGF2 and BMP7 to prevent
mesenchymalapoptosis and maintains the synthesis of WT1
•
•Leukemiainhibitory factor (LIF) from the ureteric bud induces the
mesenchyme cells to aggregate
•Lim-1 homeodomaintranscription factor causes Conversion of the
aggregated cells into a nephron
•Hoxa-13 and Hoxd-13 act on urogenital deferentiation
25Dept of Urology, GRH and KMC, Chennai.

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

27. POSITION OF KIDNEY
•The kidney, initially in the pelvic region,
•Around 6-7
th
week, ascent of the kidney is caused by
diminution of body curvature and by growth of the
body in the lumbar and sacral regions.
•In the pelvis the metanephrosreceives its arterial
supply from a pelvic branch of the aorta.
•During its ascent to the abdominal level, it is
vascularized by arteries that originate from the aorta
at continuously higher levels
•During 7-8week kidney rotate 90 degree with renal
hilum changing position from ventral to anteromedially
27Dept of Urology, GRH and KMC, Chennai.

28. Anomalies of shape
•Horse shoe kidney
•Pancake kidney
•Lobulated kidney
28Dept of Urology, GRH and KMC, Chennai.

29. Abnormal rotation
•Nonrotation: The hilum is directed forward.
•Incomplete rotation
•Reverse rotation: The hilum is directed
anterolaterally.
29Dept of Urology, GRH and KMC, Chennai.

30. Anomalies of position
•The kidneys may fail to ascend. They then lie
in the sacral region.
•Incomplete ascent = lie opposite the lower
lumbar vertebrae.
•The kidneys may ascend too far, and may even
be present within the thoracic cavity.
30Dept of Urology, GRH and KMC, Chennai.

31. 31Dept of Urology, GRH and KMC, Chennai.

32. ANATOMY OF KIDNEY
•Paired ovoid, reddish-brown retroperitoneal organs
situated in the posterior part of the abdomen on each side
of the vertebral coloumn
•Lie on the psoas muscles; thus the longitudinal axes of the
kidneys are oblique .
•The upper poles more medial and posterior than the
inferior poles.
•The medial aspect of each kidney is rotated anteriorly at an
angle of approximately 30 degrees.
32Dept of Urology, GRH and KMC, Chennai.

33. 33Dept of Urology, GRH and KMC, Chennai.

34. •The exact position of the kidney within the
retroperitoneumvaries:
➢The kidneys move inferiorly approximately 3
cm (one vertebral body) during inspiration and
during changing body position from supine to
the erect.
34Dept of Urology, GRH and KMC, Chennai.

35. DIMENSIONS
•Length-10 to 12 cm
•Width-5.0 to 7.5 cm
•Thickness-2.5 to 3.0 cm.
➢Weight of kidney = approx. 125-170 gm. ( 10-
15 gmlighter in females)
➢Relatively larger in children and have
prominent fetallobulations.
35Dept of Urology, GRH and KMC, Chennai.

36. Right kidney vsleft kidney
Right kidney
•Reside between the top
of the 1st lumbar
vertebra to the bottom of
the 3rd lumbar vertebra.
•The right kidney is
slightly shorter and wider
because of downward
compression by the liver.
•The right kidney is
related to the 12th rib,
Left kidney
•Between the 12th
thoracic vertebra and the
3rd lumbar vertebra.
•Dromedary hump more
common on left side.
•Left kidney is related to
the 11th and 12th ribs
36Dept of Urology, GRH and KMC, Chennai.

37. RELATIONS
•Surfaces of kidney are -anterior and
posterior.
•Borders are -medial and lateral.
•Poles of kidney are –superior and inferior.
•Anteriorly kidney is related -abdominal
viscera
Posteriorly -osteomusculararea
37Dept of Urology, GRH and KMC, Chennai.

38. ANTERIOR RELATIONS
RIGHT KIDNEY
•right adrenal gland
•liver,
•second part of duodenum,
•ascending colon,
•hepatic flexure of colon.
LEFT KIDNEY
•Left adrenal,
•Pancreas,
•splenic vessels,
•Stomach,
•Spleen,
•Djflexure,
•Ligament of trietz,
•Descending colon,
•Splenic flexure of colon,
•Loops of jejunum.
38Dept of Urology, GRH and KMC, Chennai.

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

40. RIGHT LEFT
40Dept of Urology, GRH and KMC, Chennai.

41. POSTERIOR RELATIONS OF KIDNEY
LEFT KIDNEY
•Projection of 11th rib
•Area for diaphragm
•Projection of 12th rib
•Area for aponeurosisof
transversusabdominis
muscle
•Area for quadratus
lumborummuscle
•Area for psoas major muscle
RIGHT KIDNEY
•Area for diaphragm
•Projection of 12th rib
•Area for aponeurosisof
transversusabdominis
muscle
•Area for quadratus
lumborummuscle
•Area for psoas major muscle
41Dept of Urology, GRH and KMC, Chennai.

42. LEFT RIGHT
42Dept of Urology, GRH and KMC, Chennai.

43. 43Dept of Urology, GRH and KMC, Chennai.

44. APPLIED ANATOMY
•Posterior reflection of the pleura extends
inferiorly to the 12th rib
•Lung edge lies above the 11th rib (at the 10th
intercostal space)
•Risk of injury to the lung from a 10th
intercostal percutaneous approach to the
kidney
44Dept of Urology, GRH and KMC, Chennai.

45. Relationship to ribs and pleura
45Dept of Urology, GRH and KMC, Chennai.

46. MEDIALBORDER
»In medial border of each kidney there is a vertical fissure
called renal hilum/porta
•Renal vessels, nerves, lymphatics, enter and exit through
throughhilum
•Concavity of hilum is continouswith deep declivity in
medial border of kidney called renal sinus
•Within renal sinus is renal pelvis, a funnel shaped sac
formed by widely expanded portion of proximal ureter and
by junction of major calices
46Dept of Urology, GRH and KMC, Chennai.

47. •Intra renal pelvisdenotes the pelvis that is
almost covered by renal parenchyma.
•Renal pelvis almost bifurcates or trifurcates
within the sinus producing 2/3 major calyx.
•Each major calyx again divide into 5-14 minor
calyxes receiving collecting ducts ( 500).
•Renal pelvis commonly lies posterior to renal
vessels.
•Has a capacity of 3 to 10 ml of urine.
47Dept of Urology, GRH and KMC, Chennai.

48. •LATERAL BORDER :
Relatedtoperirenalfascia,gerota’sfascia,
pararenalfascia.
48Dept of Urology, GRH and KMC, Chennai.

49. GEROTA’S FASCIA
•Encloses the kidney & perirenalfat and
adrenals.
•Anatomic barrier to spread of malignancy
•Superiorly and laterally it is closed
•Medially it crosses the midline to fuse with
the fellow of opp. Side
•Inferiorly it remains open-perinephricfluid
can track into pelvis
49Dept of Urology, GRH and KMC, Chennai.

50. RENAL FASCIA
50Dept of Urology, GRH and KMC, Chennai.

51. •Two distinct regions :-
Cortex -pale outer region,
Medulla -darker inner region
•Renal medulla -8 to 18 striated, distinct, conically shaped areas
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.
•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 columns of Bertin.
51Dept of Urology, GRH and KMC, Chennai.

52. •Interlobararteries traverse these columns of
Bertin
•Therefore percutaneous access to the collecting
system is usually performed through a renal
pyramid into a calyx to avoid these columns of
Bertincontaining larger blood vessels
•The functional unit of the kidney is the nephron.
Approximately 0.4 to 1.2 million nephrons are
found in each adult kidney.
52Dept of Urology, GRH and KMC, Chennai.

53. •The cortex made up of the glomeruli with PCT &
DCT.
•The renal pyramids are made up of loops of
Henleand collecting ducts.
•Ducts join to form the papillary ducts (about 20),
which open at the papillary surface (area cribosa)
and drain urine into the collecting system(into
the fornix of a minor calyx).
53Dept of Urology, GRH and KMC, Chennai.

54. 54Dept of Urology, GRH and KMC, Chennai.

55. MINOR CALYX
•The renal papillae drain into the minor calyces,
(the most peripheral portions of the intrarenal
collecting system).
•Range in number from 5 to 14 (mean-8)
•Simple(drains one papilla)
•Compound (drains two or three papillae)
•Compound calyces are the rule in the upper
calycealgroup, are common in the lower calyceal
group, and are rare in the middle calycealgroup
55Dept of Urology, GRH and KMC, Chennai.

56. •Three calycealgroups: upper, middle, and lower.
•Minor calyces, either directly or after coalescing into
major calyces, drain by infundibula into the renal pelvis
•Compound calyces of the poles of the kidney are
oriented facing their respective poles.
•Simple calyces usually come in pairs, with one facing
anteriorly and one facing posteriorly
56Dept of Urology, GRH and KMC, Chennai.

57. 57Dept of Urology, GRH and KMC, Chennai.

58. •Drainage of the upper pole into the renal pelvis is by a
single midline infundibulum in the majority of kidneys.
•Drainage from the lower pole is via a single infundibulum
in about half of human kidneys.
•The middle calyces are typically arranged in a series of
paired anterior and posterior calyces.
•In about two thirds of kidneys, there are two major calyceal
systems—an upper one and lower one—and the middle
calyces drain into either or both systems
58Dept of Urology, GRH and KMC, Chennai.

59. CLASSIFICATION OF THE
PELVIOCALYCEAL SYSTEM
Group A (62.2%)
•Two major calycealgroups (superior and inferior)
•Midzonecalycealdrainage dependent on these two
major groups
➢Type A-I (45%). The kidney midzoneis drained by minor
calyces that are dependent on the superior and/ or
inferior calycealgroups
➢Type A-II (17.2%). The kidney midzoneis drained
simultaneously by crossed calyces, one draining into
the superior calycealgroup and the other draining into
the inferior calycealgroup
59Dept of Urology, GRH and KMC, Chennai.

60. 60Dept of Urology, GRH and KMC, Chennai.

61. Group B (37.8%)
•Midzone(hilar) calycealdrainage independent of both
the superior and inferior calycealgroups
•Type B-I (21.4%). The kidney midzoneis drained by a
major calycealgroup, independent of both the superior
and the inferior groups.
•Type B-II (16.4%). The kidney midzoneis drained
by minor calyces (one to four) entering directly into the
renal pelvis .
61Dept of Urology, GRH and KMC, Chennai.

62. 62Dept of Urology, GRH and KMC, Chennai.

63. ORIENTATION OF CALYCES
•Important consideration for percutaneous surgery-
anteroposteriororientation of the calyces,
•Because access (from the typical posterior or
posterolateralapproach) into a posterior calyx allows
relatively straight entry into the rest of the kidney,
whereas
•Percutaneous puncture of an anterior calyx requires
an acute angulation to enter the renal pelvis, which
may not be possible with rigid instrumentation .
63Dept of Urology, GRH and KMC, Chennai.

64. ORIENTATION OF CALYCES
•Paired anterior and posterior calyces usually
enter at about 90 degrees from each other.
•The relative mediolateralorientation (on
anteroposteriorradiography) is determined by
the relationship of this 90-degree unit to the
frontal plane of the kidney.
64Dept of Urology, GRH and KMC, Chennai.

65. BRODEL TYPE
•Unit is rotated anteriorly, such that the posterior
calyces are about 20 degrees behind the frontal plane
•Anterior calyces are 70 degrees in front of the frontal
plane
•The posterior calyces are lateral, and the anterior
calyces are medial in this case
•Most right kidneyshave a Brodel-type orientation
(posterior calyces are lateral)
65Dept of Urology, GRH and KMC, Chennai.

66. HODSON TYPE
•Calycealpairs are rotated posteriorly, with the
posterior calyces 70 degrees behind the
frontal plane and appearing medial
•Anterior calyces 20 degrees in front of the
frontal plane and appearing lateral
•Left kidneys have a Hodson-type orientation
(posterior calyces are medial)
66Dept of Urology, GRH and KMC, Chennai.

67. 67Dept of Urology, GRH and KMC, Chennai.

68. •Mostly calyces of the upper pole are suitable
for percutaneous access from posterior
approach, whereas care must be taken to
select a posterior minor calyx in middle and
lower groups.
•Safest place to access collecting system is
directly into calycealfornix as it will avoid
interlobararteries and arcuatearteries…
68Dept of Urology, GRH and KMC, Chennai.

69. FOR PERCUTANEOUS ACCESS
▪In prone position, preferedcalyx are posterior ones.
▪Should never be directed into infundibulum or renal
pelvis.
▪Upper pole calyx is most versatile site through which to
enter the upper urinary tract collecting system.
▪Subcostal approach is safest route to kidney.
69Dept of Urology, GRH and KMC, Chennai.

70. RENAL VASCULATURE
•The renal arteries arise from the aorta at the level of the intervertebral disk
between the L1 and L2 vertebrae.
•Each artery divides into five segmental end arteries that do not anastomose
significantly with other segmental arteries.
•The renal artery usually divides to form anterior and posterior divisions.
•The anterior division supplies 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 -first and most constant branch, which separates
from the renal artery before it enters the renal hilum
70Dept of Urology, GRH and KMC, Chennai.

71. SEGMENTAL BRANCHES
•End arteries-so injury lead to segmental infarction.
•First and most constant branch POSTERIOR SEGMENTAL
BRANCH
•Four anterior branches
•APICAL
•UPPER
•MIDDLE
•LOWER
•Posterior segmental artery passes posterior to renal pelvis,
•SURGICAL IMPORTANCE -when it passes anterior to pelvis
lead to pujobstruction..
71Dept of Urology, GRH and KMC, Chennai.

72. 72Dept of Urology, GRH and KMC, Chennai.

73. 73Dept of Urology, GRH and KMC, Chennai.

74. •In the renal sinus, the segmental arteries branch into lobar arteries,
which further subdivide in the parenchyma to form interlobar
arteries.
•The interlobararteries progress peripherally within the cortical
columns of Bertin, avoiding the renal pyramids but in a close
association with the minor calycealinfundibula.
•At the base (peripheral edge) of the renal pyramids, the interlobar
arteries branch into arcuatearteries.
•Instead of moving peripherally, the arcuatearteries parallel the
edge of the corticomedullaryjunction and move radially, where
they eventually divide to form the afferent arteries to the
glomerulus.
74Dept of Urology, GRH and KMC, Chennai.

75. 75Dept of Urology, GRH and KMC, Chennai.

76. 76Dept of Urology, GRH and KMC, Chennai.

77. ANOMALIES OF RENAL ARTERY
•Multiple renal arteries-kidney supplied by more than
one artery..MCon left side.
•Accessory renal artery –2 or more branch supply the
same renal segment. MC on left side 30 to 35%
•They enter either in upper pole/ lower pole of kidney.
•Such accessory artery can cause ureteric obstruction
lead to secondary HUN..
•But ligation of accessory renal artery result in a portion
of infarction
•Arterial anomalies are more common on left and
venous anomalies are more common on right.
77Dept of Urology, GRH and KMC, Chennai.

78. COMMON ANATOMIC VARIANTS OF
VESSEL
•Occurs in 25-40%
•M.C is supernumeryarteries-More commen
on Left side.
•Lower pole arteries can cross ant to collection
system and cause PUJ obstruction
78Dept of Urology, GRH and KMC, Chennai.

79. RENAL VEIN
•The vein is located directly anterior to the
renal artery.
•This position can vary up to 1-2 cm cranially or
caudally relative to the artery
79Dept of Urology, GRH and KMC, Chennai.

80. LEFT RENAL VEIN
•The left renal vein -6 to 10 cm in length and
drains into IVC after passing posterior to the
superior mesenteric artery and anterior to the
aorta
•Left renal vein enters the IVC at a slightly more
cranial level and a more anterolateral location
•The left renal vein receives the left adrenal
vein superiorly, lumbar vein posteriorly, and
left gonadal vein inferiorly
80Dept of Urology, GRH and KMC, Chennai.

81. RIGHT RENAL VEIN
•The right renal vein is generally 2 to 4 cm in
length and enters the right lateral to
posterolateraledge of the IVC
•Right renal vein enters the IVC at a slightly
more caudal level.
•The right renal vein typically do not receive
any branches
81Dept of Urology, GRH and KMC, Chennai.

82. •Unlike the arterial supply, the venous drainage
communicates freely through “Venous
Collars” around the infundibula,
•Extensive collateral circulation is present in
the venous drainage of the kidney.
•Surgically, this is important, because unlike the
arterial supply, occlusion of a segmental
venous branch has little effect on venous
outflow
82Dept of Urology, GRH and KMC, Chennai.

83. 83Dept of Urology, GRH and KMC, Chennai.

84. 84Dept of Urology, GRH and KMC, Chennai.

85. BRODEL’S LINE /AVASCULAR PLANE
•Slightly behind the convex border at the
posterior half of kidney (approximately 2/3 rd
way from lateral border ).
•Incision in this area will permit to remove
stone within renal calices with minimal
damage.
85Dept of Urology, GRH and KMC, Chennai.

86. 86Dept of Urology, GRH and KMC, Chennai.

87. LYMPHATICS
•Largely follow blood vessels through the column
of bertin.
•Lymphaticsempty to LN near renal hilum
•L KIDNEY:-
-Lt lateral para-aortic LN
•R KIDNEY:-
-Rtinter aortocavaland Rtlateral para
cavalLN and anterior and posterior inferior
venacavalnodes.
87Dept of Urology, GRH and KMC, Chennai.

88. LYMPHATICS OF RIGHT KIDNEY
88Dept of Urology, GRH and KMC, Chennai.

89. LYMPHATICS OF LEFT KIDNEY
89Dept of Urology, GRH and KMC, Chennai.

90. NERVE SUPPLY
•SYMPATHETIC -From T8 to L1 through celiac
and aorticorenal ganglion
-Vasoconstriction
•PARA SYMPATHETIC-From vagus
-vasodilatation
➢Remember that kidney can function well even
without neurological control
90Dept of Urology, GRH and KMC, Chennai.

91. APPLIED ANATOMY
•Avoid injury to T11 and T12 nerves –to avoid
post op paraesthesiasand postop muscle
buldingfrom partial muscle paralysis.
•While suturing ensure not to entrap the lower
costal nerves.
•Injury to 12 thnerve lead to gluteal
paraesthesias.
91Dept of Urology, GRH and KMC, Chennai.

92. RADIOLOGICAL ANATOMY OF RENAL
PARENCHYMA
•On USG-In adults normal kidneys have smooth margins
and isoechoicto liver
•Both renal cortices and pyramids are usually hypoechoic
to the liver, spleen, and renal sinus. Compared with renal
parenchyma, the renal sinus appears hyperechoic
because of the presence of hilaradipose tissue, blood
vessels, and lymphatics.
•The renal cortices of newborn kidneys are isoechoicor
hyperechoicto the liver and splenic parenchyma
•Echogenicity correlates to the severity of pathologic changes
in renal parenchyma.
92Dept of Urology, GRH and KMC, Chennai.

93. ON CT
•On unenhanced computed tomography (CT), the renal
parenchyma is homogeneous, with a density ranging
from 30 to 60 (HU)
•After intravenous contrast injection = 80-120HU.
•Arterial phase= after 20 to 30 seconds of contrast
•The corticomedullary= 30-70 sec ( cortex brighter)
•The nephrographicCT phase= 80 to 120 seconds,
equally enhances renal cortex and medulla and is
considered to be the optimal phase for detection of
renal neoplasms.
•The excretory ctphase= more than 3 minutes after
contrast
93Dept of Urology, GRH and KMC, Chennai.

94. ON MRI
•MRI= 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
•Pelvis containing fat appears hypertenseon
both T1 and T2
•Nephrogenicphase= 60-90 sec
•Excretory phase= 120 sec
94Dept of Urology, GRH and KMC, Chennai.

95. THANKS
95Dept of Urology, GRH and KMC, Chennai.