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ANATOMY

The urinary system consists of the kidney, ureter, urinary bladder


and urethra. This system excretes waste products and excess water
through the tubular system in the kidney.

KIDNEY

Development

There are three different kidney systems formed during the


intrauterine life. They are Pronephros, Mesonephros and Metanephros. In
human embryos the pronephros is rudimentary and non-functional
system which tends to regress by the end of 4th intrauterine week and the
mesonephric system begins to develop. By the 8th week of intrauterine
life, majority of the cranial tubules and the glomeruli developed from the
mesonephros disappear.

The third urinary organ, the metanephros, appears in the 5th week
and it is the permanent kidney. It comprises of two systems: collecting
system and the excretory system.

Collecting System

The collecting duct system develops from the ureteric bud which is
an outgrowth of the mesonephric duct close to its entrance to the cloaca.
The bud penetrates the metanephric tissue and is moulded at its distal
end which dilates and thus forming the primitive renal pelvis. Each calyx
as it penetrates the metanephric tissue form new buds and continues to
subdivide up to 12 times or more. This process continues till the end of
the 5th month. Minor calyces are formed from the 2nd generation by
absorbing the 3rd and the 4th generation. The ureteric bud gives rise to
ureter, renal pelvis, major and minor calyces and about 1-3 millions
collecting tubules.
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The Excretory System

The cells of the metanephric tissue cap form small vesicles the
renal vesicles, which in turn form small tubules. These tubules together
with tufts of capillaries form the excretory unit known as the nephrons.
The proximal end of the nephrons which is indented by the glomerulus
forms the Bowman’s capsule. The distal end opens in to one of the
collecting ducts.

The kidney first develops in the pelvic region but ascends and lies
more cranially in the abdomen. This ascend is thought to be due to
diminution of body curvature and also due to the growth of the body in the
lumbar and sacral region.

Gross Anatomy

The kidneys are two bean shaped, reddish-brown, solid organs


which lie on either side of the vertebral column. The right kidney lies
slightly at a lower level then the left kidney. The normal kidney weighs
approximately 150 gm in the adult male & 135 gm in female. The normal
kidney is typically 10 to 12 cm in vertical dimension, 5 to 7 cm in
transverse width, and approximately 3 cm in antero-posterior thickness.

The renal hilum opens into the renal sinus, a space that forms the
central portion of the kidney and is surrounded by the renal parenchyma.
The urinary collecting structures and renal vessels occupy the renal sinus
and exit the kidney via the hilum medially.

The long axis of the kidney is parallel to the long axis of the 12 th rib.
The right kidney reaches the upper border of the 12th rib and the left
kidney reaches the lower border of the 11th rib. The outer border of the
organ lies about 1.25 cm lateral to the sacrospinalis muscle. The pelvis of
the kidney lies opposite the 1st & 2nd lumber transverse process. The
kidneys are remarkably mobile organs, and moves freely with respiration.
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Anatomic Relations

The diaphragm covers roughly the upper third or upper pole of


each kidney. The medial portion of the lower two thirds of either kidney,
with the renal vessels and pelvis, lies against the psoas muscle. Moving
from medial to lateral on the posterior surface of the kidney, the
quadratus lumborum muscle and then the aponeurosis of the transversus
abdominis muscle are encountered. The last thoracic, iliohypogastric and
ilioinguinal nerves and subcostal vessels are between the kidney and the
quadratus muscle.

Upper pole of the right kidney is related with the right adrenal gland
and liver, the hepatic flexure below, 2nd part of duodenum medially and in
the lower pole is related to posterior peritoneum and right colic vessels lie
above it. The left kidney is related with to the left adrenal gland above, the
pancreas and the splenic vessels in the middle, the stomach and the
spleen lie above the pancreas and the jejunum below. Medially the right
kidney is related to inferior vena cava and the ureter. The left kidney is
related medially to dudenojejunal flexure, inferior mesenteric vein and the
ureter. The lateral aspect of the right kidney is related to the ascending
colon and the liver. The left kidney is related to the descending colon and
spleen laterally.

Coverings of kidney

Kidney has 3 capsules. The fibrous capsule is a thin membrane


which closely invests the kidney and lines the renal sinus. Perirenal fat
layer lies out side the fibrous capsule and is thickest at the borders of the
kidney and fills up the extra space in the renal sinus. Outermost covering
is the renal fascia is an investment, completely covering the kidney.

Microscopic Anatomy

Grossly the kidney has two distinct structural demarcations - cortex


and the inner medulla. The medulla is consists of multiple distinct conical
segments, the renal pyramids (8-18 in no.). The base of each pyramid
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roughly parallels the external contour of the kidney. The renal cortex
covers the pyramids, not only peripherally but also extending between the
pyramids to the renal sinus. Microscopically, the renal parenchyma
consists of multiple tubular structures, in part the kidneys abundant
vascular and capillary networks, in part the various tubules that carry the
urinary filtrate, with scant intervening interstitial connective tissue in the
normal state.

Blood Supply

They are highly vascular organs, receiving one fifth of the total
cardiac output under normal conditions. Usually there is one renal artery,
a branch of the aorta that enters the hilum of the kidney between the
pelvis and the renal vein. It may branch before it reaches the kidney, and
2 or more separate arteries may be noted. In duplication of the pelvis and
ureter, it is usual for each renal segment to have its own arterial supply.

The renal artery divides into anterior and posterior branches. The
posterior branch supplies the mid segment of the posterior surface. The
anterior branch supplies both upper and lower poles as well as the entire
anterior surface. The renal arteries are all end arteries.

The venous drainage of the kidney is profuse and they form


venous arcades along the bases of the medullary pyramids. These
arcades collect blood from the cortex and the medulla and finally drain
into the tributaries of the renal vein. Few capsular veins drain into lumbar
veins.

Nerve Supply

The renal nerves derived from the renal plexus accompany the
renal vessels throughout the renal parenchyma.

Lymphatics

The lymphatics of the kidney drain into the para aortic lymph nodes
at the level of the origin of the renal arteries. The lymphatics from the
upper pole may drain into the Posterior mediastinum.
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CALICES, RENAL PELVIS, & URETER

1. Calices—The tips of the minor calices (8-12 in number) are


indented by the projecting pyramids. These calices unite to form 2 or 3
major calices, which join to form the renal pelvis.

2. Renal pelvis—The pelvis may be entirely intrarenal or partly


intrarenal and partly extrarenal. Inferomedially, it tapers to form the ureter.

3. Ureter—The adult ureter is about 25-30 cm long, varying in


direct relation to the height of the individual. It follows a rather smooth S
curve. Areas of relative narrowing are found (1) at the ureteropelvic
junction, (2) where the ureter crosses over the iliac vessels, and (3)
where it courses through the bladder wall.

Relations

The calices are intrarenal and are intimately related to the renal
parenchyma. If the Renal pelvis is partly extrarenal, it lies along the
lateral border of the psoas muscle and on the quadratus lumborum
muscle; the renal vascular pedicle is placed just anterior to it. The left
renal pelvis lies at the level of the first or second lumbar vertebra; the
right pelvis is a little lower. As followed from above downward, the ureters
lie on the psoas muscles, pass medially to the sacroiliac joints, and then
swing laterally near the ischial spines before passing medially to
penetrate the base of the bladder. In females, the uterine arteries are
closely related to the juxtavesical portion of the ureters. The ureters are
covered by the posterior peritoneum; their lowermost portions are closely
attached to it, while the juxtavesical portions are embedded in vascular
retroperitoneal fat.

Histology

The walls of the calices, pelvis, and ureters are composed of


transitional cell epithelium under which lies loose connective and elastic
tissue (lamina propria). External to these are a mixture of helical and
longitudinal smooth muscle fibers. They are not arranged in definite
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layers. The outermost adventitial coat is composed of fibrous connective


tissue.

Blood Supply

The renal calices, pelvis, and upper ureters derive their blood
supply from the renal arteries; the mid ureter is fed by the internal
spermatic (or ovarian) arteries. The lowermost portion of the ureter is
served by branches from the common iliac, internal iliac (hypogastric),
and vesical arteries. The veins of the renal calices, pelvis, and ureters are
paired with the arteries.

Lymphatics

The lymphatics of the upper portions of the ureters as well as those


from the pelvis and calices enter the lumbar lymph nodes. The lymphatics
of the mid ureter pass to the internal iliac (hypogastric) and common iliac
lymph nodes; the lower ureteral lymphatics empty into the vesical and
hypogastric lymph nodes.

URINARY BLADDER and URETHRA

Development:

The bladder is developed from the Allantosis, urogenital sinus and


incorporation of the Mesonephric ducts and the ureters (forming the
Trigone of the bladder). The part of the male urethra, extending from the
urinary bladder up to the opening of the Ejaculatory ducts (original
opening of the Mesonephric ducts) is derived from the caudal part of the
Vesicourethral canal (endoderm). The posterior wall of this part is
derived from the absorbed metanephric duct (mesoderm).

The rest of the Prostatic urethra and the Membranous urethra are
derived from the Pelvic part of the Definitive urogenital sinus. Penile part
of urethra (except terminal part) is derived from the epithelium of the
phallic part of the Definitive urogenital sinus. The terminal part of the
penile urethra, lying in the glans penis is derived from the Ectoderm.
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The female urethra is derived from the caudal part of the Vesico
urethral canal (endoderm). The posterior part is again of mesodermal
origin as it is formed by the absorbed mesonephric ducts. It has a slight
contribution from the pelvic part of the urogenital sinus.

Gross structure:

Urinary bladder is a muscular reservoir of urine, which lies in the


anterior part of the pelvic cavity partly covered with peritoneum. It has an
apex directed forward, a base or fundus directed backward, a neck, which
is the lowest and most fixed part of the bladder. The empty bladder is
intra pelvic, tetrahedral in shape and its cavity is merely a slit. When full it
has three surfaces---Superior, right inferolateral and left inferolateral and
4 borders—2 laterals, 1 anterior and 1 posterior. The superior surface is
covered with peritoneum. In young children the bladder occupies a higher
position because of a relatively smaller pelvis and greater sized bladder.

The male urethra is 18-20 cm long. In flaccid state, the long axis
shows 2 curvatures and therefore ‘S’ shaped. In erect state, the distal
curve is obliterated and it becomes ‘J’ shaped.

Various parts of the urethra are named accordingly to the structures


related to its course

1. Prostatic part: most dilatable and widest, 3 cm in length, semi


lunar in cut section.

2. Membranous part: the shortest (1.5- 2 cm), narrowest (next to


the urethral meatus only), least dilatable, star shaped in cut
section.

3. Penile or spongy part: the longest (15cm), dilated both


proximally (Intra bulbar fossa) and distally (fossa navicularis),
uniform in diameter (6 mm) and a transverse slit in the cut
section.
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The female urethra is only 4 cm long and 6 mm in diameter. It


starts at the internal urethral meatus and ends at the external urethral
meatus in the vestibule. The female urethra is easily dilatable.

Supports of the bladder and its relations:

Bladder is anchored securely at its neck which is fixed by its


continuity with the urethra and the prostate which are in turn bound to the
urogenital diaphragm. Supports of the bladder are reinforced by two sets
of ligaments.

True ligaments

1. Anterior puboprostatic ligament

2. Two lateral puboprostatic ligaments

3. The remnants of urachus or Median umbilical ligaments

4. Posterior ligaments.

False ligaments are the peritoneal folds and don’t give true
supports to the urinary bladder. They include the median umbilical folds,
lateral false ligaments and posterior false ligaments.

Bladder wall and its sphincters:

The bladder is made up of an unstriated muscle, known as


“detrussor”, the outer and the inner layers are longitudinal and middle is
circular in disposition. The bladder lacks the muscularis mucosa. The sub
mucosa is lax and allows mucosa to be thrown into folds or rugae all over
except the Trigone.

Existence of true sphincters in the bladder neck is still debatable.


Classically said , there are two sphincters, the ”sphincter vesicae” or
internal sphincter composed of nonstriated muscles; and another one is
“sphincter urethrae” composed of striated muscles.
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Blood supply:

The main supply is from the superior vesicle artery and inferior
vesicle artery, branches from the anterior trunk of the internal iliac
arteries. Additional supply may be derived from the Obturator, Inferior
gluteal artery and in females from the Uterine and Vaginal arteries.

The veins form a vesicle plexus on the inferolateral surfaces of the


bladder and drains into the Internal Iliac veins. In males, the Prostatic
venous plexus some times communicates to it.

Lymphatic drainage:

The lymphatics of the bladder can be divided into sub mucous,


intra muscular & adventitial. Nearly all the lymphatics drain into the
External iliac nodes. From the prostate and the membranous urethra
lymphatic mainly drain into the “Internal iliac lymph nodes” along the
internal pudendal arteries and partly into the External iliac Lymph nodes.
Almost whole of the penile urethra drains into the deep inguinal lymph
nodes. But some may drain into the superficial inguinal lymph nodes and
external iliac lymph nodes

Nerve supply:

Urinary bladder is supplied by both the Parasympathetic (S2, S3


and S4- motor to the detrussor muscles and inhibitory to the Sphincter
vesicae) & Sympathetic (T11, T12, L1 and L2- motor to the Sphincter
vesicae & inhibitory to the Detrussor and). Each of them has both
Sensory (Afferent) & Motor (Efferent) fibers.

Somatic nerves (Pudendal) arising from the S2, 3, 4 supply the


sphincter urethrae which is voluntary.

PROSTATE

Prostate is a fibro muscular organ of about the size of a chestnut. It


develops from the out growths from the primitive urethra and adjacent
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portion of the urogenital sinus. Its homologous counter part in the females
is Skene’s tubules.

It is conical in shape and measures 4cm x 3cm x 2 cm in


transverse, vertical and anteroposterior diameters. The base is concave
and surrounds the bladder neck. It is pierced by the urethra and
ejaculatory ducts .The convex anterior surface is separated from the
symphysis by a pad of fat and puboprostatic ligaments. The apex lies on
the triangular ligament and the posterior flat surface is related to the
anterior surface of the rectum. Prostate is described to have 5 lobes-
anterior, middle, posterior and 2 lateral lobes. It is enclosed in a fibrous
capsule and around its lateral and anterior surface; there is a plexus of
veins (Prostatic venous plexus of Santorini).

The arterial supply is from the branches of the Inferior vesical


artery (mainly), Middle rectal & Internal pudendal artery.

The Venous drainage is to the vesical veins through the vesical


venous plexus and ultimately to the Internal iliac veins.

The Lymphatic drainage is to the Iliac & Sacral nodes.