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The anatomy of the kidney and ureter
PHYSIOLOGY
The anatomy of the kidney and ureter
The kidneys, their anterior relations and renal vessels Left colon (splenic flexure) Spleen
Harold Ellis
Stomach Left suprarenal Duodenum Liver
Abstract The kidneys are placed retroperitoneally on the posterior abdominal wall, the right lower than the left. At the renal hilum are found, from before back, the renal vein, artery, pelvis of the ureter and a small posterior artery branch. There are also lymphatics and sympathetic fibres (T12–L1), which account for referred renal pain to the lower abdominal wall and external genitalia. The pelvis of the ureter divides into two or three major calyces, which divide into minor calyces, each indented by a renal papilla, onto which discharge the renal tubules. The three fascial layers are: the capsule, which is easily stripped from the healthy kidney; the perinephric fat; and the investing renal fascia, which adheres to the structures at the hilum and usually tamponades a closed rupture of the kidney, which can thus be treated conservatively. The ureter is 25 cm long, comprising the pelvis and an abdominal, pelvic and vesical portion; the last acting as a sphincter. The ureter is crossed by the gonadal vessels and may be injured here in gynaecological surgery. The ureter can be identified as it constantly crosses the common iliac artery at its bifurcation and then lies on the anterior aspect of the internal iliac artery.
Right colon (hepatic flexure) Inferior vena cava
Small gut
Aorta
Figure 1
Keywords blood supply; kidney; perinephric fat; renal capsule; renal fascia; renal pelvis; ureter
(derived from the aorta at about the level of L1), the pelvis of the ureter and, usually, a posterior arterial branch. In addition, the hilum transmits lymphatics, which pass to the para-aortic lymph nodes, and sympathetic nerve fibres from T12 to L1. Sympathetic afferent fibres account for the classical referral of renal pain to the lower abdominal wall and the external genitalia. Within the renal substance, the pelvis of the ureter divides into two or three major calyces, each then divides into several minor calyces. Each minor calyx is indented by a papilla, on which the renal tubules discharge urine. The calyceal system is readily appreciated on inspection of a normal intravenous urogram. The kidney possesses three fascial layers: • The true capsule: a thin lucent sheet, which strips easily from the normal organ. • The perinephric fat: an abundant fatty cushion. • The renal fascia: encloses the perinephric fat and adheres to the renal vessels and pelvis at the hilum. Tamponade of the ruptured kidney by this sheath is the reason why most of these cases can be treated conservatively.
The kidneys are situated behind the peritoneum of the posterior abdominal wall. The right kidney is lower than the left, pushed down by the liver. In most healthy individuals, the kidneys are impalpable, but, in a particularly thin person, the lower pole of the right kidney may be just tipped on full inspiration.
Relations (Figure 1) On each side, the suprarenal gland sits like a cap on the superior pole. Anterior to the left kidney lie the pancreas and its vessels, the spleen, the descending colon and the stomach, which is separated by the lesser sac. On the right lie the second part of the duodenum, the liver and the hepatic flexure of the colon. Posteriorly, both kidneys lie on the diaphragm and the muscles of the posterior wall of the abdomen; the upper pole lying at the level of the 12th rib. The renal hilum is the deep vertical slit on its medial border. This transmits, from before backwards, the renal vein (which drains into the inferior vena cava), the renal artery
The ureter The ureter is 10 inches (25 cm) long and comprises a pelvis and an abdominal, pelvic, and intra-vesical portion (which acts as a sphincter mechanism). The ureter is narrowed at three sites: the pelvi-ureteric junction; as it crosses the brim of the pelvis; and at its termination. These are the sites at which a calculus is most likely to lodge. The ureter descends on the medial edge of psoas
Harold Ellis CBE FRCS was professor of Surgery at Westminster Medical School until 1989. Since then he has taught anatomy, first in Cambridge and now at Guy’s Hospital, London, UK.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:6
Pancreas
263
© 2009 Published by Elsevier Ltd.
PHYSIOLOGY
by only one structure: the vas deferens in men and the uterine vessels in women, as it passes below the broad ligament. The ureter is at risk of injury when the uterine vessels are ligated in a hysterectomy. The ureter can be identified by its convenient location at the bifurcation of the common iliac artery, the fact that it has a thick muscle wall, which vermiculates when gently squeezed with non-toothed forceps, and that it adheres to the overlying parietal peritoneum like a fly stuck on fly-paper. ◆
major, which separates it from the transverse processes of L2–L5. It is crossed by the gonadal vessels, and is at risk of injury when these vessels are ligated in gynaecological surgery. The ureter passes into the pelvis consistently at the bifurcation of the common iliac artery, even when this vessel is tortuous or even aneurysmal (a useful site for identification at laparotomy). The ureter then runs on the lateral wall of the pelvis in front of the internal iliac artery, then turns forwards and medially in front of the ischial spine to enter the bladder. It is crossed superficially
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:6
264
© 2009 Published by Elsevier Ltd.
The anatomy of the kidney and ureter
The kidneys, their anterior relations and renal vessels Left colon (splenic flexure) Spleen
Harold Ellis
Stomach Left suprarenal Duodenum Liver
Abstract The kidneys are placed retroperitoneally on the posterior abdominal wall, the right lower than the left. At the renal hilum are found, from before back, the renal vein, artery, pelvis of the ureter and a small posterior artery branch. There are also lymphatics and sympathetic fibres (T12–L1), which account for referred renal pain to the lower abdominal wall and external genitalia. The pelvis of the ureter divides into two or three major calyces, which divide into minor calyces, each indented by a renal papilla, onto which discharge the renal tubules. The three fascial layers are: the capsule, which is easily stripped from the healthy kidney; the perinephric fat; and the investing renal fascia, which adheres to the structures at the hilum and usually tamponades a closed rupture of the kidney, which can thus be treated conservatively. The ureter is 25 cm long, comprising the pelvis and an abdominal, pelvic and vesical portion; the last acting as a sphincter. The ureter is crossed by the gonadal vessels and may be injured here in gynaecological surgery. The ureter can be identified as it constantly crosses the common iliac artery at its bifurcation and then lies on the anterior aspect of the internal iliac artery.
Right colon (hepatic flexure) Inferior vena cava
Small gut
Aorta
Figure 1
Keywords blood supply; kidney; perinephric fat; renal capsule; renal fascia; renal pelvis; ureter
(derived from the aorta at about the level of L1), the pelvis of the ureter and, usually, a posterior arterial branch. In addition, the hilum transmits lymphatics, which pass to the para-aortic lymph nodes, and sympathetic nerve fibres from T12 to L1. Sympathetic afferent fibres account for the classical referral of renal pain to the lower abdominal wall and the external genitalia. Within the renal substance, the pelvis of the ureter divides into two or three major calyces, each then divides into several minor calyces. Each minor calyx is indented by a papilla, on which the renal tubules discharge urine. The calyceal system is readily appreciated on inspection of a normal intravenous urogram. The kidney possesses three fascial layers: • The true capsule: a thin lucent sheet, which strips easily from the normal organ. • The perinephric fat: an abundant fatty cushion. • The renal fascia: encloses the perinephric fat and adheres to the renal vessels and pelvis at the hilum. Tamponade of the ruptured kidney by this sheath is the reason why most of these cases can be treated conservatively.
The kidneys are situated behind the peritoneum of the posterior abdominal wall. The right kidney is lower than the left, pushed down by the liver. In most healthy individuals, the kidneys are impalpable, but, in a particularly thin person, the lower pole of the right kidney may be just tipped on full inspiration.
Relations (Figure 1) On each side, the suprarenal gland sits like a cap on the superior pole. Anterior to the left kidney lie the pancreas and its vessels, the spleen, the descending colon and the stomach, which is separated by the lesser sac. On the right lie the second part of the duodenum, the liver and the hepatic flexure of the colon. Posteriorly, both kidneys lie on the diaphragm and the muscles of the posterior wall of the abdomen; the upper pole lying at the level of the 12th rib. The renal hilum is the deep vertical slit on its medial border. This transmits, from before backwards, the renal vein (which drains into the inferior vena cava), the renal artery
The ureter The ureter is 10 inches (25 cm) long and comprises a pelvis and an abdominal, pelvic, and intra-vesical portion (which acts as a sphincter mechanism). The ureter is narrowed at three sites: the pelvi-ureteric junction; as it crosses the brim of the pelvis; and at its termination. These are the sites at which a calculus is most likely to lodge. The ureter descends on the medial edge of psoas
Harold Ellis CBE FRCS was professor of Surgery at Westminster Medical School until 1989. Since then he has taught anatomy, first in Cambridge and now at Guy’s Hospital, London, UK.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:6
Pancreas
263
© 2009 Published by Elsevier Ltd.
PHYSIOLOGY
by only one structure: the vas deferens in men and the uterine vessels in women, as it passes below the broad ligament. The ureter is at risk of injury when the uterine vessels are ligated in a hysterectomy. The ureter can be identified by its convenient location at the bifurcation of the common iliac artery, the fact that it has a thick muscle wall, which vermiculates when gently squeezed with non-toothed forceps, and that it adheres to the overlying parietal peritoneum like a fly stuck on fly-paper. ◆
major, which separates it from the transverse processes of L2–L5. It is crossed by the gonadal vessels, and is at risk of injury when these vessels are ligated in gynaecological surgery. The ureter passes into the pelvis consistently at the bifurcation of the common iliac artery, even when this vessel is tortuous or even aneurysmal (a useful site for identification at laparotomy). The ureter then runs on the lateral wall of the pelvis in front of the internal iliac artery, then turns forwards and medially in front of the ischial spine to enter the bladder. It is crossed superficially
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:6
264
© 2009 Published by Elsevier Ltd.