left kidney hilum -> found at the level of the transpyloric plane

right kidney hilum -> found just inferior to the transpyloric plane

(because of the liver pushing the kidney down)

perirenal fascia

contains what

Gerota's fascia

defines (surrounds) the perirenal space/fat

contains the kidney, adrenal gland, ureter, gonadal vessels, and perirenal fat

pararenal fascia

deep to transversalis fascia

renal vein (most anterior)

renal artery

renal pelvis (most posterior)

(continuous with renal hilum)

renal pelvis, major and minor calyces, renal blood vessels, nerves, lymphatics, and fat

T11

left kidney is higher than the right kidney

T12

right kidney is lower that the left kidney due to presence of liver on right side

lied under the renal capsule

extends between the renal pyramids (the medulla) as renal columns of Bertin

may be divided into the cortical labyrinth and medullary rays

renal medulla

tips terminate as

composed of 5 - 11 renal pyramids (of Malpighi)

tips of pyramids terminate as 5 - 11 renal papillae

papillary ducts of Bellini open onto surface of renal papillae at the area cribrosa

how many major calyces and they divide into what

major calyces converge into what

each kidney has two to three major calyces and divide into minor calyces

converge into renal pelvis

which renal artery is longer than the other

position in relation to IVC

right renal artery is longer than the left renal artery

lies posterior to IVC

four anterior segmental arteries:

apical segmental -> to superior pole

anterosuperior segmental

anteroinferior segmental

inferior segmental -> to inferior pole

segmental arteries are end arteries and do not anastomose with one another, no collateral circulation

creates an avascular line between anterior and posterior segments -> allows longitudinal incision through kidney w/mininal bleeding

useful for surgical removal of renal (staghorn) calculi

arteries that form during fetal development and persist in adult

may arise from renal artery (hilar) or directly from aorta (polar)

ligation would result in necrosis of the entire segment of the kidney

segmental artery branches into 5 - 11 interlobar arteries

(travel btwn minor calyces and in renal columns)

interlobar arteries branch into arcuate arteries

which travel along the base of renal pyramids at the corticomedullary junction

arcuate arteries branch into interlobular arteries 

which travel through the cortex toward the capsule

efferent arteriole:

from cortical and midcortical nephrons branches into

from juxtamedullary nephrons branches into

efferent arteriole from cortical and midcortical nephrons -> branches into cortical peritubular capillary bed

efferent arteriole from juxtamedullary nephrons ->  branches into 12 -25 descending vasa recta (that run to varying depths of medulla)

to the interlobular veins -> arcuate veins -> interlobar veins -> renal vein -> IVC

interlobar veins anastomose and converge to form several renal veins that unite in a variable fashion to form the renal vein

there is no segmental organization like the arterial supply

pregang cell bodies -> IML cell column

pregang axons -> pass through paravertebral chain and become lesser, and least thoracic and, 1st and 2nd lumbar splanchnic nerves

postgang cell bodies -> in the aorticorenal ganglion

postgang axons -> enter renal plexus and are distributed to renal vasculature (juxtamedullary cells)

play important role in regulation of BP by effecting renin release

cell bodies -> dorsal root ganglion

peripheral process -> runs with least thoracic, and 1st and 2nd lumbar splanchnic nerves

central process -> T12 - L2 spinal cord segments

relay pain sensation, referred pain over T12 - L2 dermatomes

suspected in following:

lower rib fractures, transverse process fractures of lumbar vertrebrae, knife or gunshot wound over lower rib cage, car accident with seat belt marks

right kidney trauma -> assoicated with liver trauma

left kidney trauma -> associated with speel trauma

findings: flank mass and/or tenderness, flank ecchymosis, hypotension, hematuria

absolute indication for renal exploration -> presence of pulsatile or expanding retroperitoneal hematoma found at laparotomy

incision made below and parallel to 12th rib -> prevent inadvertent entry into pleural space

incision may be extended to fron of abdomen by traveling parallel to inguinal ligament

end of ureter

and surround by what and how does it enter bladder

end at ureterovesical junction surrounded by vesical venous plexus

enters into bladder at an oblique angle (the intramural portion of ureter)

intramural portion of ureter -> ureterovesical valve of Sampson, prevents retrograde flow of urine

at the pelvic brim, where the ureter is close to the ovarian blood vessels

and where the uterine artery crosses over the ureter along the side of the cervix

normaly constricted:

at ureteropelvic junction -> where renal pelvis becomes ureter

where ureters cross pelvic inlet -> right before common iliac vessels

at ureterovesical junction (intramural portion of ureter) -> the oblique opening into bladder

arterial supply of ureter

(and the most constant supply of lower part)

ureters are supplied by vessels found adjacent to that location of the ureter

abd aorta, renal artery, testicular/ovarian artery (gonadal), common iliac artery, internal iliac artery, inferior vesical artery, uterine artery

the most constant supply of the lower part is the uterine artery in females, and the inferior vesical artery in males.

have weak anastomoses -> inadvertent damage may lead to necrosis of a ureteral segment ab 1 wk postop.

innervated by ureteric plexus (contains both symp and parasymp - don't play major role in peristalsis, only modulatory role)

upper ureter -> ureteric plexus receives input from renal plexus and abd aortic plexus

middle ureter -> ureteric plexus receives input from superior hypogastric plexus

lower ureter -> ureteric plexus receives input from inferior hypogastric plexus

kidney stones

occur most often at the three sites where ureter normally constricts

causes unilateral hydronephrosis

findings: excruciating pain in flank area, abdomen, or testicular/vulvar region radiating onto inner thigh depending on obstruction site, fever, hamaturia, decreased urine output possible, pt assumes posture with a severe ipsilateral costovertebral angle

four types of stones

types of kidney stones

(names only)

calcium oxalate calculi

magnesium ammonium sulfate (strutive; triple phosphate) calculi

uric acid calculi

cystine calculi

most common type (80%)

radiopaque

UA: colorless, octahedral, look like small squares crosses by diagonal lines

form when urine pH < 6.0 or with neutral pH

associated with: absorptive hypercalcemia, vit D intoxication, hyperparathyroidism, milk-alkali syndrome and renal tubular acidosis

all which result in -> hypercalcemia, diabetes, liver disease, ethylene glycol poisoning

2nd most common (15%)

radiopaque

UA: colorless, rectangular prism shaped

typically progress to form staghorn calculi 

form when urine pH < 7.4

assoicated with UTIs by urea-splitting bacteria (proteus mirabilis, proteus vulgaris, providencia, pseudomonas, klensiella, staph)

third most common (5%)

radiolucent

UA: yellow or red-brown diamond

form when urine pH < 6.0

associated with gout, leukemia, lesch-nyhan syndrome, myeloproliferative disorders

least common

faintly radiopaque

UA: colorless, refractile, hexagonal, and may have layered appearance

form when urin pH < 6.0

caused by cystinuria -> autosomal recessive disorder that results in defective renal tubular reabsorption of cystine, ornithine, arginine, and lysine

urinary bladder

capacity

shape when empty

120  to 320 mL

when empty -> tetrahedral shape: posterior, anterior, superior surfaces, and apex and neck

surfaces of urinary bladder

(names only)

posterior surface

anterior surface

superior surface

apex

neck

fundus or base

male -> related to the rectovesical pouch, rectum, seminal vesicles, and ampulla of ductus deferens

female -> related to the anterior wall of the vagina

male -> related to the peritoneal cavity (completely covered by perioteum), sigmoid colon, termical coils of ileum

female -> related to peritoneal cavity (largely covered by peritoneum but reflected posteriorly to the uterus, forming the vesicouterine pouch) and uterus

located posterior to the upper part of the pubic symphysis

male and female -> related to the one median umbilical ligament/urachus (remnant of allantois in fetus), the two medial umbilical ligaments (remnants of right and left umbilical arteries) and the two lateral umbilical ligaments  (elevations formed by the right and left inferior epigastric vessels)

lowest region of bladder, located posterior to the lower part of pubic symphysis

pierced by internal urethral orifice

male -> related to prostate gland and prostatic urethra

female -> related to urogenital diaphragm

support of the bladder

(names only)

urogenital diaphragm

pubovesical liagments

median umbilical ligament/urachus

false ligaments

extension of the puboprostatic ligement (in males) and the pubourethral ligament (in females)

extend from the lower portion of the pubic bone to the neck of the bladder

urachus

extend from the umbilicus to the apex of the bladder

a smooth surface because the mucosa is tightly attached to the detrusor muscle

located on posterior surface of bladder (fundus or base)

limits -> openings of the ureters and inferiorly by the internal urethral orifice

superior vesical artery, inferior vesical artery, obturator artery, and inferior gluteal artery (all branches off of internal iliac artery)

in females -> branches of uterine and vaginal arteries as well (also branches of internal iliac artery)

pregang cell bodies -> IML cell column of S2-4

pregang axons -> travel to vesical plexus as pelvic splanchnic nerves

postgang cell bodies ->  located in in the vesical plexus and bladder wall

postgang axons -> distributed to detrusor muscle

cause contraction of detrusor muscle and relaxation of internal urethral sphincter

efferent limb of micturition reflex

pregang cell bodies -> IML cell column

pregang axons -> pass through paravertebral chain to become lesser and least thoracic, and 1st and 2nd splanchnic nerves, travel to inferior hypogastric plexus by way of superior hypogastric plexus

postgang cell bodies -> inferior hypogastric plexus

postgang axons -> enter the vesical plexus and are distributed to detrusor muscle

cause relaxation of the detrusor muscle and contraction of the internal urethral sphincter

cell bodies -> dorsal root ganglion

peripheral process -> pelvic splanchnic nerves

central process -> S2-4 spinal segments

relays pain and stretch information from the bladder

referred pain due to pathology sent to S2-4 dermatomes

stretch part -> afferent limb in micturition reflex

cell bodies -> dorsal root ganglion

peripheral process -> lesser and least thoracic, and 1st and 2nd lumbar splanchnic nerves

central process -> T11-L2 spinal segments

sends/relays pain information from the bladder, with referred pain due to pathology to T11-L2 dermatomes

bladder fills with urine -> stretch information due to bladder fullness from stretch receptors -> sent on pelvic splanchnic nerves (afferent limb) -> motor information/stimulation sent along pelvic splanchnic nerves to detrusor muscle -> contraction of detrusor muscle and relaxation of internal urethral sphincter (efferent limb)

external urethral sphincter innervated by the pudendal nerve -> voluntary

adult -> empty bladder: lies within minor (true) pelvis

as bladder fills -> rises out of minor pelvis above pelvic inlet and may extend up to umbilicus

infant -> empty bladder lies within abdominal cavity

needle may be passed through anterior abdominal wall without entering peritoneal cavity in order to remove the urine (suprapubic cystostomy)

skin -> superficial fascia (camper and scarpa) -> linea alba -> transversalis fascia -> extraperitoneal fat -> parietal peritoneum

locations of urine leakeage due to trauma

(names only)

rupture of superior wall (dome)

rupture of anterior wall

type I urethral

type II urethral

type III urethral

type IV urethral

type V urethral injuries

intraperitoneal extravasation of urine within peritoneal cavity

compressive force on full bladder

posterior urethra is stretched but remains intact due to rupture of puboprostatic ligaments

rare

results in extraperitoneal extravasation of urin within retropubic space

caused by fractured pelvis that punctures the bladder

posterior urethra is torn about the urogentical diaphragm

results in extraperitoneal extravasation within in retropubic space

may be caused by a fractured pelvis or improper insertion of catheter

most common; anterior urethra (bulbous urethra) is torn below urogenital diaphragm along with a disruption of the urogentical diaphragm -> membranous urethra is torn also

combined anterior/posterior urethral injury

extraperitoneal extravasion of urine w/in superficial perineal space (btwn colles fascia and dartos muscle, and the external spermatic fascia) extending into -> scrotal, penile, and anterior abd wall areas

straddle injury, findings -> blood at urethral meatus, ecchymosis, painful swelling of scortal and perineal areas, tender enlargement in suprapubic region (full bladder)

neck of bladder and proximal prostatic urethra are injured

extraperitoneal extravasation of urine within retropubic space

may be serious in internal urethral sphincter is injured -> leads to incontinence

penile urethra is torn

a pure anterior urethral injury

extraperitoneal extravasion of urine beneath deep fascia (of buck), will be confined to penis if deep fascia of buck is not torn.

if trauma also tears deep fasica of buck -> extravasation of urine within superficial perineal space

crushing injry to the penis

3-5 cm long, beings at internal urethral orifice of bladder (where detrusor muscle extends longitudinally into urethra)

courses through urogenital diaphragm where it becomes related to the deep transverse perineal muscle and external urethral sphincter muscle (both skeletal and innervated by the pudendal nerve)

posterior surface fuses with anterior wall of vagina -> external urethral sphincter doesn't completely surround the female urethra (explains high incidence of stress incontinence in women, esp after childbirth)

terminates as navicular fossa at external urethral orifice -> opens into vestibule of vagina between labia minora just below clitoris

male urethra

(and the names of the five parts)

18-20 cm long

begins at internal urethral orifice of bladder where detrusor muscle extends longitudinally into the prostatic urethra and fors a complete collar around the neck of the bladder -> internal urethral sphincter

prostatic urethra

membranous urethra

bulbous urethra

proximal part of penile (spongy) urethra

distal part of penile urethra

courses through and is surrounded by the prostate gland

elevation on posterior wall -> urethral crest

prostatic sinus -> groove on either side of urethral crest that receives most of the prostatic ducts from the prostate gland

seminal colliculus -> ovoid enlargement site along urethral crest, where ejaculatory ducts open and prostatic utricle is found

prostatic utricle -> vestigial remnant of paramesonephric duct in males that is involved in the embryologic development of vagina and uterus

courses through the urogenital diaphragm, where it becomes related to the deep transverse perineal muscle and external urethral sphincter (both skeletal and innervated by the pudendal nerve)

external urethral sphincter -> completely surrounds the male urethra

course through the bulb of the penis and develops endodermal outgrowths into the surrounding mesoderm to form the bulbourethral glands of cowper

contains the openings of the bulbourethral glands

congential malformation; kidney fusion

when one kidney is ectopic on the other and is fused with it

has a ureter still coming out of both kidneys and both ureters inserting into the bladder normally (one on each side of the bladder)

congenital malformation

duplication of the kidney on one side

found posterior to the 9th, 10th and 11th ribs

therefore not normally palpable (doesn't extend below costal margin) unless splenomegaly 

spleen is attached to the stomach -> gastrosplenic ligament

also attached to the kidney -> splenorenal ligament

gastrosplenic ligament -> contains short gastric vessels, and left gastroomental vessels

splenorenal ligament -> contains the 5 terminal splenic branches, tributaries of splenic vein, and tail of pancreas

accessory spleen

occurence and location

occur in 20% of population

commonly located near hilum, near tail of pancreas, or within gastrosplenic ligament

removal of old or abnormal RBCs

removal of inclusion bodies from RBCs -> howell-jolly bodies (nuclear remnants), pappenheimer bodies (iron granules), heinz bodies (denatured hgb)

removal of poorly opsonized pathogens

IgM production by plasma cells

storage of platelets

protection fron infection

supplied from the splenic artery -> ends with about 5 terminal branches

terminal branches -> supply individual segments of spleen with no anastomoses between them

ligation/obstruction of a terminal artery -> splenic infarction

to the splenic vein via tributaries

spelnic vein -> superior mesenteric vein -> portal vein

splenic vein thrombosis

commonly associated with what

commonly associated with pancreatitis and also one of the causes of splenomegaly

clinical signs -> gastric varices and upper GI bleeding

surgical removal of the spleen

poss injuries to nearby structures: gastric wall if short gastric arteries compromised; tail of pancreas if caudal pancreatic arteries affected or during manipulation of splenorenal ligament; left kidney during manipulation of splenorenal ligament

most common complication: atelectasis of left lower lobe of lung

thrombocytosis -> increased number of platelets within the blood

anticoagulation therapy may be necessary to prevent spontaneous thrombosis

presence of abnormal RBCs with bizarred shapes, some of which contain howell-jolly bobies (nuclear remnants), in the blood

causes -> autoimmune disease (systemic lupus erythematous, rheumatoid arthritis); infectious disease (mono, visceral leishmaniasis); infiltrative disease (lysosomal storage disease, leukemia); extramedullary hematopoiesis (myeloproliferative diseases); and vascular congestion (portal HTN in cirrhosis)

in US -> myeloproliferative disease and lymphoid malignancies (chronic lymphocytic leukemia) are the most common causes

coagulating necrosis develops in an area distal to the occlusion of an end artery.

on CT -> will see areas of diminished contrast enhancement in the spleen which represents the embolic infarction

right suprarenal -> pyramid; apex projecting superior and base embracing the kidney

left suprarenal -> half-moon; covering superior aspect of kidney and extending inferiorly along medial aspect of kidney

superior suprarenal artery (branch from the inferior phrenic artery - very first branch off of abd aorta [before celiac trunk])

middle suprarenal artery (arises directly from abd aorta)

inferior suprarenal artery (branch off of renal arteries

venous drainage of suprarenal glands

and where do they drain into

there is only one vein draining each suprarenal gland

the right and left suprarenal veins

right suprarenal vein -> IVC

left suprarenal vein -> left renal vein (so it doesn't have to cross over the abd aorta)

receives venous blood draining the coretx that has high [  ] of cortisol, which is needed in order to synthesize phenylethanolamine -N-methyltransferase, and this enzyme is a key enzyme in the systhesis of epinephrine

therefore, indirectly, cortisol from the cortex is needed to make epinephrine

pregang cell bodies -> IML cell column of T10 - L1

pregang axons -> run with splanchnic nerves

modified postgang cell bodies -> chromaffin cells, located in adrenal medulla

adrenal cortex

derived from what and names of the three zones

derived embryologically from mesoderm

zones:

zona glomerulosa

zona fasciculata

zona reticularis

zone of the adrenal cortex

15% of the cortical volume

secretes aldosterone -> which is controlled by the renin-angiotensis system

78% of the cortical volume

secretes cortisol -> controlled by the corticotropin-releasing factor (CRF) and adrenocorticotropic hormone (ATCH) from hypothalamus and adenohypophysis, respectively

7% of cortical volume

secretes dehydroepiandrosterone (DHEA) and androstenedione -> controlled by by CRF and ATCH from hypothalamus and adenohypophysis, respectively

caused by elevated levels of aldosterone -> commonly caused by either an aldosterone-secreting adenoma (conn syndrome) within the ZG or adrenal hyperplasia

findings -> HTN, hypernatremia, (due to increased Na+ reabsorption), weight gain (due to H2O retention), hypokalemia (due to increased K+ secretion) and decreased plasma renin levels

caused by elevated levels of cortisol (hypercortisolism) -> commonly due to: an ACTH-secreting adenoma w/in adenohypophysis (70% of cases), an adrenal adenoma (25% of cases), or adrenal hyperplasia

oat cell carcinoma of lung -> may also ectopically produce ATCH

cushing syndrome most commonly caused by iatrogenic corticosteriod drug therapy

features -> mild HTN w/cardiac hypertrophy, buffalo hump, osteoporosis w/ back pain, central obesity, moon facies, purple skin striae, skin ulcers (poor wound healing), thin wrinkled skin, amenorrhea, purpura, impaired glucose tolerance, emotional disturbances

can cause cushing syndrome

both adrenal glands can be enlarged while maintaining their normal anatomic shapes, so other than increased size, the glands appear normal

may demonstrate bilateral nodularity

most commonly caused by mutation in genes for enzymes involved in adrenocortical steriod biosyynthesis

21-hydroxylase deficiency (90% of cases) -> no synthesis of aldosterone or cortisol -> therefore, intermediates funneled into androgen biosynthesis -> elevating androgen levels

findings -> increased urine 17-ketosteroids and virilization of a female fetus ranging from clitoral enlargement to complete labioscrotal fusion

occurs because cortisol cannot be synthesized and therefore neg. feedback to andohypophysis doesn't occur -> ATCH continues to stimulate adrenal cortex

adrenal medulla

general features

contains chromaffin cells that are modified postgang sympathetic neurons derived embryologically  from neural crest cells

pregang symp axons synapse on the chromaffin cells and cause the cells to secrete catecholamines (90% epi, 10% norepi)

rare neoplasm (norm not malignant) of neural crest origin -> contain both epi and norepi

occurs w/in families as part of multiple endocrine neoplasia (MEN) type IIa syndrome (pheochromocytoma, hyperparathyroidism, medullary carcinoma of thyroid) or associated with von recklinghausen neurofribromatosis

found in region of adrenal gland but also in extra-adrenal sites (aortic bifurcation -> organ of zuckerland)

persistent HTN, anxiety, tremor, profuse sweating, pallor, CP, abd pain

gray-white to pink-tan in color

extracranial neoplasma containing primitive neuroblasts of neural crest origin -> associated with amplification of N-myc oncogene

most common solid tumor in children, may metastasize to bone marrow, liver and orbit

found in -> extra-adrenal sites, usually along symp chain gang (60%) or w/in adrenal medulle (40%)

features -> opsoclonus (rapid, irreg movements or eye in horizontal and vertical directions)

soft, white to gray-pink in color

as size increases -> tumor becomes hemorrhagic -> undergo calcification and cyst formation