ANATOMY OF UPPER URINARY TRACT

1. 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. ANATOMY OF UPPER URINARY
TRACT
 KIDNEY
 Maintain fluid and electrolyte balance, acid base
balance
 Renin- BP
 Erythropoietin-RBC
 Calcium metabolism
3
Dept of Urology, GRH and KMC, Chennai.

4. GROSS ANATOMY
 Reddish brown organ
 Wieght-150gm in male and 135gm in female
 Measures:-
 10-12 cm vertically
 5-7 cm transeversely
 3 cm Ap
 R kidney is shorter & wider
4
Dept of Urology, GRH and KMC, Chennai.

5. INTERNAL STRUCTURE
 RENAL SINUS
 Encountered as one proceed from periphery to central
 Vascular structure and collecting system coalesce
 Surrounded by yellow fat
 At its medial border renal sinus narrows to form hilum
 Vasculature and pelvis exit thro hilum
5
Dept of Urology, GRH and KMC, Chennai.

6. RENAL MEDULLA(Renal pyramid)
 It is not a contiguous structure
 Multiple, distinct and conical shaped areas
 Darker than cortex
 Apex of the pyramid is called renal papilla
 Papilla is cupped by individual calyx
6
Dept of Urology, GRH and KMC, Chennai.

7. RENAL CORTEX
 Lighter in colour than medulla
 Not only covers the pyramid peripherally but also
extends in bet pyramids- column of BERTIN
 Surgical importance of Bertin
- renal vessel traverse thro this column-
percut acsess thro pyramid
7
Dept of Urology, GRH and KMC, Chennai.

8. 8
Dept of Urology, GRH and KMC, Chennai.

9. 9
Dept of Urology, GRH and KMC, Chennai.

10. ANATOMIC RELATION
 R Kidney is 1-2 cm lower than L
 R kidney extends from top of L1 to bottom of L3
 L kid extends from body of T12 to body of L3
10
Dept of Urology, GRH and KMC, Chennai.

11. POSTERIOR RELATION
 UPPER THIRD:
- Diaphragm
-12th rib crossing diaphragm
-Pleura extends upto 12th rib
 LOWER 2/3rd
-Medially psoas
-Laterally QL & TA
11
Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

13. COVERINGS OF ANTERIOR
SURFACE OF KIDNEY
 Peri renal fat
 Gerota’s fascia
 Para renal fat
 Parietal posterior peritoneum
13
Dept of Urology, GRH and KMC, Chennai.

14. ANTERIOR RELATION OF R KIDNEY
 UPPER POLE- Adrenal , Liver
 Hepatorenal lig attaches R kid to liver
 MEDIAL PART – Duodenum 2nd part
 LOWER POLE – Hepatic flexure of colon and SI
14
Dept of Urology, GRH and KMC, Chennai.

15. ANT RELATION OF L KIDNEY
 L adrenal
 Spleen
 Stomach
 Pancreas
 Splenic flexure des colon & jejunum
15
Dept of Urology, GRH and KMC, Chennai.

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

17. GEROTA’S FASCIA(Perirenal fascia)
 It encloses the kidney& perirenal fat
 Anatomic barrier to spread of malignancy
 Superiorly and laterally it is closed
 Medailly it crosses the midline to fuse with the fellow
of opp side
 Inferiorly it remains open- perinephric fluid can track
inf to pelvis
17
Dept of Urology, GRH and KMC, Chennai.

18. RENAL ARTERY
 Leaves the Aorta at L2
 Gives branches to adrenal, renal pelvis & ureter
 5 segmental arteries
one posterior segmental- first and most
constant
4 anterior segmental - apical, upper,
middle & lower
cont,
18
Dept of Urology, GRH and KMC, Chennai.

19.  Segmental arteries are end arteries
 Posterior segmental art passes post to renal pelvis ,
others passes anteriorly
 Surgical importance
when post seg art passes ant it causes PUJ
obstruction
19
Dept of Urology, GRH and KMC, Chennai.

20. RENOGRAM SHOWING ARTERY
20
Dept of Urology, GRH and KMC, Chennai.

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

22. RENAL VEIN
 Post glomerular capillaries – Interlobular v – Arcuate v
– Inter lobar v- Lobar v – Segmental v- venal trunk –
Renal v.
 Extensive collaterals present in venous system
 Renal vein is directly anterior to artery
 R renal v is shorter and enters Lat or post-lat aspect of
IVC
 L renal v is longer and enters lateral aspect of IVC
22
Dept of Urology, GRH and KMC, Chennai.

23. TRIBUTARIES
 L RENAL VEIN
-L Adrenal v superiorly
-Lumbar v posteriorly
-L gonadal v inferiorly
 R RENAL V
No tributaries
23
Dept of Urology, GRH and KMC, Chennai.

24. TRIBUTARIES OF L RENAL VEIN
24
Dept of Urology, GRH and KMC, Chennai.

25. COMMON ANATOMIC VARIANTS
OF VESSEL
 Occurs in 25- 40%
 M.C is supernumery arteries- More commen on L side
 Additional art can enter thro hilum or parenchyma
 Lower pole arteries can cross ant to collection system
and cause PUJ obstruction
25
Dept of Urology, GRH and KMC, Chennai.

26. LYMPHATICS
 Largely follow blood vessels thro column of BERTIN
 Lymphatics empty to LN near renal hilum
 L KIDNEY:-
-L lateral para- aortic LN
 R KIDNEY:-
-R inter aortocaval and R para caval
LN
26
Dept of Urology, GRH and KMC, Chennai.

27. LYMPHATIC OF R KIDNEY
27
Dept of Urology, GRH and KMC, Chennai.

28. LYMPHATICS OF L KIDNEY
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Dept of Urology, GRH and KMC, Chennai.

29. RENAL INNERVATION
 SYMPATHETIC - From T8 to L1 thro celiac and
aortico renal
- Vasoconstriction
 PARA SYMPATHETIC- From vagus
- vasodilatation
➢Remember that kidney can function well even without
neurological control
29
Dept of Urology, GRH and KMC, Chennai.

30. ANATOMY OF URETER
30
Dept of Urology, GRH and KMC, Chennai.

31.  It’s a bil tubular structure responsible for the transport
of urine
 22- 30 cm long
31
Dept of Urology, GRH and KMC, Chennai.

32. LAYERS OF URETER
 MUCOSA : -
-Transitional epithelium
-Lamina propria
 MUSCLE:-
- Inner longitudinal and outer circular
-provides peristaltic wave
 ADVENTITIAL:-
-blood vessel and lymphatics
32
Dept of Urology, GRH and KMC, Chennai.

33. MICROSCOPIC STRUCTURE OF
URETER
33
Dept of Urology, GRH and KMC, Chennai.

34. ANATOMICAL RELATIONSHIP
 Begins at PUJ post to renal A & V and course along
anterior edge of psoas
 ANTERIOR RELATION
R ureter:-
Asc colon, caecum, colonic
mesentery, appendix
L ureter:-
Des colon, sigmoid and its mesentery
34
Dept of Urology, GRH and KMC, Chennai.

35.  Ureter is crossed anteriorly by gonadal vessels
 As the ureter enters pelvis it crosses anterior to iliac
vessel at its bifurcation- landmark
 Due to proximity to bowel - malignant and
inflammation of bowel may involve ureter
 In female pelvis ureter are crossed anteriorly by uterine
artery and closely related to uterine cervix- risk during
hysterectomy
35
Dept of Urology, GRH and KMC, Chennai.

36. NORMAL VARIATION IN CALIBER
THREE DISTINCT NARROWINGS
➢ PUJ- The pelvis taper into ureter
➢ Crossing of iliac vessels- Due to combination of extrinsic
compression and ant angulation of ureter first at the
crossing of vessel and second as it enters pelvis
➢ UV junction- it is a true physiological restriction of
ureter as it goes intramurally
36
Dept of Urology, GRH and KMC, Chennai.

37. NARROWINGS OF URETER
37
Dept of Urology, GRH and KMC, Chennai.

38. SIGNIFICANCE OF NARROWING
 Common location for calculus to lodge
 Angulation may restrict successful and safe passage of
scope
38
Dept of Urology, GRH and KMC, Chennai.

39. URETER SEGMENTATION AND
NOMENCLATURE
 SIMPLEST SYSTEM
Abdominal ureter- renal pelvis to iliac vessel
Pelvic ureter -from iliac vessel to bladder
ALTERNATE SYSTEM
Upper- renal pelvis to upper border of sacrum
Middle- upper to lower border of sacrum
Lower – lower border of sacrum to bladder
39
Dept of Urology, GRH and KMC, Chennai.

40. BLOOD SUPPLY
 UPPER URETER:-
-Renal art,gonadal art, aorta
and common iliac artery
 LOWER URETER:-
-Branches from internal iliac
and its branches
➢ After reaching the ureter the vessel courses longitudinally
within the adventitia
➢ Venous drainage follow the artery supply
➢ Arterial branches for abdominal ureter approach from
medial direction & for pelvic ureter from lateral direction
40
Dept of Urology, GRH and KMC, Chennai.

41. ARTERY
SUPPLY
41
Dept of Urology, GRH and KMC, Chennai.

42. LYMPHATICS
❖PELVIC URETER:-
-Internal, external and common
iliac nodes
❖ABDOMINAL URETER
L ureter- L para- aortic
R ureter- R para caval and iter-aortocaval node
42
Dept of Urology, GRH and KMC, Chennai.

43. INNERVATION
 SYMPATHETIC
Preganglionic – From T10- L2
postganglionic- From aorticorenal,
superior and inf
hypogastric plexus
 PARASYMPATHETIC
S2 –S4
➢Peristalsis – intrinsic smooth muscle pace maker
located in minor calyses
43
Dept of Urology, GRH and KMC, Chennai.

44. THANKYOU
44
Dept of Urology, GRH and KMC, Chennai.