List the structures that enter and exit the renal hilus.

Renal artery and vein

Ureter

Lymphatics

Nerves

v/a/u: anterior to posterior

Renal capsule

perirenal fat (protects and supports)

renal fascia of Gerota (anchors kidneys and adrenal glands to surrounding structures)

pararenal fat (adheres to the abdominal wall; protects and supports)

parietal peritoneum

Ptosis (Latin - “a fall”): kidney falls to a lower position than normal resulting in a kinky ureter; this results in a backup of urine --> hydronephrosis (“water in the kidney") leads to damage and eventual necrosis. Associated with anorexia

.

Pyelitis-infection of the renal pelvis and calyces

Pyelonephritis-infection or inflammatory condition affecting the entire kidney

Common cause of inpatient UTI - catheterization

At what spinal level do the renal arteries branch from the abdominal aorta?

What is the volume of blood flowing through the kidneys per minute?

L1/2

~1/4 of cardiac output: ~1200mL per minute

90% of the blood supply to the kidneys perfuse the cortex as it has the most nephrons

Dr. Reeves asks you to describe the course of blood flow to the kidney from the abdominal aorta.

The region between cortex and medulla is pinned. Dr. Reeves asks, “What artery is found at this location?”

abdominal aorta -> renal arteries -> segmental arteries (5 typically enter the hilus) -> lobar arteries (usually unlabled) -> 1. interlobular arteries (pass between the medullary pyramids) -> 2. arcuate arteries (at base of pyramids) -> 3. interlobular arteries

1/2/3 flow to the: afferent arteriole -> glomerulus -> efferent arteriole -> peritubular capillary network

The arcuate a. is found between the cortex and medulla at the pyrimidal base.

Describe the nerve supply to the kidney and ureters.

Renal plexus and ganglion:

renal plexus-syp fibers from least thoracic n. and 1^st lumbar splanchnic n. (regulate renal blood flow via vasoconstriction)

parasymp fibers from posterior and anterior vagal trunks send contributions to the celiac plexus

Dr. Reeves asks, "What about the vessels at the vascular pole are unique? They are the only place in the body that does this."

He then asks, "What structure is found at the urinary pole?"

The vascular pole is fed and drained by arterioles

Proximal convoluted tubule

What is the spinal level where the ureters begin their trek to the exterior of the body?

Dr. Still asks you, "What are the three areas of ureterial constriction and why should you care?"

Ureters start at spinal level L2

1. Ureteropelvic junction – near hilus

2. Pelvic brim - where they cross the iliac vessels

3. Ureterovesical junction - where they join the bladder

Kidney stones get lodged here!

Dr. Reeves asks you to describe in detail the three layers of the bladder wall?

Describe the smooth muscle arrangement of the bladder muscularis.

1. mucosa - transitional epithelium

2. muscularis - thick muscular layer made up of the detrusor muscle (intermediate SM fibers arranged in inner and outer longitudinal layers and a middle circular layer)

3. adventitia –fibrous layer that covers the bladder except for its superior surface, which is covered by the parietal peritoneum

Describe the trigone and the three structures that form this area.

Describe the tissue lining the urethra.

 Smooth trianglular region at the bladder's base between the openings of the 2 ureters and the urethra

Mucosal lining:

primarily pseudostratified columnar epithelium but changes near the bladder into transitional epithelium and near the opening the urethra it becomes stratified squamous non-keratinized epithelium

What are the spinal levels for the caval opening, esophageal hiatus, and aortic hiatus?

Caval opening: T8 (most anterior)

Esophageal hiatus: T10

Aortic hiatus: T12 (most posterior)

Psoas major muscle

O/I/Action/NS

O: sides of vertebral bodies, TP's, and intervertebral discs of T12 and L1-5; runs downward and laterally to enter the thigh posterior and inferior to the inguinal ligament

I: lesser trochanter of femur

Action: flexes the thigh at the hip joint on the trunk; if the thigh is fixed, flexes the trunk on the thigh (as in sitting up from a lying position)

NS: lumbar plexus (ant. branches of L2-L4)

Iliacus muscle

O/I/Action/NS

O: illiac fossa of pelvis

Quadratus lumborum muscle

O/I/Action/NS

O: TP's of L3-5; iliolumbar lig.; iliac crest

transversarius abdominis muscle becomes aponeurotic at the lateral border of the quadratus lumborum - forms a sheath for the deep back muscles

1. Tuft of fascia that covers the aorta hiatus - median arcuate lig.

2. Thickened fibrous sheath of facsia (derived from lumbat fascia) that covers the psoas muscle - medial arcuate lig.

3. Thick lumbar fascia - lateral arcuate lig.

Quadratus lumborum

Origin?

Insertion?

What is its anterior surface, and what structures does this form?

Action?

Innervation?

iliolumbar ligament, tips of TP of the lower lumbar vertebrae

12th rib, TP of upper four lumbar vertebrae

Anterior surface is covered by lumbar fascia, thickened to form the lateral arcuate line above and iliolumbar ligament below

fixes 12th rib during inspiration/depresses it during expiration, laterally flexes vertebral column ipsilaterally

lumbar plexus (ant. branches of T12, L1-4)

Femoral Sheath

what is it?

how far does it extend?

what is its relationship with respect to the femoral nerve?

A downward prolongation of fascia around the femoral vessels and lymphatics

extends 4 cm into thigh, inf to the inguinal ligament

femoral nerve lies outside the lining and has no sheath

inferior phrenic a.

lumbar a.

median sacral a. (continuation of the aorta)

At which vertebral level does the abdominal aorta terminate?

What does it bifurcate into...?

What two branches arise from the external iliac artery? Where?

L4

right, left common iliac --> internal iliac, external iliac

external iliac runs on the MEDIAL border of iliopsoas, and posterior to the inguinal ligament --> femoral a.

before external iliac passes posterior to the inguinal ligament:

inferior epigastric (lies in the lateral fold)

deep circumflex iliac (anastamose with iliolumbar artery from internal iliac aa on iliac crest)

IVC

what is its path?

what veins drain into it? *know left vs. right*

Hepatic portal vein

L5 at union of l & r common iliac veins (below aortic bifurcation, behind right common iliac artery)

Pierces the central tendon @ T8, where it enters the rt atrium of the heart

Extends entirely across 8 vertebra, nearly 2X length of aorta

right suprarenal v.

right renal v.

right gonadal v.

* on the left, these veins drain into the left renal v. which drains into the IVC*

HPV receives blood from GI, blood circulates within the liver, then exits via 3 hepatic veins to drain into IVC

Lymphatics

Visceral (preaortic) nodes

Lumbar (lateral aortic) nodes

lie at origin of celiac trunk, SMA, and IMA

drain GI tract from lower 1/3 of esophagus to upper half of anal canal, spleen, pancreas, gall bladder, liver

Efferent vessels --> the intestinal trunk

Participate in confluence of lymphatics that give rise to thoracic duct

drain kidneys, adrenals, testes, ovaries, uterine tubes, uterine fundus

Efferent vessels --> l&r lumbar trunks

Drain into cisterna chyli, ant to L1-2, right of the aorta, deep to IVC

  - the inferior end of the thoracic duct

Iliohypogastric (L1)

Ilioinguinal (L1)

Genitofermoral (L1, L2) - runs on top of psoas major

  - femoral branch runs lateral, supplies skin of femoral triangle

  - genital branch runs medial, supplies cremaster m

Lateral femoral cutaneous (L2, L3)

Femoral (L2, L3, L4) - supplies iliacus; deep to fascia (but not in it!)

Obturator (L2, L3, L4)

Celiac plexus (a.k.a. solar plexus)

Where does each individual ganglion lie?

What conceal the left and right celiac ganglia?

Renal plexus

connects to celiac ganglia, encircles celiac trunk, branches radiate out

joined by the greater and lesser splanchnic nerves

behind peritoneum, b/t celiac trunk and adrenal gland, on the crus of the diaphragm

Rt - concealed by IVC

Left - pancreas, splenic artery

The renal plexus is a derivative of the celiac plexus; it's joined by the least splanchnic (T12) and first lumbar splanchnic nerves

Suprarenal glands

Where do they receive blood from?

(3 arteries)

TQ!!

Where does blood drain from each?

Superior suprarenal arteries - branches off the inferior phrenic

Middle suprarenal - branches directly off abdominal aorta

Inferior suprarenal - branches off the renal artery

Left suprarenal gland drains into the left renal vein

Right suprarenal gland drains into the IVC