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Skandalakis’ Surgical Anatomy > Chapter 23. Kidneys and Ureters >

Introduction to the Urogenital System


The detailed surgical anatomy of the anatomic entities most immediately associated with the urogenital system will be found in the chapters on the kidneys/ureters, urinary bladder, male genital system, and female genital system.

But the study of surgical anatomy of the urogenital system is also related to the following areas:


Retroperitoneal spaces


Anterolateral abdominal wall and inguinal canal

Posterior abdominal wall

Thoracic wall

Pelvic diaphragm

Urogenital diaphragm

Lateral pelvic wall


Knowledge of the anatomy of the urogenital system is necessary not only for urologists and gynecologists, but also for general surgeons, radiologists, and transplant surgeons. In addition to being familiar with the anatomic entities, it is important that such medical professionals also understand the embryogenesis, anomalies, and variations of these anatomic entities.


The anatomic and surgical history of the kidney and ureter is found in Table 23-1.

Table 23-1. Anatomic and Surgical History of the Kidney and Ureter

Hippocrates (470-373 BC)   Prohibited renal surgery; felt it was too dangerous. Only nephritic abscesses could be opened.
Aretaeus (2nd-3rd century)   Described the kidneys; considered them to be true glands
Berenger (1470-1530)   Studied renal vasculature
Cardan of Milan 1510 Removed 18 renal stones while draining renal abscess
Vesalius (1514-1564)   Contributed to the early understanding of renal anatomy
Zambeccari 1670 Performed animal experiments showing one kidney was enough to sustain life. Advocated nephrectomy for persistent renal colic.
Rounhyzer 1672
Blancard 1690
de Marchetti (ca. 1680) Utilized open surgical removal of kidney stones
Bowman 1832 Described the relation of the glomerulus to the tubule
Henle (1809-1885)   Discovered the loop of Henle
Ludwig 1844 Suggested that urine formation begins with filtration of protein-free fluid in the glomeruli
Simon 1851 Performed first planned ureterosigmoidostomy
1869 Performed first planned nephrectomy (for urethral vaginal fistula) in which patient survived
Morris 1880 Performed first nephrolithotomy
Czerny 1880 Performed first pyelolithotomy
Hyrtl 1882 Described the avascular plane between anterior and posterior vascular segments
Wells 1884 Performed first partial nephrectomy
Witzel 1896 Described ureteric reimplantation using tunneling of the ureter
Robson 1898 First suggested use of x-rays to localize stones
Brodel 1901 Confirmed Hyrtl’s work. Published and illustrated his studies on the intrinsic blood supply of the kidney.
Lower 1913 Advocated pyelolithotomy for stones in the renal pelvis
Judd 1919 Recommended nephroureterectomy for transitional cell carcinoma of the kidney
Braasch; Carman 1919 Used interoperative fluoroscopy to localize stones
Demmings 1928 Described incision through avascular plane
Hunt 1929 Recommended nephroureterectomy with en bloc removal of a cuff of bladder for transitional cell carcinoma of the kidney
Young 1929 Reported first endoscopy of ureter. Inserted cystoscope in the dilated ureter of boy with posterior urethral valves.
Boari 1932 Utilized bladder flap to replace distal ureter
Foley 1937 Introduced Y-V plasty for ureteropelvic junction (UPJ) obstruction
Kolff & Berk 1942 Introduced the artificial kidney into clinical medicine
Davis 1943 Described intubated uterostomy
Anderson & Hynes 1949 Introduced dismembered pyeloplasty for UPJ obstruction
Bricker 1950 Popularized ureteroileal conduits
Hume 1951-1953 Performed nine cadaveric kidney transplants
Stewart 1952 Pioneered partial nephrectomy
Hutch 1952 Noted relationship between vesicoureteric reflux and pyelonephritis
Harrison & Murray 1954 Performed successful human kidney transplantation in identical twins (Harrison and Murray later transplanted cadaveric kidneys)
Merrill et al. 1956
Jameson, McKinney, & Rushton 1957 Introduced ureterocalicostomy
Politano, Leadbetter 1958 Described technique for ureteroneocystostomy involving initial intravesical dissection, with the ureter passed extravesically and then brought back through a new, more superiorly located position in the bladder
Paquin 1959 Described combined extravesical and intravesical approaches to ureteroneocystostomy
Lich, Gregoir 1961 Described extravesical ureteric reimplantation procedure
Robson 1963 Defined survival for patients with renal cell cancer treated by radical nephrectomy. Described modern classification system for renal cell cancer.
Hardy 1963 Early successful autotransplantations of the kidney
Woodruff et al. 1966
Smith, Boyce 1967 Pioneered anatrophic nephrolithotomy
Glenn & Anderson 1967 Described most popular ureteric advancement technique
Cohen 1977 Described technique of crosstrigonal advancement
Goodman 1977 Reported on endoscopic inspection of lower ureter
Perez-Castro Ellendt Martinez-Pineiro 1980 Performed ureteroscopy to level of renal pelvis
Chaussey 1980 Published first report on extracorporeal shock wave lithotripsy (ESWL)
Ploeg 1990 Report of improved preservation of kidney, permitting longer cold ischemia times and more complex resections and reconstructions

History table compiled by David A. McClusky III and John E. Skandalakis.


Dimopoulos C, Gialas A, Likourinas M, Androutsos G, Kostakopoulos A. Hippocrates: founder and pioneer of urology. Br J Urol 1980;52:73-74.

Ek A, Bradley WE. History of cystometry. Urology 1983;23:335-350.

Ellis H. Famous Operations. Media PA: Harwal, 1984.

Haeger K. The Illustrated History of Surgery. London: Starke, 1989.

Hardy JD. High ureteral injuries: management by autotransplantation of the kidney. JAMA 1963;184:97-101.

Mettler CC. History of Medicine. Philadelphia: Blakinston Co., 1947.

Ploeg RJ. Kidney preservation with the UW and Euro-Collins solutions: a preliminary report of a clinical comparison. Transplantation 1990;49:281-284.

Wells S. Successful removal of two solid circumferential tumors. Br Med J 1884;1:758.

Woodhead DM. Urology: past, present, future. Int Surg 1968;49:534-543.

Woodruff MFA, Doig A, Donald KW, Nolan B. Renal autotransplantation. Lancet 1966;1:433.

Embryogenesis of the Kidneys and Ureters

Normal Development

Three excretory organs (pronephroi, mesonephroi, and metanephroi) develop from the intermediate mesoderm2,3 (Figs. 23-1, 23-2). However, since pronephroi are never functional in human embryos and degenerate on days 24 or 25, we will present only the concepts of mesonephroi and metanephroi.

Fig. 23-1.

Development of the cervical nephrotomes and mesonephros. A. A pair of cervical nephrotomes forms in each of five to seven cervical segments, but these quickly degenerate during the 4th week. The mesonephric ducts first appear on day 24. B, C. Mesonephric nephrotomes and tubules form in craniocaudal sequence throughout the thoracic and lumbar regions. The more cranial pairs regress as caudal pairs form, and the definitive mesonephroi contain about 20 pairs confined to the first three lumbar segments. D. The mesonephroi contain functional nephric units consisting of glomeruli, Bowman’s capsules, mesonephric tubules, and mesonephric ducts. (Modified from Larsen WJ. Essentials of Human Embryology. New York: Churchill Livingstone, 1998; with permission.)

Fig. 23-2.

The three sets of excretory systems in an embryo during the fifth week. A. Lateral view. B. Ventral view. The mesonephric tubules have been pulled laterally; their normal position is shown in A. (Modified from Moore KL, Persaud TVN. The Developing Human. Clinically Oriented Embryology (6th ed). Philadelphia: WB Saunders, 1998; with permission.)

The mesonephroi (“interim or temporary kidneys”) (Fig. 23-3) appear late in the 4th week (day 24 or 25) just caudal to the pronephroi. The mesonephroi have a brief functional period from the late embryonic to the early fetal period (weeks 6 to 10), during which they produce very dilute urine. The mesonephroi take over a portion of the pronephric duct in the thoracic and upper lumbar regions, making it the mesonephric (or Wolffian) duct (Figs. 23-1 and 23-2). The mesonephric tubules form excretory units: the medial end forms Bowman’s capsule; lateral branches from the aorta form capillaries that become glomeruli which fit into Bowman’s capsule, thus forming renal corpuscles. The tubules open into mesonephric ducts. Some tubules persist in males to become ductuli efferentia which open into the mesonephric (Wolffian) ducts to become ductuli deferentia.

Fig. 23-3.

A. Lateral view of a five-week embryo showing the extent of the mesonephros and the primordium of the metanephros or permanent kidney. B. Transverse section of the embryo showing the nephrogenic cords from which the mesonephric tubules develop. C-F. Transverse sections showing successive stages in the development of a mesonephric tubule between the fifth and eleventh weeks. Note that the mesenchymal cell cluster in the nephrogenic cord develops a lumen, thereby forming a mesonephric vesicle. The vesicle soon becomes an S-shaped mesonephric tubule and extends laterally to join the pronephric duct, now renamed the mesonephric duct. The expanded medial end of the mesonephric tubule is invaginated by blood vessels to form a glomerular capsule (Bowman’s capsule). The cluster of capillaries projecting into this capsule is known as a glomerulus. (Modified from Moore KL, Persaud TVN. The Developing Human. Clinically Oriented Embryology (6th ed). Philadelphia: WB Saunders, 1998; with permission.)

The metanephroi (“hind kidneys”) (Fig. 23-4) are the final developmental stage. The metanephric diverticulum (ureteric bud) arises on day 35 from the caudal part of the mesonephric duct. This entity is destined to give rise to the collecting apparatus of the urinary system which consists of 1-3 million collecting tubules, minor and major calices, the renal pelvis, and ureters. The metanephrogenic blastema (metanephric mesoderm) forms from the caudal portion of the intermediate mesoderm and gives rise to the nephrons (800,000 to 1,000,000 in each kidney). Blastema tissue capping each arched collecting tubule differentiates into the nephron. Glomeruli form and are enveloped by Bowman’s capsule to form the renal corpuscle. The proximal convoluted tubule, loop of Henle, and distal convoluted tubule form the remainder of the nephron. The distal convoluted tubule opens into the arched collecting duct. To start with, the ureter has a lumen which later occludes and which subsequently recanalizes.

Fig. 23-4.

A. Lateral view of a five-week embryo, showing the primordium of the metanephros or permanent kidney. B-E. Successive stages in the development of the metanephric diverticulum or ureteric bud (fifth to eight weeks). Observe the development of the ureter, renal pelvis, calices, and collecting tubules. The renal lobes, illustrated in E, are still visible in the kidneys of a 28-week fetus. (Modified from Moore KL, Persaud TVN. The Developing Human. Clinically Oriented Embryology (6th ed). Philadelphia: WB Saunders, 1998; with permission.)

When the kidneys ascend from the pelvis to their permanent location in the upper lumbar region (Fig. 23-5), they come into apposition with the adrenal glands, which develop in situ. During ascent, the kidneys rotate medially so that the hilum, which initially faced anteriorly, now faces medially. The segmental vessels supplying the kidney are added cranially and lost caudally4 during ascent.

Fig. 23-5.

A-D. Ventral views of the abdominopelvic region of embryos and fetuses (sixth to ninth weeks), showing medial rotation and ‘ascent’ of the kidneys from the pelvis to the abdomen. A, B. Observe also the size regression of the metanephroi. C, D. Note that as the kidneys ‘ascend,’ they are supplied by arteries at successively higher levels and that the hilum of the kidney (where the vessels and nerves enter) is eventually directed anteromedially. (Modified from Moore KL, Persaud TVN. The Developing Human. Clinically Oriented Embryology (6th ed). Philadelphia: WB Saunders, 1998; with permission.)

Approximately 25 percent of adult kidneys have two to four arteries. Accessory renal arteries usually arise from the aorta; they may be superior or inferior to the main renal artery, and are end arteries. Accessory arteries usually form at the superior or inferior poles of the kidney. The inferior accessory artery may pass anteriorly to the ureter, sometimes compressing it and causing blockage; this is hydronephrosis, a common form of ureteropelvic junction obstruction.5 The right inferior accessory artery may cross anteriorly to both the ureter and the inferior vena cava. Supernumerary arteries are twice as common as supernumerary veins.

The ureteric bud is responsible for the genesis of the ureters. The bud, a diverticulum of the mesonephric duct, is located close to the cloaca, just above the duct’s entrance into the cloaca. The bud grows into the mesodermal metanephrogenic mass, and its cranial end becomes the renal pelvis. The stalk of the ureteric bud becomes the ureter, which enters into the urinary bladder.

Congenital Anomalies

Congenital anomalies of the kidney and ureter are seen in Figure 23-6.

Fig. 23-6.

Various anomalies of the urinary system. The small sketch at the lower right of each drawing illustrates the probable embryologic basis of the anomaly. A. Unilateral renal agenesis. B. Right side, pelvic kidney; left side, divided kidney with a bifid ureter. C. Right side, malrotation of the kidney; left side, bifid ureter and double kidney. D. Crossed renal ectopia. The left kidney crossed to the right side and fused with the right kidney. E. ‘Pancake’ or discoid kidney resulting from fusion of the kidneys while they were in the pelvis. F. Supernumerary left kidney resulting from the development of two ureteric buds. (Modified from Moore KL, Persaud TVN. The Developing Human. Clinically Oriented Embryology (6th ed). Philadelphia: WB Saunders, 1998; with permission.)

Renal agenesis is caused by failure of the ureteric bud to develop or by early degeneration of the bud. Unilateral renal agenesis occurs in 1 in 1000 newborns (Fig. 23-6A). The condition is twice as common in males. Usually, the left kidney is absent, and the other kidney undergoes compensatory hypertrophy. With a unilateral functioning kidney, compensatory renal hypertrophy is detectable in utero and may occur as early as 22 weeks gestation.6 Bilateral renal agenesis, which is incompatible with life, occurs in 1 in 3000 births. It presents with oligohydramnios, Potter’s facies, hypertelorism, epicanthic folds, low-set ears, and limb defects.

Non-rotation or abnormal rotation of the kidneys (Fig. 23-6C) is another congenital anomaly. Non-rotation results in the hilum facing anteriorly. With excessive rotation, the hilum faces posteriorly; it may face laterally if rotation occurs in the wrong direction. Abnormalities of rotation are often associated with ectopic kidneys.

Ectopic kidneys may be unilateral or bilateral. Most are located inferior to their normal location, with the hilum facing anteriorly. Most ectopic kidneys lie in the pelvis; some are found in the lower abdomen (Fig. 23-6B). Pelvic kidneys often fuse to form pancake (discoid) kidneys (Fig. 23-6E). In crossed renal ectopia, one kidney has crossed to the contralateral side (Fig. 23-6D). The blood supply of ectopic kidneys is often from multiple arteries which arise from nearby arteries such as the internal iliac, the external iliac, and/or the aorta.

Campbell7 reported 22 cases of renal ectopia with only one intrathoracic finding. Kubricht et al.8 reported such a case with renal cell carcinoma. Their patient had a thin membrane of diaphragm covering the kidney, thus making it subdiaphragmatic while being intrathoracic in position (diaphragmatic eventration). The embryogenesis of such an anomaly is enigmatic.

Horseshoe kidney occurs in 1 in 500 births. There is a seven percent incidence of horseshoe kidney in individuals with Turner’s syndrome; children with this condition are 2 to 8 times more likely to have Wilms’ tumors. In horseshoe kidney, the caudal poles fuse across the midline. Usually the horseshoe lies in the hypogastrium anterior to the lower lumbar vertebrae because of the failure of ascent which occurs when the kidney is ‘hung up’ on the inferior mesenteric artery. Horseshoe kidney is usually symptomless.

Various duplications of the urinary tract may occur. Supernumerary kidney is rare; it is probably due to two ureteric primordia forming on one side (Fig. 23-6F). The location of division of the ureteric bud determines the extent of duplication. One possibility is a divided kidney with bifid ureter (Fig. 23-6B). Occasionally the division may result in a double kidney with bifid ureter or separate ureters.

The discovery of complete ureteric duplication warrants careful imaging studies for detection of fetal renal abnormalities. According to Peng and Chen,9 upper pole nephroureterectomy is performed on a child with a nonfunctioning moiety, and ureteropyelostomy or ureteric reimplantation is utilized for functioning segments.

Ectopic ureteric orifices are defined as openings located anywhere other than at the bladder. In males, the usual opening is into the neck of the bladder or prostatic urethra; unusual places include the ductus deferens, seminal vesicle or prostatic utricle. In females the ectopic opening is at the bladder neck, urethra, vagina, or vaginal vestibule. In males with ectopic urethra, incontinence is not seen because the ectopic ureter enters into the genitourinary system (bladder neck, prostatic urethra, seminal vesicle) above the external sphincter. In females with ectopic ureter, incontinence from the urethra or vagina is common because the ectopic opening is below the external sphincter. Cloacal outlet obstruction may occur with an ectopic ureter.10

Primary obstructive megaureter is the result of an adynamic segment of the distal ureter due to derangement of ureteral musculature.11 The condition may be bilateral or unilateral, with presentation in later years. Bapat et al.12 reported that endoureterotomy is a safe and effective treatment.

Ectopic ureteric orifices result from the ureter not being incorporated into the posterior part of the bladder. The ureter is carried caudally with the mesonephric duct to open into the lower part of the vesical portion of the urogenital sinus which becomes the urethra in females and the prostatic urethra in males. When two ureters form, the one from the upper pole of the kidney opens more caudally into the bladder or prostatic urethra; this phenomenon is known as the Weigert-Meyer rule.

Shindo et al.13 report a retrocaval ureter and a preaortic iliac vein confluence on a patient with an infrarenal aortic aneurysm.

Fetal obstructive uropathy is characterized by obstruction of the urethra, renal anomalies, ureterovesical dilatation, oligohydramnios, cryptorchidism, and abdominal muscle wall changes. The renal anomalies might be related to the gestational age at which the injury occurred and to the duration of the obstruction.14

Cystic diseases of the kidney5 fall under two broad categories: genetic and non-genetic.

Autosomal recessive (infantile) polycystic disease occurs in 1 in 40,000 births. It is associated with biliary duct ectasia or hepatic fibrosis and always appears in infancy or childhood. It follows an essentially ominous clinical course, with progressive uremia in infants and portal hypertension in older children. Infantile polycystic disease is characterized histologically by multiple diffuse small cysts and marked collecting tubule ectasia.

Autosomal dominant (adult) polycystic disease occurs at a rate of 1 in 400 to 1000. It is associated with cysts of the liver and other organs. While the condition may appear in infancy or childhood it more commonly becomes apparent in the 4th decade, with azotemia. Successful minimally invasive surgery for nephrolithiasis associated with autosomal dominant polycystic kidney disease was reported by Ng et al.15 Adult polycystic disease is characterized histologically by diffuse cysts of varying size and large kidneys. Rarely, renal cell carcinoma may occur in adults with polycystic kidney disease. Hemal and colleagues16 advocate noninvasive diagnosis (ultrasound or contrast-enhanced CT) and radical nephrectomy for these patients.

Other genetic cystic diseases of the kidney include


Juvenile nephronopthisis-medullary cystic disease complex (recessive-dominant)

Congenital nephrosis (recessive)

Familial hypoplastic glomerulocystic kidney disease (dominant)

Cysts associated with multiple malformation syndromes. A current theory is that cysts are wide dilations of parts of nephrons, especially in the loops of Henle.

Non-genetic cystic diseases of the kidney include multicystic kidney, multilocular cyst, simple cyst, and medullary sponge kidney (sponge kidney disease). The occurrence of multiple unilateral renal cysts in two children with no family history or associated renal cystic disease syndromes was reported by Dugougeat et al.,17 who suggest the possibility that this might represent a distinct clinical entity.

A family in which the father and his two daughters had ureteroceles involving the upper half of a duplex system suggests a genetic background for ureteroceles, according to Aubert and colleagues.18


Surgical Anatomy of the Kidneys

General Topographic Features

The kidneys are paired, bean-shaped organs located on either side of the vertebral column in the perirenal compartment of the retroperitoneal space between the anterior and posterior leaflets of the renal fascia (Gerota’s fascia). A stroma of adipose tissue (thick or thin) covers all their surfaces.

Renal size in pediatric patients varies with age. A reasonable nomogram using ultrasound measurements, in which the kidney size is shown to vary with age, is presented in Table 23-2.

Table 23-2. Renal Size in Pediatric Patients Using Ultrasound Measurements

Age Size (cm) Standard Deviation (cm)
Birth 4.5 3.8-5.3
1 year 6.2 5-7.7
2 7 5.9-8.0
3 7.4 6.3-8.3
4 7.6 6.6-8.6
5 7.8 6.8-9.0
6 8 6.7-9.1
7 8 6.8-9.2
8 8.4 7.0-10.0
9 9 7.2-10.8
10 9.1 7.4-10.7
11 9.3 8.0-10.6
12 10 8.4-11.2
13 10 8.3-11.4
14 10 8.4-11.1
15 10.2 9.0-11.4

Source: Thomas S. Parrott, M.D.; with permission.

The adult kidney has a length of 10-14 cm, width of 5-7 cm, and thickness of 2.5-3.0 cm. Its approximate weight is 135 g in women and 150 g in men.

Each kidney has two surfaces (anterior and posterior), two borders (lateral and medial), and two poles (superior and inferior); each kidney also has its own relations with several other anatomic entities. The kidney is related anteriorly to the abdominal viscera and posteriorly to the osteomuscular area. The right kidney lies at a lower level in comparison with the left, a phenomenon that permits the right lower pole to be palpable.

When the patient is in the recumbent position, the kidneys may extend from T12 to L3, but in the erect position both may extend from L1 to L4. In addition to changing with alterations in posture, the kidneys may move upward and downward approximately 1-7 cm with respiration, according to O’Rahilly.19 The above numbers represent, if the term is permissible, the “physiologic” movements of the kidney, not the ptotic (nephroptotic, mobile, floating) kidney.


Anterior Surfaces

The anterior surfaces of the kidneys are covered by the following anatomic entities:


Perirenal fat

Gerota’s fascia

Pararenal fat

Parietal posterior peritoneum (partially)

The anterior surface of the right kidney is related to (Fig. 23-7, Fig. 23-8):


Right adrenal gland


Second part of duodenum

Inferior vena cava


Ascending colon

Hepatic flexure of the colon

Fig. 23-7.

The anterior surface of the kidney showing the areas related to neighboring viscera.

Fig. 23-8.

Anterior relations of the kidneys to the abdominal organs. (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

The anterior surface of the left kidney is related to:


Left adrenal gland


Splenic vessels



Duodenojejunal flexure

Ligament of Treitz

Inferior mesenteric vein

Descending colon

Splenic flexure of the colon

Loops of jejunum

Posterior Surfaces

The posterior surfaces (Figs. 23-9, 23-10, 23-11) of the kidneys are related to:


Psoas muscles

Transversus abdominis muscles

Quadratus lumborum muscles


12th thoracic nerves

Iliohypogastric nerves

Ilioinguinal nerves

Subcostal vessels

Anterior layer of thoracolumbar (lumbodorsal) fascia

Transversalis fascia

Pararenal fat

11th and 12th ribs


Posterior layer of Gerota’s fascia

Perirenal fat

Medial and lateral arcuate ligaments of the diaphragm

Fig. 23-9.

Schematic representation of the posterior relations of the kidney. (Modified from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol UK: Wright, 1986; with permission.)

Fig. 23-10.

The posterior surfaces of the kidney, showing the areas of relation to the posterior abdominal wall.

Fig. 23-11.

Anatomic relations of the kidneys. A. Posterior relations to the muscles of the posterior body wall and ribs. B. Relations to the pleural reflections and skeleton posteriorly. (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

The posterior surface of the right kidney is related to the 12th rib, with the superior pole extending upward into the 11th intercostal space; the posterior surface of the left kidney is related to the 11th and 12th ribs.

Lateral Border

The lateral border of the kidney is related to the perirenal fat, Gerota’s fascia, and pararenal fat. From a surgical standpoint, the lateral renal border is not important.

Medial Border

In the medial border of each kidney there is a vertical fissure called the renal porta or hilum. The renal arteries and nerves enter through the renal hilum, while the veins, lymphatics, and proximal ureter exit through it. For all practical purposes the concavity of the hilum is continuous with a deep declivity in the medial border of the kidney, the so-called renal sinus. This recess is lined by the tissues of the renal capsule and envelops the renal vessels and the renal pelvis, according to Narath.20

Within the renal sinus is the renal pelvis, a funnel-shaped sac formed by the widely expanded portion of the proximal ureter and by the junctions of the major calices. It is entirely arbitrary whether to consider the pelvis part of the kidney (e.g., ‘renal pelvis’) or part of the ureter (e.g., ‘ureteric pelvis’). Current usage in which ‘renal pelvis’ is the norm is not untidy, and has universal acceptance. Using the philosophy that would call it the ‘ureteric pelvis,’ why not call infundibuli ‘ureteric infundibuli’ and calices ‘ureteric calices’?

The term ‘intrarenal pelvis’ denotes a pelvis that is almost covered or completely covered by renal parenchyma. This term is in general use among reconstructive renal surgeons. Such terminology is helpful in describing that entity in which technical difficulty in exposure of the obstructed ‘renal pelvis’ may occur at the time of pyeloplasty.

The renal pelvis bifurcates or trifurcates within the sinus producing two or three major calices. Each of the major calices again subdivides into 7 to 14 minor calices which receive the collecting tubules (approximately 500). Fine and Keen21 reported that occasionally no formation of major calices takes place.

The renal pelvis most commonly lies posterior to the renal vessels. Occasionally it may be situated between or in front of the vessels. In some instances the renal pelvis is small, lacks an extrarenal portion, and is located entirely within the renal parenchyma.

The upper pole of each kidney is related to its associated adrenal gland, separated from it only by a thin diaphragm of connective tissue originating from the fascia of Gerota, which totally envelops each adrenal (Fig 23-12). The right and left adrenal glands are located superomedially at the front of the upper part of each kidney.

Fig. 23-12.

Highly diagrammatic representation of the renal fascia. The partition, a type of diaphragm, separates the adrenal from the upper renal pole.

Davie22 reported that in 6 out of 1500 necropsies the adrenals were fixed with the upper pole of the kidney in such a way that a nephrectomy would necessarily include the adrenal glands. This knowledge is critical for a surgeon undertaking laparoscopic adrenalectomy. The laparoscopic operation can be undertaken safely, though, according to the report of Prinz23 comparing laparoscopic adrenalectomy with open adrenalectomy. The lower pole is occasionally located close to the lumbar triangle.



The pleura and the diaphragm separate the kidney from the 12th rib (see Fig. 23-9).

The inner half of the 12th rib is related to the pleura.

The pleura (for all practical purposes) has a horizontal pathway related to the length of the 12th rib (Fig. 23-13).

The anterior surface of the right kidney (which is related to the liver and loops of small bowel) is the only area of the organ covered by peritoneum. The anterior surface of the left kidney (which is related to the stomach, spleen and loops of small bowel) is also covered by peritoneum.

The upper part of the upper pole of the right kidney is associated with the peritoneum which forms the hepatorenal pouch of Morison. This is bounded as follows (Fig. 23-14):


– Above, by the posterior layer of the coronary ligament

– Anteriorly, by the inferior surface of the liver

– Posteriorly, by the peritoneum lining the inferior surface of the diaphragm

Occasionally, the upper pole of the kidney close to the vertebrocostal angle is separated from the pleura only by a layer of connective tissue (which may be thin or thick).

The anterior pararenal space contains comparatively less fat than the posterior pararenal space, where the adipose tissue stroma is rich.

According to some authors the renal fascia does not invest each kidney completely, since at the region of the lower pole the anterior and posterior laminae of the fascia do not fuse (see Fig. 23-12); others believe the opposite.

We quote the cadaveric studies of Wolfram-Gabel et al.24 on closure of the renal space:

On each side, the kidney and the suprarenal gland are disposed in a space that is closed on all sides. The anterior and posterior layers of the renal fascia fuse at the upper pole of the space to become continuous with the inferior fascia of the diaphragm. Likewise, they merge at the lower pole and at the lateral border of the space to become continuous with the fasciae of the parietal muscles. At the medial border of the space, the two layers merge to continue medially with the peri-aortocaval connective tissue; they penetrate the hilum and beneath it enclose the ureter.

Fig. 23-13.

Showing certain important posterior relationships of the kidney. (Modified from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol UK: Wright, 1986; with permission.)

Fig. 23-14.

The hepatorenal or Morison’s pouch (X). (Modified from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol UK: Wright, 1986; with permission.)

Position of the Kidneys

Factors which are responsible for the position of the kidney include:


Renal fascia (upper part)

Peri- and paranephric fat

Intraperitoneal viscera

Intraabdominal pressure

Nephroptosis (mobile or floating kidney) is acquired; it should not be confused with the ectopic kidney. Renal ectopia is a congenital phenomenon related to placement, form, and orientation of the kidney.

The pathway of nephroptosis is downward. We believe this is due to lack of adequate fusion of the anterior and posterior laminae of the renal fascia in the vicinity of the lower pole of the kidney.

The right kidney is more mobile than the left. The ideal treatment of nephroptosis is nephropexy, either by nephrorrhaphy or one of several other methods.

We are happy to present verbatim an excellent letter which was published in the Western Journal of Medicine.25 We agree with the conclusions of the author, Jane M. Hightower, M.D., and we are grateful to her and to the journal for permission to reprint it.

Dietl’s Crisis Revisited — The Enigma of Nephroptosis

To The Editor: I would like to report a new twist on an old condition. I am a 32-year-old female physician who is athletic and thin. In January 1993 I began having intermittent abdominal pain that radiated to my back and groin. This was accompanied by a protruding mass on my right side adjacent to the lateral rectus muscle. I went to a surgeon who diagnosed a spigelian hernia. This quarter-sized defect was repaired without difficulty using mesh. After the procedure, I still had a painful mass protruding into the area of repair that was mobile in a vertical plane of about 12 cm. I then went back for a laparoscopic evaluation, but no abnormal masses were seen. After an ultrasonogram, computed tomographic (CT) scan, and intravenous pyelogram, we realized that my kidney was the culprit. The inferior pole was pushing against my abdomen where it had previously herniated. It was highly mobile and at times rotated by 90 degrees on its axis. The CT scan revealed hydronephrosis of my right ureter when lying prone. In an effort to avoid another operation and to get some relief from the pain, I learned how to manipulate the kidney by pushing it up and posteriorly, trying to hold it under my ribs. Between seeing patients, I would lie supine on the floor. When I stood up, my blood pressure would go from 90/60 to 150/90 mm of mercury. Eventually, I had the aberration fixed and have not had problems since.

The results of a literature search left me disillusioned; this condition, once known as Dietl’s crisis and which mostly affects women, had been greatly misunderstood.26 Some surgeons operated on asymptomatic ptotic kidneys in women who actually had other causes of pain.27 The surgical techniques used in the past were also known to cause complications27,28 which led to the idea that repair was futile. McWhinnie and Hamilton took this idea further by concluding that “The predominance of female patients might suggest that this syndrome was the early equivalent of later forms of nonorganic pain,” and that “like other ineffective treatments for imaginary disease, surgery for the movable kidney simply faded away.”29 As a result of earlier misfortunes of diagnosis and treatment, this anatomic variant, which occurs in 20% of women and 2% to 7% of men,28,30 is not mentioned in our current texts.

Abnormal renal mobility should be investigated and treated when secondary complications or severe symptoms occur.27,28,30,31 Information about this condition should be placed back into our kidney and urologic texts to help us diagnose and treat this common anatomic variant, which can cause real, not imaginary, symptoms.

Vascular Supply of the Kidneys

Arterial Supply

The anatomic nomenclature describing renal arteries other than the main ones – the left and right renal arteries – is confusing and controversial. In fact, sometimes the term “main” is used for clarification. More details regarding this problem will follow.

The paired (right and left) renal arteries originate from the lateral wall of the aorta just below the origin of the superior mesenteric artery at the level of the intervertebral disc between the L1 and L2 vertebrae. However, the origin of the longer right renal artery (Fig. 23-15) is more posterior in comparison to the left. Rarely, the right renal artery originates from the posterior wall and travels posterior to the inferior vena cava to reach the right kidney. Remember that arising from each renal artery prior to its trifurcation are two small arteries that must not be molested: the inferior suprarenal artery and the artery for the renal pelvis and proximal ureter.

Fig. 23-15.

Segmental branches of the right renal artery demonstrated by renal angiogram (A) and corresponding diagram (B). (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

Studying 30 adult abdominal aorta specimens dissected from cadavers, Ozan et al.32 reported the origin of the renal arteries from the aorta. The ostium of the right renal artery was more cranial than the ostium of the left renal artery (53.3%). However, the ostia of both right and left renal arteries were at the same level in three cases (10%). Locations of the ostia of the renal arteries were usually on the lateral and anterolateral regions of the aortic wall.

Each artery reaching the hilum divides into anterior and posterior divisions in relation to the renal pelvis (Fig. 23-16). Furthermore, the five branches of each renal artery participate in the formation of four renal segments: (1) apical (superior), (2) anterior (subdivided into superior and inferior), (3) posterior, and (4) basilar (inferior) (Figs. 23-17, 23-18).

Fig. 23-16.

Typical segmental circulation of the right kidney, shown diagrammatically. Note that the posterior segmental artery is usually the first branch of the main renal artery, and extends behind the renal pelvis. (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

Fig. 23-17.

The intrarenal course and relation to the anterior calices of the apical, basilar, and anterior segmental arteries. Note the short length of the apical branch. The posterior branch is shown by a broken line.

Fig. 23-18.

The branch of the renal artery supplying the posterior segment of the kidney passes along the posterior surface of the renal pelvis and then divides into smaller branches that course between the posterior calices. The apical, basilar, and anterior branches are shown by broken lines.

The arteries of each segment, which are end arteries without any collateral circulation, are as follows:


Apical branch

Basilar branch

Artery for the superior portion of the anterior segment

Artery for the inferior portion of the anterior segment

Artery for the posterior segment

Different authors give different names to the segments, as is obvious when comparing Fig. 23-19 with Fig. 23-16. Also, different authors refer to the segmental arteries by different names, such as “suprahilar” instead of “apical.” Graves stated that aberrant renal arteries are normal segmental arteries and not accessory arteries.33,34

Fig. 23-19.

The vascular segments of the left kidney, as shown in the anterior, lateral, and posterior projections.

The anterior division has branches that supply the apical, basilar, superior, and inferior portions of the anterior segment. The posterior division supplies the posterior segment of the kidney.



The very short apical artery supplies the anterior and posterior surfaces of the apical segment.

The basilar artery provides blood for the anterior and posterior surfaces of the basilar segment.

The anterior segment is supplied by two branches: one for its superior part and another for its inferior part.

The blood supply of the posterior segment is provided by a single artery.

The renal arteries are end arteries without collateral circulation.

The “avascular” line or plane (also known as Brödel’s line) (Figs. 23-20, 23-21) is the most avascular area of the kidney. It is located slightly behind the convex border at the posterior half of the kidney at the junction of the area supplied by the anterior and posterior divisions of the renal artery. This is approximately 2/3 of the way along a line from the hilum to the lateral margin of the kidney. Incision in this area will permit removal of a stone within the renal calices with minimal damage.

Fig. 23-20.

Schema of the anterior and posterior branches of the renal artery, in a horizontal section of the kidney. The “avascular” line is the region of overlap between the anterior and posterior branches, situated posterolaterally rather than laterally because of the wider distribution of the anterior branches. (Modified from Hollinshead WH. Anatomy for Surgeons. New York: Hoeber, 1956; with permission.)

Fig. 23-21.

Avascular plane of kidney. (Modified from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol UK: Wright, 1986; with permission.)

According to Banowsky,35 unilateral multiple renal arteries occur in approximately 23 percent of the population. Another 10 percent have bilateral multiple arteries. Multiple renal arteries are more common on the left side.

Banowsky35 differentiates between multiple and accessory renal arteries. He states that multiple renal arteries supply one renal segment and accessory arteries supply only part of the segment. He emphasizes that it is advisable to ligate only the accessory arteries.

Singh et al.36 stated that accessory renal arteries are more common on the left side, occurring in as many as 30-35% of cases and usually entering the upper or lower pole of the kidney (Fig. 23-22). Such an accessory artery of the lower pole may produce ureteric obstruction with secondary hydronephrosis.

Fig. 23-22.

Schematic drawings of accessory renal arteries. A. Right kidney. B. Left kidney. RK, right kidney; LK, left kidney; RU, right ureter; LU, left ureter; ROA, right ovarian artery; LOA, proximal part of the left ovarian artery; ROV, right ovarian vein; A, aorta; IVC, inferior vena cava; RARA, right accessory renal artery; LARA, left accessory renal artery. (Modified from Singh G, Ng YK, Bay BH. Bilateral accessory renal arteries associated with some anomalies of the ovarian arteries:a case study. Clin Anat 1998;11:417-420; with permission.)

A study by Satyapal et al.37 refers to “additional” renal arteries and offers this definition:

An additional renal artery, other than the main renal artery, is one which arises from the aorta and terminates in the kidney.

They add that “additional renal arteries” have been described as “accessory,” “aberrant,” “anomalous,” “supernumerary,” “supplementary,” “multiple,” “accessory aortic hilar,” “aortic superior polar,” “aortic inferior polar,” “upper polar,” and “lower polar.” They comment on the need for standardization of the nomenclature to facilitate accurate reporting of the incidence of the entities they choose to refer to as “additional.”

The above-mentioned study by Satyapal et al.37 presented these findings:

Single additional renal arteries were more common on the left side (27.6%) than the right side (18.6%). Second additional renal arteries occurred with similar incidences on either side (right, 4.7%; left, 4.4%). The lengths (cm) and diameters (cm) of first and second additional renal arteries were 4.5, 0.4 and 3.8, 0.3 (right) and 4.9, 0.3, and 3.7, 0.3 (left), respectively.

Ligation of an accessory renal artery can result in the production of an area of infarction of variable size, though often small. Renovascular hypertension may occur as a sequela of the ischemia.

Every surgeon performing renal surgery should be familiar with the segmental anatomy of the kidney. Such knowledge can save lives. A case in point can be provided by one of the authors of this chapter (JES). A patient with bilateral renal malignancy required radical nephrectomy on the left side. Twelve years after surgery the patient was still alive and well, with only two segments of the right kidney remaining in situ.

Venous Drainage

The kidney is drained by several veins which together form the renal vein (Fig. 23-23). The left renal vein is longer than the right. It receives blood from the left adrenal, the left gonad, and the body wall, including the diaphragm. The left adrenal vein enters the renal vein superiorly; the left gonadal vein enters inferiorly. Usually one or two lumbar veins empty into the posterior wall of the left renal vein.

Fig. 23-23.

Venous drainage of the left kidney, showing potentially extensive venous collateral circulation. (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

Temporary or permanent occlusion of the left renal vein close to its entrance into the inferior vena cava can usually be done with impunity. Unlike the left renal vein, the short right renal vein contains a thin valve which is not good material for suture. Therefore, in addition to excising the right renal vein, the surgeon should excise a small cuff of the medial wall of the inferior vena cava where the right renal vein enters. Multiple renal veins are not common and left renal vein duplication is rare.

Aluisio et al.38 studied the normal and anomalous anatomy of the left renal vein and its tributaries in 20 cadavers. They reported the following:


Other than the left suprarenal (adrenal) and left gonadal veins, the left renal vein had no additional tributaries

Study of the left suprarenal and left gonadal veins revealed no direct connections to the inferior vena cava

Anomalies of the left renal venous drainage system:


– Anomaly of the left renal vein itself manifested as a supernumerary left renal vein

– Bifurcation of the gonadal vein

– Bifurcation of the suprarenal vein

– Inferior phrenic vein draining into the left renal vein distal to the superior mesenteric artery

– Lumbar vein drainage into the left renal vein that may represent either an anomaly or a normal variation

Aluisio et al.38 found no evidence of a systemic collateral flow system for drainage of the left kidney following left renal vein division.

Satyapal et al.39 presented the following left renal vein variations (Note: A renal collar is the renal venous channel coursing both anteriorly and posteriorly to the abdominal aorta) (Fig. 23-24, Fig. 23-25, Fig. 23-26, Fig. 23-27):


Renal collars: 0.3%

Retroaortic vein: 0.5%

Additional veins: 0.4%

Posterior primary tributary: 23.2% (16.7%, Type IB; 6.5%, Type IIB)

Fig. 23-24.

Schematic drawing of renal collar. (Modified from Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat 1999;21:77-81; with permission.)

Fig. 23-25.

Schematic drawing of retroaortic vein. (Modified from Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat 1999;21:77-81; with permission.)

Fig. 23-26.

Schematic drawing of additional renal vein. (Modified from Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat 1999; 21: 77-81; with permission.)

Fig. 23-27.

Posterior view of plastinated left kidney demonstrating Type IB renal venous drainage. LRV, left renal vein; IVC, inferior vena cava; GV, gonadal vein; SRV, suprarenal vein; P, posterior primary tributary; Ao, aorta; RA, renal artery; Ur, ureter. (Modified from Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat 1999;21:77-81; with permission.)

A retroaortic left renal vein connected directly to the azygos system and the third lumbar vein was reported by Yoshinaga et al.40 The anomaly coursed dorsal to the abdominal aorta and opened into the IVC at the upper level of the third lumbar vertebra. It also received the posterior suprarenal and posterior inferior phrenic veins.

The renal vasculature may be appreciated by Figure 23-28.

Fig. 23-28.

The renal vasculature. (From Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; with permission.)



The renal veins intercommunicate with each other.

Temporary occlusion or permanent ligation of the left renal vein can be done with impunity if this procedure is done close to the inferior vena cava.


The renal lymphatic network is very rich. The renal lymphatics follow the blood vessels and form large lymphatic trunks. The trunks exit through the renal sinus where they receive communicating lymphatics from the renal capsule and perinephric fat. Lymphatics from the renal pelvis and upper ureter communicate with others at the renal hilum. Two or three lymph nodes close to the renal vein accept the lymph and then drain to the paraaortic lymph nodes.

The lymphatics of the right kidney (Fig. 23-29) drain into lymph nodes located between the inferior vena cava and the aorta, lateral paracaval nodes, and anterior and posterior inferior vena caval lymph nodes. They also drain upward toward the right diaphragm, and downward to the common iliac lymph nodes. Other pathways are into the thoracic duct or crossing the midline into the left lateral aortic lymph nodes.

Fig. 23-29.

Regional lymphatic drainage of the right kidney. Green nodes, anterior; black nodes, posterior. Solid lines, anterior lymphatic channels; dashed lines, posterior lymphatic channels. Arrow leads to thoracic duct.

The lymphatics of the left kidney (Fig. 23-30) drain into the lateral paraaortic lymph nodes and anterior and posterior aortic lymph nodes. They also travel upward to the diaphragm and downward to lymph nodes associated with the inferior mesenteric artery. According to Kabalin,41 malignancy of the left kidney does not metastasize to the nodes between the inferior vena cava and aorta except in advanced disease.

Fig. 23-30.

Regional lymphatic drainage of the left kidney. Green nodes, anterior; black nodes, posterior. Solid lines, anterior lymphatic channels; dashed lines, posterior lymphatic channels. Arrows lead to thoracic duct.


The kidneys characteristically exhibit a very rich network of neural elements that originate at the celiac ganglion, aorticorenal ganglion, celiac plexus, and intermesenteric plexuses. These elements intermingle, form plexuses, and follow the renal artery.

Thoracic nerves T10 to L1 participate in the innervation of the kidney. They receive pain fibers from the renal pelvis and proximal ureter that enter the spinal cord at those levels of the spinal nerves. The renal nerves have a vasomotor function.

The right and left vagus nerves participate in the formation of the renal plexus. The renal plexus gives branches to the ureteric and gonadal plexuses.



Avoid injury to the 11th and 12th intercostal nerves, not only to avoid postoperative paresthesias and neuralgias, but also to avoid postoperative bulging from partial paralysis of the muscles involved.42

Close the incision anatomically. Be sure not to entrap the lower intercostal nerves.

Avoid the phrenic nerve during opening of the diaphragm.

Partial anesthesia will develop in the gluteal area (about 20 x 10 cm) with transection of the T12 nerve.

Histology and Physiology

A detailed presentation of the histology and physiology of the kidney is beyond the scope of this chapter. We hope that the interested reader will augment this basic presentation through study of standard texts on renal histology and physiology.

Renal Structure

The renal parenchyma is formed by the cortex and the medulla (Figs. 23-31, 23-32).

Fig. 23-31.

The major blood vessels (left), the position of cortical and juxtamedullary nephrons (middle), and the major structures in the renal cortex and medulla (right). (After Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology, 2nd ed. St. Louis: Mosby Year Book, 1991, Fig. 1-40.)

Fig. 23-32.

The nephron with short loop of Henle (LH) and thin segment (TS). RC, renal corpuscle. (After Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology, 2nd ed. St. Louis: Mosby Year Book, 1991, Fig. 1-41.)

The renal cortex consists of:


Renal (malpighian) corpuscles, each one consisting of a glomerulus and its capsule

Convoluted tubules

Loop of Henle partially connecting the convoluted tubules

The renal medulla consists of:


Collecting and partially secretory tubules

Part of the loop of Henle

Renal pyramids. Their apices (the renal papillae) are cupped with minor calices.

The renal cortex covers the pyramids peripherally. It also extends between the pyramids to the renal sinus.43 The renal vessels enter and exit in these areas of cortex between the pyramids. For all practical purposes, the medulla consists of the renal pyramids.

The renal capsule consists of connective tissue. In the absence of underlying pathologic processes, it may be stripped with ease.

A renal lobe is formed by a pyramid covered by overlying renal capsule. The number of lobes is variable. Each renal lobe is subdivided into lobules. Each lobule has a central medullary ray and a surrounding stroma of cortical tissue.

Nephron and Pathway of Urine

It is not within the scope of this chapter to discuss the embryologic, anatomic, and histologic entities of nephrons (about which many authors agree to disagree).

Listed below are the parts of the nephron, as well as the path of urine flow:


Renal corpuscle (glomerulus, Bowman’s glomerular capsule)

Proximal convoluted tubule

Proximal straight tubule

Loop of Henle

Distal convoluted tubule

Collecting tubules

Table 23-3 gives the subdivisions of the nephron and collecting duct system.

Table 23-3. Subdivisions of the Nephron and Collecting Duct System

I. Nephron
  A. Renal corpuscle
    1. Glomerulus (the most frequently used term to refer to the entire renal corpuscle)
    2. Bowman’s capsule
  B. Tubule
    1. Proximal tubule
       a. Convoluted part
       b. Straight part (pars recta) or descending thick limb of Henle’s loop
    2. Intermediate tubule
       a. Descending part or thin descending limb of Henle’s loop
       b. Ascending part or thin ascending limb of Henle’s loop
    3. Distal tubule
       a. Straight part or thick ascending limb of Henle’s loop, subdivided into a medullary and a cortical part; the latter contains in its terminal portion the macula densa
       b. Convoluted part
II. Collecting duct system
  A. Connecting tubule (including the arcades in most species)
  B. Collecting duct
    1. Cortical collecting duct
    2. Outer medullary collecting duct subdivided into an outer- and inner-stripe portion
    3. Inner medullary collecting duct subdivided into a basal, middle, and papillary portion

Source: Venkatachalam MA, Kriz W. Anatomy. In: Jennette JC, Olson JL, Schwartz MM, Silva FG. Heptinstall’s Pathology of the Kidney, 5th ed. Philadelphia: Lippincott-Raven, 1998; with permission.

Each kidney contains approximately 1 million nephrons. Each nephron is formed by the glomerulus or renal corpuscle (glomerulus and glomerular capsule) and the uriniferous tubule.

The glomerulus is a rich vascular network enveloped by an epithelial sac (Bowman’s capsule). The physiologic destiny of the glomerulus is to form plasma ultrafiltrate and transmit the plasma to the Bowman’s capsule, which in turn transmits it to the uriniferous tubule and then to the pelvicaliceal system as urine.44

Modification of urine takes place within the uriniferous tubule. According to Venkatachalam and Kriz,44 the uriniferous tubule is “made up of many anatomically and cytologically distinct segments,” each performing a different function.

Surgery of the Kidney

Renal surgery includes:




Segmental resection (partial nephrectomy)

Pediatric partial nephrectomy

Simple nephrectomy

Radical nephrectomy (right, left)



Surgery for trauma

Renal transplantation

Only the six procedures that are performed most frequently will be presented here.

Surgeons should use the correct incisions for the procedures they will perform; they should be familiar with all approaches, including transperitoneal and retroperitoneal (Table 23-4). While surgeons will use the incision with which they are most comfortable, renal or ureteric pathology will dictate the most logical approach to help avoid anatomic complications. A poorly chosen incision can be catastrophic.

Table 23-4. Approaches to the Kidney

Anatomic Area Incision
Flank Subcostal (right or left) (Fig. 1)
11th rib (right or left) (Fig. 2)
With extension to the anterior lateral (right or left) abdominal wall (Fig. 3)
Anterior abdominal Subcostal, unilateral (Fig. 4)
Bilateral subcostal “chevron” (Fig. 5)
Extraperitoneal (Fig. 6)
11th rib transperitoneal (right or left) (Fig. 7)
Midline upper (Fig. 8)
Midline lower (Fig. 9)
Midline long (xiphoid/pubis) (Fig. 10)
Modified Gibson (right or left) (Fig. 11)
Combination (flank and anterior abdominal) Thoracoabdominal (right or left) (Fig. 12)
Posterior Over the 12th rib (right or left) (Fig. 13)
Dorsal lumbotomy (Fig. 14)
  Transperitoneal Two 12 mm trocars in the midclavicular line, one approximately 4 cm below the level of the umbilicus and the other 2 cm below the costal margin (Fig. 15). All secondary trocars placed under direct vision.
  Retroperitoneal Three ports along the inferior border of the 12th rib: a 12 mm port just posterior to the tip of the rib (superior lumbar triangle); a 12 mm port two finger breadths posterior to the first 12 mm port; a 5 mm port two finger breadths anterior to the first 12 mm port. Also, a 12 mm port at the inferior lumbar triangle (Fig. 16)

Note: Figures 1-14 in Table 23-4 are based on Montague DK. Surgical incisions. In: Novick AC, Streem SB, Pontes JE (eds). Stewart’s Operative Urology, 2nd ed, Vol 1. Baltimore: Williams & Wilkins, 1989, pp. 15-40.

Surgeons must also be very familiar with the structures of the anterior abdominal wall (Figs. 23-33, 23-34, and 23-35) and the posterior abdominal wall (Figs. 23-36, 23-37, 23-38, 23-39, and 23-40), including the respiratory, pelvic, and urogenital diaphragms.

Fig. 23-33.

Superficial musculature of the anterior abdominal and thoracic walls. (After Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology, 2nd ed. St. Louis: Mosby Year Book, 1991, Fig. 1-1.)

Fig. 23-34.

A. The external oblique muscle. B. The internal oblique muscle. C. The transverse abdominis muscle. (Modified from Thorek P. Anatomy in Surgery (3rd ed). New York: Springer-Verlag, 1985; with permission.)

Fig. 23-35.

Relationships of internal oblique, transversus abdominis and rectus abdominis muscles. (After Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology, 2nd ed. St. Louis: Mosby Year Book, 1991, Fig. 1-3.)

Fig. 23-36.

Cross section in the lumbar region showing lamina of the lumbar (thoracolumbar) fascia and the musculature and fusion of the anterior abdominal wall below the arcuate line. Inset shows composition of rectus sheath above the arcuate line. (After drawing in Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology (3rd ed). St. Louis: Mosby Year Book, 1996; with permission.)

Fig. 23-37.

Left, superficial musculature of the posterior abdominal wall. Right, with the removal of the latissimus dorsi and the external oblique, the intermediate group can be seen. (After Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology, 2nd ed. St. Louis: Mosby Year Book, 1991, Fig. 1-5.)

Fig. 23-38.

The diaphragm and posterior abdominal wall musculature. (After Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology, 2nd ed. St. Louis: Mosby Year Book, 1991, Fig. 1-6.)

Fig. 23-39.

Overview of thoracic musculature deep to the sacrospinalis, latissimus dorsi, and external oblique. (After drawing in Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology (3rd ed). St. Louis: Mosby Year Book, 1996; with permission.)

Fig. 23-40.

Cross-sectional view of posterolateral abdominal wall and retroperitoneal connective tissue showing potential cleavage planes. (After drawing in Redman JF. Anatomy of the genitourinary system. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW (eds). Adult and Pediatric Urology (3rd ed). St. Louis: Mosby Year Book, 1996; with permission.)

Surgical Approaches to the Kidney and Ureter Through the Posterolateral Wall

There are many surgical approaches to the kidney and ureter. Of course, knowledge of anatomy of the posterior, lateral, and anterior abdominal wall is essential. Here we re-emphasize careful study of the anatomy of the posterolateral body wall.

For purposes of description, the muscles of the posterolateral wall can be divided into four layers: outer, middle, inner, and innermost.

The outer layer (Fig. 23-41A & B) consists of:


Latissimus dorsi muscle

External oblique muscle (posterior part)

Serratus posterior inferior muscle

External intercostal muscles

Posterior lamina of thoracolumbar fascia

Fig. 23-41.

Structures of the outer muscle layer. Top: Posterior view. Dashed line indicates the plane of section in illustration below. Bottom: Transverse section. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.5A,B).

The middle layer (Fig. 23-42) contains


Sacrospinalis muscle

Internal oblique muscle

Internal intercostal muscles

Middle lamina of thoracolumbar fascia

Fig. 23-42.

Structures in the middle layer. Top: Posterolateral view. Bottom: Transverse section of the plane indicated in top illustration. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.6A,B).

The composition of the inner layer (Figs. 23-43, 23-44) includes:


Quadratus lumborum muscle

Psoas major and minor muscles

Innermost intercostal muscles

Transversus abdominis muscle (partial)

Fig. 23-43.

Structures in the inner layer. Top: Sagittal cut at the level of the right kidney. Bottom: Cut in the transverse plane indicated in top illustration. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.7A,B).

Fig. 23-44.

Attachment of the intercostal muscles, viewed anteriorly. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.8).

The innermost layer (Figs. 23-45, 23-46, 23-47) is made up of:


Psoas major muscle

Psoas minor muscle


Fig. 23-45.

Structures in the innermost layer. Top: Posterior view. Bottom: Transverse section at dashed line. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.9A,B).

Fig. 23-46.

Diaphragm. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.10).

Fig. 23-47.

Posterior approach to the kidney through the lamina of the thoracolumbar fascia. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 8.11).



If you decide to resect the 11th or 12th rib, use a subperiosteal incision. Push the periosteal instrument down toward the umbilicus at the upper side of the rib, and push up and posteriorly on the downside of the rib. Remember the phrase “above forward, below backward.”45

An anterior transperitoneal approach to the renal pedicle has excellent exposure. A posterior transperitoneal approach has limited exposure.

Remember that the lumbar fascia has three laminae (Fig. 23-45): posterior, middle, and anterior. The posterior lamina covers the sacrospinalis muscle and is the most superficial layer. The middle lamina is between the sacrospinalis and quadratus lumborum muscles. The anterior lamina covers the sacrospinalis and quadratus lumborum muscles. These three laminae unite close to the lateral borders of the quadratus lumborum and sacrospinalis. Incision of the fascia between the latissimus dorsi and sacrospinalis muscles as well as between the internal oblique and quadratus lumborum muscles will reach the transversalis fascia and posterior lamina of Gerota’s fascia.

The most common tumor of the ureter (more than 90%) is the urothelial transitional cell carcinoma.46 The treatment of choice is nephroureterectomy. However in older patients with low grade malignancy a ureteroureterostomy may be sufficient.

Partial Nephrectomy

The following are the steps of a partial nephrectomy:


1. Use the flank approach

2. Dissect the kidney

3. Isolate the vessels

4. Place a rubber dam and ice slush around the kidney (Lasix or Mannitol can also be used)

5. Clamp the artery first, then the vein. The kidney will become pale and soft

6. Incise the affected area. Close the collecting system and segmental vessels. Always use absorbable suture

7. Close the defect. Release the clamps

8. If the defect cannot be closed by use of the renal capsule, a peritoneal graft or omentum can be used

Pediatric Partial Nephrectomy

Pediatric partial nephrectomy is usually performed for diseased upper pole renal tissue associated with ureteric duplication anomalies, such as those seen with ectopic ureter or ectopic ureterocele. While some surgeons prefer a more anterior approach to the kidney in children, others find that the classic flank approach works well in this population, and leaves a less noticeable scar.

It is rarely necessary to use cooling techniques in infants and children. Because of the distinct polar distribution of blood vessels, ligation of vessels prior to division of renal tissue limits blood loss, and clamping of major vessels is unnecessary.

The surgeon can usually find the proper plane for division of the renal parenchyma by mobilizing the upper pole ureter on its inferior aspect, directly into the renal sinus. Using blunt technique, the parenchyma is dissected away to the lower pole. Often a small amount of parenchyma, in addition to the overlying capsule, requires division.

Simple Nephrectomy

Simple nephrectomy may be accomplished by the flank approach, subcapsular technique, or transperitoneal approach. It is indicated when there is no malignant process.

Radical Nephrectomy

Radical nephrectomy is the procedure of choice for renal malignancy. Suspicious renal masses may present with clinical and/or radiological features which lead to difficulties in diagnosis. According to Burga et al.,47 large renal masses are found to be malignant in approximately 85% of cases. Renal cell carcinoma is an aggressive malignant neoplasm with a usually fatal outcome, while renal oncocytoma has a characteristically benign course; both require resection.

By definition, radical nephrectomy is the removal of the kidney, adrenal, and upper (proximal) ureter by an extrafascial en bloc resection. This is carried out together with an extended lymphadenectomy from the diaphragm above to the area below the aortic bifurcation or, if necessary, down to the pelvic diaphragm.

The major renal vessels can be visualized anteriorly by separation of the peritoneum from the anterior lamina of Gerota’s fascia and posteriorly by separation of the posterior lamina of Gerota’s fascia from the transversalis fascia. In other words, the major renal vessels will be found within the anterior and posterior pararenal spaces, both of which may contain malignant cells that were spread by metastasis or direct extension of the tumor. A beautiful description of radical nephrectomy was written by Droller in 1990 in the journal Urology.48

Doublet et al.49 reported retroperitoneal laparoscopic nephrectomy without surgical or postsurgical complications. Conversion to open surgery did not occur.

Right Radical Nephrectomy

The following are the steps in a right radical nephrectomy:


1. Mobilization of ascending and proximal transverse colon

2. Kocherization of duodenum

3. Isolation and inspection of the inferior vena cava and right renal vein

4. Isolation of the right renal artery

5. Ligation of right renal artery to be followed by ligation of right renal vein

6. Careful exploration of the retroperitoneal space

7. Preparation and ligation of the right adrenal vein, inferior phrenic vein, and all vessels encountered

8. The lymph nodes around the inferior vena cava and between the inferior vena cava and aorta may be completely resected or biopsied.


In most cases the right renal artery is located superior and posterior to the right renal vein. Be careful about a branch to the ureter and one to three branches to the suprarenal gland. The renal pelvis and upper ureter are located behind the right renal artery and vein. Remember, also, that the blood supply of the renal pelvis and the upper ureter can include contributions from the common iliac artery and the gonadal artery.

Left Radical Nephrectomy

The following are the steps in a left radical nephrectomy:


1. Identify the renal pedicle (artery, vein, and ureter) as in right nephrectomy.

2. Protect the superior mesenteric artery. Its origin (Fig. 23-7) is just above the left renal vein, and it crosses the vein anteriorly. Posterior to the vein is the aorta.

3. Be careful with the distal pancreas, because the left renal artery has unpredictable posterior and inferior relations.

Renal Trauma

The approach for renal trauma is as follows:


1. Make a midline incision (because of possible associated intraperitoneal injury).

2. Incise the root of the small bowel mesentery.

3. Reflect small bowel, cecum, and ascending colon cephalad.

4. If a hematoma is visible within Gerota’s fascia, the surgeon should first control the renal vessels near their site of origin (or, for the right renal artery, between the inferior vena cava and the aorta). If the kidney is approached directly and Gerota’s fascia is opened, the tamponade effect of Gerota’s fascia will no longer be present. With a direct approach, bleeding is often profuse and nephrectomy is often the result.

5. If there is a pelvic fracture with evidence of hematoma, do not try to evacuate the hematoma prior to controlling the renal vasculature.

Severe blunt trauma may cause complete avulsion of the kidney into the chest through a ruptured diaphragm.50

Renal Transplantation

An overview of organ replacement by Niklason and Langer51 points out the significant role played by the kidneys. After the first successful dialysis of a uremic patient with a device called “the artificial kidney” was reported in 1944,52 the kidney became the first anatomic entity to undergo successful transplantation in 1954. The first renal allograft was implanted in 1959.53,54,55

Surgical Anatomy of the Renal Donor

The surgeon should be very familiar with not only the normal and abnormal anatomy of the renal vessels, but also the hepatic, pancreatic, and small bowel vasculature. Remember that 20 percent of kidneys have some vascular anomalies or variations. Pollak et al.56 found a 49% rate of renovascular variants in cadaveric kidneys procured for transplantation.

Some anatomic problems of renal transplantation relate to the means available for lengthening arteries and veins and whether multiple vessels should be ligated or left alone. Occasionally, segmental aortic and inferior vena cava resection may be necessary to secure good renal vascularization.

Special attention must be given to the blood supply of the proximal ureter, which is very closely associated with the blood supply of the renal pelvis. We agree with Hinman57 that it is absolutely necessary that the renal arteries not be dissected within the hilum and that the shortest necessary ureteric segment should be used, together with all possible perirenal and periureteric fat in this area.

A study by Sasaki et al.58 of laparoscopic technique to perform live donor nephrectomy concluded that “[p]roper surgical training and patient selection can result in a safe donor operation that provides kidneys of excellent quality.”

Procedure for Cadaveric Nephrectomy

Right Side


1. Incise at the peritoneal reflection at the right paracolic gutter

2. Elevate and reflect the right colon medially (cecum, ascending colon, hepatic flexure)

3. Kocherize the duodenum and reflect it medially

4. Carefully mobilize the inferior vena cava

5. Carefully clean the aorta

6. Locate the ureter medial to the right gonadal vessels

7. Be careful with the right gonadal vein

8. The anterior lamina of Gerota’s fascia is in view. It is not well developed

9. Do not skeletonize the ureter, but preserve 2 cm of tissue surrounding the organ to protect its blood supply

10. Do not mobilize the ureteric segment from the renal pelvis to the lower renal pole

11. Divide the ureter close to the urinary bladder

12. Remove en bloc both kidneys. Include the posterior lamina of Gerota’s fascia by separating it from the transversalis fascia

Left Side


1. As on the right side, mobilize and reflect medially the left colon (distal transverse, splenic flexure, descending, and sigmoid) and mesocolon

2. Be careful of the inferior mesenteric vein

3. Be careful with the mobilization of the spleen and the pancreatic tail. Good knowledge of the splenic ligaments is essential

4. Remember that the peritoneum is adherent to the ureter

5. Expose the left crus of the diaphragm for good visualization of the aorta and its branches, such as the inferior phrenic artery (which is superior to the crus) and the first and second lumbar arteries arising from the posterior wall of the abdominal aorta

6. Preserve the periureteric tissue as on the right and divide the ureter close to the urinary bladder

Laparoscopic Nephrectomy

Laparoscopic nephrectomy is a recent innovative approach in which the kidney can be removed by maceration or laparoscopic-assisted technique. For information on the topic, readers are referred to articles by Clayman et al.,59 McDougall et al.,60 Doehn et al.,61 Sasaki et al.,62 Shalhav et al.,63 Yao and Poppas,64 and Fabrizio et al.65

Anatomic Complications of Renal Surgery

Anatomic complications of renal surgery include the following:


Diaphragmatic injury

Pneumothorax secondary to diaphragmatic, pleural, and lower lobe lung injuries

Bleeding secondary to adrenal injury

Bleeding secondary to splenic injury

Pancreatitis and bleeding secondary to pancreatic injury

Bleeding and bile leak secondary to hepatic injury

Peritonitis secondary to duodenal injury

Peritonitis secondary to colonic injury

Adrenal insufficiency (bilateral surgery)

Diaphragmatic Injury

Diaphragmatic injury with or without pleural involvement is an extremely rare phenomenon. The injury occurs because occasionally the posterior lamina of the Gerota’s fascia is heavily fixed to the diaphragm. A tear of the diaphragm can take place when tension is applied to the fascia. It is necessary to repair the tear with interrupted, nonabsorbable 0 sutures to avoid the possibility of later occurrence of an iatrogenic diaphragmatic hernia.

Pneumothorax Secondary to Diaphragmatic, Pleural, and

Lower Lobe Lung Injuries


Any flank incision, with or without rib resection, can produce pneumothorax.

The relation of the 12th rib to the transverse (horizontal) orientation of the pleural reflection should always be kept in mind.

If the opened pleura is recognized in the operating room, it should be closed, using 3-0 absorbable sutures.

A Robinson catheter with underwater seal should be used if it is necessary and if previous air aspiration is not satisfactory. Alternatively a chest tube can be placed.

Bleeding Secondary to Adrenal Injury

Prevention of this very common injury is imperative. The adrenal gland is a very friable organ with very rich vascularization. Venous bleeding is the result of injury of the adrenal parenchyma or its draining veins, especially the right one (which is very short, emptying directly into the inferior vena cava). In the event of a caval tear due to adrenal vein avulsion, use 5-0 vascular continuous suture for closing the defect produced at the wall of the inferior vena cava. For injuries of the parenchyma, continuous absorbable sutures can be used or, if the other adrenal is in situ, partial adrenalectomy or total adrenalectomy can be considered.

Bleeding Secondary to Splenic Injury

Splenic injuries can be prevented by careful mobilization of the spleen and good knowledge of the splenic ligaments. Be conservative and try to save the spleen, thus avoiding postsplenectomy infections. Even with severe lacerations try to avoid splenectomy, if possible, by performing a partial segmental splenectomy, as well as by using surgical Avitene (see the chapter on the spleen).

Pancreatitis and Bleeding Secondary to Pancreatic Injury

Pancreatic injuries can result in bleeding or pancreatitis. Most often they occur during left kidney surgery by elevation of the tail and distal body of the pancreas. The Kocher maneuver for mobilization of the duodenum and the head of the pancreas can produce pancreatic injury, but this is rare.

If pancreatic injury is suspected, the use of a Jackson-Pratt suction drain is essential, with follow-up of serum amylase and perhaps radiologic imaging. If a pancreatic laceration is recognized in the operating room, close the pancreatic parenchyma using 4-0 nonabsorbable sutures and a Jackson-Pratt (J-P) drain.

Bleeding from the pancreas can be controlled by gently applying mosquito clamps and 5-0 nonabsorbable suture ligatures. Rest the GI tract by eliminating food by mouth, perhaps using parenteral hyperalimentation. The pancreatic leak will heal spontaneously.

Somatostatin may be useful.

Bleeding and Bile Leak Secondary to Hepatic Injury

Prevent liver lacerations by being gentle and careful. Lacerations, whether superficial or deep, should be repaired using 3-0 absorbable interrupted sutures. With deep lacerations, we favor the J-P drain. Severe bleeding should be treated by ligation of the corresponding vessels (right or left hepatic artery, portal vein, or hepatic vein) and hepatic ducts (right and left). Injury to the common hepatic duct and common bile duct is rare.

Peritonitis Secondary to Duodenal Injury

Close the laceration in two layers, using 4-0 nonabsorbable suture. Cover with a piece of omentum. If the laceration is long and closure is not satisfactory, duodenostomy will be very helpful, using a T-tube or Foley catheter. It may be possible to control duodenal hematoma by pressure; occasionally the hematoma should be opened and the bleeding vessel isolated and ligated.

If a perforated viscus is diagnosed after the patient leaves the operating room, exploratory laparotomy should be done immediately for correction.

Peritonitis Secondary to Colonic Injury

Repair the injured colon in two layers with nonabsorbable 4-0 sutures. Injuries and openings of the mesentery should be repaired to avoid internal herniation. Recognition of mesenteric arterial or venous damage without obvious bleeding is the most difficult part. We like to observe these lesions for 10 minutes and act accordingly. The surgeon must evaluate whether reoperation, partial colectomy, or perhaps exteriorization is required.

Acute Adrenal Insufficiency (Bilateral Surgery)

Acute adrenal insufficiency or acute addisonian crisis may occur among adult surgical patients in three situations: while taking chronic preoperative exogenous corticosteroids; development of bilateral adrenal hemorrhage while taking anticoagulants; and following surgical removal of all functioning adrenal glandular tissue. Chronic adrenal insufficiency is characterized by hypoglycemia, hyponatremia, hyperkalemia, hypotension, hyperpigmentation, fatigue and weakness, nausea and vomiting, and abdominal pain. Acute addisonian crisis is characterized by hypotension and fever and, if not promptly treated by corticosteroids, will result in death.

Complications of Renal Transplantation

We quote Brown et al.66:

The most frequent complications of renal transplantation include perinephric fluid collections; decreased renal function; and abnormalities of the vasculature, collecting system, and renal parenchyma. Perinephric fluid collections are common following transplantation, and their clinical significance depends on the type, location, size, and growth of the fluid collection, features that are well-evaluated with US (ultrasound). Causes of diminished renal function include acute tubular necrosis, rejection, and toxicity from medications. Radionuclide imaging is the most useful modality for assessing renal function. Vascular complications of transplantation include occlusion or stenosis of the arterial or venous supply, arteriovenous fistulas, and pseudoaneurysms. Although the standard for evaluating these vascular complications is angiography, US is an excellent noninvasive method for screening. Other transplant complications such as abnormalities of the collecting system and renal parenchyma are well-evaluated with both radionuclide imaging and US.


Surgical Anatomy of the Ureters

The right and left ureters are retroperitoneal muscular tubes which have a length of 25 to 34 cm; their upper half is abdominal and their lower half is pelvic.

Abdominal Course

Each ureter starts at the renal pelvis close to the hilum, posterior to the renal vessels. It is surrounded by the perirenal fat. On its downward pathway, it is related to the tips of the transverse processes of the lumbar vertebrae and to the psoas major muscle (Fig. 23-48). The ureter crosses over the genitofemoral nerve, passes under the gonadal vessels, and crosses the common iliac artery or the external iliac artery.

Fig. 23-48.

Ureteric course in the abdomen. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 12.43).

Observations on the abdominal course of the ureter:


The right ureter is covered by the second portion of the duodenum

The left ureter is adherent to the mesocolon

The left ureter is very close to the inferior mesenteric artery, passing under it

The abdominal part of the ureter is fused to the peritoneum

The abdominal course of the ureter is the same in male and female

The anatomic landmark of the left ureter is the intersigmoid fossa (Fig. 23-49). The ureter passes behind the fossa and therefore behind the sigmoid colon at the apex of the capital Greek lambda ()

Fig. 23-49.

The intersigmoid fossa lies in the apex of the § (capital Greek lambda) attachment of the pelvic mesocolon. The ureter is shown passing behind the fossa. (Modified from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol UK: Wright, 1986; with permission.)

Pelvic Course

The pelvic course begins after the ureter has passed anterior to the internal iliac artery and its anterior division. The pelvic ureter is not related to the peritoneum because it leaves the lateral pelvic wall at the level of the ischial spine. It follows a medial path toward the urinary bladder, at the base of and posterior to the broad ligament. In this area the ureter crosses over the uterine artery 1 cm, or perhaps slightly more, from the uterine cervix.

Observations on the pelvic course of the ureter:

In both male and female:


The ureter is crossed anteriorly by the obliterated umbilical artery

On the left, the ureter is located behind the sigmoid arteries

Remember that the upper abdominal ureter should be mobilized laterally and the pelvic ureter medially during ureteric mobilization. At the middle segment, dissection of the periureteric tissue should be avoided

In the male


The ductus deferens crosses the ureter anteriorly (Fig. 23-50)

The ureter enters the bladder just above the apex of the seminal vesicle (Fig. 23-51)

Fig. 23-50.

The ductus passes anterior to the ureter to gain its medial side. (Modified from Decker GAG, Du Plessis DJ. Lee McGregor’s Synopsis of Surgical Anatomy (12th ed). Bristol UK: Wright, 1986; with permission.)

Fig. 23-51.

Pelvic relations of the ureter in the male. A. Oblique view. B. Coronal view. C. Lateral view. (After Hinman F Jr. Atlas of Urosurgical Anatomy. Philadelphia: WB Saunders, 1993; Fig. 12.44A,B,C).

In the female


The uterine artery crosses the ureter anteriorly about 1-4 cm lateral to the cervix

Before entering the urinary bladder, the ureter passes 1 cm above the lateral fornix of the vagina close to its anterior wall and about 1-4 cm lateral to the cervix (Fig. 23-52)

The pelvic ureter is very vulnerable anterior to the bifurcation of the common iliac artery

The pelvic ureter crosses the ovarian vessels and nerves posteriorly

Fig. 23-52.

Normal anatomy of the ureters and their relations to other pelvic organs encountered in gynecologic surgery. UT, uterus. (Modified from Wharton LR Jr. Surgery of benign adnexal disease: Endometriosis, residuals of inflammatory and granulomatous diseases, and ureteral injury. In: Ridley JH. Gynecologic Surgery: Errors, Safeguards, and Salvage (2nd ed). Baltimore: Williams & Wilkins, 1981; with permission.)

Barksdale et al.68 reported the position of the ureter in the female pelvis relative to several anatomic landmarks (Fig. 23-53). The mean distances are displayed in Table 23-5. The vertical distances were measured from the ureter to the pelvic floor at three points: at the levels of the ischial spine, the obturator canal, and the insertion of the arcus tendineus, obturator internus, or arcus tendineus levator ani in the pubic bone. Vertical measurements were taken also from the arcus tendineus to the pelvic floor at the levels of the ischial spine, the obturator canal, and from the point of insertion of the arcus to the pelvic floor.

Table 23-5. Mean Distances from the Ureter and from the Arcus Tendineus to the Pelvic Floor

  Ureter to Pelvic Floor Arcus Tendineus to Pelvic Floor
Ischial spine 3.2 ± 0.1 cm 1.9 ± 0.1 cm
Obturator canal 3.2 ± 0.1 cm 2.8 ± 0.1 cm
Insertion of arcus tendineus on pubic bone 1.6 ± 0.1 cm 3.2 ± 0.1 cm

Source: Adapted from Barksdale PA, Brody SP, Garely AD, Elkins TE, Nolan TE, and Gasser RF. Surgical landmarks of the ureter in the cadaveric female pelvis. Clin Anat 1997;10:324-327; with permission.

Fig. 23-53.

Anatomic references to the ureter in relationship to other landmarks. AT, arcus tendineus. B, bladder. C, coccygeus muscle. Cx, coccyx. IA, pubic insertion of arcus tendineus. IC, iliococcygeus muscle. IS, ischial spine. OC, obturator canal. OI, obturator internus muscle. P, piriformis muscle. PC, pubococcygeus muscle. PS, pubic symphysis. R, rectum. SP, sacral promontory. V, vagina. U, ureter. *, location of measurement from ureter to base of pelvic cavity in a vertical plane. **, location of measurement from arcus tendineus to base of pelvic cavity in a vertical plane. (Modified from Barksdale PA, Brody SP, Garely AD, Elkins TE, Nolan TE, Gasser RF. Surgical landmarks of the ureter in the cadaveric female pelvis. Clin Anat 10:324-327, 1997; with permission.)

The anatomic topographic ureteric pathway from above downward is as follows.


The ureter rests anterior to the psoas muscle and is located lateral to the tip of the transverse processes of the lumbar vertebrae.

It passes behind the gonadal vessels.

The ureter crosses anterior to the common iliac vessels at the pelvic brim.

The right ureter passes behind the:


– duodenum

– ascending colon and its mesentery

– cecum

– appendix

– terminal ileum

The left ureter is behind the descending colon and the sigmoid colon and its mesentery.

In the pelvis the ureter is related to different anatomic entities depending on the person’s sex.


– In the male pelvis the ureter is posterior to the ductus deferens and just proximal to the ureterovesical junction. It enters the wall of the bladder obliquely.

– In the female pelvis the ureter is located anterior to the internal iliac artery, and posterior to the ovary, under the broad ligament just behind the uterine vessels; it obliquely enters the wall of the bladder. (The phrase “water under the bridge,” which represents the ureter passing beneath the uterine artery, is a helpful way to remember the relationship of these structures, and particularly important for avoiding ureteric injury in gynecologic surgery.)

Characteristic Narrowings of the Ureters

Narrowing of the ureter occurs


At the ureteropelvic junction

At the pelvic brim (iliac vessels)

At the intravesical course (ureterovesical junction)

When both ureters approach the urinary bladder they are approximately 5 cm apart. Their openings within the full bladder are also approximately 5 cm apart, but in an empty bladder the openings are only 2.5 cm apart.

According to Anson and McVay,69 the intravesical course of the ureter measures about 0.5-1 cm with a diameter of 3-4 mm. It is the most contracted part of the ureter and a stone may be lodged at this point (Fig. 23-54). On vaginal examination this part of the ureter can be palpated, according to Ellis.70

Fig. 23-54.

The ureter, demonstrating variations in caliber including three anatomic narrowings — at the ureteropelvic junction, the iliac vessels (pelvic brim), and the ureterovesical junction (the intravesical course). Note also the anterior displacement of the ureter, which occurs over the iliac vessels, shown here diagrammatically. F, French calibration scale. (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

Ureteric Wall

The wall of the ureter is formed by five layers (Fig. 23-55):


Retroperitoneal connective tissue sheath


Muscular coat

Lamina propria


Fig. 23-55.

The ureteric wall.

The retroperitoneal connective tissue (ureteric) sheath is a very thin layer of connective tissue fixed to the posterior surface of the peritoneum.

The adventitia is formed by collagenous fibers. It is the home of the periureteric arterial plexus, in addition to fine, unmyelinated nerves. The adventitia is loosely attached to the muscularis.



During ureteric mobilization, the adventitia as well as the ureteric vessels should be protected and preserved.

The ideal procedure produces a watertight, tension-free, mucosa-to-mucosa anastomosis.

Pathology dictates whether long or short segmental mobilization of the ureter is required.

The muscular coat is formed by three longitudinal layers: inner, middle, and outer. Smooth muscle cells are seen throughout, but there is more accumulation in the middle portion. The upper ureteric portion (the abdominal ureter) has a thin muscular network. The lower ureteric portion (the lower pelvic or juxtavesical ureter) has two layers of smooth muscle: an outer circular layer and an inner longitudinal layer. We suggest that the surgeon in the operating room consider this muscular layer not as three separate layers, but as a single layer.

The lamina propria acts as a submucosa (thin layer of fibrous tissue).

Mucosa is formed by transitional epithelium.

Vascular Supply of the Ureters


The blood supply of the ureters is peculiar: it is both rich and poor. The overall supply is excellent, with a rich anastomotic network in the ureteric adventitia. But the blood supply in the middle segment (between the lower renal pole and the pelvic brim) is poor in comparison to that of the proximal and distal segments (Fig. 23-56).

Fig. 23-56.

Blood supply of the ureter. The origin of the various vessels is indicated, but tiny twigs from the peritoneum are not shown. (Modified from Hollinshead WH. Anatomy for Surgeons. New York: Hoeber, 1956; with permission.)

The arteries that are more commonly observed providing arterial supply to the ureter include the renal artery, the gonadal artery, and the common iliac and internal iliac arteries. However, vessels other than these usually contribute to the blood supply of the ureter from the renal pelvis to the urinary bladder (Fig. 23-57). These additional vessels include:


Capsular arteries

Adrenal arteries

Aortic branches

Umbilical artery

Superior vesical artery

Inferior vesical artery

Uterine artery

Middle rectal artery

Fig. 23-57.

Ureteric arteries (schematic). Sources of supply indicated, with percentage of vessels from each of the important contributory vessels, in 50 specimens. The combined percentages cover 88 percent of the vessels (remaining 12 percent include vessels derived from the capsular, suprarenal, uterine, and urethral arteries). (Data from McCormack LJ, Anson BJ. Arterial supply of ureter. Quart Bull Northwestern Univ Med School 1950;24:291-294.)

In relation to its blood supply, the ureter can be divided into three parts: upper, middle, and lower:


The upper part (from the renal pelvis to the lower pole) receives blood from the adrenal, capsular, renal, and gonadal arteries. The renal artery is the most important artery of this segment.

The middle part (from the lower pole to the pelvic brim) receives branches of the gonadal artery, the aorta, and the common iliac artery.

The lower part (from the pelvic brim to the urinary bladder) receives branches of the internal iliac (hypogastric), superior, and inferior vesical arteries.

According to Redman,71 the richest arterial supply is to the pelvic ureter. The poorest arterial supply is to the abdominal portion; that is, from the lower pole of the kidney to the brim of the pelvis. In this area, the aorta and the common iliac give off only a few segmentally arranged lumbar rami. Therefore, mobilize laterally; leave the medial aspect intact if possible.

The rich anastomotic network of the ureter is formed by the “long arteries.” These originate above from the renal artery and other arteries, sending descending branches, and below from the internal iliac artery and others, sending ascending branches which anastomose somewhere in the middle segment. The meeting place of all these vessels is the adventitia, where all branches intercommunicate.

The anastomoses of these vessels are so rich that ischemia is a rare phenomenon; the literature supports this. However, it is our opinion that in spite of the excellence of the ureteric blood supply, extensive mobilization should be resolutely avoided. It is best to clip or ligate ureteric bleeders rather than to cauterize them. Devascularization can undoubtedly produce ischemia, necrosis, urinary fistula, or stenosis with secondary ureteric obstruction.

Basing their findings on dissection of 100 ureters, Daniel and Shackman72 reported the following:


Only two ureters did not receive blood from the renal and vesical or uterine arteries, but received three arteries in the middle part arising from the aorta, internal spermatic, common, and internal iliacs.

Ten received only peritoneal twigs, reaching them between the upper and lower ends.

The blood supply of the middle ureteric portion consisted of a single artery in 64 of 88 cases, two arteries in 20 cases, and three arteries in 4 cases.

Daniel and Shackman72 speculated that in perhaps 10 to 15 percent of cases, necrosis may occur if ureteric division takes place below the anastomosis between adjacent vessels. They advised division of the ureter 2 cm below a visible vessel or 2 cm below the common iliac arteries. They also recommended that skeletonization of the middle part should not exceed 2.5 cm.

Hinman57 reported that division of any or all except the most proximal of the multiple arteries that anastomose along the length of the ureter does not produce ureteric ischemia. He also stated that separation of the ureter from the peritoneum by division of the arterial twigs may compromise ureteric blood supply, especially in the lower ureter. Hinman wrote that the vascular network permits division of the ureter, but interference with the arterial plexus jeopardizes the viability of the ureteric end. Other workers emphasize that the most practical suggestion is to disturb as little as possible the adventitia surrounding the ureter, because this provides great protection for the collateral vascular supply.


The veins of the ureter originate in the submucosa (lamina propria) and spread out in the adventitia. In the upper part of the ureter they drain into the renal vein or the gonadal vein. At the lower end the ureteric veins drain into the venous network of the broad ligament and can produce varicosities.


According to Kabalin,41 the lymphatics of the ureter follow the pathways of the arterial and venous networks. However, there are different drainage pathways for the various segments:


The lymphatics of the upper ureter and renal pelvis drain to the ipsilateral renal lymphatics

The lymphatics of the abdominal ureter differ by side


– Right: Drains to right paracaval and interaortocaval nodes

– Left: Drains to left paraaortic nodes

The lower (pelvic) ureter drains to the common iliac and the internal and external iliac nodes

Ureteric tumors can be benign or malignant, primary or metastatic. The lymphatic pathway of metastatic disease of the ureter is shown in Fig. 23-58. The treatment for benign tumors is local excision; however, because these tumors are potentially malignant some authors advise radical treatment as in malignant tumors. Ureteroscopy allows the surgeon to obtain a tissue diagnosis preoperatively and, if the specimen is diagnosed as benign, the lesion can be excised endoscopically. The treatment for malignant tumors is total nephroureterectomy, including a cuff of the urinary bladder.

Fig. 23-58.

The lymphatics of the ureter.


The ureter has three sources of nerve supply: superior, middle, and inferior. The superior supply originates from the renal and aortic plexuses; the middle originates from the superior hypogastric plexus; and the inferior originates from the pelvic plexus. The patterns of referred somatic pain from the proximal ureter are shown in Fig. 23-59. Pain fibers from the ureter are often carried principally to the level of spinal nerve L2. Thus, a cremasteric reflex may occur by way of referral of pain to the genitofemoral nerve (L1, L2), which supplies the cremasteric muscle.

Fig. 23-59.

Patterns of referred somatic pain from the upper urinary tract. (Modified from Kabalin JN. Surgical anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s Urology (7th ed). Philadelphia: WB Saunders, 1998; with permission.)

According to Lapides,73 ureteric contractions do not need any autonomic nerve stimulus. Pacemaking cells in the renal pelvis are apparently responsible for the peristaltic waves of ureteric contraction. As a matter of fact, autonomic ganglion cells are not clearly apparent, except near the very terminal part of the ureter.



The ureteric wall does not have autonomic ganglia.

The nervous system does not activate ureteric peristalsis; ureteric peristalsis is stimulated by urine stretching the ureteric muscular coat.

Pain from a dilated ureter is distributed to the flank, inguinal area, and scrotum, all of which are supplied by T11, T12, L1, L2 nerves. The pain is carried upward by way of thoracic and lumbar splanchnic nerves, which also carry the sympathetic nerve supply transmitted by the autonomic nervous system.

The action of parasympathetic fibers is enigmatic.

Hinman57 believes that the severe pain secondary to renal pelvic distention is not associated with ureteric spasm, but results from the distention itself.

Histology and Physiology of Ureters

The histology of the ureters has been covered previously under the heading “Ureteric Wall.”

The ureteric wall of smooth muscle, innervated by the autonomic system and its intramural plexus of neurons and nerves, is perhaps responsible for a peristaltic contraction that forces the urine downward to the urinary bladder. During micturition, backflow of urine from the bladder to the ureters is prevented by pressure of the bladder wall on the ureteric walls where they have penetrated the bladder obliquely.

Wemyss-Holden et al.74 found that each ureter produces three contractions every minute; during diuresis the frequency increases.

Ureterorenal reflex is a decrease in urinary output from a kidney in response to pain or blockage of the ureter, most commonly by a stone. Severe pain may accompany the obstruction.

Surgery of the Ureter

From a surgicoanatomic standpoint the ureter may be divided into three parts: upper, middle, and lower. The upper segment is from the ureteropelvic junction to the area of the upper sacrum; the middle part is at the sacral area; and the lower segment travels through the pelvis.

The approach for each third is different. The incision should be located such that the pathologically-involved segment has excellent exposure.

Some anatomy books divide the ureter into only two parts: upper abdominal and lower pelvic. Both of these segments are divided by the iliac vessels.

Surgical Approaches

Upper Ureteric Segment

The upper ureteric segment including the ureteropelvic junction may be approached with a flank or dorsal lumbar incision.

Middle Ureteric Segment

A transperitoneal approach through a midline or paramedian incision will expose not only the middle segment but also the upper and lower segments. An extraperitoneal approach with the so-called Gibson incision gives excellent exposure to the middle segment.

This incision begins 2-3 cm medial to the anterior superior iliac spine and 2-3 cm above the inguinal ligament. It ends 2-3 cm above the pubic tubercle. The three flat muscles are incised parallel to their fibers. To expose the retroperitoneal space the transversalis fascia is opened and the peritoneum is pushed medially. This incision may be extended upward or medially if necessary.

Lower Ureteric Segment

The lower ureteric segment may be exposed with several incisions including the:


Lower anterior midline

Gibson incision

Pfannenstiel incision

The transverse Pfannenstiel incision is made horizontally just above the pubis. The anterior rectus sheaths and the linea alba are transected and reflected upward 8 to 10 cm. The rectus muscles are retracted laterally, and the transversalis fascia and the peritoneum may be cut in the midline. The iliohypogastric nerve must be identified and protected (Fig. 23-60).

Fig. 23-60.

Pfannenstiel transverse abdominal incision showing the iliohypogastric nerve between the internal oblique muscle and the external oblique aponeurosis just lateral to the border of the rectus muscle. (Modified from Grosz CR. Iliohypogastric nerve injury. Am J Surg 1981; 142:628; with permission.)

The Pfannenstiel incision may be extended in the midline or laterally by dividing the tendinous attachment of the rectus muscle to the pubis. Lateral extension also may be attained by leaving the rectus muscle attached, but retracting it medially and splitting the muscles of the anterolateral wall. This usually requires ligation of the inferior epigastric vessels. Extension too far laterally may jeopardize the iliohypogastric and ilioinguinal nerves (Fig. 23-61).

Fig. 23-61.

The courses of the iliohypogastric and ilioinguinal nerves. Transverse incisions carried too far laterally may cut (X) the iliohypogastric nerve. Inguinal incisions may injure the ilioinguinal nerve directly or it may be inadvertently included in a suture during closure of the incision. (Modified from Skandalakis JE, Gray SW, Rowe JS. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Ureteric Reconstruction

Franke and Smith75 reported that the type of ureteric reconstruction selected is based on the length of the ureteric defects and the ureteric pathology (Table 23-6).

Table 23-6. Categorization of the Usual Length of Ureteral Defect That Can Be Bridged with Various Surgical Techniques for Ureteral Reconstruction

Procedure Ureteral Defect
Ureteroureterostomy 2-3 cm
Ureteroneocystostomy alone 4-5 cm
Ureteroneocystostomy with psoas hitch 6-10 cm
Ureteroneocystostomy with Boari flap 12-15 cm
Renal descensus 5-8 cm

Source: Franke JJ, Smith JA Jr. Surgery of the Ureter. In: Walsh PC, Retik AB, Vaughn ED, Wein AJ. Campbell’s Urology, 7th Ed. Philadelphia: WB Saunders, 1998; with permission.

Endoscopic Surgery of the Ureter

It is not within the scope of this chapter to present endoscopic ureteric surgery. The reader is strongly advised to read “Surgery of the Ureter” by Franke and Smith in Campbell’s Urology.75

Anatomic Complications of Ureteric Surgery

General surgeons, gynecologists, urologists, and vascular surgeons are involved with ureteric injuries during colectomies, hysterectomies, and retroperitoneal and vascular procedures.

The anatomic complications of ureteric injuries include:




Laceration or division




Handle the ureter carefully because the ureteric wall can be molested or violated easily. Bleeding from the ureteric wall can be prevented by careful mobilization. If bleeding occurs, avoid using clamps or ligation, but use pressure with a sponge stick. If bleeding continues, use fine mosquito clamps and ligate carefully, using 6-0 nonabsorbable sutures. Insertion of a ureteric stent by ureterotomy or cystostomy is imperative in this case.

Laceration of the ureter can frequently be easily recognized in the operating room, either by identification of the lumen, or by urine leak, or both. If there is uncertainty as to whether there is a urine leak, indigo carmine will stain the urine. The injury should be repaired. Ligation without laceration is not recognized in the operating room in most cases; this is a postoperative problem. Laceration or division should be repaired in the operating room immediately by ureteroureterostomy using the technique with which the surgeon is familiar (spatulation, oblique anastomosis, right or left transureteroureterostomy with formation of retroperitoneal tunnel, reimplantation of the ureter into the bladder via psoas muscle [hitch, ileal ureter, etc.]) If it proves necessary to form an ileal conduit, the left ureter must be carefully placed so it is not twisted or kinked.

The most logical explanation for ureteric stenosis or late fistula formation is that the ureter was devascularized by stripping the periureteric sheath.

Wharton67 listed the following errors in surgery of the ureter as the most common:


Failure to know the exact position of the ureter at all times during pelvic surgery or placing clamps and sutures without knowing the position of the ureter

Failure to recognize ureteric injury immediately; incorrectly evaluating and repairing injury

Failure to recognize urinary tract injury after operation

Failure to insure adequate drainage for injury to the urinary tract

Failure to perform ureteroureteric or ureterovesical anastomosis without tension on suture lines

Failure to protect kidneys from damage when the ureter is injured

Correcting the urinary tract injury at the wrong time

Selection of the wrong procedure or technique to correct a urinary tract injury

Figs. 23-52 and 23-62 show the most common sites of ureteric injury in gynecologic surgery.

Fig. 23-62.

Most common sites of ureteric injury in gynecologic surgery. (1) Pelvic wall lateral to uterine vessels; (2) Area of ureterovesical junction; (3) Base of infundibulopelvic ligament. (Modified from Wharton LR Jr. Surgery of benign adnexal disease: Endometriosis, residuals of inflammatory and granulomatous diseases, and ureteral injury. In: Ridley JH. Gynecologic Surgery: Errors, Safeguards, and Salvage (2nd ed). Baltimore: Williams & Wilkins, 1981; with permission.)

 Read an Editorial Comment


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