These are direct branches from the aorta to each kidney, and in 30% of cases accessory renal arteries are present. The renal artery divides into three to five segmental arteries at the hilum, which divide within the sinus into six to ten lobar arteries – one for each each pyramid and associated cortex (Fig. 18.2). Each lobar artery divides into six interlobar arteries which are associated with papillae. The interlobar arteries give rise to arcuate arteries which run in a plane between cortex and medulla. The arterial supply to the cortex is derived from interlobular arteries which are branches of the arcuate arteries directed radially towards the kidney capsule, and each of these in turn gives off the afferent arterioles and supply glomeruli. The efferent arterioles that leave the glomeruli supply the capillary bed that surrounds the convoluted tubules. Arteries enter and leave each pyramid at its base and, as they penetrate deeper towards the papilla, they lose water by osmosis and gain ions by diffusion – thereby reaching equilibrium with surrounding extracellular fluid. They then loop back towards the base of the pyramid, lose ions by diffusion and gain water by osmosis until they reach normal osmolarity at the base of the pyramid. These medullary vessels lie in bundles named vasa recta and are fed on the arterial side by efferent arterioles with adjacent glomeruli lying near the corticomedullary junction.

Fig. 18.2 The arterial supply of the kidney and the vascular segments. anterior view. posterior view.

Source: Rogers op. cit.

The renal veins

These follow the arterial pattern closely. In the sinus of the kidney, interlobar veins unite into lobar veins then into segmental veins which join together to form the renal vein at the hilum of the kidney. The renal veins empty directly into the vena cava. Since the vena cava lies on the right side of the abdomen, the left renal vein is longer than the right and usually passes anterior to the aorta just caudal to the origin of the superior mesenteric artery. The left renal vein receives tributaries from the adrenal gland and gonad before entering the IVC. On the right side the adrenal vein usually drains directly into the IVC.

Each kidney lies within a cushioning bed of fat and tissue. The kidney itself is surrounded by renal fascia. There is a layer of perirenal fat which lies between the renal fascia and the true capsule of the kidney, which is continuous at the hilum with the fat and the renal sinus. In addition there is a layer of perirenal fat lying outside of the perirenal fascia (Gerota’s fascia) which is particularly obvious posterior to the kidney (Fig. 18.3).

Fig. 18.3 Cross-section of the posterior part of the abdomen, showing the coverings of the kidney.

Source: Rogers op. cit.

The adrenal glands lie within a separate compartment of the renal fascia. The surface markings of the kidney are shown in Fig. 18.4. The hilum of both kidneys lie roughly at the level of L1 (the transpyloric plane).

Fig. 18.4 The surface markings of the kidney. anterior view. posterior view.

Source: Rogers op. cit.

In surgical practice it is very important to be aware of the anterior and posterior relationships of the kidneys – particularly in situations where normal tissue planes between the kidney and its adjacent structures are disordered due to either malignant or inflammatory disease processes, where it is important to be aware of which structures need to be mobilised (Figs. 18.5 and 18.6). The relationship of the kidneys to surface markings is also important in planning the surgical approach to the patient during any procedure.

Fig. 18.5 The posterior relations of the kidney. anterior view. posterior view. areas marked on the posterior surfaces of the kidneys

Source: Rogers op. cit.

Fig. 18.6 The anterior surfaces of the kidneys, and their relations.

Source: Rogers op. cit.

URETER

The ureters convey urine from the kidneys to the bladder. Each is 25–30 cm long and approximately 3 mm in diameter.

The ureter is a hollow muscular tube which commences at the renal pelvis and terminates at its entry into the bladder.

The wall of the ureter is composed of smooth muscle with a rich innervation comprising both sympathetic and parasympathetic fibres. The sympathetic fibres arise from spinal segments T11–L1 and the parasympathetic fibres from sacral segments S2–S4. Most of the nerves to the ureters are sensory. Stretching the wall, for instance with the passage of a ureteric calculus, produces acute pain. In view of the segmental innervation of the ureter this pain is usually referred to T11–L1. In addition the pain may radiate down the front of the thigh to the area supplied by L2. The ureter is lined by transitional epithelium continuous with that of the renal pelvis and calyces. The transitional cell lining of the urinary tract deserves some comment because this is a highly specialised epithelial layer designed to prevent diffusion of urine and other solids out of the urine and conversely passage of water into the urine by osmosis. Despite this it must be borne in mind that the urothelium is not purely an inert barrier, and there are a number of active transport mechanisms which are present, particularly within the urothelium of the bladder, which facilitate the passage of many substances, including drugs, through the urothelial lining and hence into surrounding tissues and ultimately the blood stream.

The entire ureter acts as a functional complex responsible for the transport of urine from the renal pelvis to the bladder. Whilst the mechanism is still a matter of some debate, it is very clear that there are one or more pacemakers situated in the renal pelvis which produce antegrade impulses which result in the propagation of a peristaltic wave down the ureter to the bladder. It has been estimated that a few drops of urine are transported down each ureter in peristaltic boluses approximately three to five times per minute. Each of these boluses of urine represents a high pressure localised segment which propagates rapidly down the ureter and which relies upon coaptation of the ureteric wall both proximal and distal to the ‘bolus’. Any disruption of the normal ability of the ureter to form such ‘boluses’ results in severe pain and ureteric dysfunction as seen in the context of a diuretic challenge to a patient with pelviureteric junction obstruction and also commonly in a patient with a ureteric calculus undergoing an intra-venous urogram (IVU), which may precipitate a further bout of renal colic.

In order to achieve its functional role the ureter must have a thick muscular coat, and indeed in its upper two-thirds it has an inner longitudinal and outer circular smooth muscle coat. In the distal third of the ureter, as it passes across the bony pelvis, the ureter acquires a third coat of longitudinal muscle which surrounds the other two. In its intramural portion, as it passes through into the bladder, the circular coat is lost but the remaining longitudinal muscle has an embryological relationship to the trigone of the bladder. The exact mechanism of action of the smooth muscle surrounding the ureter in its intramural portion remains the subject of some debate; it has been suggested that it has a sphincteric function to occlude the ureter at the time of detrusor muscle contraction to prevent vesico-ureteric reflux. A more important component of the sphincteric role of the lower ureter is likely to be its oblique position as it passes through the wall of the bladder, which results in the intramural portion of the ureter being closed off at the time of any rise in intravesical pressure to help prevent reflux – this remains the mainstay of most surgical procedures designed to correct vesico-ureteric reflux.

The ureters on either side run down the posterior abdominal wall overlying the transverse processes of L2–L5 before crossing the pelvic brim overlying the bifurcation of the iliac vessels and running along the pelvic wall to the level of the ischial spine before turning medially and slightly upwards to enter the bladder at the level of the trigone.

The ureter can be considered to comprise three parts: (a) the pelvic ureter, (b) the abdominal part and (c) the part within the bony pelvis. The ureter receives a segmental innervation from both parasympathetic and sympathetic nerves. It is likely that the majority of the innervation is sensory in nature in view of the intrinsic peristaltic properties of the ureter. Each ureter receives a segmental blood supply from the following arteries:

• renal artery;

• lateral branches directly off the abdominal aorta;

• the gonadal vessels;

• the common iliac arteries; and

• internal iliac arteries via the inferior vesical artery.

The venous drainage is by veins following similar lines to these arteries, and there is lymphatic drainage to periaortic and internal iliac groups of lymph nodes. There is a narrow area in each of the three segments of the ureter namely:

• at the pelviureteric junction;

• at the junction of the abdominal part and the part of the ureter passing into the pelvis as it crosses the bony pelvis/iliac vessels; and

• as it passes through the wall of the bladder (the intramural portion).

It is at these levels that a renal calculus is likely to become arrested on its descent into the bladder. Congenital abnormalities relating to the function of the muscle at the pelviureteric junction result in the condition known as pelviureteric junction obstruction, producing a functional outflow obstruction, which may require surgical resolution.

Surgical injuries to the ureter are most common in its lower third, owing to the close proximity of the ureter to the blood supply of the uterus, where the ureter is easily damaged during hysterectomy. It is important to appreciate the relations of the ureters and in particular the close proximity of the ureter to the gonadal vessels (Fig. 18.7), particularly the gonadal vein and its lower abdominal course through the bony pelvis, since in this area it is not unknown for the gonadal vein to be mistaken for the ureter and indeed mobilised instead of the ureter! The anterior relations of the ureter are easily dealt with in the majority of circumstances, providing its retroperitoneal position is borne in mind (Fig. 18.8).

Fig. 18.7 The course and posterior relations of the ureters.

Source: Rogers op. cit.

Fig. 18.8 The anterior relations of the ureters. Only the structures on the posterior abdominal wall are shown.

Source: Rogers op. cit.

BLADDER

Embryology

See Chapter 16.

Macroscopic anatomy and innervation

The bladder is a distensible reservoir with muscular walls. It lies in the true pelvis posterior to the symphysis pubis. The bladder does not rise above the pubis until it is very full, and when fully distended the adult bladder projects upwards from the pelvic cavity into the abdomen, lifting the peritoneum upwards from the abdominal wall as it distends.

The relations of the bladder are as follows:

• anteriorly – the pubic symphysis;

• superiorly – the bladder is covered by peritoneum with coils of small intestine and the sigmoid colon resting on it. The relationship between the sigmoid colon and bladder is important in diverticular disease when a colovesical fistula may arise. In the female, the body of the uterus lies superior to the bladder;

• posteriorly – in the male, the rectum and the seminal vesicles; in the female the vagina and supravaginal part of the cervix; and

• laterally – the bladder is separated from the levator ani and obturator internus muscles by loose connective tissue.

The relationship of the bladder to adjacent structures in both the male and female is best appreciated on a sagittal view (Fig. 18.9).

Fig. 18.9 the male pelvis in sagittal section. the female pelvis in sagittal section.

Source: Rogers op. cit.

The bladder is a remarkable organ. As with the rest of the urinary tract it is lined by urothelium which acts as a watertight layer which nevertheless retains the ability to allow the active transport of a number of substances across its wall. The bladder should be considered to comprise two distinct functional and anatomical components. One is the trigone, which is triangular in structure and receives the two ureters at its uppermost lateral angles (Waldeyer’s sheath) and extends down to its apex at the internal urethral meatus, where the smooth muscle of the trigone is contiguous with a ridge of smooth muscle extending down the urethra to the urethral sphincter mechanism. The innervation of the trigone is distinct from that of the remainder of the bladder muscle (detrusor muscle) in that it is predominantly adrenergic (sympathetic nervous system), relying upon the release of the neurotransmitter norepinephrine. The other component is the detrusor muscle, which constitutes the majority of the bladder and forms the cap on the base provided by the trigone. The word detrusor is derived from the term detrudare (= to drive out) and represents a complex admixture of muscle fibres, passing in different directions, which are predominantly under parasympathetic neural control acting via the release of the neurotransmitter acetylcholine acting on muscarinic receptors (the M₃ subtype is functionally predominant).

Despite the great deal of work that has been carried out looking at the innervation of the lower urinary tract, a number of aspects of the innervation of the bladder remain unclear. The extrinsic nerves innervating the bladder are demonstrated in Fig. 18.10. The intrinsic nerves are derived from a perivesical plexus which lies on the connective tissue at the base of the bladder and which receives autonomic fibres from two sources: (a) parasympathetic fibres from segments S2–S4, (b) sympathetic fibres from segments T11–L2. It must be borne in mind that the contemporary textbook view of the innervation of the bladder and of the disposition of the autonomic nervous system is oversimplistic, particularly considering the fact that there are ganglia on both the sympathetic and parasympathetic nerves along their course from the spinal cord to the target organ with other ganglia both around and within the target organ, e.g. bladder, prostate, and that it is likely that there are interconnections between both the parasympathetic and sympathetic nervous systems at all of these levels. Furthermore it is now well recognised that there are a number of other sensory/motor neurotransmitters, additional to the classical neurotransmitters norepinephrine and acetylcholine, which may well be implicated in neural control pathways. There is considerable debate as to the sensory innervation of the bladder although recently the importance of purinergic and nitric oxide pathways has been clearly demonstrated. No sensory end organs have yet been identified in the human bladder, and it is thought that sensory nerves are represented by non-myelinated fibres lying within the submucosa and proprioceptive receptors associated with the peritoneum and the adventitia overlying the detrusor muscle at its dome. There has been suggestion of an intramural plexus of sensorimotor neurones, similar to that seen in the intestine, but this is as yet not fully clarified.

Fig. 18.10 The innervation of the bladder and urethra.

Source: Rogers op. cit.

Blood supply

The arterial supply to the bladder is via the superior and inferior vesical arteries, which are branches of the anterior division of the internal iliac artery. In additionthere is a rich venous plexus around the base of the bladder, draining into the internal iliac veins.

Lymphatic drainage

The lymphatics drain along the vesical vessels to the internal iliac lymph nodes and thence to the para-aortic nodes.

As with the rest of the urinary tract the bladder lies in an extraperitoneal position.

URETHRA AND URETHRAL SPHINCTER MECHANISMS

The urethra develops from the caudal portion of the urogenital sinus and associated Mullerian and Wolffian ducts. Whilst the urethra acts as a conduit for urine from the bladder to the outside world, it must be remembered that the urethra and its associated sphincter mechanisms play a vital role in terms of continence. It must be remembered that the urethra itself is no more than a layer of urothelium lying in a blood-filled arteriovenous sinus, the corpus spongiosum.

The urethra and its sphincter mechanisms act in concert with the bladder for satisfactory voiding to occur; in other words when the bladder contracts the outlet must relax and vice versa during the storage phase. Whilst our level of knowledge relating to the cerebral control of micturition remains rudimentary, it is now recognised that there are important local spinal reflexes involved in micturition, with longer reflex tracts projecting to the pons acting under the influence of higher centres which impose voluntary control on the pons. In addition there is an important motor nucleus in the lower sacral region – the nucleus of Onufrowicz (Onuf’s nucleus) – which is important in the control of urethral sphincter muscle tone and is integral to the synchronisation of detrusor and sphincter function. It is very appropriate to consider the urethral sphincter mechanisms of the male and female separately and to bear in mind the similarities and differences which are present. In addition to the autonomic nervous system the striated urethral sphincter mechanism receives a somatic nerve supply which is both motor and sensory from the pudendal nerve.

Female urethra

The female urethra is approximately 4 cm long. It opens into the anterior wall of the vagina at the urethral meatus, situated in the vestibule between the anterior ends of the labia minora about 2.5 cm behind the clitoris. Like the rest of the urinary tract it is lined by transitional urothelium. There is an area at the internal urethral meatus on the trigone where the lining is comprised of squamous epithelium which appears to be under hormonal control and which changes its character at different phases during the menstrual cycle. In the female the principal sphincter mechanism is the urethral sphincter mechanism which extends down the length of the female urethra. There is an internal component composed of smooth muscle, the so-called lissosphincter, and an extrinsic component composed of striated muscle, the so-called rhabdosphincter. The sphincter is particularly well developed in the middle third of the urethra. In addition to this sphincter the submucosa of the urethra acts by producing a passive occlusive effect during urethral closure. This submucosa is under hormonal control and is very sensitive to changes in oestrogen levels. There is a very poorly developed bladder neck in the female which does not appear to have a significant functional role.

Male urethra

The male urethra (Fig. 18.11) is approximately 20 cm inlength and comprises an anterior and posterior part. The posterior urethra, approximately 6 cm in length, is composed of that area which traverses the prostate, which is approximately 3–4 cm in length, and that which lies within the confines of the distal sphincter mechanism, which is 2 cm in length. At the external border of the distal sphincter mechanism is the junction of the posterior urethra with the anterior urethra. The anterior urethra can be further subdivided into two areas which are divided on the basis of the areas anterior and posterior to the penoscrotal junction.

Fig. 18.11 The posterior wall of the male urethra.

Source: Rogers op. cit.

In the male there are two principal sphincteric mechanisms. The bladder neck mechanism lies at the outlet of the bladder around the internal urethral meatus and is composed principally of circularly oriented fibres, although there is a longitudinal component. This sphincter is sufficiently strong to maintain continence even if the distal sphincter mechanism is destroyed. Its principal role, however, is as a genital sphincter causing rapid closure of the bladder neck at the time of emission of semen into the prostatic urethra. The principal motor control of the bladder neck mechanism appears to be adrenergic via the release of norepinephrine from the sympathetic nerves.

Just distal to the bladder neck mechanism is the prostatic urethra, and it must be remembered that the human prostate comprises a significant smooth musclecomponent. At the apex of the prostate lies the distalsphincter mechanism, which is analogous to the urethralsphincter mechanism of the female and comprises botha lissosphincter and a rhabdosphincter as in the female urethra. Just as for the female sphincter mechanism there is a triple innervation from parasympathetic, sympathetic and somatic nerves (pudendal nerve).

In both the male and female urethra a number of glands open into the posterior urethra and can be the site of infection and source of confusion on occasion at the time of urethrography. There is slight dilatation of the urethra in the bulbar area where the urethra itself is surrounded by the bulbospongiosus muscle. There is a relative constriction of the urethra within the glans penis which helps focus the stream of urine as it comes through the dilatation present at the site of the navicular fossa; this is the narrowest part of the whole urethra.

The lining of the urethra varies in different portions. In the prostatic part it is transitional epithelium; in the membraneous and penile parts, pseudostratified and stratified columnar epithelium occur proximally, but, progressing more distally, islands of stratified squamous epithelium appear until in the distal part and the navicular fossa there is a complete sheet of stratified squamous epithelium.

REPRODUCTIVE SYSTEMS

Female reproductive organs consist of paired ovaries, paired fallopian tubes, a single midline uterus and a single midline vagina. Equivalent to the penis in the female is the clitoris, which is also composed of erectile tissue.

In the male there are paired testes where spermatozoa are produced. A pair of tubes, the vasa deferentia, carry sperm back from the testes into the pelvic cavity and into the urethra. There are paired seminal vesicles which produce materials, including sugars, needed for sperm to mature and which drain into the common termination of the vasa deferentia to form the paired common ejaculatory ducts opening into the prostatic urethra. The prostate gland produces much of the bulk of the semen. The penis is traversed by the urethra. In addition to the corpus spongiosum which surrounds the urethra, it comprises paired corpora cavernosa which represent the erectile tissue. It must be remembered that at the tip of the penis, the glans penis is contiguous with the corpus spongiosum and abuts against the corpus cavernosum (Fig. 18.12). Penile erection is essential to successful intercourse and is mediated by the nervi erigentes arising from the S2–S4 nerve roots. Disorders of both penile and clitoral erection have been increasingly recognised in recent years to be a cause of significant concern within the population, and management of these disorders is an important mainstay of the subspecialty of andrology.

Fig. 18.12 The erectile tissues of the penis.

Source: Rogers op. cit.

MALE AND FEMALE GERM CELLS

Both male and female germ cells present within either the testis or ovary respectively result from meiosis and contain 23 chromosomes. There are significant differences between male and female germ cells in terms of timing of production, the number of germ cells produced and their size and shape.

In the female, cell division (mitosis) in the stem cells that result in germ cells ceases during embryonic life, and all the oogonia start their first meiotic division before birth. They remain in a resting phase until released from the ovary at ovulation, when the second meiotic division occurs rapidly after the ovum is penetrated by sperm. Meiosis can last up to 50 years. In contrast, mitosis in the male spermatogonia continues from puberty to old age and death. Cells are always entering meiosis, passing through the two divisions and maturing into sperm during a process that takes approximately 30 days. In the female, mitosis between oogonia in embryonic life produces a peak population of about six million cells two-thirds of the way through intrauterinal life. There are approximately two million left at birth, which is followed by a dramatic loss of germ cells: by puberty there are only 150 000, and 1,000 are left at the age of 50. In contrast, in the male, large numbers of germ cells persist through life, and in a healthy young man a single ejaculate contains 300 million sperm. The oocyte in the female is one of the largest cells in the body, measuring about 120 μm in diameter. It is spherical with a large active nucleus. In contrast the sperm comprises a head, which is the nucleus, containing tightly packed, condensed genetic material with a small cap. The acrosome and the body contain many mitochondria packed around a central cilium. The sperm relies upon energy reserves in the surrounding semen. It represents a motile cell packed with genetic material.

FEMALE REPRODUCTIVE TRACT

Ovary

The ovary is the size and shape of an almond and is attached to the posterior aspect of the broad ligament by the mesovarium (Fig. 18.13). At the superior (tubal) pole of the ovary is attached a prominent fold of peritoneum, the suspensory ligament of the ovary, which passes upwards over the pelvic brim and external iliac vessels to merge with the peritoneum over psoas major muscle. The ovarian artery gains access to the ovary through the mesovarium and suspensory ligament. A further ligament, the ovarian ligament, runs within the broad ligament to the cornu of the uterus.