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 The adult adrenal glands are 3 to 5 cm

 weigh approximately 5 g
 yellow-orange and
noticeably more orange
than the surrounding
adipose tissue
 both glands are enclosed within the
perirenal (Gerota's) fascia and are
separated from the
upper pole of the kidneys
by a layer of connective tissue
 The RIGHT gland is
pyramidal, directly cranial
to the upper pole of the
right kidney.

 The left gland is more

and medial to the upper
pole of the left kidney.

Left >> lunar :P

 Histologically, divided into two components:
 A- The medulla:
 It is composed of chromaffin cells derived from neural crest origin.
 B-The adrenal cortex:
 is of mesodermal origin and makes up approximately 90% of the
adrenal mass.
 It is composed of three layers, from external to internal:
 1- the zona glomerulosa, producing mineralocorticoids
(e.g., aldosterone).
 2- zona fasciculata, producing glucocorticoids (e.g., cortisol).
 3_ zona reticularis synthesizing sex steroids (androgens).
 The arterial supply to the
adrenal gland originates from
three sources.
 Superiorly, branches from the
inferior phrenic artery feed the
adrenal, while middle branches
originate directly from the
aorta. Finally, branches from
the ipsilateral renal artery
supply the adrenal gland
 Venous drainage : single large vein exits anteromedially:

 Left side joins with the inferior phrenic vein and drains
into the cranial aspect of the left renal vein.

 Right side drains into the IVC directly on its posterolateral


 lymphatic drainage of the adrenals follows the course of

these veins and empties into para-aortic lymph nodes.
 Grossly, the kidneys are bilaterally paired
reddish brown organs .

 weighs 150 g in the male and 135 g in the female.

 measure 10 to 12 cm vertically, 5 to 7 cm
transversely, and 3 cm in the anteroposterior
 The right kidney sits 1 to 2 cm lower than the left
in most individuals owing to displacement by the

 the right kidney resides in the space between the

top of the 1st lumbar vertebra to the bottom of the
3rd lumbar vertebra.

 The left kidney occupies a more superior space

from the body of the 12th thoracic vertebral body
to the 3rd lumbar vertebra.
 Posteriorly, the diaphragm covers the upper third of
each kidney, with the 12th rib crossing at the lower
extent of the diaphragm. Medially the lower two thirds
of the kidney lie against the psoas muscle, and
laterally the quadratus lumborum and aponeurosis of
the transversus abdominis muscle are encountered.

 *First, the lower pole of the kidney lies laterally and

anteriorly relative to the upper pole.
 Second, the medial aspect of each kidney is rotated
anteriorly at an angle of approximately 30 degrees.

 *Both important to note for percutaneous renal

procedures .
 Cranially, the upper pole lies against the liver and is
separated from the liver by the peritoneum except for the
liver's posterior bare spot. The hepatorenal ligament
further attaches the right kidney to the liver because this
extension of parietal peritoneum bridges the upper pole
of the right kidney to the posterior liver.

 At the upper pole, the right adrenal gland is encountered.

 On the medial aspect, the descending duodenum is

intimately related to the medial aspect of the kidney and
hilar structures.

 On the anterior aspect of the lower pole lies the hepatic

flexure of the colon.
 The left kidney is bordered superiorly by the tail of
the pancreas with the splenic vessels adjacent to the
hilum and upper pole of the left kidney.

 cranial to the upper pole is the left adrenal gland and

further superolaterally, the spleen.

 The splenorenal ligament attaches the left kidney to

the spleen.

 Superior to the pancreatic tail, the posterior gastric

wall can overlie the kidney.

 Caudally, the kidney is covered by the splenic flexure

of the colon.
 Interposed between the kidney and its surrounding
structures is the perirenal or Gerota's fascia This
fascial layer encompasses the perirenal fat and kidney
and encloses the kidney on three sides: superiorly,
medially, and laterally.

 Superiorly and laterally Gerota's fascia is closed, but

medially it extends across the midline to fuse with the
contralateral side.

 Inferiorly, Gerota's fascia is not closed and remains an

open potential space. Gerota's fascia serves as an
anatomic barrier to the spread of malignancy as well
as a means of containing perinephric fluid collections.
Thus, perinephric fluid collections can track inferiorly
into the pelvis without violating Gerota's fascia
 The renal papillae are the tip of a
medullary pyramid and constitute the first
gross structure of the renal collecting
system. Typically, there are 7 to 9 papillae
per kidney, but this number is variable,
ranging from 4 to 18.

 Each of these papillae is cupped by a minor

 After cupping an individual papillae, each
minor calyx narrows to an infundibulum.

 Infundibuli combine to form two or three major

calyceal branches.

 These are frequently termed the upper, middle,

and lower pole calyces and these calyces in turn
combine to form the renal pelvis.

 Eventually the pelvis narrows to form the

ureteropelvic junction, marking the beginning
of the ureter.
 The renal pedicle classically consists of a single artery
and a single vein that enter the kidney via the renal
hilum These structures branch from the aorta and
inferior vena cava just below the superior mesenteric
artery at the level of the second lumbar vertebra.
 The vein is anterior to the artery. The renal pelvis and
ureter are located further posterior to these vascular
 Upon approaching the kidney, the renal artery
splits into four or more branches, with five being
the most common. These are the renal segmental
arteries .Each segmental artery supplies a distinct
portion of the kidney with no collateral
circulation between them . Thus, occlusion or
injury to a segmental branch will cause segmental
renal infarction.

 Most constant branch is the posterior segmental

branch, which separates from the renal artery
before it enters the renal hilum.
 Four anterior branches, which from superior to
inferior are apical, upper, middle, and lower.
 Ureteropelvic junction obstruction caused by a
crossing vessel can occur when the posterior
segmental branch passes anterior to the ureter
causing occlusion.
 The 2 million glomeruli within each kidney
represent the core of the renal filtration
process. Each glomerulus is fed by an
afferent arteriole. As blood flows through
the glomerular capillaries, the urinary
filtrate leaves the arterial system and is
collected in the glomerular (Bowman's)
capsule. Blood flow leaves the glomerular
capillary via the efferent arteriole and
continues to one of two locations:
secondary capillary networks around the
urinary tubules in the cortex or descending
into the renal medulla as the vasa recta.
 the venous drainage communicates freely through
venous collars around the infundibula, providing for
extensive collateral circulation in the venous
drainage of the kidney .
 This is important, because unlike the arterial supply,
occlusion of a segmental venous branch has little
effect on venous outflow.
 The renal vein is located directly anterior to the
renal artery.

 The right renal vein is generally 2 to 4 cm in length

and enters the right lateral to posterolateral edge of
the IVC.

 The left renal vein is typically longer around 6 to 10

cm in length and enters the left lateral aspect of the
IVC after passing posterior to the superior
mesenteric artery and anterior to the aorta .

 The left renal vein receives the left adrenal vein

superiorly, lumbar vein posteriorly, and left gonadal
vein inferiorly, The right renal vein typically does
not receive any branches.
 The renal lymphatics largely follow blood

 On the left, primary lymphatic drainage is into the

left lateral para-aortic lymph nodes including nodes.

 On the right, drainage is into the right

interaortalcaval and right paracaval lymph nodes
 The primary function of the renal autonomic innervation is vasomotor, with the
sympathetics inducing vasoconstriction and the parasympathetics causing

 Sympathetic preganglionic nerves originate from the eighth thoracic through first
lumbar spinal segments and then travel to the celiac and aorticorenal ganglia.

 From here, postganglionic fibers travel to the kidney via the autonomic plexus
surrounding the renal artery.

 Parasympathetic fibers originate from the vagus nerve and travel with the
sympathetic fibers to the autonomic plexus along the renal artery.
 The ureters are bilateral tubular structures responsible for
transporting urine from the renal pelvis to the bladder.

 They are 22 to 30 cm in length with a wall composed of

multiple layers.

 The inner layer is transitional epithelium

 Next is the lamina propria. This is a connective tissue layer

that along with the epithelium makes up the mucosal lining.

 Overlying the lamina propria is a layer of smooth muscle that

is continous with muscle covering the renal calyces and
pelvis. It is divided into an inner longitudinal and an outer
circular layer.
 Together, these muscular layers provide the peristaltic
wave that actively transports urine from the renal
collecting system through the ureter to the bladder.

 The outermost layer is the adventitia. This thin layer

surrounds the ureter and encompasses the blood
vessels and lymphatics that travel along the ureter.
 The ureter begins at the ureteropelvic junction, which lies posterior to the renal artery and

 It then progresses inferiorly along the anterior edge of the psoas muscle.

 Anteriorly, the right ureter is related to the ascending colon, cecum, colonic mesentery, and

 The left ureter is closely related to the descending and sigmoid colon and their
accompanying mesenteries.

 Approximately a third of the way to the bladder the ureter is crossed anteriorly by the
gonadal vessels.

 As it enters the pelvis the ureter crosses anterior to the iliac vessels. usually at the bifurcation
of the common iliac
 The normal ureter is not of
uniform caliber, with three
distinct narrowings
classically described: the
ureteropelvic junction,
crossing of the iliac vessels,
and the ureterovesical
 The simplest system divides the ureter into the abdominal
ureter extending from renal pelvis to the iliac vessels and
the pelvic ureter extending from the iliac vessels to the

 Alternatively, the ureter can be divided into upper, middle,

and lower segments .
 A- The upper ureter extends from the renal pelvis to the
upper border of the sacrum.
 B-The middle ureter comprises the segment from the upper
to the lower border of the sacrum.
 C-The lower (distal or pelvic) ureter extends from the lower
border of the sacrum to the bladder.
 The ureter receives its blood supply from multiple arterial
branches along its course.

 Of greatest importance to the surgeon is that arterial branches to

the abdominal ureter approach from a medial direction whereas
arterial branches to the pelvic ureter approach from a lateral

 A- For the upper ureter these branches originate from the renal
artery, gonadal artery, abdominal aorta, and common iliac artery.

 B- After entering the pelvis, additional small arterial branches to

the distal ureter may arise from the internal iliac artery or its
branches, especially the vesical and uterine arteries, but also from
the middle rectal and vaginal arteries.
 After reaching the ureter, the arterial vessels course longitudinally
within the periureteral adventitia in an extensive anastomosing plexus.

 The venous and lymphatic drainage of the ureter parallels the arterial
supply. Thus, ureteral lymphatic drainage varies by ureteral level.
 1- renal plexus
 2- aortic plexus
 3- superior hypogastric plexus
 4- inferior hypogastric plexus
 5- Testicular ( or ovarian ) plexus
 Through nerves that follow the blood
 Afferent fibers travel with the
sympathetic nerves and enter the spinal
cord in the 1st & 2nd lumber segment .
Thank you