ANATOMY OF GENITOURINARY - PowerPoint Presentation

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ANATOMYOF GENITOURINARYSYSTEMMUDr. T. Hradec Urologická klinika 1.LF UK a VFNPřednosta Prof.MUDr.T.Hanuš, DrSc.

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Genitourinary systemKidneys, adrenal glandsUpper urinary tract- calices, pelvis, ureter Lower urinary tract- urinary bladder, urethraMale genital organs- prostate, seminal vesicles, penis, scrotum, testes, epididymis

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KidneysretroperitoneumTh12-L2right kidney lower- liverfacies anterior/posterior

margo medialis (concave)

lateralis (convex)

extremitas superior/inferior

renal capsula – fibrous tissue

p

erinephric fat

r

enal fascia (Gerota)

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KidneysCortex- nephronsMedulla- renal columns, pyramids, collecting ducts, papillaCalices- minor and majorPelvisRenal hilum

- ureter - renal artery

- renal vein

- hilar fat

- lymphatic tissue (

nodes

)

Blood

supply

- renal artery (aorta) - accesory renal artery (30%) - renal vein (vena cava inf.)

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Injuries to the Kidneys - Classification

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grade I: contusion or non-enlarging subcapsular perirenal haematoma, and no lacerationtreatment: hydration, observation

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grade II: superficial laceration <1 cm depth and does not involve the collecting system (no evidence of urine extravasation), non-expanding perirenal haematoma confined to retroperitoneum

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grade III: laceration >1 cm without extension into the renal pelvis or collecting system (no evidence of urine extravasation)treatment: observation in stabilisated cases surgery in hypotension, increasing

hematoma, massive hematuria, shock

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grade IVlaceration extends to renal pelvis or urinary extravasationvascular: injury to main renal artery or vein with contained haemorrhagesegmental infarctions without associated lacerationsexpanding

subcapsular haematomas compressing the kidney

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grade Vshattered kidneyavulsion of renal hilum: devascularisation of kidney due to hilar injuryureteropelvic avulsionscomplete laceration or thrombus of the main renal artery or vein

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Renal cell carcinoma

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Clamping of segmental artery

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Upper urinary tractUreter 25–30 cm 2-4 mm

transitional epithelium

smooth muscle (peristalsis)

Ureter narrowing

(

impaction of 

kidney stones)

-

pelvouteric

junction

bifurcation of the iliac arteries ureterovesical valve In females, the ureters pass through the 

mesometrium

and under the uterine arteries

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Congenital hydronephrosisUreteropelvic junction (UPJ) obstructionUreterovesical junction (UVJ) obstructionPosterior urethral valves (PUV)UreteroceleVesicoureteral

reflux

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Congenital hydronephrosisUreteropelvic junction (UPJ) obstructionUreterovesical junction (UVJ) obstructionPosterior urethral valves (PUV)UreteroceleVesicoureteral

reflux

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Congenital hydronephrosisUreteropelvic junction (UPJ) obstructionUreterovesical junction (UVJ) obstructionPosterior urethral valves (PUV)UreteroceleVesicoureteral

reflux

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Congenital hydronephrosisUreteropelvic junction (UPJ) obstructionUreterovesical junction (UVJ) obstructionPosterior urethral valves (PUV)UreteroceleV

esicoureteral reflux

congenital abnormality

–

distal

ureter

balloons at its opening into the bladder, forming a sac-like pouch

Treatment

-

endoscopic incision, which can be followed by surgical

ureteric

re-implantation

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Congenital hydronephrosisUreteropelvic junction (UPJ) obstructionUreterovesical junction (UVJ) obstructionPosterior urethral valves (PUV)Ureterocele

Vesicoureteral reflux

Insufficiency

of

uretero

-

vesical

occluding

mechanismTreatment - endoscopic injection of dextranomer or hyaluronic acid- surgical reimplantation

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Anatomy of the collecting system and kidney stones

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ureter X a. uterina

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Urinary bladder

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Urinary bladderLocation (Males)- between the rectum and the pubic symphysis- separated by

rectovesical excavation-

superior to the 

prostate

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Urinary bladder

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Urinary bladderLocation (Females)inferior to the uterus separated by vesicouterine excavationbetween the

vagina and the pubic symphysis

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Urinary bladder

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Epicystostomy

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Bladder cancer - urothelial cell carcinomaNon muscle invasive bladder cancer: pTa-pT1Muscle invasive

bladder cancer: pT2-pT4b

Carcinoma

in

situ

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Non muscle invasive bladder cancer: pTa-pT1Treatment: TURBT (transurethral resection)

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Non muscle invasive bladder cancer: pTa-pT1Treatment: TURBT (transurethral resection)

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Bladder perforation

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Muscle invasive bladder cancer: pT2-pT4bTreatment radical cystectomy + lymphadenectomyMen: bladder, prostate, seminal vesicles, and surrounding lymphWomen: bladder, ovaries, fallopian tube, uterus, cervix, anteriorpart of the vagina, and surrounding lymph nodes

SURROUNDING LYMPH NODES ???

nodi

lymphatici

i

liaci interni a externi

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Upper urinary tract tumorsurothelial cell carcinoma 95%diagnosis by CT urography

higher incidence in patients

with

bladder

tumor

because

of

the

same epithelial liningtreatment: nephro-ureterectomy

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Inervation and functionInervationSympathetic via plexus hypogastricus inferoir (L1–L3) m. sphincter

uretrae

internus

Parasympathetic

via pelvic splanchnic nerves (S2–S4)

m.

detrussor

vesicae

urinaeSensitive (L2–S2)

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TreatmentDetrusor overactivity: anticholinergics, botoxDetrusor underactivity: parasympathomimetic - Distigminenausea, diarrhoea, vomiting, bradykardia Sphincter overactivity: alphablockers

Sphincter underactivity: surgical

treatment

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Surgical treatment of urinary incontinence

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Male urethra12-25cmpars intramuralispars prostaticapars membranaceapars spongiosa - bulbar - penile

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Male urethraPars intramuralis (transitional epithelium) - preprostatic urethra Pars prostatica (transitional) Seminal colliculus - ejaculatory ducts (vas deferens, seminal vesicles) 

- prostatic ducts - prostatic utricle

Pars membranacea

(pseudostratified columnar)

-

1

-

2 cm

-

passing through the 

external urethral spincter

- narrowest part of the urethra

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Male urethraPars spongiosa15–16 cm in lengthPseudostratified columnar epith. - proximallyStratified squamous epith. - distally through the corpus spongiosumexternal urethral meatusbulbar, penile (bulbous, p

endulous)

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Female urethra-4cm slightly curvedventraly from vagina

- Inervation: Pudendal n.

2/3

transitional

e

pithelium

-

1/3 stratified squamous epithelium.

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Prostate

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Prostatic secretionsproteinsimple sugarsproteolytic enzymesprostatic acid phophatasebeta-microseminoproteinprostate specific antigenzinc Fluidity of

the semen, better motility of

spermatozoa

,

longer

survival

,

protection of the genetic material

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Prostate - zones

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Prostate zonesPeripheral zone (70%) sub-capsular portion of the posterior aspect ofthe prostate gland that surrounds thedistal urethra70–80%

of prostatic cancer!!!

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Prostate - zonesCentral zone (25%)surrounds the ejaculatory ducts2.5% of prostate cancers although these cancers tend to be more aggressive and more likely to invade the seminal vesicles

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Prostate - zonesTransition zone (5%)surrounds the proximal urethra responsible for Benign Prostatic Hyperplasia

10–20% of prostate cancers

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Prostate - zonesAnterior fibro-muscular zone (5%)composed only of muscle and fibrous tissue

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Prostate - lobesAnterior lobe (isthmus)Lateral lobesMedian lobe

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TransUrethral Resection of the Prostate

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TURP vs. Radical prostatectomyTURPbenign prostate hyperplasiaendoscopic removal of transitory zone adenomarisk of prostate cancer persistsRadical

prostatectomysurgical removal of the entire prostate gland, the

seminal

vesicles

,

and

the

vas

deferensvesicourethral anastomosis