Video Clips on DVD
- 1-1
Anatomy of the Full Female Urinary Tract
- 1-2
Abdominal Anatomy
- 1-3
Anatomy of the Kidneys
- 1-4
Anatomy of the Ureters and Gonadal Vessels
- 1-5
Anatomy of the Bladder and Retropubic Space
Introduction
The female urinary tract is comprised of four organs: the kidneys, the ureters, the bladder, and the urethra ( Fig. 1-1 ). (See Videos 1-1 and 1-2 for demonstration of anatomy of the full female urinary tract and abdominal anatomy. 
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Anatomy of the Kidneys
The kidneys are bean-shaped organs located retroperitoneally, just below the ribs. The kidneys maintain fluid and electrolyte balance. They usually measure 10 to 12 cm in length, 5 to 7 cm transversely, and 3 cm in anteroposterior dimension. The center of the right kidney is located approximately at the body of the second lumbar vertebra. The right kidney is 1 to 2 cm lower than the left because of its location below the liver. The renal calyces coalesce to form the renal pelvis, which collects urine and is continuous with the ureter. The renal pelvis exits the kidney medially, posterior to the renal vessels.
The kidneys receive their blood supply from the renal arteries, which originate directly from the aorta, just below the trunk of the superior mesenteric artery. Venous drainage from the kidneys is by the renal veins, which feed into the inferior vena cava. Both the arteries and the veins enter the kidney medially at the renal hilum, where the vein is anterior to the artery ( Fig. 1-2 ).
The kidneys are innervated by the sympathetic preganglionic nerves, which originate at the T8 through L1 spinal segments and travel to the celiac and aorticorenal ganglia. Postganglionic sympathetic fibers travel to the kidney through the autonomic plexus, which surrounds the renal artery. Parasympathetic fibers arrive from the vagus nerve and travel with the sympathetic fibers to the autonomic plexus. The primary function of autonomic regulation of the kidney is vasomotor, with sympathetics causing vasoconstriction and parasympathetics causing vasodilation.
In rare situations, a female infant may be born with an anatomic variation of the kidneys. A horseshoe kidney involves the fusion of one pole of each kidney (usually the lower poles), forming a larger unit in the shape of a “ U ” with two collecting systems. Horseshoe kidney is rare, with a prevalence of 0.25% in the general population. Horseshoe kidney can predispose to urinary stasis, obstruction, and stone formation, although most cases are asymptomatic ( Fig. 1-3 ).
Renal ectopia occurs when the kidney is located outside its usual position in the renal fossa, with a prevalence of approximately 0.11%. Common ectopic locations include the lower abdomen (above the pelvic crest) or the pelvis (adjacent to the sacrum). Most cases are asymptomatic; however, the ectopic kidney may exhibit decreased function.
Clinical Correlations
As renal transplantation numbers continue to increase, pelvic surgeons are more and more likely to encounter a patient who has had a prior renal transplant or one who has donated a kidney. It is imperative to understand the anatomic and vascular changes associated with these types of surgery before performing further surgical intervention in these patients.
Currently, laparoscopic-assisted and open approaches are available for live donor nephrectomy. However, with minimally invasive surgery becoming emphasized in all surgical specialties, the laparoscopic-assisted approach is quickly becoming the preferred approach. This approach can be attempted from within the peritoneal cavity or completely retroperitoneally.
The transplanted kidney is usually placed extraperitoneally. The most common location is in the contralateral iliac fossa, although some surgeons prefer the right side because of the more horizontal position of the iliac vessels. The renal artery from the transplanted kidney is usually attached to the external iliac artery, while the renal vein is attached to the external iliac vein. The ureter is usually reimplanted using an extravesical ureteroneocystostomy, which tunnels the ureter in the wall of the bladder before the new ureteral orifice is created. The implantation site is variable, but most commonly it is in the bladder dome or cephalad and lateral to the existing ureteral orifices. (See Video 1-3 to view the anatomy of the kidneys. 
)
Anatomy of the Kidneys
The kidneys are bean-shaped organs located retroperitoneally, just below the ribs. The kidneys maintain fluid and electrolyte balance. They usually measure 10 to 12 cm in length, 5 to 7 cm transversely, and 3 cm in anteroposterior dimension. The center of the right kidney is located approximately at the body of the second lumbar vertebra. The right kidney is 1 to 2 cm lower than the left because of its location below the liver. The renal calyces coalesce to form the renal pelvis, which collects urine and is continuous with the ureter. The renal pelvis exits the kidney medially, posterior to the renal vessels.
The kidneys receive their blood supply from the renal arteries, which originate directly from the aorta, just below the trunk of the superior mesenteric artery. Venous drainage from the kidneys is by the renal veins, which feed into the inferior vena cava. Both the arteries and the veins enter the kidney medially at the renal hilum, where the vein is anterior to the artery ( Fig. 1-2 ).
The kidneys are innervated by the sympathetic preganglionic nerves, which originate at the T8 through L1 spinal segments and travel to the celiac and aorticorenal ganglia. Postganglionic sympathetic fibers travel to the kidney through the autonomic plexus, which surrounds the renal artery. Parasympathetic fibers arrive from the vagus nerve and travel with the sympathetic fibers to the autonomic plexus. The primary function of autonomic regulation of the kidney is vasomotor, with sympathetics causing vasoconstriction and parasympathetics causing vasodilation.
In rare situations, a female infant may be born with an anatomic variation of the kidneys. A horseshoe kidney involves the fusion of one pole of each kidney (usually the lower poles), forming a larger unit in the shape of a “ U ” with two collecting systems. Horseshoe kidney is rare, with a prevalence of 0.25% in the general population. Horseshoe kidney can predispose to urinary stasis, obstruction, and stone formation, although most cases are asymptomatic ( Fig. 1-3 ).
Renal ectopia occurs when the kidney is located outside its usual position in the renal fossa, with a prevalence of approximately 0.11%. Common ectopic locations include the lower abdomen (above the pelvic crest) or the pelvis (adjacent to the sacrum). Most cases are asymptomatic; however, the ectopic kidney may exhibit decreased function.
Clinical Correlations
As renal transplantation numbers continue to increase, pelvic surgeons are more and more likely to encounter a patient who has had a prior renal transplant or one who has donated a kidney. It is imperative to understand the anatomic and vascular changes associated with these types of surgery before performing further surgical intervention in these patients.
Currently, laparoscopic-assisted and open approaches are available for live donor nephrectomy. However, with minimally invasive surgery becoming emphasized in all surgical specialties, the laparoscopic-assisted approach is quickly becoming the preferred approach. This approach can be attempted from within the peritoneal cavity or completely retroperitoneally.
The transplanted kidney is usually placed extraperitoneally. The most common location is in the contralateral iliac fossa, although some surgeons prefer the right side because of the more horizontal position of the iliac vessels. The renal artery from the transplanted kidney is usually attached to the external iliac artery, while the renal vein is attached to the external iliac vein. The ureter is usually reimplanted using an extravesical ureteroneocystostomy, which tunnels the ureter in the wall of the bladder before the new ureteral orifice is created. The implantation site is variable, but most commonly it is in the bladder dome or cephalad and lateral to the existing ureteral orifices. (See Video 1-3 to view the anatomy of the kidneys. 
)
Anatomy of the Ureters
The ureters are retroperitoneal tubular structures, typically 28 to 32 cm in length, that carry urine from the renal pelvis to the bladder. They are composed of multiple layers of tissue, with the innermost layer being transitional epithelium. Encompassing the epithelium is the lamina propria, a loose connective tissue layer. Next, is a muscular layer made up of an inner longitudinal and an outer circular layer of smooth muscle. This muscular layer is responsible for peristalsis that moves the urine from the renal pelvis to the bladder. The outer layer is a fragile adventitial layer that encompasses the ureter and carries the anastomosing blood vessels and lymphatics.
The ureters are commonly divided into three segments or zones. The upper ureter, zone 1, is the portion extending from the renal pelvis to iliac arteries. In this zone, the ureter travels medial and inferior to the gonadal vessels and enters the pelvis by crossing over the common iliac vessels at the bifurcation. The middle ureter, zone 2, lies between the crossover of the iliac arteries and the point at which it crosses under the uterine artery. During its course in this zone, the ureter travels lateral to the internal iliac artery along the pelvic sidewall. At the level of the uterocervical junction, the ureter travels medially within the cardinal ligament and crosses underneath the uterine artery approximately 1.5 cm lateral to the cervix. The lower ureter, zone 3, extends from where the ureter crosses under the uterine artery to the point at which it enters the bladder. In this zone, the ureter travels along the superior lateral vagina within the endopelvic fascia to enter the bladder. The terminal 1.5 cm of the ureter remains within the bladder wall before opening into the ureteral orifice in the bladder trigone ( Figs. 1-4 and 1-5 ).
