The kidney also has endocrine functions, helping to control blood pressure, bone mineralization, and erythrocyte production. The genital system consists of the testes, epididymides, deferent ducts, seminal vesicles, ejaculatory ducts, the prostate, and the penis in males; and the ovaries, uterine tubes, uterus, and vagina in females. Normally, the kidney is about the size of a mouse and measures approximately 11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thickness. Computed Tomographic Appearance of the Kidneys, Utility of Different Phases of Renal Contrast Enhancement. In other cases, both kidneys can be fused, usually at the inferior poles, which is a congenital state called the horseshoe kidney. Publication types Review MeSH terms Humans Reading time: 23 minutes. The kidneys are a pair of bean-shaped organs located below the rib cage, one on each side of the spine. A, Tips of the fornices are sharply defined. When multiple clefts in the renal cortex are present throughout the kidney, it is described as fetal lobulation. Unilateral renal agenesis occurs in approximately 1 in 1000 individuals with minimal impact on health, although it is sometimes associated with other congenital anomalies of the genitourinary tract and musculoskeletal system. Overview. Renal size can be measured in several ways. Relation between the right renal artery and the inferior vena cava (IVC). Most radiologists consider 10 to 12 cm to be an approximate reference range for renal length in adults, allowing for an additional 1 cm in either direction for patients at the extremes of height. If a kidney stone becomes lodged in the ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which can be very painful. Register now This kidney measured 14 cm in length. The medulla is the inner region of the parenchyma of the kidney. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. The presence of significant renal parenchyma may justify surgical repair to maximize the functional contribution of that kidney. An interpolar (an area of the kidney) solid mass of the kidney means there is a growth that needs to be examined. C, More severe hydronephrosis results in more pronounced shortening of the papilla. It is important to remember this order of vessels and ducts since this is the only thing that will make you able to orient the kidney and differentiate the left one from the right when they are outside of the cadaver. The kidneys are innervated by the renal plexus. Axial maximum intensity projection image from the arterial phase of a contrast-enhanced computed tomographic scan from a prospective renal donor demonstrates early prehilar branching of the left renal artery. Size disparity greater than 1.5 cm between kidneys should raise suspicion that one kidney is abnormal. Read More Created for people with ongoing healthcare needs but benefits everyone. In most cases, unenhanced CT is performed when the duration and cause of renal failure are unknown because exposure to iodinated contrast media could impair recovery of renal function. The region where the renal pelvis joins the ureter is called the, If the renal pelvis is entirely within the confines of the renal sinus, it is considered intrarenal. Each segmental branch of the renal artery divides into multiple interlobar arteries that course along the periphery of the medullary pyramids and causes small interlobular branches (Fig. Ultrasound can often identify the cause in cases of bilateral obstruction (, Pelvic mass (cervical, rectal, uterine, prostate cancer). 18-4). Figure 18-23 Axial image of the left kidney obtained in the excretory phase of a computed tomographic urogram demonstrates the effects of window settings on visualizing structures near excreted contrast. Diagnostic ultrasound uses sound wave technology to look at parts of your body, including: Brain Heart and blood vessels Breast Abdominal Organs Eyes Thyroid Skin and muscles Types of Ultrasound. After looking at the overview of the kidneys in situ, it may seemas they are cluttered with all abdominal organs. Some forms of congenital UPJ obstruction are now treated with transureteroscopic endopyelotomy in which an incision is made from within the ureter using a ureteroscope. Kenhub. The kidneys are located between your intestines and your diaphragm. Solid masses are more likely to be cancerous but they are not all cancerous. 18-26). Parasympathetic innervation enhances the peristalsis while sympathetic innervation inhibits it. Most radiologists consider 10 to 12 cm to be an approximate reference range for renal length in adults, allowing for an additional 1 cm in either direction for patients at the extremes of height. In the medulla, 5-8 renal pyramids are separated by connective tissue renal columns. This is called the nutcracker phenomenon. The region where the renal pelvis joins the ureter is called the ureteropelvic junction (UPJ). Axial image of the left kidney obtained in the excretory phase of a computed tomographic urogram demonstrates the effects of window settings on visualizing structures near excreted contrast. Best, Susan. The renal corpuscle has two components: the glomerular (Bowmans) capsule in which sits the glomerulus. On axial sections, the polar regions of the kidney typically form a closed circle or donut shape, with the hole formed by renal sinus fat. Kidneys are located just below your ribcage and behind your belly. These are chronic processes that lead to a loss of renal cortex gradually and uniformly. The goal of imaging patients with renal failure is to identify a correctable cause in an effort to recover or preserve renal function. Because the fascia of the retroperitoneum prevents significant extravasation, the incision usually heals to form a larger lumen. Axial image from unenhanced computed tomography of the kidneys performed 2 days after an angiographic procedure demonstrates stasis of contrast in the renal cortex, resulting in a persistent corticomedullary phase of enhancement. The dynamics of obstruction and quantification of relative renal function between the two kidneys may be important considerations in two general circumstances: (1) it is unclear whether obstruction is severe enough to warrant surgical intervention; or (2) significant parenchymal atrophy exists, and the relative merits of repair and nephrectomy are being compared. Reviewer: Ultrasound It can be seen as a triangular echogenic cortical defect, frequently seen in upper lobe parenchyma. When the fine, weblike complex of ureteral arteries is recruited to contribute to collateral circulation, enlarged vessels are seen surrounding the proximal ureter, causing the classic ureteral notching seen on intravenous urogram (IVU). This can cause varicocele of the left testicle because gravity works against the column of the blood in the left testicular vein. Figure 25.1.2 Left Kidney. This significantly affects the testicle, since an obstruction of drainage causes an obstruction of fresh arterial blood inflow, which can result in the infarction of testicular tissue. Static-fluid (T2-weighted) MR urography and phase-contrast MR angiography are useful techniques that do not require intravenous contrast material. These surfaces are separated by the edges of the kidney, which are the major convexity laterally, and minor concavity medially. B, A curved planar reformation of the crossing vein demonstrates its course. Around 40% of kidney cancers are localized renal masses. It is notable that the kidney has a very rich blood supply. This is just a peek into the kidney physiology. The urinary system comprises the upper urinary tracts (kidneys and ureters), the urinary bladder, and the urethra. 18-5). The opposite situation is possible too, if the kidneys excrete too many hydrogen ions, the pH of blood becomes too alkaline, and leads to a state called alkalosis. Further testing/diagnosis is required. Kidney cysts can occur with disorders that may impair kidney function. Creatinine is a breakdown product of creatine, found within muscle. 18-25). In order to understand the functions of the kidney, we must first learn its anatomy. 18-24). D, If pressure on the papilla persists, the ischemic papilla undergoes necrosis, allowing the calyx to protrude outward toward the cortex. When the renal cortex is more echogenic than the adjacent liver, there is a high correlation with renal disease, although sensitivity is relatively low, according to Platt and colleagues (Fig. This is because the liver and the stomach offset the symmetry of the abdomen, with the liver forcing the right kidney a bit down, and the stomach forcing the left kidney a bit up. Cells in our body constantly produce hydrogen ions. Kidney stones are most often treated by ultrasound shock therapy, during which high-frequency radio waves break the stone into smaller pieces that can be passed naturally into the urine. Poorly functioning kidneys with little residual parenchymal volume may be removed because preservation offers opportunities for future complications (infection, hypertension) without contributing significantly to renal function. Some centers use diuretics or fluid bolus, or both, during CT urography to dilute the excreted contrast to improve assessment of the urothelium. Ultrasound to get images of your kidneys. Illustration demonstrating the anatomy of the renal collecting system. Each segmental branch of the renal artery divides into multiple interlobar arteries that course along the periphery of the medullary pyramids and causes small interlobular branches (Fig. Because the interlobular arteries form an arch overlying the pyramid, they are called the arcuate arteries. Figure 18-6 Frontal image of the left kidney from an intravenous urogram demonstrating an aberrant renal papilla in the lower pole infundibulum. If, however, a vessel crosses the UPJ at the level of obstruction, a blind incision made from the inside of the ureteral lumen can result in severe hemorrhage. The anteromedial aspect of the interpolar region is interrupted by the renal hilum to make a C shape. The segmental arteries then branch into the interlobar arteries, which further branch into the arcuate arteries. a bifid renal pelvis, ultimately drained by a common ureter. Comparative views of the CT scan ( a axial, b coronal, and c sagittal planes) and corresponding views of the physical model ( d superior view, e median view, and f median view). Because repeat imaging does not expose the patient to additional radiation, multiple phases including delayed images may be obtained and allow the creation of quantitative curves that define the initial filling and then clearing of dilated collecting system structures. As the lobules of metanephric blastema coalesce to form each kidney, they do not always result in a smooth, uniform band of cortex. Depending on where the cyst is located, it can affect how the kidney works. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. The vascularity of some tumors may be most apparent during this phase (Fig. 18-25). Fetal lobulation is best differentiated from renal scars during the corticomedullary phase of enhancement on computed tomography (CT) or magnetic resonance imaging (MRI) because cortex can be followed into the indentation that occurs between calyces (Fig. The kidneys can be divided into three main regions from cranial to caudal. The solid renal parenchyma consists of the peripheral renal cortex and more central renal medulla. 18-2). Note diameter of arteries because small accessory arteries may be sacrificed in many cases. The anterior surface of the left kidney, has the following anatomical relations: The posterior surfaces of both kidneys are related to certain neurovascular structures and muscles: You can easily remember these with the mnemonic: 1-2-3-4 All Boys Need Muscle. Unlike other filling defects within the renal collecting system (e.g., tumor, stone, clot), an aberrant papilla usually has a small fornix around it, seen as a halo on conventional urography (Fig. But more often, kidney cysts are a type called simple kidney cysts. Table 18-7 lists causes of unilateral smooth renal atrophy. The uniform high attenuation of the nephrographic phase provides an optimal background for detecting small, low-attenuation lesions in the renal parenchyma (Fig. Calcifications and renal calculi are notoriously poorly demonstrated with MRI. If this appearance were present bilaterally, chronic renal disease such as chronic glomerulonephritis would be a more likely explanation. It doesn't have to be that way. But here is a neat little mnemonic to help. Table 18-6 Causes of Bilateral Small Smooth Kidneys. Pain that radiates to the lower abdomen and groin. The large left proximal ureteral stone seen in this image is only partially obstructing, causing mild dilation in the left kidney collecting system. The medial border of the kidney contains a very important landmark called the hilum of the kidney, which is the entry and exit point for the kidney vessels and ureter. The defect is the extension of sinus fat into the cortex, usually at the border of the upper pole and interpolar region of the kidney. The Modification of Diet in Renal Disease (MDRD) is another method for estimating renal function that yields a value often called estimated glomerular filtration rate (eGFR). (Courtesy of Karl T. Rew, MD) Introduction Synonyms Epidemiology The highest portion of the superior pole is covered with the, The superior one-half of the anterior surface is in contact with the layer of, At exactly the center of the anterior surface, imagine a horizontal stripe that extends from the medial concavity toward the center of the lateral convexity that is the area of the kidney that is directly touched by the retroperitoneal posterior wall of the, The lateral part of the inferior pole is directly contacted with the, The rest of the inferior pole is associated with the peritoneum of the, Just like the right kidney, the highest part of the superior pole of the left is also covered with the, The inferior portion of the superior pole contacts with the peritoneum of the, Just inferior to the stomach and spleen impression, is where the left kidney directly contacts, The lateral part of the inferior half of the anterior surface is directly associated with the left colic flexure (also known as the splenic flexure) and, The medial part of the inferior half and the inferior pole are contacted by the peritoneum of the, Kidney structure (overview) - Mohammed Albakkar, Kidneys in situ (overview) - Johannes Reiss, Internal anatomy of the kidney (overview) - Mohammed Albakkar, Arteries of the kidney (overview) - Abdulmalek Albakkar, Kidneys in a cadaver - Prof. Carlos Surez-Quian. 18-8). Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Advantages of scintigraphy include accurate quantitative measurement of function. Figure 18-11 Three-dimensional volume rendering from contrast-enhanced multidetector computed tomography examination of the kidneys demonstrates typical orientation of a horseshoe kidney. Figure 18-14 Axial maximum intensity projection image from the arterial phase of a contrast-enhanced computed tomographic scan from a prospective renal donor demonstrates early prehilar branching of the left renal artery. Made aware of such a vessel, the urologist may choose to perform an alternate procedure to avoid hemorrhagic complications. Figure 18-27 T2-weighted maximum intensity projection image from a magnetic resonance urogram performed to evaluate urinary obstruction identified in a patient with an obstructing soft tissue mass in the pelvis on unenhanced computed tomography (CT). Anatomical Position of the Kidneys Kidney Structure Urine that is concentrated in the renal papilla is subsequently excreted into a lumen lined with transitional epithelium. 2023 Several calyces drain into each infundibulum, an elongated transition from the polygonal calyces to the saclike renal pelvis. B, Low-attenuation lesion in the late nephrographic/early excretory phase is less suspicious in appearance. The posterior branch supplies the posterior part of the kidney, whereas the anterior branch arborizes into five segmental arteries, each supplying a different renal segment. Perhaps of even greater importance, serum creatinine is not a sensitive test for minor insults to the kidney in otherwise healthy individuals. At that point, you may experience these symptoms: Severe, sharp pain in the side and back, below the ribs. I hope this helps. 18-15). All content published on Kenhub is reviewed by medical and anatomy experts. Enlargement of a congenitally unilateral kidney is typical and presumed to be compensatory. Internal Anatomy. Read more. . B, Axial CT image from a different patient demonstrates the more common location of the right renal artery posterior to the IVC. Each kidney has a single renal vein which conducts the blood out of the kidney and is positioned anterior to the artery. Figure 18-12 Axial sections of the right kidney from contrast-enhanced computed tomography demonstrate a bar of renal parenchyma separating renal hila in the superior and inferior poles, consistent with duplication. Illustration demonstrating basic intrarenal arterial anatomy. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see Fig. The minor calyces unite to form a major calyx. Unenhanced MRI can also be used to diagnose obstruction and identify the source (Fig. It participates in vital processes such as regulation of blood osmolarity and pH, regulation of blood volume and blood pressure, production of hormones, and filtration of foreign substances. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. The kidneys are positioned retroperitoneally, meaning that they are not wrapped with the peritoneal layers the way most abdominal organs are, but rather are placed behind it. Bone scan and chest x-ray to find out if the cancer has spread. Thus, an AML is a tumor that contains these 3 components. 18-23). Supernumerary kidneys are quite rare and have been associated with aortic coarctation, vaginal atresia, and urethral duplications. A, Axial image demonstrates the dilated renal pelvis and crossing vessel. Each time a professor says 'nephron', a student gets a headache. Yet, the relations of the kidneys with other organs are often found in Anatomy tests. On the other hand, the products of cellular metabolism and drug metabolites are eliminated from the blood which prevents their depositing in the body and potential toxicity. Other common kidney conditions are acquired through life, and one of the most common is nephrolithiasis (kidney stones). Learning a quickmnemonic'VAD' can help you remember these structures (renal Vein, renal Artery, Duct a.k.a ureter). Technetium 99m dimercaptosuccinic acid (DMSA) and glucoheptonate (GHA) are both used for evaluation of renal parenchyma. The adrenal cortex directly influences renal function through the production of the hormone aldosterone to stimulate sodium reabsorption. Recent advances in MDCT and MRI permit cross-sectional vascular studies to replace conventional angiography before UPJ repair (Fig. Note that retroaortic components are usually near the inferior poles (Fig. Copyright Duplication affects the axial appearance of the kidneys by dividing the renal sinus into superior and inferior components, separated by a circumferential band of cortex in the central region (Fig. The center of the minor concavity is marked as the hilum of the kidney where the renal artery enters the kidney, and the renal vein and ureter leave the kidney. The main function of the kidney is to eliminate excess bodily fluid, salts and byproducts of metabolism this makes kidneys key in the regulation of acid-base balance, blood pressure, and many other homeostatic parameters. Luckily, the kidneys also feel this increase of pressure, and in cases when this happens, they increase the filtration rate of blood and production of urine, which subsequently leads to the increase fluid excretion and decrease of blood pressure. Summary: A variety of factors, including patient body habitus, local renal anatomy, cost and patient preference, must be taken into consideration when determining the optimal treatment modality for lower pole renal calculi. Right-sided pain was related to crossed renal ectopia. Note distance from origin to the first arterial division (Fig. Crossed ectopia can be either fused or unfused. They are branches of the abdominal aorta and all together are called the extrahilar renal arteries. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. The kidneys are bilateral organs placed retroperitoneally in the upper left and right abdominal quadrants and are part of the urinary system. 18-14). Increasing pressure within the lumen initially distends the fornices (acutely angled portions of the calyx along the sides of the papillae), whereas the central portion of the papillary impression is preserved. If the renal pelvis extends out of the renal sinus, it is considered to be an. Figure 18-9 Coronal computed tomographic image in the corticomedullary phase shows normal corticomedullary differentiation along the lobulated contour, consistent with fetal lobulation. Hypotension is a stimulus for the kidneys to increase the retention of fluid and thus increase blood pressure. Usually, there are two to three major calyces in the kidney (superior, middle, and inferior), which again unite to form the renal pelvis from which the ureter emerges and leaves the kidney through the hilum. Living renal donor allografts account for more than half of the transplanted kidneys in the United States. 18-6). Prominent extrarenal pelves are typically positioned anteriorly (Fig. Get instant access to this gallery, plus: Introduction to the musculoskeletal system, Nerves, vessels and lymphatics of the abdomen, Nerves, vessels and lymphatics of the pelvis, Infratemporal region and pterygopalatine fossa, Meninges, ventricular system and subarachnoid space. This kidney measured 14 cm in length. Renal function is better evaluated by measured creatinine clearance, which takes into account not only the amount of creatinine in the blood but also the amount of creatinine within a specified volume of urine over a given period. Alternatively, the anterior to posterior orientation follows the same pattern: renal vein, renal artery and ureter. Figure 18-3 Illustration demonstrating basic intrarenal arterial anatomy. The initiation is caused by the increase in volume that stretches the walls of the calyces. In most cases, the kidneys are situated with the inferior poles slightly. Chronic obstruction, however, results in damage to the papilla, evident in the clubbed calyx of papillary necrosis (Fig. The most superior vessel is the renal vein which exits the kidney, just under it is the renal artery that enters in, and under the artery is the exiting ureter. Coronal reformation from contrast-enhanced computed tomography performed for renal donation demonstrates a retroaortic left renal vein crossing the aorta well inferior to the level of the renal hila. The superior poles (extremities) (T12) of both kidneys are more medially pointed towards the spine than the inferior poles (extremities) (L3). On the superior aspect of each kidney is the adrenal gland. Typically, one kidney sits on either side of your spine. Obstruction can cause renal failure if it is bilateral (Box 18-3) or if there is preexisting disease in the unobstructed kidney. 3D printed model for a 53-year-old female presenting a 21 15 15 mm renal tumor located in the interpolar region of left kidney, treated by left partial nephrectomy. Now that weve mastered the borders, it will be easier to take a closer look at the anatomical relations that the kidneys share with other abdominal structures. When abnormal echogenicity is detected, it is important to note whether it is unilateral or bilateral. Now lets pay attention to the borders of the kidneys. BOX 18-3 Causes of Bilateral Hydronephrosis. Figure 18-1 Annotated three-dimensional volume rendering of the left kidney acquired using a combined nephrographic phase and excretory phase during computed tomographic urography demonstrates regional anatomy of the kidney. Bilateral echogenic kidneys with renal hypertrophy can be seen associated with human immunodeficiency virus disease (see. The normal appearance of the calyx is created by the impression of the renal papilla. At the Brady Urological Institute, we believe in the adage, "An ounce of prevention is worth a pound of cure," so we place great emphasis on a thorough metabolic evaluation, so that therapies can be appropriately directed towards reducing the risk of recurrent stone disease. Axial image of the left kidney from a contrast-enhanced computed tomographic scan demonstrates an extrarenal pelvis. Localized means that the tumor has not spread out from where it first started. The information we provide is grounded on academic literature and peer-reviewed research. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. Because an extrarenal pelvis is not confined by the renal parenchyma, there is a tendency for it to expand. 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