KIDNEY AND URETER Grays Anatomy Chapter 74.

KIDNEY Reddish brown in fresh state Situated posteriorly behind the peritoneum on each side of the vertebral column and are surrounded by adipose tissue Superiorly: upper border of T12 vertebrae Inferiorly: L3 vertebrae Long axis: directed inferolaterally hence anterior aspect is anterolateral Transverse axis: posteromedially hence posterior aspect is posteromedial R is usually slightly inferior to the L d/t the liver L kidney is 1.5 cm longer than the right, narrower and near the median Length: 11 cm Breadth: 6 cm Anteroposterior Dimension: 3 cm Average Weight: 150 g (men) or 135 (women) Fetal & Newborn kidney has 12 lobules which fuse in adults although traces of lobulation may remain. Functions: Excrete waste products of metabolism Control water-electrolyte balance Maintain acid-base balance in the blood Produce and release erythropoietin & renin Congenital Anomalies: Absent kidney (1/1200 individuals) o results from failure of metanephric blastema to join with a ureteric bud on affected side o Single kidney shows compensatory hypertrophy Renal Ectopia (1/2500 individuals) o Failure of the kidney to descend into the renal fossa in utero o Kidney is found in the pelvis and associated with malrotation anomalies and may have marked fetal lobulation o Pelvic kidneys become hydronephrotic Crossed Renal Ectopia o Two renal masses (may be fused) are on the same side Horseshoe Kidney (1/400 individuals) o Transverse bridge of renal tissue (isthmus) connects the 2 renal masses o Isthmus lies between the inferior poles anterior to the great vessels Perirenal Fascia

A dense, elastic connective tissue sheath which envelops each kidney and suprarenal gland together with a layer of surrounding perirenal fat which is thickest at the renal borders and extends into the renal sinus at the hilum A single multilaminated structure which is fused posteromedially with the muscular fasciae of psoas major and quadratus lumborum Proceeds anterolaterally behind the kidney as a bilaminated sheet Midline superiorly, the anterior and posterior renal fasciae fuse and are attached to the crura of their respective hemidiaphragms Single nephrectomy removes the kidney from within the perirenal fascia while a radical nephrectomy removes the entire contents of the perirenal space including the perirenal fascia Relations (Both) Superior Poles: Thick, round and related to its suprarenal gland Inferior Poles: Thinner and extend to within 2.5 cm of the iliac crest Lateral Borders: convex Medial Borders: convex adjacent to the poles, concave between them and slope inferolaterally with a hilum Hilum: bounded by anterior and posterior lips. Contain the renal vessels, nerves and renal pelvis o Renal Vein (anterior) o Renal Artery (Intermediate) o Pelvis of the Kidney (posterior) o Suprarenal gland (above) o Origin of the ureter (below) *Relations of the anterior surface of the kidney differ on the right and left while posterior relations are similar on both sides. Anterior Relations (Right Kidney) Superior Pole: R suprarenal gland Below Superior Pole: R lobe of the liver Narrow Medial Area: retroperitoneal descending part of the duodenum Inferolaterally: retroperitoneal R colic flexure Inferomedially: intraperitoneal small intestine Anterior Relations (Left Kidney) Medial Area of Superior Pole: L suprarenal gland Lateral half: Spleen Central Quadrilateral Area: retoperitoneal pancreas and splenic vessels Above the quadrilateral Area: triangular region between the suprarenal and splenic areas is the stomach

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 Below pancreatic & Splenic Areas: retroperitoneal L colic flexure and the beginning of the descending colon Medial Area: Jejunum Gastric Area: covered by peritoneum of Lesser Sac Splenic & Jejunal Areas: covered by Greater sac

Hilum- leads into a central sinus lined by the renal capsule & almost filled by the renal pelvis and vessels, the rest filled by fat Renal Capsule - covers the external surface of the kidney and continues through the hilum to line the sinus and fuse with the adventitial coverings of the minor calyces Collecting Tubules open onto the summits of the renal papillae to drain into minor calyces Minor Calyces funnel-shaped expansions of the upper urinary tract surrounds either a single papilla or, more rarely, groups of two or three papillae unite with their neighbours to form two or possibly three larger chambers, the major calyces which drain into the infundibula Calyces usually grouped so that 3 pairs drain into the upper pole infundibulum and 4 pairs into the lower pole infundibulum With a middle infundibulum, 3 pairs drain into the upper pole, 2 in the middle & lower pole each. Renal Pelvis Funnel shape and tapers as it passes inferomedially, traversing the renal hilum to become continuous with the ureter normally formed from the junction of two infundibula, one from the upper and one from the lower pole calyces, but there may be a third, which drains the calyces in the mid-portion of the kidney. VASCULAR SUPPLY AND LYMPHATIC DRAINAGE Renal Arteries 20% of cardiac output supply Branch laterally from the aorta below the origin of the superior mesenteric artery R renal artery is longer and higher, passing posterior to the IVC, R renal vein, head of the pancreas & descending duodenum L renal artery is a little lower & passes behind the L renal vein, body of the pancreas & splenic vein and may be crossed anteriorly by the inferior mesenteric vein Extrarenally gives off 1 or more inferior suprarenal arteries, a branch to the ureter, branches supplying the perinephritic tissue, the renal capsule & pelvis Divides into an anterior & posterior division near the renal hilum which divide into segmental arteries.

Posterior Relations embedded in fat and devoid of peritoneum Superiorly: diaphragm & arcuate ligaments Inferiorly (M to L): psoas major, quadratus lumborum & aponeurotic tendon of transversus abdominis, subcostal vessels then the subcostal, iliohypogastric & ilioinguinal nerves. Upper pole (R): 12th rib Upper pole (L): 11 & 12th ribs Diaphragm- separates the kidney from the pleura - Descends to form the costodiaphragmatic recess Postnatal Kidney- has a thin fibrous capsule composed of collagen-rich tissue with some elastic and smooth muscle fibers Internal Macrostructure Internal Medulla consists of pale, striated, conical renal pyramids, their bases peripheral, their apices converging to the renal sinus. At the renal sinus they project into calyces as papillae. External Cortex o subcapsular, arching over the bases of the pyramids and extending between them towards the renal sinus as renal columns o Peripheral Regions: Cortical Arches which are traversed by radial, lighter-coloured medullary rays, separated by darker tissue, the convoluted part o Inner Zone: demarcated from the medulla by arcuate arteries & veins o Subcortex lie on the medullary side of the inner zone

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70% of individuals single renal artery Accessory renal arteries Occurs in 30% of individuals rise from the aorta above/below the main renal artery and follow it into the renal hilum at the inferior pole may cross anterior to the ureter & obstruct it causing hydropnephrosis Renal Artery Segmental Arteries Lobar Interlobar Arcuate Interlobular Afferent artery Glomerulus Efferent artery Segmental Arteries the kidney has 5 arterial segments 1. Apical Segment occupies the anteromedial region of the superior pole 2. Superior (anterior) segment the rest of the superior pole & central anterosuperior region 3. Middle Segment between the anterior & inferior segments 4. Inferior Segment lower pole 5. Posterior Segment the whole posterior region between the apical & inferior segments

Divides into Interlobular arteries, which diverge radially into the cortex Interlobar Arteries ascend towards the superficial cortex or may branch occasionally en route. Some are more tortuous and recurve towards the medulla at least once before proceeding towards the renal surface Afferent Glomerular Arterioles mainly the lateral rami of interlobular arteries deeper ones incline obliquely back towards the medulla intermediate pass horizontally the more superficial approach the renal surface obliquely before ending in a glomerulus responsible for tubuloglomerular feedback Efferent Glomerular Arterioles arise from most glomeruli except at juxtamedullary & intermediate cortical levels divide to form a dense peritubular capillary plexus around the proximal & distal convoluted tubules 2 sets of capillaries (glomerular & peritubular) linked by efferent glomerular tubules Have thicker walls & narrowe caliber than the corresponding afferents Relatively long, wide vessels when passing into the medulla where they divide into 12-15 descending vasa recta Vasa Recta run straight to varying depths in the renal medulla, contributing side branches to a radially elongated capillary plexus applied to the descending and ascending limbs of renal loops and to collecting ducts *proximity of descending and ascending vessels with each other and adjacent ducts provides the structural basis for the countercurrent exchange and multiplier phenomena. Renal Medulla largely from efferent arterioles of juxtamedullary glomeruli, supplemented by some from more superficial glomeruli, and aglomerular' arterioles Interlobular Veins Fine radicles from the venous ends of the peritubular plexuses converge to join interlobular veins, one with each interlobular artery

Bloodless line of Brodel avascular longitudinal line along the convex renal border however many vessels cross it so it is not actually bloodless. *Radial or Intersegmental incisions during surgery are preferable. Lobar Arteries initial branches of segmental arteries (1 each pyramid) Interlobar Arteries (2-3) subdivisions of the lobar arteries upon reaching the pyramid. Extend towards the cortex around each pyramid Arcuate Arteries Division of the interlobar arteries at right angles Arches between the cortex & medulla

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Interlobar Veins begin beneath the fibrous renal capsule by the convergence of several stellate veins, which drain the most superficial zone of the renal cortex and so are named from their surface appearance pass to the corticomedullary junction and also receive some ascending vasa recta before ending in arcuate veins Arcuate Veins drain into interlobar veins, which anastomose and form the renal vein. RENAL VEINS lie anterior to the renal arteries and open into the inferior vena cava almost at right angles L renal vein is closely related to the IVC and is 3x longer than the right (7.5 cm & 2.5 cm respectively) and enter the IVC a little superior and to the right. It can be double (1 posterior, 1 anterior) referred to as the persistence of the renal collar L renal vein: runs from its origin posterior to the splenic vein & body of the pancreas, across the anterior aspect of the aorta, just below the origin of the superior mesenteric artery L Collateral Venous Drainage: gonadal & suprarenal veins R renal vein: behind the descending duodenum & sometimes the lateral part of the head of the pancreas. Has no significant collateral drainage & cannot be ligated with impunity. LYMPHATIC DRAINAGE begin in three plexuses, around the renal tubules, under the renal capsule, and in the perirenal fat (the latter two connect freely). Collecting vessels from the intrarenal plexus form four or five trunks which follow the renal vein to end in the LATERAL AORTIC NODES perirenal plexus drains directly into the same nodes. INNERVATION dense plexus of autonomic nerves around the renal artery consisting of o the coeliac ganglion and plexus, o aorticorenal ganglion o lowest thoracic splanchnic nerve o first lumbar splanchnic nerve o aortic plexus Renal Plexus Small ganglia occur in the renal plexus, the largest behind the origin of the renal artery continues into the kidney around the arterial

branches and supplies the vessels and renal glomeruli, and especially the cortical tubules Axons innervate juxtamedullary efferent arterioles and vasa recta which control the blood flow between the cortex and medulla without affecting the glomerular circulation MICROSTRUCTURE The kidney is composed of many tortuous, closely packed uriniferous tubules, bounded by a delicate connective tissue in which run blood vessels, lymphatics and nerves Parts of a Tubule (embryologically distinct) Nephron produces urine Collecting Duct completes the concentration of urine and through which urine passes out into the calyces of the kidney, the renal pelvis, the ureter and urinary bladder Nephron consists of a renal corpuscle concerned with filtration from the plasma, and a renal tubule, concerned with selective resorption from the filtrate to form the urine. Renal Corpuscle small rounded structures averaging 0.2 mm in diameter, visible in the renal cortex deep to a narrow peripheral cortical zone has a central glomerulus of vessels and a glomerular (Bowman's) capsule, from which the renal tubule originates amount decreases with age, decrease accelerated by high blood pressure, GFR also after 40 yrs old cannot regenerate Glomerulus collection of convoluted capillary blood vessels, united by a delicate mesangial matrix and supplied by an afferent arteriole which enters the capsule opposite the urinary pole, where the filtrate enters the tubule. Efferent arteriole also emerges from its vascular pole In simple form until late prenatal life-6 months after birth then mature by 6-12 years old. Renal corpuscle renal tubule collecting ducts terminal papillary duct minor calyx (apex of renal papilla) major calyx infundibulum renal pelvis Bowmans capsule blind expanded end of a renal tubule, and is deeply invaginated by the glomerulus Parietal lining is simple squamous epithelium

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 Glumarular juxtacapillary (visceral) wall is composed of specialized epithelial podocytes Between its two walls is the urinary (Bowmans) space continuous with the PCT. Podocytes stellate cells whose foot processes curve around the capillary loops and branch to form secondary processes which are applied closely to the basal lamina; secondary or tertiary processes give rise to terminal pedicels. Cannot replicate once differentiated Has nephrin, podocin, synaptopodin & GLEPP-1 Pedicels alternate with those of an adjacent cell and interdigitate tightly with each other, separated by narrow (25 nm) gaps, the filtration slits Filtration Slits are covered by a dense, membranous slit diaphragm, through which filtrate must pass to enter the urinary space Sialoglycoproteins composes the dense surface coat covering the luminal membrane & slit diaphragm gives this surface a very high negative charge and is one of the key characteristics of the permselectivity barrier Glomerular Endothelium - finely fenestrated Glomerular Basal Lamina the fused endothelial and podocyte basal laminae which is the principal barrier to the passage of fluid from capillary lumen to urinary space usually 0.33 m thick in man, and acts as a selective filter, allowing the passage from blood, under pressure, of water and various small molecules and ions in the circulation Glomerular Basement Membrane skeleton of the glomerular tuft outer aspect is completely covered by podocytes, and the interior is filled by capillaries and a delicate mesangial matrix (mesangium) 3 major components: laminin, type IV collagen & heparin sulphate proteoglycans Mesangial Cells Has phagocytic and contractile properties which help regulate blood glow Lie within & secrete the glomerular mesangium

Related to vascular pericytes & are concerned with the turnover of glomerular basement membrane Clear the glomerular filter of immune complexes and cellular debris Extraglomerular Mesangial (Lacis) Cells lie outside the glomerulus at the vascular pole and form part of the juxtaglomerular apparatus. Glomerular Mesangium a specialized connective tissue which binds the loop of glomerular capillaries and fills the spaces between endothelial surfaces that are not invested by podocytes Renal Tubule consists of a glomerular capsule that leads into a proximal convoluted tubule connected to the capsule by a short neck and continuing into a sinuous or coiled convoluted part which straightens as it approaches the medulla, and becomes the descending thick limb of the loop of Henle and then the ascending limb by an abrupt U-turn then continues into the distal tubule then it straightens once more as the connecting tubule which ends by joining a collecting duct lined by a single layered epithelium whose cells vary according to the functional roles of different regions Functional Roles 1. Active transport and passive diffusion of various ions and water into and out of the tubules 2. Reabsorption of organic components such as glucose and amino acids 3. Uptake of any proteins which leak through the glomerular filter. Proximal Convoluted Tubule cuboidal or low columnar epithelium & has a brush border of tall microvilli on its luminal surface (shape depends on distension d/t tubular fluid pressure) Basal cytoplasm is rich in mitochondria, oriented perpendicularly and highly infolded Water & solutes pass between cells passively along osmotic & electrochemical gradients Permeable to water so filtrate remains isotonic Pinocytotic vesicles are near its apical surface Loop of Henle Thin segment: low cuboidal to squamous cells o Forms most of the loop in juxtamedullary nephrons w/c reach deep into the medulla

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o Has few organelles w/c play a passive role in ion transport Thick segment: cuboidal cells like DCT o Has many mitochondira, deep basolateral folds & short apical microvilli indicating an active metabolic role o Source of Tamm-Horsfall protein in normal urine Distal Convoluted Tubule cuboidal & resemble those in the proximal tubule have few microvilli so lumen is more distinct enzymes concerned in active transport of Na, K etc are abundant comes close to the vascular pole of its parent renal corpuscle where tubular cells form the macula densa cells at its terminal end have fewer basal folds & mitochondria Collecting Ducts originate in the cortical medullary rays and join others at intervals. They finally open into wider papillary ducts which open on to a papilla, their numerous orifices forming a perforated area cribrosa on the surface at its tip lined by simple cuboidal/columnar epithelium w/c in height from the cortex where the ducts receive contents of the DCT to the papillary ducts has few organelles & occasional microvilli has intercalated or dark cells which secrete H+ into the filtrate for maintenance of acid-base homeostasis Macula Densa focal thickening of the tubule wall where it comes close to the vascular pole of its parent glomerulus at the start of the DCT Sensory structure concerned with the regulation of blood flow & filtration rate a cluster of up to 40 tightly packed cells in the tubule wall; the cells have large, oval nuclei and apically concentrated mitochondria. osmoreceptors, sensing the NaCl content of the filtrate after its passage through the loop of Henle. Releases nitric oxide w/c inhibits tubuloglomerular feedback response & reduces filtration rate. Pacemaker cells cells situated within calyces which initiate renal pelvic & ureteric peristalsis (6/min) Glomerular Filtration passage of water containing dissolved small molecules from the blood plasma to the urinary space in the glomerular capsule

>70 kda & those with negative charge cannot pass occurs along a steep pressure gradient between the large glomerular capillaries and the urinary space, the principal structure separating the two being the glomerular basal lamina. This gradient exceeds the colloid osmotic pressure of the blood which opposes the outward flow of filtrate can be altered by changes in the tome of the glomerular arterioles Filtrates is isotonic with glomerular blood at first Glomerular Filtration Rate based on the renal clearance of a marker in plasma, expressed as the volume of plasma completely cleared of the marker per unit time. Markers used to measure GFR may be endogenous (creatinine, urea) or exogenous (inulin, iothalamate) substances Ideal markers are endogenous, freely filtered by the glomerulus, neither reabsorbed nor secreted by the renal tubule, and eliminated only by the kidney. Selective Resorption an active process and occurs mainly in the PCTs, which resorb glucose, amino acids, phosphate, chloride, sodium, calcium and bicarbonate; they also take up small proteins (e.g. albumin) by endocytosis Urine is reduced in volume & hypertonic to blood when it reaches the calyces Depends on the establishment of high osmolality in the medullary interstitium in order to exert sufficient osmotic pressure on water-permeable regions of the tubule, and is achieved by a countercurrent multiplier mechanism. Countercurrent Multiplier Mechanism responsible for producing a high osmolality in the extratubular interstitial tissue of the renal medulla The osmotic gradient within the interstitium is multiplied from the corticomedullary boundary to the medullary pyramids, where it reaches an equilibrium of four to five times the osmolality of plasma. Although the tonicity of the tubular fluid changes during its passage through the steep osmotic gradient 1. Along the descending limb water passes freely from the tubular lumen into the interstitial space. This part is less permeable to solutes. 2. In the thick ascending limb, Na & Cl are actively transported from the tubule lumen into interstitial spaces while the tubular epithelium remains impermeable to water. (Furosemide &

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Bumetamide act here) 3. Water is withdrawn from the descending part of the loop thus concentrating the filtrate d/t interstitial osmolality. 4. Tubular fluid flows in a countercurrent on its descent into and ascent out of the medulla: it is augmented by new isotonic fluid entering the loop and depleted by hypotonic fluid leaving the loop, as solutes are actively resorbed. Countercurrent Exchange Mechanism Minimizes rapid removal of ions from the renal medulla by the circulation of blood Arterioles entering the medulla pass for long distances parallel to the venules leaving it, before ending in capillary beds around tubules. This close apposition of oppositely flowing blood allows the direct diffusion of ions from outflowing to inflowing blood, so that the vasa recta conserve the high osmotic pressure in the medulla. Concentration of Urine Na & Cl are selectively absorbed by the ascending limbs & DCT under aldosterone control so filtrate at the distal end of the convoluted tubule is hypotonic. As it reaches the collecting ducts, fluid descends again through the medulla and thus re-enters a region of high osmotic pressure. The collecting ducts are variably permeable to water under ADH. Tonicity of the filtrate gradually rises along collecting ducts, until at the tip of the renal pyramids it is above that of blood Juxtaglomerular Apparatus provides a tubuloglomerular feedback system which maintains systemic arterial blood pressure during a reduction in vascular volume and decrease in filtration rate Components: JG & lacis cells, macula densa JG cells are large, rounded myoepithelioid cells and their cytoplasm contains many mitochondria and dense, renin-containing vesicles, 1040 nm in diameter

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KIDNEY AND URETER Grays Anatomy Chapter 74. URETER two muscular tubes whose peristaltic contractions convey urine from the kidneys to the urinary bladder thick walled and narrow continuous with the renal pelvis descends slightly medially to open into the base of the urinary bladder Length: 25-30 cm Diameter: 3 mm but slightly less at its junction with the renal pelvis, at the brim of the lesser pelvis and where it runs within the wall of the bladder which is its narrowest part (areas for stone impaction) Distal 1-2 cm is surrounded by an incomplete collar of non-striated muscle which forms a sheath (of Waldeyer) They pierce the posterior aspect of the bladder and run obliquely through its wall for a distance of 1.52 cm (intramural ureters) before terminating at ureteric orifices Intramural Ureters assist in the prevention of urine reflux as they are occluded during increases in bladder pressure and at the ureteric orifices become continuous with the superficial trigone muscle. Ureteric Openings 5 cm apart in a distended bladder and 2.5 cm apart when the bladder is empty. Relations in the Abdomen descends posterior to the peritoneum on the medial part of psoas major, which separates it from the tips of the lumbar transverse processes It crosses in front of the genitofemoral nerve & obliquely crossed by the gonadal vessels. It enters the lesser pelvis anterior to either the end of the common iliac vessels or at the origin of the external iliac vessels Right Ureter Relations At its origin, it is overlapped by the descending part of the duodenum Descends lateral to the IVC and is crossed anteriorly by the R colic & ileocolic vessels It passes behind the lower part of the mesentery & terminal ileum near the superior aperture of the lesser pelvis. Left Ureter Relations L ureter is lateral to the aorta with the inferior mesenteric vein lying close to its medial aspect

Is crossed by the gonadal & L colic vessels Passes posterior to the loops of jejunum & sigmoid colon and its mesentery in the posterior wall of the intersigmoid recess. Relations in the Pelvis ureter lies in extraperitoneal areolar tissue descends posterolaterally on the lateral wall of the lesser pelvis along the anterior border of the greater sciatic notch. Opposite the ischial spine it turns anteromedially into fibrous adipose tissue above levator ani to reach the base of the bladder. On the pelvic side wall, it is anterior to the internal iliac artery, posterior to it is the internal iliac vein, lumbosacral nerve & sacroileal joint. Laterally, it lies on the fascia of the obturator internus It then becomes medial to the umbilical, inferior vesical & middle rectal arteries Anterior to the seminal vesicles Posterior to the ovary *waaaaah! Kabaliw! Basahin mo nalang yung grays para sa the rest ng relations ng ureter. Andami!* Duplex Ureter (1/125 individuals) Two ureters drain the renal pelvis on 1 side Contained in a single fascial sheath and may fuse at any point or separate until they insert through separate ureteric orifices into the bladder Ureter from the upper pole of the kidney (longer) inserts more medially & caudally in the bladder than the ureter from the lower pole (prone to reflux) Bilateral Duplex Ureter (1/800 individuals) Ectopic Ureters Single ureters, and more commonly the longer ureter of a duplex system, can insert more caudally and medially than normal in some individuals. Males: can insert at the bladder neck, posterior urethra or seminal vesicles Females: distal to the external urethral sphincter in the urethra or vagina resulting to incontinence Ureteroceles cystic dilatation of the lower end of the ureter: the ureteric orifice is covered by a membrane which expands as it is filled with urine and then deflates as it empties. Can be a cause of obstruction in the ureter and

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pelvicalcyceal system but do not cause bladder outflow obstruction except for prolapsing ureterocele Tend to be bilateral and small resulting in a cobrahead halo around the ureteric orifice Retrocaval Ureter (1/1500 individuals) persistence of the posterior cardinal vein, associated with high confluence of the R & L common iliac veins or a double inferior vena cava No clinical sequelae although it can result in upper ureteric obstruction VASCULAR SUPPLY AND LYMPH DRAINAGE Arteries: *constant Renal artery* Gonadal artery Common Iliac artery Internal Iliac artery Vesical artery* Uterine Arteries Abdominal Aorta Abdominal Ureter vessels supplying it are medial Pelvic Ureter vessels supplying it are lateral Venous Drainage: (follows the arterial supply) Lymphatic Drainage: begin in submucosal, intramuscular and adventitial plexuses which all communicate. Upper abdominal ureter may join the renal collecting vessels or pass directly to the lateral aortic nodes Lower abdominal ureter drain into the common iliac nodes Pelvic Ureter drain into the common, external or internal iliac nodes Innervation lower three thoracic, first lumbar, and the second to fourth sacral segments of the spinal cord by branches from the renal and aortic plexuses, and the superior and inferior hypogastric plexuses. Density of innervation increases gradually from the renal pelvis and upper ureter (where autonomic nerves are sparse) to a maximum density in the juxtavesical segment. Neurotransmitter Phenotype: Cholinergic Noradrenergic Peptidergic (substance P)

Ureteric Peristalsis contraction waves originate in the proximal part of the upper urinary tract and are propagated in an anterograde direction towards the bladder Pacemaker sites are in the walls of the minor calyces Contraction is propagated through the wall of the adjacent major calyx and activates the smooth muscle of the renal pelvis. Pressures at time of peristalsis reach 20-80 cm H20 Autonomic nerves DO NOT play a major part in the propagation of peristalsis, they play only a MODULATORY ROLE. Myogenic conduction mediated by electrotonic coupling via intercellular gap junctions is the most likely to account for impulse propagation Referred Pain due to Distension or Spasm Provokes severed pain (ureteric colic) which is spasmodic & agonizing Pain is referred to cutaneous areas innervated by those supplying the ureter, mainly T11-L2 shooting down & forwards from the loin to the groin & scrotum/labium majus and extend in the proximal aspect of the thigh by the projection of the genitofemoral nerve (L1,2) Cremaster may reflexively retract the testis Renal & Ureteric Calculi Smaller renal calculi are treated with extracorporeal shock wave lithotripsy Ureteric calculi tend to be arrested in their descent in either the pelviureteric region, or the point where the ureter passes over the pelvic brim as it crosses the common iliac artery, or the vesicoureteric junction, because these are the three areas where the ureter is narrowest. Kidney and upper ureter move with respiration within the perirenal fascia. Microstruture of the Ureter external adventitia, a smooth muscle layer and an inner mucosal layer (folded urothelium with connective tissue lamina propria) Upper Part: Inner Longitudinal, outer Circular/Oblique muscle bundles Middle & Lower Part: additional outer longitudinal Ureterovesical Junction: predominantly longitudinal muscle bundles

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