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1 Anatomy oftheKidney
run cranial and anterior to the renal pelvis when entering the hilum [15]. Due to the
proximity of the aorta to the left kidney, the left renal artery is short and travels
straightforwardly to its respective kidney, while the right artery is long and crosses
the inferior vena cava (IVC) posteriorly before reaching its respective kidney.
Inversely, due to the proximity of the inferior vena cava (IVC) to the right kidney,
the right renal vein is approximately two to three times shorter than its left counterpart and travels straight to the IVC [15, 20]. The left renal vein travels anterior to the
aorta below the origin of the superior mesenteric artery before entering the left side
of the IVC.Rarely the left renal vein travels behind the aorta, being referred to as a
retroaortic renal vein. In the very rare cases where the left renal vein duplicates,
the two branches can separate and travel anterior and posterior to the aorta, forming
the so-called circumaortic left renal vein. Contrary to its right counterpart, the left
renal vein has many tributaries, namely the gonadal vein inferiorly, the adrenal
vein superiorly, the inferior phrenic veins, the rst or second lumbar veins pos-
teriorly, and paravertebral veins which are encountered in one-third of cases [15].
The renal artery divides into interlobar, arcuate, and interlobular arteries, in
progressive order. With no anastomosis between them, the interlobar arteries arise
from the kidney hilum and give rise to the arcuate arteries that lie at the junction
between the cortex and the outer medulla. The arcuate arteries give rise to the interlobular arteries toward the capsule and nally to the afferent vessels of the
glomeruli. Then the glomerular efferent vessels form a peritubular capillary network. There is a profuse peritubular vascular network surrounding the convoluted
tubules.
The venous return from the medulla occurs through numerous vessels rising
within and beside the vascular bundles. The hierarchy starts with the peritubular
capillary venous plexus, then the venae rectae, and the arcuate veins. From this
level, the venous system resembles the arterial one: the interlobular veins unite to
form the renal vein anterior to the renal pelvis (Fig.1.6). However, contrary to the
arterial organization, there are anastomotic longitudinal venous arcades that
communicate between the interlobular veins. Thus, these veins are not terminal,
and major branches can be surgically ligated without risking a venous obstruction.
In two-thirds of the cases, there is a retrocolic vein draining a portion of the posterior part of the kidney [15, 16, 21, 22].
Interventional radiologists and urologists should be aware of the anatomical
variations of the renal arterial supply. Roughly, the published series from various
populations show a distribution of 70–82% of single arteries, 17–20% of double
arteries, and 1–2% of triple arteries [14, 15, 23, 24]. After an analysis of 266 cadaveric kidneys performed in Brazil, Sampaio, and Passos provided more details on
these variations: 53.3% had one hilar artery, 14.3% had one hilar artery with one
superior pole extra-hilar branch, 7.9% had two hilar arteries, 6.8% had a superior
polar artery, 5.3% had an inferior polar artery, 3.4% had two hilar arteries with one
superior pole extra-hilar branch, 2.6% had one hilar artery with early bifurcation,
1.9% had three hilar arteries, and other variations in 2.5% [25, 26] (Fig.1.7).
Note: The numbers in bold represent cases of single arteries for a total of 70.2%.
1.5 Arterial Supply andVenous Drainage
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Fig. 1.6 Section of the
human kidney showing the
major vessels that supply
the blood ow to the
kidney and schematic of
the microcirculation of
each nephron. (From
Guyton and Hall [21], with
permission from Elsevier)
11
1 hilar artery
55.3%
2 hilar arteries
1 inferior polar
artery
with 1 superior pole
extra-hilar branch
5.3% 3.4%
1 superior pole
extrahilar branch
14.3%
2 hilar arteries
7.9% 6.8%
1 hilar artery
with an early
bifurcation
2.6%
1 superior pole artery
3 hilar arteries
1.9%
Fig. 1.7 Graphic illustration of variant renal anatomy. (From Lopez-Gonzalez etal. [26], with
permission from Georg Thieme Verlag KG)
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1 Anatomy oftheKidney
It has been suggested to avoid the term “supernumerary” when referring to the
accessory arteries, as no artery is superuous, each being essential for one or more
segments in the kidney, and to reserve the term “aberrant” for vessels whose course
is truly abnormal, for example, those entering the kidney by the poles, or whose
origin is from a vessel other than the aorta, such as the hepatic artery, the superior
or inferior mesenteric arteries, the right colic artery, or the lumbar arteries [11, 15].
Based on 153 kidney dissections, David Sykes proposed to divide the renal artery
into three types [12]:
(a) The rst type (“the typical”) represents 83.1%. The artery is unique and divides
near or within the renal hilum into an anterior branch carrying 75% of the blood
and a posterior branch carrying 25% of the blood [14]. From the two divisions
arise a total of ve segmental branches, namely, the apical, upper, middle,
lower, and posterior branches. These segmental arteries are end arteries and
do not have collateral circulation. Hence, ligation of each of them causes irreversible ischemia and infarction of its supplied territory [15, 16].
Unlike the apical and lower segmental arteries, the upper, middle, and posterior arteries are limited to the avascular Brӧdel’s line which only runs between
the territories supplied by the apical and the lower segmental arteries, in a plane
between the anterior 2/3 and the posterior 1/3 of the kidney, measured by recent
studies to be at 2.04cm (1.8–2.4cm) medial to the lateral convex border of
the kidney [27]. Based on a limited sample (only 15 kidneys), the ndings of
this recent study challenge those of David Sykes, as they mention that the
Brӧdel avascular plane extended from the apical to the inferior segment in six
cases (40%). Anyway, it is important to know that this line is not truly avascular
as there are some overlapping terminal branches of the anterior and posterior
branches [11, 12, 27, 28].
(b) The second type represents 8.4%: The arterial pattern corresponds to the
venous arrangement. Here the renal artery divides into three branches: the
upper, middle, and lower branches. Each of these arteries divides into an anterior and a posterior branch and supplies its respective third, anteriorly and
posteriorly.
(c) The third type represents also 8.4%: Here there is a dual arterial pattern where
the kidney receives two arteries from the aorta, with comparable diameters.
In the abovementioned research, accessory renal arteries were encountered in
25.8%, entering the kidney cortex at one of its poles. Sampaio proposed a more
practical approach that demarcates three arterial regions worthy of notice for surgical trauma management or partial nephrectomy [14]:
(a) Superior pole: In 86.6% of the cases, the superior pole is supplied by three
arteries: the apical segmental artery and two other branches (i.e., anterior and
posterior).
1.6 Congenital Abnormalities
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(b) Inferior pole: In 62.2% of the cases, the inferior pole is supplied only by the
inferior segmental artery, anteriorly and posteriorly, and its bleeding control
is less complicated than for the upper pole.
(c) Mid- or hilar zone: Its anatomy is very complex. Mid-kidney resection is also
technically more challenging to perform than a polar one, as it must not only
control a complex vascular network but also maintain adequate vascularization
and a patent collecting system for the superior and inferior poles.
13
1.6 Congenital Abnormalities
Nowadays, due to generalized antenatal ultrasonography, many abnormalities have
become detectable. A German study including over 30,000 infants and fetuses
showed major malformations in 6.9% and mild errors of morphogenesis in 35.9%
of all infants. Among major malformations, the most frequent were musculoskeletal, internal urogenital, and cardiovascular malformations, which collectively
accounted for more than 60%, with the incidence of 239, 162, and 113 per 10,000
infants, respectively [29].
Kidney anomalies are reported to account for 20–30% of all detectable anomalies [30]. The congenital kidney malformations include the following phenotypes
[8, 9, 30, 31] (Fig.1.8):
– Horseshoe kidney (HSK) or renal fusion: This is the most frequent abnormal-
ity with an incidence of 1in every 400–500 live births.
– Malrotation: The result of the malrotation is the hilum facing anteriorly, and the
incidence is 1/500.
– Duplex kidney.
– Polycystic kidney disease.
– Multicystic dysplastic kidney (MCDK): 1in 3640 births.
– Ectopic kidney: Often in pelvic location, can be unilateral or bilateral. The inci-
dence of simple ectopia is 1/10,000. Bilateral pelvic kidneys can fuse in a so-
called pancake kidney. The ectopic kidney can cross and fuse with the
contralateral one with an incidence of 1/2000. Very rarely, a three-in-one anom-
aly consisting of a solitary crossed renal ectopia has been described with only
about 35 cases reported in the literature and an estimated incidence of 1/1,500,000.
However, in all crossed kidneys, the ureters retain the embryological mem-
ory, crossing back the midline and inserting into the normal bladder site.
– Renal dysplasia: Can be unilateral with an incidence of 1/4300 for multicystic
dysplastic kidneys and 1/1000 for dysplastic kidneys, or rarely bilateral with an
incidence of 1/7500.
– Renal hypoplasia: Can be unilateral (1/1000) or bilateral (1/4000).
– Supernumerary or accessory kidney.
– Renal agenesis: Unilateral (1/1000) or bilateral (1/10,000). The latter is more
common in males and is incompatible with life.
14
Inf
ab
cd
ef
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1 Anatomy oftheKidney
erior vena cava
Aorta
Bladder
Suprarenal
Metanephric
mesoderm
Absence of
ureteric bud
Suprarenal gland
Bifid ureter
Complete division
of ureteric bud
gland
Double
kidney
Suprarenal
gland
Pelvic kidneyPelvis
Fused kidneys
Suprarenal gland
Divided kidney
Bifid ureter
Incomplete division
of ureteric bud
Suprarenal gland
Ureters
Left kidney migrated
to right side
Discoid (”pancake”) kidney
Ureters
Fusion
of kidneys
Supernumerary kidney
Two ureter ic buds
Fig. 1.8 Drawings illustrating various anomalies of the urinary system. The small sketch to the
lower right of each drawing illustrates the probable embryological basis of the anomaly. (a)
Unilateral renal agenesis. (b) Right side, pelvic kidney; left side, divided kidney with a bid ureter.
(c) Right side, malrotation of the kidney; left side, bid ureter and supernumerary kidney. (d)
Crossed renal ectopia. The left kidney crossed to the right side and fused with the right kidney. (e)
Discoid (also pancake kidney) resulting from the fusion of the kidneys while they are in the pelvis.
(f) Supernumerary left kidney resulting from the development of two ureteric buds. (From Zweyer
M [9], with permission from Springer Nature)
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Springer; 2018. https://doi.org/10.1007/978- 3- 319- 39202- 8_7.
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Springer; 2021. https://doi.org/10.1007/978- 3- 030- 56802- 3_17.
9. Zweyer M.Embryology of the kidney. In: Quaia E, editor. Radiological imaging of the kidney,
Medical radiology. Berlin: Springer; 2010. https://doi.org/10.1007/978- 3- 540- 87597- 0_1.
10. White RD, Moore KS, Salahia MG, Thomas WR, Gordon AC, Williams IM, Wood AM, Zealley
IA.Renal arteries revisited: anatomy, pathologic entities, and implications for endovascular
management. Radiographics. 2021;41(3):909–28. https://doi.org/10.1148/rg.2021200162.
11. Vordermark JS 2nd. Segmental anatomy of the kidney. Urology. 1981;17(6):521–31. https://
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12. Sykes D.The arterial supply of the human kidney with special reference to accessory renal
arteries. Br J Surg. 1963;50:368.
13. Part I: Size of normal kidneys in adults. Acta Radiol. 1961;os-56(206_Suppl):7–31. https://doi.
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14. Sampaio FJ. Renal anatomy. Endourologic considerations. Urol Clin N Am.
2000;27(4):585–607, vii. https://doi.org/10.1016/s0094- 0143(05)70109- 9.
15. Klatte T, Ficarra V, Gratzke C, Kaouk J, Kutikov A, Macchi V, Mottrie A, Porpiglia F, Porter J,
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16. Mahadevan V. Anatomy of the kidney and ureter. Surgery (Oxford). 2019;37(7):359–64.
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18. Blausen.com Staff. Medical gallery of Blausen Medical 2014. WikiJournal Med. 2014;1(2)
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TT, Pavikuttan N, Sudhakaran R Sr. Prevalence and relevance of multiple renal arteries: a Radioanatomical perspective. Cureus. 2021;13(10):e18957. https://doi.org/10.7759/
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1 Anatomy oftheKidney
Epidemiology ofRenal Trauma
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The kidney is the third most injured organ in abdominal trauma after the spleen and
liver [1, 2] (Fig.2.1).
By the end of the last century (1997–1998), a population-based study showed an
incidence of renal trauma in the USA of 4.9 per 100,000 population, comprising
1.2% of all trauma cases [3]. However, more recent estimations based on the
American National Trauma Data Bank (NTDB) suggest a lower rate of 0.3–0.5%
[4, 5]. The same proportion has been found elsewhere in Europe in general and in
France in particular [6, 7]. A systematic review of 15 adult renal trauma articles
including nearly 11,000 patients showed an overall male predominance of 72% and
a mean age of 30.8years [8]. A more recent and larger review of 46 articles including 48,660 patients conrmed the above data showing 75.3% of males and a mean
age of 33years [9], and a Japanese retrospective study conducted during the same
period and including 3550 patients showed a nearly equal male predominance
(74.2%) but a higher median age of 43years, which probably correlated to the age
distribution in this country [10]. In the Middle East, higher male predominance and
younger age of the victims might prevail in urogenital trauma (UGT) as suggested
by an Iranian study that found a male rate of 91% and an average age of 25years [11].
The majority of renal injuries are caused by blunt trauma accounting for 80.5%
versus only 19.5% for penetrating trauma, and the overall mortality rate is 6.4%
(4.8–8.4%) [9]. However, penetrating injuries are reported to predominate in underdeveloped countries and areas of social insecurity and civil unrest. This fact was
suggested by a retrospective study in a Turkish region subjected to increased sociopolitical tensions, which showed that 59% of the encountered renal injuries were
secondary to gunshot wounds [12], and by a South African study that showed threequarters of renal injuries being caused by penetrating agents and half by gunshots
only [13]. In penetrating renal injuries, the median age of patients is lower (28years),
and the male predominance of the victims is strikingly higher, reaching 93% [14].
When specifying UGT after road trafc accidents (RTA), the male predominance
increases to 76% and the mean age remains almost the same (30.3years) [6]. When
2
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_2
17
18
11%
19%
30%
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Fig. 2.1 Distribution of
the four most frequent
abdominal injuries in the
combined data set for the
years 1993–1998. (From
Yoganandan N etal. [2],
with permission from the
Association for the
Advancement of
Automotive Medicine)
9%
2 Epidemiology ofRenal Trauma
31%
Spleen
Liver
Kidney
Digestive
Other
Fig. 2.2 Overall distribution of GUI after trafc accidents (n=963 victims). (From Terrier etal.
[7], with permission from Wolters Kluwer Health, Inc.)
especially addressing penetrating renal trauma, the male predominance even deepens to 88% and the mean age falls to 28years. For the pediatric group, there is a
lesser male predominance, 67%, and the mean age is 9.3years [8].
Among urogenital organs, the most frequently injured ones after motor vehicle
accidents (MVA) are the kidneys and the testicles with 41–43% and 23–24%,
respectively, and ureteric trauma is almost not observed [6, 7] (Fig.2.2). However,
when considering only motorcyclists, 62% of injuries involved the external genitalia, and the testes were the most injured organs (38–41%). The penis was the most
References
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19
involved organ among cyclists (23–41%), while the pedestrians showed a nearly
equal frequency for all organs [6, 7].
Minor renal trauma grades are fortunately more frequently encountered than
major ones, and data show the following distribution: grade I, 22–28%; grade II,
28–30%; grade III, 20–26%; grade IV, 15–19%; and grade V, 6–7%. Details of this
grading will be discussed later in this section [8, 15, 16].
Notably, 85% of children sustaining renal trauma are older than 6years with a
mean age of 9.3years. The distribution parallels that of the adults with the majority
of blunt injuries occurring in males (67–77%) [8, 17]. However, there is a discrepancy with regard to the injury grade distribution in the pediatric group due to a lack
of large reviews; some studies show a great proportion of high-grade injuries [8],
while others present a predominance of low-grade ones [17].
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9. Petrone P, Perez-Calvo J, Brathwaite CEM, Islam S, Joseph DK.Traumatic kidney injuries: a
systematic review and meta-analysis. Int J Surg. 2020;74:13–21. ISSN: 1743-9191. https://doi.
org/10.1016/j.ijsu.2019.12.013.
10. Nakao S, Katayama Y, Hirayama A, etal. Trends and outcomes of blunt renal trauma management: a nationwide cohort study in Japan. World J Emerg Surg. 2020;15:50. https://doi.
org/10.1186/s13017- 020- 00329- w.
11. Salimi J, Nikoobakht MR, Zareei MR.Epidemiologic study of 284 patients with urogenital
trauma in three trauma center in Tehran. Urol J. 2004;1(2):117–20.
12. Ersay A, Akgün Y. Experience with renal gunshot injuries in a rural setting. Urology.
1999;54(6):972–5.
13. Madiba TE, Haffejee AA, John J.Renal trauma secondary to stab, blunt and rearm injuries: a
5-year study. S Afr J Surg. 2002;40(1):5–9; discussion 9–10.
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