What is the anatomy of the kidneys relevant to radical nephrectomy?

Updated: Feb 05, 2019
  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

The kidneys are paired vital organs located on either side of the vertebral column and embedded in the intermediate stratum of retroperitoneal connective tissue. The perirenal fascia, also called the Gerota fascia, encloses both the kidneys and adrenal glands.

Renal malignancies tend to remain within this fascia and can be excised completely by removing the kidney and its surrounding fascia as a single entity. In most individuals, a single renal artery and vein enters the kidney medially through the renal hilum, but multiple renal arteries are not uncommon.

The renal artery arises from the lateral aspect of the aorta, just below the superior mesenteric artery, and passes behind the renal vein. The main renal artery then divides into 4-5 segmental vessels to supply the corresponding renal parenchyma. These segmental vessels are end arteries without collateral circulation; thus, any injury to the renal artery at any level results in infarction of the corresponding parenchyma.

Unlike the renal arteries, the renal parenchymal veins intercommunicate freely among the various renal segments. Usually, a single renal vein joins the inferior vena cava on its lateral aspect. Multiple renal arteries occur unilaterally in 23% of the population, whereas multiple renal veins are less common.

The right adrenal gland lies above the kidney posterolateral to the inferior vena cava. The inferior phrenic artery is the main blood supply, with additional branches from the aorta and renal artery. The venous drainage usually is through a common vein on the right, exiting the apex of the gland and entering the posterior surface of the inferior vena cava. This vein is short and fragile and is a common source of bleeding during right adrenalectomy. The left vein empties directly into the left renal vein approximately 3 cm from the inferior vena cava and often opposite to the gonadal vein. Not well-recognized is the left inferior phrenic vein, which typically communicates with the adrenal vein but then courses medially and can be injured during dissection of the medial edge of the gland.

The paired gonadal arteries arise from the anterolateral aorta at a level somewhat below the renal vessels. Occasionally, a gonadal artery arises from the ipsilateral renal artery or from the aorta above the level of the renal vessels. In their retroperitoneal course, the gonadal arteries pass anteriorly to the ureter on either side. Gonadal veins parallel the gonadal arteries in their inferior course but, superiorly, tend to be more lateral and closer to the ipsilateral ureter. The left gonadal vein usually enters the inferior aspect of the left renal vein perpendicularly. The right gonadal vein usually drains obliquely into the right lateral aspect of the inferior vena cava, below the level of the right adrenal vein.


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