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 a LANGE medical book

Smith & Tanagho’s

General Urology
NINETEENTH EDITION

Edited by

Jack W. McAninch, MD, FACS, FRCS(E)(Hon)

Professor of Urology
University of California School of Medicine
Chief, Department of Urology
San Francisco General Hospital
San Francisco, California

Tom F. Lue, MD, FACS, ScD (Hon)

Professor of Urology
Department of Urology
University of California School of Medicine
San Francisco, California

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 Contents
Contributors vii 10 Laparoscopic Surgery 149
Preface xi
David B. Bayne, MD, MPH;
J. Stuart Wolf, Jr., MD, FACS;
1 Anatomy of the Genitourinary Tract 1
Marshall L. Stoller, MD; & Thomas Chi, MD
Emil A. Tanagho, MD; &
Tom F. Lue, MD, ScD (Hon), FACS 11 Robotic Surgery in Urology 167
Maxwell V. Meng, MD, MPH
2 Embryology of the Genitourinary System 17
Emil A. Tanagho, MD; Hiep T. Nguyen, MD; 12 Urinary Obstruction & Stasis 177
& Michael DiSandro, MD
Marshall L. Stoller, MD; &
Tom F. Lue, MD, FACS, ScD (Hon)
3 Symptoms of Disorders of the
Genitourinary Tract 31
13 Vesicoureteral Reflux 191
Benjamin N. Breyer, MD, MAS, FACS
Thomas W. Gaither, MD, MAS; &
Hillary L. Copp, MD, MS
4 Physical Examination of the
Genitourinary Tract 41
14 Bacterial Infections of the
Maxwell V. Meng, MD, MPH; & Genitourinary Tract 201
Emil A. Tanagho, MD
Mary K. Wang, MD; &
Hillary L. Copp, MD, MS
5 Urologic Laboratory Examination 49
Anobel Y. Odisho, MD, MPH; 15 Specific Infections of the
Sima P. Porten, MD, MPH; & Genitourinary Tract 229
Kirsten L. Greene, MD, MS
Emil A. Tanagho, MD; &
Christopher J. Kane, MD, FACS
6 Radiology of the
Urinary Tract 63
16 Sexually Transmitted Infections 243
Daniela Franz, MD; Scott Gerst, MD; &
Hedvig Hricak, MD, PhD Kristin Madden, PharmD;
Amanda B. Reed-Maldonado, MD, FACS;
& John N. Krieger, MD
7 Vascular Interventional Radiology 107
Ryan Kohlbrenner, MD; & Roy L. Gordon, MD 17 Urinary Stone Disease 259
Marshall L. Stoller, MD
8 Retrograde Instrumentation of
the Urinary Tract 117
18 Injuries to the Genitourinary Tract 291
Marshall L. Stoller, MD
Benjamin N. Breyer, MD, MAS, FACS
9 Percutaneous Endourology and
Ureterorenoscopy 129 19 Urothelial Carcinoma: Cancers of the
Bladder, Ureter, and Renal Pelvis 309
David B. Bayne, MD, MPH;
Joachim W. Thüroff, MD; Badrinath R. Konety, MD, MBA; &
Rolf Gillitzer, MD; & Thomas Chi, MD Peter R. Carroll, MD, MPH

iii

McAninch_FM_pi-xii.indd 3 11/02/20 11:21 AM

 iv Contents

20 Renal Parenchymal Neoplasms 329 31 Disorders of the Adrenal Glands 509

Anobel Y. Odisho, MD, MPH; & Michelle L. McDonald, MD; &
Kirsten L. Greene, MD, MS Christopher J. Kane, MD, FACS

21 Cancer of the Prostate Gland 351 32 Disorders of the Kidneys 521

Matthew R. Cooperberg, MD, MPH; David B. Bayne, MD, MPH;
Samuel L. Washington III, MD; & Jack W. McAninch, MD, FACS, FRCS(E)(Hon); &
Peter R. Carroll, MD, MPH Thomas Chi, MD

22 Genital Tumors 377 33 Diagnosis of Medical Renal Diseases 539

Sima P. Porten, MD, MPH; & Brian K. Lee, MD; & Flavio G. Vincenti, MD
Joseph C. Presti, Jr., MD
34 Acute Kidney Injury and Oliguria 551
23 Urinary Diversion and
Brian K. Lee, MD; & Flavio G. Vincenti, MD
Bladder Substitutions 391
Maxwell V. Meng, MD, MPH; 35 Chronic Kidney Disease and
Susan Barbour, RN, MS, WOCN; & Renal Replacement Therapy 557
Peter R. Carroll, MD, MPH
Brian K. Lee, MD; &
Flavio G. Vincenti, MD
24 Systemic Therapy of Urologic Tumors 407
Vadim S. Koshkin, MD; & Eric J. Small, MD 36 Renal Transplantation 563
John M. Barry, MD
25 Immunotherapy in
Urologic Malignancies 415
37 Disorders of the Ureter and
Arpita Desai, MD; & Eric J. Small, MD Ureteropelvic Junction 571
Barry A. Kogan, MD
26 Radiotherapy of
Urologic Tumors 421
38 Disorders of the Bladder, Prostate,
Yun Rose Li, MD, PhD; and Seminal Vesicles 585
Alexander R. Gottschalk, MD, PhD; &
Mack Roach III, MD Samuel L. Washington III, MD; &
Katsuto Shinohara, MD
27 Neurophysiology and Pharmacology
of the Lower Urinary Tract 453 39 Male Sexual Dysfunction 605
Karl-Erik Andersson, MD, PhD Amanda B. Reed-Maldonado, MD, FACS; &
Tom F. Lue, MD
28 Neurogenic Bladder 473
40 Women’s Sexual Health 631
Anne M. Suskind, MD, MS, FACS
Alan W. Shindel, MD, MAS; &
Tami S. Rowen, MD, MS
29 Urodynamics 485
Anne M. Suskind, MD, MS, FACS 41 Disorders of the Penis and
Male Urethra 645
30 Urinary Incontinence 499
Benjamin N. Breyer, MD, MAS, FACS; &
Tom F. Lue, MD, FACS, ScD (Hon); & Jack W. McAninch, MD, FACS, FRCS(E)(Hon)
Emil A. Tanagho, MD

McAninch_FM_pi-xii.indd 4 11/02/20 11:21 AM

 Contents v

42 Disorders of the Female Urethra 659 46 Genital Gender-Affirming Surgery:

Patient Care, Decision Making, and
Donna Y. Deng, MD, MS
Surgery Options 747
43 Disorders of Sex Development 671 Maurice M. Garcia, MD, MAS

Laurence S. Baskin, MD
47 History and Physical Examination in
Pediatric Urology 769
44 Male Infertility 703
Michael DiSandro, MD
Thomas J. Walsh, MD, MS; &
James F. Smith, MD, MS
48 Introduction to Clinical
Research Design 781
45 The Aging Male 735
June M. Chan, ScD; David Tat, DO; &
James F. Smith, MD, MS; Stacey Kenfield, ScD
Bogdana Schmidt, MD, MPH; &
Thomas J. Walsh, MD, MS Index 793

McAninch_FM_pi-xii.indd 5 11/02/20 11:21 AM

 This page intentionally left blank

McAninch_FM_pi-xii.indd 6 11/02/20 11:21 AM

 Contributors
Karl-Erik Andersson, MD, PhD June M. Chan, ScD
Institute for Regenerative Medicine Program Director, Genitourinary Cancer Epidemiology and
Wake Forest University School of Medicine Population Sciences
Winston Salem, North Carolina Department of Urology
UCSF School of Medicine
Susan Barbour, RN, MS, WOCN San Francisco, California
Palliative Care Services
UCSF School of Medicine Thomas Chi, MD
San Francisco, California Associate Professor and Katzman Endowed Professor in
Clinical Urology
John M. Barry, MD Department of Urology
Professor of Urology and Professor of Surgery UCSF School of Medicine
Division of Abdominal Organ Transplantation San Francisco, California
Organ Health and Science University
Portland, Oregon Matthew R. Cooperberg, MD, MPH
Associate Professor
Laurence S. Baskin, MD Department of Urology
Chief of Pediatric Urology Helen Diller Family Comprehensive Cancer Center
University of California Children’s Medical Center UCSF School of Medicine
UCSF School of Medicine San Francisco, California
San Francisco, California
Attending Urologist Hillary L. Copp, MD, MS
Children’s Hospital Oakland Associate Professor of Urology and Pediatric Urology
Oakland, California Fellowship Director
Benioff Children’s Hospital
David B. Bayne, MD, MPH UCSF School of Medicine
Endourology Fellow San Francisco, California
Department of Urology
UCSF School of Medicine Donna Y. Deng, MD, MS
San Francisco, California Neurourology Lead, Kaiser Permanente Northern
California
Benjamin N. Breyer, MD, MAS, FACS Medical Director, Kaiser NorCal Regional Spina Bifida
Associate Professor and Vice Chair Program
Department of Urology Associate Fellowship Director, Female Pelvic Medicine
UCSF School of Medicine Reconstructive Surgery, Kaiser East Bay/UCSF
San Francisco, California Oakland, California

Peter R. Carroll, MD, MPH Arpita Desai, MD

Professor Clinical Instructor
Ken and Donna Derr-Chevron Endowed Chair in Department of Genitourinary Medical Oncology
Prostate Cancer Helen Diller Family Comprehensive Cancer Center
Department of Urology UCSF School of Medicine
UCSF School of Medicine San Francisco, California
San Francisco, California

vii

McAninch_FM_pi-xii.indd 7 11/02/20 11:21 AM

 viii Contributors

Michael DiSandro, MD Kirsten L. Greene, MD, MS

Professor of Urology Professor and Chair
Department of Urology Department of Urology
UCSF School of Medicine University of Virginia
San Francisco, California Charlottesville, Virginia

Daniela Franz, MD Hedvig Hricak, MD, PhD

Department of Diagnostic and Interventional Radiology Chair
Klinikum rechts der Isar Department of Radiology
Munich Technical University Memorial Sloan-Kettering Cancer Center
Munich, Germany Professor of Radiology
Cornell University
Thomas W. Gaither, MD, MAS New York, New York
Urology resident
University of California Christopher J. Kane, MD, FACS
Los Angeles, California Dean of Clinical Affairs
UC San Diego School of Medicine
Maurice M. Garcia, MD, MAS CEO, UC San Diego Health Physician Group
Associate Professor of Urology and Anatomy (Adjunct) La Jolla, California
Departments of Urology and Anatomy
UCSF Medical Center Stacey A. Kenfield, ScD
San Francisco, California Associate Professor
Director, Cedars-Sinai Transgender Surgery and Department of Urology
Health Program UCSF School of Medicine
Division of Urology San Francisco, California
Cedars-Sinai Medical Center
Los Angeles, California Barry A. Kogan, MD
Professor, Surgery and Pediatrics
Scott Gerst, MD Falk Chair in Urology
Associate Attending Physician Albany Medical College
Department of Radiology Albany, New York
Memorial Hospital, Memorial Sloane-Kettering
Cancer Center Ryan Kohlbrenner, MD
New York, New York Assistant Professor of Interventional Radiology
Departments of Radiology and Biomedical Imaging
Rolf Gillitzer, MD UCSF School of Medicine
Clinical Director San Francisco, California
Department of Urology
Johannes Gutenberg University Medical Center Mainz Badrinath R. Konety, MD, MBA
Mainz, Germany Associate Dean for Innovation
Professor of Urology
Roy L. Gordon, MD Director of the Institute for Prostate and Urologic Cancers
Professor of Interventional Radiology University of Iowa
Department of Radiology Iowa City, Iowa
UCSF School of Medicine
San Francisco, California Vadim S. Koshkin, MD
Assistant Clinical Professor
Alexander R. Gottschalk, MD, PhD Genitourinary Medical Oncologist
Professor of Radiation Oncology Departments of Hematology and Oncology
Director of CyberKnife UCSF School of Medicine
Departments of Radiation and Oncology San Francisco, California
UCSF School of Medicine
San Francisco, California

McAninch_FM_pi-xii.indd 8 11/02/20 11:21 AM

 Contributors ix

John N. Krieger, MD Anobel Y. Odisho, MD, MPH

Professor of Urology Assistant Professor
University of Washington School of Medicine Department of Urologic Oncology
Seattle, Washington UCSF School of Medicine
San Francisco, California
Brian K. Lee, MD
Professor of Medicine Sima P. Porten, MD, MPH
The Connie Frank Kidney Transplant Center Assistant professor
UCSF School of Medicine Department of Urology
San Francisco, California UCSF School of Medicine
San Francisco, California
Yun Rose Li, MD, PhD
Resident Physician Joseph C. Presti, Jr., MD
Departments of Radiation and Oncology Lead for Urologic Oncology
UCSF School of Medicine Kaiser Permanente Northern California
San Francisco, California Oakland, California

Tom F. Lue, MD, FACS, ScD (Hon) Amanda B. Reed-Maldonado, MD, FACS
Professor of Urology Chief, Male Reproductive Urology
Emil Tanagho Endowed Chair in Clinical Urology Department of Urology
Department of Urology Tripler Army Medical Center
UCSF School of Medicine Honolulu, Hawaii
San Francisco, California
Mack Roach III, MD
Kristin Madden, PharmD Professor of Radiation Oncology and Urology
Pharmacist Department of Urology
Department of Veterans Affairs UCSF School of Medicine
San Antonio, Texas San Francisco Comprehensive Cancer Center
San Francisco, California
Jack W. McAninch, MD, FACS, FRCS(E)(Hon)
Professor of Urology Tami S. Rowen, MD, MS
UCSF School of Medicine Assistant Professor
San Francisco, California Departments of Obstetrics, Gynecology, and
Reproductive Sciences
Michelle L. McDonald, MD UCSF School of Medicine
Urologist San Francisco, California
San Diego, California
Bogdana Schmidt, MD, MPH
Maxwell V. Meng, MD, MPH Urologic Oncology Fellow
Professor Stanford University Medical Center
Department of Urology Stanford, California
UCSF School of Medicine
San Francisco, California Alan W. Shindel, MD, MAS
Associate Professor
Hiep T. Nguyen, MD Department of Urology
Associate Professor University of California
Surgery and Urology Davis, California
Harvard Medical School and Children’s Hospital
Boston, Massachusetts

McAninch_FM_pi-xii.indd 9 11/02/20 11:21 AM

 x Contributors

Katsuto Shinohara, MD David Tat, DO

Professor Infectious Disease Specialist
Helen Diller Family Chair in Clinical Urology Moses H. Cone Memorial Hospital
Department of Urology Greensboro, North Carolina
UCSF School of Medicine
San Francisco, California Joachim W. Thüroff, MD
Professor
Eric J. Small, MD Department of Urology
Professor of Medicine and Urology University Medical Center
Urologic Oncology Program and Program Member, Mannheim, Germany
Comprehensive Cancer Center
UCSF School of Medicine Flavio G. Vincenti, MD
San Francisco, California Professor of Medicine
The Connie Frank Kidney Transplant Center
James F. Smith, MD, MS UCSF School of Medicine
Associate Professor San Francisco, California
Director, Male Reproductive Health
Departments of Urology, Obstetrics, Gynecology, and Thomas J. Walsh, MD, MS
Reproductive Sciences Associate Professor
UCSF School of Medicine Department of Urology
San Francisco, California University of Washington School of Medicine
Seattle, Washington
Marshall L. Stoller, MD
Professor of Urology Mary K. Wang, MD
Department of Urology Childrens’ Urology
UCSF School of Medicine Austin, Texas
San Francisco, California
Samuel L. Washington, III, MD
Anne M. Suskind, MD, MS, FACS Urologic Oncology Clinical Fellow
Associate Professor of Urology, Obstetrics, Gynecology, and Department of Urology
Reproductive Sciences UCSF School of Medicine
Director, Neurourology, Female Pelvic Medicine & San Francisco, California
Reconstructive Surgery
UCSF School of Medicine J. Stuart Wolf, Jr., MD, FACS
San Francisco, California Professor, Department of Surgery and Perioperative Care
Dell Medical School
Emil A. Tanagho, MD The University of Texas at Austin
Professor of Urology Austin, Texas
Department of Urology
UCSF School of Medicine
San Francisco, California

McAninch_FM_pi-xii.indd 10 11/02/20 11:21 AM

 Preface
Smith & Tanagho’s General Urology, nineteenth edition, provides the updated information for the understanding, diagnosis,
and treatment of urological diseases in a concise and well-organized format. The book is up-to-date, to the point, and readable.
Medical students will find this book useful because of its concise, easy-to-follow format, and its breadth of information on
common urological diseases. Residents, as well as practicing physicians in urology, family practice, or general medicine, will find
it an efficient and current reference, particularly because of its emphasis on diagnosis and treatment.
This nineteenth edition has been thoroughly updated with clinical information and current references. The reader will find
that this edition is written in an uncomplicated, straightforward manner that provides relevant clinical information and guide-
lines for diagnosis and management of urologic conditions. Chapters on immunotherapy in urologic malignancies, radiotherapy
of urologic tumors, urinary incontinence, and vascular interventional radiology have all undergone extensive revision. For
this current edition, we have added two chapters on the timely topic of gender dysphoria and introduction to clinical research
design.
Many illustrations and figures have been modernized and improved with added color. The classic fine anatomic drawings
demonstrate well the important clinical findings.
This book has been one of the leading sources of information for students, trainees, and urologists around the world. In addi-
tion to English, this book has been published in many other foreign languages, like Chinese, French, Greek, Italian, Japanese,
Korean, Portuguese, Russian, Spanish, and Turkish.
We greatly appreciate the patience and efforts of our McGraw-Hill staff, the expertise of our contributors, and the support
of our readers.

Jack W. McAninch, MD, FACS, FRCS(E) (Hon)

Tom F. Lue, MD, FACS, ScD (Hon)
San Francisco, California, January 2020

xi

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 This page intentionally left blank

McAninch_FM_pi-xii.indd 12 11/02/20 11:21 AM

 1

1
Anatomy of the
Genitourinary Tract

Emil A. Tanagho, MD; & Tom F. Lue, MD, ScD (Hon), FACS

Urology deals with diseases and disorders of the adrenal ▶▶Blood Supply
gland, the male genitourinary tract, and the female
urinary tract. These systems are illustrated in Figures 1–1 A. Arterial
and 1–2. Each adrenal gland receives three arteries: one from the infe-
rior phrenic artery, one from the aorta, and one from the
ADRENALS renal artery.

B. Venous
▶▶Gross Appearance
A. Anatomy Blood from the right adrenal gland is drained by a very short
vein into the vena cava; the left adrenal vein terminates in the
Each kidney is capped by an adrenal gland, and both left renal vein.
organs are enclosed within Gerota’s (perirenal) fascia.
Each adrenal gland weighs 4–5 g. The right adrenal is tri- ▶▶Lymphatics
angular in shape; the left is more rounded and crescentic.
The average dimensions are 3 cm width, 5 cm length, and The lymphatic vessels accompany the suprarenal vein and
1 cm thickness. Each gland is composed of a cortex, chiefly drain into the lumbar lymph nodes.
influenced by the pituitary gland, and a medulla derived
from chromaffin tissue (Avisse et al, 2000; O’Donoghue KIDNEYS
et al, 2010).
▶▶Gross Appearance
B. Relations A. Anatomy
Figure 1–2 shows the relationships between the adrenals and The kidneys lie along the borders of the psoas muscles and
other organs. The right adrenal lies between the liver and are therefore obliquely placed. The position of the liver
the vena cava. The left adrenal lies close to the aorta and is causes the right kidney to be lower than the left (Figures 1–2
covered on its lower surface by the pancreas. The spleen lies and 1–3). The adult kidney weighs between 125 and 170 g in
superior and lateral to it. men and 115 and 155 g in women. It is about 10–12 cm long,
5–7 cm wide, and 3–5 cm thick.
The kidneys are supported by the perirenal fat (which is
▶▶Histology enclosed in the perirenal fascia), the renal vascular pedicle,
The adrenal cortex, which makes up 85% of the mass, is com- abdominal muscle tone, and the general bulk of the abdomi-
posed of three distinct layers: the outer zona glomerulosa, the nal viscera (Rusinek et al, 2004). Variations in these factors
middle zona fasciculata, and the inner zona reticularis. The permit variations in the degree of renal mobility. The aver-
medulla lies centrally and is made up of polyhedral cells with age descent on inspiration or on assuming the upright posi-
hormone-containing granular cytoplasm. These chromaf- tion is 4–5 cm. Lack of mobility suggests abnormal fixation
fin cells are accompanied by a small number of sympathetic (eg, perinephritis), but extreme mobility is not necessarily
ganglion cells. pathologic.

McAninch_CH01_p001-p016.indd 1 07/02/20 9:58 AM

 2 SMITH & TANAGHO’S GENERAL UROLOGY

▲▲Figure 1–1. Anatomy of the male genitourinary tract. The upper tract and midtract have urologic function only.
The lower tract has both genital and urinary functions.

McAninch_CH01_p001-p016.indd 2 07/02/20 9:58 AM

 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 3

▲▲Figure 1–2. Relations between the kidneys, ureters, and bladder (anterior aspect).

On longitudinal section (Figure 1–4), the kidney is seen gastrointestinal symptoms that accompany kidney diseases
to be made up of an outer cortex, a central medulla, and the (Glassberg, 2002).
internal calices and pelvis. The cortex is homogeneous in
appearance. Portions of it project toward the pelvis between ▶▶Histology
the papillae and fornices and are called the columns of A. Nephron
Bertin. The medulla consists of numerous pyramids formed
by the converging collecting renal tubules, which drain into The functioning unit of the kidney is the nephron, which is
the minor calices at the tip of the papillae. composed of a tubule that has both secretory and excretory
functions (Figure 1–4). The secretory portion is contained
largely within the cortex and consists of a renal corpuscle and
B. Relations
the secretory part of the renal tubule. The excretory portion of
Figures 1–2 and 1–3 show the relationships between the this duct lies in the medulla. The renal corpuscle is composed
kidneys and adjacent organs and structures. Their intimacy of the vascular glomerulus, which projects into Bowman’s cap-
with intraperitoneal organs and the autonomic innervation sule, which, in turn, is continuous with the epithelium of the
that they share with these organs explain, in part, some of the proximal convoluted tubule. The secretory portion of the renal

McAninch_CH01_p001-p016.indd 3 07/02/20 9:58 AM

 4 SMITH & TANAGHO’S GENERAL UROLOGY

▲▲Figure 1–3. Relations between the kidneys (posterior aspect). The dashed lines represent the outline of the kidneys,
where they are obscured by overlying structures.

tubule is made up of the proximal convoluted tubule, the loop of the posterior surface. The anterior branch supplies both
of Henle, and the distal convoluted tubule. upper and lower poles as well as the entire anterior surface.
The excretory portion of the nephron is the collecting The renal arteries are all end arteries.
tubule, which is continuous with the distal end of the ascend- The renal artery branches further divide into interlobar
ing limb of the convoluted tubule. It empties its contents arteries, which travel in the columns of Bertin (between the
through the tip (papilla) of a pyramid into a minor calyx. pyramids) and then arch along the base of the pyramids
(arcuate arteries). These arteries then divide as interlobular
B. Supporting Tissue arteries. From these vessels, smaller (afferent) branches pass
to the glomeruli. From the glomerular tuft, efferent arterioles
The renal stroma is composed of loose connective tissue and
pass to the tubules in the stroma.
contains blood vessels, capillaries, nerves, and lymphatics.
B. Venous
▶▶Blood Supply (Figures 1–2, 1–4, and 1–5)
The renal veins are paired with the arteries, but any of them
A. Arterial
will drain the entire kidney if the others are tied off.
Usually there is one renal artery, a branch of the aorta that Although the renal artery and vein are usually the sole blood
enters the hilum of the kidney between the pelvis, which vessels of the kidney, accessory renal vessels are common and
normally lies posteriorly, and the renal vein. It may branch may be of clinical importance if they are so placed so as to com-
before it reaches the kidney, and two or more separate arter- press the ureter, in which case hydronephrosis may result.
ies may be noted (Budhiraja et al, 2010). In duplication of the
pelvis and ureter, it is common for each renal segment to have
its own arterial supply. ▶▶Nerve Supply
The renal artery divides into anterior and posterior The renal nerves derived from the renal plexus accompany
branches. The posterior branch supplies the midsegment the renal vessels throughout the renal parenchyma.

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 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 5

▲▲Figure 1–4. Anatomy and histology of the kidney and ureter. Upper left: Diagram of the nephron and its blood supply.
(Courtesy of Merck, Sharp, Dohme: Seminar. 1947; 9[3].) Upper right: Cast of the pelvic caliceal system and the arterial
supply of the kidney. Middle: Renal calices, pelvis, and ureter (posterior aspect). Lower left: Histology of the ureter. The
smooth-muscle bundles are arranged in both spirally and longitudinally. Lower right: Longitudinal section of kidney
showing calices, pelvis, ureter, and renal blood supply (posterior aspect).

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 6 SMITH & TANAGHO’S GENERAL UROLOGY

▲▲Figure 1–5. (A) The posterior branch of the renal artery and its distribution to the central segment of the posterior
surface of the kidney. (B) Branches of the anterior division of the renal artery supplying the entire anterior surface of the
kidney as well as the upper and lower poles at both surfaces. The segmental branches lead to interlobar, arcuate, and
interlobular arteries. (C) The lateral convex margin of the kidney. Brödel’s line, which is 1 cm from the convex margin, is
the bloodless plane demarcated by the distribution of the posterior branch of the renal artery.

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 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 7

▶▶Lymphatics
The lymphatics of the kidney drain into the lumbar lymph
nodes.

CALICES, RENAL PELVIS, AND URETER

▶▶Gross Appearance
A. Anatomy

1. Calices—The tips of the minor calices (8–12 in number)

are indented by the projecting pyramids (Figure 1–4). These
calices unite to form two or three major calices that join to
form the renal pelvis (Sozen et al, 2008).
2. Renal pelvis—The pelvis may be entirely intrarenal or
partly intrarenal and partly extrarenal. Inferomedially, it
tapers to join the ureter.
▲▲Figure 1–6. Anatomy and relations between the
3. Ureter—The adult ureter is about 30 cm long, varying ureters, bladder, prostate, seminal vesicles, and vasa
in direct relation to the height of the individual. It follows a deferentia (anterior view).
rather smooth S curve. Areas that stones are often impacted
are (a) at the ureteropelvic junction, (b) where the ureter
crosses over the iliac vessels, and (c) where it courses through helical and longitudinal smooth-muscle fibers. They are not
the bladder wall. arranged in discrete layers. The outermost adventitial coat is
composed of fibrous connective tissue.
B. Relations
▶▶Blood Supply
1. Calices—The calices are intrarenal and are intimately A. Arterial
related to the renal parenchyma.
The renal calices, pelvis, and upper ureters derive their blood
2. Renal pelvis—If the pelvis is partly extrarenal, it lies along supply from the renal arteries; the midureter is fed by the
the lateral border of the psoas muscle and on the quadratus internal spermatic (or ovarian) arteries. The lowermost por-
lumborum muscle; the renal vascular pedicle is just anterior tion of the ureter is served by branches from the common
to it. The left renal pelvis lies at the level of the first or second iliac, internal iliac (hypogastric), and vesical arteries.
lumbar vertebra; the right pelvis is a little lower.
3. Ureter—On their course downward, the ureters lie on the B. Venous
psoas muscles, pass medially to the sacroiliac joints, and then The veins of the renal calices, pelvis, and ureters are paired
swing laterally near the ischial spines before passing medi- with the arteries.
ally to enter the base of the bladder (Figure 1–2). In females,
the uterine arteries are closely related to the juxtavesical por-
tion of the ureters. The ureters are covered by the posterior
▶▶Lymphatics
peritoneum; their lowermost portions are closely attached to The lymphatics of the upper portions of the ureters as well
it, while the juxtavesical portions are embedded in vascular as those from the pelvis and calices enter the lumbar lymph
retroperitoneal fat (Koff, 2008). nodes. The lymphatics of the midureter pass to the internal
The vasa deferentia, as they leave the internal inguinal iliac (hypogastric) and common iliac lymph nodes; the lower
rings, sweep over the lateral pelvic walls anterior to the ureteral lymphatics empty into the vesical and hypogastric
ureters (Figure 1–6). They lie medial to the latter before join- lymph nodes.
ing the seminal vesicle and penetrating the base of the pros-
tate to become the ejaculatory ducts. BLADDER

▶▶Histology (Figure 1–4) ▶▶Gross Appearance

The walls of the calices, pelvis, and ureters are composed of The bladder is a hollow muscular organ that serves as a res-
transitional cell epithelium under which lies loose connec- ervoir for urine. In women, its posterior wall and dome are
tive tissue (lamina propria). External to these are a mixture of invaginated by the uterus. The adult bladder normally has

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 8 SMITH & TANAGHO’S GENERAL UROLOGY

a capacity of 400–500 mL. The wall of the bladder is about ▶▶Blood Supply
3–5 mm in thickness; it is thinner when it is distended.
A. Arterial
A. Anatomy The bladder is supplied by the superior, middle, and inferior
When empty, the adult bladder lies behind the pubic sym- vesical arteries, which arise from the anterior trunk of the
physis and is largely a pelvic organ. In infants and children, internal iliac (hypogastric) artery, and by smaller branches
it is situated higher (Berrocal et al, 2002). When it is full, it from the obturator and inferior gluteal arteries. In females,
rises well above the symphysis and can readily be palpated the uterine and vaginal arteries also send branches to the
or percussed. When overdistended, as in acute or chronic bladder.
urinary retention, it may cause the lower abdomen to bulge
visibly. B. Venous
Extending from the dome of the bladder to the umbilicus Surrounding the bladder is a rich plexus of veins that ulti-
is a fibrous cord, the median umbilical ligament, which rep- mately empties into the internal iliac (hypogastric) veins.
resents the obliterated urachus. The ureters enter the bladder
posteroinferiorly in an oblique manner and at these points ▶▶Nerve Supply
are about 5 cm apart (Figure 1–6). The orifices, situated at
the extremities of the crescent-shaped interureteric ridge that The bladder receives innervation from sympathetic and
forms the proximal border of the trigone, are about 2.5 cm parasympathetic nervous systems. The sensory afferent of
apart. The trigone occupies the area between the ridge and the bladder originates from both subepithelial nerve endings
the bladder neck. and nerve fibers between detrusor muscle bundles (Andersson,
The internal sphincter, or bladder neck, is not a true cir- 2010; Birder et al, 2010; McCloskey, 2010).
cular sphincter but a thickening formed by interlaced and
converging muscle fibers of the detrusor as they pass distally ▶▶Lymphatics
to become the smooth muscle component of the urethra. The lymphatics of the bladder drain into the vesical, external
iliac, internal iliac (hypogastric), and common iliac lymph
B. Relations nodes.
In males, the bladder is related posteriorly to the seminal
vesicles, vasa deferentia, ureters, and rectum (Figures 1–7 PROSTATE GLAND
and 1–8). In females, the uterus and vagina are interposed
between the bladder and rectum (Figure 1–9). The dome ▶▶Gross Appearance
and posterior surfaces are covered by peritoneum; hence, in
A. Anatomy
this area, the bladder is closely related to the small intestine
and sigmoid colon. In both males and females, the bladder is The prostate is a fibromuscular and glandular organ lying just
related to the posterior surface of the pubic symphysis, and, inferior to the bladder (Figures 1–6 and 1–7). The normal
when distended, it is in contact with the lower abdominal prostate weighs about 20 g and contains the posterior urethra,
wall. which is about 2.5 cm in length. It is supported anteriorly by
the puboprostatic ligaments and inferiorly by the urogenital
diaphragm (Figure 1–6). The prostate is perforated posteri-
▶▶Histology (Figure 1–10) orly by the ejaculatory ducts, which pass obliquely to empty
The mucosa of the bladder is composed of transitional epi- through the verumontanum on the floor of the prostatic ure-
thelium. Beneath it is a well-developed submucosal layer thra just proximal to the striated external urinary sphincter
formed largely of connective and elastic tissues. The mucosa (Figure 1–11).
may be considered as a single functional unit that consists The prostate can be subdivided into two ways: by lobe
of the epithelial layer, basement membrane, and lamina pro- or by zone. The lobe classification is often used in cystoure-
pria. Physical or chemical stress on the bladder elicits releases throscopic examinations and consists of five lobes: anterior,
of multiple factors that modulate afferent and efferent nerve posterior, median, right lateral, and left lateral. The zone clas-
activities (Fry and Vahabi, 2016). External to the submu- sification is often used in pathology. McNeal (1981) divides
cosa is the detrusor muscle that is made up of a mixture of the prostate into four zones: peripheral zone, central zone
smooth-muscle fibers arranged at random in a longitudi- (surrounds the ejaculatory ducts), transitional zone (sur-
nal, circular, and spiral manner without any layer formation rounds the urethra), and anterior fibromuscular zone (Myers
or specific orientation except for proximity to the internal et al, 2010) (Figure 1–12). The segment of urethra that tra-
meatus, where the detrusor muscle assumes three definite verses the prostate gland is the prostatic urethra. It is lined
layers: inner longitudinal, middle circular, and outer longitu- by an inner longitudinal layer of muscle (continuous with
dinal (John et al, 2001). a similar layer of the vesical wall). Incorporated within the

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 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 9

▲▲Figure 1–7. (A) Anatomic relationship between the bladder, prostate, prostatomembranous urethra, and root of
the penis. (B) Histology of the testis. Seminiferous tubules lined by supporting basement membrane for the Sertoli and
spermatogenic cells. The latter are in various stages of development. (C) Cross sections of the testis and epididymis.
(Images [A] and [C] reproduced with permission from Walsh PC, Campbell MF: Campbell’s Urology, 6th ed. Philadelphia, PA:
Saunders; 1992.)

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 10 SMITH & TANAGHO’S GENERAL UROLOGY

▲▲Figure 1–8. Top: Relations between the bladder, prostate, seminal vesicles, penis, urethra, and scrotal contents.
Lower left: Transverse section through the penis. The paired upper structures are the corpora cavernosa. The single
lower body surrounding the urethra is the corpus spongiosum. Lower right: Fascial planes of the lower genitourinary
tract. (After Wesson.)

prostate gland is an abundant amount of smooth muscula- separated from the rectum by the two layers of Denonvilliers’
ture derived primarily from the external longitudinal bladder fascia, serosal rudiments of the pouch of Douglas, which
musculature. This musculature represents the involuntary once extended to the urogenital diaphragm (Raychaudhuri
smooth muscle sphincter of the posterior urethra in males. and Cahill, 2008) (Figure 1–8).

B. Relations ▶▶Histology (Figure 1–10)

The prostate gland lies behind the pubic symphysis. Located The prostate consists of a thin fibrous capsule under
closely to the posterosuperior surface are the vasa deferentia which lie circularly oriented smooth-muscle fibers and
and seminal vesicles (Figure 1–7). Posteriorly, the prostate is collagenous tissue that surrounds the urethra (involuntary

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 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 11

▲▲Figure 1–9. Anatomy and relations of the bladder, urethra, uterus and ovary, vagina, and rectum.

▲▲Figure 1–10. Left: Histology of the prostate. Epithelial glands embedded in a mixture of connective and elastic tissue
and smooth muscle. Right: Histology of the bladder. The mucosa is transitional cell in type and lies on a well-developed
submucosal layer of connective tissue. The detrusor muscle is composed of interlacing longitudinal, circular, and spiral
smooth-muscle bundles.

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 12 SMITH & TANAGHO’S GENERAL UROLOGY

▲▲Figure 1–11. Section of the prostate gland shows the

prostatic urethra, verumontanum, and crista urethralis,
in addition to the opening of the prostatic utricle and
the two ejaculatory ducts in the midline. Note that the
prostate is surrounded by the prostatic capsule, which
is covered by another prostatic sheath derived from the
endopelvic fascia. The prostate is resting on the genitouri-
nary diaphragm. (Reproduced with permission from Walsh
PC, Campbell MF: Campbell’s Urology, 6th ed. Philadelphia,
PA: Saunders; 1992.) ▲▲Figure 1–12. Anatomy of the prostate gland. Prostatic
adenoma develops from the periurethral glands at the
site of the median or lateral lobes. The posterior lobe,
however, is prone to cancerous degeneration. (Adapted
sphincter). Deep in this layer lies the prostatic stroma,
with permission from McNeal JE: The zonal anatomy of the
composed of connective tissues and smooth-muscle fibers
prostate. Prostate 1981;2(1):35–49.)
in which are embedded the epithelial glands. These glands
drain into the major excretory ducts (about 25 in number),
which open chiefly on the floor of the urethra between
the verumontanum and the vesical neck. Just beneath ▶▶Lymphatics
the transitional epithelium of the prostatic urethra lie the The lymphatics from the prostate drain into the internal iliac
periurethral glands. (hypogastric), sacral, vesical, and external iliac lymph nodes
(Saokar et al, 2010).
▶▶Blood Supply
A. Arterial SEMINAL VESICLES
The arterial supply to the prostate is derived from the inferior
vesical, internal pudendal, and middle rectal (hemorrhoidal) ▶▶Gross Appearance
arteries. The seminal vesicles lie just cephalic to the prostate under
the base of the bladder (Figures 1–6 and 1–7). They are about
B. Venous 6 cm long and quite soft. Each vesicle joins its corresponding
vas deferens to form the ejaculatory duct (Kim et al, 2009).
The veins from the prostate drain into the periprostatic The ureters lie medial to each, and the rectum is contiguous
plexus, which has connections with the deep dorsal vein of with their posterior surfaces.
the penis and the internal iliac (hypogastric) veins.

▶▶Histology
▶▶Nerve Supply The mucous membrane is pseudostratified. The submu-
The prostate gland receives a rich innervation from the sym- cosa consists of dense connective tissue covered by a thin
pathetic and parasympathetic nerves of the inferior hypogas- layer of muscle that, in turn, is encapsulated by connective
tric plexus. tissue.

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 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 13

▶▶Blood Supply EPIDIDYMIS

The blood supply of the seminal vesicles is similar to that of
the prostate gland. ▶▶Gross Appearance
A. Anatomy
▶▶Nerve Supply The upper portion of the epididymis (globus major) is con-
The nerve supply is mainly from the sympathetic nerve nected to the testis by numerous efferent ducts from the testis
plexus. (Figure 1–7). The epididymis consists of a markedly coiled
duct that, at its lower pole (globus minor), is continuous with
▶▶Lymphatics the vas deferens. An appendix of the epididymis is often seen
on its upper pole; this is a cystic body that in some cases is
The lymphatics of the seminal vesicles are those that serve
pedunculated, but in others, it is sessile.
the prostate.
B. Relations
SPERMATIC CORD
The epididymis lies posterolateral to the testis and is nearest
▶▶Gross Appearance to the testis at its upper pole. Its lower pole is connected to
the testis by fibrous tissue. The vas lies posteromedial to the
The two spermatic cords extend from the internal ingui- epididymis.
nal rings through the inguinal canals to the testicles
(Figure 1–7). Each cord contains the vas deferens, the
internal and external spermatic arteries, the artery of
▶▶Histology
the vas, the venous pampiniform plexus (which forms The epididymis is covered by serosa. The ductus epididy-
the spermatic vein superiorly), lymph vessels, and nerves midis is lined by pseudostratified columnar epithelium
(Jen et al, 1999). The entire cord contents are enclosed in throughout its length.
investing layers of thin fascia. A few fibers of the cremaster
muscle insert on the cords in the inguinal canal (Bhosale ▶▶Blood Supply
et al, 2008; Kim et al, 2009). A. Arterial

▶▶Histology The arterial supply to the epididymis comes from the internal
spermatic artery and the artery of the vas (deferential artery).
The fascia covering the cord is formed of loose connective
tissue that supports arteries, veins, nerve, and lymphatics. B. Venous
The vas deferens is a small, thick-walled tube consisting of an
internal mucosa and submucosa surrounded by three well- The venous blood drains into the pampiniform plexus, which
defined layers of smooth muscle encased in a covering of becomes the spermatic vein.
fibrous tissue. Above the testes, this tube is straight. Its proxi-
mal 4 cm tends to be convoluted. ▶▶Lymphatics
The lymphatics drain into the external iliac and internal iliac
▶▶Blood Supply (hypogastric) lymph nodes.
A. Arterial
TESTIS
The external spermatic artery, a branch of the inferior epigas-
tric, supplies the fascial coverings of the cord. The internal ▶▶Gross Appearance
spermatic artery passes through the cord on its way to the
testis. The deferential artery is close to the vas. A. Anatomy
The average testicle measures about 4 × 3 × 2.5 cm
B. Venous (Figure 1–7). The volume can be measured by an orchidom-
The veins from the testis and the coverings of the spermatic eter or by a formula with ultrasonic measurement (length ×
cord form the pampiniform plexus, which, at the internal width × height × 0.71). The average volume is 18 mL (rang-
inguinal ring, unites to form the spermatic vein. ing from 12 to 30 mL). The testicle has a dense fascial cov-
ering called the tunica albuginea testis, which, posteriorly,
is invaginated somewhat into the body of the testis to form
▶▶Lymphatics the mediastinum testis. This fibrous mediastinum sends
The lymphatics from the spermatic cord empty into the fibrous septa into the testis, thus separating it into about
external iliac lymph nodes. 250 lobules.

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 14 SMITH & TANAGHO’S GENERAL UROLOGY

The testis is covered anteriorly and laterally by the visceral SCROTUM

layer of the serous tunica vaginalis, which is continuous with
the parietal layer that separates the testis from the scrotal ▶▶Gross Appearance
wall (Bidarkar and Hutson, 2005). A small amount of fluid
normally exists within the tunica vaginalis sac. At the upper Beneath the corrugated skin of the scrotum lies the dartos
pole of the testis is the appendix testis, a small pedunculated muscle. Deep to this are the three fascial layers derived from
or sessile body similar in appearance to the appendix of the the abdominal wall at the time of testicular descent. Beneath
epididymis. these is the parietal layer of the tunica vaginalis (Kim et al,
2007).
B. Relations The scrotum is divided into two sacs by a septum of con-
nective tissue. The scrotum not only supports the testes but
The testis is closely attached posterolaterally to the epididy- also, by relaxation or contraction of its muscular layer, helps
mis, particularly at its upper and lower poles (Klonisch et al, to regulate their temperature.
2004).
▶▶Histology
▶▶Histology (Figure 1–7) The dartos muscle, under the skin of the scrotum, is nonstri-
Each lobule contains one to four markedly convoluted ated. The deeper layer is made up of connective tissue.
seminiferous tubules, each of which is about 60 cm long.
These ducts converge at the mediastinum testis, where ▶▶Blood Supply
they connect with the efferent ducts that drain into the A. Arterial
epididymis.
The seminiferous tubule has a basement membrane con- The arteries to the scrotum arise from the femoral, internal
taining connective and elastic tissue. This supports the semi- pudendal, and inferior epigastric arteries.
niferous cells that are of two types: (1) Sertoli (supporting)
cells and (2) spermatogenic cells. The stroma between the B. Venous
seminiferous tubules contains connective tissue in which the The veins are paired with the arteries.
interstitial Leydig cells are located.
▶▶Lymphatics
▶▶Blood Supply The lymphatics drain into the superficial inguinal and subin-
The blood supply to the testes is closely associated with that guinal lymph nodes.
to the kidneys because of the common embryologic origin of
the two organs. PENIS AND MALE URETHRA
A. Arterial
▶▶Gross Appearance
The arteries to the testes (internal spermatics) arise from the The penis is composed of two corpora cavernosa and the
aorta just below the renal arteries and course through the corpus spongiosum, which contains the urethra. The corpus
spermatic cords to the testes, where they anastomose with spongiosum enlarges distally and forms the glans penis. Each
the arteries of the vasa deferentia that branch off from the corpus is enclosed in a fascial sheath (tunica albuginea), and
internal iliac (hypogastric) artery. all three corpora are surrounded by a thick fibrous envelope
known as Buck’s fascia. A covering of skin, devoid of fat, is
B. Venous loosely wrapped these bodies. The prepuce forms a hood
The blood from the testis returns in the pampiniform plexus over the glans.
of the spermatic cord. At the internal inguinal ring, the Beneath the skin of the penis (and scrotum) and extend-
pampiniform plexus forms the spermatic vein. ing from the base of the glans to the urogenital diaphragm is
The right spermatic vein enters the vena cava just below Colles’ fascia, which is continuous with Scarpa’s fascia of the
the right renal vein; the left spermatic vein empties into the lower abdominal wall (Figure 1–8).
left renal vein. The proximal ends of the corpora cavernosa are attached
to the pelvic bones just anterior to the ischial tuberosities.
The ischiocavernosus muscles insert into the lateral surface
▶▶Lymphatics of the tunica albuginea at the proximal corpora cavernosa.
The lymphatic vessels from the testes pass to the lumbar Occupying a depression of their ventral surface in the midline
lymph nodes, which, in turn, are connected to the medias- is the corpus spongiosum, which is connected proximally to
tinal nodes. the undersurface of the urogenital diaphragm, below which

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 ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 15

lies the urethral bulb. This portion of the corpus spongiosum FEMALE URETHRA
is surrounded by the bulbospongiosus muscle.
The suspensory ligament of the penis arises from the linea ▶▶Gross Appearance
alba and pubic symphysis and inserts into the fascial covering
of the corpora cavernosa. The adult female urethra is about 4 cm long and 8 mm in
diameter. It is slightly curved and lies beneath the pubic sym-
physis just anterior to the vagina.
▶▶Histology
A. Corpora and Glans Penis ▶▶Histology
The corpora cavernosa, the corpus spongiosum, and the The epithelial lining of the female urethra is squamous in
glans penis are composed of smooth muscles, intracaverno- its distal portion and pseudostratified or transitional in the
sal struts (corpus cavernosum only), and endothelium-lined remainder. The submucosa is made up of connective and
sinusoids. The sympathetic and parasympathetic (as well as elastic tissues and spongy venous spaces. Embedded in it are
the nonadrenergic, noncholinergic [NANC]) nerve termi- many periurethral glands, which are most numerous distally;
nals are often seen around the vessels and near the smooth the largest of these are the periurethral glands of Skene that
muscles. open on the floor of the urethra just inside the meatus.
External to the submucosa is a longitudinal layer of
B. Urethra smooth muscle continuous with the inner longitudinal
layer of the bladder wall. Surrounding this is a heavy layer
The urethral mucosa that traverses the glans penis is formed
of circular smooth-muscle fibers extending from the exter-
of squamous epithelium. Proximal to this, the mucosa is tran-
nal vesical muscular layer. This constitutes the involuntary
sitional in type. Underneath the mucosa is the submucosa that
internal urethral sphincter. Distal to this is the external stri-
contains connective and elastic tissue and smooth muscle. In
ated (voluntary) sphincter surrounding the middle third of
the submucosa are the numerous glands of Littre, whose ducts
the urethra composed of smooth and striated muscles within
connect with the urethral lumen. The urethra is surrounded by
the midurethra (Ashton-Miller and Delancey, 2009; Morgan
the vascular corpus spongiosum and the glans penis.
et al 2009; Thor and de Groat, 2010).

▶▶Blood Supply ▶▶Blood Supply

A. Arterial The arterial supply to the female urethra is derived from the
The penis and urethra are supplied by the internal pudendal inferior vesical, vaginal, and internal pudendal arteries. Blood
arteries. Each artery divides into a cavernous artery of the from the urethra drains into the internal pudendal veins.
penis (which supplies the corpora cavernosa), a dorsal artery
of the penis, and the bulbourethral artery. These branches ▶▶Lymphatics
supply the corpus spongiosum, the glans penis, and the ure- Lymphatic drainage from the external portion of the urethra
thra. Accessory pudendal arteries originate from inferior is to the inguinal and subinguinal lymph nodes. Drainage
vesical, obturator, or other arteries may also supply the penis from the deep urethra is into the internal iliac (hypogastric)
(Henry et al, 2017). lymph nodes.

B. Venous BIBLIOGRAPHY
The superficial dorsal vein lies external to Buck’s fascia and
drains to the saphenous vein. The deep dorsal vein is placed Adrenals
beneath Buck’s fascia and lies between the dorsal arteries. The Avisse C et al: Surgical anatomy and embryology of the adrenal
cavernous veins drain the hilum and crura of the penis. These glands. Surg Clin North Am 2000;80:403–415.
veins connect with the pudendal plexus that drains into the O’Donoghue PM et al: Genitourinary imaging: Current and emerg-
internal pudendal vein and periprostatic plexus. ing applications. J Postgrad Med 2010;56:131–139.

Kidneys
▶▶Lymphatics
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ficial inguinal and subinguinal lymph nodes. The lymphat- Glassberg KI: Normal and abnormal development of the kidney:
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into the internal iliac (hypogastric) and common iliac lymph Rusinek H et al: Renal magnetic resonance imaging. Curr Opin
nodes (Wood and Angermeier, 2010). Nephrol Hypertens 2004;13:667–673.

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