Urologic Principles and Practice, 2nd Edition

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 This edition of Urologic Principles and Practice is dedicated to
William D. Steers, co-author of the first edition. Dr. Steers, a man of many
diverse interests and talents, had a dominant presence in International
urology until his untimely passing on April 10, 2015. He was the Paul
Mellon professor and Chair of the Department of Urology at the
University of Virginia School of Medicine. He was a past President of the
American Board of Urology from 2010 to 2011 and Editor of the Journal
of Urology from 2007 until his passing. With a strong interest in female
and pelvic medicine and sexual medicine, Dr. Steers served as chair of the
joint ABU/ABOG fellowship in female pelvic medicine and Director on the
American Board of Obstetrics and Gynecology. Steers was a member of
the U.S. Food and Drug Administration 's Reproductive Medicine Advisory
Panel and chaired the National Institutes of Health ’s urinary
incontinence and interstitial cystitis clinical trial groups. In 2011, Steers
was appointed to the advisory council at National Institutes of Health by
Kathleen Sebelius and Francis Collins . Steers was President of the
University of Virginia physician’s practice plan from 2002 to 2009 and
was a member of the Health System Strategic Planning and Executive
Committees. In 1998, he described the efficacy of Viagra in a highly cited
New England Journal of Medicine publication.
In 2003, the University of Virginia awarded Dr. Steers the Hovey
Dabney Professorship. Dr. Steers was named by Men’s Health magazine as
one of the top 15 doctors for men in the USA. He was awarded the
American Urological Association ’s Hugh Hampton Young Award , Gold
Cystoscope Award, Dornier’s Innovation prize, Gineste Award for research
in erectile dysfunction, and the Zimskind Award in Neurourology.
Dr. Steers had many interests. He was a viticulturist aficionado and
with his wife Amy co-owned Well Hung Vineyard in Charlottesville , VA. He
also authored YOURometer an iPhone App. used to record urological-
related symptoms. Steers' entrepreneurial activities include the
development of a cell phone application to record patient symptoms and
using the internet Crowdcasting to fund medical research. He was an
active runner and outdoorsman.
Bill is survived by his wife, Amy; sons, Colin and Ryan; daughter-in-
law, Ali; and grandchildren, Rex and Reese. His vibrant personality,
incredible knowledge, and medical skills and thoughtful and generous
nature is sorely missed by many. We honor him with this second edition.
Christopher R. Chapple and Christopher P. Evans
Contents
Part I Basic Sciences in Urology
1 Gross and Laparoscopic Anatomy of the Upper Tract and
Retroperitoneum
Paras H. Shah and Bradley C. Leibovich
2 Gross and Laparoscopic Anatomy of the Lower Tract and Pelvis
Bastian Amend and Arnulf Stenzl
3 Male Reproductive Physiology
Peter N. Schlegel and Michael A. Katzovitz
4 Clinical Evaluation of the Lower Urinary Tract
Christopher R. Chapple
5 Ureteral Physiology and Pharmacology
Ravin Bastiampillai, Daniel M. Kaplon and Stephen Y. Nakada
6 Symptoms Complexes in Urology
Kyle J. Wilson and Nadir I. Osman
7 Anatomy, Physiology and Pharmacology of the Lower Urinary
Tract
Karl-Erik Andersson and Alan J. Wein
8 Physiology and Pharmacology of the Prostate
Matthias Oelke
9 Urologic Endocrinology
V. Mirone and R. La Rocca
10 Pharmacology of Male Sexual Function
Walter Cazzaniga, Paolo Capogrosso, Luca Boeri,
Francesco Montorsi and Andrea Salonia
11 Immunology in Tumor and Transplant
Romain Boissier, Angelo Territo and Alberto Breda
12 Pathophysiology of Renal Obstruction
Scott V. Wiener and Marshall L. Stoller
13 Urologic Imaging
 Ezequiel Becher, Angela Tong and Samir S. Taneja
14 Urologic Instrumentation:​Endoscopes and Lasers
Robert B. Lurvey and Noah Canvasser
15 Wound Healing and Plastic Surgery Principles
Hunter Wessells
Part II Clinical Urologic Practice
16 Haematuria:​Evaluation and Management
Karl H. Pang and James W. F. Catto
17 Chronic Prostatitis/​Chronic Pelvic Pain Syndrome
R. Christopher Doiron and J. Curtis Nickel
18 Disorders of the Scrotal Contents:​Epididymoorchiti​s, Testicular
Torsion, and Fournier’s Gangrene
Sarah C. Krzastek, Parviz K. Kavoussi and Raymond A. Costabile
19 Overview of the Evaluation of Lower Urinary Tract Dysfunction
(LUTD)
Annabelle Auble and Jean-Nicolas Cornu
20 Benign Prostatic Hyperplasia (BPH)
Cosimo De Nunzio, Riccardo Lombardo, Antonio Maria Cicione and
Andrea Tubaro
21 Practical Guidelines for the Treatment of Erectile Dysfunction
and Peyronie’s Disease
Julian Marcon and Christian G. Stief
22 Treatment of Adult Male Hormonal Disorders
Raul I. Clavijo
23 Metabolic Evaluation and Medical Management of Stone
Disease
Russell S. Terry and Glenn M. Preminger
24 Innovations in the Surgical Management of Nephrolithiasis
Christopher Haas, Marla Wardenburg and Ojas Shah
25 Reconstruction of the Renal Pelvis and Ureter
Jennifer G. Rothschild
26 Current Trends in Urethral Stricture Management
Christopher R. Chapple
27 Contemporary Management of Urinary Incontinence
Sophia Delpe Goodridge and Roger Dmochowski
28 Neurogenic Bladder
Altaf Mangera
29 Pelvic Organ Prolapse
Thomas G. Gray and Stephen C. Radley
30 Urologic Trauma
German Patino, Andrew Cohen and Benjamin N. Breyer
31 Urinary Tract Fistula
Andrew C. Margules and Eric S. Rovner
32 Urothelial Cancer of the Upper Urinary Tract
Steffen Rausch and Arnulf Stenzl
33 Renal Cancer Including Molecular Characterization​
Egbert Oosterwijk and Peter F. A. Mulders
34 Bladder Cancer
Ó scar Rodríguez Faba, José Daniel Subiela and Joan Palou
35 Management of Localized and Locally Advanced Prostate
Cancer
Derya Tilki and Christopher P. Evans
36 Management of Local, Regional, and Metastatic Penile Cancer
Salim Koshi Cheriyan, Ahmet Murat Aydin, Pranav Sharma,
Juan Chipollini, Evan Michael Holsonback, Jennifer Garcia-
Castaneda, Alfredo Herb De la Rosa and Phillippe Edouard Spiess
37 Chemotherapeutic​Agents for Urologic Oncology:​Basic
Principles
Simon Y. F. Fu, Martin Gleave and Kim N. Chi
38 Diagnosis, Staging and Management of Testis Cancer
Noel W. Clarke
Index
Part I
Basic Sciences in Urology
© Springer Nature Switzerland AG 2020
C. R. Chapple et al. (eds.), Urologic Principles and Practice, Springer Specialist Surgery Series
https://doi.org/10.1007/978-3-030-28599-9_1

1. Gross and Laparoscopic Anatomy of

the Upper Tract and Retroperitoneum
Paras H. Shah1 and Bradley C. Leibovich1

(1) Division of Urology, Albany Medical Center, Albany, NY, USA

Paras H. Shah
Email: [email protected]

Bradley C. Leibovich (Corresponding author)

Email: [email protected]

Keywords Retroperitoneum anatomy – Retroperitoneal surgery –

Laparoscopy – Nephrectomy – Retroperitoneal lymph node dissection –
Perirenal space – Anterior pararenal space – Central vascular
compartment – Gerota’s fascia

Introduction
It is of paramount importance that the Urologic surgeon possess a
comprehensive anatomic understanding of the retroperitoneal
compartment given that in this space, and the contiguous extravesical
domain below the peritoneal reflection, reside all the major urologic
organs. Moreover, traversing the retroperitoneum are the body’s
primary blood vessels—the aorta and inferior vena cava (IVC)—from
which emerge the vascular supply to the urologic organs. As control of
arterial and venous structures is often a critical component to surgery,
particularly when performed for an oncologic indication, familiarity
with both the conventional and variant anatomic course of these
vessels as they approach their target organ is essential. Within the
retroperitoneal space is also a rich lymphatic network intimately
associated with the aorta and IVC. Secondary infiltration of these
lymphatics by kidney, upper tract urothelial, and primary testicular
germ cell tumors may necessitate surgical resection of the peri-caval
and peri-aortic lymph nodes, emphasizing the importance of
understanding principles by which the retroperitoneal compartment is
accessed.
Herein, we review the structural organization of the retroperitoneal
space, highlighting how the anatomy of this compartment is
maneuvered during major urologic procedures, performed via either an
open or laparoscopic approach.

Anatomy
The retroperitoneum is bounded anteriorly by the parietal peritoneal
layer and posterolaterally by the transversalis fascia. The compartment
itself rests upon the belly of the psoas and paraspinal (specifically the
quadratus lumborum) muscles, over which lies the lumbodorsal fascia
—a connective tissue layer that is itself continuous more laterally with
the transversalis fascia (Fig. 1.1).

Fig. 1.1 Retroperitoneum vs. peritoneal cavity: the boundaries of the retroperitoneal space,
which is highlighted in yellow, are formed by the parietal peritoneum (red) and the transversalis
fascia (green). The retroperitoneal compartment is continuous anteriorly with the pre-peritoneal
space (dense yellow shade). Within the retroperitoneum are bilateral Kidneys (K), the 2nd and
transverse segments of the Duodenum (D), Ascending Colon at the level of the hepatic flexure (AC),
Descending Colon below the splenic flexure (DC), Aorta (A) and Inferior Vena Cava (IVC).
Additionally, the Liver (L), Gallbladder (GB), Transverse Colon (TC) and Jejunal loops of small
intestine are appreciated within the intraperitoneal space
The retroperitoneum can be divided further into four
compartments, which from a surgeon’s perspective aids in the
understanding of access to the urologic organs and major blood vessels
situated within this space. These compartments include the Perirenal
Space, the Anterior Pararenal Space, the Posterior Pararenal Space, and
the Central Vascular Compartment (Figs. 1.2a, b).
Fig. 1.2 Cross-sectional image of CT abdomen. (a) Cross-section image of CT abdomen. (b)
Divisions of the Retroperitoneum: The peritoneal cavity is lined by a layer of mesothelial tissue
referred to as the parietal peritoneum (yellow). The retroperitoneum can be subdivided into four
compartments: the perirenal space (blue/green), the central vascular compartment (red), the
anterior pararenal space (yellow/orange lines), and the posterior pararenal space (purple). (c)
Perirenal Space: The Kidneys (K) are situated within the perirenal space, which is bordered by the
Gerota’s fascia anteriorly (green) and the Zuckerkandl’s fascia posteriorly (blue). Additionally, the
Gerota’s fascia crosses over the midline (dashed green) as it drapes over the central vascular
compartment to connect to the contralateral perirenal space; within this are the Kneeland’s
channels, which may allow for communication between the spaces. The Zuckerkandl’s fascia
continues anteriorly (blue) off the lateral contour of the kidney, forming the lateral border of the
anterior pararenal space and connecting to the parietal peritoneum. The perirenal space rests on
top of the psoas (P) and Quadratus Lumborum (QL) muscles. (d) Central Vascular Compartment:
The Aorta (A) and Inferior Vena Cava (IVC) are located within the central vascular compartment,
outlined in red and shaded in purple. Peri-aortic and peri-caval lymph nodes are within the
surrounding fibroadipose tissue. The Gerota’s fascia can be seen crossing the midline and draping
over the central vascular compartment (dashed green lines). (e) Anterior Pararenal Space: Seen
here within the Anterior Pararenal Space, which is outlined in yellow anteriorly and orange
posteriorly, is the Ascending Colon (AC), the Duodenum (D), and the Descending Colon (DC). The
anterior connective tissue border of this space is formed anteriorly by the parietal peritoneum
(yellow), which serves as the posterior abdominal wall of the peritoneal compartment, and
posteriorly by the Toldt’s fascia (orange). (f) Posterior Pararenal Space: This compartment,
outlined in purple, contains only adipose tissue

Perirenal Space
The perirenal space contains within it the adrenal gland, kidney, and
ureter—organs that are all supported by a body of perinephric fat. The
volume of fat within this compartment varies widely and is based partly
on age, gender, and body mass (Fig. 1.3). The perirenal space is
delineated anteriorly by Gerota’s fascia (anterior perirenal fascia) and
posteriorly by Zuckerkandl’s fascia (posterior perirenal fascia), which
fuse laterally to essentially envelop these organs and overlying fat layer
(Fig. 1.2c). The point of fusion along the lateral contour of the kidney is
of clinical relevance as it offers a nice cleavage plane through the
perinephric fat by which the capsular kidney surface can be accessed,
as is necessary during partial nephrectomy.
Fig. 1.3 Perinephric fat. (a) Intraoperative view of the Kidney with the surrounding Perinephric
fat removed off its capsular surface. (b) A large volume of perinephric fat, as delineated by yellow
arrows, is appreciated around both kidneys. The anterior and posterior perirenal fascia are
delineated in green and blue, respectively. (c) Minimal perinephric fat volume, as delineated by
yellow arrows, is appreciated around both kidneys. The anterior and posterior perirenal fascia are
delineated in green and blue, respectively
The posterior perirenal fascia is in fact comprised of two layers, the
deep and superficial lamina, which explains its prominence on cross-
sectional imaging. Whereas the deep layer is continuous with the
anterior renal fascia, the superficial layer of the perirenal fascia
deviates anteriorly off the lateral contour of the perirenal space, and is
referred to here as the lateral conal fascia. The lateral conal fascia runs
along the lateral edge of the anterior pararenal space as it fuses here
with the parietal peritoneum (Fig. 1.2c).
 The perirenal space is shaped as an inverted pyramid, with the
diaphragm serving as the base of this space and the apex of the space
directed towards the pelvis. Although the superior border of the
perirenal space is solely the diaphragm on the left (Fig. 1.4), the
superior border of the perirenal compartment on the right is formed
anteriorly by the bare segment of the liver, which is devoid of a
peritoneal lining, and posteriorly by the diaphragm (Fig. 1.5). The
perirenal space rests on top of the psoas and quadratus lumborum
muscles; this interface is formed by close apposition of the Zuckerkandl
fascia with the psoas fascia and thoracodorsal fascia, which overlie the
psoas and quadratus lumborum muscles, respectively (Figs. 1.2c and
1.6).
Fig. 1.4 Left perirenal space. (a) The superior border of the left perirenal space is the diaphragm
(red). The anterior and posterior perirenal fascia are delineated in green and blue, respectively. (b)
Medial reflection of the left mesocolon permits access to the left perirenal space. (c, d) Division of
the splenorenal ligament permits medial reflection of the spleen (intraperitoneal location) off the
superior aspect of the left perirenal space. DC descending colon, K kidney, S spleen
Fig. 1.5 Right perirenal space. (a) The superior border of the right perirenal space is formed by
both the bare segment of liver (anteriorly; yellow) and the diaphragm (posteriorly; red). The
anterior and posterior perirenal fascia are delineated in green and blue, respectively. (b)
Intraoperative view of the intraperitoneal portion of liver. (c) The bare segment of the liver,
serving as the superior border of the right perirenal space, can be visualized upon accessing the
upper region of the right perirenal space. Of note, the adrenal gland and surrounding perirenal fat
have been removed. K Kidney, L liver

Fig. 1.6 The posterior perirenal fascia of the right (a) and left (b) perirenal spaces is lifted
anteriorly off the Psoas muscle/fascia
Piercing the perirenal fascia medially are renal hilar vessels, which
are derived from the great vessels situated within the central vascular
compartment (Fig. 1.7). Although the right and left perirenal spaces are