|Year : 2021 | Volume
| Issue : 4 | Page : 240-245
Renal fascia in normal and ectopic pelvic kidneys: Evidence-based clinical and anatomical review
Kalpana Ramachandran1, Sriram Krishnamoorthy2
1 Professor and Head, Department of Anatomy, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Professor of Urology, Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
|Date of Submission||19-Apr-2021|
|Date of Decision||27-Jun-2021|
|Date of Acceptance||24-Jul-2021|
|Date of Web Publication||28-Oct-2021|
Professor and Head, Department of Anatomy, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The natural location of the kidney is the loin and the fascial sheaths around it gives it inherent protection against trauma and various other diseases. While there is enough evidence for fascia around well ascended normally located kidneys, there is very little evidence for its presence in ectopic pelvic kidneys. This evidence-based review discusses the recent changes in concepts regarding renal and perirenal fascia in normal and ectopic kidneys. The perirenal fascia was described as anterior and posterior layers that fuse laterally to form the lateral conal fascia. However, subsequent studies have shown that these fasciae are multi-laminated structures that blend and fuse with underlying muscles. However, in pelvic kidneys, the anterior and posterior renal fascia is not so well-documented. The medial extension of the enlarged kidney enables an easy cross-over to the opposite side. A subcapsular urinoma or a perirenal hematoma is usually self-contained in a closed space, owing to the attachments of the renal capsule and the perirenal fasciae. The hematoma in such closed space acts as a self-tamponade, preventing further blood loss or hemodynamic instability. Computed tomography has enhanced the understanding of perirenal space and pathologies. Tri-compartmental theory formed the basis for a clear understanding of these fasciae. A better knowledge of these fascial planes helps the surgeons to identify the avascular planes, better. A larger prospective study is needed to get further insights into renal fascia in pelvic kidneys.
Keywords: Hydronephrosis, kidney, nephrectomy, perinephric space, perirenal fascia
|How to cite this article:|
Ramachandran K, Krishnamoorthy S. Renal fascia in normal and ectopic pelvic kidneys: Evidence-based clinical and anatomical review. Natl J Clin Anat 2021;10:240-5
|How to cite this URL:|
Ramachandran K, Krishnamoorthy S. Renal fascia in normal and ectopic pelvic kidneys: Evidence-based clinical and anatomical review. Natl J Clin Anat [serial online] 2021 [cited 2022 Jan 23];10:240-5. Available from: http://www.njca.info/text.asp?2021/10/4/240/329496
| Introduction|| |
Kidneys are paired retroperitoneal organs that are located in the loin. They are well protected from blunt or penetrating injuries of the abdomen. Its deep-seated location inherently protects from trauma. Besides, the perirenal fascia also offers natural protection to the kidney from injury, inflammation, or infections. The clinical significance of renal capsule and perirenal fascia stems from the fact that they act as natural barrier mechanisms by not allowing the further spread of infection or hematoma and act as main sources of containment of the spread of pathology beyond the confines of the kidney. Self-contained hematomas in the subcapsular or perirenal spaces offer an effective tamponade that prevents further blood loss and ensures hemodynamic stability.
While this mechanism of natural protection is observed in patients with normally ascended kidneys, the same defense mechanism may not be expected to happen in individuals with unascended and ectopic pelvic kidneys. Scarce evidence is available in the literature to suggest the presence or absence of anterior and posterior renal fasciae in ectopic pelvic kidneys. To the best of our knowledge, there is only one published study in PubMed literature by Apul Goel et al. (discussed in greater detail under anatomical considerations) on the presence or absence of renal fasciae in pelvic kidneys. In this review, the authors have discussed the embryological anatomy of perirenal fascia, and emerging concepts in various natural protective mechanisms in the prevention of the spread of pathology beyond the kidney.
The authors also have shared their personal experience on the significance of renal fascia in ectopic pelvic hydronephrotic left kidney. The various plausible mechanisms for hydronephrosis in unascended pelvic kidneys include malrotated kidney, abnormal high insertion of the ureter onto the renal pelvis, anteriorly placed renal pelvis, and anomalous artery supplying the lower pole and pressing on the ureteropelvic junction.
Conceptual knowledge about the renal fasciae, retroperitoneal spaces, and interfascial planes would further enhance our understanding of the retroperitoneal anatomy and revolutionize the basic perspectives of various pathologies related to the kidneys that are more often difficult to diagnose or treat. The purpose of this manuscript is to revisit the anatomical and developmental concepts of renal fascia and interfascial planes with reference to the normally located and unascended ectopic pelvic kidneys.
| Embryological Anatomy Of Renal Fascia (In Normal and Pelvic Kidneys)|| |
The development of renal fasciae is more complex than it was thought to be. The fundamentals of the development of renal fascia originated from the initial research works of “His” in 1874, where he proposed that the subtle changes that happen in the loose and thin mesenchymal tissue form the basis for the development of adult extraperitoneal connective tissue. Based on the theory proposed by His, Hayes further postulated that the apparent cranial migration of the kidney associated with a differential growth of the body wall and intrinsic growth of the organ formed the basis for predictable changes that happen in the spongy mesenchymal tissue that surrounds them. The migration of the kidney creates a linear orientation of the connective tissue, which is further compressed into a sheet-like lamina by the intrinsic growth of the kidneys.
A study on 29 human fetuses by Ishikawa et al. observed that a loose connective tissue was found to be uniformly distributed like a sheet in the retroperitoneum, as early as the 9th week of gestation. This further specializes in renal fasciae and transversalis fascia by the 12th week. By the 23rd week, renal and transversalis fasciae are well developed. Furthermore, a fascia was noted to run parallel to the posterior renal fascia, emerging between the renal fascia and adipose tissue of the flank pad. Congdon and Edson in 1941 termed this fascia as lateral conal fascia, which is formed by the compression of this migration fascia due to the growth of the flank pad of fat. They observed that this fascia runs close to the posterior renal fascia and appears like a single-layered one. Matsubara et al., in their study on the development of human retroperitoneal fasciae, observed that the lateral conal fascia appeared as a result of secondary mechanical shearing force.
| Anatomical Considerations|| |
[Figure 1] illustrates the pictorial representation of the extent of perirenal fasciae. The fascia around the kidney is traditionally described as two distinct entities, the anterior fascia of Gerota and the posterior fascia of Zuckerkandl. The lateral conal fascia is formed by the fusion of anterior and posterior fascia. According to Burkill and Healy, the lateroconal fascia continued anterolaterally behind the colon to blend with the parietal peritoneum. However Mitchell et al., in 1950, demonstrated that perirenal fascia is not composed up of distinct fasciae but is a single layer of the multi-laminated structure. This structure extends anterior and lateral behind the kidney and subsequently divides into a thin anterior lamina and a thicker posterior lamina. [Figure 2]a illustrates the cross-sectional anatomy of renal fasciae. However, a detailed evaluation of computed tomography (CT) images or anatomical sections of cadavers, following injection of contrast or colored latex into the perirenal space, revealed that fluid could extend across the midline from the third to fifth lumbar levels through a narrow channel. [Figure 2]b demonstrates the lateral longitudinal view of the renal fasciae. In the midline superiorly, the anterior and posterior renal fasciae fuse and are attached to the crus of the corresponding hemidiaphragm. Inferiorly, the fasciae separate for a variable distance.
|Figure 1: Schematic illustration of perirenal fasciae, reproduced with written permission from Radiopedia; Case courtesy of Dr. Matt Skalski, Radiopaedia.org, rID: 44105|
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|Figure 2: Line diagrammatic representation of renal fasciae, perirenal spaces, and bridging septae, in axial section (a) and longitudinal section (b), reproduced with written permission from Goran Mitreski|
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While there is no ambiguity in delineating the extent of renal fasciae in a normally located kidney, limited reports are available on the presence of fasciae in an ectopic pelvic kidney. Apul Goel, in his report on the role of Gerota's fascia in ectopic pelvic kidney with renal cell carcinoma, observed that there was no evidence of Gerota's fascia during nephrectomy. In his subsequent prospective analysis on 11 patients with ectopic kidneys, Goel observed that the Gerota's fascia was difficult to be identified distinctly in the preoperative CT imaging but was able to identify the anterior renal fascia in two-third of their patients, intraoperatively. However, the posterior renal fascia was not seen in any of the patients during surgery. Forbes, in his report on the status of Gerota's fascia, noted that the ectopic pelvic kidney had no supporting perirenal supporting tissue and that the stability of the kidney entirely depended on its retroperitoneal location, its adhesions with adjacent structures, and the blood vessels that enter and leave the hilum from various directions.
Conventionally, in surgical anatomy teaching, hydronephrosis in a well-ascended kidney does not cross the midline. In pelvic kidneys, the anterior and posterior renal fasciae are not so well delineated and the medial extensions of these fasciae are unpredictable. This permits a free extension of the hydronephrosis across the midline, which mimics a lower midline mass.
| Pathological Considerations|| |
Subcapsular and perirenal spaces are two distinct spaces related to the kidneys. Subcapsular urinoma that occurs as a result of forniceal rupture in acute ureteric obstruction is often self-contained. Such fluid collections would result in compression of the renal parenchyma resulting in renal ischemia and renin-mediated hypertension called as “Page kidney effect.” This is a well-recognized sequel of subcapsular urinoma, which usually resolves after relief of obstruction.
The perirenal space is formed between the anterior fascia of Gerota and the posterior fascia of Zuckerkandl. Conventionally, the perirenal space is considered to communicate with its counterpart from the opposite side by medial communications across the great vessels.,, However, in their study on nine cadavers by anatomic dissection, latex injection, and cross-sectional anatomy of the kidneys, Raptopoulas et al. observed that renal fascia is closed beyond the kidneys and forms an inverted cone inferiorly. In yet another study, Raptopoulas observed that the interlobar septae formed a barrier preventing the spread of disease from the kidney to the rest of the retroperitoneum.
Perirenal hematoma is another condition that may sometimes present as an emergency. Blunt or penetrating trauma to kidneys, rupture or leakage from abdominal aortic aneurysms, renal tumors, and coagulopathies may result in such a condition. As perirenal space acts as a closed space, hematoma would cause a tamponade effect and may prevent further bleed, thereby ensuring hemodynamic stability. Thus, when large volumes of blood or urine accumulate in a closed space, the expansile retroperitoneal fascial planes serve as an effective conduit, resulting in an effective decompression. Gore et al. called it a “Great Escape.”
Renal lymphangiectasia is an uncommon benign condition that presents with perirenal lymph collection, mimicking either urinoma or hematoma. The renal fasciae keep the collection self-contained. A thorough anatomical knowledge of the fasciae greatly aids in planning appropriate treatment, as such conditions are usually asymptomatic or self-limiting.
| Radiological Considerations|| |
Renal fasciae have been one of the well-studied structures. Knowledge about its structural basis, extensions, and radiological significance has constantly been evolving over the past few decades. In the pre-CT era, X-ray tomograms were used to distinguish and demarcate the renal fascia. Axial imaging with CT scan and magnetic resonance imaging (MRI) has resulted in a paradigm shift in understanding the clinical concepts related to these fasciae and has obsoleted conventional X-ray imaging.,,
Steinbach and Smith in 1955, during their study on retroperitoneal pneumography, highlighted the clinical utility of renal fascia in distinguishing the renal and adrenal masses from those originating from the rest of the abdominal organs. Barbaric concluded that normal renal fascia may be difficult to be visualized in excretory urography and may be nonspecific. Whalen and Ziter illustrated the role of renal fascia in facilitating the effective localization of solid renal masses. Bigongiari observed renal fascia in plain radiography and reported the role of this fascia in reflux-related scarring, inflammation-associated thickening, or malignancy-associated stretching of the capsule. Kochkondan concludes in his study that an intact perirenal and pararenal pad of fat offers a differential density and is a basic prerequisite for a clear demonstration of the renal fascia.
The “tri-compartmental theory” proposed by Meyers et al. formed the basis for a clear understanding of the radiological dimensions of renal fasciae. According to this theory, the renal fasciae merely formed boundaries of the three compartments of the retroperitoneal space, enabling the prevention of the spread of disease from one compartment to another. With the advent of CT scans, the three compartments were studied in greater detail. It was observed that this tri-compartmental theory could not explain why perinephric collections or hematoma extended beyond their contained space onto the contralateral space or pelvic peritoneum.
Molmenti et al. were the first to propose the concept of interfascial planes in 1996. They coined the terms retrorenal and retromesenteric planes based on their study by injection of contrast medium in cadavers. Their study revolutionized the concepts of the spread of retroperitoneal lesions beyond their original compartments by dissecting these fasciae.
Earlier, Kunin in 1986, documented that perinephric spaces are not just fat-filled spaces but were divided into various compartments by bridging septae and fibrous lamellae. Axial imaging with CT scan delineates the bridging septae and lamellae better than the cadaveric dissections. These septae become more prominent and thickened in cases of infections and inflammations. Aizenstein et al. attempted to put an end to all controversies related to the spread of lesion between retroperitoneal compartments. They concluded that the lesions from the kidney extend onto the contralateral side not by direct contiguous spread but by way of diffusion through the bridging septae.
On the contrary, there is very little published literature on the presence of such fasciae, septae, and planes in the ectopic pelvic kidney. There is only one original research published literature on renal fascia in pelvic kidneys. Apul Goel et al., in their study on 11 patients with pelvic kidneys, concluded that surgical dissection demonstrated a well-defined anterior renal fascial layer in seven of their patients. In their patients, axial imaging with CT scan could not delineate this fascia. This only reiterates the limited utility of such radiological imaging in pelvic ectopic kidneys. However, in the earlier case report, the same authors observed the absence of anterior renal fascia in the pelvic kidney in their observations during laparoscopic radical nephrectomy. However, more prospective studies are required to arrive at any meaningful conclusion.
| Urological Considerations|| |
As the interfascial planes are bloodless, surgeons and urologists identify these planes to be relatively avascular and plan their layers of dissection in these planes to minimize intraoperative blood loss. Anatomical reports in the past have reported renal fascia as a membranous structure mainly comprised of collagenous and elastic connective tissue. As mentioned earlier by Mitchell Gag, the renal fascia that is described in the anatomy and urology textbooks was largely based on the research work done by Zuckerkandl, Sappey, and Gerota. Emil Zuckerkandl in 1883 described the thicker posterior layer of renal fascia as a distinct fascia, located anterior to the fascial coverings of the psoas major and quadratus lumborum and continuing as the lateral conal fascia, fusing with parietal peritoneum. However, he did not mention the anterior renal fascia. In 1895, Gerota reported the thinner anterior renal fascia that passes around the front of the kidney and variably fuses and intersperses with that of the contralateral side.
Tobin describes renal fascia as a condensation of the local retroperitoneal tissue. He reiterates that the renal fasciae are conspicuously absent in patients with renal agenesis. Coffin et al., in their review on the radiological anatomy of the retroperitoneal fasciae, describe that the anterior and posterior renal fascia fused cranially and laterally while remaining separated medially, adheres to the connective tissue surrounding the aorta and inferior vena cava, running anterior to the great vessels to fuse with its counterpart from the contralateral side. This establishes a theoretical conduit that connects both the perirenal spaces, known as the “Kneeland Channel.” In their in vivo study on the CT scans of 20 patients, Kneeland et al. observed a cross-communication in a few of their patients. If this medial communication exists indeed, one would expect the perinephric hematoma and urinoma to track on to the opposite side. On the right side, the perirenal space closely abuts the bare area of the liver and on the left, the subphrenic space. Furthermore, communication with the mediastinum is said to exist through the diaphragmatic hiatus. In their CT scan study on retroperitoneal spaces, Lim et al. concluded that the perirenal fascia, in its superior aspect, is open toward the upper abdominal extraperitoneal space. Hence, an abscess of the right perirenal space migrates through the bare area of the liver, closely resembling and mimicking a lesion of the liver. Similarly, inflammatory lesions of the pancreas may cause pleural effusions. Such effusions may be due to the diffusion of fluid from the pancreas, through the perirenal spaces onto the pleural spaces, called porous diaphragm syndromes.
In their study on retroperitoneal renal effusions, Meyers concluded that perinephric collections were strictly localized to the ipsilateral side, indicating that there was a fusion of the anterior lamina to the great vessels. Caudally, the two layers ensheath the ureters and fuse to form an inverted cone.
The concepts and clinical importance of renal fascia have undergone a paradigm change in the past three decades. With the advent of axial imaging including CT scan and MRI scan, the understanding of communications between the retroperitoneal spaces got more clarity and clinical significance. Korobkin et al., in their comprehensive review on the renal fascia and retroperitoneal spaces, concluded that renal fascia, its communications, and the perirenal spaces are more complex than what it was earlier thought to be.
In their 5-year study on 28 cases of radical nephrectomy, Takahashi et al. observed that the perinephric space is filled with an intricate fiber-fatty connective tissue that is arranged irregularly and haphazardly, without any definite alignment. But during a surgical procedure, when traction is applied on the same tissue, the loose connective tissue stretches out, becomes taut, and gets organized in a definite alignment, to eventually get thickened to form renal fascia. This principle is demonstrated by a schematic line diagram in [Figure 3].
|Figure 3: Diagrammatic representation of renal fascia when unstretched (a) and stretched (b), reproduced with written permission from Takahashi et al.|
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In their study on combined radiological and cadaveric dissections, Ochi et al. illustrated the anatomical relation between perirenal fat and urinary tract. Their study provided a new dimension to zoning within the renal fascia, paving way for the selection of appropriate planes of dissection around the urinary system, especially in cases of donor nephrectomy. They concluded that anatomical zoning exists within the renal fascia and that the urinary system and perirenal fat are two embryologically distinct entities.
| Conclusions|| |
The authors have re-explored the anatomical and developmental concepts of renal fascia and interfascial planes in normal and pelvic kidneys. The concepts of renal fascia have kept evolving. With the advent and increased usage of axial imaging in the assessment of retroperitoneal pathologies, more knowledge and information about the renal fascia of normally located kidneys is available. Apart from merely being an anatomical fascia, its clinical significance and therapeutic considerations have enabled a better understanding of the various concepts involving retroperitoneal spaces, interfascial planes, and bridging septae. The newer anatomical concept of zoning within renal fascia could help to recognize tissue layers during dissection and help to preserve blood supply to the juxtaureteropelvic junction ureter.
However, knowledge on the presence of this fascia in ectopic pelvic kidneys, its extent, clinical significance, and therapeutic considerations is very limited and needs more validation. A larger prospective study integrating multiple disciplines including anatomy, radiology, and urology is needed to further validate the clinical significance of this fascia in ectopic unascended pelvic kidneys.
I profusely thank Prof. Dr. Daniel J. Bell, Managing Editor, Radiopedia, and Juliette Hancox, Image Licensing and User Support Manager, Radiopedia, for their permission to use their images in [Figure 1], with the case courtesy of Dr. Matt Skalski, Radiopaedia.org, rID: 44105. I would also like to thank Prof. Dr. Goran Mitreski, for permitting me to use his images from his publication, “Radiological diagnosis of perinephric pathology: pictorial essay 2015,” Insights Imaging (2017) 8:155–169, for use in [Figure 2]. I would also like to thank Prof. Ryosuke Takahashi, for allowing me to use his schematic diagram from his publication, “Surgical considerations of the renal fascia and the retroperitoneal space around the kidney” in Journal of Bodywork and “Movement Therapies (2012) 16, 392e396,” for use in [Figure 3].
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]