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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)

Department of Urology
University of California School of Medicine
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
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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; &
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
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

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

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

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
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
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
vii

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
Johannes Gutenberg University Medical Center Mainz Badrinath R. Konety, MD, MBA
Mainz, Germany Associate Dean for Innovation
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
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

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
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
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
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
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
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

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
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
Professor of Urology Mary K. Wang, MD
Department of Urology Childrens’ Urology
UCSF School of Medicine Austin, Texas
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

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)

San Francisco, California, January 2020
xi

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).
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.

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

▲▲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.

▲▲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).

▲▲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.

▶▶Lymphatics
The lymphatics of the kidney drain into the lumbar lymph
nodes.
CALICES, RENAL PELVIS, AND URETER
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

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

▲▲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.)

▲▲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

▲▲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.

▲▲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.

▶▶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.

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
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

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
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17
2
Embryology of the
Genitourinary System
Emil A. Tanagho, MD; Hiep T. Nguyen, MD;

& Michael DiSandro, MD
At birth, the genital and urinary systems are related only in nearby primary nephric duct as it grows caudally to join
the sense that they share certain common passages. Embryo- the cloaca (Figure 2–1). This primary nephric duct is now
logically, however, they are intimately related. Because of the called the mesonephric duct. After establishing their con-
complex interrelationships of the embryonic phases of the nection with the nephric duct, the primordial tubules elon-
two systems, they are discussed here as five subdivisions: gate and become S-shaped. As the tubules elongate, a series
the nephric system, the vesicourethral unit, the gonads, the of secondary branches increase their surface exposure,
genital duct system, and the external genitalia. thereby enhancing their capacity for interchanging material
with the blood in adjacent capillaries. Leaving the glomeru-
NEPHRIC SYSTEM lus, the blood is carried by one or more efferent vessels that
soon break up into a rich capillary plexus closely related to
The nephric system develops progressively as three distinct
the mesonephric tubules. The mesonephros, which forms
entities: pronephros, mesonephros, and metanephros.
early in the 4th week, reaches its maximum size by the end
of the second month.
▶▶Pronephros
The pronephros is the earliest nephric stage in humans, and ▶▶Metanephros
it corresponds to the mature structure of the most primitive
The metanephros, the final phase of development of the
vertebrate. It extends from the 4th to the 14th somites and
nephric system, originate from both the intermediate meso-
consists of 6–10 pairs of tubules. These open into a pair of
derm and the mesonephric duct. Development begins in the
primary ducts that are formed at the same level, extend cau-
5–6-mm embryo with a budlike outgrowth from the meso-
dally, and eventually reach and open into the cloaca. The pro-
nephric duct as it bends to join the cloaca. This ureteral bud
nephros is a vestigial structure that disappears completely by
grows cephalad and collects mesoderm from the nephro-
the 4th week of embryonic life (Figure 2–1).
genic cord of the intermediate mesoderm around its tip. This
mesoderm with the metanephric cap moves, with the grow-
▶▶Mesonephros ing ureteral bud, more and more cephalad from its point of
The mature excretory organ of the larger fish and amphib- origin. During this cephalic migration, the metanephric cap
ians corresponds to the embryonic mesonephros. It is becomes progressively larger, and rapid internal differentia-
the principal excretory organ during early embryonic life tion takes place. Meanwhile, the cephalic end of the ureteral
(4–8 weeks). It, too, gradually degenerates, although parts bud expands within the growing mass of metanephrogenic
of its duct system become associated with the male repro- tissue to form the renal pelvis (Figure 2–1). Numerous out-
ductive organs. The mesonephric tubules develop from the growths from the renal pelvic dilatation push radially into
intermediate mesoderm caudal to the pronephros shortly this growing mass and form hollow ducts that branch and
before pronephric degeneration. The mesonephric tubules rebranch as they push toward the periphery. These form the
differ from those of the pronephros in that they develop a primary collecting ducts of the kidney. Mesodermal cells
cuplike outgrowth into which a knot of capillaries is pushed. become arranged in small vesicular masses that lie close to
This is called Bowman’s capsule, and the tuft of capillaries the blind end of the collecting ducts. Each of these vesicular
is called a glomerulus. In their growth, the mesonephric masses will form a uriniferous tubule draining into the duct
tubules extend toward and establish a connection with the nearest to its point of origin.

▲▲Figure 2–1. Schematic representation of the development of the nephric system. Only a few of the tubules of the
pronephros are seen early in the 4th week, while the mesonephric tissue differentiates into mesonephric tubules that
progressively join the mesonephric duct. During this time, the first sign of the ureteral bud from the mesonephric duct is
seen. At 6 weeks, the pronephros has completely degenerated and the mesonephric tubules start to do so. The ureteral
bud grows dorsocranially and has met the metanephrogenic cap. At the 8th week, there is cranial migration of the differ-
entiating metanephros. The cranial end of the ureteric bud expands and starts to show multiple successive outgrowths.
(Data from several sources.)
As the kidney grows, increasing numbers of tubules are the ends of the anterior pronephric tubules; (4) this pronephric
formed in its peripheral zone. These vesicular masses develop duct serves subsequently as the mesonephric duct and as such
a central cavity and become S-shaped. One end of the S gives rise to the ureter; (5) the nephric duct reaches the cloaca
coalesces with the terminal portion of the collecting tubules, by independent caudal growth; and (6) the embryonic ureter
resulting in a continuous canal. The proximal portion of the is an outgrowth of the nephric duct, yet the kidney tubules dif-
S develops into the distal and proximal convoluted tubules ferentiate from adjacent metanephric blastema.
and into Henle’s loop; the distal end becomes the glomeru-
lus and Bowman’s capsule. At this stage, the undifferentiated
mesoderm and the immature glomeruli are readily visible on ▶▶Molecular Mechanisms of Renal and
microscopic examination (Figure 2–2). The glomeruli are
Ureteral Development
fully developed by the 36th week or when the fetus weighs The kidney and the collecting system originate from the
2500 g (Osathanondh and Potter, 1964a, b). The metaneph- interaction between the mesonephric duct (Wolffian duct)
ros arises opposite the 28th somite (fourth lumbar segment). and the metanephric mesenchyme (MM). The uretic bud
At term, it has ascended to the level of the first lumbar or (UB) forms as an epithelial outpouching from the meso-
even the twelfth thoracic vertebra. This ascent of the kidney nephric duct and invades the surrounding MM. Reciprocal
is due not only to actual cephalic migration but also to differ- induction between the UB and MM results in branching
ential growth in the caudal part of the body. During the early and elongation of the UB from the collecting system and in
period of ascent (7th–9th weeks), the kidney slides above the condensation and epithelial differentiation of MM around
arterial bifurcation and rotates 90°. Its convex border is now the branched tips of the UB. Branching of the UB occurs
directed laterally, not dorsally. Ascent proceeds more slowly approximately 15 times during human renal development,
until the kidney reaches its final position. generating approximately 300,000 and 1 million nephrons
Certain features of these three phases of development must per kidney (Nyengaard and Bendtsen, 1992).
be emphasized: (1) the three successive units of the system This process of reciprocal induction is dependent on the
develop from the intermediate mesoderm; (2) the tubules at all expression of specific factors. Glial cell-derived neurotrophic
levels appear as independent primordia and only secondarily factor (GDNF) is the primary inducer of ureteric budding
unite with the duct system; (3) the nephric duct is laid down (Costantini and Shakya, 2006). GDNF interacts with sev-
as the duct of the pronephros and develops from the union of eral different proteins from the MM (eg, Wt1, Pax2, Eyal,

EMBRYOLOGY OF THE GENITOURINARY SYSTEM CHAPTER 2 19
▲▲Figure 2–2. Progressive stages in the differentiation of the nephrons and their linkage with the branching collecting
tubules. A small lump of metanephric tissue is associated with each terminal collecting tubule. These are then arranged
in vesicular masses that later differentiate into a uriniferous tubule draining into the duct near which it arises. At one
end, Bowman’s capsule and the glomerulus differentiate; the other end establishes communication with the nearby
collecting tubules.
Six1, Sall1) and from the UB itself (Pax2, Lim1, Ret) result- termination and tubule maintenance (hepatocyte growth fac-
ing in outgrowth of the UB (reviewed by Shah et al, 2004). tor, transforming growth factor-α, epidermal growth factor
Proper activation of the Ret/GDNF signaling pathway in receptor) (reviewed by Shah et al, 2004). BMP7, SHH, and
the tip of UB epithelium appears to be essential in the pro- Wnt11 produced from the branching ureteric bud induce the
gression of branching morphogenesis (reviewed by Michos, MM to differentiate. These factors induce the activation of
2009). B-catenin and Gata3 are important regulators of Ret Pax2, α-8-integrin, and Wnt4 in the renal mesenchymal cells,
expression, and correct activity of Ret is regulated by posi- resulting in condensation of the MM and the formation of
tive (Wnt11 from MM) and negative (Sprouty1 from the UB) pretubular aggregate and primitive renal vesicle (reviewed by
feedback signaling. Additional specific factors are required for Burrow, 2000). With the continued induction from the UB
(1) early branching (eg, Wnt4 and Wnt11, fgf 7–10); (2) late and the autocrine activity of Wnt4, the pretubular aggregates
branching and maturation (bmp2, activin); and (3) branching differentiate into comma-shaped bodies. Platelet-derived

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Fenstern auf allen Seiten würden in Mosul unerträgliche Steinkamine
sein. Auch die Häuser der Armen haben dieselbe Bauart; nur fehlt
natürlich der Marmorschmuck; oft sind sie aus unbehauenem Stein
oder nur aus an der Sonne getrocknetem Lehm.
Dem kunstverständigen Auge, das auf diesen Höfen der
zahlreichen vornehmen Häuser an malerischen Motiven reiche
Ausbeute findet, mag Mosul leicht als eine Perle unter den Städten
des Orients erscheinen. Das Panorama von einem hohen Dache aus
enttäuscht aber stark. Man sieht nichts als graue, fensterlose
Mauern, flache Hausdächer mit Brustwehren in verschiedener Höhe,
runde Minarette mit einem oder mehreren Rundgängen für die
Gebetsrufer, und hier und da die viereckigen Türme und flachen
Kuppeln der christlichen Kirchen und Klöster.
Toros, 60jähriger armenischer Karawanenfuhrer aus
Erserum.
Basarstraße in Mosul.
Weit dankbarer ist eine Wanderung durch die Straßen und
Basare, wahrhaftige Labyrinthe, durch die man sich nur unter
kundiger Führung hindurchfindet. Eng und winkelig sind die Gassen,
wie in Bagdad, weniger häufig die Holzerker. Die belebteren
Stadtviertel haben Steinpflaster, aber so schlechtes, daß eine
Droschke verunglücken würde, wenn sie sich überhaupt hier
durchzwängen könnte. Schmutz, Unrat, Gerümpel, Fruchtschalen,
Gedärme und andere Küchenabfälle liegen haufenweise umher, die
widerwärtigen Hunde wühlen darin herum. Die Straßenreinigung
besorgt nur ab und zu ein heftiger Sturmwind mit riesengroßem
Besen; ganze Kehrichtwolken füllen dann die Basare. Vergebliche
Mühe! In den Winkeln sammelt und häuft sich der Schmutz um so
höher, und dort bleibt er liegen.
Eine schöne Ecke im Basar.
In den lebhaftesten Straßen des Basars sind die Läden der
Waffenschmiede und Gelbgießer, die Stände der Schmiede und
Seiler, Fleischbänke und Obstläden, wo Rosinen und Mandeln,
Nüsse, Gurken, Gewürze usw. feilgehalten werden. Das Geschäft
der Töpfer blüht, denn der Krug geht solange zu Wasser, bis er
bricht, und ganz Mosul braucht die hübschen Trinkgefäße, die die
Frauen so anmutig auf dem Kopfe einhertragen. In den Buchläden
schmökern Männer im Turban oder Fes umher. Durchmarschierende
Soldaten kaufen Tabak und Pfeifen, Feuerstahl und Mundstücke.
Mächtige Ballen europäischer Stoffe liegen aufgestapelt, immer in
schreiender Farbe, die das Auge des Orientalen erfreut. Ein
Hammam, ein Bad, ist überall in der Nähe. Kleine Tunnel, deren
spitzbogige Tore oft von schönen Skulpturen umrahmt sind, führen
zu den Karawansereien der Großkaufleute, und Stände mit alten
Kleidern, wahre Herde für ansteckende Krankheiten und Ungeziefer,
fehlen auch nicht. In den engsten Gassen arbeiten die Barbiere in
schattigen Gewölben. Schutzdächer aus dünnen Brettern oder
Bastmatten über den Läden erhöhen noch die malerische Buntheit
der Straßenbilder.
Bab-el-Dschiser.
Das Herz des Basars ist ein kleiner, unregelmäßiger Marktplatz,
auf den die Hauptstraßen zusammenlaufen. Hier liegen mehrere
Kaffeehäuser. Auf der offenen Veranda des einen habe ich viele
Stunden zugebracht. Unter mir ein Gewimmel, wie in einem
Ameisenhaufen; würdig einherschreitende Orientalen im Turban
oder Fes und in weißen, braunen oder gestreiften Kopftüchern mit
Scheitelringen, Chaldäer und Syrier — im Fes, aber sonst
europäisch gekleidet —, Priester und Bettler, Frauen mit und ohne
Schleier, Hausierer und lärmende Kinder, Eseltreiber mit ihren
störrischen Langohren und Kameltreiber durchziehender
Karawanen, die nie ein Ende nahmen. Das Reizvollste aber war der
Blick über dies Gewimmel hinweg durch den mächtigen Rundbogen
des gegenüberliegenden Tores Bab-el-dschiser auf den nahen
Strom, die Brücke, die seine Ufer verbindet, und auf die Ruinenhügel
von Ninive.
In 35 Bogen zwischen mächtigen Steinpfeilern setzt die Brücke
über den Strom. Aber nur auf dem linken Ufer ist sie landfest; bei
niedrigem Wasserstand steht sie dort zum größten Teil auf dem
Trockenen. Die Strömung geht am rechten Ufer entlang, wo auch
das Bett am tiefsten ist, und bei Hochwasser, nach der
Schneeschmelze oder nach Frühjahrsregen, würde auch die stärkste
Steinbrücke der rasenden Gewalt des Wassers nicht widerstehen.
Deshalb hat man hier eine Pontonbrücke angesetzt, deren
Verbindungsteil mit der Steinbrücke, je nach dem Wasserstand,
seine Lage selbsttätig ändert. Auch unterhalb der festen Brücke läuft
ein Fußsteig, der aber nur bei niedrigem Wasserstand begangen
werden kann; jetzt war er überschwemmt. Die Brücke wurde vor
achtzig Jahren von einem Italiener gebaut, dessen Sohn noch jetzt
in Mosul leben soll.
Das orientalische Gepräge Mosuls wird starke Einbuße erleiden,
wenn nach dem Kriege die Bagdadbahn fertig ist, und Eisenbahnen,
Lokomotiven und Güterzüge die Kamele verdrängen. Schon jetzt
hatte die Regulierungsmanie eines Wali auch hier gewütet. Vom
künftigen Bahnhof brach man eine Straße quer durch die Stadt zum
Tigris. Dadurch fiel eine Menge schöner alter Häuser und Höfe der
Spitzhacke zum Opfer. Der Krieg verhinderte bisher den Neubau;
infolgedessen sah die Straße aus, als habe ein Erdbeben sie
zerstört, oder als hätten die Russen hier wie in Ostpreußen gehaust.
Halb abgerissene Häuser standen da, und bloßgelegte Höfe mit
hohen Gewölben, Säulen und Marmorarabesken boten einen
traurigen Anblick. Ich fragte den Gendarm, den mir der Kommandant
als Begleiter mitgegeben hatte, ob der für diese Zerstörung
verantwortliche Wali nicht gehängt worden sei. „Im Gegenteil,“
antwortete er lachend, „jedenfalls ist er Ehrenbürger von Mosul
geworden!“
Tunnel im Basar.
Meine Streifzüge durch Mosul beschloß ich gewöhnlich mit dem

Besuch eines Gasthauses, dessen Besitzer, der Italiener Henriques,
mit einer tüchtigen deutschen Frau verheiratet ist; aus Bagdad hatte
man ihn ausgewiesen, in Mosul aber ließ man ihn unbehelligt. Er
wohnte fast außerhalb der Stadt an einem großen Platz zwischen
den Infanteriekasernen, dem Konak und dem Serail, wo die
Zivilbehörden ihren Sitz haben, und verschenkte den herrlichsten
Nektar, den man sich in der Sonnenglut wünschen konnte, eiskalte
Limonade.
Der chaldäische Patriarch, rechts der Herzog, links Koeppen und Staudinger.
Monseigneur Chajat.
Von den Kirchen Mosuls soll die ältere chaldäische aus dem 7.
Jahrhundert stammen. Unmittelbar neben ihr liegt die jetzige
chaldäische Kathedrale, die im 14. Jahrhundert erbaut und 1810 und
1896 erneuert wurde. Es war gerade Vespergottesdienst, als wir sie
in Begleitung mehrerer Priester besuchten, und der Gesang der
Chorknaben erfüllte die niedrigen Wölbungen des Kirchenschiffs,
das vom Altar durch einen Vorhang getrennt war. Die Wölbungen
ruhen auf acht Säulen; Kapitäle und das sie verbindende Gebälk
sind mit Bibelsprüchen bedeckt, der Boden mit Teppichen belegt. An
die Kathedrale schließt sich das Seminar mit einem geräumigen Hof.
Ein Gang und eine Treppe führen in eine Krypta, eine andere Treppe
auf einen kleinen Hof, an dem ein Zimmer gezeigt wird, das
Feldmarschall von Moltke 1837 bewohnt haben soll. Ein dritter Hof
umschließt eine Begräbnisstätte der Chaldäer. Sonntag, den 18.
Juni, waren der Herzog und wir andern frühmorgens ½6 Uhr zu einer
feierlichen Messe in der Kathedrale eingeladen. Der Vorhang vor
dem Chor war nun aufgezogen, der Altar strahlte im Kerzenlicht, und
Knaben- und Männerchöre sangen oder vielmehr schrien Psalmen
und Lieder. Der Patriarch, ein ehrwürdiger Greis mit langem, weißem
Haar und freundlichen Augen hinter runden Brillengläsern,
zelebrierte selbst und murmelte mit dumpfer Stimme uns
unverständliche Worte aus goldbeschlagenen Büchern. Die
Morgensonne flutete durch die Fenster herein auf die dichte Menge
der Andächtigen, und die Festkleider der chaldäischen Frauen
leuchteten in allen Farben.
Erntetanz.
Am zweiten Sonntag lud mich der Chorbischof der syrischen
Kirche, Monseigneur Chajat, Fondateur de l’Institut Pius X. à
Mosoul, zu einer höchst originellen Tanzvorstellung kurdischer
Landleute, die zur Erntearbeit nach Mosul zu kommen pflegen. Die
Männer trugen Turbane, Westen, Leibgürtel und lange Hosen, die
Frauen leichte Kopftücher, Mieder oder Jäckchen und bunte Röcke.
Vier Musikanten spielten auf; ihre Instrumente waren ein Kanun, ein
zitherartiges Saitenspiel, das man aus den Knien hält, ein Oud oder
eine Gitarre, ein Dumbug oder eine Trommel und ein Tamburin mit
rasselnden Tellerchen an der Seite, genannt Daff (vgl. das Bild S.
348).
Der erste Teil des Erntetanzes: Die Sicheln werden geschliffen.

In raschem Tempo.
Erst traten die Männer vor, faßten sich an den Händen und
begannen jenen rhythmisch wiegenden Tanz, den ich schon bei den
Arabern gesehen hatte. Bald warfen sie sich nach rechts, bald nach
links vornüber, jedesmal den Fuß gegen die Steinplatten stemmend,
und zwar mit solchem Nachdruck, daß man fürchtete, sie müßten
sich die Fußsohlen zerreißen. Der Schweiß floß ihnen vom Gesicht
herab, die Augen glänzten vor Eifer; die Tänzer schienen völlig im
Bann der immer leidenschaftlicher anschwellenden Musik, die Finger
rissen immer ungestümer die Saiten, die Knöchel schlugen mit
rasender Schnelligkeit das gespannte Trommelfell, und wie ein
saugender Strudel des Tigris wirbelte es um die Maulbeerbäume des
Hofes herum.
Am zweiten Tanz nahmen auch die Frauen teil, und den Schluß
bildete der Erntetanz der Männer. Erst saßen sie auf dem Boden und
schliffen ihre Sicheln zum Takt der Musik. Dann standen sie auf und
machten in wiegendem Gang die Bewegungen des Schnitters beim
Mähen der Saat. Dann steigerte sich der Tanz zu einem wilden
Krescendo.
Hinterher gaben uns die Musikanten in einer Loggia noch ein
besonderes Konzert. Sie spielten einen algerischen Marsch, der an
der Nordküste Afrikas volkstümlich sein soll, und melancholische,
eintönige Weisen zu den Liedern eines arabischen Sängers, denen
man stundenlang zuhören konnte.
Das Haus des Chorbischofs war einer der schönsten Paläste in
Mosul, und Monseigneur Chajat hatte die Liebenswürdigkeit, mir
eines seiner Zimmer als Atelier einzuräumen und mir zahlreiche
männliche und weibliche Modelle zu beschaffen. Die Bilder, die ich
von ihnen entwarf, erheben keinen Anspruch auf künstlerischen
Wert, geben aber wohl einen Begriff von der Mannigfaltigkeit
charakteristischer Typen, die Mosuls Straßen und Basare beleben
und dem Auge des Malers einen unerschöpflichen Reiz bieten.
Das Tor Bab-el-Dschiser in Mosul mit Blick auf die Tigrisbrücke und Ninive.
Dreiundzwanzigstes Kapitel.
Ninive.
I m vorigen Kapitel berichtete ich schon, daß ich am 11. Juni 1916
die alte Seldschukenburg in Mosul bestieg, die sich auf einem
steilen Felsen über dem rechten Ufer des Tigris erhebt, und zum
erstenmal die alte Königsstadt Ninive vor mir sah — oder vielmehr
die Stelle, wo sie ehemals gestanden hat. Keine grauen Massen
gewaltiger Mauern, keine Türme mit Zinnen, keine Terrassen von
Königspalästen oder festen Bürgerhäusern sind mehr zu sehen;
nicht einmal Reste ihrer Grundmauern ragen über der Erde hervor.
Alles ist verschwunden; nur drei ausgedehnte, gleichförmige Hügel
mit schroffen Abhängen verraten den Ort, wo vor Jahrtausenden die
Hauptstadt des assyrischen Weltreichs blühte. Von der
beherrschenden Höhe der Seldschukenburg aus erhält man aber
wenigstens einen ungefähren Begriff von der Lage und Größe dieser
Stadt, und die Phantasie glaubt den Lauf der Stadtmauer zu
erkennen. Sonst nichts als graubraune Wüste in glühendem
Sonnenbrand.
Und diesen Eindruck unendlicher Verwüstung erhielt ich auch, als
ich am 16. Juni mit Professor Tafel, der ebenfalls von Bagdad
herübergekommen war, auf dem Ruinenfeld selbst umherstreifte.
Nur an zwei Stellen dieses ungeheuern Friedhofes hat sich das
Leben noch festgenistet; die eine ist das Dorf Nebi Junus,
unmittelbar neben dem südlichen Hügel und selbst auf einer kleinen
Anhöhe gelegen, von der die Grabmoschee des Propheten Jonas
weithin sichtbar ist, und das Dorf Kujundschik, berühmt als einer der
ergiebigsten Fundorte der Assyriologen.
Die Droschke, mit der wir von Mosul über das Rollsteinpflaster
der Tigrisbrücke Ninive entgegenfuhren, war mit Seilen umschnürt,
weil ihre gesprungenen und eingetrockneten Radkränze und
Speichen auseinanderzufallen drohten. Auf dem linken Ufer bogen
wir rechts ab und hielten bald am Fuße des Abhangs, von wo ein
Fußweg zur Grabmoschee Nebi Junus hinaufführt. Es war gerade
Freitag und Gottesdienst in der Moschee.
Oberster Priester der Grabmoschee des
Propheten Jonas.
Man empfing uns freundlich und geleitete uns zu einer
Dachterrasse hinauf, von der aus eine Tür in den Tempel führte. In
einem kleinen Kiosk, einem Turmzimmer mit Fenstern nach allen
Himmelsrichtungen, die eine prächtige Aussicht auf das
gegenüberliegende Mosul darboten, mußten wir warten, bis die
Gebete zu Ende waren, die Allahs Segen auf den Sultan, auf Kaiser
Wilhelm und Kaiser Franz Joseph herabflehten und um Sieg über
die Feinde baten — eine erbauliche Zeremonie für die anwesenden
englischen Untertanen, wenn anders sie aufrichtige Gefühle für
England im Herzen hegten. Ein kleiner weißbärtiger Alter, den
Turban auf dem Kopf und eine Brille auf der Nase, leistete uns mit
mehreren andern Mohammedanern Gesellschaft.
Als die Gläubigen die Moschee zu verlassen begannen, zogen
wir die Schuhe aus; unser Führer ergriff meine Hand und bat uns
ihm zu folgen. Das Innere des Tempels war sehr einfach und
entbehrte jedes Schmucks, nur ein paar verschlissene Teppiche
lagen auf dem Boden. Seitwärts vor einem Gitterfenster standen
einige indische Mohammedaner im Gebet versunken. Durch dieses
Gitter sah man in die Krypta des Propheten Jonas hinab, ein dunkles
Loch, in dessen Mitte sich eine sarkophagähnliche Erhöhung abhob.
Das eigentliche Grab des Toten soll aber unter diesem Denkmal
liegen.
Indische Mohammedaner in der Moschee Nebi Junus.

Eins der Minarette von Mosul hängt bedenklich über. Der Sage
nach verbeugten sich alle Gebetstürme in Ehrfurcht, als der Prophet
Jonas gleich unterhalb dieses Dorfes, das seinen Namen trägt, vom
Walfisch ans Land gespien wurde. Nachher richteten sie sich wieder
auf bis auf einen, der noch heute fortfährt, die Bewohner Mosuls an
das Grab des Heiligen zu erinnern.
Aus der stillen Kühle der Moschee gingen wir wieder in den
Sonnenbrand hinaus und stiegen langsam den Hügel hinab, auf
dessen Abhang die ärmlichen Hütten des Dorfes Nebi Junus in
amphitheatralischer Anordnung liegen. Auf einem der Höfe hatte sich
eine Schar armenischer Flüchtlinge gelagert. Dann fuhren wir eine
Strecke nordwärts bis zum Flusse Choser, der von Osten nach
Westen die Ruinenstätte durchfließt. Eine schöne neue
Bogenbrücke führte hinüber, die aber auch schon so verfallen war,
daß wir vorzogen, sie zu Fuß zu überschreiten. Auf einer Landspitze
nahm eine Eselkarawane, Führer und Tiere, in dem kristallklaren,
fast stillstehenden Wasser ein Bad.
Josefine Saijo, 13jährige Syrierin.

Bald hinter der Brücke beginnt der eine von den Hügeln Ninives,
und wir steigen seinen niedrigen Gipfel hinan. Ringsum nur Schutt
und Disteln — nichts, was auch nur einigermaßen an die Welt des
Altertums erinnert, kaum daß die eingestürzte Mündung eines
Tunnels die Spur älterer englischer und französischer Ausgrabungen
verrät. Lautlos und öde dehnt sich die sonnenverbrannte Wüste vor
uns; nur Scherben zerbrochener Wasserkrüge liegen umher,
zwischen denen zahlreiche Eidechsen über glühend heiße Steine
dahinhuschen. Die Grundmauern, auf denen Königspaläste und
Festungen ruhten, sind im Schutt verborgen, und die Phantasie
versagt, wenn sie aus diesem öden Nichts die Herrlichkeit
vergangener Jahrtausende erwecken soll. Auf diesem ungeheuern
Friedhof sind nicht einmal mehr Grabsteine zu finden, die ihr als
Führer dienen könnten, und in meinen Ohren klingen die Worte des
Propheten Nahum, zu dessen Grab in dem Dorf Alkosch, neun
Stunden nördlich von Mosul, an bestimmten Festtagen die Juden
wallfahren: „Es wird der Zerstreuer wider dich heraufziehen und die
Feste belagern. Siehe wohl auf die Straße, rüste dich aufs beste und
stärke dich aufs gewaltigste. Denn der Herr wird die Pracht Jakobs
wiederbringen, wie die Pracht Israels. Die Schilde seiner Starken
sind rot, sein Heervolk glänzt wie Purpur, seine Wagen leuchten wie
Feuer, wenn er sich rüstet; ihre Spieße beben. Die Wagen rollen auf
den Gassen und rasseln auf den Straßen. Sie glänzen wie Fackeln
und fahren einher wie die Blitze. Er aber wird an seine Gewaltigen
denken; doch werden sie fallen, wo sie hinaus wollen, und werden
eilen zur Mauer und zu dem Schirm, da sie sicher seien. Aber die
Tore an den Wassern werden doch geöffnet, und der Palast wird
untergehen. Die Königin wird gefangen weggeführt werden, und ihre
Jungfrauen werden seufzen wie die Tauben und an ihre Brust
schlagen. Denn Ninive ist ein Teich voll Wasser von jeher; aber
dasselbe wird verfließen müssen. Stehet, stehet, werden sie rufen,
aber da wird sich niemand umwenden. So raubet nun Silber, raubet
Gold, denn hier ist der Schätze kein Ende und die Menge aller
köstlichen Kleinode. Nun muß sie rein abgelesen und geplündert
werden, daß ihr Herz muß verzagen, die Kniee schlottern, alle
Lenden zittern und alle Angesichter bleich werden. Wo ist nun die
Wohnung der Löwen und die Weide der jungen Löwin, da der Löwe
und die Löwin mit den jungen Löwen wandelten und niemand durfte
sie scheuchen? Der Löwe raubte genug für seine Jungen und
würgte es seinen Löwinnen. Seine Höhlen füllte er mit Raub und
seine Wohnungen mit dem, was er zerrissen hatte. Siehe ich will an
dich, spricht der Herr Zebaoth, und deine Wagen im Rauch
anzünden, und das Schwert soll deine jungen Löwen fressen; und
will deines Raubens ein Ende machen auf Erden, daß man deiner
Boten Stimme nicht mehr hören soll. Wehe der mörderischen Stadt,
die voll Lügen und Räuberei ist und von ihrem Rauben nicht lassen
will. Denn da wird man hören die Geißeln klappen und die Räder
rasseln und die Rosse jagen und die Wagen rollen. Reiter rücken
herauf mit glänzenden Schwertern und mit blitzenden Spießen. Da
liegen viel Erschlagene und große Haufen Leichname, daß ihrer
keine Zahl ist und man über die Leichname fallen muß. Und alle, die
dich sehen, werden vor dir fliehen und sagen: Ninive ist zerstört; wer
soll Mitleiden mit ihr haben, und wo soll ich dir Tröster suchen?
Siehe dein Volk soll zu Weibern werden in dir, und die Tore deines
Landes sollen deinen Feinden geöffnet werden, und das Feuer soll
deine Riegel verzehren. Schöpfe dir Wasser, denn du wirst belagert
werden! Bessere deine Festen! Gehe in den Ton und tritt den Lehm
und mache starke Ziegel! Aber das Feuer wird dich fressen, und das
Schwert töten; es wird dich abfressen wie die Käfer, ob deines Volks
schon viel ist wie Käfer, ob deines Volks schon viel ist wie
Heuschrecken. Deiner Herren sind so viele wie Heuschrecken und
deiner Hauptleute wie Käfer, die sich an die Zäune lagern in den
kalten Tagen. Wenn aber die Sonne aufgeht, heben sie sich davon,
daß man nicht weiß, wo sie bleiben. Deine Hirten werden schlafen, o
König zu Assur, deine Mächtigen werden sich legen; und dein Volk
wird auf den Bergen zerstreut sein und niemand wird sie
versammeln. Niemand wird deine Schaden lindern, und deine
Wunde wird unheilbar sein.“ —

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Smith & Tanagho’s General Urology

19th Edition Jack W. Mcaninch - eBook

Smith & Tanagho’s General Urology 19th Edition Edition

Campbell Walsh Wein Urology 12th Edition Alan W Partin

General, organic, & biological chemistry Third Edition

Vaughan & Asbury’s General Ophthalmology 19th Edition

Campbell Walsh Wein Handbook of Urology 1st Edition

General, Organic, and Biological Chemistry 5th Edition

Principles of General, Organic, & Biological Chemistry

Campbell-Walsh Urology 12th Edition Review, 3e (Mar 2,

Smith & Tanagho’s

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

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

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

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

22 Genital Tumors 377 33 Diagnosis of Medical Renal Diseases 539

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

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

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

Daniela Franz, MD Hedvig Hricak, MD, PhD

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

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Katsuto Shinohara, MD David Tat, DO

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

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CALICES, RENAL PELVIS, AND URETER

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

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

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

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

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▶▶Blood Supply EPIDIDYMIS

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The testis is covered anteriorly and laterally by the visceral SCROTUM

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▶▶Blood Supply ▶▶Blood Supply

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Emil A. Tanagho, MD; Hiep T. Nguyen, MD;

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Meine Streifzüge durch Mosul beschloß ich gewöhnlich mit dem

Der erste Teil des Erntetanzes: Die Sicheln werden geschliffen.

Indische Mohammedaner in der Moschee Nebi Junus.

ebook download Smith & Tanagho’s General Urology 19th Edition Jack W. Mcaninch - eBook PDF all chapter

ebook download Smith & Tanagho’s General Urology 19th Edition Jack W. Mcaninch - eBook PDF all chapter