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Hello, everyone. Thank you for joining us today. Uh My name is Luke, I'm one of the education directors for SA um And this week we are focusing on um flank pain under the er subtopic er urology. Um We're excited to have you all with us today. Uh So I'm joined by Schumer and FDI, um who will guide you through today's topic of flank pain. Uh Shma and Fadi are 3rd and 1st year medical student from Plymouth Medical School. Um to make these sessions as engaging as possible. We'll be releasing polls throughout these are completely anonymous. So we encourage you to participate actively. If you have any questions during the session, please put them in the chat and we'll do our best to address them at the end of the session. We'll share a feedback form. If you complete this, you will receive a certificate of attendance and exclusive discount codes for teaching me surgery and pass the MRC SS. Additionally, the session is being recorded and the recording and slides will be shared on our me page a couple of hours after the session. So be sure to keep an eye out for that. We're also excited to share that an exclusive question bank and other resources will be available on our learning portal. So be sure to check out our website to access them. If you create a free membership account with us, you'll automatically receive a discount code for 10% off the geek medics, anatomy flash cards, surgery, flash cards and knowledge B bundle. We also have an exciting opportunity for all our attendees. Two lucky people will win free access to the GKI medics, surgical flashcards and the ki medics ory stations to enter simply complete the Google form at the end of the session and enter these unique codes that we will provide. The more sessions you attend the higher your chances of winning. So be sure to stay until the end of today's session and attend as many of our other sessions as well. And just finally, before we begin, we'd like to thank our partners who are the Royal College of Surgeons in England, Ek Medics, the MDU more than skin deep meal, teach me surgery and pass the M RT S. So without further ado, I'll hand over to Shama and far. Hi, everyone. So I'm sorry, I'm gonna start the session off. Um So today, the things that we're gonna, that we're gonna discuss are uh the gross anatomy of the kidney and the neurovascular supply of the kidney itself. Then we're gonna look at clinical features of pyelonephritis. One of the pathologies that happens in the kidney and the difference between the pyelonephritis and lower uti, so, lower urinary tract infections as well as the investigation and the basic medical management in tackling these two things. Then we're gonna look at the anatomy and the neurovascular supply of the ureters. And then we're gonna discuss an etiology that is involved with um sorry, we're gonna discuss a pathology that's involved with the ureter, which is a renal stone or renal calculi and medical management for that as well. Then I'm gonna pass on to my colleague uh and he's gonna discuss the congenital abnormalities of the kidney and the surgical significance and then also renal cell carcinoma. So malignancy in the kidney and the clinical signs of that. So we'll start with the gross anatomy. So the kidney itself is retroperitoneal. So it's on the posterior aspect of the abdominal cavity. Um It is at the level of T 12 and L3. So between uh t 12, um vertebrae and L3 vertebrae. So that's the entire uh kidney itself. Now, as you can see in the image on the right hand side, the right kidney is a bit lower than the left kidney and that is due to the liver being uh just superior to it. So it pushes it a bit lower. Um The left kidney will be protected by the rib 11 and rib 12. Whereas the right kidney will be mainly protected by the rib 12, that is mainly due to the liver, pushing it further down, uh the hilum of the kidney. So the opening of the kidney where all the neurovascular supply uh is goes in and out of the kidney. Um is at the level of, of L1 for the left kidney and is at the level of L1 and L2 for the right kidney. So that's also due to the liver being on the right side, pushing the right kidney down. Ok. So the hilum of the kidney. So we just said that um for the, for each kidney is a bit different. So the right kidney is a bit lower and in the hilum of the kidney, few things come out. And I've used this not pneumonic here called VA V AP. So this is from anterior to posterior. So it's as if you're looking at the kidney from the anterior aspect. So V stands for vein. So first you have the renal vein, then you have the artery more posterior to it. So the renal artery and on most posteriorly, you have the renal pelvis or the ureter. So where the pelvis stems out, um where the um pelvis is, that's where the ureter stems out from. So, on the most posterior aspect, you've got the ureter and that's key to now, especially in surgical practice. Now, here we have the superior mesenteric artery, which is at the level of L1. Then we have the celiac trunk at the level of T 12. So we can see that in the image here on the right hand side. So we can see the celiac trunk, uh the most superior structure here. And then we have the superior mesenteric. And as you guys can see in the image, the superior mesenteric actually descends down and it, and it goes right over that vein, the renal vein especially here. And this is gonna be where this is gonna be the left side, right, because we can see the vena cava is on the right hand side. So that is quite important and we'll discuss that uh a little bit more in a second. Um Because there's a pathology that happens there due to the superior mesenteric artery crossing the renal vein. And then finally, we have the superior uh suprarenal artery. Now this is more superior to the celiac trunk. So we can't really see on this image. Um But that artery supplies the suprarenal gland as the name suggests. So that's the adrenal gland. And also we have an inferior suprarenal artery and that actually comes from the renal artery itself. So, not from the aorta and tho both those arteries will supply the adrenal gland. Ok. Here on the image, we can see something and we can uh this vein here and this vein is called the gonadal vein. And the gonadal vein is quite important and there's a specific slide for that in a minute and we'll discuss it. So the vascular supply of the kidney itself. Uh So after the renal um artery exits the aorta, it will go into the hilum and it will supply the kidney segment. So it's got the anterior aspect and the posterior aspect and it sort of branches off and makes a posterior branch and an anterior branch. So the posterior will supply the posterior aspect, the anterior will supply the anterior aspect. And once it enters into the kidney, it will split into different segments. And these are called segmental arteries. And we have five segmental arteries as the bullet point suggests. And on the image, you can see them here. So they're all branching off into each segment of the kidney. And if we follow the segmental arteries, they will make these, you know, arched arteries and because they're arched like a bow, they're called arcuate. So arcuate arteries and anything that's a bow like like a bow arrow or a um an arch is called an arcuate in the body. So we have an arcuate ligament, anything like that in the body, it's called an arcuate. So here we have the arch arteries and from the award arteries, we have small little branches that come out from it. And these are the intralobular arteries and the interlobular arteries will make difference, different little branches and these will be your afferent arterial arterioles. So the the ones that actually go into the Nephron itself and supply uh the blood supply uh there in order for filtration to happen. So the gonadal veins and just shown it in the image previously. So these are quite important because there, there is a variation in this. So we have a right and a left gonadal vein. And we can see here this is for males because we've got the testes and here for the females. Now, the right gonadal vein uh will go into the actual er uh the IVC, the inferior vena cava, whereas the left gonadal vein will actually go all the way up. So it goes further up into the renal vein, so into the renal vein and it, and it supply and it puts the blood into the renal vein. So there's a variation there and that's quite important. Now, if we have a renal cancer that presents with the uh that presents in the left side of the kid, left kidney that can travel down the left gonadal vein. And when it travels down the left gonadal vein, it can present into the uh scrotum. So it can present with something called left-sided varice, which is an enlarged vein in the scrotum, right? Because of the anatomical uh location and the connection between the two. Ok. Now, nut cracker er phenomenon is what we talked about a minute ago with the superior mesenteric artery. So we can see in the image on the right hand side, the superior mesenteric will go over the left renal vein. And when it goes over the left renal vein, it can actually compress it down and when it does, that a lot of issues can happen. So if we compress it, you can just think about it, it will prevent.