Ureters (319,320)

25cm in length; 

- Arise at renal hilum posterior to renal artery and vein ~L1 level, and run retroperitoneally

- Pass down on psoas major on a slight S-curve; crosses under gonadal vessels at inferior pole of kidney; crosses GF nerve on psoas

-           R ureter: Upper part behind duodenum; root of mesentery, R colic, ileocolic and superior mesenteric vessels cross lower down.

-           L: lat to inferior mesenteric vessels, crossed by L colic vessels and apex of sigmoid colon. 

Leave psoas at bifurcation of common iliac, passe over the over SIJ, then curve laterally to pelvis

In Pelvis:
-
Enters pelvis crossing anteriorly to ilaiac vessels, usually at common iliac bifurcation; coming 5cm apart before diverging laterally again
- here, runs anterolaterally to internal iliac; curves anteromedially to join bladder.
- Ovarian vessels travel in suspensory iigament of ovary, cross ureter anterioly and lateral to iliacs
- Then ureters course out to ischial spines before passing (under ductus deferens in males) to base of bladder
- ie is deep to braod ligament and through cardinal ligament in females; uterine artery runs anteriorly in rectrouterine fold of peritoneum

Narrowest at (1) PUJ, (2) point of crossing pelvic brim and (3) VUJ.

On AXR: ureters run just medial to tips of transverse processes, crosses at SIJ jt, then to ischial spine and finally to pubic tubercle.

Surface markings: palpable for tenderness: from tip of 9th CC ® bifurcation of common iliac.

Blood supply

Ureteric branch of renal artery ® upper part.

Gonadal artery ® middle part. (also aorta and common/internal iliacs)

Inferior & superior vesical, middle rectal arteries  ® inferior part. 

-           form an anastomosis around it; stripping adventitia can endanger this bld supply.

Veins: renal, gonadal and iliac veins paired with arteries

Lymph drainage

Upper ® para-aortic nodes, lower ® internal iliac nodes. 

Pelvic ® common / internal iliacs

Nerves

Symp: T10-L1 via coeliac, hypogastric plexi (carries pain, as in kidney)

Para: pelvic splanchnics; S2-4 segments; pain from region of ribs down to groin.

Structure:

Stellate 3-4mm tube in section, round in life, smooth muscle with internal transitional epithelium m.m.

-           no muscularis mucosa.

-           Single coat with fibres in many different directions (inter-twined helix)

Development: mesodermal; caudal end of mesonephric duct.

-           upper end divides in 2 or 3 ® major calyces; may be double if low division occurs.

Variations

Can be duplicated in up to 1%; from incomplete Y variant to complete duplication
Ectopic kidneys

Clinical Points

Close association with ovarian vessels at pelvic brim and uterine artery at rectouterine fold means subject to injury at oophorectomy or hysterectomy.

In Gen Surg, most commonly injured in L sided colonic surgery
- prevention by constant awareness; at risk in high ligation of IMA, mobilization of upper mesoretum at sacral promontory, pelvic proctectomy or deep phase of AP resection
- patient, surgeon and disease risk fx incl past operations, anatomical variations;, inexperience, diverticular inflammation or inflammatory bowel, large masses, irradiation; slightly higher lap risk but operator dependent; haemorrhage during surgery = major risk fx.
- in most cases finding the ureter is not difficult
- if not obvious find it by examining: examine inter-sigmoidal fossa (behind sigmoid mesentery), inferomedial to gonadals after IMA, extend search up and down psoas; evaluate at common iliac bifurcation where will run over-top; gently opening tissue planes with right angle.
- whitish colour and will demonstrate visible peristalsis on gentle grasping
- if still not obvious, request urological support and +/- stenting

If injured?
- may be ligated, kinked, lacerated, crush or devascularized (delay to stricture)
- get exposure, get help from a urologist.
- define anatomy and define injury; use of indigo-carmine die (IV or into ureter through bladder) can help show blue-tinged urine leak
- if post op, IV urography
- if not detected at surgery, presentation may be subtle; pain in flank, excessive fluid in drains, ileus,
- management depends on nature of injury, length of ureter, timing of diagnosis and associated comorbidities
--> optimal is at time of injury; best success rates; late associated with greater morbidity
--> upper 1/3, no loss of length, spatulated repair over stent with 5-0 prolene, middle third repair or ligate distal stump and Boari flap or psoas hitch repair; lower third: ligation of distal stump and neo-ureterocystostomy.