- 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.
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
Upper ® para-aortic nodes, lower ® internal iliac nodes.
Pelvic ® common / internal iliacs
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.