Applied anatomy and Embryology Flashcards
Case 1
47 years f, Known Endometriosis, Symptoms of pain were affecting her Quality of life, Underwent laparoscopy for Excision of Endometriosis, Surgery performed by Multidisciplinary team, Patient recovered well- Discharged on Day 2, Presented on Day 7 with: Severe Abdominal pain, Vomiting, Temperature. Bloods revealed raised Urea Creatinine and inflammatory markers, CT scan confirmed Diagnosis of Ureteric injury, Patient was managed surgically.
how long is the ureter?
25cm, muscular tubular structure, opens into the trigone of the bladder
outline the histology of the ureter
Lumen of Ureter is 3mm, Inner Mucosal layer. Ureter is lined by Transitional epithelium.Middle Layer of Smooth Muscle. Muscle coat in upper 2/3 has Inner Longitudinal and outer circular layer. Muscle in lower 1/3 has additional layer of outer longitudinal layer. Outer layer of Adventitia
what is the course of the ureter? - abdominal part
Arise from the renal pelvis – a funnel like structure located within the hilum of the kidney. The renal pelvis receives urine from the major calyces. The point at which the renal pelvis narrows to form the ureter is known as the ureteropelvic junction.
After arising from the ureteropelvic junction, the ureters descend through the abdomen, along the anterior surface of the psoas major. Here, the ureters are a retroperitoneal structure (located behind the peritoneum).
At the area of the sacroiliac joints, the ureters cross the pelvic brim, thus entering the pelvic cavity. At this point, they also cross the bifurcation of the common iliac arteries
Anteriorly on to right side ureter is related to 3rd part of duodenum, gonadal vessels & terminal part of Ileum, colic vessels. On left anterior side it is related to root of mesentery, sigmoid colon and sigmoid meso colon..
Posteriorly it is related to Psoas major and transverse process of L2-L5 vertebrae.
Medially is inferior vena cava
what is the course of the ureter? - pelvic part
Once within the pelvic cavity, the ureters travel down the lateral pelvic walls along the anterior margin of greater sciatic notch. At the level of the ischial spines, they turn anteromedially, moving in a transverse plane towards the bladder.
Near the cervix, the uterine artery lies above ureter. ( water under bridge)
Posteriorly related to Sacroiliac joint, common iliac vessels and laterally related to obturator nerve and vessels.
Closely related to IP ligament in pelvis.
what is the course of the ureter? - intramural part
Upon reaching the bladder wall, the ureters pierce its lateral aspect in an oblique manner. This creates a one way valve, where high intramural pressure collapses the ureters – preventing the back-flow of urine.
blood supply of the ureter?
Ureter is supplied by 3 sets of long arteries.
Upper part receive branches from renal artery.
Middle part receive blood supply directly from gonadal vessels and direct branches from aorta
Pelvic part is supplied by arteries from superior vesicle, middle rectal and uterine vessels.(which come off the internal iliac a.)
nnerve supply of the ureter?
Renal Ovarian and hypogastric nerve plexus in pelvis
Sympathetic nerve from T10- T11 segment and Parasympathetic supply from S2-S4.
Sensory fibres from the ureters enter the spinal cord at T11-L2, with ureteric pain referred to those dermatomal areas
Parasympathetic fibres causes contraction of smooth muscle fibres of ureter and bladder and relaxation of internal ureteric sphincter, Sympathetic fibres have got opposite effect.
lymphatic drainage of the ureter?
majority to the lumbar lymph nodes, pelvic portions to various iliac lymph nodes. All which drian into the cisterna chyli/ thoracic duct.
where are the constricitions in the ureter?
Ureter has constriction at 3 places
a) Pelvi-ureteric Junction
b) Pelvic Brim
c) Where it enters bladder- intramural part
Clinical Relevance: Ureteric Calculus - A ureteric calculus (or kidney stone), is the presence of a solid stone in the urinary tract, formed from minerals within the urine. These can obstruct urinary flow, causing renal colic (an acute and severe loin pain) and haematuria (blood in the urine).
where are the common sites of injury?
Near IP ligament at or near pelvic brim
Base of broad ligament where ureter pass under Uterine vessels
Lateral Pelvic wall above uterosacral ligament
Intramural portion near the insertion of trigone
rf’s for injury
Anatomical risk factors: due to variable course of ureter and is difficult to palpate or seen
Pathological risk factors: Due to 1) Congenital anamolies of ureter, 2) Displacement of ureter due to a) Prolapse, b) Pelvic mass, 3) Adhesions due to previous surgery, endometriosis and PID.
how can ureteric injuries be prevented?
Intraoperative recognition Ureter by: Peristalsis, Dissection & exposure in complex cases, Mobilization of Ureter- preserve vascular plexus. Pre Operative imaging. Intraoperative Stenting. Cystoscopy, Cystoscopy+IV indigocaramine Dye, Stent insertion, Uretroscopy, Retrograde, antegrade/IV Uretropyelography
types of ureteric injury?
Angulation, Crush, Ligation, Thermal, Laceration, Transection(most common), Resection
surgical management of ureteric injury…
Transuretero-uretrostomy, Psoas hitch, Boari flap.
