Basics of Urologic Surgery

Question 1

1. The uterine vessels are found ______________ to the ureter.
   a. laterally
   b. posteriorly
   c. anteriorly
   d. medially
   e. running together in a common sheath

Answer 1

1. c. Anteriorly. In women, the ureter first runs posterior to the ovary,
   then turns medially to run deep to the base of the broad ligament
   before entering a loose connective tissue tunnel through the
   substance of the cardinal ligament.

Question 2

2. All of the following are TRUE EXCEPT:
   a. The angle between the inferior pubic rami is obtuse in women.
   b. The female pelvis is larger and broader than the male pelvis.
   c. The female inlet is heart shaped (as compared with the oval-
   shaped male inlet).
   d. The female pelvis is shorter and wider, with a less pronounced
   sacral promontory.
   e. Female pelvic inlet faces anteriorly, allowing pressure of the
   intra-abdominal and intrapelvic contents to be directed to the
   bony pelvis.

Answer 2

2. c. The female inlet is heart shaped (as compared with the oval-
   shaped male inlet). The female inlet is oval in shape (as compared
   with the heart-shaped male inlet) and wider, which contributes to
   the weakness of the pelvic floor.

Question 3

3. In contrast to that of the male, the female bladder neck:
   a. has extensive adrenergic innervation.
   b. has a thickened middle smooth muscle layer.
   c. is largely responsible for urinary continence.
   d. is surrounded by type I (slow-twitch) fibers.
   e. has longitudinal smooth muscle fibers that extend to the
   external meatus.

Answer 3

3. e. Has longitudinal smooth muscle fibers that extend to the
   external meatus. At the female bladder neck, the inner
   longitudinal fibers converge radially to pass downward as the inner
   longitudinal layer of the urethra. The middle circular layer does not
   appear to be as robust as that of the male. The female bladder neck
   differs strikingly from the male in possessing little adrenergic
   innervation.

Question 4

4. Relative to the anterior portion of the uterosacral ligament, the
   ureter:
   a. lies inferior.
   b. lies posterior.
   c. lies superior.
   d. lies lateral.
   e. runs along with it.

Answer 4

4. d. Lies lateral. The uterosacral originates from the greater sciatic
   foramen and inserts into the lateral aspect of the fascia surrounding
   the cervix, isthmus of the uterus, and vaginal wall. The ureter lies
   lateral to the anterior portion of the uterosacral ligament (closest to
   the cervix).

Question 5

5. To avoid denervation of the striated urethral sphincter, incisions
   through the vaginal wall to enter the retropubic space should be
   made:
   a. perpendicular to the urethra.
   b. over the urethra.
   c. close to the lateral margins of the urethra.
   d. cephalad to the bladder neck.
   e. far lateral in the vaginal wall, parallel to the urethra.

Answer 5

5. e. Far lateral in the vaginal wall, parallel to the urethra. Somatic
   and autonomic nerves to the urethra travel on the lateral walls of
   the vagina near the urethra. During transvaginal incontinence
   surgery, the anterior vaginal wall should be incised laterally to
   avoid these nerves and prevent type III urinary incontinence.