ureter Flashcards
Describe the course of the ureter
The ureters run inferiorly from the apex of the renal pelves at the hila of the kidneys (at the level of L1-L2) , lying overtop of poses muscle, passing over the pelvic brim at the bifurcation of the common iliac arteries.
They then run along the lateral wall of the pelvis, parallel to greater sciatic notch between parietal pelvic peritoneum and internal iliac arteries. Opposite the ischial spine they curve anteriomedially, superior to Levator Ani to enter the urinary bladder obliquely.
In females the ureter passes medially from origin of uterine arteries until the level of the ischial spine where it is crossed superiorly by the uterine arteries. This point is ~2cm superior to the iliac spine, near the lateral fornix of vagina.
The ovarian vessels travel in the infundibulo-pelvic ligament of the ovary and cross the ureters anteriorly and laterally to the iliac vessels
Abdominal parts adhere closely to peritoneum and are retroperitoneal throughout course
The anteromedial surface of the pelvic ureter is covered by peritoneum, and it runs posterior to the ovary and then deep into the broad ligament and through the cardinal ligament. The uterine artery crosses the ureters anteriorly in the posterior uterine fold of peritoneum, like the ureters are “water under the uterine-artery bridge”. The distance between the ureter and the cervix is about 1.5cm. The ureter then courses out to the ischial spines and continues medially onto the anterior vaginal fornix. It then penetrates the base of the bladder just above the trigone
Describe the blood supply of the ureter
abdominally - medially from branches of the renal arteries
(i.e. retract medially in abdomen)
pelvic portion arise laterally, from branches of common iliac, internal iliac artery and ovarian arteries
What are the common sites of surgical injury to ureter?
- lateral to the uterine vessels
- the area of the ureterovesical junction close
to the cardinal ligaments - the base of the infundibulopelvic ligament
as the ureters cross the pelvic brim at the
ovarian fossa - at the level of the uterosacral ligament.
What increases the risk of ureteric injury at time of surgery
adhesions endometriosis neoplasm enlarged uterus previous pelvic surgery distorted pelvic anatomy coexistent bladder injury massive intraoperative haemorrhage
what are the mechanisms of injury to the ureter
- Intraoperatively,
~ligation or kinking by a ligature,
~crushing by a clamp,
~division, complete or partial transection,
~devascular- isation or diathermy-related injury. - postoperatively,
~avascular necrosis may occur following extensive dissection of periureteric tissue with impairment of the anastomotic blood supply.
~kinking and subsequent obstruction over a haematoma or lymphocele.
what are surgical strategies to prevent ureteric injuries?
- Appropriate operative approach
- Adequate exposure
- Avoid blind clamping of blood vessels
- Ureteric dissection and direct visualisation
- Mobilise bladder away from operative site
- Short diathermy applications
what are the signs and symptoms of ureteric injury
- Fever
- Haematuria
- Flank pain
- Abdominal distension
- Abscess formation/sepsis
- Peritonitis/ileus
- Retroperitoneal urinoma
- Postoperative anuria
- Urinary leakage (vaginally or via abdominal wound) • Secondary hypertension
what investigations would you use to diagnose ureteric injury
- Intravenous urogram
- Abdominal and pelvic CT scan with IV contrast
- Retrograde ureterogram
- Renal ultrasound
- Cystoscopy
- Contrast-dye tests
what are the general principles of ureteric repair
a. call consultant and urologist
1. Tension-free anastomosis by ureteric mobilisation
2. Ureteric dissection preserving adventitial sheath and its
blood supply
3. Minimal use of fine absorbable suture to attain watertight closure
4. Use of peritoneum or omentum to surround the anastomosis
5. Drain the anastomotic site with a passive drain to prevent urine accumulation
6. Stent with a ureteric catheter
7. Consider a proximal diversion
What are the management options for ureteric injury?
Needle injury - No action unless bleeding or leakage Partial transection- Stent placement Complete transection (no loss of length) 5 cm from vesicoureteric junction-Ureteroneocystostomy 5 cm from vesicoureteric junction- Ureteroureterostomy Complete transection (loss of length): - Psoas hitch - Boari flap with a psoas hitch - Transureteroureterostomy - Ureteroileocystostomy - Ureterocalycostomy - Renal autotransplantation
Describe the course of the ureter once it enters the pelvic brim
• Enters the pelvis - crossing the division of the common iliac.
• Passes inferiorly and anteriorly along the pelvic sidewall lateral to the peritoneum, medial
to the branches of the internal iliac artery (obturator, inferior umbilical and superior vesical arteries) and medial to the obturator nerve.
• Passes anteriorly superior to the uterosacral ligaments, medial to pelvic sidewall (levator ani), lateral to the cervix and inferior to the uterine artery before entering the trigone of the bladder.
