Anatomy of Ureter

Anatomy
• The ureters are bilateral muscular retroperitoneal ducts with narrow
lumens that carry urine from the kidneys to the urinary bladder
• They then run along the lateral wall of the pelvis to enter the urinary
bladder.
• 22 to 30 cm in length; 1.5 to 6 mm in diameter
• In neonates - 6.5 to 7.0 cm long.
• The ureter is arbitrarily divided into proximal (upper), middle (over the
sacrum), and distal (lower) segments.
Anatomy
• According to International anatomic
terminology the ureter
• Abdominal (from renal pelvis to iliac
vessels)
• Pelvic (from iliac vessels to the bladder)
• Intramural segments.
• Normally, three constrictions could be
identified radiologically in each ureter
• At its junction with the renal pelvis (UPJ)
• Crossing of iliac vessels
• At the intramural ureter or ureterovesical
junction
Anatomy
• The pelvic segment of the ureter is approximately 15 cm long—a half
of its total length.
• The length of this intramural part of the ureter in adults is 1.2 to 2.5
cm, and in neonates it is approximately 0.5 to 0.8 cm
• The intramural ureter represents the narrowest part of the ureter,
with an average diameter of 3 to 4 mm.
• Being the narrowest ureteral segment, the intramural ureter may need
to be dilated before ureteroscopy
Anatomy
• Posteriorly, both ureters descend anterior to the
psoas major muscle and then cross the ventral
surface of transverse processes of the 3rd to 5th
lumbar vertebrae and enter the pelvis at the
bifurcation of the common iliac vessels .
• The right ureter begins behind the descending
part of the duodenum, where it is crossed by the
gonadal vessels (testicular or ovarian), which is
called “water under the bridge”
Anatomy
• The left ureter is covered at its origin by the
initial part of the jejunum.
• The gonadal vessels cross the left ureter after
running parallel to it for a small distance.
Anatomy
• At the pelvic inlet, it crosses the common iliac
vessels near their bifurcation.
• The ureter then runs downward and laterally
toward the ischial spine on the lateral pelvic
wall along the anterior border of the greater
sciatic notch.
• Near the bladder, the terminal ureter is
enveloped by a muscular layer, the Waldeyer
sheath, and then pierces the bladder wall
obliquely as the intramural segment.
Relations of Ureter
• On the left side, the sigmoid arteries and veins
embedded in the sigmoid mesocolon run in front
of the ureter towards the sigmoid colon. The
inferior mesenteric artery and its terminal
branch, the superior rectal artery, follow a
curved course close to the left ureter.
• Proceeding from medial to lateral, the following
sequence of structures is found:
• Superior rectal vessels
• Left ureter
• Left testicular or ovarian vessels.
• Just above the entry to the pelvis, the ureter is
still covered by peritoneum by virtue of the
ureteric fold.
• Next to the ureteric fold, the gonadal vessels
form an adjacent fold (in female,
infundibulopelvic or suspensory ligament of
ovary).
• One of the most common areas of ureteric
injury is near the pelvic brim in close relation to
the peritoneal fold of the gonadal vessels (for
instance the ovarian vessels in the
infundibulopelvic ligament of ovary).
• The pelvic segment of the ureter crosses the
common iliac vessels near their bifurcation (on the
left side commonly anterior to the common iliac
artery and on the right side commonly anterior to
the external iliac artery).
• Within the pelvis the ureter can be divided into
two portions. The descending part runs caudally
still covered by peritoneum. It is dorsally
accompanied by the internal iliac artery and its
visceral branches as well as marked venous
plexuses. Projected on to the lateral wall of the
pelvis, the descending part of the ureter crosses
the obturator artery, vein and nerve.
The pelvic space in the male, with
neurovascular structures surrounding the pelvic
segment of the right ureter (cranial view)
• In the female, the descending part of the pelvic
segment of the ureter courses posterior to the ovary.
• Following that, the bent part passes the middle rectal
artery in the lateral ligament of the rectum
(paraproctium), swings in a convex curve and crosses
the uterine vessels in a sagittal direction near, i.e.
1.5–2 cm (occasionally even 1–4 cm) away from the
margin of the cervix of uterus.
• At this level, the ureter reaches the base of broad
ligament of uterus (paracolpium)
• Finally, the terminal ureter runs forward,
accompanied by the neurovascular bundle of the
bladder.

The pelvic space in the female, with

neurovascular structures surrounding the pelvic
segment of the right ureter (cranial view)
• Just before entering the bladder, it passes the
anterior vaginal fornix.
• As a rule, the left ureter has a more close
relation to the anterior wall of the vagina than
the right.
• Note the close proximity of the ureter to the
uterine vessels. This is the site where ureteral
injuries most commonly occur during
gynaecological procedures.
• In case of vaginal surgery, there is a high risk of
injury especially for the left ureter

The pelvic space in the female, with

neurovascular structures surrounding the pelvic
segment of the right ureter (cranial view)
Blood supply of Ureter
• Abdominal portion – Main renal arteries
(abdominal aorta or gonadal arteries)
• Mid ureter – Common iliac artery
• Distal ureter - superior vesical artery
Abdominal Medial

Mid Posterior

Distal Lateral
Blood supply of Ureter
• Veins draining the abdominal part of the ureters drain into the renal
and gonadal veins.
• Venous drainage of the mid and distal ureters is into the common and
internal iliac veins
Lymphatics of Ureter
• The lymphatics from the Abdominal ureter
• Left - Para-aortic lymph nodes
• Right - Right paracaval and inter aortocaval lymph nodes.
• Lymphatic vessels from the middle part - Common iliac lymph nodes
• Intrapelvic part - Common, external, and internal iliac lymph nodes.
Nerve supply of Ureter
• The sympathetic supply to the ureter arises from the preganglionic
fibers of the 11th,12th thoracic and 1st lumbar segments.
• Parasympathetic vagal fibers supply the upper part of the ureter via
the celiac plexus, and the lower portion is supplied by the sacral
segments S2 to S4.
 Histology of Ureter
• The innermost is the mucosa, the middle
muscular layer is the muscularis, and the
outer layer is the adventitia.
• The mucosa consists of transitional
epithelium, which has four to six layers of
cells when the ureter is contracted.
• These cells encircle a large number of
junctional complexes containing a
consistent level of keratin precursors that is
responsible for the waterproof property of
this layer.
Histology of Ureter
Radiological Anatomy of Ureter
• The ureter could be delineated by excretory
urography during expiration, because it may
be kinked during inspiration as a result of
downward movement of the kidney
• Radiologists describe three segments of the
ureter
• Proximal portion extending from its origin down
to the upper border of the sacroiliac joint
• Middle portion lying over the sacroiliac joint
• Distal segment from the lower border of that
joint to its entrance into the bladder
Radiological Anatomy of Ureter
• The entire length of the ureter is rarely seen in
a single film of the excretory urography
because of its peristaltic activity.
• Otherwise, ureteral atony or obstruction
should be suspected
• Similarly, crossing vessels may compress the
ureter and simulate areas of stricture.
Therefore the diagnosis of a ureteral stricture
should not be based on a single film of
excretory urography with the presence of
ureteral dilatation proximal to the site of
narrowing.
 Endoscopic Anatomy of Ureter
• Once the cystoscope is inside the bladder
neck, the trigone can be seen as a raised,
smooth triangle.
• The apex of that triangle is situated at the
bladder neck, and its base is formed by the
interureteral ridge or Mercier’s bar, extending
between the two ureteric orifices.
• The interureteral ridge is more prominent in
males than females,
 Endoscopic Anatomy of Ureter
• The ureteric orifices are symmetrically located
along it, approximately 1 to 2 cm from the
midline.
• The trigone is the most vascular part of the
bladder and is formed by an extension of the
longitudinal muscle fibers of the ureters over
the detrusor muscle.
• Therefore it appears cystoscopically to be
more deeply colored than the rest of the
bladder.
Endoscopic Anatomy of Ureter
• The normal ureteric orifice may appear as a volcano or a horseshoe
that is prominent and obvious on endoscopy.
• However, it might look like a slit that can be identified with only
meticulous examination
• The other ureteral narrowing areas at the pelvic brim and UPJ are
identified endoscopically by being stenotic and relatively non-
distensible.
• The pulsating iliac vessels could be seen endoscopically as the ureters
cross the pelvic brim
Endoscopic Anatomy of Ureter

• The ureteric orifices are classified according to their position.

• Position A – At the trigone
• Position C – Lateral wall of the bladder or at its junction with the
trigone
• Position B - in between positions A and C
Endoscopic Anatomy of Ureter
• In terms of configuration
• Grade 0 - Normal ureteric orifice - a cone or a
volcano.
• Grades 1 – Stadium
• Grade 2 – Horse shoe
• Grade 3 – Gold-hole
• The higher the grade of the orifice, the
higher the tendency to be laterally located
and to reflux
Endoscopic Anatomy of Ureter
• The UPJ could be identified easily endoscopically during its frequent
opening and closing.
• The UPJ merges into the wider and more dependent part of the renal
pelvis.
• The kidneys lie on the diaphragm, and thus they are affected by the
respiratory movements.
• Therefore, during ureteroscopy, the tidal volume could be decreased
to minimize renal excursions during respiration
Endoscopic Anatomy of Ureter
• In the renal pelvis, the flexible ureteroscope first faces the ostia of the
major calyces, which look like circular openings separated by carinae.
• Then the flexible ureteroscope enters a long tubular infundibulum that
branches into the minor calyces.
• These infundibula usually connect the ostia of major calyces with their
apex.
• For a flexible ureteroscope to pass from the axis of the upper ureteral
segment to the axis of the lower infundibulum, it should deflected 140
(104 to 175) degrees at the uretero-infundibular angle.
Embryology of Kidney and Ureter
• The definitive human kidney
arises from two distinct sources.
• The secretory part, i.e. excretory
tubules (or nephrons) are derived
from the metanephros, the cells of
which form the metanephric
blastema.
• The collecting part of the kidney is
derived from a diverticulum called
the ureteric bud which arises from
the lower part of the mesonephric
duct
 Ascent of Kidney
• The definitive human kidney is derived from the
metanephros and lies in the sacral region in the initial
stages of development.
• Differential growth of the abdominal wall causes the kidney
to ascend to the lumbar region
• The metanephros, at first, receives its blood supply from
the lateral sacral arteries
• The definitive renal artery represents the lateral splanchnic
branch of the aorta at the level of the second lumbar
segment.
• The hilum of the kidney, at first, faces anteriorly. The organ
gradually rotates so that the hilum comes to face medially.
Absorption of lower parts of
mesonephric ducts into cloaca
• The lower ends of the mesonephric ducts open into that part of the cloaca that forms
the urogenital sinus.
• The ureteric buds arise from the mesonephric ducts, a little cranial to the cloaca.
• The parts of the mesonephric ducts, caudal to the origin of the ureteric buds, are
absorbed into the vesicourethral canal; with the result the mesonephric ducts and the
ureteric buds now have separate openings into the cloaca.
• These openings are at first close together. However, the openings of the ureteric buds
move cranially and laterally due to continued absorption of the buds.
• The triangular area (on the dorsal wall of the vesicourethral canal) between the
openings of the ureteric buds and those of the mesonephric ducts is derived from the
absorbed ducts and is, therefore, of mesodermal origin.
Absorption of lower parts of
mesonephric ducts into cloaca
 Golden Triangle
• Bordered by the lower pole of the kidney on the left,
the junction between the renal vein and the inferior
vena cava on the right and gonadal vein
• The vast majority of leaks occur at the distal portion
of the ureter, most commonly at the site of the
ureteroneocystostomy.
• Distal ureteral ischemia and necrosis secondary to
compromised blood supply is thought to be the main
culprit for early ureteral complications in most
patients in the absence of technical difficulties during
the transplant operation.
Golden Triangle
• In contrast to the native ureters, which derive their
blood supply via both renal arteries and pelvic
collaterals, the transplanted ureter depends solely
on the blood supplied by the branches of the renal
artery that traverse in peri-ureteric tissues.
• This area, also known as the “golden triangle”
contains important arterial branches, such as the
lower polar artery, which supplies the distal ureter.
Indeed, the importance of preserving the peri-
ureteral connective tissue in order to prevent
disastrous urinary complications
Ureteric injuries
• 75% ureteric injuries take place during gynaecological procedures.
• Abdominal Hysterectomy is the most common procedure.
• 30% chance of injury during gynaec-oncosurgery.
• 0.5-1% —Abdominal Hysterectomy.
• 0.1 % —Vaginal Hysterectomy.
• 9-10%-Wertheim's Hysterectomy
Common sites of Injury
• At the pelvic brim during clamping of
infundibulopelvic ligament.
• At the bifurcation of common iliac artery during
internal iliac artery ligation.
• Lateral pelvic wall above the uterosacral ligament.
• Base of broad ligament, ureter passes under the
uterine artery.
• Intramural portion near the insertion into the trigone
when base of bladder is injured or repaired.
Laparoscopic Injuries
• 0.3-0.4%
• Due to Thermal injury
• Avoiding electrocoagulation of bleeding points around uterosacral
ligaments and use of sutures or clips instead
AAST Classification
General Principle
• Mobilize the injured ureter carefully, sparing the adventitia widely, so
as not to devascularize the ureter further.
• Debride the ureter minimally but judiciously until edges bleed
• Repair ureters with spatulated, tension-free, stented watertight
anastomosis, using fine absorbable sutures and retroperitoneal
drainage afterward.
General Principle
• Retroperitonealize the ureteral repair by closing peritoneum over it if
possible.
• If immediate repair is not possible, or the patient hemodynamically
unstable, one management option is to ligate the ureter with long silk
or polypropylene suture, and plan to repair it later, or place a
nephrostomy tube after ICU resuscitation (damage control).
• The other option is a temporary cutaneous ureterostomy over a single-
J stent or pediatric feeding tube with a suture tied around the ureter
proximal to the injury site, in order to secure the stent in place, and to
prevent urinary leakage.
Treatment Options
Upper ureter Injury
• Ureteroureterostomy -
Ureteral avulsion from the
renal pelvis, or even very
proximal ureter, can be
managed by reimplantation of
the ureter directly into the
renal pelvis
Mid Ureteral injury
• The majority of midureteral complete transections (above the iliac vessels),
regardless of the mechanism, can be repaired by primary
ureteroureterostomy over a stent.
• When the midureteral injury/defect is very long, however, and the ends of the
ureters cannot be brought together without tension, then a
transureteroureterostomy (TUU) can be considered
Lower Ureteral Injury
• Ureteroneocystostomy – It is used to repair distal ureteral injuries that
occur so close to the bladder that the bladder does not need to be
brought up to the ureteral stump with a psoas hitch or Boari
procedure.
• Standard principles of ureteroneocystostomy include a long,
nontunneled, spatulated, stented anastomosis
 Lower Ureteral Injury
• Psoas Bladder Hitch is a mainstay in the
treatment of injuries to the lower third of
the ureter and has a high success rate, from
95% to 100%
• It is preferred over ureteroureterostomy in
lower ureteral injuries because the tenuous
ureteral blood supply may not survive
transection.
• For lower ureteral injuries, the ureteral gap
can be bridged by “hitching” (suturing) the
apex of the bladder to the ipsilateral psoas
muscle and psoas minor tendon.
 Lower Ureteral Injury
• The contralateral superior vesical
pedicle is often divided to improve
mobilization.
• When hitching the bladder, it is
important not to injure or entrap the
genitofemoral nerve in the sutures.
The psoas hitch is relatively quick to
perform
Lower Ureteral Injury
• Boari Flap - Injuries to the lower two-
thirds of the ureter with long ureteral
defects (too long to be bridged by
bringing the bladder up in the psoas
hitch procedure) can be managed
• If the bladder is normal in size and
thickness, a long pedicle of bladder can
be incised and rotated cephalad and
tubularized to bridge the gap to the
injured ureter.
Procedure and Defect Length
PERINEUM AND URETHRAL
INJURY
• INTRODUCTION
OUTLINE
– DEFINITION
– STATEMENT OF SURGICAL IMPORTANCE
– EPIDEMIOLOGY
• RELEVANT ANATOMY
• CLASSIFICATION
– SITE
– TYPE OF INJURY
• AETIOPATHOGENESIS
• MANAGEMENT
– RESUSCITATION
– HISTORY
– EXAMINATION
– INVESTIGATION
– TREATMENT
– COMPLICATIONS
• FOLLOW UP/PROGNOSIS
• CONCLUSION
 INTRODUCTION
• URETHRAL INJURY IS A BREACH IN THE STRUCTURAL
INTEGRITY OF THE URETHRA RESULTING FROM EXCESSIVE
TRAUMA

• WITH INCREASING INDUSTRIALIZATION, HIGH-SPEED

COMMUTE, HUMAN CONFLICT AS WELL AS ADVANCES IN
SURGICAL SCIENCE THE INCIDENCE OF URETHRAL INJURY
IS ON THE RISE. TIMELY AND ACCURATE DIAGNOSIS ARE
NECESSARY FOR APPROPRIATE ACUTE MANAGEMENT
AND REDUCTION OF LONG TERM MORBIDITY
 INTRODUCTION
• EPIDEMIOLOGY
– IT IS THE COMMONEST CAUSE OF URETHRAL
STRICTURE
– MAKES UP MAJORITY OF GU INJURIES
– 10% OF PELVIC FRACTURES ASSOCIATED WITH
URETHRAL INJURY
RELEVANT ANATOMY
 CLASSIFICATION
• SITE
– POSTERIOR URETHRAL INJURY
– ANTERIOR URETHRAL INJURY
• TYPE OF INJURY
– CONTUSION
– PARTIAL RUPTURE
– COMPLETE RUPTURE
 AETIOPATHOGENESIS
• POSTERIOR URETHRAL
INJURY
– PELVIC FRACTURE
– 10% ASSOC WITH URETHRAL
INJURY. ALMOST ALL
PERINEAL INJURY 2O BLUNT
TRAUMA HAVE ASSOCIATED
PELVIC FRACTURE
– RTA COMMONEST CAUSE OF
PELVIC FRACTURE
– INJURY OCCURS IN
MEMBRANOUS URETHRA
– IATROGENIC – VERMOTEENS
– CATHETER-RELATED SIGN
– SURGERY – RADICAL
PROSTATECTOMY
 AETIOPATHOGENESIS
• ANTERIOR URETHRAL INJURY (MOSTLY
ISOLATED)
– STRADDLE INJURY
– INJURY OCCURS IN BULBAR URETHRA
– IATROGENIC
– CATHETER-RELATED
– CIRCUMCISION
– PENETRATING INJURY
– GUNSHOT
– SELF-MUTILATION
– MENTALLY ILL
– SEXUAL GRATIFICATION
 AETIOPATHOGENESIS
• FEMALE URETHRA
– PELVIC FRACTURE
– VAGINAL SURGERY
 MANAGEMENT
• RESUSCITATION
– IMPORTANT IN PERINEAL INJURY DUE TO PELVIC
FRACTURE
– LIFE-THREATENING CONDITIONS TAKE
PRECEDENCE OVER URETHRAL INJURY
 MANAGEMENT
• HISTORY
– INABILITY TO PASS URINE DESPITE THE URGE
– HAEMATURIA
– PAINFUL MICTURITION
– URETHRAL BLEEDING
 EXAMINATION
• GENERAL EXAMINATION NOT
SPECIFICALLY CONTRIBUTORY TO
DIAGNOSIS OF URETHRAL INJURY
• ABDOMEN
– ECCHYMOSIS
– DISTENDED URINARY
BLADDER
• EXT. GENITALIA
– BLOOD AT MEATUS
– ANY SURGERY OR
PENETRATING INJURY?
– PENILE OR PERINEAL
ECCHYMOSIS
– FOREIGN BODY IN
URETHRA MAY BE FOUND
 EXAMINATION
• DIGITAL RECTAL EXAM
– BOGGINESS
– HIGH RIDING OR ABSENT
PROSTATE

• VAGINAL EXAM
– BLEEDING
– VAGINAL LACERATION

• MUSCULOSKELETAL
– POSITIVE PELVIC COMPRESSION
AND DISTRACTION TESTS
 INVESTIGATION
• TO CONFIRM DIAGNOSIS
– RETROGRADE URETHROGRAPHY
• CONFIRMS INJURY
• TYPE
• LOCATION
• PRESENCE OF FOREIGN BODY
• ASSOC INJURY e.g. BLADDER
 INVESTIGATION
• TO DETERMINE EXTENT OF DISEASE
– PELVIC XRAY
– IMAGING FOR INVOLVED ORGAN SYSTEMS
• TO SUPPORT MANAGEMENT
– CBC
– RFT
– URINALYSIS
– CXR
– ECG
 TREATMENT
• AIM IS TO HAVE A CONTINENT PATIENT WITH
SATISFACTORY VOIDING AND SEXUAL FUNCTION
• PATIENT IS GIVEN ANALGESIA AND ANTIBIOTICS
• AVOID REPEATED ATTEMPTS AT BLIND
CATHETERIZATION
• PENETRATING INJURY IS JUDICIOUSLY DEBRIDED
• DEFINITIVE TREATMENT IS ACHIEVED BY
– EARLY REPAIR OR
– DELAYED REPAIR
 TREATMENT
• EARLY REPAIR
• DONE WITHIN ONE WEEK OF INJURY
• URINE DIVERSION VIA SUPRAPUBIC CYSTOSTOMY
• MODALITIES INCLUDE
– USE OF INTERLOCKING URETHRAL SOUNDS (‘RAILROADING’)
– ENDOSCOPIC REALIGNMENT
– OPEN SURGERY AND REPAIR OVER A CATHETER
• IT IS FRAUGHT WITH COMPLICATIONS SUCH AS
– INFECTION OF HAEMATOMA
– STRICTURE – 70%
– ERECTILE DYSFUNCTION – 45%
– INCONTINENCE – 20%
 TREATMENT
• DELAYED REPAIR
• URINE DIVERSION BY SUPRAPUBIC CYSTOSTOMY
• AT 12 WEEKS POSTINJURY RUG IS DONE TO ASSESS
URETHRAL STRICTURE
• REPAIR OF STRICTURE IS CARRIED OUT
• COMPLICATION RISK
– STRICTURE – 50%5
– ERECTILE DYSFUNCTION – 12%5
– INCONTINENCE – 2%5
• DELAYED REPAIR IS MOST COMMON
 TREATMENT
• CATHETERS LEFT IN SITU FOR 4 WEEKS
• PERICATHETER RUG DONE AND CATHETER
REMOVED IF NO EXTRAVASATION NOTED
• PATIENT’S VOIDING ABILITY NOTED
 COMPLICATIONS
• EXTRAVASATION OF URINE NECROTIZING
INFECTION OF PENILE AND PERINEAL SKIN
• URETHRAL STRICTURE
• ERECTILE DYSFUNCTION
• URINARY INCONTINENCE
 PROGNOSIS
• WITH PROPER MANAGEMENT PROGNOSIS IS
EXCELLENT
• UNRECOGNIZED URETHRAL INJURY HOWEVER
LEADS TO HIGHER INCIDENCE OF
COMPLICATIONS
 CONCLUSION
RECOGNITION OF CARDINAL SIGNS AND
SYMPTOMS OF URETHRAL INJURY FACILITATES
TIMELY RADIOGRAPHIC DIAGNOSIS AND EARLY
COMMENCEMENT OF APPROPRIATE INITIAL
MANAGEMENT.
CLINICIAN MUST MAINTAIN A HIGH INDEX OF
SUSPICION, AS THESE INJURIES ARE
FREQUENTLY OVERSHADOWED BY
MULTISYSTEM TRAUMA.
THANK YOU