Anatomy, Abdomen and Pelvis, Ureter


Article Author:
Hernan Lescay


Article Editor:
Faiz Tuma


Editors In Chief:
Stephen Leslie
Karim Hamawy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/13/2018 11:59:10 PM

Introduction

The ureters are bilateral thin (3 to 4 mm) tubular structures that connect the kidneys to the urinary bladder, transporting urine from the renal pelvis into the bladder. The muscular layers are responsible for the peristaltic activity that the ureter uses to move the urine from the kidneys to the bladder.

Embryologically, the ureter originates from the ureteric bud, which is a protrusion of the mesonephric duct, a part of the genitourinary system development.

The ureters begin at the ureteropelvic junction (UPJ) of the kidneys, which lie posteriorly to the renal vein and artery in the hilum[1]. The ureters then travel inferiorly inside the abdominal cavity. They pass over (anterior to) the psoas muscle and enter the bladder on the posterior bladder aspect in the trigon.

Three areas along the path of the ureter are clinically significant for renal stones lodging. These areas are: the ureteropelvic junction (UPJ), the ureterovesical junction (UVJ), and the crossover of the common iliac arteries. The UPJ is where the pelvis of the kidney transitions into the ureter and the UVJ is where the ureters enter the bladder.

The blood supply to the ureter is segmental. The upper ureter closest to the kidneys receives blood directly from the renal arteries. The middle part is supplied by the common iliac arteries, branches from the abdominal aorta, and the gonadal arteries. The most distal part of the ureter receives blood from branches of the internal iliac artery.

T12 through L2 provide innervation to the ureters, creating a ureteric plexus. Pain may refer to T12-L2 dermatomes.

The ureter is often injured in all types of hysterectomies as it is near the infundibulo-pelvic ligament.

Structure and Function

The ureteric wall is composed of three main of tissue: inner mucosa, middle muscle layer and outer serosa. The lining of the inner layer is transitional epithelium. Deeper to it is the lamina propria, which is combined with the epithelium make up the mucosal lining. The next deeper layer of tissue is the smooth muscle layer or lamina propria. An inner longitudinal and an outer circular layer comprise the smooth muscle layer of the ureter.

The path of the ureter is along the anterior edge of the psoas muscle, which is the general area where the gonadal vessels cross anteriorly to the ureter a third of the way to the bladder. The ureter crosses over the common iliac arteries, showing the anatomical landmark of the bifurcation of the common iliac vessels into internal and externa iliac vessels. The ureters finally enter on the posterior wall of the bladder where they incorporate into the trigone[2]. The ureters have specific anatomic relationships dependent upon which side of the body. The right ureter lies in close relationship to the ascending colon, cecum, and appendix. The left ureter is close to the descending and sigmoid colon.[1]

The nomenclature of the ureter is based on its anatomic relationship to surrounding structures. The abdominal ureter is the segment of the ureter that extends from the renal pelvis to the iliac vessels. The pelvic ureter extends from the iliac vessels to the bladder[3]. There is an alternative method of ureteral nomenclature: upper, middle, and lower segments. The upper ureter extends from the renal pelvis to the upper border of the sacrum. The middle ureter continues from the upper to lower borders of the sacrum. The distal ureter continues from the lower border of the sacrum to the bladder.

Embryology

The stalk of the ureteric bud which is a diverticulum from the mesonephric duct gives rise to the ureter. The bud branches near the cranial aspect into the collecting tubules which become confluent and form the major calyces.[1]

Blood Supply and Lymphatics

The ureters receive their blood supply from multiple arterial branches[4]. In the upper or abdominal ureter, the arterial branches stem from the renal and gonadal artery, abdominal aorta, and common iliac arteries. In the pelvic and distal ureter, the arterial branches come from the vesical and uterine arteries, which are branches of the internal iliac artery. The arterial supply will course along the ureter longitudinally creating a plexus of anastomosing vessels. This is of clinical significance because it allows for safe mobilization of the ureter during surgery when proper exposure from surrounding structures is crucial.

The venous and lymphatic drainage of the ureter mirrors that of the arterial supply. The lymphatic drainage is to the internal, external, and common iliac nodes[5]. The lymphatic drainage of the left ureter is primarily to the left para-aortic lymph nodes while the drainage of the right ureter primarily drains to the right paracaval and interaortocaval lymph nodes.

Nerves

The exact role of the innervation of the ureter is unclear, but the innervation for ureteral peristalsis originates from the intrinsic smooth muscular pacemaker sites. Within the renal collecting system, the minor calyces are the location for the pacemaker sites.[6]

There is preganglionic sympathetic input from T10 through L2[7]. The aorticorenal, superior, and inferior hypogastric autonomic plexuses give rise to the postganglionic fibers.

S2 through S4 provide parasympathetic innervation to the ureter.

Physiologic Variants

Abnormalities of the ureteric bud give rise to duplications of the abdominal ureter[8]. Abnormal division, specifically incomplete division of the metanephric diverticulum results in a bifid ureter with a divided kidney, while a complete division of the metanephric diverticulum results in a bifid ureter with a double kidney.[9]

An ectopic ureter does not enter the urinary bladder and can open into the bladder neck or the prostatic urethra in males[10]. In females, the ectopic ureter can open into the vestibule or vagina. This presents as urinary incontinence due to the direct communication between the urinary system and the vagina, causing continuous leakage of urine[11].

Surgical Considerations

The most common causes of ureteral injury are iatrogenic[12]. The overall incidence of iatrogenic ureteral injury varies between 0.5% to 10%. The most common type of procedure responsible for iatrogenic injury to the ureter is a hysterectomy (54%) due to the proximity of the uterine artery to the distal ureter[13][14]. As the ureter courses into the pelvis, it nears the infundibulo-pelvic ligament where it courses below to the uterine artery. Ureteral injuries may present with flank pain, ileus, hematuria, and prolonged high drain outputs. Elevated laboratory levels include BUN and creatinine.[15]

Clinical Significance

There are 3 specific areas of narrowing along the ureter. These areas of narrowing poise significant clinical sequelae when dealing with ureteral calculi[16]. The first is the ureteropelvic junction or UPJ. This is the area where the renal pelvis tapers into the proximal ureter. The second region of narrowing occurs where the ureter crosses the iliac vessels. The narrowing is due to the extrinsic compression of the iliac vessels on the ureter and the angle of the ureter as it enters the pelvis. The ureterovesical junction or UVJ is the third site of ureteral narrowing. A retrospective study of 94 patients presenting to the emergency department for colic found that 60.6% of stones were located at the UVJ.[17]


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Anatomy, Abdomen and Pelvis, Ureter - Questions

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In following the course of the ureter intraoperatively, which of the following is not a correct statement about the anatomic relationship between the ureter and adjacent structures?



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A 33-year-old female presents to the emergency department with left flank pain that radiates to her groin. A non-contrast CT of the abdomen and pelvis shows an 8 mm obstructing ureteral stone. Which of the following anatomic areas is not associated with narrowing of the ureter?



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Which of the following is the correct order of layers in the ureter from innermost to outermost?



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A 59-year-old female presents with left flank pain, abdominal bloating, and gross hematuria. She underwent laparoscopic hysterectomy and bilateral salpingo-oophorectomy six days prior. What structure courses near the ureter that causes it to be inadvertently damaged during this procedure?



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What is the primary lymphatic drainage site for the left ureter?



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Anatomy, Abdomen and Pelvis, Ureter - References

References

Engelsgjerd JS,LaGrange CA, Ureteral Injury null. 2018 Jan     [PubMed]
Eisner BH,Reese A,Sheth S,Stoller ML, Ureteral stone location at emergency room presentation with colic. The Journal of urology. 2009 Jul     [PubMed]
Bhimji SS,Leslie SW, Anatomy, Abdomen and Pelvis, Kidneys null. 2018 Jan     [PubMed]
Di Benedetto A,Arena S,Nicotina PA,Mucciardi G,Galì A,Magno C, Pacemakers in the upper urinary tract. Neurourology and urodynamics. 2013 Apr     [PubMed]
Dorko F,Tokarčík J,Výborná E, Congenital malformations of the ureter: anatomical studies. Anatomical science international. 2016 Jun     [PubMed]
Reisner DC,Elgethun MT,Heller MT,Klepchick PR,Hartman MS, Congenital and Acquired Disorders of Ureteral Course. Current problems in diagnostic radiology. 2017 Mar - Apr     [PubMed]
Tonar Z,Zát'ura F,Grill R, Surface morphology of kidney, ureters and urinary bladder models based on data from the visible human male. Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia. 2004 Dec     [PubMed]
Leslie SW,Sharma S, Anatomy, Abdomen and Pelvis, Renal Artery null. 2018 Jan     [PubMed]
Kohlmann HW,Respondek M, [Lympho-venous shunts and thromboids in urinary obstruction]. Der Pathologe. 2012 Mar     [PubMed]
Campi R,Minervini A,Mari A,Hatzichristodoulou G,Sessa F,Lapini A,Sessa M,Gschwend JE,Serni S,Roscigno M,Carini M, Anatomical templates of lymph node dissection for upper tract urothelial carcinoma: a systematic review of the literature. Expert review of anticancer therapy. 2017 Mar     [PubMed]
Kaza RM,Garg PK,Ramani S,Jain SK, Triplicate ureter with contralateral duplicate ureter. Annals of the Academy of Medicine, Singapore. 2010 May     [PubMed]
Mikuz G, [Ectopias of the kidney, urinary tract organs, and male genitalia. German version.] Der Pathologe. 2018 Sep     [PubMed]
Murtaza B,Mahmood A,Niaz WA,Akmal M,Ahmad H,Saeed S, Ureterovaginal fistula--etiological factors and outcome. JPMA. The Journal of the Pakistan Medical Association. 2012 Oct     [PubMed]
Douissard J,Ris F,Morel P,Buchs NC, Current Strategies to Prevent Iatrogenic Ureteral Injury During Colorectal Surgery. Surgical technology international. 2018 Jun 1     [PubMed]
Matsumura Y,Iemura Y,Fukui S,Kagebayashi Y,Samma S, [Iatrogenic Injuries of Urinary Tract : Outcomes of Surgical Repairs]. Hinyokika kiyo. Acta urologica Japonica. 2018 Mar     [PubMed]
Barbic M,Telenta K,Noventa M,Blaganje M, Ureteral injuries during different types of hysterecomy: A 7-year series at a single university center. European journal of obstetrics, gynecology, and reproductive biology. 2018 Jun     [PubMed]
Gild P,Kluth LA,Vetterlein MW,Engel O,Chun FKH,Fisch M, Adult iatrogenic ureteral injury and stricture-incidence and treatment strategies. Asian journal of urology. 2018 Apr     [PubMed]

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