a presentation on the surgical anatomy of kidneys and the ureters

1. Presenter: Dr. Sneha Daniel (1st year PGT)
Moderator: Dr. P.P. Dhar (Asstt. Prof.)

2. OVERVIEW
1. Embryology of the kidney
2. Embryology of the ureter
3. Congenital anomalies of the kidneys and ureter
4. Surgical anatomy of the kidneys
5. Surgical approach to the kidneys
6. Surgical anatomy of the ureters
7. Surgical approach to the ureters

3. INTERMEDIATE MESODERM
3 excretory organs
PRONEPHRON
Degenerates on D24
or D25
MESONEPHRON
Appears on D24 or
D25
Functional from W6 to
W10
take over a portion of
the pronephric duct
(thoracic and upper
lumbar regions)
FORMING MESONEPHRIC
(OR WOLFFIAN) DUCT
METANEPHRON
The final developmental
stage

4. A. A pair of cervical nephrotomes forms in each of five to seven cervical segments, but
these quickly degenerate during the 4th week. The mesonephric ducts first appear on day 24.
B, C. Mesonephric nephrotomes and tubules form in craniocaudal sequence throughout the
thoracic and lumbar regions. The more cranial pairs regress as caudal pairs form, and the
definitive mesonephron contain about 20 pairs confined to the first three lumbar segments.

5. The three sets of excretory systems in an embryo during the fifth week. A.
Lateral view. B. Ventral view.
The mesonephric tubules have been pulled laterally; their normal position is
shown in A.

6. MESONEPHRIC TUBULES
Medial end
Bowmans capsule
Lateral branches from the
aorta fit into it to form the
RENAL CORPUSCLE
Lateral end
Opens into the
mesonephric duct
Gives rise to the ureteric
bud (D35)→→ the
collecting system
Few persist in males to
form the ducutus
efferentia which drain the
Wolfian duct to form the
ductus deferens
Excretory units
The collecting system consists of 1-3 million collecting tubules,
minor and major calices, the renal pelvis, and ureters.
To start with, the ureter has a lumen which later occludes and
which subsequently recanalizes.

7. Lateral view of a five-week embryo showing the extent of
the mesonephros and the primordium of the metanephros
or permanent kidney.

8. Transverse section of the embryo showing the nephrogenic
cords from which the mesonephric tubules develop.

9. Transverse sections showing successive stages in the development of a mesonephric tubule
between the fifth and eleventh weeks. Note that the mesenchymal cell cluster in the
nephrogenic cord develops a lumen, thereby forming a mesonephric vesicle. The vesicle soon
becomes an S-shaped mesonephric tubule and extends laterally to join the pronephric duct,
now renamed the mesonephric duct. The expanded medial end of the mesonephric tubule is
invaginated by blood vessels to form a glomerular capsule (Bowman's capsule). The cluster of
capillaries projecting into this capsule is known as a glomerulus.

10. Successive stages
in the development
of the metanephric
diverticulum or
ureteric bud (fifth
to eight weeks).
The development
of the ureter, renal
pelvis, calices, and
collecting tubules
can be seen. The
renal lobes,
illustrated in E, are
still visible in the
kidneys of a 28-
week fetus.

11. When the kidneys ascend from the pelvis to their
permanent location in the upper lumbar region, they
come into apposition with the adrenal glands, which
develop in situ.
During ascent, the kidneys rotate medially so that the
hilum, which initially faced anteriorly, now faces
medially.
The segmental vessels supplying the kidney are added
cranially and lost caudally during ascent.

12. Ventral views of the abdominopelvic region of embryos and fetuses (sixth
to ninth weeks), showing medial rotation and 'ascent' of the kidneys from the
pelvis to the abdomen

13. EMBRYOGENESIS OF URETERS
• The ureteric bud is responsible for the genesis of
the ureters.
• The bud, a diverticulum of the mesonephric duct,
is located close to the cloaca, just above the
duct's entrance into the cloaca.
• The bud grows into the mesodermal
metanephrogenic mass, and its cranial end
becomes the renal pelvis.
• The stalk of the ureteric bud becomes the ureter,
which enters into the urinary bladder.

14. CONGENITAL ANOMALIES
Renal agenesis →→ failure of the ureteric
bud to develop or by early degeneration
of the bud.
Unilateral renal agenesis
1 in 1000 newborns.
M:F= 2:1
.Usually, the left kidney is absent, and
the other kidney undergoes
compensatory hypertrophy.
Bilateral renal agenesis
incompatible with life,
1 in 3000 births
oligohydramnios, Potter's facies,
hypertelorism, epicanthic folds, low-set
ears, and limb defects.

15. Non-rotation or abnormal rotation
• Non-rotation→→ hilum faces
anteriorly
•excessive rotation→→ the hilum
faces posteriorly
•Malrotation → may face laterally .
•Abnormalities of rotation are
often associated with ectopic
kidneys.

16. Ectopic kidneys
• unilateral or bilateral
•Usu. located inferior to their
normal location, with the hilum
facing anteriorly.
• Most ectopic kidneys lie in the
pelvis; some are found in the
lower abdomen.
Crossed renal ectopia
one kidney has crossed to the
contralateral side.

17. HORSESHOE KIDNEY
•1 in 500 births
•The caudal poles fuse across the midline.
•Usually lies in the hypogastrium anterior to the lower
lumbar vertebrae
•kidney is 'hung up' on the inferior mesenteric artery.
Horseshoe kidney is usually symptomless.

18. Discoid/ Pancake kidneys
resulting from the fusion of
the kidneys while they’re in
the pelvis.
Horseshoe kidneys resulting
when the ascent of the kidneys is
obstructed by the inferior
mesenteric artery.

19. CONGENITAL ANOMALIES OF URETERS
• Ectopic ureteric orifices are defined as openings located anywhere
other than at the bladder.
• In males, the usual opening is into the neck of the bladder or
prostatic urethra; unusual places include the ductus deferens,
seminal vesicle or prostatic utricle.
• In females the ectopic opening is at the bladder neck, urethra,
vagina, or vaginal vestibule.
• In males with ectopic ureter, incontinence is not seen because the
ectopic ureter enters into the genitourinary system (bladder neck,
prostatic urethra, seminal vesicle) above the external sphincter.
• In females with ectopic ureter, incontinence from the urethra or
vagina is common because the ectopic opening is below the
external sphincter. Cloacal outlet obstruction may occur with an
ectopic ureter.

20. Primary obstructive megaureter
•Due to an adynamic segment of the distal ureter
due to derangement of ureteral musculature.
•The condition may be bilateral or unilateral,
with presentation in later years.
•Endoureterotomy is a safe and effective
treatment.
Fetal obstructive uropathy
is characterized by obstruction of the urethra,
renal anomalies, ureterovesical dilatation,
oligohydramnios, cryptorchidism, and
abdominal muscle wall changes.

21. DUPLICATION OF URETER
• Usually unilateral.
• Common on the left side.
• Upper renal pelvis is small, drains the upper calyces. Lower
renal pelvis is larger, drains the middle and lower calyces.
• Double ureter when associated, may be partial where two
ureters join in lower third or complete where upper ureter
opens into the bladder at a lower level and lower ureter
opens into the bladder at the upper, normal ureteric orifice.
This is called as “Weigert Meyer Law”.
• In partial duplex, there is reno-renal reflux resulting in
infection, stone formation and hydronephrosis

22. SURGICAL ANATOMY OF THE KIDNEYS
• Paired, bean-shaped organs located on either side of
the vertebral column in the perirenal compartment of
the retroperitoneal space between the anterior and
posterior leaflets of the renal fascia (Gerota's fascia).
• A stroma of adipose tissue (thick or thin) covers all
their surfaces.
• Length: 10-14 cm
• Width: 5-7 cm
• Thickness: 2.5-3.0 cm
• Approximate weight: 135 g in women and 150 g in
men.

23. Each kidney has two surfaces (anteriolateral and posteromedial) ,
two borders (lateral and medial), and two poles (superior and
inferior.)
The kidney is related anteriorly to the abdominal viscera and
posteriorly to the osteomuscular area.
The right kidney lies at a lower level in comparison with the left, a
phenomenon that permits the right lower pole to be palpable.
In the recumbent position, the kidneys may extend from T12 to L3,
but in the erect position extend from L1 to L4.
The kidneys may move upward and downward approximately 1-7
cm with respiration.

24. ANTERIOR RELATIONS
• The anterior surfaces of the kidneys are
covered by the following anatomic entities:
– Perirenal fat: adipose tissue lying outside the
fibrous capsule
– Gerota's fascia
– Pararenal fat:
• lying outside the renal fascia.
• Fills up the paravertebral gutter
• More towards the lower pole
– Parietal posterior peritoneum (partially)

25. ANTERIOR RELATIONS OF THE RIGHT KIDNEY
• The anterior surface of the right kidney is
related to :
– Right adrenal gland
– Liver
– Second part of duodenum
– Inferior vena cava
– Ureter
– Ascending colon
– Hepatic flexure of the colon

26. ANTERIOR RELATIONS OF THE LEFT KIDNEY
The anterior surface of the left kidney is related to:
• Left adrenal gland
• Pancreas
• Splenic vessels
• Stomach
• Spleen
• Duodenojejunal flexure
• Ligament of Treitz
• Inferior mesenteric vein
• Descending colon
• Splenic flexure of the colon
• Loops of jejunum

27. The anterior surface of the kidney showing the areas related to
neighboring viscera.

28. Anterior relations of the kidneys to the abdominal
organs.

29. POSTERIOR RELATIONS OF THE
KIDNEYS
The posterior surfaces of the kidneys are related to:
– Psoas muscles
– Transversus abdominis muscles
– Quadratus lumborum muscles
– Diaphragm
– 12th thoracic nerves
– Iliohypogastric nerves
– Ilioinguinal nerves
– Subcostal vessels

30. – Anterior layer of thoracolumbar (lumbodorsal) fascia
– Transversalis fascia
– Pararenal fat
– 11th and 12th ribs
– Pleurae
– Posterior layer of Gerota's fascia
– Perirenal fat
– Medial and lateral arcuate ligaments of the diaphragm

31. Posterior relations
• RIGHT kidney is related to the 12th rib, with
the superior pole extending upward into the
11th intercostal space;
• LEFT kidney is related to the 11th and 12th
ribs.

32. Schematic representation of the posterior relations of
the kidney.

33. The posterior surfaces of the kidney, showing the areas
of relation to the posterior abdominal wall

34. Anatomic relations of the kidneys.
A. Posterior relations to the muscles of the posterior body wall and
ribs.
B. Relations to the pleural reflections and skeleton posteriorly.

35. Lateral border
• The lateral border of the kidney is related to :
– the perirenal fat,
– Gerota's fascia, and
– Pararenal fat.

36. Medial border
• In the medial border of each kidney there is a vertical
fissure called the renal porta or hilum.
• The renal arteries and nerves enter through the renal
hilum
• Veins, lymphatics, and proximal ureter exit through it.
• The concavity of the hilum is continuous with a deep
declivity in the medial border of the kidney, k/a the
renal sinus.
• This recess is lined by the tissues of the renal capsule
and envelops the renal vessels and the renal pelvis.

37. •Within the renal sinus is the intra-renal pelvis, a funnel-
shaped sac formed by the widely expanded portion of the
proximal ureter and by the junctions of the major calices.
•The renal pelvis most commonly lies posterior to the renal
vessels. Occasionally it may be situated between or in front of
the vessels.
•In some instances the renal pelvis is small, lacks an extrarenal
portion, and is located entirely within the renal parenchyma.

38. •The UPPER POLE of each kidney is related to its associated
adrenal gland, separated from it only by a thin diaphragm of
connective tissue originating from the fascia of Gerota, which
totally envelops each adrenal.
•The right and left adrenal glands are located superomedially
at the front of the upper part of each kidney.
•The LOWER POLE is occasionally located close to the lumbar
triangle.
•Associated with the psoas medially
• quadratus lumborum and transversus abdominis laterally

39. • POSTERIORLY pleura and the diaphragm
separate the kidney from the 12th rib.
• The ANTERIOR SURFACE is the only area of the
organ covered by peritoneum.

40. The upper part of the upper
pole of the right kidney is
associated with the
peritoneum which forms the
hepatorenal pouch of
Morison. This is bounded as
follows :
– Above, by the
posterior layer of the
coronary ligament
– Anteriorly, by the
inferior surface of the liver
– Posteriorly, by the
peritoneum lining the
inferior surface of the
diaphragm.

41. GEROTA’S FASCIA
•The kidney and the suprarenal gland are disposed in a
space that is closed on all sides.
•The anterior(Fascia of Toldt) and posterior(Fascia of
Zuckerkandl) layers fuse at the upper pole of the space &
continues with the inferior fascia of the diaphragm.
•Lower pole and lateral border become continuous with
the fasciae of the parietal muscles.
•At the medial border, the two layers merge to continue
medially with the peri-aortocaval connective tissue; they
penetrate the hilum and beneath it enclose the ureter.

42. Diagrammatic
representation of
the renal fascia.
The partition, a
type of
diaphragm,
separates the
adrenal from the
upper renal pole.

43. ARTERIAL SUPPLY
• The paired renal arteries :
– originate from the lateral wall of the aorta
– just below the origin of the SMA
– between the L1 and L2 vertebrae.
• The origin of the longer right renal artery is more posterior
than the left.
• Rarely, the right renal artery originates from the posterior
wall and travels posterior to the inferior vena cava to reach
the right kidney.
• Arising from each renal artery prior to its trifurcation are
two small arteries:
– the inferior suprarenal artery
– the artery for the renal pelvis and proximal ureter.

44. Segmental branches of the right renal artery demonstrated by renal
angiogram (A) and corresponding diagram (B).

45. • Each artery reaching the hilum divides into
anterior and posterior divisions in relation to the
renal pelvis.
• Furthermore, the five branches of each renal
artery participate in the formation of four renal
segments:
(1) apical(superior),
(2) anterior (subdivided into superior and inferior),
(3) posterior, and
(4) basilar (inferior)

46. Typical segmental circulation of the right kidney, shown diagrammatically.
Notethat the posterior segmental artery is usually the first branch of the main
renal artery, and extends behind the renal pelvis.

47. The intrarenal course and relation to the anterior calices of
the apical, basilar, and anterior segmental arteries. Note
the short length of the apical branch. The posterior branch
is shown by a broken line.

48. The branch of the renal artery supplying the posterior segment of the kidney
passes along the posterior surface of the renal pelvis and then divides into
smaller branches that course between the posterior calices. The apical, basilar,
and anterior branches are shown by broken lines.

49. The arteries of each segment, which are end
arteries without any collateralcirculation, are
as follows:
– Apical branch
– Basilar branch
– Artery for the superior portion of the anterior
segment
– Artery for the inferior portion of the anterior
segment
– Artery for the posterior segment

50. The vascular segments of the left kidney, as shown in the
anterior, lateral, and posterior projections

51. BRÖDEL'S LINE
• most avascular area of the kidney.
•located slightly behind the convex border at the
posterior half of the kidney
•at the junction of the area supplied by the anterior
and posterior divisions of the renal artery.
• approx. 2/3 of the way along a line from the hilum to
the lateral margin of the kidney.
•Incision in this area will permit removal of a stone
within the renal calices with minimal damage.
(Anaplastic pyelolithotomy)

52. Scheme of the anterior and posterior branches of the renal artery,
in a horizontal section of the kidney. The "avascular" line is the
region of overlap between the anterior and posterior branches,
situated posterolaterally rather than laterally because of the wider
distribution of the anterior branches.

53. Avascular plane of kidney.

54. Multiple renal arteries supply one renal segment while
accessory arteries supply only part of the segment. It is
advisable to ligate only the accessory arteries.
An accessory artery of the lower pole may produce
ureteric obstruction with secondary hydronephrosis.
Ligation of an accessory renal artery can result in the
production of an area of infarction of variable size,
though often small. Renovascular hypertension may
occur as a sequelae of the ischemia.

55. Schematic drawings of accessory renal arteries. A. Right kidney. B.
Leftkidney. RK, right kidney; LK, left kidney; RU, right ureter; LU, left
ureter; ROA, right ovarian artery; LOA, proximal part of the left
ovarian artery; ROV, right ovarian vein; A, aorta; IVC, inferior vena
cava; RARA, right accessory renal artery; LARA, left accessory renal
artery.

56. Venous drainage
• The kidney is drained by several veins which together form
the renal vein.
Left renal vein Right renal vein
longer shorter
receives blood from the left adrenal, the
left gonad, and the body wall, including
the diaphragm
The left adrenal vein enters the renal
vein superiorly; the left gonadal vein
enters inferiorly.
Temporary or permanent occlusion of
the left renal vein close to its entrance
into the inferior vena cava can usually be
done with impunity
contains a thin valve which is not good material
for suture.
in addition to excising the right renal vein, the
surgeon should excise a small cuff of the medial
wall of the inferior vena cava where the right
renal vein enters

57. Venous drainage of the left kidney, showing potentially
extensive venous collateral circulation

58. • Anomalies of the left renal venous drainage
system:
– supernumerary left renal vein
– –Bifurcation of the gonadal vein
– –Bifurcation of the suprarenal vein
– Inferior phrenic vein draining into the left renal
vein distal to the superior mesenteric artery
– Lumbar vein drainage into the left renal vein that
may represent either an anomaly or a normal
variation

59. Lymphatics
• Follow the blood vessels and form large
lymphatic trunks.
• The trunks exit through the renal sinus
receiving communicating lymphatics from the
renal capsule and perinephric fat.
• Lymphatics from the renal pelvis and upper
ureter communicate with others at the renal
hilum.
• Then drain to the paraaortic lymph nodes.

60. Regional lymphatic drainage of the right kidney. Green
nodes, anterior; black nodes, posterior. Solid lines, anterior
lymphatic channels; dashed lines,posterior lymphatic
channels. Arrow leads to thoracic duct.
The lymphatics of the right
kidney
•drain into lymph nodes
located between the IVC and
the aorta, lateral paracaval
nodes, and anterior and
posterior inferior vena caval
lymph nodes.
•They also drain upward
toward the right diaphragm,
and downward to the common
iliac lymph nodes.
•Also into the thoracic duct or
crossing the midline into the
left lateral aortic lymph nodes.

61. Regional lymphatic drainage of the left kidney. Green nodes,
anterior; black nodes, posterior. Solid lines, anterior lymphatic
channels; dashed lines, posterior lymphatic channels. Arrows
lead to thoracic duct.
The lymphatics of the left kidney
• drain into the lateral paraaortic
lymph nodes and anterior and
posterior aortic lymph nodes.
•to the diaphragm and downward
to lymph nodes associated with
the inferior mesenteric artery.

62. INNERVATION
• The kidneys characteristically exhibit a very rich network of neural
elements that originate at the celiac ganglion, aorticorenal
ganglion, celiac plexus, and intermesenteric plexuses. These
elements intermingle, form plexuses, and follow the renal artery.
• Thoracic nerves T10 to L1 participate in the innervation of the
kidney.
• They receive pain fibers from the renal pelvis and proximal ureter
that enter the spinal cord at those levels of the spinal nerves. The
renal nerves have a vasomotor function.
• The right and left vagus nerves participate in the formation of the
renal plexus.
• The renal plexus gives branches to the ureteric and gonadal
plexuses.

63. Remember
•Avoid injury to the 11th and 12th intercostal nerves, not
only to avoid postoperative paresthesias and neuralgias, but
also to avoid postoperative bulging from partial paralysis of
the muscles involved.
•Close the incision anatomically. Be sure not to entrap the
lower intercostal nerves.
•Avoid the phrenic nerve during opening of the diaphragm.
•Partial anesthesia will develop in the gluteal area (about 20
x 10 cm) with transection of the T12 nerve.

68. SURGICAL APPROACH TO THE KIDNEYS
• The outer layer consists
of:
– Latissimus dorsi muscle
– External oblique muscle
(posterior part)
– Serratus posterior
inferior muscle
– External intercostal
muscles
– Posterior lamina of
thoracolumbar fascia

69. • The middle layer
contains:
– Sacrospinalis muscle
– Internal oblique muscle
– Internal intercostal
muscles
– Middle lamina of
thoracolumbar fascia

70. The inner layer is
composed of :
– Quadratus lumborum
muscle
– Psoas major and minor
muscles
– Innermost intercostal
muscles
– Transversus abdominis
muscle (partial)

71. • The innermost layer is
made up of:
– Psoas major muscle
– Psoas minor muscle
– Diaphragm

72. SURGICAL ANATOMY OF THE URETERS
• The right and left ureters are retroperitoneal
muscular tubes
• Length: 25 to 34 cm;
• Their upper half is abdominal and their lower
half is pelvic.

73. Abdominal course
• Each ureter starts at the renal pelvis close to
the hilum, posterior to the renal vessels
• On its downward pathway, it is related to the
tips of the transverse processes of the lumbar
vertebrae and to the psoas major muscle.
• The ureter crosses over the genitofemoral
nerve, passes under the gonadal vessels, and
crosses the common iliac artery or the
external iliac artery.

74. Ureteric course in the abdomen.

75. •The right ureter is covered by the second portion of the
duodenum
•The left ureter is adherent to the mesocolon
•The left ureter is very close to the inferior mesenteric artery,
passing under it
•The abdominal part of the ureter is fused to the peritoneum
•The abdominal course of the ureter is the same in male and
female
•The anatomic landmark of the left ureter is the intersigmoid
fossa .
•The ureter passes behind the fossa and therefore behind the
sigmoid colon at the apex of the capital Greek lambda

76. The intersigmoid fossa lies in the apex of the § (capital Greek lambda)
attachment of the pelvic mesocolon. The ureter is shown passing behind the
fossa.

77. Pelvic course
• The pelvic course begins after the ureter has passed
anterior to the internal iliac artery and its anterior
division.
• The pelvic ureter is not related to the peritoneum
because it leaves the lateral pelvic wall at the level of
the ischial spine.
• It follows a medial path toward the urinary bladder, at
the base of and posterior to the broad ligament.
• In this area the ureter crosses over the uterine artery 1
cm, or perhaps slightly more, from the uterine cervix.

78. In both male and female:
The ureter is crossed anteriorly by the obliterated umbilical
artery.
On the left, the ureter is located behind the sigmoid arteries.
Remember that the upper abdominal ureter should be
mobilized laterally and the pelvic ureter medially during
ureteric mobilization. At the middle segment, dissection of
the periureteric tissue should be avoided.
In the MALE
The ductus deferens crosses the ureter anteriorly.
The ureter enters the bladder just above the apex of the
seminal vesicle.

79. The ductus passes anterior to the ureter to gain its
medial side

80. Pelvic relations of the ureter in the male. A. Oblique
view.

81. Pelvic relations of the ureter- Coronal view

82. Pelvic relations of the ureter – Lateral view

83. •IN THE FEMALE
•The uterine artery crosses the ureter anteriorly about 1-4
cm lateral to the cervix.
•Before entering the urinary bladder, the ureter passes 1 cm
above the lateral fornix of the vagina close to its anterior
wall and about 1-4 cm lateral to the cervix.
•The pelvic ureter is very vulnerable anterior to the
bifurcation of the common iliac artery.
•The pelvic ureter crosses the ovarian vessels and nerves
posteriorly.

84. Normal anatomy of the ureters and their relations to
other pelvic organs encountered in gynecologic surgery.
UT, uterus

85. PATHWAY
• The anatomic topographic ureteric pathway from above downward is as
follows.
• The ureter rests anterior to the psoas muscle and is located lateral to the
tip of the transverse processes of the lumbar vertebrae.
• It passes behind the gonadal vessels.
• The ureter crosses anterior to the common iliac vessels at the pelvic brim.
• The right ureter passes behind the:
 – duodenum
 – ascending colon and its mesentery
 – cecum
 – appendix
 – terminal ileum
• The left ureter is behind the descending colon and the sigmoid colon and
its mesentery.

86. In the pelvis the ureter is related to different anatomic entities depending
on the person's sex.
– In the MALE pelvis the ureter is posterior to the ductus deferens and
just proximal to the ureterovesical junction. It enters the wall of the
bladder obliquely.
– In the FEMALE pelvis the ureter is located anterior to the internal iliac
artery, and posterior to the ovary, under the broad ligament just behind
the uterine vessels; it obliquely enters the wall of the bladder. (The
phrase "water under the bridge," which represents the ureter passing
beneath the uterine artery, is a helpful way to remember the relationship
of these structures, and particularly important for avoiding
ureteric injury in gynecologic surgery.)

87. CONSTRICTIONS
•At the ureteropelvic junction
•At the pelvic brim (iliac vessels)
•At the intravesical course (ureterovesical junction)
When both ureters approach the urinary bladder they are
approximately 5 cm
apart.
Their openings within the full bladder are also
approximately 5 cm apart,
but in an empty bladder the openings are only 2.5 cm apart.

88. the intravesical course of the ureter
•measures about 0.5-1 cm with a diameter of 3-4 mm. It is
the most contracted part of the ureter and a stone may be
lodged at this point .
•On vaginal examination this part of the ureter can be
palpated

89. The ureter, demonstrating variations in caliber including three anatomic
narrowings — at the ureteropelvic junction, the iliac vessels (pelvic brim),
and the ureterovesical junction (the intravesical course). Note also the
anterior displacement of the ureter, which occurs over the iliac vessels.

90. Ureteric wall
• The wall of the ureter is
formed by five layers:
– Retroperitoneal
connective tissue sheath
– Adventitia
– Muscular coat
– Lamina propria
– Mucosa

91. Arterial supply
• The blood supply of the ureters is peculiar: it
is both rich and poor.
• a rich anastomotic network in the ureteric
adventitia
• the blood supply in the middle segment
(between the lower renal pole and the pelvic
brim) is poor in comparison to that of the
proximal and distal segments.

92. • ARTERIES SUPPLYING
THE URETERS are:
• the renal artery,
• the gonadal artery,
• and the common iliac
and
• internal iliac arteries.

93. ADDITIONAL VESSELS include:
•Capsular arteries
•Adrenal arteries
•Aortic branches
•Umbilical artery
•Superior vesical artery
•Inferior vesical artery
•Uterine artery
•Middle rectal artery

94. • In relation to its blood supply, the ureter can be divided
into three parts: upper, middle, and lower:
• The upper part (from the renal pelvis to the lower
pole) receives blood from the adrenal, capsular, renal,
and gonadal arteries. The renal artery is the most
important artery of this segment.
• The middle part (from the lower pole to the pelvic
brim) receives branches of the gonadal artery, the
aorta, and the common iliac artery.
• The lower part (from the pelvic brim to the urinary
bladder) receives branches of the internal iliac
(hypogastric), superior, and inferior vesical arteries

95. Venous drainage
• The veins of the ureter originate in the
submucosa (lamina propria) and spread out in
the adventitia.
• In the upper part of the ureter they drain into
the renal vein or the gonadal vein.
• At the lower end the ureteric veins drain into
the venous network of the broad ligament and
can produce varicosities.

96. Lymphatics
• The lymphatics of the ureter follow the pathways of
the arterial and venous networks. However, there are
different drainage pathways for the various segments:
• The lymphatics of the upper ureter and renal pelvis
drain to the ipsilateral renal lymphatics.
• The lymphatics of the abdominal ureter differ by side
– Right: Drains to right paracaval and interaortocaval
nodes
– Left: Drains to left paraaortic nodes
• The lower (pelvic) ureter drains to the common iliac
and the internal and external iliac nodes.

97. The lymphatics of the ureter

98. Innervation
• The ureter has three sources of nerve supply: superior,
middle, and inferior.
 The superior supply originates from the renal and aortic
plexuses;
 the middle originates from the superior hypogastric plexus; and
 the inferior originates from the pelvic plexus.
• Pain fibers from the ureter are often carried principally to
the level of spinal nerve L2. Thus, a cremasteric reflex may
occur by way of referral of pain to the genitofemoral nerve
(L1, L2), which supplies the cremasteric muscle.

99. Patterns of referred somatic pain from the upper
urinary tract

100. • The ureteric wall does not have autonomic ganglia.
• The nervous system does not activate ureteric peristalsis;
ureteric peristalsis is stimulated by urine stretching the
ureteric muscular coat.
• Pain from a dilated ureter is distributed to the flank, inguinal
area, and scrotum, supplied by T11, T12, L1, L2 nerves. The
pain is carried upward by way of thoracic and lumbar
splanchnic nerves, which also carry the sympathetic nerve
supply transmitted by the autonomic nervous system.

101. • From a surgicoanatomic standpoint the ureter
may be divided into three parts:upper, middle,
and lower.
• The upper segment is from the ureteropelvic
junction to the area of the upper sacrum;
• the middle part is at the sacral area; and
• The lower segment travels through the pelvis.

102. SURGICAL APPROACHES• Upper Ureteric Segment
– The upper ureteric segment including the ureteropelvic junction may be approached with a
flank or dorsal lumbar incision.
• Middle Ureteric Segment
– A transperitoneal approach through a midline or paramedian incision will expose the middle
segment.
– An extraperitoneal approach with the Gibson incision gives excellent exposure to the middle
segment.
– This incision begins 2-3 cm medial to the anterior superior iliac spine and 2-3 cm above the
inguinal ligament. It ends 2-3 cm above the pubic tubercle. The three flat muscles are incised
parallel to their fibers. To expose the retroperitoneal space the transversalis fascia is opened
and the peritoneum is pushed medially.
• Lower Ureteric Segment
– The lower ureteric segment may be exposed with several incisions including the:
– Lower anterior midline
– Gibson incision
– Pfannenstiel incision
– The transverse Pfannenstiel incision is made horizontally just above the pubis. The anterior
rectus sheaths and the linea alba are transected and reflected upward 8 to 10 cm. The rectus
muscles are retracted laterally, and the transversalis fascia and the peritoneum may be cut in
the midline. The iliohypogastric nerve must be identified and protected.