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Anatomy oftheUreter
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11.1 General Aspects
The ureter is a retroperitoneal tubular structure that measures 25–30cm, with a
diameter of 1.5–6mm, and connects the kidney to the bladder. It is a continuation
of the renal pelvis, which is rightly called by some anatomists ureteral pelvis rather
than renal pelvis with regard to the embryological origin of the collecting system
arising from the ureteric bud.
The ureter is a contractile conduit whose wall is made up of three main layers
[1]
– An inner mucosal layer lined by a transitional epithelium (urothelium) that is
identical to the lining of the renal pelvicalyceal system, the bladder, and the
proximal urethra.
– An intermediate muscular coat made of interweaving and interlacing smooth
muscle bers allowing peristaltic movements.
– An outer adventitial layer adherent to the posterior parietal peritoneum and con-
taining a network of blood vessels and fatty tissue.
Urologists classically divide the ureter into three segments: The lumbar or
proximal or upper ureter overlying the lumbar vertebrae above the sacro-iliac
joint, the mid-ureter overlying the sacro-iliac joint, and the pelvic or distal or
lower ureter below the sacro-iliac joint. However, it has been proposed to simplify
the description into two segments of approximately equal length: abdominal and
pelvic segments being arbitrarily demarcated by the pelvic brim. Finally, the international anatomical terminology of the ureter describes three parts: the abdominal,
the pelvic, and the intramural segments [1, 2].
The ureter has three anatomical narrowings
– at the pelviureteric junction,
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_11
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– at the pelvic brim, where it is compressed by the bones and the iliac vessels, and,
– and at the uretero-vesical junction, which is the narrowest segment.
Functionally, these hollow structures have intrinsic peristaltic movements initiated by pacemakers located in the renal pelvis and transmitted up to the ureteric
orices from where the urine can be seen intermittently efuxing on cystoscopy.
The ureteral peristalsis was described in 1869 by the German Physiologist and polymath Theodor Wilhelm Engelmann (1843–1909), who made the same conclusion
for intrinsic heart beating and proposed to consider the whole ureter as a functional
syncytium [3, 4].
11 Anatomy oftheUreter
11.2 Course
In the retroperitoneum, the ureter generally lies close to the tips of the transverse
processes of the lumbar vertebrae. However, this position varies normally among
individuals because of the mobility of the upper half of the ureter, being sometimes
more medial or lateral [2].
Cadaveric studies have conrmed the relative mobility of the ureter bathing in
the perirenal fat, but they also showed that it becomes rmly xed to the anterior
aspect of the psoas major muscle distally from the crossing point of the gonadal
vessels [5]. Due to this cranial mobility, the ureter may exhibit various degrees of
kinking observable on CT-urography. The kinking can be classied into grade 1
(mild), grade 2 (moderate), and grade 3 (severe) [5]. In the same individual, the
mechanism of intermittent kinking of the cranial portion to the crossing level is
caused by the adaptation of the ureter to the kidney ascent and descent during respiration while the caudal portion remains relatively xed [5].
Regardless of the kinking, the normal ureter’s course is not straightforward; after
a descent in front of the psoas fascia, it leaves the psoas major muscle and turns
medially, and crosses the pelvic brim by lying anterior to the bifurcation of the common iliac artery. Then its pelvic segment runs rst in a posterolateral direction close
to the lateral wall of the pelvic cavity, anteriorly to the internal iliac artery, then
turns at the level of the ischial spine and travels anteromedially above the pelvic
oor before entering the trigonal region on the posterior bladder wall [1].
11.3 Topography
(a) Posterior relations: These are similar on both sides and for both sexes. The
abdominal ureter descends in front of the genitofemoral nerve (or its genital and
femoral branches) on the anterior aspect of the psoas major muscle that separates it from the tips of the lumbar transverse processes. At the level of the
pelvic brim, the common iliac artery lies behind the ureter.
11.3 Topography
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(b) Anterior relations:
– Right ureter: The abdominal segment is crossed by the lower end of the root
of the small intestinal mesentery, the right gonadal vessels, the right colic
vessels, and ileocolic vessels. The upper end is in proximity to the second
part of the duodenum.
– Left ureter: The upper end is crossed by the body of the pancreas. The
abdominal segment is crossed by the left gonadal vessels, the left colic vessels, and the sigmoid vessels embedded in the mesocolon.
Within the pelvic cavity, the ureter travels postero-lateral to the bladder and its
relations depend on the gender. In male subjects, it is crossed anteriorly by the vas
deferens traveling from lateral to medial. In females, it is crossed superiorly by the
uterine artery [1, 2] (Figs.11.1 and 11.2). Near the bladder, the terminal ureter is
covered by the muscular layer of Waldeyer and its 1.2–2.5-cm intramural segment
runs obliquely through the bladder wall coalescing with bundles of the detrusor
muscle to end with the ureteric orice [2].
Fig. 11.1 The
retroperitoneal space with
the anatomical structures
surrounding the left and
the right ureter. 1,
duodenum; 2, ureter; 3,
psoas; 4, inferior
mesenteric artery; 5,
testicular/ovarian artery
and vein; 6, genitofemoral
nerve—femoral and genital
branches; 7, sigmoid
arteries; 8, superior rectal
artery. (From Fröber R [2],
with permission from John
Wiley and Sons)
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ab
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Ureter
Internal iliac
artery
11 Anatomy oftheUreter
Urete
Common iliac
artery
Uterine artey
Vas deferens
Bladder
Uterus
Pelvic brim
(pelvic inlet)
Anterio
abdominal wall
Fig. 11.2 Relations of intrapelvic ureter; (a) male, (b) female. (From Mahadevan, V. (2019) [1],
with permission from Elsevier)
11.4 Blood Supply
The ureter has a segmental or staged blood supply with different sources, distributed
cranio-caudally, forming a rich and delicate longitudinal anastomosis in the periureteric adventitia [1, 2] (Figs.11.3 and 11.4):
– The upper third: ureteric branch of the ipsilateral renal artery.
– The middle third: small branches from the gonadal artery, and from the common
iliac and internal iliac arteries.
– The intrapelvic segment: branches from the superior and inferior vesical arteries
(branches of the internal iliac artery).
Because of the rich collateral circulation and anastomosis, it is possible to cauterize or ligate a single arteriole as it travels through the so-called mesoureter before
entering the ureteral wall without causing necrosis (Fig.11.5). However, unnecessary and excessive mobilization should be avoided as more arterial sources might be
damaged and cause ischemia, increasing the risk of postoperative ureteric stricture.
11.4 Blood Supply
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Fig. 11.3 Arterial supply
of ureter. (From
Mahadevan V [1], with
permission from Elsevier)
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Fig. 11.4 The arterial
supply to the abdominal
segment and the
descending portion of the
pelvic segment of the
ureter. 1, renal arteries; 2,
ovarian/testicular arteries;
3, aorta; 4, common iliac
arteries; 5, internal iliac
arteries. (From Fröber R
[2], with permission from
John Wiley and Sons)
11 Anatomy oftheUreter
11.5 Congenital Abnormalities
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Fig. 11.5 The nutrient
vascular structures in a
schematic illustration of a
microscopic transverse
section of the ureter. 1,
mucosa; 2, muscle coat; 3,
adventitia; 4, mesoureter;
5, supplying artery and
vein; 6, adventitial vascular
plexus; 7, perforating
arteries; 8, mucosal
vascular plexus. (From
Fröber R [2], with
permission from John
Wiley and Sons)
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11.5 Congenital Abnormalities
The ureteral congenital abnormalities can be summarized as follows [6–8]
– Uretero-pelvic junction obstruction: This is the most common congenital ure-
teral abnormality with an incidence of 1in 1000–1500 newborns.
– Double ureter or ureteral duplication: May be partial or complete.
– Primary vesicoureteral reux: The most common cause of antenatal hydrone-
phrosis (40%).
– Primary megaureter.
– Ectopic ureter: Complete ureteral duplication is found in 70% of ectopic ure-
ters. In complete ureteral duplication with separate ureteral orices in the bladder,
the Weigert-Meyer law1 states that the ureter connected to the upper pole moi-
1
Carl Weigert (1845–1904) and Robert Meyer (1864–1947) were two German pathologists.
Weigert described the caudal termination of the ureter from the upper moiety in 1877 [9] and
Meyer described the medial termination of the same in 1907 [10] compared to the ureter draining
the lower moiety.
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11 Anatomy oftheUreter
ety opens into the bladder medial and inferior to the orice of the ureter draining
the lower renal moiety. Moreover, the ureter draining the upper pole moiety is
frequently prone to ureterocele, while the one draining the lower moiety is
mostly subjected to reux.
– Ureterocele: About 75% of ureteral duplications are associated with
ureterocele.
– Retrocaval ureter (or more correctly pre-ureteric vena cava).
– Ureteral folds, valves, and strictures.
References
1. Mahadevan V.Anatomy of the kidney and ureter. Surgery (Oxford). 2019;37(7):359–64.
2. Fröber R. Surgical anatomy of the ureter. BJU Int. 2007;100(4):949–65. https://doi.
org/10.1111/j.1464- 410X.2007.07207.x.
3. Engelmann TW. Zur Physiologie des Ureter. Püger Arch. 1869;2:243–93. https://doi.
org/10.1007/BF01628404.
4. Osman F, Romics I, Nyírády P, Monos E, Nádasy GL.Ureteral motility. Acta Physiol Hung.
2009;96(4):407–26. https://doi.org/10.1556/APhysiol.96.2009.4.2. PMID: 19942548
5. Kamo M, Nozaki T, Yoshida K, Tateishi U, Akita K.Kinking of the upper ureter in CT urography: anatomic and clinical signicance. Surg Radiol Anat. 2016;38(10):1115–21. https://doi.
org/10.1007/s00276- 016- 1689- 7. Epub 2016 May 9
6. Berrocal T, López-Pereira P, Arjonilla A, Gutiérrez J. Anomalies of the distal ureter, bladder, and urethra in children: embryologic, radiologic, and pathologic features. Radiographics.
2002;22(5):1139–64. https://doi.org/10.1148/radiographics.22.5.g02se101139.
7. Dorko F, Tokarčík J, Výborná E.Congenital malformations of the ureter: anatomical studies. Anat Sci Int. 2016;91(3):290–4. https://doi.org/10.1007/s12565- 015- 0296- 8. Epub
2015 Aug 19
8. Young DW, Lebowitz RL. Congenital abnormalities of the ureter. Semin Roentgenol.
1986;21(3):172–87. https://doi.org/10.1016/0037- 198X(86)90018- 0.
9. Weigert C. Über einige Bildungsfehler der Ureteren. Archiv für pathologische Anatomie und
Physiologie und für klinische Medizin. 1877;70:490–501.
10. Meyer R. Zur Anatomie und Entwicklungsgeschichte der Ureterverdoppelung. Archiv für
pathologische Anatomie und Physiologie und für klinische Medizin. 1907;187:408–34.
Epidemiology ofUreteral Injuries
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Non-iatrogenic ureteral injury is a very rare event occurring in only 3 per 10,000
trauma admissions [1].
To substantiate this rarity, it is enough to mention that a French review of over
43,000 Road Trafc Accident (RTA) cases showed 199 cases of urogenital trauma
(UGT), but not a single ureteral trauma was recorded [2]. With a larger French study
including 162,690 RTA victims, 963 UGT (0.59%) were detected, and a total of ve
ureteric injuries were recorded (0.003% of total RTA trauma, or 0.5% of UGT) [3].
Further enlargement was achieved through a 4-year analysis of the American NTDB
identifying 582 ureteral injuries out of 22,706 UGT, representing 2.56% [1]. This
study showed that, contrary to renal trauma, penetrating causes are more frequent
than blunt ones and comprise 61.5% of ureteral injuries.
A single-institution experience showed an even more striking predominance of
penetrating injuries in ureteral trauma reaching 96.5%, with a great proportion arising from gunshots (91%), while stab wounds occurred in only 5.5%. Blunt injuries,
mainly due to motor vehicle accidents (MVA), were an extremely rare cause of
ureteral injury (3.5%) in this study [4].
Like renal trauma, penetrating ureteral trauma has a higher incidence of associated injuries in intraabdominal organs. The overall associated injuries in ureteral
trauma are present in 90.4% of cases [5]. Most encountered associations are injuries
to the small bowel (46%), the large bowel (44%), and the vessels (38%). However,
blunt trauma is associated with a higher incidence of bony pelvic injuries (20%) [1].
Another NTDB review showed that even blunt traumatic ureteral injuries expose
to serious outcomes, as 66.7% of the patients were unstable and 34.7% had highgrade ureteral injuries. Conrming the rarity of ureteral injuries and especially those
arising from blunt traumas, only 147 blunt traumatic ureteral injuries were recruited
over a 10-year period [6].
There is a male predominance in ureteral injury reaching 84%. The proportion of
males is even greater when specifying to study to penetrating injuries with 91% vs.
73% for blunt injuries. Most of the victims are young with a mean age of 31years [1].
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_12
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12 Epidemiology ofUreteral Injuries
Ultimately, as already stated above, it is important to remember that iatrogenic
complications (surgery and radiation therapy) are the most frequent causes of ureteral injuries accounting for 80%, while non-iatrogenic or external violence or accidents account for 20% only [7]. Among iatrogenic causes, Gynecologic procedures
are incriminated in 64–82% of cases, followed by colorectal, vascular, and urological surgeries [8]. Of course, the innumerable minor ureteral injuries caused by
endourological procedures are not taken into account here.
References
1. Siram SM, Gerald SZ, Greene WR, Hughes K, Oyetunji TA, Chrouser K, Cornwell EE 3rd,
Chang DC.Ureteral trauma: patterns and mechanisms of injury of an uncommon condition.
Am J Surg. 2010;199(4):566–70. https://doi.org/10.1016/j.amjsurg.2009.11.001.
2. Paparel P, N’diaye A, Laumon B, Caillot J-L, Perrin P, Rufon A.The epidemiology of trauma
of the genitourinary system after trafc accidents: analysis of a register of over 43,000 victims.
BJU Int. 2006;97(2):338–41. https://doi.org/10.1111/j.1464- 410x.2006.05900.x.
3. Terrier JE, Paparel P, Gadegbeku B, Rufon A, Jenkins LC, N'Diaye A.Genitourinary injuries
after trafc accidents: analysis of a registry of 162,690 victims. J Trauma Acute Care Surg.
2017;82(6):1087–93. https://doi.org/10.1097/TA.0000000000001448.
4. Best CD, Petrone P, Buscarini M, Demiray S, Kuncir E, Kimbrell B, Asensio JA.Traumatic
ureteral injuries: a single institution experience validating the American Association for the
Surgery of Trauma-Organ Injury Scale grading scale. J Urol. 2005;173(4):1202–5. https://doi.
org/10.1097/01.ju.0000155526.37963.ef.
5. Pereira BM, Ogilvie MP, Gomez-Rodriguez JC, etal. A review of ureteral injuries
after external trauma. Scand J Trauma Resusc Emerg Med. 2010;18:6. https://doi.
org/10.1186/1757- 7241- 18- 6.
6. Mendonca SJ, Jessica Pan SM, Li G, Brandes SB.Real-world practice patterns favor mini-
mally invasive methods over ureteral reconstruction in the initial treatment of severe blunt
ureteral trauma: A National Trauma Data Bank Analysis. J Urol. 2021;205(2):470–6. https://
doi.org/10.1097/JU.0000000000001347.
7. Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin N Am.
2006;33(1):55–66. https://doi.org/10.1016/j.ucl.2005.11.005.
8. Gild P, Kluth LA, Vetterlein MW, Engel O, Chun FKH, Fisch M.Adult iatrogenic ureteral
injury and stricture-incidence and treatment strategies. Asian J Urol. 2018;5(2):101–6. https://
doi.org/10.1016/j.ajur.2018.02.003.
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