Anatomy
Abdomen
A 49 year old female patient undergoes surgery for uterine cancer. Whilst attempting to ligate the uterine artery, the surgeon accidentally ligates the structure that the uterine artery crosses anteriorly as it passes from the internal iliac artery to the uterus. Which of the following structures has most likely been injured:
Answer:
The ureter is crossed anteriorly by the uterine artery just lateral to the cervix.Ureter
Anatomy / Abdomen / Urinary Tract
Last Updated: 11th April 2019
The ureters are muscular tubes that transport urine from the kidneys to the bladder. They are continuous superiorly with the renal pelvis at the ureteropelvic junction (at the level of the renal hilum, vertebra L1).
Anatomical Course
Inferior to the ureteropelvic junction, the ureters descend retroperitoneally on the medial aspect of the psoas major muscle, anterior to the tips of the transverse processes of the lower lumbar vertebrae. The ureters cross the pelvic brim anterior to the bifurcation of the common iliac arteries to enter the pelvic cavity and continue their journey down the lateral pelvic walls.
Within the pelvic cavity, the ureters are crossed by the uterine artery lateral to the cervix in women, and by the ductus deferens just posterior to the bladder in men.
At the level of the ischial spines, they turn anteromedially, moving in a transverse plane towards the bladder. The ureters enters obliquely through the base of the bladder at the level of the pubic tubercle.
The right ureter lies in close relation to the appendix, and thus be irritated in acute appendicitis causing urinary frequency.
![Modified by FRCEM Success. Original by Jordi March i Nogué [1] (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL , via Wikimedia Commons](https://mrcemsuccess.com/wp-content/uploads/2017/02/Ureters.png)
Constrictions of the Ureter. (Image modified by FRCEM Success. Original by Jordi March i Nogué [1] (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL , via Wikimedia Commons)
Constrictions
At three points along their course, the ureters are constricted;
- the first point is at the ureteropelvic junction (where the renal pelvis becomes continuous with the ureter)
- the second point is where the ureter crosses the common iliac vessels at the pelvic brim
- the third point is at the vesicoureteric junction (where the ureter enters the wall of the bladder)
Kidneys stones can become lodged at these constrictions.
Innervation
Visceral afferent fibres from the ureters enter the spinal cord at T11 - L2, with ureteric pain (usually from ureteric distension) thus referred to the dermatomes supplied by T11 - L2; the posterior and lateral abdominal wall below the ribs and above the iliac crest, the pubic region, the scrotum in males, the labia majora in females and the proximal anterior aspect of the thigh (loin to groin pain).
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
