This document discusses the anatomy and surgical risks related to the ureter. It describes the course, blood supply, innervation and identification of the ureter. It also outlines the types of operative ureteral injuries that can occur during gynecologic surgery, including crushing, ligation, transection, angulation and ischemia. The most common sites of injury are near the pelvic brim during hysterectomy when attempting hemostasis. Laparoscopic injuries typically result from thermal damage to the ureter. Surgical procedures like hysterectomy, adnexectomy, incontinence surgery and radical trachelectomy carry risks of ureteral injury.

1. URETER andURINARY
BLADDER

2. HISTOLOGY

3. COURSE &
RELATIONS
OFURETER

4. RELATIONS
OFURETER

5. PELVIC
RELATIONS
OFURETER

6. PELVIC
COURSEOF
URETER

7. CONSTRICTIONS

8. BLOOD
SUPPLYOF
URETER
Dissect from
lateral side
Dissect from
medial side

9. NERVE
SUPPLYAND
LYMPHATIC
DRAINAGE
 SYMPATHETIC NERVE SUPPLY= T10 – L2
 Pelvic plexus
 Inferior mesenteric plexus
 Ovarion plexus
 LYMPHATIC DRAINAGE:
 Abdominal part – Lumbar LN
 Pelvic part – External and Internal iliac LN

10. BLADDER

11. Hollow organ
Spherically shaped when full
Stores urine
Size varies with urine volume,
reaching a maximum volume
of at least 300 mL
The bladder mucosa is
transitional cell epithelium
and the muscle wall
(detrusor). Rather
than being arranged in layers,
it is composed of
intermeshing muscle fibers.

12. Divided into two areas
Base of the bladder –
urinary trigone posteriorly and a
thickened area of detrusor
anteriorly.
The three corners of the trigone
are formed by the two
ureteral orifices and the opening
of the urethra into the bladder.
The bladder base receives α-
adrenergic sympathetic
innervation
Is the area responsible for
maintaining continence.

13. Dome of the bladder –
Area above the bladder base
Parasympathetic innervation and
is responsible for micturition.
The bladder is positioned
posterior to the pubis and lower
abdominal wall and anterior to
the cervix, upper vagina, and
part of the cardinal ligament.
Laterally, it is bounded by the
pelvic diaphragm and obturator
internus muscle.

14. Blood Supply
The blood supply to the
bladder is from the
superior, middle, and
inferior vesical arteries,
with contribution from the
uterine and vaginal
vessels.
Innervation
The innervation to the
bladder is from the vesical
plexus, with contribution
from the
uterovaginal plexus.

15. Urethra
The vesical neck is the
region of the bladder
that receives and
incorporates the
urethral lumen. The
female urethra is about
3 to 4 cm in length and
extends
from the bladder to the
vestibule, traveling just
anterior to the vagina

16. IDENTIFICATION
OFURETER
 PALE GLISTENING STRUCTURE
 PERISTALSIS
 LONGITUDINALVESSELSONTHE SURFACE
 UNIQUE SNAP

17. Dissection of
Ureter

18. TYPESOF
OPERATIVE
URETERAL
INJURIES
1. Crushing with clmap(necrosis)
2. Ligation (suture/stapler)
3. Transection
4. Angulation (with secondary obstruction)
5. Ischemia (diathermy /stripping of adventitia)
6. Resection

19. URETERAL
INJURY
LOCATIONS
1. Cardinal ligament where the ureter crosses
under the uterine artery
2. Tunnel ofWertheim
3. Intramural portion of the ureter
4. Dorsal to the infundibulo-pelvic ligament
near or at the pelvic brim
5. Lateral pelvic sidewall above the uterosacral
ligament

20. URETERAL
INJURY
ASSOCIATED
WITH
GYNECOLOGIC
SURGERY:
“MOST
COMMONS”
 Most common site: Pelvic brim near the
infundibulopelvic ligament
 Most common procedure: Simple abdominal
hysterectomy
 Most common type of injury: Obstruction
 Most common “activity” leading to injury: Attempts to
obtain hemostasis
 Most common time of diagnosis: None: 50-50 split
between intraoperative and postoperative
 Most common long-term sequelae: None

21. Laparoscopy-
Associated
Ureteral
Injuries
 Uncommon-0.3% to 0.4%
 Result of a thermal injury than incision, transaction, or
encroachment/ligation- extreme caution!
 Delayed diagnosis- 2 to 5 days after the surgery
A) decreases the probability of a successful immediate primary
repair and
 B) increases the risk of a long-term complication
 M/c sites of injury- laparoscopic hysterectomy-
 i)When the uterine vessels are stapled or electrocoagulated
 Ii)When the infundibulopelvic ligament is transected

22. OTHER
SURGICAL
RISKS
 SIMPLE HYSTERECTOMY-
 i) Reapplication of clamp to uterine artery
 Ii) Suturing at vaginal fornices
 OBSTETRIC HYSTERECTOMY-
 i) Distorted anatomy
 ii)Vascularity
 ADNEXECTOMY
 INCONTINENCE SURGERY-
 i) Burch colposuspension(high sutures)
 Ii) Overzealous dissection of space of ritzeous
 Iii) Excessive mobilisation of bladder

23. SURGICAL
RISKS
 VVF REPAIR-Transvescical approach
 WERTHEIM’S HYSTERECTOMY-
 i) Below uterine artery
 Ii)At tunnel ofWherthim
 Iii) Over anterior fornix
 RADICALTRACHELECTOMY- (more risk than werthim’s)

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