Course of the Ureter in the Pelvis

Entry into the Pelvis

• Fischer's Mastery of Surgery, p. 7629

General Course in the Pelvis

• Retroperitoneally, just deep to the parietal peritoneum
• Along the lateral wall of the pelvis, anterior to the internal iliac vessels, in extraperitoneal fatty tissue
• At the level of the ischial spine, it curves anteromedially, superior to levator ani, to enter the bladder
• Campbell-Walsh-Wein Urology, p. 2549

In the FEMALE (Clinically important)

1. Ovarian vessels - cross over the ureter as it approaches the pelvic brim; they lie lateral to the ureter as it enters the pelvis
2. Broad ligament - as it descends into the pelvis, the ureter runs within the broad ligament just lateral to the uterosacral ligament, separating it from the mesosalpinx, mesovarium, and ovarian fossa
3. Uterine artery - at the approximate level of the ischial spine, the ureter passes under the uterine artery in the base of the broad ligament (cardinal ligament) - the classic "water under the bridge" relationship. The ureter lies 2-3 cm lateral to the cervix at this point
4. Anterior vaginal wall - the ureter turns medially to cross the anterior upper vagina as it enters the bladder wall

• Berek & Novak's Gynecology, p. 207
• Color Atlas of Human Anatomy Vol. 2, p. 408

The ureter is most vulnerable at point 3 (under the uterine artery). About 75% of all iatrogenic ureteral injuries are from gynecologic procedures; 91% occur at the level of the pelvic ureter. The risk is highest with laparoscopic hysterectomy.

In the MALE

• The ureter runs beneath the peritoneum along the lateral pelvic wall
• The only structure passing between the pelvic ureter and peritoneum is the ductus (vas) deferens
• The ductus deferens crosses over the ureter within the ureteric fold of peritoneum - the ureter lies posterolateral to the vas deferens
• The ureter then reaches the posterolateral wall of the bladder, just superior to the seminal vesicle, entering the posterosuperior angle of the bladder
• Color Atlas of Human Anatomy Vol. 2, p. 408
• Campbell-Walsh-Wein Urology, p. 2549

Intravesical (Intramural) Part

• The ureter passes obliquely through the bladder wall in an inferomedial direction, ~2 cm long
• This forms the third constriction of the ureter
• The internal pressure of the filling bladder collapses this passage, creating a valvular mechanism that prevents vesicoureteric reflux

Summary Table: 3 Constrictions of the Ureter