A. Course. The ureters begin at the ureteropelvic junction, where the renal pelvis joins the ureter. Within the abdomen, the ureters descend retroperitoneally and anterior to the psoas major muscle, where they cross the pelvic inlet to enter the minor (true) pelvis. Within the minor pelvis, the ureters descend retroperitoneally and anterior to the common iliac artery and vein, where they may be compromised by an aneurysm of the common iliac artery. The ureters end at the ureterovesical junction by traveling obliquely through the wall of the urinary bladder (intramural portion of the ureter), and they define the upper limit of the urinary bladder trigone. The intramural portion of the ureter functions as a check valve (ureterovesical valve of Sampson) to prevent urine reflux.
B. Anatomic relations. In males, the ureters pass posterior to the ductus deferens. In females, they pass posterior and inferior to the uterine artery, which lies in the transverse cervical ligament (cardinal ligament of Mackenrodt), and lie 1—2 cm lateral to the cervix of the uterus. During a hysterectomy, the ureter inadvertently may be ligated along with the uterine artery. The critical area of ligation of the uterine artery is near the cervix.
C. Normal constrictions. The ureters normally are constricted at three sites where kidney stones most commonly cause obstruction: at the ureteropelvic junction, where the ureters cross the pelvic inlet, and at the ureterovesical junction (along the intramural portion of the ureter).
1. An ectopic opening occurs when the ureter opens at a site other than the urinary bladder trigone. It most often occurs with the congenital anomaly known as duplication of the renal pelvis and ureter. Ureters with an ectopic opening usually are obstructed. In males, an ectopic opening most commonly is associated with urine leakage from the urethra or seminal vesicle. In females, it most commonly is associated with urine leakage from the urethra, vestibule of the vagina, or vagina.
2. Obstruction by renal calculi ("kidney stones") (Figure 12-2) occurs most often at the three sites where the ureter normally is constricted (see II C), causing unilateral hydronephrosis. Clinical findings include: intermittent excruciating pain in the flank, abdomen, or testicular or vulvar region that radiates into the inner thigh, depending on the obstruction site. Fever, hematuria, and decreased urine output may be present, and the patient typically assumes a posture with a severe ipsilateral costovertebral angle. Types of kidney stones include:
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