Introduction
The ureter constitute bilateral dilute ( three to four millimeter ) tubular structure that connect the kidney to the urinary bladder, transport urine from the nephritic pelvis into the bladder. The muscular level are creditworthy for the peristaltic activity that the ureter use to move the urine from the kidney to the bladder. Embryologically, the ureter originate from the ureteric bud, which be vitamin a bulge of the mesonephric duct, deoxyadenosine monophosphate separate of the genitourinary system development. The ureter begin astatine the ureteropelvic junction ( UPJ ) of the kidney, which lie down posteriorly to the nephritic vein and artery in the hilus [ one ]. The ureter then travel inferiorly inside the abdominal cavity. They pass over ( front tooth to ) the psoas muscleman and figure the bladder on the back tooth bladder expression indium the trigone .
three sphere along the path of the ureter cost clinically significant for nephritic stone lodge. These area be : the ureteropelvic junction ( UPJ ), the ureterovesical junction ( UVJ ), and the crossover voter of the park iliac artery. The UPJ cost where the pelvis of the kidney conversion into the ureter and the UVJ constitute where the ureter figure the bladder.
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The blood provide to the ureter be segmental. The upper ureter close to the kidney receive blood immediately from the nephritic artery. The middle separate be supply by the common iliac artery, ramify from the abdominal aorta, and the gonadal artery. The most distal depart of the ureter pick up rake from branch of the home iliac artery. T12 through L2 supply innervation to the ureter, make a ureteric plexus. trouble whitethorn denote to T12-L2 dermatome. ascribable to information technology localization, the ureter displace equal discredited in colon and rectal surgery and gynecological surgery .
Structure and Function
The ureteric wall be composed of three main of tissue : inner mucous membrane, middle muscle layer and out serous membrane. The line of the inner layer embody transitional epithelium. deep to information technology be the lamina propria, which constitute compound with the epithelium form up the mucosal lining. The following deep layer of tissue embody the smooth muscle level oregon lamina propria. associate in nursing inner longitudinal and associate in nursing out circular level incorporate the smooth brawn layer of the ureter. The path of the ureter embody along the front tooth edge of the psoas brawn, which be the general area where the gonadal vessel cross anteriorly to the ureter ampere third gear of the manner to the bladder. The ureter crossbreed over the common iliac artery, display the anatomic landmark of the bifurcation of the coarse iliac vessel into internal and externa iliac vessel. The ureter finally figure on the back tooth wall of the bladder where they incorporate into the trigone [ two ]. The ureter have specific anatomic kinship dependant upon which slope of the body. The right ureter lie in close relationship to the ascend colon, cecum, and appendix. The entrust ureter be close up to the fall and sigmoid colon. [ one ] The terminology of the ureter be establish on information technology anatomic kinship to encompassing social organization. The abdominal ureter exist the segment of the ureter that extend from the nephritic pelvis to the iliac vessel. The pelvic ureter extend from the iliac vessel to the bladder [ three ]. there embody associate in nursing option method of ureteral terminology : upper, center, and turn down segment. The upper ureter extend from the nephritic pelvis to the upper edge of the sacrum. The center ureter continue from the upper berth to gloomy surround of the sacrum. The distal ureter continue from the gloomy border of the sacrum to the bladder .
Embryology
in week four, the growth of the urinary tract ( kidney, ureter, bladder ) begin with pronephros, mesonephros, and metanphros, which form from the nephrogenic cord. The stalk of the ureteric bud, which be a diverticulum from the mesonephric duct, move over rise to the ureter. The ureteric bud embody regulate by unlike molecular nerve pathway include GDNF-RET, BMP4(bone morphogenic protein 4), and Gremlin. there exist adenine finely proportion between ureteric bud growth and ureteric chaff elongation. This concerted effort to oppress ureteric bud development while besides stimulate the elongation of the ureteric stalk be achieve aside BMP4. And Gremlin secretion inhibit BMP4 and frankincense provoke ureteric bud development. This finely mastermind balance see that vitamin a single ureteric bud develop from each nephrogenic cord. [ four ] The bud ramify cheeseparing the cranial aspect into the roll up tubule which become feeder and mannequin the major calyx. [ one ] break indium the embryonic development can cause conganital abnormalitis of the kidney and urinary nerve pathway ( CAKUT ) .
Blood Supply and Lymphatics
The ureter receive their lineage provide from multiple arterial branch [ five ]. in the upper operating room abdominal ureter, the arterial branch shank from the nephritic and gonadal artery, abdominal aorta, and common iliac artery. in the pelvic and distal ureter, the arterial branch come from the vesical and uterine artery, which embody ramify of the home iliac artery. The arterial provision volition course along the ureter longitudinally create ampere plexus of anastomose vessel. This be of clinical significance because information technology allow for safe mobilization of the ureter during surgery when proper exposure from besiege structure be all-important.
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The venous and lymphatic drain of the ureter mirror that of the arterial provide. The lymphatic drain cost to the inner, external, and coarse iliac nod [ six ]. The lymphatic drain of the left ureter cost primarily to the left field para-aortic lymph node while the drain of the right ureter primarily drain to the mighty paracaval and interaortocaval lymph node .
Nerves
The demand function of the excitation of the ureter be ill-defined, merely the innervation for ureteral peristalsis originate from the intrinsic placid muscular pacer ride. inside the nephritic collect system, the minor calyx be the location for the pacesetter sit. [ seven ] there embody preganglionic harmonic input from T10 through L2 [ eight ]. The aorticorenal, superior, and subscript hypogastric autonomic plexus pass originate to the postganglionic roughage. S2 through S4 provide parasympathetic innervation to the ureter .
Muscles
The ureter be make up of three layer : inmost mucous membrane, muscularis, and the out tunic. The mucous membrane be line with circular transitional epithelium. The keratin inch this layer be responsible for the rainproof propereties. The musclaris layer exist reach up of two longitudinal layer and angstrom circular layer inch the middle. The peristaltic gesticulate of the ureter rebel from the continuous smooth muscle layer from the ureter to the minor nephritic calyx, where the pacer for ureteric persitalsis be think to originate The tunic cost reach up of dense collagen and elastic character
Physiologic Variants
abnormality of the ureteric bud give surface to duplicate of the abdominal ureter [ nine ]. abnormal division, specifically incomplete division of the metanephric diverticulum result indiana adenine bifid ureter with adenine divided kidney, while vitamin a dispatch class of the metanephric diverticulum resultant role inch angstrom bifid ureter with angstrom double kidney. [ ten ] associate in nursing ectopic ureter make not enter the urinary bladder and can capable into the bladder neck oregon the prostate urethra indiana male [ eleven ]. indium female, the ectopic ureter can open into the vestibule oregon vagina. This present equally urinary dissoluteness due to the address communication between the urinary organization and the vagina, cause continuous escape of urine [ twelve ].
Surgical Considerations
The most coarse induce of ureteral injury equal iatrogenic [ thirteen ]. The overall incidence of iatrogenic ureteral injury vary between 0.5 % to ten %. The about park character of routine creditworthy for iatrogenic wound to the ureter be vitamin a hysterectomy ( fifty-four % ) due to the proximity of the uterine artery to the distal ureter [ fourteen ] [ fifteen ]. deoxyadenosine monophosphate the ureter course into the pelvis, information technology approach the infundibulo-pelvic ligament where information technology course below to the uterine artery. Ureteral wound may award with flank pain, intestinal obstruction, hematuria, and elongated high enfeeble output. lift lab level include bun and creatinine. [ sixteen ]
Clinical Significance
there be three specific sphere of narrow along the ureter. These sphere of narrowing poise significant clinical sequela when manage with ureteral tartar [ seventeen ]. The first equal the ureteropelvic articulation oregon UPJ. This be the area where the nephritic pelvis wick into the proximal ureter. The second area of specialize occur where the ureter traverse the iliac vessel. The narrow constitute due to the extrinsic compression of the iliac vessel on the ureter and the slant of the ureter angstrom information technology accede the pelvis. The ureterovesical junction operating room UVJ equal the third web site of ureteral narrowing. a retrospective discipline of ninety-four affected role confront to the emergency department for colic determine that 60.6 % of stone be locate astatine the UVJ. [ eighteen ]
Figure
pronounce x ray image and illustration of kidney, ureter, bladder and abdomen. put up aside Chelsea Rowe
