Blood Supply of the Ureters

The blood supply of the ureters is segmental and derived from multiple nearby arteries along their course from the kidneys to the urinary bladder. These arteries form a rich anastomotic network around the ureters, ensuring continuous perfusion despite ureteral mobility during respiration and body movement. Knowledge of these segmental sources is crucial during surgical mobilization to avoid ischemic injury.

Segmental Arterial Supply

Venous Drainage

Venous return generally parallels the arterial supply:

• Upper segment drains into the renal vein
• Middle into the gonadal and iliac veins
• Lower into the internal iliac vein tributaries

Arterial Pattern and Surgical Considerations

• Longitudinal arcade: Small branches from regional arteries form a plexiform arcade that runs longitudinally around the ureter
• Medial vs lateral entry:
  • In the abdomen: arteries approach ureter from the medial side
  • In the pelvis: arteries approach from the lateral side
• Clinical importance: During ureteric mobilization, preserving the surrounding adventitial tissue is critical to maintain perfusion

Clinical Significance

• Ureteral ischemia: Excessive stripping of the ureter (e.g., during transplant or cancer surgery) may disrupt segmental blood supply and cause necrosis or stricture
• Transplantation: The distal ureter is at highest risk for ischemia due to its tenuous blood supply
• Vascular anomalies: Aberrant renal or iliac arteries can create surgical complications or unexpected bleeding

The ureter’s blood supply is an intricate, multi-source system that must be preserved during surgical handling. Segmental perfusion patterns explain why even short segment injuries can lead to significant functional compromise.