Ureter – Course and Relations

The ureters are paired muscular tubes that transport urine from the renal pelvis of each kidney to the urinary bladder. Each ureter measures approximately 25–30 cm in length and is divided into abdominal and pelvic parts. Understanding the course and anatomical relations of the ureters is essential for avoiding injury during abdominal and pelvic surgeries and for interpreting radiological imaging.

Course

The ureter is classically divided into two parts:

• Abdominal ureter: From the renal pelvis to the pelvic brim
• Pelvic ureter: From the pelvic brim to the bladder

Abdominal Part:

• Begins at the ureteropelvic junction (UPJ) at the hilum of the kidney
• Descends vertically on the psoas major muscle
• Crosses anterior to the genitofemoral nerve
• Crossed anteriorly by:
  • In males: testicular artery and vein
  • In females: ovarian artery and vein
• Crosses over the common iliac artery (or external iliac artery) near the pelvic brim

Pelvic Part:

• Descends within the pelvic cavity, anterior to the internal iliac artery
• In males:
  • Passes posterior to the ductus deferens
  • Enters the bladder posterolaterally near the seminal vesicle
• In females:
  • Passes medial to the ovarian vessels (within the infundibulopelvic ligament)
  • Runs under the uterine artery (important landmark: "water under the bridge")
  • Enters the bladder near the anterior vaginal fornix

Relations

Clinical Significance

• Ureteric injury: Common during pelvic surgery (e.g., hysterectomy, oophorectomy); knowledge of course helps prevent iatrogenic damage
• Referred pain: Due to its course over the psoas and into the pelvis, ureteric colic refers pain from the flank to the groin
• Stone obstruction: Most stones lodge at physiological constrictions along this path (e.g., UPJ, pelvic brim, vesicoureteric junction)
• Radiological identification: Course helps in tracing ureters on CT urograms, IV pyelograms, and ultrasound

The ureter’s course is a key anatomical pathway with important surgical and diagnostic implications. Its close proximity to major vessels and reproductive organs makes it vulnerable during pelvic procedures, necessitating a precise understanding of its topography.