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Gross and Histologic Anatomy of the Pelvic Ureter

Clinical Applications to Pelvic Surgery

Jackson, Lindsey A., MD; Ramirez, Denise M. O., PhD; Carrick, Kelley S., MD; Pedersen, Rebecca, MD; Spirtos, Alexandra, MD; Corton, Marlene M., MD, MSCS

doi: 10.1097/AOG.0000000000003221
Contents: Gynecologic Surgery: Original Research

OBJECTIVE: To further evaluate relationships of the pelvic ureter to clinically relevant structures and to characterize the anatomy, histology, and nerve density of the distal ureter.

METHODS: In this observational cadaveric study, 35 female cadavers were examined, 30 by gross dissections and five microscopically. Ureter length and segments of pelvic ureter were measured. Closest distances between the ureter and clinically relevant points were recorded. The distal pelvic ureter and surrounding parametrium were evaluated microscopically. Nerve density was analyzed using automated quantification of peripheral nerve immunostaining. Average measurements of nerve density in the anterior and posterior quadrants surrounding the ureter were statistically compared using a two-tailed t test. Descriptive statistics were used for analyses with distances reported as mean±SD (range).

RESULTS: Gross dissections revealed ureter length of 26.3±1.4 (range 24–29) cm (right), 27.6±1.6 (25–30.5) cm (left). Lengths of ureter from pelvic brim to uterine artery crossover were 8.2±1.9 (4.4–11.5) cm (right), 8.5±1.5 (4.5–11.5) cm (left) and from crossover to bladder wall 3.3±0.7 (2.4–5.8) cm (right), 3.2±0.4 (2.6–4.1) cm (left). Intramural ureter length was 1.5±0.3 (1–2.2) cm (right) and 1.7±1.2 (0.8–2.5) cm (left). Distances from the ureter to uterine isthmus: median 1.7 (range 1–3.0) cm (right) and 1.7 (1.0–2.9) cm (left); lateral anterior vaginal fornix 1.5 (1.0–3.1) cm (right) and 1.7 (0.8–3.2) cm (left); lateral vaginal apex 1.3 (1.0–2.6) cm (right) and 1.2 (1.1–2.2) cm (left) were recorded. Microscopy demonstrated denser fibrovascularity posteromedial to the ureter. Peripheral nerve immunostaining revealed greater nerve density posterior to the distal ureter.

CONCLUSION: Proximity of the ureter to the uterine isthmus and lateral anterior vagina mandates careful surgical technique and identification. The intricacy of tissue surrounding the distal ureter within the parametrium and the increased nerve density along the posterior distal ureter emphasizes the importance of avoiding extensive ureterolysis in this region.

Proximity of the ureter to surgical landmarks and increased nerve density along the posterior distal ureter highlights the importance of careful surgical technique and avoidance of extensive ureterolysis.

Departments of Obstetrics and Gynecology, Neurology and Neurotherapeutics, and Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.

Corresponding author: Lindsey A. Jackson, MD, Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the 39th Annual Scientific Meeting of the American Urogynecologic Society, October 9–13, 2018, Chicago, Illinois.

The authors thank the Willed Body Program at the University of Texas Southwestern Medical Center for their invaluable contribution to cadaver provision and preparation, the Histo Pathology Core at the University of Texas Southwestern Medical Center for their preparation of histological specimens, and Elizabeth Han for the illustrations used in this article.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.