Blood Supply to the Ureter
The ureter receives its blood supply from multiple arterial sources along its course, including branches from the renal artery, gonadal artery, aorta, common iliac, and internal iliac arteries, forming a segmental vascular network that must be preserved during surgical interventions to prevent ischemic complications.
Anatomical Blood Supply of the Ureter
The ureter's blood supply follows a segmental pattern with rich anastomoses:
Proximal (Upper) Third:
- Primary supply from branches of the renal artery
- Additional contributions from gonadal arteries
- In some cases (43.75%), gonadal arteries may originate from the renal artery, which has surgical significance 1
Middle Third:
- Supplied by branches from the aorta
- Additional supply from gonadal arteries
- Common iliac artery branches
Distal (Lower) Third:
- Primarily supplied by branches from the internal iliac artery
- Contributions from vesical arteries (including inferior vesical artery)
- In females, branches from uterine arteries may contribute
Clinical and Surgical Significance
Ureteral Injury Management
- When managing ureteral injuries, preservation of blood supply is critical to prevent ischemic complications and stricture formation
- During surgical repair of ureteral injuries, ureteral devascularization must be kept to a minimum 2
- For upper and middle third injuries, ureteroureterostomy with minimal mobilization is preferred to preserve blood supply
- For lower third injuries, ureteroneocystostomy (reimplantation) is typically required 2
Surgical Techniques and Blood Supply Considerations
- When performing anastomosis, the ureter should be mobilized as little as possible to avoid disrupting blood supply 2
- Stent placement is strongly recommended in all ureteral repairs to reduce failures and strictures 2
- For proximal ureteral injuries, primary repair over a ureteral stent is recommended when possible 2
- For distal ureteral injuries, reimplantation or primary repair over a stent is recommended 2
Potential Complications Related to Vascular Supply
- Inadequate preservation of blood supply during repair can lead to:
- Ureteral stricture
- Urinary extravasation
- Ureteral necrosis
- Anastomotic failure
Special Considerations
- Variations in ureteral blood supply are common and must be considered during surgical planning
- Gonadal arteries with renal origin (found in 16 cases in one study) may be at risk during renal surgery 1
- Injury to the ureteral blood supply during percutaneous procedures may lead to hydronephrosis
- The rich anastomotic network between vessels supplying the ureter provides some protection against ischemia, but segmental devascularization should still be avoided
Understanding the segmental blood supply of the ureter is essential for successful management of ureteral injuries and for performing reconstructive procedures while minimizing the risk of ischemic complications.