Ureter and Bladder Anatomical Considerations During Hysterectomy
The ureter is at highest risk of injury at specific anatomical points during hysterectomy: at the pelvic brim where it crosses the infundibulopelvic ligament, at the point where it crosses under the uterine artery ("water under the bridge"), and at its distal portion near the vesicouterine ligament and bladder entry point. 1, 2, 3
Critical Anatomical Danger Zones
The ureter traverses multiple high-risk areas during hysterectomy where injury commonly occurs 3:
At the pelvic brim entrance: During ligation of the infundibulopelvic ligament, the ureter lies immediately medial and can be inadvertently included in the clamp or ligature 3
At the uterine artery crossing: The ureter passes beneath the uterine artery approximately 1.5-2 cm lateral to the cervix—this is the most common site of injury during clamping or ligation of the uterine pedicle 2, 3
During vesicouterine ligament dissection: The distal ureter is embedded within the anterior leaf of the vesicouterine ligament and lies very close to the cervix as it approaches the bladder 4, 3
At the uterosacral ligament: During transection of the uterosacral ligaments, the ureter runs along the lateral aspect and can be injured 3
During anterior vaginal wall incision: The terminal ureter at the ureterovesical junction is vulnerable during vaginal cuff creation 3
Protective Surgical Techniques
Ureter Identification and Mobilization
Direct visualization and lateral mobilization of the ureter significantly increases the safety margin during dissection 2:
Lateralization technique: Pulling the uterus laterally increases the distance between the ureter and uterine artery from 11.6 mm to 25 mm 2
After sectioning the ascending uterine artery: The distance increases further to 25-38.6 mm, providing a safer working space 2
Extrafascial dissection: Separating the connective tissue of the anterior leaf of the vesicouterine ligament allows the ureter with its surrounding tissue to be "rolled out" laterally, making the distal ureter near the ureterovesical junction clearly visible 4, 2
Vascular Anatomy Considerations
Understanding the blood supply is essential to avoid both ureteral injury and devascularization 4, 5:
Cervicovesical vessels: These branches of the superior vesical artery cross over the ureter and must be identified during dissection of the vesicouterine ligament 4
Ureteral blood supply: The ureter receives its blood supply from multiple sources along its length; excessive dissection or stripping of periureteral tissue can cause ischemia 5
Preserve periureteral tissue: Minimal devascularization is critical—maintain the adventitial sheath around the ureter during mobilization 6
Bladder Considerations
Bladder Mobilization
Bladder dissection: The bladder must be adequately mobilized off the lower uterine segment and cervix to avoid injury during the anterior colpotomy 1
Identify the correct tissue plane: Separate the bladder peritoneum from the cervical fascia to visualize the outline of the distal ureter near the ureterovesical junction 4
Catheter Management
Urinary catheters should be used for postoperative bladder drainage in complex vaginal surgery but may be safely eliminated in simple vaginal hysterectomy 6:
Short-duration catheterization: Removal after a brief postoperative period is associated with lower rates of recatheterization, bladder infection, and shorter hospital stays 6
Retrograde bladder filling: Consider this technique during vaginal surgery as it may shorten recovery time 6
Management of Iatrogenic Injuries
If ureteral injury occurs intraoperatively 6:
Partial transection: Minimally invasive techniques including percutaneous nephrostomy, wire recanalization, and stent placement are preferred 6
Complete transection of lower third: Direct reimplantation (ureteroneocystostomy) is required, potentially with psoas hitch or Boari flap techniques if the remaining ureter cannot reach the bladder 6
Upper/middle third injuries: Ureteroureterostomy with tension-free, stented anastomosis is the first-line repair 6
Common Pitfalls to Avoid
Blind clamping: Never clamp tissue without direct visualization of the ureter, especially near the uterine artery and cardinal ligament 3
Inadequate bladder mobilization: Insufficient dissection increases risk of bladder injury during anterior colpotomy 1
Excessive traction: Aggressive pulling on tissue can avulse the ureter from the bladder or cause thermal injury during electrosurgery 1, 5
Failure to identify anatomical variants: Be aware that radiation history causes vascular damage, fibrosis, and reduced tissue integrity, markedly increasing fistula risk 7