A 40 years old multi gravida woman comes to the hospital with two months history of worsening right pelvic pain. She experiences the pain daily. The intensity does not vary with menstruation. The patient’s waist size was increased despite her poor appetite. The pelvic examination shows irregularly shaped fixed adnexal mass. One week later, the patient undergoes surgery for removal of large ovarian neoplasm. Within the true pelvis, the surgeon can most likely palpate the right ureter immediately anterior to
Correct Answer: Internal iliac artery
Description: Answer: (c) Internal Iliac arteryURETERS* 25cm long, upper half lies in the abdomen and the lower half in the pelvis. The course is:* Begins within the renal sinus as a funnel shaped dilatation, (the renal pelvis)- Passes through the hilum-Goes downwards & medially-Enters the pelvis by crossing in front of common iliac artery- Reach the base of the bladder -Obliquely enters the bladder wall & opens into it at the lateral angle of trigone.* In pelvis, the ureter is crossed by ductus deferens in men & uterine artery in women.Constrictions on ureter:* At the pelvis - ureteric junction* At the brim of the lesser pelvis: where the ureters cross the common iliac vessels.* At its passage through the bladder wall RELATIONS OF THE URETER ABDOMINAL PART OF URETERAnteriorlyPosteriorlyMediallyRight sideLeft side* Psoas major* Tips of transverse Process* Genitofemor al nerveRight sideIVC* 3rd part of duodenum* Peritoneum* Right colic vessels* Ileocolic vessels* Gonadal vessels* Root of mesentery* Terminal part of Ileum* Peritoneum* Gonadal artery* Left colic vessels* Sigmoid colon* Sigmoid mesocolonLeft side* Left gonadal vein* Inferior mesenteric veinPELVIC PART OF URETER:The internal iliac A begins at the level of IV disc between L5 & SI vertebrae, where it is crossed by ureter.* The ureter passes posterior to the uterine artery through the cardinal ligament within the ureteric tunnel.* In the pelvis the ureter lies in extraperitoneal areolar tissue.* At first it descends posterolaterally on the lateral wall of the lesser pelvis along the anterior border of the greater sciatic notch.* Opposite the ischial spine it turns anteromedially into fibrous adipose tissue above levator ani to reach the base of the bladder.* On the pelvic wall it is anterior to the internal iliac artery and the beginning of its anterior trunk, posterior to which are the internal iliac vein, lumbosacral nerve and sacroiliac joint.* Laterally it lies on the fascia of obturator internus. It progressively crosses to become medial to the umbilical, inferior vesical, and middle rectal arteries.In its Downward CourseIn its Forward CoursePosteriorlyLaterallyIn MalesIn Females* Internal Iliac. A and its anterior division* Internal Iliac.V* Lumbosacral trunk* Sacro-lliac joint* Fascia of obturator internus* Superior vesical.A* Obturator.N* Obturator.A* Obturator.V* Inferior vesical.V* Middle Rectal. A* Ductus deferens crosses from lateral to medial side* Seminal vesicle lies below and behind the ureter* Vesical veins surround its terminal part* Ureter lies in lower & medial part of broad ligament* Uterine. A lies first above and in front and then crosses it from lateral to medial side* Ureter lies 2cm lateral to the supra vaginal portion of cervix & runs above the lateral fornix* The terminal portion lies anterior to vaginaBLOOD SUPPLY:o Upper part - renal artery, common iliac & internal iliaco Middle part-Aortao Pelvic part- Vesical, middle rectal or uterine vessels
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