The ureters are tubes composed of smooth muscle that transport urine from the kidneys to the urinary bladder. In adult humans, the ureters are typically 20–30 centimeters long and 3–4 millimeters in diameter. They are lined with urothelial cells, a form of transitional epithelium, and feature an extra layer of smooth muscle in the lower third to aid peristalsis. The ureters can be affected by diseases including urinary tract infections and kidney stones. Stenosis is the narrowing of a ureter, often caused by chronic inflammation. Congenital abnormalities can cause development of two ureters on the same side or abnormally placed ureters. Reflux of urine from the bladder into the ureters is common in children. The ureters have been identified for at least two thousand years, with the word ureter stemming from the stem uro- relating to urinating and seen in written records since at least the time of Hippocrates. It is, however, only since the 16th century that the term "ureter" has been consistently used to refer to the modern structure, and only since the development of medical imaging in the 20th century that techniques such as X-ray, CT, and ultrasound have been able to view the ureters. The ureters are also seen from the inside using a flexible camera, called ureteroscopy, which was first described in 1964.
Structure
The ureters are tubular structures, approximately 20–30 cm (8–12 in) in adults, that pass from the pelvis of each kidney into the bladder. From the renal pelvis, they descend on top of the psoas major muscle to reach the brim of the pelvis. Here, they cross in front of the common iliac arteries. They then pass down along the sides of the pelvis and finally curve forward and enter the bladder from its left and right sides at the back of the bladder. The ureters are 1.5–6 mm (0.06–0.24 in) in diameter and surrounded by a layer of smooth muscle for 1–2 cm (0.4–0.8 in) near their ends just before they enter the bladder. The ureters enter the bladder from its back surface, traveling 1.5–2 cm (0.6–0.8 in) before opening into the bladder at an angle on its outer back surface at the slit-like ureteric orifices. This location is also called the vesicoureteric junction. In the contracted bladder, they are about 25 mm (1 in) apart and about the same distance from the internal urethral orifice; in the distended bladder, these measurements may be increased to about 50 mm (2 in). A number of structures pass by, above, and around the ureters on their path down from the kidneys to the bladder. In its upper part, the ureter travels on the psoas major muscle and sits just behind the peritoneum. As it passes down the muscle, it travels over the genitofemoral nerve. The inferior vena cava and the abdominal aorta sit to the midline of the right and left ureters, respectively. In the lower part of the abdomen, the right ureter sits behind the lower mesentery and the terminal ileum, and the left ureter sits behind the jejunum and the sigmoid colon. As the ureters enter the pelvis, they are surrounded by connective tissue, and travel backward and outward, passing in front of the internal iliac arteries and internal iliac veins. They then travel inward and forward, crossing the umbilical, inferior vesical, and middle rectal arteries. From here, in males, they cross under the vas deferens and in front of the seminal vesicles to enter the bladder near the trigone. In females, the ureters pass behind the ovaries and then travel in the lower midline section of the broad ligament of the uterus. For a short part, the uterine arteries travel on top for a short (2.5 cm (1 in)) period. They then pass by the cervix, traveling inward towards the bladder.
Blood and lymphatic supply The arteries which supply the ureter vary along its course. The upper third of the ureter, closest to the kidney, is supplied by the renal arteries. The middle part of the ureter is supplied by the common iliac arteries, direct branches from the abdominal aorta, and gonadal arteries; the gonadal arteries being the testicular artery in men and the ovarian artery in women. The lower third of the ureter, closest to the bladder, is supplied by branches from the internal iliac arteries, mainly the superior and inferior vesical arteries. The arterial supply can be variable, with arteries that contribute include the middle rectal artery, branches directly from the aorta, and, in women, the uterine and vaginal arteries. The arteries that supply the ureters end in a network of vessels within the adventitia of the ureters. There are many connections (anastamoses) between the arteries of the ureter, particularly in the adventitia, which means damage to a single vessel does not compromise the blood supply of the ureter. Venous drainage mostly parallels that of the arterial supply; that is, it begins as a network of smaller veins in the adventitia; with the renal veins draining the upper ureters, and the vesicular and gonadal veins draining the lower ureters. Lymphatic drainage depends on the position of lymphatic vessels in the ureter. Lymph collects in submucosal, intramuscular and adventitial lymphatic vessels. Those vessels closer to the kidney drain into renal collecting vessels, and from here into the lateral aortic nodes near the gonadal vessels. The middle part of the ureter drains into the right paracaval and interaortocaval nodes on the right, and the left paraaortic nodes on the left. In the lower ureter, lymph may drain into the common iliac lymph nodes, or lower down in the pelvis to the common, external, or internal iliac lymph nodes.
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