A woman undergoes a vaginal hysterectomy for uterovaginal prolapse. During ligation of the uterine artery near the lateral fornix of the vagina, the ureter is at risk because of its proximity. What is the precise anatomical relationship?

• A The ureter passes superior to the uterine artery
• B The ureter passes approximately 1–1.5 cm lateral and inferior to the uterine artery at the level of the internal os ✓
• C The ureter passes through the broad ligament medial to the uterine artery
• D The ureter is at risk medial to the ovarian artery in the infundibulo-pelvic ligament

Explanation

The uterine artery crosses over the ureter ('water under the bridge') at approximately 1–1.5 cm lateral to the cervix at the level of the internal os. The artery arches medially above the ureter as both structures pass in the parametrium. During hysterectomy, if the uterine artery is clamped or sutured without careful identification, the ureter — which lies just below the artery — can be kinked, ligated, or transected. This anatomical relationship is the classic explanation for ureteric injury at hysterectomy. The infundibulo-pelvic ligament carries the ovarian vessels and relates to ovarian surgery, not the ureter at the cervix.

Reference: BD Chaurasia's Human Anatomy, 8th ed.

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Written and medically reviewed by the StethoPrep medical team.