During a hysterectomy, a ureteric injury is suspected. Which anatomical relationship makes the ureter vulnerable at the level of the uterine cervix?

• A The ureter passes anterior to the uterine artery
• B The ureter crosses the ovarian vessels medially
• C The ureter passes beneath the uterine artery close to the cervix ✓
• D The ureter lies lateral to the infundibulopelvic ligament throughout its course

Explanation

The classical teaching phrase is water under the bridge: the uterine artery crosses above the ureter, so the ureter runs beneath it approximately 1.5 to 2 cm lateral to the cervix, exactly where clamps are applied during hysterectomy. At the pelvic brim the ureter crosses the common iliac vessels, and near the ovary it lies beneath the infundibulopelvic ligament, other sites at risk. Injury may present late as a urinoma or ureterovaginal fistula with continuous leakage.

Reference: Gray's Anatomy for Students, 4th ed.

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