During total abdominal hysterectomy, a surgeon injures the ureter at its most vulnerable point along its pelvic course. At which location does the ureter most commonly sustain iatrogenic injury during this operation?

• A At the level where it crosses the pelvic brim over the iliac vessels
• B At the vesicoureteric junction
• C Where it passes beneath the uterine artery near the cervix ✓
• D Where it lies on the psoas major in the abdomen

Explanation

Near the cervix the ureter passes approximately 2 cm lateral to it, running just deep to the uterine artery, described as water running under the bridge. Clamping or ligating the uterine vessels during hysterectomy is therefore the commonest site of iatrogenic ureteric injury. The crossing at the pelvic brim is a recognised but less frequent site of surgical injury.

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

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