A 40-year-old nulligravida woman comes to the office with a 2-month history of worsening right pelvic pain. She experiences the pain daily, and its intensity does not vary during her menstrual cycle. In addition, the patient's waist size has increased despite a decreased appetite. Pelvic examination shows an irregularly shaped, fixed adnexal mass. One week later, she undergoes surgery to remove a large ovarian neoplasm. Within the true pelvis, the surgeon can most likely palpate the right ureter immediately anterior to which of the following structures?

Question

A 40-year-old nulligravida woman comes to the office with a 2-month history of worsening right pelvic pain.  She experiences the pain daily, and its intensity does not vary during her menstrual cycle.  In addition, the patient's waist size has increased despite a decreased appetite.  Pelvic examination shows an irregularly shaped, fixed adnexal mass.  One week later, she undergoes surgery to remove a large ovarian neoplasm.  Within the true pelvis, the surgeon can most likely palpate the right ureter immediately anterior to which of the following structures?

Quizplus · Accepted Answer

11ec160b_35de_605c_9249_fb3509247218_MD0001_00 The ureters originate bilaterally at the renal pelvis and course inferiorly toward the bladder within the retroperitoneum just anterior to the psoas muscles. Midway from the kidney to the pelvic inlet, the ureters cross posterior to the gonadal artery and vein. The ureters then gain access to the pelvis by crossing anterior to the external iliac artery at, or just after, the bifurcation of the common iliac artery. At this point, the ureter lies medial to the ovarian vessels and anterior to the internal iliac artery. Due to their course and proximity to other structures, the ureters are at particular risk for injury during pelvic and abdominal surgery. (Choice A) The ureters cross posterior to the gonadal vessels within the retroperitoneum before entering the pelvis. In females, the ureters lie within the true pelvis medial to the ovarian vessels. In males, the testicular vessels never enter the true pelvis; instead, they pass around the pelvic brim before entering the deep ring of the inguinal canal. (Choice B) The inferior vena cava rests on the right side of the vertebral bodies and is formed by the union of the common iliac veins at the L4 level. The internal and external iliac veins join to form the common iliac veins at the pelvic inlet. (Choice D) The round ligaments of the uterus originate at the uterine fundus and course through the inguinal canal out to the labia majora. The ureters do not lie in close proximity. (Choice E) The uterine artery courses within the cardinal ligament to reach the uterus. The ureters course along the uterosacral ligament and cross posterior to the uterine artery ("water under the bridge") before entering the bladder. Educational objective: The ureters pass posterior to the ovarian (gonadal) vessels within the retroperitoneum and cross anterior to the common/external iliac arteries to reach the true pelvis. Within the true pelvis, the ureters lie anterior to the internal iliac artery and posterior to the uterine artery.

A 40-Year-Old Nulligravida Woman Comes to the Office with a 2-Month