A 45-year-old man with a history of end-stage renal disease undergoes renal allograft transplantation. The donor kidney and proximal ureter are transplanted in the right iliac fossa, with implantation of the ureter into the patient's bladder. Six days following surgery, the donor kidney appears to be functioning well, but the patient develops fever and right lower quadrant abdominal pain. Imaging studies reveal a large pelvic fluid collection. Exploratory laparotomy is performed and discovers urinary leakage, with significant ischemia and necrosis of the transplanted ureter immediately adjacent to the site of implantation into the bladder. The proximal portion of the ureter appears normal. The healthy segment of this patient's transplanted ureter is most likely receiving blood from which of the following arteries?

Question

A 45-year-old man with a history of end-stage renal disease undergoes renal allograft transplantation.  The donor kidney and proximal ureter are transplanted in the right iliac fossa, with implantation of the ureter into the patient's bladder.  Six days following surgery, the donor kidney appears to be functioning well, but the patient develops fever and right lower quadrant abdominal pain.  Imaging studies reveal a large pelvic fluid collection.  Exploratory laparotomy is performed and discovers urinary leakage, with significant ischemia and necrosis of the transplanted ureter immediately adjacent to the site of implantation into the bladder.  The proximal portion of the ureter appears normal.  The healthy segment of this patient's transplanted ureter is most likely receiving blood from which of the following arteries?

Quizplus · Accepted Answer

11ec160b_35de_123b_9249_7db78b75889a_MD0001_00 The blood supply to the proximal ureter comes from branches of the renal artery. At the distal ureter, arterial blood supply arises from the superior vesical artery. In between, the arterial supply to the ureter is anastomotic and highly variable, with possible afferent branches from the gonadal, common and internal iliac, aorta, and uterine arteries. In a kidney transplant operation, the native kidneys are typically left in place, and the donor kidney is placed retroperitoneally in the right iliac fossa. Blood supply is established by anastomosing the donor renal artery with the recipient's external iliac artery. The proximal 1/3 of the donor ureter is preserved and used to establish continuity from the collecting system of the kidney to the recipient's bladder. Although the transplanted ureter will continue to receive blood through the donor's renal artery, the most distal portion may be susceptible to ischemia due to lack of anastomotic connections. Distal ureteral ischemia is a recognized complication of renal transplant and causes leakage of urine 5-10 days following transplant. (Choices A, B, and F) Branches from the common iliac, internal iliac, and superior vesical arteries supply more distal segments of the ureter, which are not typically retained in the transplanted specimen in order to limit distal ureteral ischemia. (Choice C) The lumbar arteries arise directly from the aorta to supply the lumbar vertebrae and surrounding structures. (Choice D) The inferior phrenic arteries are branches of the aorta that supply the diaphragm and provide branches to the suprarenal glands. Educational objective: The proximal ureter receives its blood supply from the renal artery whereas the distal ureter is supplied by the superior vesical artery. Circulation to the middle portions of the ureter is variable and anastomotic.

A 45-Year-Old Man with a History of End-Stage Renal Disease