Miscellaneous

What is in 4 3 ureters. Types of operations for strictures of the ureter: indications, contraindications, postoperative period. Crushing stones in the ureter

Disease of the two tubular organs responsible for moving urine from the kidneys to bladder, is called the expansion of the ureter. As a result of impaired urine transport, serious problems with urinary function. Megaureter is an acquired or congenital disease that leads to disruption of the kidneys, and with a bilateral inflammatory process, renal failure appears. With the expansion of the tubular organs, there is no possibility of a rapid outflow of urine and the appearance of chronic inflammation kidneys, which leads to disruption of the blood circulation.

Inflammatory processes in the kidneys can negatively affect the healthy shape of the ureter.

The essence of the expansion of the tubular process

The walls of the ureter have a three-layer structure, which allows urine to move gradually. The outer muscular layer contains nerve and collagen fibers, which allows you to move urine up to 5 contractions per minute. With an increase in ureteral enlargement, the ability to contract is weakened, urine evacuation becomes more difficult, and intrarenal pressure increases. Stagnation of urine leads to the presence of infection, which exacerbates the pathological process. Lack of treatment leads to kidney failure.

Often, infections and their presence in the urinary tract are accompanied by the expansion of the ureter itself.

The expansion of the two tubular organs is determined using an ultrasound examination of the fetus. If there is no megaureter after the birth of the baby, the expansion of the tubular organs will not manifest itself in the future. The diameter of the ureter in the normal state should not exceed 5 mm, if the organ is expanded during diagnosis, this leads to a deeper examination of the internal organs. In adolescents, the presence of blood in the urine, incontinence, complaints of constant pain in the abdomen and lumbar region, as well as the formation of stones in the urinary organs.

Types of megaureter


Acquired deformity of the ureteral canal occurs due to an imbalance of pressure in the bladder or a complication of cystitis.

There are such types of diseases:

  • The primary type is a congenital ailment. It appears in the absence of coordinated work of the muscular and connective tissues of the ureter. There is no force needed to move the urine. The megaureter can arise even in the embryonic period. Most often, the megaureter is observed in boys.
  • The secondary view is associated with high pressure in the bladder. This happens due to a neurological disorder or chronic cystitis. Most of the identified diseases after multiple examinations and treatment are likely to disappear during the first two years of a baby's life.

Causes of dilated ureters

There are several sources explaining that the tubular organs are dilated. main reason - high pressure ureter and obstruction of urine flow. There are cases that when the pressure normalizes, the ureter remains in an expanded state. There is a congenital insufficiency of the muscles of the tubular organ. Therefore, the ureter becomes weakened and cannot push urinary fluid into the bladder. The next reason to explain the increase in the ureter is the narrowing of the tubes at the point of their connection with the reservoir for the accumulation of urine.

Sources of expansion of the ureteral process:

  • high pressure inside the tubular organ and the renal pelvis leads to expansion of the ureter and difficulty in the outflow of urine;
  • weak muscle membrane;
  • lack of development of nerve endings;
  • urine is thrown into the pelvis thanks to.

Symptoms of a megaureter


A deformed ureter signals from itself pain in the lower back and abdomen, blood impurities in the urine, vomiting and fever.

Signs of expansion of tubular organs are different. In the absence of the primary type of disease, the megaureter proceeds in a latent form, accompanied by a satisfactory condition of the person and the absence of signs of illness. AT otherwise there may be complaints of pain in the abdomen or lower back, tumor-like growths are felt or observed in urine bleeding. In the acute phase of the megaureter, a high number of leukocytes in the urine, gag reflexes and high temperature body.

Acute symptoms of the disease are most noticeable at stages II-III, it is during this period that complications such as chronic insufficiency kidney or pyelonephritis.

With a double lesion or expansion of the processes in children, double urination appears. This is due to the fact that after the first emptying of the organ urinary system filled with urine from the dilated organs and there is a secondary urge to urinate. The second time the urine is accompanied by a fetid odor, increases in volume and has a cloudy sediment. These babies are susceptible to infections, there may be a delay physical development or skeletal abnormalities. Often, babies experience loss of appetite, fatigue, weakness, constant thirst, pallor, dehydration, and urinary incontinence.

Grades of severity of megaureter

After the examination, the doctor assesses the state of damage to the renal system and predicts future treatment. There are 3 stages of disease severity:

  • Mild: Moderate dilatation or dilatation of the lower ureter. His condition often recovers without surgery.
  • Medium degree: dilated diameter of the ureter. Competent timely therapy gives excellent results.
  • Severe form: megaureter may be accompanied by a decrease. An operation is required.

Features of a megaureter in a newborn


Dilated ureter in children early stages cured without surgery.

With improvement ultrasound diagnostics it became possible and affordable to detect megaureter and intrauterine anomalies of the genitourinary system. Early diagnosis of megaureter leads to unreasonable surgical intervention. This is due to the fact that in a number of cases, babies stop expanding the ureter and restore the outflow of urine during 2 months of a newborn's life. At this age, regular monitoring and urinalysis, as well as ultrasound, are necessary. The correct timely diagnosis will help to avoid exacerbations, as well as save from surgical intervention. The newborn still has some time for the maturation of the organs, so in the first few months of life it is not always easy to evaluate the entire work of the urinary and renal systems.

During the diagnosis, the attending physician should be especially careful, as there is a risk of making mistakes that will lead to unjustified surgical intervention. Getting rid of the deviation is possible only in the case of timely examination and the correct course of treatment. Often, the megaureter in children disappears on its own; in adults, when an acute stage is detected, one cannot do without surgical intervention, which is performed in 40% of cases.

What is the danger of dilatation of the ureter?

Dilatation of the ureter is formed due to a violation of the outflow of urine. The most well-known cause of an increase in the volume of tubular organs and blockage of the transport of urine is urolithiasis. Often the presence of a single stone of impressive size is enough to block the connecting process. A sharp narrowing of some parts of the ureter leads to a violation of the outflow of urine. Due to a congenital disease, a newborn has almost no lumen of the urethra. In this case, it is necessary to expand the urethral canal with the help of surgical intervention.


Difficulty in the outflow of urine is a consequence of complications of diseases of the kidneys and ureter.

When the right kidney descends and occupies an unusual position, the kink of the ureter can be seen. Tumor formations located in the pelvis, have negative impact on the ureter, squeezing it from both sides. Inflammation in the tubular organs and the pelvis leads to swelling of the mucosa, which contributes to improper outflow of urine. , namely saccular protrusion, may be a clear cause of dilatation of the ureter.

Most often, pathology in adults develops during blockage of the ureter with pus, mucus or stone.

Reasons for the development of dilatation of the ureter:

  • ureterocele;
  • narrowing of the perivesical section of the tubular organ;
  • narrowing of the intravesical department;
  • insufficiency of motor function of the ureteral process.

The ureters are paired, symmetrical organs that connect the renal pelvis to bladder. The task of the system is to transport urine from the kidneys to the bladder, and then to exit the body.

A healthy person has 2 ureters, 1 for each kidney. There are pathologies that one of them is absent or, on the contrary, double or triple tubes are noticed:

  • The length of the organ reaches 300 mm, but the size of the order of 200 - 350 mm is considered within the normal range.
  • The appearance is most similar to an elastic tube, which is hollow inside. It originates in a narrow region of the kidneys, near the gate. Through this connection blood supply is achieved. The ureters are located in the space behind the peritoneum, so they do not belong to the organs of the abdominal cavity.
  • Conventionally, the tube is divided into sections, they have names comparable to the areas of urine movement:
  1. The first area, it is located at the beginning and is called the abdominal. Located near the outer wall of the lumbar muscle, this muscle structure is considered one of the walls of the retroperitoneal cavity. On the front side of the right element of the outflow system is the duodenum 12, which goes into the intestine.
  2. On the left side of the bend, it characterizes the flow further into the jejunum. On the front part, the location of the vessels of the ovaries is noted, then the peritoneum, which separates abdominal cavity from the retroperitoneum.
  • The ureters have a number of bends, the first is located at the very beginning, in the area of ​​connection with the kidneys. In the same area, the connecting tube is very narrow. In the abdominal region there is a second constriction, it is characterized by a connection with the subsequent region of the pelvic organ. It is noted here that the left ureter passes through the root of the mesentery in the region of the sigmoid colon. The mesentery is a sheet located in the parietal region and is necessary for fixing various organs to the walls of the abdomen.

The location of the ureter depends on the gender of the person. Women are characterized by lying behind the ovaries, then passes near the cervix. Then it goes between the vagina (its initial area) and the bladder, which is the ultimate goal of the tube. In the transition area, a sphincter of muscles is formed.

For men, the structure is distinctive, the ureter passes near the vas deferens, then moves into the bladder. The area along the wall is the shortest, occupies about 15 - 20 mm, is located directly in the shell of the bladder. When connected to the bladder, a third and it is the last narrowing of the lumen is observed.

At the same time, the ureters in men are somewhat longer, approximately 20–25 mm.

The base of the ureter is the renal pelvis. The organ itself is a small tube, it has a normal diameter of about 5 - 6 mm (the average size along the entire length), and the length reaches 300 mm. In addition to the outflow of urine, the function of preventing reverse flow is performed.

The membrane of the ureter consists of 3 layers:

  1. The inner mucous layer, it helps easy transportation of urine. The entire layer consists of folds.
  2. The middle layer is made up of muscles. Includes several layers of muscles: circular and longitudinal. In the central region, the circular layer is located between the 2nd longitudinal layers.
  3. External is a connective tissue coating.

There is a strong movement of blood in the organ, while several vascular systems supplies. It carries blood from the testicular and renal arteries. In the middle of the ureter, the supply occurs due to the branching of the ureteral artery.

In general, the diameter in a larger area reaches 8 mm, but as the connecting pipe lengthens, a narrowing is noticed, so in some places the clearance reaches 3 - 4 mm. At the same time, the movement of urine is usually not hindered, since due to the described structure of the wall, stretching is easily performed, even a lot of urine can be quickly skipped if the organ is healthy. In the case of pressure from the inside, from the liquid side, the diameter can increase up to 12 mm.

It is worth noting that the ureter can perform the action of peristalsis, translational movements with visible contractions, which are carried out thanks to a layer of muscles, this contributes to the flow of urine. To improve conductivity, it is not enough just to expand, therefore, the increase in size occurs unevenly throughout the length of the organ. In some areas, a narrowing is noticeable, while in others, expansion, as if pushing out the liquid. In case of any pathologies in the organ, an x-ray is performed using a contrast agent.

Symptoms

The main symptoms indicating diseases of the ureter are:

  • pain in the lumbar region;
  • pain in the lower abdomen and scrotum, penis;
  • renal colic;
  • oligurgy;
  • excessively frequent urination;
  • the color of the urine has changed and the urine has acquired an unpleasant odor;
  • blood in the urine.

Diseases

Based on the symptoms, certain categories of ureteral disease can be distinguished, including:

  • Congenital type (dilation, hypoplasia of the ureter, ureterocele).
  • Inflammatory character ().
  • Obstructive (obstruction).
  • Tumor character (fibroepithelial polyp, various tumors).
  • Traumatic (rupture of the ureter).

The size of the ureter is an inaccurate value, since not only the difference in the structure of the body of each individual individual plays a role here, but also the differences in diameter as the organ moves.

You can also learn about the ureter from this video.

Hello. In May, I was admitted to the hospital with renal colic. Ultrasound-diffuse changes in the kidneys were made, pronounced pyeloctasia on the right. Hydrocalicosis on the right. Hydronephrotic deformity of the right kidney. Microlithiasis. Baralgin, platifillin, no-shpu, a/b ceftriaxone were injected intravenously. After ultrasound treatment, diffuse changes in the kidneys. Concrements of the right kidney. Hydronephrotic deformity of the right kidney. In August, I had an ultrasound in the city - obstructive uropathy on the right, a pronounced expansion of the right kidney and the upper third of the ureter on the right. It was recommended to undergo contrast urography. I underwent urography - hydronephrosis of the right kidney, a stone in the lower third of the ureter. Our doctors sent me to the region, where they put me - mkb, a stone in the lower third of the ureter. Transferred renal colic. They said that the stone would come out by itself. c, cyston for 2 t-3 r-2 months, warm baths. ultrasound diffuse changes in the kidneys, hydronephrotic deformity of the right kidney, microlithiasis. Signs of a calculus of the right ureter (stone approximately 4.5 mm) oam-leukocytes-2-3, urine according to Nechiporenko-leukocytes -4-5 to 10 to 6 degrees. There are no severe pains, urination is not disturbed. Please what else can be treated so as not to resort to surgical intervention, because it is no longer possible to travel very far to the region. Thank you. Hello. In May, I was admitted to the hospital with renal colic. Ultrasound-diffuse changes in the kidneys were made, pronounced pyeloctasia on the right. Hydrocalicosis on the right. Hydronephrotic deformity of the right kidney. Microlithiasis. Baralgin, platifillin, no-shpu, a/b ceftriaxone were injected intravenously. After ultrasound treatment, diffuse changes in the kidneys. Concrements of the right kidney. Hydronephrotic deformity of the right kidney. In August, I had an ultrasound in the city - obstructive uropathy on the right, a pronounced expansion of the right kidney and the upper third of the ureter on the right. It was recommended to undergo contrast urography. I underwent urography - hydronephrosis of the right kidney, a stone in the lower third of the ureter. Our doctors sent me to the region, where they put me - mkb, a stone in the lower third of the ureter. Transferred renal colic. They said that the stone would come out by itself. c, cyston for 2 t-3 r-2 months, warm baths. During treatment, ultrasound-diffuse changes in the kidneys, hydronephrotic deformity of the right kidney, microlithiasis passed. urine according to Nechiporenko-leukocytes -4-5 to 10 in 6 degrees. There are no severe pains, urination is not disturbed. aleko. Thank you.

Malformations ureters account for 22% of all anomalies of the urinary system. In some cases, they are combined with anomalies in the development of the kidneys. As a rule, anomalies of the ureters lead to a violation of urodynamics. The following classification of malformations of the ureters has been adopted.

■ agenesia (aplasia);

■ doubling (complete and incomplete);

■ tripling.

■ retrocaval;

■ retroiliacal;

■ ectopia of the mouth of the ureter.

Anomalies in the shape of the ureters

■ spiral (annular) ureter.

■ hypoplasia;

■ neuromuscular dysplasia (achalasia, megaureter, megadolichoureter);

■ congenital narrowing (stenosis) of the ureter;

■ ureter valve;

■ diverticulum of the ureter;

■ ureterocele;

■ vesicoureteral pelvic reflux. Abnormalities in the number of ureters

Agenesia (aplasia)- congenital absence of the ureter, due to underdevelopment of the ureteral germ. In some cases, the ureter can be determined in the form of a fibrous cord or a blindly ending process (Fig. 5.28). One-sided agenesis of the ureter is combined with agenesis of the kidney on the same side or multicystosis. bilateral is extremely rare and incompatible with life.

Diagnosis is based on the data of X-ray methods of examination with contrast and nephroscintigraphy, which reveal the absence of one kidney. Characteristic cystoscopic signs are underdevelopment or absence of half of the bladder triangle and the mouth of the ureter on the corresponding side. With the preserved distal ureter, its opening is also underdeveloped, although it is located in the usual place. In this case, retrograde ureterography allows confirming the blind end of the ureter.

Surgical treatment is performed with the development of a purulent-inflammatory process and the formation of stones in the blindly ending ureter. Perform surgical removal of the affected organ.

Doubling- the most common malformation of the ureters. In girls, this anomaly occurs 5 times more often than in boys.

As a rule, during caudal migration, the ureter of the lower half of the kidney is the first to connect to the bladder and, therefore, occupies a higher and lateral position than the ureter of its upper half. The ureters in the pelvic regions mutually cross and flow into the bladder in such a way that the mouth of the upper one is located lower and more medially, and the lower one is higher and more lateral (Weigert-Meyer law) (Fig. 5.29).

Doubling of the upper urinary tract can be one- or bilateral, full (ureter duplex) and incomplete (ureter fissus)(Fig. 41, 42, see color insert). In case of full doubling, each

Rice. 5.28. Aplasia of the left kidney. Blindly ending ureter

Rice. 5.29. Weigert-Meyer law. Crossing of the ureters and the location of their mouths in the bladder with complete doubling of the urinary tract

the ureter opens at a separate opening in the bladder. Incomplete duplication of the upper urinary tract is characterized by the presence of two pelvises and ureters, connecting in the pelvic region and opening in the bladder with one mouth.

The described features of the topography of the ureters in doubling the upper urinary tract are predisposing to the occurrence of complications. Thus, the ureter of the lower half of the kidney, which has a higher and laterally located mouth, has a short submucosal tunnel, which is the reason for the high frequency of vesicoureteropelvic reflux in this ureter. On the contrary, the orifice of the ureter of the upper half of the kidney is often ectopic and predisposed to stenosis, which is the cause of hydroureteronephrosis.

Doubling of the ureter in the absence of a violation of urodynamics is not clinically manifested. This anomaly can be suspected by sonography, in which the doubling of the kidney is determined, and the ureters, in the presence of expansion, can be seen in their pelvic or pelvic regions. The final diagnosis is established on the basis of excretory urography, multislice CT with contrast, MRI and cystoscopy. In the absence of function of one half of the kidney, the diagnosis can be confirmed by antegrade or retrograde ureteropyelography.

Tripling of the pelvis and ureters is casuistry.

Treatment is operative in the development of complications. In case of narrowing or ectopia of the ureter, ureterocystoanastomosis is performed, and in case of vesicoureteral reflux, antireflux operations are performed. If the function of the entire kidney is lost, nephroureterectomy is indicated (Fig. 60, see color insert), and one of its halves - heminephroureterectomy.

Anomalies in the position of the ureters

Retrocaval ureter- a rare anomaly in which the ureter in the lumbar region goes under the vena cava and, having circled around it in an annular shape, returns to its previous position when it passes into the pelvic region (Fig. 43, see color insert). Compression of the ureter by the inferior vena cava leads to a violation of the passage of urine with the development of hydroureteronephrosis and its characteristic clinical picture. This anomaly can be suspected by ultrasound and excretory urography, which reveals an expansion of the cavitary system of the kidney and ureter to its middle third, a loop-shaped bend and a normal structure of the ureter in the pelvic region. The diagnosis is confirmed by multislice CT and MRI.

Surgical treatment consists in crossing, as a rule, with resection of the altered sections of the ureter and performing an ureteroureteroanastomosis with the location of the organ in its normal position to the right of the vena cava.

Retroiliac ureter- an extremely rare malformation in which the ureter is located behind the iliac vessels (Fig. 43, see color insert). This anomaly, like the retrocaval ureter, leads to its obstruction with the development of hydroureteronephrosis. Surgical treatment consists in crossing the ureter, releasing it from under the vessels and performing an antevasal ureteroureteroanastomosis.

Ectopia of the mouth of the ureter- an anomaly characterized by an atypical intra or extravesical location of the orifices of one or both ureters. This malformation is more common in girls and is usually associated with duplication of the ureter and/or ureterocele. The cause of this anomaly is a delay or violation of the separation of the ureteric germ from the Wolffian duct during embryogenesis.

To intravesical types of ectopia of the mouth of the ureter include its displacement down and medially to the neck of the bladder. Such a change in the location of the mouth, as a rule, is asymptomatic. The mouths of the ureters with their extravesical ectopias open into the urethra, paraurethral, ​​into the uterus, vagina, vas deferens, seminal vesicle, rectum.

The clinical picture of extravesical ectopia of the mouth of the ureter is determined by its localization and depends on gender. In girls, this malformation is manifested by urinary incontinence while maintaining normal urination. In boys, during the intrauterine development of the wolfs, the duct turns into the vas deferens and seminal vesicles, so the ectopic mouth of the ureter is always located proximal to the urethral sphincter and urinary incontinence does not occur.

Diagnosis is based on the results of a comprehensive examination, including excretory urography, CT, vaginography, urethro and cystoscopy, catheterization of the ectopic orifice, and retrograde urethro and ureterography.

The treatment for this anomaly is surgical and consists in transplanting the ectopic ureter into the bladder (ureterocystoanastomosis), and in the absence of kidney function, nephroureterectomy or heminephroureterectomy.

Anomalies in the shape of the ureters

Spiral (ring-shaped) ureter- an extremely rare malformation in which the ureter in the middle third has the shape of a spiral or ring. The process can be one- and bilateral character. This anomaly is a consequence of the inability of the ureter to rotate with the kidney during its intrauterine movement from the pelvic to the lumbar region.

Twisting of the ureter leads to the development of obstructive retention processes in the kidney, the development of hydronephrosis and chronic pyelonephritis. Excretory urography, multislice CT, MRI, and, if necessary, retrograde or antegrade percutaneous ureterography help establish the diagnosis.

Surgical treatment. Resection of the ureter with ureteroureteroanastomosis or ureterocystoanastomosis is performed.

Anomalies in the structure of the ureters

hypoplasia of the ureter is usually combined with hypoplasia of the corresponding kidney or its half when doubling, as well as with a multicystic kidney. The lumen of the ureter with this anomaly is sharply narrowed or obliterated, the wall is thinned, peristalsis is weakened, the mouth is reduced in size. Diagnosis is based on data from cystoscopy, excretory urography and retrograde ureterography.

Neuromuscular dysplasia ureter was described under the name "mega-ureter" by J. Goulk in 1923 as a congenital disease manifested by the expansion and lengthening of the ureter (similar to the term "megacolon"). This is one of the frequent and severe malformations of the ureters, due to the underdevelopment or complete absence of its muscular layer and impaired innervation. As a result, the ureter is not capable of active contractions and loses its function of moving urine from the pelvis to the bladder. Over time, this kind of dynamic obstruction leads to its even greater expansion and elongation with the formation of cranked kinks (megadolichoureter). The deterioration of urine transport is facilitated by the normal tone of the bladder detrusor and the combination of this anomaly with other malformations (ectopia of the ureter orifice, ureterocele, vesicoureteropelvic reflux, neurogenic bladder dysfunction). Frequent accession of infection against the background of urostasis contributes to the development of chronic ureteritis, followed by scarring of the ureteral wall and an even greater decrease in the function of the upper urinary tract. The characteristic histological features of the megaureter are a significant underdevelopment of the neuromuscular structures of the ureter with a predominance of scar tissue.

Achalasia ureter is a neuromuscular dysplasia of its pelvic region. The underdevelopment of the ureter in this anomaly is local in nature and does not affect its overlying sections, where they are little changed or developed normally. From these positions, achalasia of the ureter should be considered not a stage in the development of the megaureter, but one of its varieties. As a rule, the expansion of the ureter in its pelvic region with achalasia remains at the same level throughout life. In some cases, the overlying ureter may be involved

Rice. 5.30. Excretory urogram. Achalasia of the left ureter

into the pathological process secondarily as a result of stagnation of urine in an enlarged cystoid, that is, dynamic obstruction.

The clinical picture of neuromuscular dysplasia of the ureter depends on the degree of its severity. With unilateral achalasia or megaureter, the general condition remains satisfactory for a long time. Symptoms are mild or absent, which is one of the reasons for the late diagnosis of neuromuscular dysplasia already in adulthood. The first signs of a megaureter are due to the addition of chronic pyelonephritis. There are pains in the corresponding lumbar region, fever with chills, dysuria. A severe clinical course is observed with bilateral megaureter. FROM early age symptoms of chronic renal failure

sufficiency: child's lag in physical development, decreased appetite, polyuria, thirst, weakness, fatigue.

Diagnosis of neuromuscular dysplasia is based on laboratory, radiation, urodynamic and endoscopic methods research. Sonography reveals the expansion of the pelvicalyceal system and the ureter in its peripelvic and prevesical sections, a decrease in the layer of the renal parenchyma. A characteristic sign of achalasia on excretory urograms is a significant expansion of the pelvic ureter with unchanged overlying sections of the urinary tract (Fig. 5.30).

With a megaureter, there is an increase in length and a significant expansion of the ureter along its entire length with areas of knee-shaped kinks. Antegrade pyeloureterography makes it possible to establish a diagnosis in the absence of kidney function according to excretory urography.

In differential diagnosis, megaureter should be distinguished from hydroureteronephrosis, which occurs as a result of narrowing of the ureter.

Surgical treatment of neuromuscular dysplasia of the ureter largely depends on the stage of the disease. More than 100 methods of operative correction have been proposed. The degree of compensatory capabilities, especially characteristic of young children, depends on the severity of anatomical and functional disorders, the diameter of the ureter and the activity of the pyelonephritic process. Surgical treatment consists in resection of the dilated ureter in length and width with submucosal implantation.

it into the bladder according to Politano-Leadbetter. More pronounced changes in the wall of the ureter with significant impairment of its function are an indication for intestinal ureteroplasty (Fig. 54, 55, see color insert).

Congenital narrowing (stenosis) of the ureter as a rule, it is localized in its prilokhanochny, less often - prevesical departments, as a result of which hydronephrosis or hydroureteronephrosis develops. Due to the frequency, features of the etiology, pathogenesis, clinical course and methods of surgical correction, hydronephrotic transformation is singled out as a separate nosological form and is discussed in Chapter 6.

Ureteral valves- these are local duplications of the mucous and submucosal or less often all layers of the ureter wall. This anomaly is extremely rare. The reason for its formation is a congenital excess of the ureteral mucosa. Valves can have an oblique, longitudinal, transverse direction and are more often localized in the pelvic or prevesical sections of the ureter. They can cause obstruction of the ureter with the development of hydronephrotic transformation, which is an indication for surgical treatment- resection of the narrowed section of the ureter with anastomosis between the unchanged parts of the urinary tract.

A diverticulum of the ureter is a rare anomaly that manifests itself as a saccular protrusion of its wall. Most often there are diverticula of the right ureter with predominant localization in the pelvic region. Bilateral diverticula of the ureter have also been described. The wall of the diverticulum consists of the same layers as the ureter itself. Diagnosis is based on excretory urography, retrograde ureterography, helical CT and MRI. Surgical treatment is indicated for the development of hydroureteronephrosis as a result of obstruction of the ureter in the area of ​​the diverticulum. It consists in resection of the diverticulum and the wall of the ureter with ureteroureteroanastomosis.

ureterocele- cyst-like expansion of the intramural part of the ureter with its protrusion into the lumen of the bladder (Fig. 15, see color insert). It refers to frequent anomalies and is diagnosed in 1-2% of patients of all age groups subjected to cystoscopy.

The ureterocele may be one- and bilateral. The reason for its formation is a congenital neuromuscular underdevelopment of the submucosal layer of the intramural ureter in combination with the narrowness of its mouth. Due to such a malformation, a displacement (stretching) of the mucous membrane of this section of the ureter into the cavity of the bladder gradually occurs with the formation of a rounded or pear-shaped cystic formation of various sizes. Its outer wall is the mucous membrane of the bladder, and the inner wall is the mucous membrane of the ureter. At the apex of the ureterocele is a narrowed orifice of the ureter.

There are two types of this anomaly of the ureters - orthotopic and heterotopic (ectopic) ureterocele. The first occurs with the normal location of the mouth of the ureter. It is small, well reduced and, as a rule, does not interfere with the outflow of urine from the kidneys. Such an asymptomatic ureterocele is more often diagnosed in adults. A heterotopic ureterocele occurs when there is low ectopia of the orifice of the ureter towards the outlet of the ureter.

Bladder. In young children, in 80-90% of cases, an ectopic type of ureterocele is diagnosed, more often than the lower orifice, with doubling of the ureter. The unilateral form prevails, less often the disease is detected on both sides.

A ureterocele causes a violation of the passage of urine, which gradually leads to the development of hydroureteronephrosis. A frequent complication of ureterocele is the formation of a stone in it.

Clinical symptoms depend on the size and location of the ureterocele. The larger the ureterocele and the more pronounced the obstruction of the ureter, the earlier and more clearly the symptoms of this anomaly appear. There are pains in the corresponding lumbar region, with the formation of a stone in it and the attachment of an infection - dysuria. If the ureterocele is large, there may be difficulty urinating due to obstruction of the bladder neck. In women, the ureterocele may protrude beyond the urethra.

The main place in the diagnosis is given to radiation methods of research and cystoscopy. A characteristic feature in sonography is a rounded hypoechoic formation in the bladder neck, above which an enlarged ureter can be detected (Fig. 5.31, 5.32).

Excretory urograms, contrast-enhanced CT, and MRI show ureterocele and varying degrees severity of hydroureteronephrosis (Fig. 5.33).

Cystoscopy is the main method for diagnosing ureterocele (Fig. 15, see color inset). With its help, you can confidently confirm the diagnosis of this anomaly, establish the type of ureterocele, its size, and the side of the lesion. Ureterocele is defined as a round formation located in the triangle of the bladder, at the top of which the mouth of the ureter opens, when urine is excreted, the ureterocele contracts and decreases in size (falls off).

Orthotopic ureterocele of small size without disturbance of urodynamics does not require treatment. The type of surgical intervention is determined taking into account the size and location of the ureterocele, as well as the degree

Rice. 5.31. Transabdominal sonogram. Left ureterocele (arrow)

Rice. 5.32. Transrectal sonogram. Large sizes ureterocele (1) with significant dilatation of the ureter (2)

Rice. 5.33. Excretory urograms at the 7th (a) and 15th (b) minutes of the study. Ureterocele (1) on the right with dilatation of the ureter (2) (hydroureteronephrosis)

hydronephrotic transformation. Depending on this, transurethral endoscopic resection of the ureterocele or its open resection with ureterocystoanastomosis is used.

Vesicoureteropelvic reflux (VUR)- the process of retrograde reflux of urine from the bladder into the upper urinary tract. It is the most common pathology of the urinary system in children and is divided into primary and secondary. Primary VUR occurs as a result of congenital failure (incomplete maturation) of the vesicoureteral fistula. Secondary - is a complication of infravesical obstruction, developing due to high blood pressure in the bladder.

PMR can be active and passive. In the first case, it occurs at the time of urination with a maximum increase in intravesical pressure, in the second case, it can be observed at rest.

A characteristic clinical manifestation of VUR is the occurrence of pain in the lumbar region during urination. When the infection is attached, symptoms of chronic pyelonephritis appear.

X-ray radionuclide research methods play a leading role in the diagnosis of VUR. Retrograde cystography at rest and during urination (micting cystography) reveals not only its presence, but also the severity of the anomaly (see Chapter 4, Figure 4.32).

Conservative treatment is possible in the initial stages of the disease, surgical treatment consists in performing various antireflux surgeries.

of which the simplest is the endoscopic submucosal introduction of shaping bioimplants (silicone, collagen, Teflon paste, etc.) into the mouth area, preventing the reverse flow of urine. Operations for the reconstruction of the ureteral orifice, which are currently performed, including with the use of robotic-assisted technique, have found wide application.

Urolithiasis is dangerous with complications, among which are ureteral calculi, which are formed as a result of the movement of stones from the kidneys. When entering the ureter, stones stop in narrow passages, for example, at the border of the ureter and at the walls of the bladder.

The formation of stones in the ureter is called ureterolithiasis. This is a dangerous pathology that requires complex and lengthy treatment and removal of stones. Severe complications often develop.

Etiology

What is dangerous retention of stones in the ureter? With urinary retention, loosening of the tissues of the organ, abundant hemorrhages in the mucous membrane, as well as hypertrophy of the muscle walls are observed. As a result, tissue degeneration occurs, nerve and muscle cells atrophy, and the tone of the ureter decreases. In the altered tissues, the infection spreads, complex diseases develop: ascending pyelonephritis, cystitis, periurethritis.

There are single and multiple formations, the diameter of which is over 2 mm. There are calculi various shapes and sizes, are formed in the right and left parts of the ureter. Medical statistics show that the formation of stones depends on the composition of water and food, non-compliance with personal hygiene rules, and insufficient medical care.

Causes

The appearance of the disease is determined by genetic predisposition, lifestyle, diet and drink. Often inflammatory processes in internal organs provoke pathological changes in the kidneys and bladder, which causes the formation of stones. One of the main reasons for the formation of calculi is a violation of phosphate and oxalic acid metabolism.

Main reasons:

  • diseases of the gastrointestinal tract;
  • infectious diseases of the kidneys;
  • incomplete emptying of the bladder;
  • diseases of the skeletal system;
  • pathology of the endocrine system;
  • injuries of various kinds;
  • insufficient fluid intake;
  • altered structure of the pelvis and calyces;
  • preference for spicy, smoked and fatty foods.

The risk group includes people diagnosed with gout, osteoporosis, prostate adenoma, urinary tract diverticulum.

Symptoms

Ureterolithiasis is characterized by severe symptoms - severe pain in the abdomen, fever and elevated temperature. If the stone has not completely blocked the passage of the ureter, there are dull pains in the region of the ribs and spine. With complete overlap, there is a violation of the movement of urine, the renal pelvis is stretched and deformed, and pressure rises inside.

With obturation (blockage), the patient notes severe unbearable pain caused by a change in microcirculation in the renal tissue and irritation of the nerve endings. Pain appear abruptly at physical activity. The duration is from 2-3 hours to 2-3 days, there are periods of calm and resumption of pain.

Attacks are accompanied by frequent urge to empty the bladder (if the calculus is located in the lower part of the ureter) or the inability to excrete urine (if there is a complete blockage of the duct).

The main signs of the appearance of stones in the ureter:

  • acute or Blunt pain in the lumbar region, spine, hypochondrium;
  • vomiting, flatulence, stool disorder;
  • headache, fever, chills;
  • temperature rise;
  • tension in the abdominal muscles.

With self-excretion of stones, pain and other symptoms disappear. As the disease progresses, seizures recur regularly. Serious complications of ureterolithiasis are pyelonephritis, renal failure, urosepsis, etc.

Diagnostics

  • analysis of the patient's life history. The doctor determines whether the patient's relatives have had kidney disease and stone formation. In addition, eating habits and the amount of fluid consumed are determined;
  • general urine analysis. The concentration of erythrocytes, proteins, leukocytes, the presence of pus and salts is determined;
  • acid balance of urine;
  • blood chemistry;
  • general blood analysis;
  • bakposev. Detects the presence of infectious agents;
  • determination of the structure of stones;
  • ultrasound. Reveals the localization of stones, shape and size;
  • endoscopy and echography;
  • urography;
  • CT scan of the kidneys;
  • ureteroscopy;
  • radioisotope alternative diagnostics.

Comprehensive data will allow the doctor to assess the severity of the disease and prescribe the necessary therapy.

Treatment

Treatment of ureterolithiasis involves several areas: medical and surgical. The chosen therapy depends on the degree of progression of the disease and the size of the stones.

If the stone is small up to 2-3 mm in diameter, then doctors adhere to expectant tactics. Along with this, a number of drugs are prescribed that crush stones, relieve inflammation and muscle tone. Often prescribed homeopathic remedies that accelerate the crushing of stones.

A conservative technique involves the use of the following drugs:

  • antispasmodics;
  • urolytics (Cistenal, Blemaran, Soluran, etc.);
  • antibiotics;
  • analgesics;
  • blockade in renal colic.

In addition to drugs, prescribed:

  • Physiotherapy procedures.

If medicines or homeopathic remedies do not have a positive effect, it is indicated surgical intervention. In this case, there are several methods for removing stones.

  • endovascular method. Compared to surgical operation a more gentle method of treatment, since it does not require intervention in the integrity of organs. It implies the introduction of glycerin, novocaine and papaverine into the ureter, which activates the excretion of stones. Often, an electric current is used to accelerate the movement of the stone along the duct.
  • Endourological therapy is aimed at eliminating formations with the help of a trap in the form of a loop. A ureteroscope is used for this procedure. If the stone is located at the mouth of the ureter, it is cut into several parts, which contributes to the rapid removal.

Surgical intervention is necessary when the size of the calculi exceeds 1 cm. To remove large stones, laparoscopy and open urethrolithotomy are performed. In addition, indications for surgery are severe infections, obstructive colic, kidney obstruction, or failure of other treatments.

Often, the surgical method entails serious consequences, so doctors are less likely to resort to this method of therapy. Patients note a long recovery period and the presence of discomfort after surgery. Stones are removed by direct incision in the skin and ureter.

Prevention

The main methods of prevention are to follow a diet and the necessary drinking regimen. It is important to consume at least 2 liters of fluid per day, including teas, soups, etc. Sufficient drinking removes mucus, sand, white blood cells and microorganisms from the body. Pathogenic bacteria provoke the formation of stones in the kidneys and ureters.

Diet food should include the following products:

  • gourds;
  • decoction of wild rose and dried fruits;
  • fruit juices, in particular carrot juices;
  • fresh vegetables and fruits.

The slightest discomfort in the pelvic area is a signal to see a doctor in order to prevent the development of urolithiasis.