1. Etiology of congenital obstruction
(1) Segmental nonfunctionality Due to segmental muscle loss, hypoplasia or anatomical structure disorder at the junction of renal pelvis and ureter, the normal peristalsis of this segment of ureter is affected, resulting in dynamic obstruction. If this disease occurs at the entrance of ureter and bladder, it will form congenital megaureter, and the consequences will be renal and ureteral dilatation and hydronephrosis.
(2) Ureteral stricture usually occurs at the junction of ureteropelvic junction, and the stricture is usually 1 ~ 2mm or 1 ~ 3cm long, resulting in incomplete obstruction and secondary distortion. Under electron microscope, there were too many collagen fibers around and between muscle cells in the obstructive segment, and the muscle cells were damaged for a long time, forming an inelastic narrow segment dominated by collagen fibers, hindering the transmission of urine and forming hydronephrosis.
(3) Ureteral distortion, adhesion, banded or valvular bifurcation, which can be congenital or acquired, often occur at the junction of ureteropelvic pelvis, and children and infants account for almost 2/3.
(4) Ectopic vascular compression is located in front of the ureteropelvic junction. Others include horseshoe kidney and renal rotational obstruction during embryonic development.
(5) Ureteral opening height can be congenital or asymptomatic renal pelvis malformation caused by perirenal fibrosis or vesicoureteral reflux, which leads to the relative upward movement of the junction between ureter and renal pelvis, and no stenosis can be found during operation.
(6) Other congenital ectopic ureters, cysts, double ureters, etc.
2. Acquired obstruction
(1) Local fixation caused by inflammation or ischemic scar.
(2) Bladder-ureter reflux causes ureteral distortion and fibrosis around ureter, which eventually leads to ureteropelvic junction or ureteral obstruction.
(3) Tumors and polyps of renal pelvis and ureter can be primary or metastatic.
(4) Ectopic kidney.
(5) Stone, trauma and scar stenosis after trauma.
3. Blockage caused by external reasons
Mainly including arterial and venous lesions; Lesions of female reproductive system; Tumors and inflammation in pelvic cavity; Gastrointestinal diseases; Retroperitoneal lesions (including retroperitoneal fibrosis, abscess, hemorrhage, tumor, etc. ).
4. Obstruction caused by various lower urinary tract diseases.
Such as prostatic hyperplasia, bladder neck contracture, urethral stricture, tumor, calculus and even phimosis. It will also cause difficulty in emptying the upper urinary tract and form hydronephrosis.
clinical picture
broadcast
Patients are often asymptomatic for a long time, and they are not noticed until they have abdominal mass and swollen waist. Masses are mostly found by accident and are generally sexy. The pain is generally mild or even completely painless. However, in the case of intermittent hydronephrosis (caused by ectopic vascular compression or nephroptosis), renal colic may occur, with severe pain and radiation along the costal margin and ureter. Most of them are accompanied by nausea, vomiting, abdominal distension and oliguria. It usually relieves in a short time or a few hours, and then excretes a lot of urine. The enlarged kidney can be felt during the examination. If it is a huge hydronephrosis, its tension is not very great.
Hydronephrosis complicated with infection has symptoms of pyuria and systemic poisoning, such as chills, fever, headache and gastrointestinal dysfunction. Urinary tract infection is the first symptom of some patients, and patients with poor therapeutic effect on urinary tract infection must pay attention to the existence of obstructive factors. When the obstruction is serious, the inflammatory exudate can't be discharged with urine, and there are no white blood cells in urine, but in this case, local pain and tenderness are more obvious.
Swelling hydronephrosis is easily affected by trauma, and minor injuries may lead to rupture and bleeding. Urine flowing into retroperitoneal space or peritoneal cavity can cause serious reactions, including pain, tenderness and systemic symptoms.
cheque
broadcast
1.b-ultrasound examination
B-ultrasound examination is simple, non-invasive and helpful for diagnosis. It can also show the morphology of residual kidney tissue, which is also helpful to understand the urinary tract (renal pelvis, renal calyx and proximal ureteral obstruction).
2. diuretic renogram
Diuretic renogram is a very important examination to diagnose hydronephrosis in recent years. It is helpful to identify early pathological changes (presence or absence of hydronephrosis) and determine whether hydronephrosis needs surgical treatment and the state of renal function damage. In particular, a single hydronephrosis is relatively light, or one side of hydronephrosis is serious and the other side is relatively light. Whether mild hydronephrosis needs surgical treatment is more valuable. Diuretic renogram can also be used as a monitoring method for functional recovery after operation (pyeloplasty).
3. Determination of renal pelvis flow pressure
It is also one of the valuable clinical examination methods in recent years, and its significance is similar to diuretic renogram.
4. Urography and other examinations
It is extremely important to evaluate the renal function of hydronephrosis. It is of great significance to the need for surgery, the mode of surgery and the chance of postoperative renal function recovery.
5. Image inspection
If the thickness of residual renal parenchyma in hydronephrosis exceeds 1.5cm, then the kidney is valuable.
diagnose
broadcast
The diagnosis can be made according to the clinical manifestations, the location, time, occurrence speed, whether there is secondary infection, and the nature and examination of the primary disease.
treat cordially
broadcast
Surgical treatment of hydronephrosis should be carried out as soon as possible. Reasonable application of plastic surgery technology to correct the abnormality of ureteropelvic junction and strive for a greater degree of renal function recovery. Hydronephrosis is serious and renal function is seriously damaged. If the contralateral kidney is normal, nephrectomy for hydronephrosis is feasible.
The principle of operation is that simple orthopedic surgery should be performed when the obstruction is light and the dilatation of renal pelvis and calyx is not serious; If the dilatation is obvious, the narrow segment of the lesion and the excessively dilated renal pelvis should be removed, and then anastomosis should be performed; In more serious cases, nephrectomy is performed.
The treatment of hydronephrosis should be more cautious, and the kidney should be preserved as much as possible. Generally speaking, there are several situations:
1. One side of hydronephrosis is serious.
One side is lighter: the severe side can be treated first. In order to avoid renal insufficiency, the safety of contralateral operation after successful operation can be increased. Surgical indications should be carefully judged on the lighter side and closely observed when necessary.
2. Bilateral hydronephrosis is serious.
It can be treated by stages, but it is better to treat the heavier side first.
3. Hydronephrosis on both sides is light.
Careful analysis should be made to determine the indication of operation.