urology
Urology is a hospital department that mainly treats "surgical" diseases of urinary system, mainly treating various urinary diseases.
Scope of treatment
Various urinary calculi and complex kidney calculi; Kidney and bladder tumors; Prostatic hyperplasia and prostatitis; Inflammation and tumor of testis and epididymis; Hydrocele of spermatic cord sheath; Various urinary system injuries; Congenital malformation of urinary system, such as hypospadias, cryptorchidism, hydronephrosis caused by ureteropelvic junction stenosis, etc.
Urology is an ancient specialty with a long history. But at the same time, it is a relatively new major. Even in 20 13, in some branches, there are other specialties but no urology. This shows that this major is very important, but its development is not balanced.
differentiate
Urology should not be called "Urology" because it does not include "internal medicine" related to urine, such as nephritis, diabetes, diabetes insipidus and so on. , should be distinguished to avoid confusion. However, the situation is changing, science is progressing, and new projects are constantly transferred from internal medicine to urology, such as renal vascular hypertension and some diseases of adrenal gland, so we should also look at the problem dialectically and materialistically.
urology
Urology mainly includes renal transplantation, laparoscopic surgery, adrenal adenoma, pheochromocytoma, primary aldosteronism and other adrenal surgical treatments, kidney, bladder and prostate tumor surgery, prostate cancer surgery, ureteropelvic junction stenosis surgery, kidney, ureter and bladder calculus surgery, transurethral resection of bladder tumor, and cystoscopic holmium laser resection of bladder tumor. In recent years, the etiology examination and treatment of chronic prostatitis, as well as the diagnosis and treatment of male sexual dysfunction and male infertility have been carried out.
Case: Obstructive urinary tract disease
Obstruction is one of the most important abnormalities of urinary tract, because it eventually leads to the imbalance of muscular catheter and blood storage pool, back pressure and renal parenchyma atrophy. It can also lead to infection and stone formation, which will cause additional damage and eventually lead to complete destruction of one or both kidneys.
Obstruction is one of the most important abnormalities of urinary tract, because it eventually makes the muscle duct and its container lose its compensatory ability, leading to back pressure and renal parenchyma atrophy. It can also lead to infection and stone formation, aggravate kidney damage, and eventually completely destroy one or both kidneys.
The level and degree of obstruction are very important for understanding the pathological results. Any obstruction at the bladder neck or the distal end of the bladder neck may lead to back pressure affecting both kidneys. Obstruction at or near the ureteral orifice will lead to unilateral injury unless the lesion involves both ureters at the same time. Complete obstruction leads to rapid decompensation of the system near the obstruction site and immediate muscle failure. For example, if the obstruction is at the distal end of the bladder, acute retention occurs, and if the obstruction involves both ureters, anuria occurs. Partial obstruction leads to gradual muscle hypertrophy, and then gradually relaxes. Decompensation and hydronephrosis. In some cases, vesicoureteral reflux may occur.
The level and degree of obstruction are very important for understanding the consequences of the disease. Bladder neck or bladder neck obstruction can affect both kidneys, while ureteral orifice or its proximal obstruction can cause unilateral damage unless both ureters are sick at the same time. Complete obstruction can make the urinary system above the obstruction rapidly increase its decompensation ability, accompanied by immediate muscle loss. For example, lower bladder obstruction can lead to acute urinary retention, while bilateral ureteral obstruction can lead to anuria. Partial obstruction gradually causes progressive muscle hypertrophy, followed by gradual expansion, loss of compensatory function and hydronephrosis. In some cases, vesicoureteral reflux can occur.
aetiology
The cause of disease
Acquired urinary tract obstruction may be caused by inflammatory or traumatic urethral stricture, bladder outlet obstruction (benign prostatic hypertrophy or prostate cancer), bladder tumor, neurobladder, exogenous ureteral compression (tumor, retroperitoneal fibrosis or lymphadenopathy), ureteral or pelvic calculus, ureteral stricture or ureteral or pelvic tumor.
Acquired urinary tract obstruction can be caused by inflammatory or traumatic urethral stricture, bladder outlet obstruction (benign prostatic hypertrophy or prostate cancer), bladder tumor, neuropathic bladder disease, exogenous ureteral compression (tumor, retroperitoneal fibrosis or giant lymph nodes), ureteral calculi or renal pelvis calculi, ureteral stricture, ureteral or renal pelvis tumor.
pathogenesis
aetiology
Whatever the cause, acquired obstruction will lead to similar changes in urinary tract, which depends on the severity and duration of obstruction.
No matter what the cause, acquired obstruction will cause similar changes in urinary tract, and the specific conditions of the changes vary according to the severity and duration of obstruction.
A. Urethral changes: At the proximal end of the obstruction, the urethra is dilated and balloon-shaped. Urethral diverticulum may develop, and prostate and ejaculatory duct may expand and open.
A. Urethral changes: Obstructive proximal urethral dilatation can develop into urethral diverticulum, prostatic duct and ejaculatory duct dilatation and fissure.
B. Changes of bladder: In the early stage, thickening and hypertrophy of detrusor and triangle make up for outlet obstruction and make bladder completely empty. This change leads to the progressive development of bladder trabeculation, honeycomb, balloon and diverticulum. Subsequently, bladder decompensation occurs, which is characterized by the above changes and incomplete bladder emptying, resulting in residual urine. Due to the increase of ureteral flow resistance in bladder, triangular hypertrophy leads to secondary ureteral obstruction. With detrusor decompensation and residual urine accumulation, the hypertrophy triangle area contracts and ureteral obstruction increases obviously. This is the mechanism of kidney back pressure when bladder outlet is obstructed (while the junction of urethra and bladder keeps its function). Catheter drainage of bladder reduces the tension of deltoid muscle and improves the drainage of upper urinary tract.
B. Bladder changes: In the early stage, in order to completely empty the bladder, detrusor and bladder triangle were thickened to compensate for bladder outlet obstruction. This change gradually developed into trabecula, acinus and vesicle of bladder, and finally became bladder diverticulum. Finally, the bladder loses its compensatory function, which is manifested by the aggravation of the above changes, incomplete bladder emptying and finally residual urine. Hypertrophy of the triangular area of bladder can cause secondary ureteral obstruction, which is caused by increased resistance when urine passes through part of the ureter of bladder wall. Due to detrusor decompensation, the residual urine increases, and the hypertrophy triangle is overstretched, which aggravates ureteral obstruction. This is the mechanism that bladder outlet obstruction produces back pressure on the kidney (at this time, the function of bladder-ureter junction is sound). Bladder catheter drainage can reduce triangular stretch and improve upper urinary tract drainage.
The late change of persistent obstruction (more common in neurosexual dysfunction) is the compensatory imbalance at the junction of ureter and bladder, which leads to reflux. Reflux aggravates the back pressure effect on the upper urinary tract by exposing the upper urinary tract to abnormally high bladder pressure-in addition, it also promotes the onset or persistence of urinary tract infection.
Because the compensation at the junction of ureter and bladder is lost very late, persistent obstruction (usually due to neurogenic bladder dysfunction) changes to urinary reaction. In the face of very high bladder pressure, urine reflux not only promotes or persists urinary tract infection, but also aggravates upper urinary tract back pressure.
C. Ureteral changes: The first change noticed is the gradual increase of ureteral dilatation. This increases the extension of the ureteral wall, which in turn increases the contraction force, resulting in overactivity and hypertrophy of the ureter. Because the ureteral muscle tissue runs in an irregular pattern, the stretching of its muscle components leads to lengthening and widening. This is the beginning of ureteral decompensation, and the bending and expansion become obvious. These changes have been developed until the ureter is weak and the peristalsis is reduced, ineffective or completely disappeared.
C. Ureteral changes: The first visible change is the gradual increase of urethral dilatation, which increases the tension of the ureteral wall, thus increasing the contraction force, resulting in excessive activity and hypertrophy of the ureter. Because the ureter is an irregular spiral, the stretching of intramuscular components makes the ureter longer and wider. The bending and expansion of ureter marks the beginning of its dysfunction, and this change continues until the ureter loses tension, peristalsis decreases or disappears completely.
D. Changes of renal pelvis and calyx: The renal pelvis and calyx gradually expand due to the increasing urine retention. The pelvis first shows hyperactivity and hypertrophy, and then gradually expands and becomes weak. According to whether the renal pelvis is intrarenal or extrarenal, the renal calices show the same changes in different degrees. In the latter case, although there is obvious pelvic dilatation, cervical dilatation may be the smallest. In the renal pelvis, renal calyx dilatation and renal parenchyma damage are the biggest. The continuous stage of obstruction is that the dome becomes round, then the nipple becomes flat, and finally the small dome is rod-shaped.
D. changes of renal pelvis and calyx: due to the gradual increase of residual urine, the renal pelvis and calyx expand. The early manifestations of renal pelvis are increased peristalsis and hypertrophy, and then gradually expand without tension. The renal pelvis shows the same changes in different degrees according to whether it is intrarenal pelvis or extrarenal pelvis. In the latter case, although the renal pelvis has obviously increased, the expansion of renal calices may not be obvious; However, if the renal pelvis is intrarenal, the renal calyx will expand and the renal parenchyma will be seriously damaged. In the successive stages of obstruction, the dome is round, then the renal papilla is flat, and finally the renal calyx is rod-shaped.
E. Changes of renal parenchyma: During progressive pyeloplasty, renal parenchyma compresses renal capsule. This, together with the more important factor-the compression of arcuate blood vessels caused by the expanded renal calyx, leads to a significant decrease in renal blood flow. This leads to progressive parenchymal compression and ischemic atrophy. The nephron in the lateral group is more affected than that in the central group, resulting in patchy atrophy of different severity. Glomerulus and proximal convoluted tubules are most affected by ischemia. With the increase of renal pelvis pressure, collecting tubules and distal tubules gradually expand, and renal tubular cells are compressed and atrophied.
E. Changes of renal parenchyma: With the progressive enlargement of renal pelvis and calyx, renal parenchyma is compressed to the capsule side, and the important factor of renal calyx's enlargement compressing arcuate artery finally makes the blood flow decrease obviously, leading to the progressive compression of renal parenchyma and ischemic atrophy. Nephron involvement in the lateral group is more serious than that in the central group, resulting in patchy atrophy in different degrees. Ischemia has the most serious damage to glomerulus and proximal convoluted tubules. With the increase of renal pelvis pressure, collecting duct and distal convoluted tubule gradually increase, and renal tubular cells shrink under pressure.
Clinical discovery
clinical picture
A. Symptoms and signs: According to the different parts of obstruction, the examination results are also different:
Symptoms and signs: Its manifestations vary with the location of obstruction.
Subvesical obstruction-Subvesical obstruction leads to difficulty in urination, weakness in urination, decreased flow rate and terminal salivation. Burning sensation and frequency are common related symptoms. The swollen or thickened bladder wall can be touched. Rectal examination can find urethral stricture and sclerosis, benign prostatic hypertrophy or prostate cancer. Urethral stricture and incarcerated urethral calculi can be easily diagnosed by physical examination.
Subvesical obstruction: Subvesical obstruction leads to early dysuria, dysuria, decreased urine flow rate, and post-urinary drip. Burning sensation and frequent urination are common accompanying symptoms. The swollen or thickened bladder wall can be touched, and urethral sclerosis, benign prostatic hyperplasia or prostate cancer can be found in the stenosis by anal examination. Urethral stricture and urethral impaction stones can often be diagnosed by physical examination.
Upper bladder obstruction-Renal pain or renal colic is usually associated with gastrointestinal symptoms. When the upper bladder obstruction develops gradually within a few weeks or months, it may be completely a symptom. You can touch the enlarged kidney. Tenderness of the costal angle may occur.
Upper bladder obstruction: Renal pain or renal colic often occurs simultaneously with gastrointestinal symptoms. When the upper bladder obstruction develops slowly. After a few weeks or months, it may be completely asymptomatic. The swollen kidney can be felt. There may be tenderness in the costal crest angle.
B. Laboratory results: You can see signs of urinary tract infection, hematuria or lens urine. Renal function is impaired by the increase of blood urea nitrogen and serum creatinine, which is much higher than the normal 10: 1 due to urea reabsorption.
B. Test results: Infected urine, hematuria or lens urine, blood urea nitrogen and serum anhydride increase, and the ratio is higher than 10: 1 due to the reabsorption of urea nitrogen, suggesting that renal function is impaired.
C.x-ray manifestations: Radiological examination is usually of diagnostic significance for stasis, tumor and stenosis. Dilation and anatomical changes occur above the plane of obstruction, while at the distal end of obstruction, the morphology is usually normal. This helps to locate the obstruction. According to the location of obstruction, it is sometimes necessary to combine intravenous urography anterograde imaging with ureterography or urethrography retrograde imaging to display the range of obstruction. In upper bladder obstruction, it is very important to confirm stasis and delayed drainage for determining and measuring the severity of obstruction.
C.x-ray shows that cases of urinary retention, tumor or stenosis can be diagnosed by radiological examination. There are dilation and anatomical changes above the level of obstruction, but the distal shape of obstruction is normal, which is helpful for the diagnosis of obstruction. According to the location of obstruction, it is sometimes necessary to carry out unobstructed intravenous urography and retrograde ureterography or urethrography at the same time to determine the scope of obstruction. Obstruction above the bladder is characterized by stagnation and delay, and drainage is very important to determine and estimate the severity of obstruction.
D. special examinations:
D. special inspection:
Percutaneous nephrostomy anterograde urography is of special value when the obstructed kidney cannot discharge radiopaque substances in excretory urography. This program allows the application of Whitaker test, during which fluid is injected into the renal pelvis at different rates. The fluid delivery can be measured and the degree of blockage can be estimated by using a pressure monitor.
Anterograde urography: It is especially valuable to use percutaneous needle or catheter for nephrostomy when the blocked kidney cannot discharge the contrast agent in the urinary tract. This operation can be performed by Whitaker test, during which different degrees of fluid can be injected into the renal pelvis. Liquid transfer can be measured by pressure monitor, and the degree of blockage can be estimated by pressure monitor.
Ultrasonic examination-This will show the degree of dilatation of the renal pelvis and calyx, and allow prenatal diagnosis of hydronephrosis.
Ultrasonic imaging: it can show the enlargement degree of renal pelvis and calyx, and can diagnose fetal hydronephrosis.
Isotope study-Technetium 99m DMSA scan depicts the degree of hydronephrosis and renal function. The use of directional agents during scanning can provide information similar to Whitaker test.
Isotope examination: The degree of hydronephrosis and renal function can be known by technetium 99M DMSA scanning. Using diuretics during scanning can get similar effect to Whitaker test.
CT scan-In many cases, it is valuable to show the degree and location of obstruction and the cause. The residual renal function can be evaluated by contrast agent.
CT scan: In some cases, it is valuable to show the location, degree and cause of obstruction, and the residual renal function can be estimated by using contrast media.
complication
complication
The most important complication of urinary tract obstruction is renal parenchyma atrophy caused by back pressure. Obstruction is also easy to cause infection and stone formation, and the infection caused by obstruction will lead to rapid kidney damage.
The most important complication of urinary tract obstruction is renal parenchyma atrophy caused by back pressure. Obstruction will also make the kidney easy to infect and form stones, and the infection in obstruction will accelerate the destruction of the kidney.
deal with
treat cordially
The purpose of treatment is to relieve obstruction (such as catheterization to relieve acute urinary retention). Surgery is often necessary. Simple urethral stricture can be treated conservatively by dilation or urethrotomy. However, urethroplasty may be required. Benign prostatic hypertrophy and obstructive bladder tumor need surgical resection.
The purpose of treatment is to relieve obstruction (such as putting a catheter to relieve acute urinary retention). Surgery is usually needed. Simple urethral stricture can be treated by conservative methods such as urethral dilatation and urethrotomy, but sometimes urethroplasty is needed. Benign prostatic hyperplasia and obstructive bladder tumor need surgical resection.
If it is thought that incarcerated stones may be discharged by themselves, they must be removed or shunted by catheter. If stones cannot be discharged naturally, they must be removed by surgery later.
Incarcerated stones must be removed; If you think that the stones may be discharged by themselves, you can also put a tube through the bypass. If it cannot be discharged by itself, the stones must be removed by surgery in the future.
Obstruction of ureter or ureteropelvic junction needs surgical correction and plastic repair through uretercystoplasty, ureterostomy, bladder flap bridging the gap at the lower end of ureter, ureteropelvic anastomosis or ureteropelvic plasty. Punitive stones can be removed by percutaneous nephrostomy or by washing a tube directly into the kidney.
Urethral delivery or ureteropelvic junction obstruction needs surgical correction or plastic repair; Uretercystoplasty, pyeloureterostomy or pyeloureterostomy. In the lower ureter, bladder flap can be used as a bridge to fill the defect. Kidney calculi can be removed by percutaneous instruments, percutaneous nephrostomy or direct irrigation through renal catheter.
Initial drainage above obstruction sometimes needs to improve renal function. Occasionally, permanent drainage and shunt are needed through skin ureterostomy, ileum or colon loop shunt or permanent nephrostomy. If the damage intensifies, nephrectomy may be necessary.
Sometimes, in order to improve renal function, a catheter can be placed above the obstruction, and sometimes permanent drainage, ureterostomy, urinary diversion, ileum or colon diversion or permanent nephrostomy is needed. If the damage is aggravated, nephrectomy can be performed.
prognosis
prognosis
The prognosis depends on the cause, location, duration and degree of renal damage and renal decompensation. Generally speaking, the relief of obstruction leads to the improvement of renal function, except for severely damaged kidneys, especially those damaged by inflammatory scars.
The prognosis depends on the etiology, location, course of disease, degree of renal damage and renal loss. Generally speaking, removing obstruction can improve renal function unless the kidney is seriously damaged, especially inflammatory scar.
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