Hydroureteronephrosis is a hydronephrotic transformation of the kidney with the expansion of the ureter and the development of hypotrophy or atrophy of the renal parenchyma against the background of impaired urodynamics and hemocirculation. The symptoms depend on the severity of the pathology. There may be an asymptomatic course or the appearance of pain in the lower back, weakness, increased blood pressure. Diagnosis is based on ultrasound of the kidneys and prostate, review and excretory urography, ureteropyelography, microvision cystoureterography, CT, MRI and laboratory tests: urinanalysis, blood test. Treatment is mainly operative, aimed at removing obstacles to the outflow of urine.
ICD 10
N13.0 N13.1 N13.2 N13.4
Meaning
Hydroureteronephrosis occurs quite often, in childhood it is registered mainly in boys (5:2), more often on the left, bilateral lesion is diagnosed in 15%. At the age of 20 to 40 years, the disease occurs in 1% of people, women suffer twice as often as men, which is associated with pregnancy and the prevalence of tumor gynecological pathology. In patients over 50 years of age, hydroureteronephrotic transformation develops against the background of another pathology that determines the prognosis of the diseas.
Causes
The cause of hydroureteronephrotic transformation is obstruction of any part of the urinary tract. An obstacle may occur in the bladder, urethra or the ureter itself (due to compression from the outside or internal changes). The deviation of the position and stroke of the ureter also violates the urodynamics. Diseases that can lead to hydroureteronephrosis:
- benign prostatic hyperplasia;
- urethral stricture;
- cancer of the bladder, urethra, prostate, urethra;
- developmental abnormalities, ureteral valves that contribute to urine reflux (diagnosed in early childhood);
- fibrous processes in the abdominal cavity with the formation of a mass squeezing the ureters and vessels feeding the kidney (Ormond’s disease, metastatic lesion, endometriosis);
- vascular malformations leading to an inflection of the ureter through an additional vessel;
- ureterocele;
- pelvic organ prolapse in women;
- spinal cord and spinal cord injuries that potentiate bladder dysfunction;
- inflammatory bowel diseases.
Predisposing factors include the passage of radiation therapy, urolithiasis. Congenital hydroureteronephrosis provokes the effects of a toxic-embryological agent during the mother’s pregnancy, prolonged alcohol and nicotine intoxication, work associated with harmful working conditions. With obstruction of the lower urinary tract, hydroureteronephrosis is bilateral in nature.
Pathogenesis
Secretory and reabsorbing renal functions at the early stage of hydroureteronephrosis are preserved, but the lag of reverse absorption leads to the accumulation of urine in the pelvis and its deformation. Stasis initiates hypertrophy of the muscles of the RP. Excessive development of the spiral muscles of the calyx contributes to a sharp increase in the pressure of urine on the papillae and the fornic zone. The normal release of filtrate from the papillae into the pelvis is disrupted, which reduces diuresis.
Prolonged hypertrophy is replaced by thinning, urodynamics suffers, the RP begins to expand. Due to microcirculation disorders, tissues undergo hypotrophy. The part of the parenchyma where high pressure is maintained produces filtrate, which enters the RP, and then, with the help of tubular reflux, enters the collecting tubules functioning at a lower pressure. A general violation of parenchymal blood circulation develops, complete atrophy of the cerebral and cortical substance.
Classification
Pathology can be acquired and congenital, unilateral and bilateral. According to the degree of involvement of kidney structures , there are several stages of hydronephrotic transformation of the kidneys and ureter:
- First. With pyeloectasia, the volume of the pelvis is slightly increased, the walls are stretched, but the changes are still reversible. There is no violation of functional ability.
- The second. Hydrocalicosis is characterized by a significant expansion of the calyx-pelvic system of the kidneys. There is an increase in the size of the organ, atrophy of the tissue structures of the kidney. The function is reduced by 40%.
- Third. For the terminal stage of hydroureteronephrosis, 80-100% loss of function is typical. The kidney is enlarged 1.5-2 times. The modified organ is considered as a potential focus of purulent infection in the body.
Hydroureteronephrosis in the 2nd trimester of pregnancy, due to the influence of progesterone and mechanical compression of the pelvic ureter by the pregnant uterus, is considered as physiological. After childbirth, a gradual normalization of the condition is observed within 6-12 weeks.
Symptoms
The clinical picture is associated with the underlying disease, in the acute period, the leading symptom is renal colic on the affected side – severe pain in the lumbar region, inability to find a position to relieve suffering, nausea, sometimes vomiting associated with reflex irritation of the solar plexus. In some patients with uronephrolithiasis, there are pains with frequent urination, an admixture of blood in the urine.
15% have complaints of an increase in blood pressure caused by disorders of the renin-angiotensin-aldosterone system. With a water load, the pain increases. Typical changes in the properties of urine – smell and color, the appearance of sediment. Hyperthermia indicates the addition of acute inflammation. Common symptoms are weakness, fatigue. In the compensated form, the disease is asymptomatic for a long time.
Complications
Complications of hydroureteronephrosis include the addition of recurrent urinary tract infections. Pyelonephritis attacks can be repeated several times a year, and the resistance of microflora to the antimicrobial drugs used is gradually being developed. A permanent focus of infection weakens the immune forces of the body.
Patients with hydroureteronephrosis and immunosuppression are more likely to develop purulent apostematous pyelonephritis, kidney carbuncle, urosepsis. Stagnant filtrate in the cup-pelvis system is a favorable environment for the reproduction of bacteria. As the density increases, salts precipitate, which serves as a matrix for stone formation. Atrophy of the cortical and cerebral layers leads to loss of renal function, with bilateral hydroureteronephrosis, CRF develops.
Diagnostics
Diagnostic activities traditionally begin with a conversation with the patient, assessment of complaints, analysis of the medical history. The symptom of pounding is positive. In patients with an undeveloped fat layer at an advanced stage of the disease, an enlarged kidney can be palpated. Antenatal hydroureteronephrosis in the fetus is visualized at 16-20 weeks of gestation using ultrasound. The algorithm of examination in a patient with suspected hydronephrotic transformation includes:
- Urine test. Urinanalysis – pronounced leukocyturia, bacteriuria, proteinuria. One or more microbial pathogens are identified in the bakposev. To exclude CRF, the level of urea, creatinine, and glomerular filtration rate are evaluated.
- Blood test. ESR can be accelerated with a shift of the formula to the left, which indicates concomitant inflammation. With anemia, there is a suspicion of CRF or a neoplastic process.
- Instrumental diagnostics. First–line examination – ultrasound of the kidneys, bladder, internal genitalia. If lower obstruction is suspected, urethrocystoscopy is performed. CT scans detect stones better compared to urography and ultrasound. MRI of the kidneys with contrast enhancement visualizes tumors, vascular malformations.
Differential diagnosis is carried out with pyelonephritis, congenital megacalicosis, perihelvical cyst. With severe pain syndrome, nephrolithiasis and nephroptosis are excluded. Palpable formation in the retroperitoneal space is suspicious of a tumor, hematuria and pyuria – for pyonephrosis and tuberculosis of the kidney. In case of secondary hydrourethernephrosis, it is important to determine the cause and take measures to eliminate it.
Treatment
Treatment is associated with a pathogenetic factor, mainly operative. The purpose of medical measures is to restore an adequate passage of urine, preserve or improve renal function, and eliminate obstacles. In the postoperative period, during the year, it is necessary to undergo ultrasound of the kidneys, to examine the levels of urea and creatinine, a general urine analysis. The terminal stage of hydroureteronephrosis is an indication for surgery in the volume of nephroureterectomy.
Conservative therapy
Conservative therapy plays an auxiliary role in preparation for surgery or is used to eliminate complications of hydroureteronephrosis. The drug is selected taking into account the results of cultural analysis, the duration of the course is determined individually, a combination of several antibiotics is used for mixed infection.
Surgical treatment
With frequent exacerbations of pyelonephritis, the formation of stones, the progression of renal failure, uncupable pain syndrome, surgical treatment is justified. In acute inflammation, deterioration of function with bilateral lesion or with a single kidney, severe concomitant pathology that prevents radical intervention, percutaneous puncture nephrostomy is resorted to, the installation of a stent in the RP through the ureter.
Patency of the pelvic-ureteral segment can be restored with the help of open or laparoscopic reconstructive intervention. Urologists practice:
- Andersen-Hines LMS plastic surgery (ureteropyeloanastomosis with resection of the narrowed area);
- operation Calpe de Virda;
- pyeloplasty V-Y shaped (according to Foley);
- Neuwirth surgery (ureterokalikoanastomosis).
Recently, endoscopic plastic surgeries using percutaneous or transurethral approaches have become popular. Augmentation, balloon dilation, and the use of a balloon catheter have a lower risk of complications compared to open interventions. Endoscopic plastic surgery is not performed during previous operations on abdominal organs or unsuccessful previous reconstructive plastic interventions.
Prognosis and prevention
The prognosis for life depends on the underlying disease, the stage at which hydroureteronephrosis was first diagnosed, and the adequacy of therapy. Timely detection and active treatment tactics provide a radical improvement, maintaining a good quality of life. Physiological expansion of the kidney cavities during pregnancy is not considered as a pathology and requires monitoring in dynamics with weekly monitoring of the general urine analysis.
Prevention involves early consultation with a urologist, nephrologist, ultrasound antenatal urological examination in the 2nd trimester and after the birth of a child. A woman before the planned pregnancy and during gestation should protect herself as much as possible from contact with harmful factors. All patients with urological pathology are subject to dispensary registration and, according to indications, need anti-inflammatory treatment.