Pyeloectasia is the expansion of the renal pelvis due to the accumulation of urine. It is considered as an independent (physiological) or concomitant condition in a number of urological diseases with urodynamic disorders. Complaints are more often absent, but may be represented by symptoms of the underlying pathology. Diagnosis is based on kidney ultrasound, excretory urography and cystography, pyelography, MRI or CT with contrast. Treatment is required with the progression of dilation, surgery to restore an adequate passage of urine is performed in 25-45% of cases, which prevents the terminal stage of hydronephrosis and chronic renal failure.
ICD 10
Q62 N28.8
Meaning
The term “pyeloectasia” comes from the Greek words “pyelos” – “pelvis” and “ektasis” – “expansion”. Changes are sometimes detected during antenatal ultrasound scanning of the fetus in the second trimester, in boys – 3-4 times more often than in girls. Pyelectasia is often diagnosed in women 30-35 years old during pregnancy, the condition is considered physiological in the absence of changes in urine, passes independently 4-8 weeks after delivery. In older men, the expansion of the pelvis is associated with prostate adenoma, which causes obstruction of the lower urinary tract. Urologists often consider pyelectasia to be the initial manifestation of hydronephrosis.
Causes
There are two main causes of this condition: an obstacle to the outflow of urine (obstruction) and its reflux (reflux). The renal pelvis may increase due to excessive simultaneous fluid intake, which is not considered a pathology, the situation resolves spontaneously. There are a large number of conditions accompanied by pyeloectasia. There are the following reasons that lead to a violation of the outflow of urine:
- Obstruction. A stone, a blood or salt clot, a tumor process of the bladder, prostate can cause pyelectasia. Narrowing of the cup-pelvic segment, strictures of the ureter and urethra, prostate adenoma are also considered as obstructive uropathy, with these pathologies, vesicoureteral-pelvic reflux with expansion of the renal cavity systems are often formed.
- Compression. Any part of the ureter can be squeezed by external tumors localized in the uterus, ovaries, large intestine. In advanced forms of cancer of the pelvic organs, the ureteral lumen is narrowed due to metastatic lesions. The compression effect can be caused by inflammatory processes in the retroperitoneal space, for example, Ormond’s disease, pelvic lipomatosis.
- Anomalies of development. Horseshoe kidney, pelvic dystopia, nephroptosis are urological anomalies, which in mild cases are manifested by pyelectasia, and in advanced cases by hydronephrotic transformation. Similar changes are noted with ectopia, torsion, high discharge of the ureter, an additional vessel and bending of the ureter through it. Posterior urethral valves are the most common cause of pyelectasia in newborn boys.
- Neurogenic disorders. Neurogenic bladder is caused by a violation of innervation and constant stagnation of urine in the bladder after urination. The long-existing condition leads to the formation of vesicoureteral reflux, which is often accompanied by recurrent urinary tract infections and pyelectasia.
Predisposing factors include endocrine disorders associated with increased production of urine, previously performed urological operations, and radiation therapy. Teratogenic effects are significant for the development of intrauterine pyelectasia: radiation, taking certain medications, transferred viral diseases at critical times for organogenesis. A certain role belongs to the hereditary predisposition to urological or nephrological pathology.
Pathogenesis
With stagnation of urine, compensatory and adaptive reactions are initiated, which lead to atrophy of the renal structures. When the secondary microbial flora is attached, an inflammatory process occurs, which exacerbates morphological changes. Their severity correlates with the degree of occlusion of the ureter, the stage of the disease, the age of the patient, involvement in the process of the contralateral organ, compensatory capabilities of the body.
In children, pyelectasia sometimes resolves spontaneously by changing the position of the organs relative to each other, maturing the structures of the urinary tract as the pressure in the urinary system grows and redistributes. Anomalies and malformations (strictures, valves, vascular malformations that have a compressive effect on the ureter) significantly aggravate the prognosis and lead to hydronephrotic transformation of the kidneys without treatment.
Symptoms
Clinical manifestations of pathology are often absent, some patients note dull pulling pains in the lumbar region, intensifying in the morning or after consuming a large amount of fluid. Fever, weakness, dysuric disorders indicate the development of concomitant inflammation in the kidney.
Often the symptoms are caused not by pyeloectasia itself, but by the main pathological process. Thus, in diseases accompanied by obstruction of the lower urinary tract, the patient is concerned about the inability to urinate without straining, weak jet, frequent urges (BPH, tumor, narrowing of the urethra), periodic renal colic with the release of stones or sand (nephrolithiasis), leakage of urine from the vagina (ectopia ureter), etc.
Complications
Since the expansion of the pelvis has been asymptomatic for a long time, and the kidneys work with a significant load, pyeloectasia progresses into pyelokalikoectasia and hydronephrosis, in which normal functioning tissue is replaced by connective tissue with loss of organ functions.
Stagnant urine in pyelectasia is a favorable environment for the persistence of pathogenic microflora, which leads to recurrent urinary tract infections. Another complication is the development of nephrogenic hypertension, resistant to the action of drugs. Nephrologists consider elevated blood pressure and hydronephrotic transformation of the kidneys as harbingers of CRF.
Diagnostics
The patient is led by a urologist or nephrologist. In case of a suspected neoplasm of the uterus or ovaries, the consultation of a gynecologist, oncologist is justified. In adults, one-time detection of pyelectasia is not regarded as a pathology, in such cases, dynamic ultrasound scanning is mandatory. Examination with pyeloectasia is aimed at excluding organic or functional causes, in addition to ultrasound may include:
- Laboratory tests. With a compensated form, there are no changes in urine tests, leukocyturia, proteinuria, bacteriuria are characteristic of the inflammatory process. Precipitation of salts is typical for dysmetabolic nephropathy or urolithiasis. Blood test for creatinine and urea is justified in case of bilateral damage, an increase in their level indicates kidney failure. If bacteria are detected in the urine, a study of the biomaterial for flora is prescribed.
- Instrumental diagnostics. If the ultrasound data are ambiguous, excretory urography with cystography, CT or MRI of the kidneys with contrast, nephroscintigraphy, angiography are performed. If bladder cancer is suspected, cystoscopy, TRB is performed to confirm prostate cancer. In the fetus, pyelectasia is determined by ultrasound screening during the 2nd trimester of pregnancy (25%), after birth, according to the indications, one or another method of additional diagnosis is chosen.
Differentiation is carried out between the physiological and pathological form of pyeloectasia. When the expansion of the pelvis is detected for the first time, in the absence of other changes, it is impossible to assume whether the condition will progress, therefore, the patient is monitored in dynamics. The main task of the clinician is to establish the root cause of pyeloectasia.
Treatment
If the expansion of the renal pelvis does not progress, active therapeutic measures are not required. For preventive purposes, decoctions of diuretic herbs, vegetable uroseptics are prescribed. The patient is not recommended to consume a lot of fluids at the same time. To reduce the load on the kidneys, it is necessary to urinate at night.
Medical treatment and nutrition
Concomitant confirmed pyelitis, pyelonephritis or cystitis implies the appointment of drugs to stop the infectious and inflammatory process. Used:
- antibiotics;
- uroseptics;
- immunomodulators;
- means that improve blood circulation;
- multivitamin complexes;
- litholytic drugs, the action of which prevents the formation and precipitation of crystals (in urolithiasis).
At the same time, it is recommended to follow a diet that takes into account the composition of salts. In the treatment of pyelectasia, saturated meat, chicken, mushroom, fish broths, chocolate, strong tea and coffee, all alcoholic beverages, smoked meats and marinades are excluded from the diet.
Surgical treatment
It is indicated with the progression of pyeloectasia. The volume of the operation depends on the cause that led to the expansion of the intracavitary structures of the kidney. The intervention can be laparoscopic, open or endourological, aimed at restoring normal urodynamics. The following techniques are used:
- Plastic surgery of the pelvic-ureteral segment with excision of the stretched pelvis shell and suturing of the ureter into the kidney, augmentation, balloon dilation, endotomy using a laser scalpel or electric current.
- Removal of the concretion by one of the methods (contact or remote lithotripsy, endoscopic nephrolitholapaxy, open surgery).
- Palliative operations and manipulations to normalize urinary outflow in acute inflammation: epicystostomy, nephrostomy, catheterization of the bladder, installation of a stent catheter through the ureter into the pelvis, etc.
- Removal of tumors that negatively affect urodynamics.
Nephrectomy with loss of kidney function and destruction of its parenchyma to eliminate the source of infection in the body. In children, if at least 10% of normal tissue has been preserved, organ-bearing surgery is not performed due to high regenerative capabilities.
Prognosis and prevention
The prognosis for pyeloectasia is favorable, provided adequate observation, inadmissibility of progression and timely treatment of the underlying pathology. Prevention involves regular visits to a urologist or nephrologist with ultrasound, urine test examination. A conversation is held with the patient about the importance of a reasonable diet, adherence to a healthy lifestyle, exclusion of hypothermia. According to the indications, the use of uroseptics, herbal diuretics in the autumn-spring period is justified.
