Or obstruction of the urinary tract occurs. Obstructive uropathy

The goal of treating ureteral obstruction is to correct it, if possible, or to bypass urine flow to avoid irreversible kidney damage. Due to the structure of your urinary system, you may need several treatments.

Restoring urine flow
If ureteral obstruction causes severe pain, immediate surgery may be needed to remove urine from the body and temporarily relieve the condition. Your doctor (urologist) may recommend:

• Placement of a ureteral stent, which is a hollow tube that is placed inside the ureter to keep it open.
• Percutaneous nephrostomy, a catheter is inserted through a hole in the skin under ultrasound control, through which urine is removed from the renal pelvis.
• Catheterization bladder... A catheter, which is a narrow, hollow tube, is inserted through the urethra into the bladder. The urine is collected in a urine collection bag. This can be especially important if the cause of the urinary outflow obstruction is related to bladder.

Your doctor will tell you which treatments or combinations of treatments are best for you. Drainage of urine can be temporary or permanent, depending on your condition. For example, many people with ureteral obstruction undergo ureteral stenting or percutaneous nephrostomy when they receive chemotherapy for oncological diseasesto ensure that the kidneys are functioning properly during treatment.

Endoscopic surgery
Endoscopic surgery is minimally invasive. A special optical instrument, an endoscope, is inserted through the urethra into the bladder and other parts of the urinary tract. The surgeon makes an incision in the affected area of \u200b\u200bthe ureter and inserts a hollow tube (stent) that maintains the patency of the ureter. Endoscopic interventions can be diagnostic and therapeutic.

Other types of surgery
Surgical procedures for correcting ureteral obstruction include:

• Ureterolysis. Ureterolysis (ureterolysis) is an operation to free the ureter from the abnormal fibrous or scar tissue (adhesions) surrounding it.
• Pyeloplasty. During pyeloplasty (pi-e-lo-place-ti-ka), the surgeon resects and removes the affected part of the ureter and inserts a hollow tube (stent) to keep the ureteral lumen open. The stent remains in place for six weeks and is removed on an outpatient basis.
• Partial nephrectomy. In a partial nephrectomy, the surgeon removes the damaged part of the kidney caused by the obstruction of the ureter.
• Ureterectomy. In this procedure, the surgeon removes all or part of the ureter, and then reconstructs the urinary tract by displacing the kidney downward, pulling the bladder towards it or creating an artificial ureter from other tissues.
• Reimplantation of the ureter. The poorly functioning part of the ureter is removed, and the remaining healthy parts are reconnected and reattached to the bladder.
• Transureteroureterostomy. During a transureteroureterostomy (trans-u-re-te-ro-u-re-te-ro-stomiya), the surgeon attaches one ureter to the other. This creates a pathway for urine to flow and prevents kidney damage. The operation is shown when urolithiasis or the presence of a malignant tumor.

These surgical procedures can be performed from different approaches:

• Open operations, during which the surgeon makes an incision on abdominal wallto complete the procedure.
• Laparoscopic operations, which are performed using special equipment with a light source and a camera for you. The surgeon makes one or more small incisions in the skin to insert the necessary instruments and cameras into the abdomen.
• Robotic laparoscopic surgery, in which a surgeon uses a robotic system to perform a laparoscopic procedure.

The main differences between these approaches are recovery time after surgery and the number and sizes of incisions used by surgeons. Your doctor (urologist) will determine which species surgical intervention will be optimal for you.

Drug treatment
Ureteral obstruction is complicated by a urinary tract infection that requires treatment.

After surgery, your doctor may prescribe a single dose of an antibiotic. Longer course antibacterial therapy required if ureteral obstruction was complicated by urinary tract infection. Antibiotics may be recommended after removal of the stent or catheter for percutaneous nephrostomy.

If the stent is accompanied by abdominal pain, the doctor may prescribe drugs from the group of alpha-blockers to eliminate this side effect.

Complete or partial obstruction of the urinary tract is called obstruction of the ureter. In most cases, it manifests itself in inflammatory and infectious processes. As well as the advanced stage of obstruction, it causes serious complications of kidney damage and genitourinary systemthat can be fatal.

If left untreated, obstruction can lead to renal dysfunction.

What is this pathology?

Ureteral problems are less common in men, but prostate disease is a serious risk factor, which affects 65% of men.

Ureteral obstruction is the partial or complete cessation of the flow of urine between the kidney and the bladder. Obstruction is caused by abnormal narrowing of the pathways and blockages caused by inflammatory or mechanical damage... The work of the genitourinary system consists in the timely removal of fluid and metabolic products of the body.

When healthy, after the formation of urine in paired organs (kidneys), it is freely excreted through 2 connecting tubes (ureters) into the bladder, and then out through the urinary tube (urethra). Urine flow is disrupted due to obstruction, which can occur anywhere in the ureter. The disease responds well to treatment, but if the disease is left unattended, the symptoms rapidly increase and lead to serious complications: hydronephrosis, hydrouronephrosis, and renal dysfunction.

Varieties of anomalies determine the causes of occurrence

Blockage of the ureter is unilateral, less often bilateral. There are 2 main groups of obstruction:

Both groups of obstruction can occur in the background genetic predisposition to cancer, the formation of cysts or stones.

How to suspect and confirm the diagnosis?

Ureteral obstruction symptoms

One of the first symptoms of pathology may be a rise in pressure.

On early stages the clinical picture does not appear or gives insignificant symptoms. Doctors distinguish manifestations such as:

• the discomfort;
• increase in temperature and pressure;
• mild form of dysuria;
• pain syndrome in the lumbar region and back.

As the disease progresses, symptoms worsen. Clinical picture complement manifestations primary cause obstruction of the ureter, they depend on the etiology of the disease itself. In advanced or acute phases, such manifestations are observed:

• dysuria;
• sharp pains;
• false urge to urinate.

Diagnostic procedures

Obstruction is often diagnosed based on ultrasound findings. Such an examination allows you to identify defects in the early stages. Diagnosis is carried out during pregnancy. Thus, an early diagnosis of the fetus allows early treatment to begin after birth. The list of examinations both for the primary and secondary development anomalies resort to the following list of diagnostic methods:

Cystoureteroscopy is one of the studies that a patient needs to undergo to make a diagnosis.

• blood and urine tests for general indicators and biochemistry;
• cystoureteroscopy - examination of the urea from the inside;
• Ultrasound, CT and MRI;
• studies with contrast - X-ray, pyelography, kidney scintigraphy,;
• vocal cystourethrography - pictures of urea in the process of emptying;
• gynecological and proctological examination.

A set of therapeutic measures for blockage of the ureter

In therapy, a medical and radical method is used. Treatment depends on the characteristics of the disease, the severity and spread. Both methods are aimed primarily at restoring the normal function of the genitourinary system and kidney function. Then other symptoms are eliminated. In cases of particularly severe diseases such as cancer, treatment is aimed at eliminating the primary disease.

Professor Yu.A. Pytel. This is a very apt expression, since it is the bladder that suffers as a result of compression (obstruction) by the growing adenoma. Changes in the detrusor due to increased functional load and aging of the organ determine the severity of bladder dysfunctions and the possibility of their recovery as a result of treatment.

Image of a male bladder

Bladder obstruction

When the enlarging prostate compresses the initial part of the urethra and the neck of the bladder, the outflow of urine from it is disturbed.

With prostate adenoma, smooth muscle elements rich in nerve endings occupy on average about 40% of the gland volume. In the process of growth and progression of adenoma, constant irritation of these receptors and a response increase in the tone of the smooth muscle structures of the bladder neck, posterior urethra and prostate gland are observed. This mechanism is responsible for the development of dynamic obstruction (movement disorders) of the bladder in prostate adenoma.

At the beginning of the development of the pathological process and the appearance of minimal signs bladder obstruction the detrusor contractility increases compensatory. This leads to the temporary maintenance of adequate urination.

Further progression of adenoma growth is accompanied by mechanical compression of the bladder neck, and an excessive increase in the tone of the muscular apparatus leads to the fact that, despite the efforts of the bladder, they become insufficient to maintain normal urination. There is an increase in pressure in the bladder cavity, as well as a significant increase in pressure during urination. All this, together with the increasing obstruction (compression) of the bladder, leads to a gradual depletion of the detrusor contractility.

Progressive obstruction of the bladder, poor blood supply to the detrusor due to its thickening, cicatricial changes in the bladder wall lead to even greater functional impairment. The tone of the bladder sharply decreases and its contractility decreases, which makes it difficult or impossible to urinate independently.

The severity of the described changes in the bladder plays an important role in the development of manifestations of prostate adenoma, the progression of the disease and its prognosis.

Thus, it is impossible to single out one thing among the causes and mechanisms of development of prostate adenoma. Aging of the male body, hormonal imbalance, activation of growth factors and other factors contribute to the formation of this disease. Each factor separately and their combination at certain stages of the development of the male body can play a leading role in the development of prostate adenoma. However, it is obvious that prostate adenoma as a disease occurs when three factors interact: enlargement of the gland, signs of bladder obstruction and symptoms of urinary dysfunction.

Have healthy person The urinary system consists of two kidneys and the urinary tract (ureters), through which urine enters the bladder, and from there is excreted through the urethra. The kidneys are paired organs that are located next to the muscles of the human back. They perform an extremely important function of cleansing the body of metabolic products, ions and chemical formations in the blood.

In the kidneys, urine begins to accumulate and form. The ureters are two paired ducts that link the kidneys to the bladder. In our body, the ureters are parallel to the spine and are thin long tubes (about 12 cm each). In the bladder, urine is collected and stored. The bladder can hold up to 500 ml of fluid (in women) and up to 800 ml (in men). Then, thanks to the timely reaction of the spinal cord, and then the brain, urine is excreted outside through the urethra.

The slightest obstacle to the outflow of urine can lead to the formation of stones, infection of the genitourinary system. However, obstruction of the urinary tract precedes these diseases. An obstruction of the urinary tract is a violation of the natural outflow of urine in the urinary system, which is characterized by high blood pressure in the ureters, bladder, kidneys.

This disease usually occurs in an acute and chronic form. Acute obstruction of the urinary tract can cause renal colic, pain from which can even radiate to the genitals. Chronic obstruction is usually characterized by polyuria (excessive urine production) and nocturia (the largest amount of urine excreted at night).

The causes of urinary tract obstruction can be both physical and mechanical. Among the physical, there are congenital defects development of the urinary tract (too narrow). Mechanical are various obstacles to the natural outflow of urine with a normal structure of the urinary tract. It can be:

• stones in the kidneys;
• prostate cancer;
• bPH;
• hernia;
• trauma;
• infections;
• obstruction of feces;
• blood clots in the urinary tract.

If the mechanical obstruction to the outflow of urine is above the level of the bladder, this can lead to such consequences as hydronephrosis (blockage of the urinary tract), hydroureter (abnormal expansion of the ureter).

Children can suffer from congenital urinary tract disorders. Among them, the retrocaval localization of the ureter is distinguished, which often leads to the development of a disease such as bilateral hydronephrosis. In addition, among the reasons that can cause kidney obstruction (obstructive nephropathy) are:

1. cervical cancer.
2. colon cancer.
3. lymphoma in the retroperitoneal space.
4. ormond's disease.

The danger of this disease is that in the first stages it passes almost asymptomatically - the patient does not feel the slightest discomfort. At the same time, the pressure in the renal calyx-pelvis system increases, due to which the patient feels renal colic.

Pain with renal colic so strong that it can be given to the patient's genitals. Over time, the patient's body can adapt to the "incorrect" functioning of the urinary system: the kidney increases in volume and becomes able to retain more fluid, but its normal work is disrupted. As a result, the patient may complain of: frequent urination, unexplained pressure increases.

Diagnostics

If the first symptoms of the disease occur, you should urgently contact a urologist. First, the doctor will start taking anamnesis: he will learn about the symptoms of the disease, when they began to appear, how often they occur. This is followed by a referral for tests for an accurate diagnosis of the disease:

• Ultrasound abdominal cavity;
• urography;
• cystocopy;
• retrograde pyelography;
• isotope renography;

Abdominal ultrasound allows the doctor to see the condition of the patient's organs such as the kidneys, spleen, pancreas, gall bladder, bladder. Thanks to ultrasound, you can notice the presence of kidney stones, pathological changes appearance internal organs, polyps.

Urography includes an examination of the entire urinary system: kidneys, ureters, bladder. With an obstructive type of urination (this is a decrease in the flow rate of urine), excretory urography is usually used. This type of urography is characterized by the fact that the patient is injected intravenously with a special contrast agent, which contains iodine. A series of X-rays are then taken. The contrast agent allows you to clearly highlight the organ necessary for the study.

Cystocopy is an examination of the patient's bladder to identify pathologies. This procedure is carried out using a special device - a cystoscope. Before carrying out a cystocopy, the patient is given anesthesia to avoid unpleasant sensations during it.

Retrograde pyelography is an X-ray examination of the kidneys. Retrograde pyelography is performed using a cystoscope with a catheter. A contrast agent is also used. The volume of contrast should not exceed the volume of the kidney.
Isotope renography examines the kidneys and upper urinary tract. To conduct isotope renography, the patient is injected intravenously with contrast, and then using a special apparatus, the radiation is monitored.

CT (computed tomography) is the most effective method X-ray studies. CT is done using a tomograph. A significant advantage of CT in comparison with conventional X-ray is that the tomograph takes a number of images, which are then processed using a computer. Then a three-dimensional image of the organ that was examined is modeled. With the help of CT, the doctor is able to accurately determine the pathological development of certain human organs, and then - to prescribe an effective treatment.

Treatment

Treatment of urinary tract obstruction will be aimed primarily at eliminating obstruction (blockage of hollow organs) in order to avoid unpleasant consequences: sepsis, kidney obstruction. Therefore, the doctor's actions will be aimed at eliminating excess fluid from the organs of the urinary system, which creates dangerous pressure. For this, catheterization of the bladder or ureters is performed (with obstruction of the ureters). After removing excess fluid from the urinary tract, the doctor may prescribe the patient a course of antibiotics to avoid the development of infectious diseases genitourinary system.

If the disease becomes recurrent, surgery may be performed. Surgical intervention necessary if the patient has:

1. retention of urine.
2. recurrent urinary tract infection.
3. sharp pain.
4. progressive renal failure.

In some cases, radiation therapy is used to eliminate urinary tract obstruction.

Effects

After the obturation is removed, the urine flow rate will naturally improve. If the patient turns to the doctor at the wrong time, the process can be pathological in nature: acute renal failure occurs, kidney stones can form, infections of the genitourinary system can be recurrent. With prolonged delay in treatment, the patient may develop chronic renal failure.

Urinary obstruction in children

This disease in children is congenital and acquired. As a rule, ultrasound can detect the presence of such pathologies in the fetus. Nevertheless, sometimes when examining a newborn child, obstruction is no longer detected. However, if the child was unable to urinate on his own within 24 hours after birth, he may be suspected of hydronephrosis. Poor urine flow in boys may be an alarming signal.

The diagnosis of urinary tract obstruction in children is rarely different from that in adults. So, diagnostic tests for a child include the following analyzes:

• Ultrasound of the kidneys;
• vocal cystourethrography;
• uroflowmetry.

Obstructive uropathy - a group of diseases that are characterized by a structural or functional obstruction to the normal outflow of urine, sometimes leading to impaired renal function. Symptoms less likely to occur with chronic obstruction include T 11-12 spinal cord pain, anuria, nocturia, and polyuria. Depending on the level of obstruction, the diagnosis is based on the results of bladder catheterization, ultrasound examination, computed tomography, cystoureteroscopy, cysto- and ureterography, pyelography. , depending on the cause, may consist in drainage, instrumental intervention, surgery, including lithotripsy, endoscopic guidance, drug therapy.

Each year, approximately 2 in 1000 people in the United States are hospitalized for obstructive uropathy. These diseases are equally common among men and women. different ages... IN childhood it occurs mainly against the background of urinary tract abnormalities. With age, the incidence of these diseases decreases to 60 years, after which it increases mainly in men as a result of the appearance benign hyperplasia prostate and. In general, obstructive uropathy is the cause of 4% of all cases of terminal chronic uropathy. At autopsy, hydronephrosis is detected in 2-4%.

Causes of obstructive uropathy in men and women

Many pathological conditions can cause obstructive uropathy. Obstruction can be acute or chronic, complete or partial, unilateral or bilateral. It can occur at any level, from the renal tubules to the external opening of the urethra, leading to an increase in the lumen of the urinary tract, urostasis, urinary tract infection, the formation of stones, which can also cause obstruction. In men, it is more often caused by urethral strictures, in women - by stenosis of the external urethral opening, tumors of the genitals, radiation therapy, surgical interventions.

Diagnosis of obstructive uropathy

Obstructive uropathy should be suspected when oliguria, an unexplained progressive anuria, appears. History may include indications of arterial hypertension, malignant neoplasms or urolithiasis. Since the restoration of the disturbed outflow of urine can eliminate the obstruction, early diagnosis and early treatment can prevent irreversible kidney damage.

To be fulfilled general analysis urine and biochemical blood test with the determination of plasma electrolytes, urea, creatinine. Other tests are done depending on the symptoms and the level of obstruction suspected. Urinary tract infection associated with obstructive uropathy is an emergency and requires immediate evaluation and treatment.

If the volume of self-excreted urine is reduced or absent, it is necessary differential diagnosis anuria and acute urinary retention. For this purpose, it can be performed ultrasound procedure and / or catheterization. If by catheterization the disturbed outflow of urine is restored, and the placement of the catheter was difficult, obstruction of the urethra should be suspected. Such patients are shown urethrocystoscopy and voiding cystoureterography. The latter helps to diagnose most obstructions of the bladder neck and urethra, as well as vesicoureteral, demonstratively reflecting the nature of the changes and the volume of residual urine.

If the patient is asymptomatic with long-term obstructive uropathy, urinalysis may be normal or reveal only casts, leukocytes, erythrocytes in the sediment. If the obstruction is bilateral and complete, acute renal failure may develop. Severe chronic obstruction leads to chronic renal failure.

With unilateral obstruction and intact function of the second kidney, plasma creatinine levels are usually normal. Hyperkalemia due to type 1 renal tubular acidosis due to decreased distal secretion of hydrogen and potassium ions and loss of sodium ions may occur, which predisposes to a decrease in extracellular fluid volume.

Obstructive uropathy research methods

The use of imaging methods, their choice and sequence depend on the suspected cause and location of the changes, as well as the results of previous studies.

Abdominal ultrasonography and the retroperitoneal space - the primary method of investigation in most patients, with the exception of those suffering from urethral diseases, since it avoids potential allergic and toxic complications intravenous administration X-ray contrast agents and assess renal changes. Taking into account the most minimal diagnostic criteria, frequency false positives is 25%. The combination of ultrasonography, plain radiography of the abdominal organs and, if necessary, computed tomography makes it possible to diagnose obstructive uropathy in more than 90%, however, ultrasonography and without contrast are often unable to differentiate hydronephrosis from multiple renal or parapelvic cysts.

Duplex Doppler ultrasonography helps in diagnosis unilateral obstructive uropathy by determining an increased resistance index, reflecting the increased renal vascular resistance in the affected kidney. Sometimes these changes can be detected at the very beginning of acute obstruction before the limiting expansion of the calyceal system occurs. An increase in vascular resistance develops as a result of activation of the renin-angiotensin system and increased synthesis of thromboxane A2 and endothelin. This study is difficult in obesity, and in bilateral obstruction, its results are difficult to distinguish from changes in primary bilateral renal disease.

Excretory urography began to be used much less frequently with the introduction into practice of X-ray computer and without and against the background of contrast. However, difficulties in determining the level of obstruction, especially when the urinary tract is blocked by calculus, necrotic renal papilla, or blood clot, serve as an indication for excretory urography, and if it is ineffective, for retrograde ureteropyelography.

Radioisotope study of the kidneys. If the kidney under conditions of obstruction does not release a radiopaque substance, it can help to assess the safety of the functioning parenchyma, but it is not able to determine the level of blockage of the upper urinary tract. It is mainly used in the form " diuretic renography»To assess the degree of urinary passage disturbance in the absence of clearly visible obstruction.

Antegrade and retrograde pyelography more often performed in patients with azotemia. Antegrade examination is performed after percutaneous puncture nephrostomy, retrograde - after cystoscopy with catheterization of the corresponding ureter. Under-examination with intermittent obstruction significantly reduces the diagnostic value of these methods.

Diuretic renography performed most often in the presence of pain with a slight expansion of the upper urinary tract. Immediately before the radioisotope kidney study, prescribe loop diuretic... If there is significant obstruction, passage of the radiopharmaceutical may be delayed despite the increase in urine production. Similar changes can be recorded in the form of a delay of a radiopaque substance during excretory urography. The greatest differential diagnostic difficulties arise if the renogram curves do not change or change symmetrically for both kidneys. Persistent complaints of the patient about pain require a study of the perfusion pressure in the calyx-pelvis system. After percutaneous puncture and catheterization of the pelvis, it is perfused with saline at a rate of 10 ml / min. In the presence of obstruction, with a significant increase in the volume of the transported fluid during perfusion, an increase in pressure in the pelvis of more than 22 mm Hg is observed. Diuretic radionuclide study, urography and a positive perfusion test causing similar pain confirm obstruction. The absence of an increase in perfusion pressure indicates an extrarenal origin of pain. However, false positive and false negative results are possible.

Obstructive uropathy - prognosis

Most obstructions can be corrected, but delayed treatment can lead to permanent damage to the kidney. Treatment outcome is determined by the duration of the obstruction that preceded the nephropathy and complicating urinary tract infection.

Treatment of obstructive uropathy

Treatment of obstructive uropathy may include the elimination of the obstruction by surgery, instrumental intervention, drug therapy... Emergency restoration of urine outflow by drainage in acute obstruction is indicated for urinary tract infection, impaired renal function, intractable pain. If lower urinary tract obstruction occurs, bladder catheterization or epicystostomy may be required. Temporary percutaneous drainage may be required to treating severe obstructive uropathy, urinary tract infections and urolithiasis. Intensive care is a must for urinary tract infections and kidney failure.

Minor manifestations of hydronephrosis without severe obstruction may be an indication for surgical treatmentif there is persistent pain and a positive diuretic renogram. In asymptomatic patients with negative diuretic renogram or positive renogram but normal renal function, no treatment may be required, observation is preferred.