Hydronephrosis of the kidney: an overview of information

Hydronephrosis (from the Greek words hydor - "water" and nephros - "kidney") is a kidney disease characterized by the expansion of the cup-and-pelvis system, progressive renal parenchymal hypotrophy, with deterioration of all major renal functions as a result of impairment of urine outflow from the pelvis and cups of the kidney and hemocirculation in the renal parenchyma. Hydronephrosis, accompanied by the expansion of the ureter, is called ureterohydronephrosis.

The synonym is hydronephrosis transformation.

[1], [2], [3], [4]

Epidemiology

Hydronephrosis is a relatively common disease. In childhood, hydronephrosis in boys is more common than in girls (ratio 5: 2); more often on the left than on the right. Bilateral obstruction in children is noted in 15% of cases. In women aged 20 to 40 years, hydronephrosis is 1.5 times more common than in men, and only among adults - in 1% of cases. At the age of more than 40 years, hydronephrosis often serves as a symptom of other diseases, while the prognosis depends on the treatment of the underlying disease.

[5], [6], [7], [8]

Causes of the hydronephrosis

Hydronephrosis always develops as a result of obstructions to urine outflow localized in any part of the urinary tract, but more often in the LMS region. Often there is a combination of reasons that cause an outflow of urine. All causes of hydronephrosis are divided into five groups:

1. obstructions in the urethra and in the bladder;
2. obstructions along the ureter, but outside its lumen;
3. Obstacles caused by abnormalities in the position and progress of the ureter;
4. Obstacles present in the lumen of the ureter itself or in the cavity of the pelvis;
5. changes in the walls of the ureter or pelvis, causing difficulties for the outflow of urine.

Causes of hydronephrosis of the first group - diseases that cause IVO, and with prolonged existence - and violation of outflow of urine from the upper urinary tract:

• strictures, stones, tumors, diverticula, valves and foreign bodies of the urethra;
• sclerosis and prostate adenoma;
• tumors, stones, diverticula and foreign bodies of the bladder.

The cause of ureterohydronephrosis may even be phimosis. Often when the obstruction in the urethra and the bladder is localized, bilateral ureterohydronephrosis develops. To the same group conditionally (there is a combination of causes!) Can be attributed ureterocele, vesicoureteral reflux, neurogenic bladder. In children of the first year of life, the most common cause of hydronephrosis is the valves of the urethra.

The causes of hydronephrosis of the second group are diseases that cause external compression of the ureter at any of its levels:

• chronic cystitis of various etiology (including interstitial) with ureteral stomata damage;
• adenoma of the prostate with retrotrigonal growth (a symptom of "fishing" hooks);
• cancer and tuberculosis of the prostate with compression of the mouth;
• paraplevikalnuyu kidney cyst;
• tumor processes in the small pelvis and retroperitoneal tissue (sarcomas, lymphomas, intestinal tumors, etc.);
• enlarged lymph nodes (cancer metastases) and inflammatory processes of the retroperitoneal space (Ormond's disease, pelvic lipomatosis);
• intestinal diseases (Crohn's disease, ulcerative colitis);
• the consequences of gynecological, surgical, urological interventions and radiotherapy for neoplasms of the pelvic organs (cervix, rectum), etc.

The so-called supplementary vessel (vessel leading to the lower segment of the kidney). Crossing the ureter in the place of its exit from the pelvis - in LMS, is considered one of the most common causes of hydronephrosis. The value of the additional vessel consists in the mechanical compression of the ureter (LMS) and in the impact on its neuromuscular apparatus.

As a result of the inflammatory reaction around the additional vessel and ureter, perivascular and periureteral cicatricial adhesions are formed, creating fixed kinks or compressing LMS, and in the very ureteral wall at the site of pressure a scarring zone with a sharply narrowed lumen is formed, a strangulation furrow. With stricture of the ureter, their cause may be the so-called ovaricarvikocele. Changes caused by an additional (cross) vessel are a typical example of a combination of causes that cause an outflow of urine (2nd and 4th groups of causes of hydronephrosis).

Causes of hydronephrosis of the third group - anomalies of the ureters, their excesses, curvature, twisting around the longitudinal axis of the retrovascular arrangement of the ureter. These causes usually lead to the onset of unilateral ureterohydronephrosis.

The causes of hydronephrosis of the fourth group are stones, tumors and foreign bodies of the pelvis and ureter, valves and spurs on the mucosa in the LMS region. Congenital and inflammatory strictures of LMS and ureter, cystic ureteritis, diverticula of the ureter.

The causes of hydronephrosis of the latter group are associated with functional disorders of the pelvis and ureter, one- or two-sided hypotension or atony of the ureter. The same group includes patients with neuromuscular dysplasia of the ureter, a primary megoureter, as well as with the so-called "high" ureteral retraction from the pelvis, although in these diseases there is a combination of causes of hydronephrosis development.

[9], [10], [11], [12], [13], [14]

Pathogenesis

According to the modern teaching about hydronephrosis, its course is divided into three stages.

• I stage - enlargement of the pelvis alone (pyeloectasia) with a slight disturbance of renal function.
• II stage - expansion of not only the pelvis, but also calyxes (hydrocalicosis) with a decrease in the thickness of the kidney parenchyma and a significant disruption of its function.
• III stage - a sharp atrophy of the kidney parenchyma, the transformation of the kidney into a thin-walled sac.

Regardless of the cause (anatomical, functional, mixed) of the development of obstruction in hydronephrosis, the outflow of urine from the kidney is disturbed, with typical pathophysiological processes beginning to develop in the kidney and VMP, which allowed pathophysiologists to call this condition "obstructive uropathy". With hydronephrosis, the processes of urinary secretion and reabsorption remain, but reabsorption lags behind the secretion, which determines the accumulation of urine in the renal pelvis. This gives the right to count the kidney during hydronephrosis of any stage by a functioning organ. As shown by radioisotope studies, with obstruction at the level of LMS, the isotopes of sodium, iodine and colloidal gold are reabsorbed from the pelvis to the bloodstream.

At the initial stage of hydronephrosis transformation with urine stasis in the pelvis, hypertrophy of the musculature of the calyx-pelvis system develops. Gradual hypertrophy of the spinal musculature of the calyx leads to a sharp increase in the pressure of urine on the papilla and fornicinal zone in comparison with the secretory pressure in the urinary tubules; this creates an obstacle to the normal excretion of urine. However, with this relative balance, the kidney does not function for long. The working hypertrophy of the muscular elements of small calyxes and pelvis is replaced by their thinning, which disturbs the outflow of urine from them and leads to dilatation of the renal pelvis and calyces, followed by atrophy of the papillae and renal parenchyma (stage II).

One of the important moments in the emergence of hydronephrosis is a delay in the introduction of urine from the functionally active parts of the kidney, which is observed even with a brief increase in intra-venous pressure, when the pelvis has not yet been enlarged. High pressure in the renal pelvis is caused only by the urine entering it, but also by contraction of the musculature of the calyx, especially the fornic and sphincter sphincters. Reduction of these hypertrophic sphincters contributes to the violation of the integrity of the calyx arches, which facilitates the return of urine from the pelvis to the kidney parenchyma (reflux-renal reflux).

Already after 24 hours after obstruction of the ureter, hypotrophy and atrophy of the renal pyramids develops as a result of their compression by transforatory edema; the papillae gradually flatten. After 6-10 days, the hypotrophy and atrophy of the pyramids reaches a considerable extent; The papillae gradually become concave. By the end of the 2nd week, forixes disappear, the calyx walls in the fornicks become more flat, rounded. The Bertinian columns remain unchanged. Henle's hinges are shortened or slowly disappear. Increasing fluid pressure in the renal pelvis leads to a gradual obliteration of the pyramids, as well as to compression of the berthine columns.

Damage to the kidney glomeruli at this time is still insignificant. Some glomeruli function with high filtration pressure, others with low filtration pressure, so glomerular filtrate, which is secreted by part of the parenchyma, where glomerular filtration is still provided by high blood pressure, reaches the cup-and-pelvic system. From there, due to tubular reflux, the filtrate enters the collecting canals of that part of the parenchyma, where the glomeruli still function, but with reduced blood pressure. The large difference in the blood pressure of two such groups of glomeruli contributes to the reverse filtration of urine into the glomerulus of low pressure.

In connection with the disappearance of the fornixes, the lumen of the collecting tubules widens, which facilitates the entry of urine from the pelvis into the tubular system. The current of urine does not stop, and pyelovenous reflux and lymphatic reabsorption are replaced by glomerular reverse filtration. Due to the extensive atrophy of the tubular apparatus, the urine circulating in the kidney is identical to the glomerular filtrate. Additional intermittent increases in intra-abdominal pressure gradually lead to a disorder of circulation in the renal glomeruli and their destruction (more often by 6-8 weeks from the onset of obstruction). Later, with complete obstruction, multiple ruptures of calyx arches occur, as a result of which urine freely enters the renal interstitial spaces, into the blood and lymphatic system.

Increased intraparenchymal pressure disrupts the blood flow in the brain of the kidney, which leads to atrophy of the pyramids. Due to prolonged transformant edema, the atrophy of the renal parenchyma is particularly noticeable in the pyramids, whereas in the cortical layer and the berthinium columns it is less pronounced. Disturbance of blood circulation in the cortical and medullary capillaries leads to a general violation of blood circulation in the parenchyma, hypoxia and tissue metabolism, contributing to the total atrophy of the cortical substance of the kidney.

Thus, the development of hydronephrosis is characterized by two phases: in the first, the brain substance is atrophied, in the second - the cortical one.

The vascular apparatus of the kidney under the conditions of hydronephrosis transformation undergoes significant changes. Both cortical and interblob vessels under hydronephrosis reorganization become thinned and elongated. There is a violation of the elastic membrane of the kidney vessels, as well as proliferation of the endothelium.

Production of urine and its admission to the renal pelvis, as well as some reabsorption of the glomerular filtrate occur even with a far gone hydronephrosis transformation: after the disappearance of the phoenixes, the reabsorption of the glomerular filtrate is carried out by tubulovenous reflux. Consequently, pelvic-renal reflux plays an important role in the pathogenesis of hydronephrosis transformation of the organ.

These compensatory mechanisms lead to a decrease in pressure in the cup-and-pelvic system, thereby contributing to the preservation of renal secretion.

[15], [16], [17], [18], [19], [20], [21], [22]

Symptoms of the hydronephrosis

Symptoms of hydronephrosis are often absent and can only be detected if an infection is attached, with a kidney injury, or is accidentally detected by palpation of the abdominal cavity in the form of a fluctuating tumor. Clinicians do not separately identify the symptoms of hydronephrosis. The most frequent pain in the kidney, of varying intensity or constant noisy character, and in the early stages of pain are characterized by attacks of renal colic. Patients often note a decrease in the amount of urine before the attacks, as well as during them and an increase in the amount of urine after the stroke subsides.

With far gone hydronephrosis, acute pain disappears. Body temperature during attacks of pain during hydronephrosis may increase in the case of the adherence of urinary infection and pyelonephritis, as a result of pyelovenous reflux. One of the symptoms of hydronephrosis is a tumor-like formation, palpable in the hypochondrium, and with large hydronephrosis - beyond its limits. Hematuria is common, sometimes the only symptom of hydronephrosis. It occurs due to a sudden and rapid decrease in intra-venous pressure during a short-term recovery of urine outflow from the kidney. The source of bleeding is the veins of the phoenix.

Aseptic unilateral hydronephrosis can be latent, patients for a long time consider themselves healthy, despite the progressing process. Even with far-reaching unilateral hydronephrosis, the symptoms of renal failure are usually not observed, since the opposite kidney compensates compensatively for the function of the affected.

Bilateral hydronephrosis gradually leads to the progression of chronic renal failure and death from uremia. Among the complications of hydronephrosis, acute or chronic pyelonephritis, formation of secondary stones and ruptures of the hydronephrosis sac in trauma, bilateral bilateral hydronephrosis is characterized by chronic renal failure and nephrogenic arterial hypertension.

[23], [24], [25], [26], [27]

Forms

Based on modern theoretical concepts of hydronephrosis, the disease is divided into two forms.

• Primary, or congenital, hydronephrosis, developing due to some abnormality of the upper urinary tract.
• Secondary, or acquired, hydronephrosis as a complication of any disease (eg, urolithiasis, kidney tumors, pelvis or ureter, damage to the urinary tract).

Hydronephrosis can be unilateral and bilateral. Both congenital and acquired hydronephrosis can be aseptic or infected.

[28], [29], [30], [31]

Diagnostics of the hydronephrosis

[32], [33], [34], [35], [36], [37]

Clinical diagnosis of hydronephrosis

Hydronephrosis often proceeds asymptomatically. The most common symptoms of hydronephrosis are:

• pain in the lumbar region;
• palpable formation in the hypochondrium, and with large sizes - in the corresponding half of the abdomen;
• hematuria;
• hyperthermia;
• dysuria.

Anamnesis history includes:

• the presence of the above symptoms and the time of their appearance from the moment of examination
• transplanted operations and other diseases of the pelvic organs, abdominal cavity and organs of the retroperitoneal space.

[38], [39], [40], [41], [42], [43]

Physical examination includes:

• palpation - the detection of education in the hypochondrium;
• percussion - tympanic sound with retroperitoneal arrangement of education, blunt sound with large size of the kidney and displacement of the abdominal cavity;
• rectal or vaginal examination - evaluation of the prostate and external genital organs.

Laboratory diagnostics of hydronephrosis

At the general or common analysis of a blood pay attention to the maintenance or contents of leucocytes the formula of white blood, ESR. Leukocytosis with a shift of the formula to the left and an increase in ESR indicate an infection. With bilateral hydronephrosis, a low hemoglobin content may indicate renal failure.

At the general analysis of urine leucocyturia, tubular proteinuria, hematuria are revealed, at bilateral defeat - decrease in relative density of urine. In the presence of nephrostomy drainage, urinalysis from the drainage allows you to indirectly judge the function of the kidney.

Analysis of urine by Nechiporenko allows you to judge the activity of the inflammatory process.

Bacteriological analysis of urine with the determination of the sensitivity of microflora to antibacterial drugs can identify the causative agent of infection of the upper urinary tract and prescribe adequate antibacterial therapy. Leukocyturia with multiple negative bacteriological analyzes of urine on a nonspecific microflora is an indication for specific studies to exclude tuberculosis of the genitourinary system.

When biochemical blood analysis it is necessary to determine the content of creatinine and urea, as well as electrolytes: potassium and sodium. An increase in the concentration of creatinine and urea is often observed with bilateral hydronephrosis.

If there is a suspicion of secondary hydronephrosis, the laboratory diagnosis includes tests necessary to diagnose the underlying disease [prostate specific antigen (PSA) blood test, urine cytology].

Instrumental diagnostics of hydronephrosis

Ultrasound is used as a screening test, it allows you to assess the extent of expansion of the calyx, the ureter, the presence of stones, the condition of the contralateral kidney.

Doppler sonography allows you to assess the blood supply of the kidney, to identify the presence or absence of an additional or a cross vessel.

Survey urography allows to reveal the stones the cause or complication of hydronephrosis.

With the help of excretory urography, the anatomy and function of the kidneys and the VMP are evaluated, the localization of the obstruction of the VMP is determined, and its length is established. When excretory urography is performed in early photographs (7th and 10th mines), the condition of the contralateral kidney is evaluated and the calyx and pelvis system and the ureter are visualized. The state of the affected kidney and VMP from the ipsilateral side is assessed on delayed images (hour or more). Exercise of excretory urography is completed when the ureter is contrasted below the level of obstruction; thus, it is possible to determine the extent of obstruction.

Mikcionnaya cystourethrography - a method of detecting vesicoureteral reflux, in 14% of cases combined with stricture LMS or megoureter.

A spiral CT with bolus contrast enhancement is indicated for:

• insufficient information of excretory urography;
• suspicion of tumors of the abdominal cavity organs, retroperitoneal space, kidneys and VMP.

Unlike excretory urography, spiral CT can assess not only the localization and extent of stricture, but also the state of surrounding tissues (vessel, degree of periurethral fibrosis).

Dynamic nephroscintigraphy and radioisotope renography provide mainly information on the function of the kidneys and upper urinary tract. The implementation of this study is necessary to judge the degree of impaired renal function, the nature of excretion of RFP from the upper urinary tract, the state of the contralateral kidney.

With the established diagnosis of hydronephrosis, special test methods are used according to the indications.

• Antegrade pyeloneureography in the presence of nephrostomy drainage allows you to visualize the upper urinary tract, establish the localization and extent of obstruction.
• Retrograde ureteropyelography is used before surgery; the method allows to establish the extent of obstruction. Indication for the performance of retrograde ureteropyelography is the absence of ureter visualization below the level of obstruction when performing other research methods (excretory urography, antegrade pyeloureterography, CT).
• Diuretic ureteropyeloscopy is an invasive endoscopic intervention used in the absence of clear data on the state of the ureter after applying non-invasive methods of investigation or the first stage in performing an endoscopic operation to correct the stricture of the upper urinary tract.
• Endoluminal ultrasonography is an expensive research method that requires training in the use and interpretation of the information obtained. The advantage of the method is the possibility of a detailed assessment of the condition of the ureter wall and surrounding tissues.
• Perfusion pyelomanometry (Whitaker test) is used for differential diagnosis between obstructive and non-obstructive expansion of the tubular and pelvic system and ureter. To perform this method of examination, nephrostomy drainage, special urodynamic equipment and an electron-optical converter are necessary. By drainage in the pelvis, liquid is supplied at a rate of 10 ml / min. The pressure in the pelvis and in the bladder is measured, the difference is less than 15 mm Hg. Considered normal, with a difference of more than 22 mm Hg. The presence of obstruction is considered confirmed. With a pressure difference of more than 15 mm Hg, but less than 22 mm Hg. The perfusion rate is increased to 15 ml / min; the difference is more than 18 mm Hg. Treated as a sign of obstruction.

To clarify the diagnosis, it is possible to perform ultrasound, excretory urography and dynamic nephroscintigraphy with a diuretic, which allows to increase the diagnostic value of these research methods. The algorithm for diagnosing hydronephrosis is shown in Fig. 19-1.

Differential diagnosis

Differential diagnosis of hydronephrosis is conducted between hydronephrosis and various diseases of the kidneys and abdominal organs, depending on which symptom of hydronephrosis prevails in the clinical picture.

With a pain symptom, hydronephrosis should be differentiated from nephrolithiasis and nephroptosis. Survey urography or CT scan with X-ray negative stones confirms or excludes nephrolithiasis. In nephroptosis, in contrast to hydronephrosis, pain occurs during movement and physical stress and quickly subsides at rest. Establish a diagnosis allows comparison of excretory urograms in a lying and standing position. Quite often a combination of nephroptosis and stricture LMS.

When formed, palpable in the retroperitoneal space, hydronephrosis Differentiates from a tumor, a polycystosis and a solitary cyst of the kidney.

In a tumor, the kidney is inactive, dense, and tuberous, and the pyelogram is characterized by a deformity of the pelvis with compression or "amputation" of the calyx. With polycystic kidneys, both kidneys are enlarged, bumpy; symptoms of renal failure are noted. A characteristic pyelogram: an elongated pelvis and branching calyxes, elongated in the form of half-moon. With a solitary cyst of the kidney, a characteristic cystogram reveals compression of the cup-and-pelvic system according to the location of the cyst.

Execution of CT allows you to clarify the diagnosis.

With hematuria and pyuria, hydronephrosis must be differentiated from pelvic tumors, pionephrosis and tuberculosis (mainly by roentgenologic methods).

When pyelocalicectasia is detected, differential diagnosis should be performed with the following conditions and diseases:

• diabetes insipidus;
• reception of diuretics;
• physiological polydipsia and polyuria;
• calyx "diverticula:
• polimegakalikozom;
• extrarenal pelvis;
• the Prune-Belli syndrome;
• paraplevikalnoy cyst;
• papillary necrosis;
• pregnancy.

In most of these diseases and conditions, a radioisotope study does not reveal a violation of kidney function.

When detecting ureteropylo-calicoectasia, differential diagnosis should be performed between vesicoureteral reflux (urethrocystography), ureterocele, megaureter, abnormalities of the ureter (retrovascular ureter, retroiliacular ureter). Diagnosis of "hydronephrosis" helps to establish excretory urography, antegrade and retrograde ureteropyelography, spiral CT.

Treatment of the hydronephrosis

Treatment of hydronephrosis has certain goals:

• Elimination of the cause of the development of hydronephrosis.
• Preservation of the kidney.
• Reducing the size of the pelvis (if necessary).

Indications for hospitalization

The patient is hospitalized if necessary for routine surgical treatment of hydronephrosis. Emergency hospitalization is indicated for the elimination of complications of hydronephrosis, such as:

• renal colic (to relieve pain and clarify the diagnosis);
• attack pyelonephritis (drainage of the kidney, antibacterial therapy);
• spontaneous rupture of hydronephrosis (nephrectomy);
• exacerbation of chronic renal failure (hemodialysis).

Non-drug treatment of hydronephrosis

Dynamic observation is used in the absence of clinical manifestations of the disease and the normal function of the ipsilateral kidney. If the kidneys function normally in children, dynamic observation for 6-12 months followed by a repeated complex examination of the child is used to avoid mistakes in the choice of treatment (with functional hydronephrosis, a variant of the pelvis development).

Conservative treatment of hydronephrosis is not of primary importance and plays an auxiliary role in the preparation of the patient for surgical treatment, as well as in the elimination of complications of hydronephrosis.

Operative treatment of hydronephrosis

Surgical treatment of hydronephrosis sets such goals:

• restoration of normal passage of urine from the kidney;
• preservation of kidney function;
• prevention of progression of chronic pyelonephritis and death of the renal parenchyma.

X-ray endoscopic and open plastic surgery is shown in the stage of one- and two-sided hydronephrosis, when the parenchyma function is sufficiently preserved, and the cause that caused the disease can be eliminated.

Indications for surgical treatment of hydronephrosis:

• frequent exacerbations of chronic pyelonephritis;
• formation of "secondary" stones;
• decreased kidney function;
• pain, leading to social disadaptation of the patient;
• chronic renal failure.

The implementation of percutaneous puncture nephrostomy or the installation of an internal stent in the preoperative period is indicated in the following situations:

• exacerbation of chronic pyelonephritis;
• progression of chronic renal failure in a bilateral process or in hydronephrosis of a single anatomical or functioning kidney;
• relief of pain in patients with severe concomitant diseases;
• terminal stages of hydronephrosis, when it is necessary to decide the choice between nephrectomy and organ-preserving surgery.

To restore the patency of LMS use the following types of operations for hydronephrosis:

• "Open" reconstructive-plastic interventions:
  • various variants of ureteropyeloanastomosis with resection or without resection of the narrowed section;
  • "Patchwork" plastic surgery;
  • ureterokalikoanastomoz;
• endourological (X-ray-endoscopic) interventions using percutaneous and transurethral approaches;
  • bougie;
  • balloon dilatation;
  • endotomy (endopyelotomy, endoureterotomy);
  • use of a balloon catheter "Acucise";
• laparoscopic and retroperitoneoscopic plastic surgery using transabdominal and retroperitoneal approaches.

The method of choice for the treatment of hydronephrosis reconstructive and plastic surgery aimed at restoring the anatomical and functional integrity of the urinary tract and preserving the organ. The efficiency of open reconstructive-plastic surgeries with hydronephrosis is 95-100%.

Advantages of open surgical treatment of hydronephrosis:

• high frequency of successful results;
• wide experience of application;
• possibility of resection of the pelvis during surgery, control of the presence of vessels in the para-urethral region;
• acquaintance of the majority of urologists with the technique of these operations.

[44], [45], [46], [47]

The disadvantages are:

• large amount of operation;
• presence of a large incision (tenderness, trauma of the muscles of the anterior abdominal wall, cosmetic defect);
• long periods of hospitalization, low economic efficiency;
• application of organ-carrying operations in case of failure (in 5-10% of cases).

In hydronephrosis, due to stricture of LMS, the following are the most known reconstructive-plastic operations.

Operation with Fengger's hydronephrosis, based on the Heinec-Mikulich pyloroplasty technique, consists of a longitudinal dissection of the ureteral posterior wall in the stricture region and cross-stitching of its walls. However, even the use of atraumatic sutures does not exclude the subsequent deformation of newly formed LMS. This method was used only in the case of hydronephrosis with "low" ureteral discharge.

With the "high" retreatment of the ureter, the VY-shaped plastic for many years had a wide distribution in accordance with Foley. The operation in several modifications is sometimes used now, especially with laparoscopic and retroperitoneoscopic access. The method consists in creating a wide funnel-shaped extension of the ureteral region of the ureter. They mobilize the upper third of the ureter and the posterior surface of the dilated pelvis. Y-shaped incision, passing from the ureter through the stricture to the lower wall of the pelvis, form a triangular flap facing the apex to the ureter. Then the top of the angle of the pelvic flap is hemmed to the lower corner of the ureteral incision. The lateral edges of the incisions of the newly formed funnel are sewn with a nodular or continuous suture without suture of the mucosa by means of an atraumatic needle. A frequent complication of this method is the necrosis of the top of the flap. Confession

Among the various variants of the "patchwork" LMS plastics, Kalp-De Wird's operation in the modification of Scardino-Prince was widely recognized. To perform it, careful mobilization of the anterior and posterior surfaces of the pelvis and ureter is required. The incision on the posterior surface of the ureter starts from healthy tissues, continues through the stricture to the posterior wall of the pelvis and further along its medial, upper and lateral margin to the lower lateral angle, cutting out the silt of the posterior wall of the pelvis, a semilunar flap 1-2 cm wide with the base at the lower edges of the pelvis. The flap is folded downwards, its edges are sewn with the edges of the ureter, due to which a new LMS is formed with a wide lumen. This operation can be used in both "high" and "low" retreatment of the ureter.

All of the above operations for hydronephrosis, despite their specific efficacy, are currently performed relatively rarely, since they all have a significant number of limitations and disadvantages, chief among which are the absence of resection of the narrowed section.

In hydronephrosis due to LMS stricture, the Anderson Hynes operation is effective, consisting in resection of the narrowed section, with an end-to-end anastomosis between the ureter and pelvis, and a pelvis resection can be performed in the presence of a large pelvic pelvis. Such an operation has become widespread.

Often the cause of hydronephrosis transformation is an additional vascular bundle to the lower segment of the kidney. Operation of a choice in a similar situation resection of the narrowed site of LMS with performance of an amtevazal pyel-pyelo- or pyelo-uretero-anastomosis. Changing the ratio between the vessel and the zone of LMS, as a result of which the vessel is behind the anastomosis and does not squeeze it.

The greatest difficulties are the treatment of hydronephrosis with an inwardly located pelvis and an extensive stricture of the LMS and the upper third of the ureter. In such situations, uretero-calico-anastomosis can be used - the Neuwirth operation. The ureter, cut off within the limits of healthy tissues, is sewed into the lower calyx, fixing it to the cup by internal seams and to the capsule of the kidney by external sutures. Disadvantages of the method: the difficulty of fixing the ureter inside the calyx and the possible formation of a similarity of the valve at the site of the anastomosis. Cases of scarring of the lower segment of the kidney with restenosis of the ureter are described. In this regard, the operation is supplemented by planar or wedge-shaped resection of the parenchyma of the lower segment of the kidney with a careful allocation of the cup for anastomosis with the ureter or perform the operation developed by NA. Lapatkin in 1979 latero-lateral uretero-pyelo-calico-anastomosis.

Operation in hydronephrosis involves careful mobilization of the kidney, its vascular pedicle and ureter. Next, resection of the medial half of the lower segment of the kidney parenchyma to its gates, widely opening the lower calyx, its neck and pelvis of the kidney and beware of damage to the main vessels. The ureter is dissected lengthwise to a length corresponding to the length of the dissected pelvis, cervix and calyx. The next stage on the intubating drainage is sewn the edges of the dissected ureter with the corresponding edges of the dissected pelvis, cervix and calyx with a continuous suture on the atraumatic needle with the capture of the edge of the kidney parenchyma. Such an operation, forming an official pelvis, creates favorable conditions for the preservation of urodynamics close to the physiological, and passage of urine from the kidney, in contrast to the Neuwirth operation, after which urinary evacuation occurs with increased hydrostatic pressure in the pelvis.

Ureterolysis - isolation of the ureter and LMS from the adhesions, is now practically not used as an independent operation for the treatment of hydronephrosis, since the removal of an external obstruction does not always eliminate the consequences of its pressure on the ureter wall. In connection with the prolonged compression of the scar strand or an additional vessel in the thickness of the ureter wall, sclerotic processes develop that cause narrowing of its lumen. In such situations it is necessary to combine ureterolysis with resection of the narrowed section, especially if after cutting the adhesion or strand on the ureter wall, the "sulcular groove" is clearly visible. With ureterolysis, for whatever purpose it is conducted, it is necessary to be guided by a firm rule - to be careful to avoid damage to the surrounding ureteral organs, to take care of cicatricial tissues and not to damage the tissue of the ureter itself. It is necessary to work "in a layer", try to maximize the use of dissection of tissues "by a sharp path," and not their delamination. Preliminary hydropreparation is advisable where possible. Gentle manipulation - prevention of recurrence of the scar process.

In most cases, after reconstructive-plastic surgery in hydronephrosis, draining of the pelvis and splinting of the LMS zone is performed. The splicing tube is removed 2-3 weeks after the operation. Nephrostomy drainage is removed from the pelvis only by restoring the free flow of urine down the ureter (usually after 3-4 weeks). Recovery of urine outflow is determined with the help of antegrade pyeloureterography.

Laparoscopic and retroperitoneoscopic surgeries with similar efficacy have no shortcomings in "open" operations. The main factors limiting the prevalence of these transactions are:

• high cost of consumables;
• technical complexity of anastomosis application;
• increased risk of anesthesia complications with a long duration of surgery.

Contraindications to the implementation of this type of operation in hydronephrosis:

• operative interventions on the abdominal organs in the anamnesis;
• repeated reconstructive-plastic surgery on the upper urinary tract.

Operation with hydronephrosis begins with pneumoperitoneum or retro-pneumoperitonemia. With the help of several trocars introduced into the abdominal cavity or retroperitoneal (4-5 trocar, one of which is injected with an endoscope connected to a video camera, and in others - various manipulators), the kidneys, pelvis and ureter are excreted in a blunt and acute way, perform a resection narrowed area (pelvis) and impose an anastomosis. To perform such interventions, special equipment is required, as well as a high qualification of a urologist who has the skills of performing both open and endoscopic interventions.

With the development of X-ray endoscopic techniques, endourological minimally invasive methods for the treatment of hydronephrosis have appeared and began to develop: bulging balloon dilatation and endotomy (endoscopic dissection) of stricture of LMS and ureter using antegrade (percutaneous) and retrograde (transurethral) approaches.

Buzhirovanie stricture consists in its expansion by successive replacement of buoya of an increasing caliber by a string-conductor under the X-ray-television control. Balloon dilatation is technically performed in the same way as balloon dilatation of vessels: radiopaque labels of a balloon under X-ray television control are set so. So that the stricture is between them: the balloon is filled with a diluted contrast agent, and as the "waist" on the balloon is removed, the expansion is narrowed. Endotomy (endopyelotomy, endoureterotomy) is performed "by eye" through a special endoscope inserted into the pelvis of the kidney or ureter; by longitudinal or oblique cutting of the stricture with a cold knife or an electrode through all the layers of narrowing to the paranephric fiber. In all methods of X-ray endoscopic treatment of stricture of LMS and ureter, stricture (intubation) of stricture is performed for 4-6 weeks (for example, internal or external stent, intubating nephrostomy). A special "cutting" balloon-catheter ("Asusise") was developed, combining the principles of balloon dilatation and endotomy.

In hydronephrosis due to stricture of LMS, the effectiveness of X-ray endoscopic interventions performed from percutaneous and transurethral access is 75-95% for primary interventions and 65-90% for repeated operations. Endopyelotomy from percutaneous and transurethral access with subsequent splicing of the stricture zone for 4-6 weeks is the most pathogenetically grounded method of X-ray endoscopic interventions. Favorable prognostic criteria for the effectiveness of X-ray endoscopic intervention:

• no indication of an operative intervention in the history ("primary" stricture);
• early terms (up to 3 months) of the operation in case of formation of a "secondary" stricture of the VMP;
• the stricture length is less than 1 cm;
• dilatation of the CLS up to 3 cm; o Insufficient (up to 25%) or moderate (26-50%) deficiency of ipsilateral kidney secretion;
• absence of data indicative of a tubal-vasal conflict, significant paraureteral fibrosis in the constriction zone.

In case of complete death of the ipsilateral kidney, nephrectomy (with stricture of LMS) or nephrectorectomy with removal of the ureter below the constriction (with ureteric strictures) is performed. In the case of death of the kidney as a result of vesicoureteral reflux or megaureter, nephrureterectomy with endoscopic resection of the bladder is performed.

Further management

After 3-4 weeks after the open and 4-6 weeks after any endoscopic operation in hydronephrosis, intubating drainage (internal stent) is removed; perform ultrasound (in the dilatation of the cup-and-pelvis system) excretory urography.

Radioisotope research is performed once a year. The control laboratory examination (general blood test, general urine analysis) is carried out one month after the operation, before the removal of the internal stent and subsequently every 3 months during the first year after the operation.

A year after the operation with hydronephrosis and in the absence of complaints, the function of the patient's kidneys should be monitored once a year and the kidney ultrasound should be performed every 6 months.

Information for Patient

A patient with a diagnosis of hydronephrosis should be informed about:

• the need for a comprehensive clinical and laboratory examination aimed at elucidating the causes of hydronephrosis and the degree of decrease in kidney function;
• whether effective treatment of hydronephrosis;
• the need to eliminate the causes that violate the outflow of urine from the kidney;
• the possibility of developing renal failure in bilateral hydronephrosis.

Prevention

Fetal ultrasound at the 16th week of gestation is an effective method of screening congenital hydronephrosis.

Prevention of the primary form of the disease is not developed. Secondary hydronephrosis can be prevented if the time is spent preventing the diseases that lead to its development.

[48], [49], [50], [51], [52], [53], [54]

Forecast

The prognosis for recovery in hydronephrosis is determined by the preserved passage of urine along the upper urinary tract and the degree of decrease in the function of the ipsilateral kidney. The prognosis for life with unilateral hydronephrosis is relatively favorable. With bilateral hydronephrosis, the prognosis is very serious due to the development of chronic renal failure due to the progression of atrophy of the parenchyma of both kidneys, pyelonephritic and nephrosclerotic processes.

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