Treatment of megoureteritis

Megaureter treatment always involves surgical intervention (except for bladder-dependent variants of the disease). In cases where megaureter is a consequence of ureterocele, an occlusive stone in the distal ureter or any other obstruction to urine outflow, surgical treatment of megaureter should be aimed at its elimination, and if necessary, combined with correction of the ureter and antireflux plastic surgery of the orifice.

Groups of surgical treatment of megaureter depending on access to the vesicoureteral sphincter area:

• intravesical;
• extravesical;
• combined.

The most popular intravesical method of ureteral reimplantation is the Cohen operation (1975). The Barry operation is the most successful variant of extravesical ureterocystoanastomosis. Among the methods of ureterocystoanastomosis from a combined approach, the Politano-Lidbetter operation is most actively performed.

Modeling of the ureter

Such a feature of ureterocystoanastomosis as modeling deserves a more extensive coverage in this article. It is quite obvious that with a pronounced expansion of the UUT in megaureter, it is not enough to limit oneself to restoring urine evacuation. In these conditions, it is necessary to reduce the diameter of the expanded ureter, that is, to perform its "narrowing". Among the methods of "narrowing" the ureter, the methods of Kalitsinsky, Matissen, Hodson and Hendren, Lopatkin-Pugachev have found application. Lopatkin-Lopatkina.

After the ureter is cut off from the bladder, it is emptied, which leads to its partial contraction.

The sharp and blunt methods are used to gradually straighten the folds and advance the ureter towards the kidney. In most cases, the megaureter is covered with embryonic connective tissue membranes ("adhesions"), which act as a fixing mechanism for the ureter's bends. Dissection of these "adhesions" allows the ureter, which is usually sharply elongated, to be straightened. Such "undressing" does not disrupt its blood supply and innervation, which is confirmed by the data of follow-up examinations of operated patients with normal contractile activity of the ureter (the presence of cystoids on excretory urograms).

The next stage of modeling is transverse resection of the ureter in order to ensure its necessary length for correct imposition of the ureterocysto-anastomosis. The resected tissue of the ureter wall is sent for histological examination, which is of significant importance in determining the timing of postoperative splinting of the anastomosis and the prognosis for restoration of contractility.

The next stage of surgical treatment of megaureter involves longitudinal oblique resection of the distal ureter. Depending on the patient's age, the length of the longitudinal resection may vary, but, as a rule, it corresponds to the lower third. N.A. Lopatkin performs ureter duplication rather than resection in order to minimize trauma to the ureter and preserve its neuromuscular elements to the greatest extent possible. When performing duplication, it is recommended to use interrupted sutures, and to apply ureterocystoanastomosis according to the "inkwell-spill-proof" principle.

The ureter is sutured along the lateral wall using absorbable suture material in a continuous manner. The lumen of the ureter after modeling should ensure unimpeded passage of urine in conditions of reduced evacuation function, and its diameter should correspond to the size of the antireflux tunnel of the bladder wall. The further course of surgical treatment of megaureter does not differ from that in the standard technique of performing ureterocystoanastomosis. Immediately before the imposition of the anastomosis, the ureter is splinted with an intubating drainage tube of the required diameter (10-12 CH). Depending on the degree of expression of sclerotic changes in the wall, which is determined by histological examination, splinting of the ureter is carried out for a period of 7 to 14 days.

As a rule, histological examination reveals a sharp decrease in nerve and elastic fibers, pronounced sclerosis of the muscular layer with almost complete atrophy of muscle bundles, fibrosis of the submucous layer, segmental ureteritis.

The effectiveness of ureterocystoanastomosis in megaureter, depending on the method of surgery, is 93-99%.

In case of an extremely pronounced decrease in the secretory capacity of the kidney (secretion failure during dynamic nephroscintigraphy of more than 95%), nephroureterectomy is performed.

In case of immediate threat to the patient's life due to renal failure or purulent-septic complications with megaureter, a "rescue" ureterocutaneostomy (suspension, T-shaped, terminal) is performed, which allows the patient to be brought out of a serious condition. Subsequently, after eliminating the main cause of megaureter, ureterocutaneostomy is performed.

An alternative method of urine diversion from the UUT is percutaneous puncture nephrostomy, which is considered less traumatic compared to ureterocutaneostomy. Subsequently, there is no need to perform repeated surgical treatment of megaureter to close the ureterocutaneostomy.

Treatment of megaureter: minimally invasive methods

Recently, various minimally invasive methods of treating megaureter have been increasingly actively introduced:

• endoscopic dissection;
• bougienage;
• balloon dilation;
• PMS stenting for obstructive megaureter;
• endoscopic introduction of bulking agents into the ureteral orifice in refluxing megaureter.

However, the lack of data on the long-term consequences of minimally invasive methods of megaureter treatment determines the limited use of these methods. Minimally invasive methods are mainly used in weakened patients; in the presence of severe concomitant diseases and other contraindications to the generally accepted open methods of surgical treatment of megaureter.

Thus, surgical treatment of megaureter in neuromuscular dysplasia of the ureter is aimed at restoring the passage of urine from the renal pelvis through the ureter into the bladder, reducing the length and diameter without violating the integrity of its neuromuscular apparatus and eliminating VUR. More than 200 methods of correction for its dysplasia have been proposed. The choice of the method and method of surgical intervention is determined by the nature and degree of clinical manifestation of the disease, the presence of complications, and the general condition of the patient.

Conservative treatment of megaureter is not promising. It can be used in the preoperative period, since with the most careful selection of antibacterial agents it is possible to achieve remission of pyelonephritis for several weeks and very rarely - for several months.

However, if normal renal function is established (radioisotope research methods), it is advisable to temporarily abandon surgical treatment of megaureter, since differential diagnostics between neuromuscular dysplasia of the ureter, functional obstruction, and disproportion of its growth in young children is extremely difficult.

If loss of kidney function is detected, surgical treatment of megaureter is indicated.

Palliative surgeries (nephro-, pyelo-, uretero- and epicystostomy) are ineffective. Radical methods of treating neuromuscular dysplasia of the ureters are indicated. The best results are obtained in patients operated on at stages 1 and 2 of the disease. The majority of patients are referred to the clinic for urological examination and treatment at stage 3 or 2 of the disease. At stage 3, indications for surgery are relative, since at this time the process in the kidney and ureter is practically irreversible. Consequently, the effectiveness of treatment for megaloureter can be increased, first of all, by improving the diagnostics of this developmental defect, that is, by more widespread introduction of uroroentgenological examination methods into the practice of somatic children's hospitals and clinics.

Surgical treatment of megaureter is indicated at any age after diagnosis and preoperative preparation according to general requirements. Waiting tactics for this disease is unjustified. Plastic surgeries give the better result the earlier they are performed.

Nephroureterectomy is used only in cases of irreversible destructive changes in the kidney, a sharp decrease in its function and the presence of a healthy contralateral kidney.

A. Ya. Pytel, A. G. Pugachev (1977) believe that the main tasks of reconstructive plastic surgery for neuromuscular dysplasia of the ureter are excision of the area creating the obstruction, modeling the diameter to a normal caliber, neoimplantation into the bladder, and antireflux surgery.

Experience shows that simple ureteral reimplantation fails to create a satisfactory functioning opening, since resection of the distal section damages the entire complex antireflux mechanism. Surgical treatment of megaureter should be aimed at normalizing urodynamics and eliminating VUR. Direct or indirect ureterocystoneostomy without antireflux correction is complicated by VUR in most patients, which contributes to the development of irreversible destructive processes in the renal parenchyma. Antireflux operations can be successful provided that a long submucosal canal is created. The diameter of the reimplanted ureter should be close to normal. Therefore, when reconstructing the ureter, it is not enough to resect the excess length of the section.

Megaureter surgeries

Operation by Bischoff

The corresponding half of the bladder and the pelvic part of the ureter are mobilized. The ureter is dissected, preserving the pelvic part of the section. The expanded part of the distal section is resected. A tube is formed from the remaining part and sutured with the preserved section of the intramural section of the ureter. In case of a bilateral anomaly, surgical treatment of the megaureter is performed on both sides.

J. Williams, after resection of the megaloureter, implants the ureter into the wall of the bladder in an oblique direction, creating a "cuff" from the wall.

Operation according to V. Gregor

A lower pararectal incision is made. The peritoneal sac is bluntly dissected and moved to the opposite side. The ureter is exposed and isolated extraperitoneally from the opening in the bladder. Then the posterior wall of the bladder is isolated and dissected to the mucous membrane from the place where the ureter enters towards the apex at a distance of 3 cm. The ureter is placed in the wound, and the wall of the bladder is sutured above it with knotted sutures. The wound is sutured tightly.

V. Politano, V. Leadbetter: the reimplanted ureter is first passed under the mucous membrane of the bladder for 1-2 cm and only then brought to the surface and fixed.

Some authors excise the narrowing of the ureteral opening and suture its end into the formed opening in the wall of the bladder.

Operation according to N.A. Lopatkin - A.Yu. Svidler

After the ureter is formed using M. Bishov's method, it is immersed under the serous membrane of the descending colon, i.e. ureteroenteropexy is performed. According to the authors, the ureter is well "embedded" in the surrounding tissues, and a vascular network is formed between the intestine and the ureter, providing additional blood supply. The disadvantage of this treatment of megaureter is that it can only be performed on the left side. On the right, immersion can only be antiperistaltic, which disrupts the passage of urine. In addition, this operation does not eliminate the expansion of the lower ureteral cystoid. A significant disadvantage of this method is the need for complete mobilization of the lower cystoid, which leads to complete avascularization and denervation.

Taking these shortcomings into account, N.A. Lopatkin, L.N. Lopatkina (1978) developed a new method of surgical treatment of megaureter, which consists of the formation of an intramural valve while maintaining the vascularization and innervation of the ureter, its muscular layer, as well as narrowing the lumen of the expanded part to a slit-like one by means of duplication.

Operation by N. Lopatkin-L.N. Lopatkina

An arcuate incision is made in the inguinal region. The upper angle of the incision may reach the costal arch. The dilated portion of the ureter is mobilized. A special feature of this stage is the extremely careful attitude towards the ureteral vessels. The most affected area that has lost contractility (usually the lower cystoid) is resected not along the border of the intercystoid stenosis, but retreating 1 cm, that is, along the lower cystoid. A ureteral duplication is formed along the remaining dilated cystoids (with full preservation of its vessels) on a splint with a continuous suture of chromic catgut, starting from the intercystoid stenosis. The sutures should be converging. A special feature of the ureterocystoanastomosis is the formation of an antireflux ridge from the flap of the lower cystoid (in front of its opening).

The opening resembles a snail-like formation. Thus, the duplication of the ureter narrows the lumen, and the resulting blind channel functions as an anatomical valve: at the moment of urination or when intravesical pressure increases, the urine flow rushes to the ureter and fills both of its channels. The blind channel, overfilled with urine, touches the through channel with its walls and blocks the flow of urine from the bladder to the pelvis.

Surgical treatment of megaureter proposed by N.A. Lopatkin and L.N. Lopatkina (1978) is qualitatively different from interventions based on resection of the ureter by width. The authors achieve narrowing of the ureter lumen not by cutting out a strip of a certain width from it, but by creating a duplication. This technique has a number of advantages. Resection by width disrupts the blood supply to the abnormal ureter over a significant distance. When a long wound surface cicatrizes, the ureter turns into a rigid tube with a sharply impaired contractility. Formation of a duplication does not disrupt its blood supply, and due to the "doubling" of the wall, the peristaltic activity of the ureter is somewhat enhanced. With neoimplantation, the "doubled" wall, forming a ridge around the artificial opening, prevents reflux.

A.V. Lyulko (1981) performs this operation as follows. The ureter is exposed extraperitoneally by a club-shaped incision and mobilized along the dilated portion. Then, retreating 2 cm from the wall of the bladder, the lower cystoid is resected and its distal end is invaginated into the bladder through the opening. Along the remaining dilated cystoids of the central section of the ureter, while preserving its mesentery and vessels, a duplication is formed by applying a continuous catgut suture on a splint. After this, the central end is passed into the bladder through its invaginated distal end using a specially created clamp. Both ends are sutured with interrupted catgut sutures. If the distal end of the invaginated ureter is very narrow and it is not possible to pass the end, it is dissected lengthwise and additionally fixed to the duplication with separate catgut sutures.

A. V. Lyulko, T. A. Chernenko (1981) conducted experimental studies which showed that the formed "papilla" does not atrophy, but flattens and is covered with the epithelium of the urinary bladder. Even when creating high intravesical pressure, the formed anastomosis in most cases prevents the occurrence of VUR.

It is extremely difficult to develop a treatment plan for patients with bilateral neuromuscular dysplasia of the ureter in stage III of the disease with symptoms of chronic renal failure. In such patients, surgical treatment can be performed in two stages. First, nephrostomy tubes are applied, and then radical surgical intervention is performed on the distal sections. In recent years, this tactic has been abandoned. First, intensive detoxification therapy, antibacterial treatment, and a regime of forced frequent urination are performed.

After some improvement in the condition, a decrease in the activity of pyelonephritis symptoms, a radical operation is performed with subsequent longer drainage of the operated ureter and bladder. In such patients, a one-stage operation on both sides is effective, since in the postoperative period there is a very high risk of exacerbation of pyelonephritis or the development of its purulent forms in the kidney drained by the non-operated ureter. In cases where the patient's condition does not allow a one-stage corrective operation on both sides, a nephrostomy is applied on the second side.

Surgery for neuromuscular dysplasia of the ureters should be considered as one stage in complex therapy. Before and after surgery, patients should be prescribed anti-inflammatory drugs strictly under the control of antibiograms. Young children (under 3 years) and older children with clinical manifestations of chronic renal failure in the immediate postoperative period, in addition to intensive antibacterial treatment, are prescribed infusion therapy for 5-7 days. Monitoring and correction of the electrolyte composition of blood plasma, normalization of the acid-base balance are necessary. Blood transfusions in fractional doses depending on the child's age at intervals of 2-3 days, vitamin therapy are indicated. In order to more quickly sanitize the ureteral urinary tract, it is necessary to wash the drainage tubes inserted into the ureters and bladder with a solution of dimethyl sulfoxide or other antiseptics.

After discharge from the hospital, patients should be under the dispensary observation of a urologist, and pediatric patients - under the observation of a pediatrician. Every 10-14 days continuously for 10-12 months, it is necessary to carry out antibacterial treatment with a change of drugs, preferably based on the data of bacteriological analysis of urine and antibiogram. It is advisable to combine oral administration of antibacterial agents with their local use by iontophoresis (iontophoresis of antiseptics, potassium iodide, neostigmine methyl sulfate, strychnine, inductothermium, electrical stimulation). The appointment of hyaluronidase, pyrimidine bases, aloe and other biogenic stimulants in the postoperative period helps to improve the blood supply to the operated ureter, reduce sclerosis and enhance reparative processes in the wall of the urinary tract and in the surrounding tissues.

Further management

Outpatient monitoring of patients who have undergone surgical treatment of megaureter should be carried out by a urologist and a nephrologist, and for pediatric patients - by a pediatrician. Good patency of the PMS and the absence of exacerbations of pyelonephritis for 5 years allow the child to be removed from the register.

Forecast

The postoperative prognosis for megaureter largely depends on the preservation of kidney function.