Disorders in the work of the ureters: causes. How to treat

Disadvantages in the functioning of the ureters - a fairly common disease of the reproductive and urinary system. They account for 13.4% of all defects in the development of the kidneys and upper urinary tract.

The basic signs of classification of anomalies in the development of ureters are: their number, location, shape and structure.

At present, there exists a classification, approved by all, approved at the second All-Union meeting of urologists in 1978:

  • deviations in the number of kidneys (aplasia, an increase in the number of kidneys twice, three times, and others);

  • disturbances in the location of the kidneys (retrocaval or retroileal ureter, ectopic ureteral lumen);

  • defects in the shape of the kidneys (corkscrew or annular);

  • defects in the structure of the kidneys (hypoplasia, neuromuscular dysplasia, including achalasia, megaureter, hydroureteronephrosis, ureterocele, valves, diverticula).


  • Anomalies in the number of ureters



    Aplasia, or ureteral agenesis is a particularly rare type of anomaly. Defectiveness arising from both sides is often accompanied by renal agenesis, which also occurs from two sides. Not so often it is accompanied by a bilateral cystic kidney. Such an anomaly is considered fatal.

    The increase in the number of ureters is considered to be one of the most numerous birth defects of the urinary system. Such a defect is characterized by the simultaneous development of two ureters from the two ureteral sources of the nephrogenic blastema or the separation of one ureteral source. In this case, one of them can grow correctly, and the second - with violations. It is characteristic that one ureter transports urine from the upper part of the kidney, and the second - from the lower part. While the upper part is smaller and consists mainly of only 2-3 cups. Duplication of ureter is complete (ureter duplex) and partial (ureter fissus). A partial type of disturbance appears due to the separation of the mesonephrosis duct (until unification with the metanephrogenic blastema) for branching before the normal period. This division may well begin both in remote areas and located closer to the center of the ureter.

    The development of complete doubling is achieved by the appearance of two channels of mesonephrosis on one side, directed towards the metanephrogenic blastema. According to the Meyer-Weigert law, from the part of the kidney located at the top, the ureter will enter the bladder below, and into a place closer to the median longitudinal plane (ectopic ureter) with respect to the ureter that drains the lower part (orthotopic ureter). In the case of doubling the number of ureters, they are often directed in a single fascial bed. In more detail, this type of deviation is described in the section devoted to the anomalies of the number of kidneys. An increase in the number of ureters to three (triplication) is observed in very rare cases.

    Deviations of the normal location of the ureters



    The retracing ureter - relatively infrequent deviation in development - only 021%, characterized by a spiral-like coverage of the lower hollow vein at an elevation of L3-4 by the right ureter.

    Retroiliac ureter - a very rare deviation due to placement of the ureter behind the common or external iliac vein. Excretory urography, as a rule, determines the J-shaped deflection of the upper third part of the ureter by obstruction in the backbone zone, and only retrograde ureterography gives the chance to determine the S-shaped bend.

    Cavography does not provide ancillary data, computed tomography and magnetic resonance imaging also contribute to the identification of a urinary incompatibility. If necessary, CT can be used as an additional option for retrograde ureterography. The spiral type of computed tomography makes it possible to visually show the course of the ureter. Such abnormalities are accompanied by symptoms of ureterohydronephrosis. The goal of the treatment is correction of urodynamics with the exception of the backbone or pozadieleakalnoy zone of the ureter. It is carried out by an open and laparoscopic method.

    The pathology of development, in which the orifice of the ureter is bifurcated and located incorrectly, and also, if its lumen emerges into the urethra or vagina cavity, is called ectopic opening of ureter .

    In general, the ectopic ureteral opening is accompanied by such a deviation in the structure of the urinary system, like ureterohydronephrosis. However, ectopia itself is difficult to diagnose with ultrasound. However, MRI and MSCT allow you to make an accurate diagnosis even in severe cases, when the kidney function is greatly reduced. Cure ectopia can only be surgical. When narrowing (stricture) of the terminal segment of the ureter is performed ureterocystostomy. With terminal changes in the kidneys perform a nephrectomy.

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    Pathology of the structure and shape of the ureters



    Mochetochnik in the form of a ring or corkscrew - such a pathology is extremely rare. It was discovered by M.E. Campbell, who had an autopsy of 12080 children, met her only twice. With this deviation, the ureter turns around several times around the kidneys, while hydronephrosis and narrowing of the LMS develops.

    A violation of embryo development, expressed in a decrease in the size (hypoplasia) of the ureter and the associated kidney or its half, is often accompanied by the presence of multicystic kidney dysplasia. In this case, the ureter strongly narrows in the section, and in some segments it can be completely obliterated.

    A fairly common deviation in the structure of the ureters is stenosis. Narrowing of the ureter is most often found in the tubular ureteric anastomosis, the vesicoureteral segment, and in rare cases in the zone of the cross with iliac vessels. Determine whether the narrowing of the ureter lumen congenital or later developed is impossible in either clinical or histological ways. Correction of this pathology is performed surgically. If the kidneys continue to function, then the recovery of the urinary function is performed. In case of terminal changes of the kidney and upper urinary tract, it is removed by nephrectomy.

    Duplicate, consisting of the tissue of the urothelial membrane, forms the ureter valve. In some cases, such a valve is formed immediately from all types of tissue of the ureter wall. Detect the valves most often in the circumcise, okololohanochnom, as well as the pelvic parts of the ureter. Diagnose this violation is equally rare, both in boys and girls. Valves can be formed in both the right and left ureters. This pathology leads to a violation of excretion of urine, and, as a consequence, ureterohydronephrosis. As a rule, correction is performed surgically.

    A hollow neoplasm that connects to the lumen of the ureter is called a diverticulum. As a rule, it is localized in the lower part of the ureter. Can be either single or multiple. However, this deviation is extremely rare. According to the structure of the tissues, the diverticulum somewhat resembles the walls of the ureter. Diverticulum can be detected using excretory urograms. It looks like a darkening of the saccular or spherical shape on the ureter in the pelvic region.

    Cystoid enlargement of the intravesical ureter is called a ureterocele. This disorder is expressed in the cystic bulging of one of the walls of the distal ureter into the bladder, which prevents the urine from freely entering the bladder from the kidneys. Outside, the ureterocele is protected by the mucous membrane of the bladder, and its cavity has a ureteric mucosa. It consists of a cystic formation from the cells of the ureter's walls.

    The pathology of ureterocele is diagnosed quite often, it accounts for 1.6% of abnormalities in the structure of the upper urinary tract and kidneys. When the ureter is bifurcated, the ureterocele occurs quite often, and it can be either one-or two-sided. The main cause of ureterocele is an insufficiently developed neuromuscular apparatus in the distal ureter with a reduced diameter of the mouth. In the overwhelming majority of urological units, patients with ectopic ureterocele prevail - about 80%. This is due to the high ability of ureterocele to destroy kidney tissue due to impaired urine circulation. Adult often affects the orthotopic ureterocele.

    It is worth noting that the orthotopic ureterocele is able for a long time not to manifest external symptoms and not lead to a disturbance of the urinary function and stagnation of urine. In this case, it is not necessary to correct it. There are a lot of ways to diagnose this pathology at present, so it is quite easy to detect it. Ultrasound is one of the mandatory diagnostic procedures to detect a ureterocele. Also effective: excretory urography, retrograde cystography, to determine the presence of vesicoureteral reflux, magnetic resonance urography, MRI, computed tomography, MSCT. On X-rays, the ureterocele looks like a slightly more contrasting round spot at the junction of the ureter with the bladder. MRI and MSCT also allow you to consider a circular hollow formation on the border of the ureter and bladder.

    Physicians disagree about the advisability of direct surgical intervention, while many favor endoscopic treatment of ureterocele. Minimally invasive surgery to remove the ureterocele may be of several types:

  • surgical incision of ureterocele with the help of a one-stage ureterocystostomy, performed even in those cases when half of the kidney, or it all, functions at a minimum level;

  • if the functional capacity of the kidney is preserved, perform pyelo- or uretero-ureterostomy. In this case the ureterocele can be removed, dissected or left in its original state;

  • heminephrectomy, which may be accompanied by a cut or removal of the ureterocele, or not accompanied.


  • Such operations are welcomed by most of the children's urologists. The high probability of formation of vesicoureteral reflux after endoscopies with dissection of the ureterocele is perhaps the most weighty argument of supporters of open-type operations. Endoscopic intervention was first announced by Dr. Zielinski in 1962. And although the doctors admit the probability of PMR in endoscopy, there is, in their opinion, a way out. For those 30% of patients who develop reflux, it is suggested to adjust it using reconstructive surgeries. In this case, with the help of endoscopy, the first stage of treatment of the upper urinary tract is made to reduce their expansion. This greatly facilitates the further treatment. Approximately 5238% of ureterocele patients undergo no urinary retention in the kidney and urinary function disorders. In this case, the patient is simply under observation, and no surgical correction is performed.

    Treatment



    Very often cases when congenital pathologies of the VMP and kidneys contribute to the development of other diseases of the urinary system, such as: urolithiasis, ureterohydro- and hydronephrosis, acute pyelonephritis, kidney tumors. Since their manifestations are largely similar, the causes and effects during the diagnosis can be misinterpreted.

    Hence the complexity of the treatment of certain diseases. An additional complication is the effect of one or another pathology on the method of treatment, as well as on the conduct of operations.

    Modern technologies in the treatment and diagnosis of malformations of VMP and kidneys allow to determine with accuracy the type of disturbance, the condition of nearby organs and their interaction with the urinary system. Studies in the field of small and non-invasive methods of treatment of steel are now very relevant, because direct open intervention and outdated technology gave only a vague picture of the disease some decade ago.