PYONEPHROSIS (pyonephrosis; grech, pyon pus + a nephrosis) — a purulent inflammation of a kidney, at Krom owing to extensive destruction of fabric it turns into a thin-walled cavity with purulent contents.
The first references of P. belong to 2 century AD. In K. Galen's works there are also data on this disease. In 1622 N. van Tulp executed operation of opening of a pionefrotichesky calculous kidney with removal of concrements then recovery followed. In domestic literature of P. it was for the first time described by A. A. Nechayev (1883) and Island V. Korzhenevsky (1888). The first nephrectomy concerning P. in Russia was executed in 1884 Yu. F. Kosinskpm.
The disease occurs at any age, but a thicket at persons 30 — 40 years. At P. children develops seldom; it is generally caused by malformations of bodies of urinogenital system.
The etiology and a pathogeny
In P.'s etiology plays the main role infection of a kidney various, hl. obr. the mixed flora in which find colibacillus, staphylococcus, a streptococcus, a .mikobakteriya of tuberculosis more often. P.'s development is promoted by obstacles to outflow of urine or disturbance of regulatory mechanisms of its removal. Mechanical obstacles to outflow of urine arise at the inborn or acquired narrowing of an ureter or an urethra, malformations of urinogenital system (an allotopia, a fused kidney, doubling of a kidney, doubling of ureters). However the most frequent factor promoting P.'s emergence is nephrolithiasis (see), followed by disturbance of passability of upper uric ways and thereof frustration uro-and a hemodynamics in a kidney. Bilateral P. is observed generally at patients with the complicated bilateral nephrolithiasis. Nonspecific P. can be an outcome pyelonephritis (see), the passage of urine which is followed by disturbance owing to a nefroureterolitiaz, a stricture or a prelum of an ureter, a vesicoureteral reflux with an atony of an ureter. Tubercular P. is a final stage of a nephrophthisis and uric ways.
The pathological anatomy
Usually pionefrotichesk the changed kidney is increased in volume. Macroscopically she reminds a thin-walled bag on which surface there are protrusions corresponding to the stretched renal cups and the involved hems. Stagnation of the infected urine leads to expansion of pyelocaliceal system with a prelum and an atrophy of a parenchyma of a kidney. The replacement of tissue of a kidney in intervals between cups fibrous and fatty tissue leads to sharp narrowing of their anastomosis with a pelvis therefore the kidney is consisting of a number of the cavities containing pus, a part completely closed, a part reported with a pelvis (the so-called closed and open P.). The renal pelvis at an extrarenal arrangement is increased, and at an intra renal arrangement — the usual sizes. The parenchyma of a kidney is kept slightly. In it the phenomena hron, inflammations with death of the majority of balls and tubules, a sclerosis and fatty dystrophy are observed. Walls of a pelvis dense, infiltrirovanny. Preferential marrow in the form of diffusion and focal growths of intersticial fabric is surprised. The centers of an inflammation contain a significant amount nucleinic to - t and a glycogen. In late stages of P. dystrophic and necrobiotic changes of epithelial cells and an atrophy of cortical substance of a kidney are observed. In pionefrotichesk to the changed kidney sites of calcification and stones quite often meet. As a result hron, inflammatory process with a sklerozirovaniye in which are always involved a fibrous renal capsule perinephric cellulose and vessels, happens a spayaniye of a pionefrotichesky bag to surrounding fabrics and sharp reduction of caliber of vessels of the renal leg surrounded with a neogenic dense fatty tissue. The expressed changes are noted also in an ureter on the party of defeat (a thickening of its wall, reduction of caliber, disturbance of uniformity of a gleam and a strong spayaniye with a peritoneum).
A clinical picture
At unilateral open P. complaints to dull ache in lumbar area are characteristic. For a long time body temperature can remain normal, sometimes subfebrile, the general state satisfactory. The main symptom during this period is the massive pyuria (see. Leukocyturia ). The periods of relative wellbeing can alternate with attacks of pains, substantial increase of temperature. The aggravation of process is caused by disturbance of outflow of purulent urine (migration of a stone, an aggravation of an ureteritis and a periureteritis, ureteral occlusion purulent masses). Along with it the pyuria disappears. At a palpation the painful kidney increased slow-moving dense, sometimes is defined. The sizes of a kidney and morbidity in the period of a zatikhaniye and an aggravation of process are various. The size of the probed kidney does not give a fair idea of the sizes of a purulent bag owing to masking by its massive stratifications of a pararenal fatty tissue. Bilateral P. along with the described symptoms is followed by signs renal failure (see).
At it is long the current P. other kidney can be exposed to amyloid degeneration. In the beginning it is shown by toxic nephrite (see), caused by nephrotoxins of the affected kidney. Such nephrite is not a contraindication for removal of a pionefroticheska of the affected kidney; after operation elimination of nephrite is possible. In rare instances at P. the integrity of the fibrous capsule is broken that leads to emergence of purulent paranephritis (see). In the subsequent pus can break in an abdominal cavity, intestines, a pleural cavity, bronchial tubes with formation of internal fistulas.
The diagnosis is based on anamnestic data, a wedge, signs and results laboratory, endoscopic and rentgenol, researches. The massive pyuria is a characteristic sign of P. (see. Leukocyturia ), disappearing in the period of ureteral occlusion or purulent cavities. Urine contains a large number of leukocytes and microbes. At tsistoskopiya (see) a mucous membrane of a bladder it is usually not changed, the mouth of an ureter on the struck party often gapes and from it muddy urine or dense pus is emitted (as paste from a tube). At hromotsistoskopiya (see) indigo carmine usually it is not allocated. At tubercular P. specific changes of a mucous membrane of a bladder are observed (grumous rashes, hypostasis, etc.). On survey Urogramum the dense shadow of the increased kidney is often visible, is absent or indistinctly the contour of a lumbar muscle is defined. At tubercular P. the centers of calcification in a renal parenchyma are quite often visible. On excretory Urogramums there is no release of contrast medium the affected kidney. A retrograde ureteropiyelografiya (see. Piyelografiya ) allows to reveal cavities of various size with uneven contours and changes of an ureter (fig). At tubercular P., besides, chetkoobrazny change of an ureter is defined. On an arteriogram-move vessels of a kidney are thinned, extended, deformed, the drawing of a kidney is absent or is poorly expressed in certain sites. Ultrasonic investigation (see. Ultrasonic diagnosis ) reveals existence of ekhonegativny formations of various size with ekhostrukturny inclusions that is caused by purulent contents. Given to a radio isotope renografiya (see. Renografiya radio isotope ), scannings of kidneys (see. Scanning ) and stsintigrafiya (see) specify a pas lack of function of a kidney. The research by means of a computer tomography is very valuable (see. Tomography computer ).
Treatment operational. At unilateral process usually resort to one - or double-stage nephrectomies (see). Method of the choice is primary nephrectomy. Double-stage operation is shown at serious condition of the patient with the expressed intoxication, is frequent with break of pus in pararenal cellulose. At first carry out nephrostomy (see) and after the general condition of the patient improves — nephrectomies). Due to the existence of unions of a kidney with surrounding bodies and fabrics the nephrectomy can be considerably complicated and be followed by complications (opening of belly or pleural cavities, injury of intestines, the lower vena cava, etc.) therefore usually make a subkapsulyarny nephrectomy according to Fedorov. At thoracoabdominal access more optimal conditions for mobilization of a vascular leg and allocation of a kidney and perinephric cellulose from the changed surrounding fabrics are created, danger of intraoperative complications decreases. At a bilateral pyonephrosis carry out bilateral nephrostomies).
The forecast and Prevention
the Forecast at unilateral P. after radical operational treatment favorable. At bilateral process the bilateral nephrostomy allows to prolong life of the patient.
Prevention: timely diagnosis and treatment of diseases of the uric ways which are followed by disturbance of outflow of urine and infection of a kidney.
Bibliography: Aliyev S. S. The observation of a spontaneous rupture of a pionefroticheska of the changed kidney which was complicated by diffuse purulent peritonitis, Klin, hir., No. 9, page 77, 1968; The Guide to clinical urology, under the editorship of A. Ya. Pytel, t. 1, page 379, M., 1969; Cukier J., And yes b e of t J. et BrocA. Les pyon6phroses, J. Urol. Nephrol., t. 77, p. 737, 1971; J i m e n e z J. F. a. o. Treatment of pyonephrosis, J. Urol. (Baltimore), v. 120, p. 287, 1978; K o s i n s k i I. Wyci-§cie nerki (nephrectomia), Medycyna, t. 12, s. 645, 1884; Ro metti A. et Boschi J. A propos de trois pyonephroses avec phlegmon perinephretique, J. Urol. Nephrol. t. 81, p. 263, 197 5.
T. D. Datuashvili.