URETER [ureter (PNA, JNA, BNA)] — an output channel, on Krom urine from a renal pelvis comes to a bladder.
Embryology, anatomy and histology
At the person M. develops in the form of an outgrowth of a mezonefralny channel at the beginning of the 2nd month of embryonic development. This outgrowth forms semi-spherical expansion of laying of a renal pelvis, around to-rogo concentrates mesenchyma (see), creating so-called metanephrogenic fabric. From the last the parenchyma of a definitivny kidney (fig. 1) develops.
The m has an appearance of the cylindrical, slightly flattened tube. The narrowed piece of a renal pelvis is considered M.'s beginning. M.'s end obliquely probodat a wall bladder (see) also opens from his mucous membrane a slit-like ostium ureteris (ostium ureteris). M.'s wall contains a muscular coat (tunica muscularis). It has no correctly located isolated layers: outside circular (stratum circulare), internal longitudinal (stratum longitudinale) and additional outside longitudinal layer (stratum longitudinale ext.), the M located in the bottom. The muscular layer of M. consists of fancy textures of the muscle bundles of various thickness going in the slanting, longitudinal and cross directions. The course of muscle fibers reminds curls of a snail or the space extended spirals, to-rye from the outside and from above pass through M.'s wall of a knutra and from top to bottom. The mucous membrane (tunica mucosa) covering M. consists of a multirow transitional epithelium and of own plate of a muscular coat (lamina propria mucosae) rich with elastic fibers. Throughout M. the mucous membrane forms longitudinal folds. Falling slantwise, at an acute angle in a bladder, M. an upper part of a wall forms the fold covered on both sides by a mucous membrane. Thanks to the muscle cells which are contained in its thickness it is capable to be reduced and close M.'s gleam, interfering with flowing of urine from a bladder in M. Outside M. is shrouded by an extima (tunica adventitia) and covered with a fascia.
The m is located in retroperitoneal cellulose of a back wall of a stomach and passes to a sidewall of a small pelvis. Respectively distinguish 2 departments of M. — belly and pelvic. M.'s length at the adult fluctuates from 28 to 34 cm depending on growth of an individual and height of an arrangement (bookmark) of a kidney; The M is shorter on the right, than at the left, approximately on 1 cm Apprx. 1,5 cm of M. is located in the thickness of a wall of a bladder (pars intramuralis). In M.'s diameter it is not identical — narrowings alternate with spindle-shaped expansions (fig. 2).
The narrowest gleam of M. has at the beginning (to dia. 2 — 4 mm) and in the place of transition to a small pelvis (to dia. 4 — 6 mm). The widest is its belly department, at the adult its width is equal to 8 — 15 mm. The pelvic department of M. represents evenly expanded tube with a diameter of gleam up to 6 mm. M.'s wall has big elasticity, at difficulties in outflow of urine M. is capable to extend considerably (to 8 cm in the diameter).
M.'s vessels are located in an extima in the form of the long thin descending and ascending loops. Arterial ureteric branches (rami ureterici) depart in an upper part from renal arteries, yaichkovy or ovarian arteries, in lower — from branches of an internal ileal artery (umbilical, vesical, uterine). Venous blood flows in veins, of the same name with arteries. Regional limf, nodes are for a lower part internal ileal limf, nodes, for an average — lumbar limf, nodes, for upper — lumbar (renal) limf. nodes.
The innervation is carried out due to vegetative neuroplexes of an abdominal cavity and a basin.
Topography. At well developed renal pelvis of M. begins below its decussation with renal vessels; at a short pelvis its beginning lies behind renal vessels. The belly department of M. lies on the anteroexternal surface of a big lumbar muscle, being projected on cross shoots of vertebrae. Going down from top to bottom, it obliquely crosses this muscle so at an excess through ileal vessels it appears on its medial surface. Above ileal vessels at medial edge of a big lumbar muscle of M. cross yaichkovy vessels. From M., except yaichkovy vessels, various departments of intestines with vessels and a mesentery and sites of a parietal peritoneum (fig. 3, 4, 5) are located with Kperedi. The pelvic department of M. passes at the level of a sacroiliac joint (sometimes a little lateralny it) directly behind a peritoneum of a kpereda from internal ileal arteries and a vein. In a small basin of M. lies on its sidewall, evading kpered and knutr. From the medial party it crosses umbilical and a locking artery, a vein and a nerve. After this M. is bent knutr and approaches a bladder, crossing at right angle a deferent duct. At women in the field of an entrance to a small pelvis of M. crosses vessels of an ovary, slightly below it lies near an ovary, separating from it only a leaf of a peritoneum. Going down from top to bottom, M. enters a parametrium where prilezhit at the level of an isthmus of a uterus to a uterine artery (fig. 6), and then, passing about a perednebokovy wall of a vagina, falls into a bladder.
M.'s Activity is inseparably linked with operation of the sphincteric device of cups, a pelvis of a bladder. Coordinate function of these departments of an uric path provides normal urodynamic of the person. The m possesses autonomous rhythmical motor function. The generator of rhythmic reductions of M. is the pacemaker (pacemaker) located most often in the field of a top of a lokhanochno-ureteric anastomosis, however also its other arrangement is possible. There are two theories of transport of urine according to M. — tsistoidny and peristaltic. It agrees the first, in M. distinguish 2 — 4 dynamic sections — tsistoida. Consecutive reduction overlying and expansion underlying sections provides advance of urine in a bladder. The role of sphincters is carried out by the vascular educations located in the area fiziol, M.'s narrowings (the tsistoidny type of advance of urine arises only in the presence of supertension in M). According to the second theory transport of urine according to M. is carried out thanks to active peristaltic reduction which is characterized by simultaneous longitudinal shortening and circular narrowing of a gleam. The rhythm of reduction changes depending on position of a body, breath, speed of formation of urine, a condition of a nervous system, irritation of the lower uric ways. Sokratitelny ability of smooth muscles of M. is in direct dependence on concentration of calcium ions in it. M.'s reduction is connected with passing of excitement on neuromuscular structures, at the same time an excitation wave as S. A. Bakunts (1970) showed, by 0,15 — 0,2 sec. advances a peristaltic wave. According to G. F. Kolesnikova (1977), the frequency of reductions of M. makes 3 — 5 in 1 min., duration of a wave 2 — 5 sec., an interval between waves 9 — 27 sec. At the same time the renal pelvis is reduced by 3 times more often than M. Boley high, in comparison with a pelvis and a bladder, the intra urethral pressure equal of 40 cm w.g. in an upper part and to 60 cm w.g. in a lower part, it is capable to provide the maximum perfusion of urine, equal 10 ml/min., and to support by that normal urodynamic. At the same time pressure in pelvic department of M. changes in rather wide limits depending on pressure in a bladder. Thanks to a uniform innervation of a terminal part of an ureter, mouths, a vesical triangle coordinate activity of an ureter and a bladder and by that vesicoureteral is warned is provided reflux (see).
Methods of a research
In assessment of an anatomo-functional state and diagnosis of diseases of M. use all-clinical (the anamnesis, survey, a palpation, percussion), rentgenol, and tool methods of a research.
Existence of a painful symptom is characteristic of the majority of diseases of M. Pain can have the aching, pricking, pristupoobrazny character and to irradiate from lumbar area in a bottom of a stomach: from an upper part of M. to the celiac or ileal area, from average department to the inguinal area, from lower — in generative organs. The dysuria is characteristic of defeat of pelvic and intraparietal departments of M. At a palpation determine a muscle tension of a front abdominal wall and morbidity by the course of M. The lower part of M. can be palpated at a bimanual research through a vagina or a rectum. At a lab. research urine (see) in a case of M. find leukocyturia (see) and hamaturia (see). Tsistoskopiya (see) allows to examine M.'s mouths, to define their form and an arrangement, to find existence patol. allocations (pus, blood), a tumor or the stone born from the mouth M. With the help hromotsistoskopiya (see) it is possible to establish disturbance of outflow of urine according to M. (its damage, obstruction by a stone). Delay or lack of allocation from M.'s mouth of indigo carmine after its intravenous administration demonstrates disturbance of passability of M. Results of catheterization of M. have great diagnostic value (see. Catheterization of uric ways ), to-ruyu make for determination of level of an obstacle in it, for the purpose of assignment or separate receiving urine for a research, performance of a retrograde ureteropiyelografiya. Rentgenol. the research M. is begun with survey urography (see). In a survey picture of M. are not visible, but on the course it is possible to find them the shadows caused by ureteric stones. It is possible to track M.'s course on excretory (infusional) Urogramums. If necessary make a retrograde ureterografiya (see. Piyelografiya ). For the purpose of identification of relationship of M. with patol, the changed bodies and fabrics apply a layer-by-layer X-ray analysis of uric ways (urotomografiya) in combination with excretory urography or a retrograde ureteropiyelografiya. To judge sokratitelny ability of M. and to reveal hypotonia, an atony or a hyperkinesia the urokimografiya allows. It is possible to investigate motor function M. by means of an urokinematografiya in more detail (see. X-ray cinematography ) and X-ray television (see. Television in medicine ), and also elektroureterografiya — researches of electric activity of M.
Malformations of M. submit one of difficult sections of urology. A. Ya. Pytel, G. M. Chebanyuk (1969) distinguish anomaly of number of initial and terminal segments M., anomaly of a form and their structure.
Doubling — the most frequent malformation of M. According to N. A. Lopatkin (1978), it occurs at 1 on 150 newborns, and at girls twice more often than at boys. Distinguish full doubling of M. when they begin separately and fall into a bladder two mouths on one half of a vesical triangle (fig. 7, a) that call ureter duplex, and partial when beginning separately, they then merge in the general M. and open in a bladder one mouth (ureter fissus). Occasionally other forms of doubling of M. and even trebling meet. Anomaly can be one - and bilateral. Veygert (S. of Weigert, 1877 — 1878) established that at full doubling of M. they always cross also the mouth of M. beginning from a pelvis of an upper accessory kidney always opens in a bladder below the basic. R. Meyer (1907) found out that additional M.'s mouth is located medialny and distalny the basic. Such arrangement of mouths in literature received the name of the law of Veygert — Meyer.
Uncomplicated doubling of upper uric ways can not give any a wedge, manifestations and does not demand treatment. At the same time partial doubling of M. can be followed by an interureteric reflux that promotes development of pyelonephritis. Often these malformations are combined with the ureterotsel and an ectopia of the mouth of an additional ureter. Existence of the combined malformations is the indication to correction of anomaly (in detail see the course of operative measures below — the section of operation).
Ureterotsele — cystous expansion of intravesical part M. According to V. N. Yermolin (1964), formation to an ureterotsela is caused by unusually long intraparietal part and narrowing of the mouth of an ureter. Campbell (M. Campbell, 1963), G. Belloli et al. (1976) is distinguished ectopic and orthotopical to an ureterotsela (fig. 7, b) and at the same time pointed out dominance ectopic (a ratio 18: 4). A. Ya. Pytel (1969) distinguishes simple to an ureterotsela with the next M.'s compression at its doubling or with a prelum contralateral and to ectopic M.'s ureterotsela, terminating blindly or opening in an urethra or a diverticulum of a bladder.
The wedge, a picture to an ureterotsela is characterized by a persistent pyuria, a dysuria, attacks of renal colic, sometimes loss of a cyst from an outside opening of an urethra and an acute delay of an urination.
In diagnosis to an ureterotsela the excretory urography is of great importance. Described Schiffer (E. Schiffer, 1950) characteristic rentgenol. a sign to an ureterotsela — «a gas shadow» in a bladder. Data are of great importance tsistografiya (see) and tsistoskopiya (See).
Treatment to an ureterotsela operational: transurethral electroresection or transcystic excision of a cyst. The upper geminefroureterektomiya is most rational (see. Nephrectomy ) with suction of contents of a cyst since at the same time the malformation and the changed segment of a double kidney — a source of an infection of uric ways in one step is eliminated. E. A. Ostropolskaya (1973) observed good results after this operation.
The ectopic ureter, more precisely an ectopia of the mouth of additional M., is one of the frequent accompanying defects during the doubling of upper uric ways (0,5 — 1% of all cases of doubling of a kidney). In 75% of cases occurs at women. Yu. G. Ediny's (1953) classification is widespread, according to a cut distinguish an ectopia of the mouth of M. in derivatives of an urogenital sine and an ectopia of the mouth of M. in derivatives of paramezonefralny (myullerovy) channels.
The main sign of an ectopia of the mouth of M. is the constant incontience of urine at the normal act of an urination. Diagnosis is based on detection of the extracystic mouth of M. after intravenous administration of solution of indigo carmine given excretory Urografinum, a retrograde piyeloureterografiya.
The urethral ectopia of M. is differentiated with functional or organic insufficiency of a neck of a bladder.
Treatment of an ectopia of M. operational, the standard operation is a geminefroureterektomiya. At funkts, full value of both segments of a double kidney that happens exclusively seldom, can make piyelouretero-or an uretero-ureterostomy in an upper tsistoid M.
Megaureter — the inborn, often bilateral expansion M. caused by an underdevelopment of its neuromuscular device and a stricture of intramural department. This anomaly is called a neuromuscular dysplasia of M. and distinguishes three stages of development patol. changes at it. The first stage (achalasias) — urodynamic is broken only in the lower tsistoid; the second stage (megaureter) — compensatory opportunities of M. are already exhausted and its gleam is expanded throughout; the third stage — full irreversible disturbance of urodynamic of M. and hydronephrotic transformation of a kidney (see. Hydronephrosis ).
In the first stage the disease is shown only at accession of an infection, the persistent current hron is characteristic of the second, pyelonephritis (see), in the third stage signs prevail renal failure (see). In diagnosis of defect data excretory Urografinum, a retrograde piyelografiya, indicating on dilatation) M., and renografiya matter (see. Renografiya radio isotope ), on a cut judge extent of disturbance of outflow of urine; the tsistografiya helps to reveal a vesicoureteral reflux.
For definition funkts, M.'s conditions use an urokimografiya.
Treatment hron, pyelonephritis at the kept sokratitelny ability of M. antibacterial.
In case of unilateral process with defunctionalization of a kidney the nephroureterectomy is shown. At satisfactory function of a kidney apply intestinal plastics (see).
A retrocaval ureter — a misplaced of a middle part of the right M. behind the lower vena cava — as result of the wrong embryonic development. This defect occurs in one case on 1500 autopsies, usually on the one hand, and at men by 4 times more often than at women.
A wedge, manifestations of defect depend on extent of disturbance of outflow of urine, weight of hydronephrotic changes, existence of an infection and stones, the nephralgia and a pyuria is observed. Diagnosis is based on data excretory Urografinum in combination with kavografiya (see): the picture of a hydronephrosis, expansion of an upper third of M., S-shaped bend and shift of an average third of M. to a backbone comes to light.
Treatment operational. At the kept function of a kidney M.'s movement kpered from the lower vena cava by its section and the subsequent reanastomoz the end in the end or ureteropyelostomies is recommended. In the absence of function of a hydronephrotic kidney the nephroureterectomy is shown.
A ring-shaped ureter — rare anomaly. D. D. Murvanidze et al. (1978) specifies that ring-shaped M. is the secondary disease caused by existence of an obstacle is lower than a ring-shaped bend, ring-shaped M. is more often in a pelvic part (yukstavezikalny department) of M. Obnaruzhivayetsya at excretory Urografinum, a retrograde piyelografiya.
Diverticulum of an ureter — the protrusion of a wall of M. Razlichayut limited on an extent primary diverticulum of M. connected with an underdevelopment of a muscular layer of its wall, and secondary, caused patol, process in M.'s wall or the fabrics surrounding it. Typical localization of a diverticulum of M. is the area of a piyeloureteralny anastomosis and decussation with ileal vessels. Long time a diverticulum remains hidden, there is no complication yet: a tumor, a stone, an infection, perforation with an uric zatek and phlegmon. M.'s diverticulum more often accidentally on the basis of data excretory Urografinum or a retrograde ureterografiya, undertaken in connection with complications in any other occasion is distinguished.
Treatment — a diverticulectomy with a resection of an affected area of M. and imposing of an ureteroureteroanastomoz the end in the end.
A stricture of an ureter — one of the frequent reasons of a hydronephrosis. Distinguish the inborn and acquired stricture. At children M.'s narrowing in the field of a piyeloureteralny anastomosis because of an inborn hyperplasia of muscles and nizhnepolyarny additional vessels of a kidney is often observed. The cicatricial changed folds of a mucous membrane at various levels can also be the reason of a stricture. It is necessary to distinguish a true stricture when there is a scarring, a hyperplasia of muscles, hypostasis of a wall of M., and false when M.'s gleam is narrowed as a result of its prelum from the outside (an additional vessel, a tumor, cicatricial tyazha, etc.). The stricture can be single and multiple, have various extent and be located at various levels. The above narrowing is located, the hydronephrosis develops quicker. Low located strictures lead to an ureterohydronephrosis.
Clinically M.'s stricture is shown by a dull or acute pain in a kidney, at infection — the attacks of pyelonephritis, a pyuria. Diagnosis is based on excretory Urografinum, seldom retrograde ureteropiyelografiya and X-ray cinematography characterizing localization and extent of a stricture, staz urine and the expansion M. (hydroureter) caused by it or pyelocaliceal system of a kidney (ureterohydronephrosis).
To lay down. actions at M.'s stricture depend on the reason which caused it. At cicatricial strictures apply one of plastic surgeries — expansion of the waist of M. with movement of the rag found from a pelvis, a resection of an ureter with the subsequent uretero-ureterostomy the end in the end, a piyeloureterostomiya or an ureterocystoneostomy. During the loss the kidney of function showed a nephrectomy.
Damages happen open and closed, full and partial. On the mechanism of an injury they are divided into 4 groups: damages to result of influence of external force (gunshot and chipped and cut wounds, the closed damages); surgical damages (is more often at operations on pelvic bodies); damages at endovesical tool interventions (M.'s catheterization, bringing down of a stone an extractor). At heavy necrotic changes of a wall of M. also spontaneous gaps are possible.
The isolated M.'s wounds are extremely rare. Usually they are combined by € wound of a backbone, large vessels, hollow bodies etc. and therefore signs of damage of M., especially in the first days after an injury, can be not noticed. Main symptoms of an injury of M.: hamaturia (see), retroperitoneal uric became numb (see) and release of urine from a wound (at open damages). The hamaturia can be short-term, and uric flowed and release of urine from a wound can appear only in several days after an injury. At a hromotsistoskopiya it is possible to find allocation of a clot or liquid blood from M.'s mouth, lack of release of indigo carmine on the party of damage of M. The excretory urography or a retrograde ureterografiya finds flowing of radiopaque substance in retroperitoneal space, and the catheter at a retrograde ureteropiyelografiya meets an obstacle, without reaching a pelvis.
Treatment of damages of M. almost always operational. Only at small partial gaps or M.'s perforation a catheter it is possible to be limited to leaving of a constant ureteric catheter. Primary seam M. (ureterorrhaphy) is applied seldom, only at the surgical damages distinguished during operation. Usually M.'s damage is diagnosed late, already in the presence of considerable uric infiltration and an inflammation in surrounding cellulose. Therefore at the first operative measure are limited to removal of urine by a nephropyelostomy and drainage of uric zatek. Later 3 — 4 weeks after an injury make recovery operation — reanastomoz M. At M.'s damage to pelvic department (yukstavezikalny department) it is shown ureterotsistoanastomoz or Boari's operation (see. Boari operation ), at more major defects — M.'s substitution by a segment of a small bowel or autotransplantation of a kidney, i.e. moving of a kidney to an ileal pole with crossing of vessels, their anastamosing with ileal vessels and imposing of an ureterotsistoanastomoz.
M.'s injuries in wartime diagnose seldom since most of wounded perishes in early terms as a result of heavy damages of other bodies. Assistance at stages of medical evacuation consists in fight against shock, blood loss and in perhaps early operational treatment. On M.'s wound put stitches or make an ureteropyelostomy. At development of an infection in a kidney it is deleted. In all cases operation comes to an end with drainage of retroperitoneal space.
Before operation on bodies of a basin in particularly complex situations make M.'s catheterization for prevention of surgical damages of M., and at endovesical manipulations without the imperative need do not use an ureteric catheter with metal mandrin, avoid careless movements by an extractor at bringing down of a stone from M.
Inflammatory diseases. The inflammation M. (ureteritis) happens primary and secondary. Primary ureteritis meets extremely seldom. The disease begins sharply, with temperature increase, a tremendous fever. Pristupoobrazny pains with characteristic irradiation on the course of M disturb. During an attack the increased kidney can be palpated, edges out of an attack decreases (a symptom of the alternating hydronephrosis). There is a muddy, purulent urine with fibrinous films. At a tsistoskopiya find the expanded mouth of M., sometimes with violent hypostasis of a mucous membrane around it. If at M.'s catheterization purulent urine is emitted in the beginning, and during the carrying out a catheter to a pelvis — transparent, then the diagnosis of primary ureteritis is undoubted. On an ureteropiyelogramma it is possible to see M.'s narrowing at almost not changed pelvis. Treatment in the beginning conservative: antibiotics of a broad spectrum of activity, a himiopreparata, plentiful drink, M.'s washing on a catheter with introduction of antibiotics. In the absence of effect of conservative treatment can be required nephrostomy (see), and sometimes and nephroureterectomy.
The secondary ureteritis as a complication of inflammatory diseases of a kidney and bladder meets considerably more often. The infection gets with the infected urine from a pelvis or on limf, to vessels. In the presence of a vesicoureteral reflux (see) an infection gets in the ascending way from a bladder. Sometimes process extends to M. from surrounding fabrics at a periureteritis, retroperitoneal fibrosis (Ormond's disease), periappendikulyarny abscess, prostatitis. Process in M. begins with a hyperemia, hypostasis of a mucous membrane, then erosion are formed, also surrounding cellulose (periureteritis) is involved. The m becomes dense, its gleam is narrowed that leads to disturbance of outflow of urine and an ureterohydronephrosis. Treatment of a secondary ureteritis shall be directed to elimination of basic process. At the developed stricture M. (ureterostenosis) plastic surgery can be required (see. Ureteroplasty ).
A cystous ureteritis — a rare form of a chronic ureteritis when on all mucous membrane small cysts with transparent contents are located. One connect this disease with inborn local accumulations of flat epithelial cells (Brunn's nest), others consider that process is caused by parasites (mikrosporidiya, psorosporidiya).
In silt lozny, or fleecy, the ureteritis meets at long irritation of upper uric ways and Klin is expressed in a productive inflammation with a hyperplasia of an epithelium and education on a mucous membrane of outgrowths in the form of small vorsinony, symptoms are also caused by narrowing of a gleam of M. and existence of a hamaturia.
The cystous and villozny ureteritis is considered a precancerous state. Conservative treatment is ineffective. At hemilesion in hard cases resort to a nephroureterectomy.
Fistulas. Ureterovaginalnye, the combined fistulas are options urinogenital fistulas (see).
Tuberculosis of an ureter develops in M. for the second time at distribution of tubercular process from a kidney. On a mucous membrane of M. pour out hillocks, ulcers are formed. Owing to scarring of ulcers M.'s stricture forms, is more often in prevesical and prilokhanochny departments. Disturbance of outflow of urine aggravates progressing of destruction in a kidney and leads to emergence of an ureterohydronephrosis. Sometimes owing to far come fibrous process in M. there is its full obliteration and death of the affected kidney (autonefrektomiya). Disturbance of a neuromuscular tone and trophicity of an ureter and a bladder and their cicatricial and sclerous changes cause the return throwing of urine — a vesicoureteral reflux (fig. 8).
Except the symptoms characteristic of tuberculosis of kidneys and a bladder, at M.'s defeat often there are pristupoobrazny pains like renal colic. At a tsistoskopiya reveal violent hypostasis of a mucous membrane around M.'s mouth, the tightened, funneled mouth. On excretory Urogramums in the presence of tubercular changes in a kidney narrowings and expansions M. — so-called chetkoobrazny M. (fig. 9) are visible. The same changes observe also at a retrograde ureteropiyelografin (fig. 10).
Treatment at initial stages of a tubercular ureteritis consists in treatment of the main center, in a kidney. However exclude streptomycin and Kanamycinum from antitubercular drugs, to-rye strengthen fibroplastic processes and cause rough scarring of ulcers in M., and combine antitubercular therapy with glucocorticoids. Apply M.'s bougieurage, Endo a vesical obkalyvaniye of a zone of violent hypostasis around the mouth a hydrocortisone. At the formed resistant strictures of M. and the functioning kidney depending on an arrangement and prevalence of an ureterostenosis autotransplantations of a kidney resort to an ureterotsistoanastomoz, Boari's operation, an ureterokaliksoanastomoz (to formation of an anastomosis between M. and the lower cup of a kidney), to M.'s substitution by an intestinal segment. In case of death of a kidney as at tubercular, and other types of an ureteritis delete not only a kidney, but also all M. (a total nephroureterectomy). Leaving of a stump of M. is fraught with formation of its empyema or pyoureter (fig. 11), is long not healing fistulas demanding repeated operation — an ureterectomy.
Stones. In M. stones are almost always secondary since they move to it from a kidney. Very seldom the stones formed in M. at its atony, existence of a stricture or a diverticulum meet. M.'s stones can be single (fig. 12) or multiple (fig. 13), and also bilateral. They usually rounded or oblong shape, various size. On chemical structure M.'s stones are similar to stones of kidneys (see. Urinary stones ). Stones are late in places fiziol more often. M.'s narrowings: in prilokhanochny department, in the place of decussation of M. with ileal vessels, in yukstavezikalny or intramural departments of M. Long finding of a stone in M. leads to disturbance of outflow of urine and expansion M. and a pelvis (a hydroureter and a hydronephrosis). On site infringements of a stone M.'s wall is sclerosed that leads to emergence of a stricture. Accession of an infection causes development of an ureteritis, periureteritis, and also pyoinflammatory process in a kidney, to-ry a thicket develops at stones of an upper part of M. A characteristic symptom of a stone of M. — an attack of renal colic (see. Nephrolithiasis ). In the mezhpristupny period there are dull aches in a kidney and on M.'s course, the hips giving to a medial surface and in generative organs. At stones in paravesical M.'s department the dysuria joins. Traumatizing a mucous membrane of M. leads to a micro or gross hematuria. At a half of patients with M.'s stones the pyuria is noted. In time or after an attack of renal colic the stone can independently depart. Sometimes on a surface of a stone the fillet is formed, on Krom urine flows. After recovery of outflow of urine patients a long time do not show any complaints.
In diagnosis the leading value belongs to roentgenourologic researches. The majority of stones of M. comes to light on the survey roentgenogram. For difference of a shadow of a stone of M. from shadows of other nature do a picture in two projections with the catheter entered into M. The diagnosis of a stone of M. is confirmed if in both pictures the shadow, suspicious on a stone, matches a shadow of an ureteric catheter. Apprx. 10% of stones of a rentgenonegativna (uratny, tsistinovy, ksantinovy) are also not visible on the survey roentgenogram. The tsistoskopiya (the «born» stone or existence of violent hypostasis around M.'s mouth), a hromotsistoskopiya helps with diagnosis (absence or delay of release of indigo carmine on the party of renal colic). M.'s catheterization reveals an absolute or formidable obstacle in this or that level. More precisely stones come to light on excretory Urogramum; on it it is possible to see an expanded pelvis (fig. 14) and a shadow of a contrast agent it is frequent in expanded M., reaching a stone (fig. 15). On a retrograde ureterogramma with a liquid or gaseous contrast agent M.'s fillings on site a stone find defect.
For the choice of a method of treatment it is necessary to investigate a condition of urodynamic and funkts, ability of a kidney by means of a hromotsistoskopiya, excretory Urografinum, an isotope renografiya, stsintigrafiya (see).
Treatment can be conservative or operational. Sometimes the otkhozhdeniya of a stone during the stopping of renal colic (heat baths, spasmolysants, novocainic blockade of a seed cord or a round ligament of a uterus) is possible to achieve.
Conservative treatment is successful at 75% of patients when a stone smooth, with a diameter up to 1 cm, and M.'s tone is kept. At such patients apply water loadings (reception of 1 — 1,5 l of liquid in 10 — 15 min.) in a combination to spasmolysants and the strengthened walking. Drugs of terpenic oils are effective (cystenal, enatin, Avisanum).
At unsuccessfulness of these actions at stones of a lower part of M. resort to endovesical to methods of their removal: M.'s catheterizations with introduction of a warm liquid paraffin or glycerin, to bringing down of a stone a loop-like extractor of Tseyss or korzinchaty Dormia's extractors or Pashkovsky, to a section of the mouth of M. scissors or the electrocoagulator which is carried out on the cystoscope. The ureterolithotomy (removal of a stone through coal mine M.) is shown in the absence of a tendency to an independent otkhozhdeniye of a stone, at development of a gidroureteronefroz, not stopped acute pyelonephritis, an anury, frequent attacks of renal colic with fervescence. At stones of an upper part of M. quick access same, as well as at operations on to a kidney (see). For access to an average third use a kosoprodolny pararectal section. In the lower third of M. bare, using a slanting section of Pirogov. At thin patients intermuscular accesses to all departments of M. are possible, at to-rykh a muscle of a stomach stupidly stratify, but do not cut. To a single-step removing calculus from lower parts of both M. apply Kay's section on the white line of a stomach from a navel to a symphysis. At repeated operations sometimes it is necessary to use transabdominal access, and at stones of intramural department of M. — transcystic access. When at women through an abdominal wall approach to a lower part of M. is complicated, resort to vulval access (an ureterolithotomy vulval).
Leukoplakia of an ureter meets very seldom, it is characterized by emergence on a mucous membrane of M. of whitish plaques owing to a metaplasia of an epithelium (see. Leukoplakia ). Inflammatory process, M.'s stones causing long mechanical irritation of a mucous membrane happen its reasons hron. The opinion on a leukoplakia of uric ways extended before as about a precancerous disease does not divide a number of specialists. Clinically the disease is shown by formation of narrowing of M., disturbance of outflow of urine and development of an ureterohydronephrosis. Find the keratosic epithelium in the form of small scales or layers in urine. The excretory urography, M.'s catheterization, an endovesical biopsy of a mucous membrane from area of the mouth of M help with diagnosis. Treatment antiinflammatory (antibiotics and himiopreparata). At development of a stricture of M. plastic surgery can be required.
Malakoplakia of an ureter — even more rare disease of not clear nature, at Krom on a mucous membrane of M. there are yellowish or brown small knots or plaques, slightly eminating, soft, surrounded with a corbel of a hyperemia, sometimes ulcerating (see. Malakoplakia ). At microscopic examination of these educations find cells of a malakollakiya or Mikhaelis's little body — Guttmanna, epithelioid type, spindle-shaped, with a small kernel. Diagnosis and treatment of a disease are similar to M., that at a leukoplakia,
to the Tumour
Primary tumors of M. meet seldom. The most widespread classification subdivides M.'s tumors into three groups: papillomas without the invasive growth, papilloma with invasive growth, not papillary tumors with invasive growth. Use also the classification subdividing M.'s tumors on epithelial and a connective tissue origin. Epithelial tumors on gistol, to a structure most often correspond to papillomas (see. Papilloma, papillomatosis ), planocellular to cancer (see), is more rare to an adenocarcinoma.
Primary tumors in 65% of cases are localized in the lower third of M., to 10% of tumors happen bilateral; they quickly sprout body and metastasize. The main symptoms of a disease are a hamaturia (to 90%) and pain (to 65%). In process of growth of the tumor complicating outflow of urine the hydronephrosis develops.
For diagnosis methods of a research have major importance rentgenol. On excretory Urogramums on M.'s course the defect of filling (fig. 16) which is especially expressed at papillary new growths comes to light. The m in a zone of an arrangement of a tumor is usually expanded, at far come tumoral process there can come its full occlusion, the retrograde ureterografiya (fig. 17) in that case helps to establish the diagnosis. Carrying out a catheter according to M. by a tumor quite often causes a hamaturia, and at further advance up M. transparent urine (a symptom of Shevassyu) begins to be emitted.
Certain help in diagnosis of tumors of M. is given by a tsistoskopiya, at a cut around the mouth it is possible to see novooorazovaniye or a prolapse of a tumor through the mouth in a bubble. In some cases release of blood from the mouth of M is visible. Promotes establishment of the diagnosis tsitol, a research of an urocheras, in Krom tumor cells find. Existence of metastasises in regional limf, nodes is revealed with the help limfografiya (see).
At unilateral tumoral defeat of M. the nephroureterectomy with a resection of a wall of a bladder is shown. M.'s resection is admissible at bilateral tumoral process and in some cases at the single tumor which does not have infiltriruyushchy growth. Radiation therapy at M.'s tumors is not effective.
At planocellular cancer and M.'s adenocarcinoma life expectancy of patients after operation usually less than 5 years; with an infiltrative growth of papillomas patients after operation live more than 5 years only in 10 — 30% of cases; with not an invasive growth — in 50 — 60% of cases. The persons which underwent operational treatment need dispensary observation with periodic carrying out a tsistoskopiya and excretory Urografinum during all subsequent life.
the Purpose of all plastic surgeries on M. is recovery of its passability and preservation of function of the corresponding kidney that can be reached by mobilization of its fabrics due to M.'s regeneration or M.'s substitution by some body or a prosthesis (see. Ureteroplasty ). The lokhanochno-ureteric anastomosis, intraparietal part M. or M. on an extent can be the place of an operative measure.
The indication for plastic surgeries is disturbance of passability of M. Sposob of reconstruction choose strictly individually. A contraindication consider acute inflammatory process and tumoral damage of a kidney and M. An important preparatory stage before similar operations is careful sanitation of uric system. Operation is performed under the general anesthesia using muscle relaxants (see).
At intervention on a lokhanochno-ureteric segment apply any option lumbotomies (see), napr, the kosopoperechny Extra peritoneal section according to Fedorov, at repeated operations can be used a section on Nagamatsa. Technology of allocation of a pelvis and M. always shall be sparing; search and M.'s allocation are facilitated if carry beforehand out a catheter to M.
In case of a short stenosis or a low otkhozhdeniye of M. the simplest operation of a pelvioureteralny myotomy on Allemanna can be executed, but because of a frequent recurrence of a stenosis this operation is applied extremely seldom. For treatment of narrowing of big extent of Marion (N. Marion) and Davis (D. M of Davis) offered an intubation ureterotomy — a longitudinal section of stenosed M. with its subsequent intubation and drainage through nefrosty. For the same reason operation is almost left. The inborn stricture of small extent can be eliminated with a longitudinal section of a back wall of M. in the field of a stricture and sewing together of edges in transverse direction. For this purpose Fenger's (fig. 106) operation was offered, a shortcoming it is deformation of a lokhanochno-ureteric segment. It is reasonable to apply Schweitzer's way in Foley's modification in children's surgery (fig. 107). Y-shaped section find the wedge-shaped rag turned by the basis up from a pelvis, from a corner continue a section according to M. at the length of 1 from m, move a rag with seams on M. and create funneled expansion in the place of a stricture. Operation is insufficiently radical since remains not resected patholologically the changed site M.; therefore resort to operations more often, at to-rykh make a resection of a pelvis with plastics of a lokhanochno-ureteric anastomosis; from them the plastics is most widespread on Kalp Verdu (fig. 109): the section on a back wall of M. is continued on a back wall of a pelvis and further on medial edge to its upper wall and, having turned in the opposite direction, find the long rag turned by the basis to M. from a back wall of a pelvis; the rag is thrown back down and sewed in longwise dissect M. Operation allows to eliminate a stenosis of big extent. At high M.'s otkhozhdeniya finds application piyeloureteroanastomoz on Albarrana in Likhtenberg's (fig. 108) modification: cut longwise M. on lateral, and a pelvis respectively on medial edge, so that cuts had one against another and it would be possible to connect seams of edge of a pelvis and M. In case of a stenosis of big extent and an intra renal arrangement of a pelvis operation on Neyvirt (fig. 18) is shown: the affected area of M. is resected, M.'s stump is split on two rags and sewed in the lower cup, fixing it P-shaped seams to a cup p outside to a renal capsule from within. If the additional vessel to the lower pole of a kidney is a cause of infringement of passability of M., then M.'s movement kpered from a vessel with excision of the changed site and an antevazalny ureteropiyeloanastomoz is justified.
Feature of the following group of operations is the resection of piyeloureteralny area; from them the most perfect is Haynes's operation — Anderson in Kucera's (fig. 19) modification. The ureter is crossed slantwise below the place of narrowing, cut it on lateral edge on 1 — 1,5 cm, then resect a pelvis in necessary limits. Compare and sew edges of a pelvis and in its bottom corner anastomose M.
Zavershayut any reconstructive operation by a nephropyelostomy. M.'s splintage is made not always. The drainage is deleted in 3 — 4 weeks after control of passability of an anastomosis.
At cicatricial narrowing, fistula or M.'s injury in the lower third carry out ureterotsistoneoanastomoz (see. Ureterocystoneostomy ). A contraindication is highly located M.'s defect, cancer infiltration of pelvic cellulose, damage of a bladder.
There are three essentially various ways of connection M. with a bladder. 1. Lateral ureterotsistoneoanastomoz: M do not cut and impose an anastomosis above narrowing a side sideways with a bladder. 2. M.'s reimplantation in a bladder: M cross above narrowing, through the mouth or a small section on a front surface enter the tool into a bubble, perforate its wall in the field of a bottom from within and, having taken M.'s end, lead him to a cavity of a bubble. M. 1 — 1,5 cm long end leave free in a bladder or fix to a mucous membrane one of described below ways. According to Franz and Paine, M.'s end is split on two rags, rags part to the opposite sides and P-shaped seams fix to a mucous membrane of a bubble. N. A. Lopatkpn recommends to cut M.'s end only on a first line and, having straightened it in the form of a petal, to implant in a wall of a bubble, connecting separate seams of edge of a section of a mucous membrane of a bladder and M. Sposob Riccardo — Blochina provides creation from M.'s duplikatura of a cuff for what M.'s end is turned out, fix the turned-out part at the edges by four catgut seams and the same threads fix from within M. to a wall of a bubble. As each of the described operations does not exclude emergence of a vesicoureteral reflux, connection M. with a bladder is made usually by the anti-reflux technique (fig. 20) offered by G. W. Leadbetter and V. A. Politano: the waist of M. is excised, from a small section in the field of a bottom of a bubble in the direction to a neck in a submucosa create the tunnel not less than 3 — 5 cm long, spend to it M.'s end and sew it edges with a mucous membrane of a bubble. Enter into anastomozirovanny M.'s gleam on depth of 12 — 15 cm a drainage and keep it within one and a half-two weeks. M. located submukozno at the filled bladder is pressed down to a muscular wall thanks to what the reflux of urine is warned. Similar operations are of particular importance at a neuromuscular dysplasia of M. In this case the ureterotsistoanastomoz is preceded by a resection of the lower tsistoid of M. which lost sokratitelny ability, formation from the remained rag of the anti-reflux roller and M.'s duplikatura, to-ruyu make on the tire the continuous pulling together sutures. 3. In case of defeat of pelvic part M. when it is impossible to make reimplantation or ureteroureteroanastomoz, it is shown indirect ureterotsistoanastomoz. The principle of operations consists in substitution of defect of M. tissues of a bladder. Across Boari (Fig. 201), from a perednebokovy wall of a bladder find a narrow rag, create of it a tube, to-ruyu and connect to M. by an anti-reflux technique. At bilateral defeat of M. from an anterosuperior wall of a bubble find two rags — Grégoire's method or one wide (fig. 21), from to-rogo create a tubular stalk and connect it to M. — Lopatkin's method. According to Demel the tubular stalk is created of all upper half of a bubble that allows to replace much bigger defect of M. Connection M. with a bladder carry out on the tire in the way the end in the end, invagination or implantation in the submucosal tunnel. The Shiniruyushchy tube is deleted in 10 — 12 days. The first days after operation drain cellulose of a small pelvis and hypodermic cellulose of a front abdominal wall.
At operation of an ureteroureteroanastomoz M.'s ends connect in several ways. The anastomosis the end in the end is carried out at an injury, a forced section of M. or at its retrocaval arrangement. The most admissible limit of a resection of fabric allowing to compare the dissect ends without tension is equal to 5 cm. Before connection M.'s ends economically resect, cross or better slantwise cut off, and then is free, without tension, pull together on a catheter and sew 3 — 4 noose catgut sutures, taking adventitious and muscular covers (fig. 22).
The Invaginatsionny anastomosis is applied most often at reconstructive operation when there is an expansion M. over the place of obstruction: the vesical end by means of two P-shaped seams is involved in renal, and threads are tied outside. The anastomosis is strengthened several seams. Advantage of this way is reliability of an anastomosis, but at the same time more fabrics M are used. Depending on the level of intervention shiniruyushchy M. a tube is removed outside through nefropiyelosty (see. Nephrostomy ) or through suprapubic vesical fistula. The anastomosis the end sideways is carried out more often at the cross ureteroureteroanastomoz used instead of an ureterocutaneostomy or after an ureterosigmoanastomoz for decrease in frequency of the ascending infection in kidneys, at high ureteric fistula, a unilateral vesicoureteral reflux. A contraindication to operation is the urolithiasis. Usually transperitoneal access will mobilize the replaced and healthy M. (fig. 23) struck with M. cut above ileal vessels, carry out on the opposite side and anastomose with healthy M., sewing at first back, then a lobby of a wall. The peritoneum over a stump of the struck M. and over area of an anastomosis is carefully taken in, and the retroperitoneal space is drained; shiniruyushchy drainages enter into a gleam of both M.
For the purpose of substitution of the struck M. it was offered to use transplants from vessels, a uterine tube, a worm-shaped shoot, a tube of a peritoneum, however practically they were unsuitable for these purposes. The most acceptable remain M.'s substitution by a loop of a small bowel; satisfactory results are received from use of artificial prostheses. Using a loop of a small bowel, it is possible to replace a part or all M. (see. Intestinal plastics , Ureteroplasty ). The need for similar operation arises at a major defect or a widespread stricture, at retroperitoneal fibrosis, a neuromuscular dysplasia.
M.'s prosthetics is limited to cases of obstruction of M. of big extent when other ways of substitution cannot be used (tumors of a basin, post-radiation strictures, etc.). Contraindication are destructive diseases of kidneys, an urolithiasis, active pyelonephritis with a fosfaturiya and release of alkalinuria. As prostheses use the tubes from silicone rubber equipped with a rodergonovy cuff and the anti-reflux valve.
The type of an operative measure and type of a prosthesis depend on extent and localization of a stricture of M. according to what apply three techniques of implantation of a prosthesis: a subtotal resection of M. with implantation of a prosthesis in an upper third of M, and a bladder; partial replacement of M. in an average third; replacement in an upper third with implantation of a prosthesis in a pelvis and the distal end of an ureter. The prosthesis is fixed reliable, it is long not resolving suture material. Drainage of uric ways is not made.
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H. A. Lopatkin, V. V. Mazin, P. A. Shchep-lev, K. D. Yesipov (An.), B. P. Matveev (PMC.), A. T. Pulatov (it is put. hir.).