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Signs of formation of the third right ureter. Types of operations for ureteral strictures: indications, contraindications, postoperative period

A disease of the two tubular organs responsible for moving urine from the kidneys to the bladder is called ureteral enlargement. Due to impaired urine transport, serious problems with urinary functions occur. Megaureter is an acquired or congenital disease that leads to impaired renal function, and with a bilateral inflammatory process, renal failure appears. When the tubular organs expand, there is no possibility of rapid outflow of urine and chronic inflammation of the kidneys may occur, which leads to disruption of the blood circulation.

Inflammatory processes in the kidneys can negatively affect the healthy shape of the ureter.

The essence of the expansion of the tubular process

The walls of the ureter have a three-layer structure, this allows urine to gradually move. The outer muscular layer contains nerve and collagen fibers, which allows urine to be moved up to 5 times per minute. With increasing enlargement of the ureter, the ability to contract is weakened, urine evacuation becomes more difficult and intrarenal pressure increases. Stagnation of urine leads to the presence of infection, which aggravates the pathological process. Lack of treatment leads to kidney failure.

Often, infections and their presence in the urinary tract accompany the expansion of the ureter itself.

The dilation of the two tubular organs is determined using ultrasound examination of the fetus. If after the birth of a baby there is no megaureter, the expansion of the tubular organs will not manifest itself in the future. The diameter of the ureter in a normal state should not exceed 5 mm; if the organ is dilated during diagnosis, this leads to a deeper examination of the internal organs. Adolescents sometimes experience the presence of blood in the urine, incontinence, complaints of constant pain in the abdomen and lumbar region, as well as the formation of stones in the urinary organs.

Types of megaureter

Acquired deformation of the ureteral canal occurs due to an imbalance of pressure in the bladder or a complication of cystitis.

There are such types of disease:

The primary type is a congenital disease. It appears in the absence of coordinated work of the muscular and connective tissues of the ureter. There is no force necessary to move urine along. Megaureter can occur during the embryonic period. Megaureter is most often observed in boys.
The secondary type is associated with high pressure in the bladder. This occurs due to a neurological disorder or chronic cystitis. Most of the identified diseases after multiple examinations and treatment are likely to disappear during the first two years of the baby’s life.

Causes of dilated ureters

There are several sources explaining that the tubular organs are dilated. The main reason is high ureteral pressure and difficult urine outflow. There are cases that when the pressure normalizes, the ureter remains dilated. Congenital insufficiency of the muscles of the tubular organ occurs. Therefore, the ureter becomes weakened and cannot push urinary fluid into the bladder. The next reason explaining the enlargement of the ureter is the narrowing of the tubes at the point of their connection with the reservoir for storing urine.

Sources of expansion of the ureteric process:

high pressure inside the tubular organ and the renal pelvis leads to expansion of the ureter and difficulty in the outflow of urine;
weak muscle tissue;
lack of development of nerve endings;
urine is thrown into the pelvis thanks to.

Symptoms of megaureter

A deformed ureter is indicated by pain in the lower back and abdomen, blood in the urine, vomiting and fever.

Signs of expansion of tubular organs are different. In the absence of a primary type of disease, megaureter occurs in a latent form, accompanied by a satisfactory condition of the person and the absence of signs of illness. Otherwise, there may be complaints of pain in the abdomen or lower back, tumor-like growths may be felt, or blood discharge may be observed in the urine. In the acute phase of megaureter, a high number of leukocytes in the urine, gag reflexes and high body temperature can be identified.

Acute symptoms of the disease are most noticeable at stages II-III; it is during this period that complications such as chronic kidney failure or pyelonephritis become visible.

With double damage or expansion of the processes, children experience double urination. This is explained by the fact that after the first bowel movement, the organ of the urinary system is filled with urine from the dilated organs and a secondary urge to urinate appears. The second time, the urine is accompanied by a fetid odor, increases in volume and has a cloudy sediment. Such babies are susceptible to infections, and may experience delayed physical development or skeletal abnormalities. Children often experience loss of appetite, fatigue, weakness, constant thirst, pallor, dehydration and urinary incontinence.

Megaureter severity

After the examination, the doctor assesses the condition of the damage to the renal system and predicts future treatment. There are 3 stages of disease severity:

Mild: moderate dilatation or dilatation of the lower ureter. His condition often recovers without surgery.
Medium degree: expanded diameter of the ureter. Competent, timely therapy gives excellent results.
Severe form: megaureter may be accompanied by a decrease. Surgery is definitely necessary.

Features of megaureter in a newborn

An enlarged ureter in children in the early stages can be cured without surgery.

With the improvement of ultrasound diagnostics, it has become possible and accessible to detect megaureter and intrauterine anomalies of the genitourinary system. Early diagnosis of megaureter leads to unreasoned surgical intervention. This is explained by the fact that in some cases, babies experience a stop in the expansion of the ureter and restoration of the outflow of urine during 2 months of the newborn’s life. At this age, regular monitoring and urinalysis, as well as ultrasound examination, are necessary. Correct timely diagnosis will help avoid exacerbations, as well as avoid surgical intervention. A newborn’s organs still mature for a certain period of time, so in the first few months of life it is not always easy to assess the entire functioning of the urinary and renal systems.

During diagnostics, the attending doctor should be especially careful, as there is a risk of making mistakes that will lead to unjustified surgical intervention. Getting rid of the deviation is possible only with timely examination and the correct course of treatment. Megaureter often disappears on its own in children; in adults, when an acute stage is detected, surgical intervention is necessary, which is performed in 40% of cases.

What are the dangers of ureteral dilatation?

Dilatation of the ureter is formed due to a violation of the outflow of urine. The most well-known cause of an increase in the volume of tubular organs and blockage of urine transport is urolithiasis. Often the presence of one stone of impressive size is enough to block the connecting process. A sharp narrowing of some parts of the ureter leads to disruption of the outflow of urine. Due to a congenital disease, a newborn has almost no urethral lumen. In this case, it is necessary to widen the urethral canal through surgery.

Obstruction of urine outflow is a consequence of complications of kidney and ureter diseases.

When the right kidney drops lower and occupies an unusual location, you can notice a bend in the ureter. Tumor formations located in the pelvis have a negative effect on the ureter, squeezing it on both sides. Inflammation in the tubular organs and pelvis leads to swelling of the mucous membrane, which contributes to improper outflow of urine. , namely saccular protrusion, may be an obvious cause of ureteral dilatation.

Most often, pathology in adults develops during blockage of the ureter with pus, mucus or stone.

Reasons for the development of ureteral dilatation:

ureterocele;
narrowing of the peri-vesical section of the tubular organ;
narrowing of the intravesical section;
insufficiency of motor function of the ureteric process.

Strictures of the ureter (ureter) are a pathological narrowing of its lumen, to one degree or another causing a violation of the outflow of urine from the pelvis. This narrowing can be congenital or acquired.

Ureteral strictures can be asymptomatic and lead to severe renal dysfunction. Most often, narrowing of the ureter is complicated by secondary infection (recurrent pyelonephritis, pyelitis, etc.) and the formation of stones.

For small strictures, placement of a stent in the ureter, balloon dilatation, and endoureterotomy are possible. Let us consider in more detail the causes of ureteral strictures and the types of operations used to treat this pathology.

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1. Classification of strictures

Classification criterion	Types of strictures	Description
By time of occurrence	Congenital
By time of occurrence	Purchased
Due to obstruction	External
Due to obstruction	Domestic
By nature	Benign
By nature	Malignant
By etiology	Iatrogenic	Ureteroscopy. Irradiation. Kidney transplant.
By etiology	Noniatrogenic
Depending on location	Proximal
	Average
	Distal

Table 1 - Classification of ureteral strictures

2. Epidemiology

The widespread use of endoscopic examinations of the upper ureter has led to an increase in the incidence of iatrogenic strictures.

The likelihood of ureteral obstruction after endoscopic treatment for stones is 3-11%. According to recent studies, when using smaller diameter fiber endoscopes, laser lithotripsy, and smaller instruments in the treatment of urolithiasis, the incidence of ureteral strictures decreases and is less than 1%.

Risk factors for the formation of strictures are also the time of stone wedging into the wall of the ureter and perforation of the ureter during endoscopic treatment.

Factors that increase the likelihood of ureteral narrowing after ureteroscopy:

1 Large diameter fiber endoscope.
2 Long-term persistence of stone in the lumen of the ureter.
3 Wedging of a stone.
4 Large size of the stone.
5 Proximal localization of the stone.
6 Perforation of the ureter during ureteroscopy.
7 Application of intracorporeal lithotripsy.

Narrowing can be a complication of external and internal drainage of the ureter. The incidence of stricture formation of the ureterointestinal anastomosis is 3-5%.

Damage to the ureter can occur during any surgical intervention on the pelvic organs or retroperitoneum. Gynecological operations account for 75% of iatrogenic ureteral injuries.

3.

The ureter (ureter) is a muscular tube, lined from the inside with transitional epithelium, connecting the renal pelvis to the bladder. Throughout its entire length, the ureter is located in the retroperitoneal space.

Its length is 20-30 cm and often depends on the height of the person. The diameter of the lumen of a normal ureter is 4-10 mm and varies throughout (physiological narrowing).

The two most important narrowings of the ureter are ureteropelvic and ureterovesical. The narrowest part of the ureter is located at the point of its transition to the small pelvis (ureterotpelvic junction): at this point the ureter is thrown over the bifurcation of the common iliac artery.

In men and women, the ureter passes behind the gonadal vessels and in front of the m. iliopsoas, crosses the common iliac vessels (artery and vein) and below passes into the pelvic cavity.

In men, the vas deferens goes around the ureter in front, before it enters the bladder. In women, the ureter is located behind the vessels of the uterus close to its cervix, passing lower into the intramural section in the wall of the bladder.

Figure 1 - Anatomy of the ureter. Illustration source -

The blood supply to the ureter is provided from several sources. In the upper third, the ureter is supplied with blood by branches arising from the renal and gonadal arteries. In the middle third, the blood supply is provided by small branches from the aorta. In the pelvic area, the ureteral wall is supplied by branches of the iliac, vesical, uterine and hemorrhoidal arteries.

4. Pathophysiology

The process of stricture formation most often occurs against the background of ischemia, which results in the proliferation of connective tissue in the wall of the ureter.

The proliferation of fibrous tissue can occur in response to injury (for example, during the passage of a stone) or during chronic inflammation (chronic tuberculosis, local inflammatory reaction to suture material).

Pathohistological analysis of ureteral strictures reveals disordered deposition of collagen fibers, fibrosis, and different stages of inflammation (depending on the etiological factor and time since the onset of the inflammatory response).

The resulting ureteral obstruction can be mild, with asymptomatic progression, proximal ureteral dilatation and hydronephrosis, or it can be severe, causing complete obstruction with loss of function of one of the kidneys.

5. Clinical picture of the pathology

In some patients, strictures are not accompanied by any symptoms. Often the clinic appears only at the time of urination or when renal colic occurs.

The severity of symptoms does not correlate well with the degree of obstruction of the ureteral lumen. At times, even the most severe obstruction is not accompanied by clinical symptoms.

When strictures are localized on both sides (with retroperitoneal fibrosis, retroperitoneal lymphadenopathy), chronic renal failure and azotemia can develop. The possibility of restoring renal function depends on the time elapsed since the obstruction and its degree.

The most characteristic symptoms:

Pain in the lower back (pain can be dull, nagging, with colic the pain is paroxysmal, acute, radiating along the ureter to the groin).
Fever.
Increased/decreased urination.
Blood in the urine.

6. Patient examination

6.1. Laboratory research

2 with determination of the sensitivity of the infectious agent.
3 Biochemical blood test (assessment of kidney function based on the level of electrolytes, urea, creatinine).

6.2. Instrumental studies

Ultrasonography. Often, ultrasound is the first instrumental examination that allows us to identify changes in the lumen of the ureter and signs of hydronephrosis.

The study is non-invasive, has no contraindications and does not require the administration of contrast agents. The main limitation of ultrasonography is poor visualization of the ureter along its length, especially in obese patients.

Also, ultrasound can only assess the anatomical state of the ureter and does not provide an opinion about the functional state of the kidney or the degree of obstruction.

Computed tomography. CT can be used in patients with acute low back pain and is often used in patients with a history of urolithiasis.

CT results are highly sensitive and specific in identifying hydroureteronephrosis and the location of ureteral dilatation, and assessing the thickness of the ureteral wall.

According to CT data, one can judge the presence of impacted, wedged stones, and suspect extravasation of urine.

The use of intravenous contrast allows one to assess the degree of obstruction and obtain information about the relationship of adjacent anatomical structures.

The use of contrast must be weighed against its nephrotoxicity. CT with contrast injection is the best method for assessing the external causes of strictures, the oncological process and its metastasis.

Intravenous pyelography. Until recently, intravenous pyelography was the method of choice for assessing the degree of obstruction. Since the widespread introduction of contrast-enhanced CT, intravenous pyelography has become rare.

Figure 2 - Severe stricture of the distal right ureter. Intravenous pyelography performed on a patient 4 weeks after hysterectomy for endometriosis. The ureteral injury was identified during surgery and repaired. Illustration source -

Figure 3 – Intravenous pyelography in the same patient. Condition after combined ante- and retrograde laser endureterotomy of the stricture followed by dilatation with a balloon catheter and stenting. The patient experienced resolution of symptoms and disappearance of signs of obstruction 3 months after endoureterotomy and stent placement. Illustration source -

Retrograde pyelography. The study is of high value, as it allows us to assess the condition of the ureter without systemic administration of nephrotoxic contrast. Retrograde pyelography allows you to decide on the choice of treatment method.

Figure 4 – Retrograde pyelography. On the right, in the middle part of the ureter, a stricture is determined. The patient has a history of surgical treatment (3 years ago) - aortobifemoral bypass surgery for obliterating atherosclerosis. During the examination, the patient was found to have increased urea levels in a biochemical blood test, and according to ultrasonography, bilateral hydronephrosis. Illustration source -

Intraluminal ultrasonography. The main advantages of the method include the ability to assess the degree of ureteral obstruction and the condition of adjacent structures. The main disadvantage is the invasiveness of the study, as well as the impossibility of assessment in case of complete obstruction of the lumen of the ureter.
Scintigraphy. The method allows you to assess the functional state of the kidneys, measure the clearance of the radiopharmaceutical and calculate renal blood flow.

6.3. Histological characteristics

If there is doubt about the nature of the stricture, ureteroscopy with a biopsy from the site of obstruction is performed before surgical treatment.

The histology of benign strictures is nonspecific: the formation of a scar with the deposition of collagen fibers, surrounding the stricture with an inflammatory infiltrate.
Strictures formed as a result of radiation therapy are characterized by a low content of cellular elements at the site of narrowing and hypertrophy of vessels with an acellular matrix.
Malignant strictures contain cellular elements characteristic of tumors (loss/reduction of cell differentiation, nuclear atypia, tumor invasion into underlying layers). The most common tumor found in the ureter is transitional cell carcinoma.

7. Surgical treatment

Currently, experts do not have a common opinion regarding the choice of the main method of treatment for patients with ureteral strictures. Surgical interventions for stricture include:

1 Balloon dilatation.
2 Endoureterotomy.
3 Stenting (intraluminal stent in the ureter).
4 Open operations.
5 Minimally invasive laparoscopic and robotic surgeries (replacing open methods of treatment).

Figure 5 – Options for endoscopic correction of ureteral strictures. Source of illustration - www.nature.com

7.1. Indications and contraindications for surgical treatment

Indications for intervention in patients with stricture may include:

1 Pain syndrome.
2 Chronic recurrent pyelonephritis.
3 Severe ureteral obstruction, which can lead to irreversible impairment of renal function.
4 Hematuria.
5 Formation of a stone proximal to the obstruction site.

Contraindications to surgical treatment:

1 The main contraindication to surgical treatment (both open and endoscopic) is the active phase of the infectious process.
2 Severe disorders of the coagulation system that cannot be corrected.

When planning surgical treatment, many factors are taken into account. In the terminal stage of oncology, decompensation of chronic diseases, elderly patients have a significant risk of complications from surgical treatment.

In this situation, it is necessary to consider placing a stent in the ureter for a long time. According to Chung, in 41% of cases after stenting, symptoms of obstruction return within a year.

In 30% of patients, an external nephrostomy tube was required within 40 days from the installation of the ureteral stent. Predictors of poor results of stenting: strictures due to an oncological process, creatinine level above 13 mg/l.

If less than 25% of normal renal function is maintained, balloon dilatation and endoureterotomy are highly likely to have no therapeutic effect.

In this case, open surgery (up to nephrectomy) will be required. The functional state of the kidney can significantly improve after the obstruction is eliminated (the less time has passed since the obstruction, the greater the effect of the operation).

If less than 10% of the normal functional capacity of the kidney is retained, the option of nephrectomy is considered, since complete restoration of kidney function on the side of the obstruction should not be expected.

7.2. Before surgery

1 Assessment of the anatomical features of the stricture according to contrast-enhanced CT and retrograde pyelography.
2 Assessing the degree of obstruction and renal function (scintigraphy is used to assess the functional state of the kidneys).
3 In patients with a history of malignant pathology, a biopsy from the site of narrowing should be obtained before surgery.
4 To reduce the risk of postoperative infection, the patient should have sterile urine specimens available prior to surgery.
5 When planning intestinal interposition, the patient undergoes mechanical and antibacterial bowel preparation the day before the intervention.
6 Antibacterial prophylaxis (administration of 2nd generation cephalosporin 1.0 - 1.5 g 1-2 hours before surgery).
7 Anesthesia: in most cases, the choice is made towards endotracheal anesthesia.

8. Balloon dilatation

Typically, balloon dilatation is the first step to relieve the obstruction, followed by placement of a temporary ureteral stent in the area of the stricture for 4 to 6 weeks.

The probability of final success from this combination is 55%. The best results from balloon dilatation can be obtained with non-ischemic short-term obstruction.

The prognosis is influenced by the following factors: duration of the stricture (optimally up to 3 months), small extent of narrowing.

Complications of balloon dilatation are:

1 Infection.
Lack of effect from the intervention.

9. Endoureterotomy

The operation is usually performed for benign strictures and has better treatment outcomes compared to balloon dilatation.

The desired effect of the operation can be achieved in 78-82% of patients with ureteral strictures. A weak effect of the operation may occur if the functional capacity of the kidneys is reduced (below 25% of normal), the length of the stricture is more than 1 cm, or there is a pronounced narrowing of the lumen of the ureter (less than 1 mm in diameter).

There are two options for the operation:

1 Antegrade endoureterotomy.
2 Retrograde endoureterotomy.

Retrograde endoureterotomy does not require a skin incision and is less invasive compared to antegrade endoureterotomy.

In excision of the stricture, the cold knife technique, electrocoagulation or laser are used.

An incision is made at the site of narrowing to the full depth of the wall, the instrument reaches the tissue surrounding the ureter. The incision should begin 1-2 cm distal and end proximal to the site of narrowing.

Dissection of the wall is performed under the control of an endoscope inserted into the ureter through the urethra and bladder. After the procedure, a temporary stent with a diameter of 7F-14F is placed for 4-6 weeks.

Possible complications:

1 Infection.
2 Damage to adjacent structures (vessels, intestines).

10. Placement of a stent in the ureter

Intraluminal stents are more often used in the treatment of malignant stricture in patients who are not subject to open/minimally invasive surgical treatment (with severe concomitant pathology, decompensation of chronic pathology).

Removing a stent from the ureter can be difficult. Sometimes spontaneous migration of the stent occurs.

According to Liatsikos, ureteral patency was restored in 66% of cases. After 1 year, lumen patency was observed in 37.8% of patients, after 4 years – in 22.7% of patients. Stents can be replaced every 6-12 months.

11. Open operations

Open operations performed to restore the lumen of the ureter:

1 Psoas hitch.
2 Boari flap.
3 Ureteroneocystostomy - excision of the stricture and reimplantation of the proximal part of the ureter into the bladder.
4 Ureteroureterostomy – formation of an anastomosis between unchanged sections of the ureter (the operation is feasible if the stricture is small and the ureter is mobile).
5 Ureteropyelostomy - anastomosis between the unchanged portion of the ureter and the renal pelvis (the operation is feasible for short proximal strictures). For cicatricial deformities of the pelvis, it is possible to perform ureterocalicostomy (anastomosis between the ureter and the renal cup).
6 Intestinal interposition.

The probability of permanent resolution of obstruction during open surgery is 90%.

Possible complications:

1 Dynamic intestinal obstruction.
2 Formation of urinoma (pararenal urinary pseudocyst).
3 Urine leakage from the anastomosis site.
4 Iatrogenic damage to the intestinal wall.
5 Impaired functional state of the bladder (with psoas hitch, Boari flap techniques).

The choice of surgical option is determined by the location and extent of the stricture. Strictures of the terminal ureter can be eliminated by ureteroneocystostomy, psoas hitch.

With proximal localization of the stricture, it is possible to use the Boari technique, which allows prosthetics of the distal 10-15 cm of the ureter.

For short-term mid-ureteral strictures, ureteroureterostomy can be performed. For the success of this operation, it is important to form an anastomosis with minimal tension, which requires adequate mobilization of the ureter throughout.

Figure 6 – Formation of ureteroureteroanastomosis. Illustration source - Medscape.com

Proximal strictures can be eliminated by performing ureteropyelostomy (if the length of the ureter allows). To reduce tension in the anastomotic area, the operation can be supplemented by mobilization of the kidney.

With cicatricial deformation of the pelvis, it is possible to form an anastomosis with the ureteral stump and the renal calyx (ureterocalicostomy). Operations on strictures of the proximal ureter can be performed from different approaches (laparotomy, lumbotomy).

11.1. Psoas hitch

The method is used in the treatment of strictures of the distal ureter (last 3-4 cm of the ureter).

Figure 7 – Scheme of the psoas hitch operation. Source of illustration - http://cursoenarm.net

Operation stages:

1 Skin incision (Pfannenstiel transverse incision or inferomedial vertical incision).
2 Mobilization of the bladder
3 Fixation of the bladder to the psoas muscle with non-absorbable sutures.
4 Excision of the stricture and replantation of the ureter into the dome of the bladder.
6 Placement of a cystostomy outside the dome of the bladder (the figure shows a sutured cystostomy).

11.2. Boari flap

Indications:

1 Extended stricture of the ureter.
2 Inability to mobilize the ureter sufficient to form a tension-free ureterovesical anastomosis.

Figure 8 – Scheme of the Boari flap operation. Source of illustration - www.researchgate.net

Operation stages:

1 Access (median laparotomy).
2 Excision of the narrowed section of the ureter.
3 Cutting out a flap from the bladder wall.
4 The cut flap is brought to the ureteral stump to create an anastomosis.
5 This method allows you to create a flap 12-15 cm long and apply a ureterovesical anastomosis without tension.
5 Placement of a temporary stent while the anastomosis is healing (10-21 days).
7 Placement of drainage to the anastomosis area.

Contraindications for performing psoas hitch and Boari flap:

1 Shriveled bladder with reduced distensibility.
2 Limited bladder mobility.
3 Ureteral strictures located above the pelvic inlet.

11.3. Intestinal interposition

The principle of the operation is to replace the affected ureter with a loop of small intestine.

The operation is performed when:

1 Extended strictures of the ureter.
2 Proximal localization of the stricture.
3 Inability to sufficiently mobilize the ureter and bladder.

Contraindications:

1 Chronic renal failure (plasma creatinine level more than 20 mg/l).
2 Obstruction in the path of urine outflow from the bladder.
3 Chronic inflammatory bowel diseases (ulcerative colitis, Crohn's disease).
4 Enteritis due to exposure to radiation.

Figure 9 – Scheme of intestinal interposition. Source of illustration - www.icurology.org

Operation stages:

1 Access (middle, lower middle laparotomy).
2 Resection of the ureter with stricture.
3 Mobilization of the small intestinal loop (it is extremely important during mobilization to maintain adequate blood supply to the loop) and its cutting off with two linear staplers.
4 Interposition of the mobilized loop (the intestinal loop serves as a conductor of urine from the proximal stump of the ureter to the bladder): formation of ureterointestinal and vesicointestinal anastomoses.
7 Placement of drainage to the anastomosis area.

11.4. Laparoscopy and robotic surgeries

Increasingly, minimally invasive techniques are used in the treatment of strictures. Open operations are being replaced by laparoscopy.

The main advantages of laparoscopy and robotic operations (Da Vinci system):

Minimally invasive.
Improved visualization of the surgical field due to multiple magnification.
Less chance of postoperative complications.
Early mobilization of the patient after surgery.
Less hospitalization period and shorter rehabilitation period.

12. Postoperative period

1 Antibacterial therapy continues until the postoperative drains are removed.
2 Drains are removed when there is a small amount of discharge (less than 30 ml/day), in the absence of urine excretion through the drainage (assessment of the level of creatinine in the discharge; when urine is excreted, the creatinine level will be several times higher than the normal level of creatinine in the blood plasma).
3 In patients undergoing endoureterotomy, stents are left in place for 4–6 weeks.
4 In patients with newly formed anastomoses, stents are left in place for 2-3 weeks.
5 Depending on the treatment method, the rehabilitation period may vary. In open operations and uncomplicated postoperative periods, the patient remains in the hospital for 4-10 days. With minimally invasive interventions (laparoscopy, endoureterotomy), the length of hospital stay is reduced to several days.

Article Highlights

CongenitalCongenital megaureter with stricture PurchasedSecondary external and internal strictures Due to obstructionExternalExternal strictures are formed as a result of compression of the ureter by a pathological process from the outside. Primary tumors of the pelvic organs (cervix, prostate, bladder, colon) lead to compression of the ureter from the outside and the development of signs of obstruction. Retroperitoneal lymphadenopathy, which can develop as a result of oncology (lymphoma, testicular cancer, breast cancer, prostate cancer) most often leads to the development of signs of obstruction of the mid-ureter. In rare cases, with retroperitoneal fibrosis, fibrous tissue grows in the retroperitoneal space with the development of unilateral or bilateral compression of the ureters, leading to renal failure. DomesticTransitional cell carcinoma (originating from the epithelial lining of the ureter) can cause internal stricture. Transitional cell carcinoma may manifest only as symptoms of renal obstruction on the affected side. Against the background of the tumor process, the ureter expands over the obstruction zone. By natureBenignFormation of a stricture against the background of stone passage, surgical trauma to the ureteral wall, and the inflammatory process in tuberculosis. MalignantTumors of the ureter and adjacent organs. By etiologyIatrogenicEtiology of iatrogenic benign strictures:
Ureteroscopy.
Open or laparoscopic operations during which accidental damage to the ureter occurs.
Irradiation.
External or internal drainage of the ureter.
Kidney transplant. NoniatrogenicNon-iatrogenic causes of the formation of strictures include urolithiasis (passage of stones through the ureter leads to injury and proliferation of connective tissue), an inflammatory process due to tuberculosis, schistosomiasis, etc. Depending on locationProximal Average Distal

Article Highlights
Ureteral stricture can sometimes be asymptomatic, leading to significant impairment of renal function. Most often, the stricture is complicated by infection and the formation of stones.
Currently, there are a large number of methods for studying strictures that make it possible to assess the extent, degree of ureteral obstruction, functional state of the kidneys, and obtain histological data.
The choice of surgical option should be based on examination data.
For small strictures, it is possible to use stenting, balloon dilation, or endoureterotomy.
Open operations are accompanied by permanent elimination of obstruction, but have a high probability of severe complications.
Increasingly, laparoscopic techniques are used to treat ureteral structures, which is accompanied by a marked reduction in the incidence of complications and rapid recovery of the patient.

Stones in the ureter are one of the most dangerous diseases in urology. Statistics show that this type of urological disease ranks second among all other diseases in this group. The disease is dangerous not only because it is expressed by severe pain, but also because of its numerous complications.

Characteristics and causes of the disease

This disease has an official medical name - ureterolithiasis. With it, calculi (stones) appear in the human kidneys, which mainly consist of cholesterol, sodium and potassium salts, which are part of uric acid. Stones may contain sulfur and even soap. The stones actively settle in the lower part of the kidneys, increasing in size.

The stones themselves have a dense structure. Initially, this type of urolithiasis does not give any serious manifestations, but then the stones begin to penetrate from the kidneys into the ureter, where there is a high risk that they will get stuck in its narrow sections. This can occur where the ureter enters the bladder. All this leads to severe pain in humans. In such cases, hospitalization, treatment and even surgery to remove stones are necessary.

Stones appear in the ureter more often in men than in women. This is due to the physiology of the stronger sex. Stones can lead not only to painful urination, but also to impaired sexual function.

There are a number of reasons for the appearance of a problem such as a stone in the ureter. Among them:

Congenital defects in the human kidneys and bladder play a significant role in the development of urolithiasis. Double kidneys or narrowing of the ureter often leads to the development of the disease. Men who drink alcohol are at high risk. Alcohol addiction leads to the development of gout, and it provokes the disease.

Symptoms of the disease

As in men, symptoms in women with this disease manifest themselves in the form of severe colic in the kidney area. Associated symptoms:

lumbar pain;
constant urge to urinate and cutting pain when doing so;
pain above the pubis;
urination with traces of blood;
pain under the ribs;
nausea with vomiting, flatulence and diarrhea, possible problems with stool retention;
increased body temperature, chills, sweating.

Pain with stones in the ureter has symptoms similar to those of cystitis. In women, the pain is in the form of attacks that appear and then subside. The pain can be sharp, dull, or aching. They often radiate strongly to the perineum: in women to the labia area, in men - to the penis area. The pain can last quite a long time: from a couple of hours to several days.

Most often, the stone gets stuck in the lower part of the ureter. This occurs in 72% of cases. Much less often, stones get stuck at the beginning of the ureter and in its middle part. Pain syndrome occurs in 96% of cases only when a stone blocks the ureter. There are also cases when a small stone (less than 2 mm) passes out of the body along with urine on its own.

When a stone in the ureter in men and women cannot pass on its own, then they should expect recurrence of attacks. Even if the stone has left the body, this does not mean that the disease has receded. There is always a chance that new stones will appear in the kidneys.

Diagnosis of the disease

The primary way to diagnose this disease is palpation, during which the urologist examines the patient and palpates his abdomen, lower back and area under the ribs. But a more accurate diagnosis of ureterolithiasis is carried out through the following measures:

X-ray examination;
urine analysis, which reveals the presence of salts, blood, proteins, and purulent discharge in it;
computed tomography of both kidneys;
tests to determine the acidity of urine;
urography;
blood test;
ultrasound examination of the genitourinary system;
research using bacteriological culture;
endoscopy, with the help of which stones emerging into the ureter are detected;
urethroscopy;
diagnostics using radioisotopes.

Based on the data from all studies, the urologist can make an accurate diagnosis and prescribe the necessary treatment for a patient suffering from urolithiasis.

Conservative methods of treating the disease

When answering the question of what to do if there are signs of a stone in the ureter, the attending physician determines its size. For stone sizes up to 3 mm. Treatment is usually prescribed with conservative methods. These methods include:

prescribing a special diet, from which foods and vegetables containing oxalic acid are excluded;
prescription of antispasmodics;
prescription of physiotherapy;
taking urolitic drugs;
physical exercise for therapeutic purposes;
taking painkillers.

Treatment through a special diet for the patient deserves special attention. Products such as sorrel, cabbage in combination with cheese and dairy products can create salt compounds in the human body that are poorly soluble. Due to the large amount of oxalic acid in a number of plant products, people who consume them often develop urolithiasis. The patient will benefit from eating watermelons and cucumbers, which have good diuretic properties.

Conservative treatment is effective only when the stone does not get stuck in the ureter and can leave the body without consequences for the patient. In other cases, doctors resort to active methods of treating the disease by crushing or removing stones removed from the body through an incision in the ureter.

Endovesical method

This method is used when a stone is stuck in the ureter and needs to be removed from the patient’s body. To do this, a special drug is injected into the ureteral canal, which provokes its release to the outside. The most common drugs are glycerin or novocaine. As an additional stimulation for the removal of stones, the technique of applying electric current to the patient’s urinary system is used. Two other non-surgical methods are also used to remove stones from the ureter - ureteroscopy and lithotripsy.

Ureteroscopy and lithotripsy

Both methods do not involve any incisions on the patient’s body, but are full-fledged operations that are performed under general or local anesthesia.

Ureteroscopy involves removing a stone from the ureter using a ureteroscope. The distal end of the device is smoothly inserted and passes through the urethra throughout the genitourinary system of a man and a woman, reaching the ureter. The stone is removed using special forceps available on the instrument. If the stone is quite large, it is crushed with a laser fiber and then removed from the patient’s body.

Crushing the stone to remove it from the patient's ureter is part of an operation called lithotripsy. This operation is often performed in cases where the patient is diagnosed with a stone at the mouth of the ureter. The procedure takes only one hour and is one of the safest operations in which there is no risk of damage to the patient’s genitourinary system.

Lithotripsy allows you to expel a stone from the ureter by exposing it to electromagnetic waves, which crush it. The remains of the crushed stone are excreted from the body along with urine. This method is effective in cases where the size of the stone is 6-9 mm. If the size of the stone stuck in the ureter is large, a surgical operation called ureterolithotomy is performed.

Surgical stone removal with ureterolithotomy

To remove a stone from the ureter in men and women, when its size exceeds 1 cm, a ureterolithotomy is performed. During this operation, the patient is put under anesthesia, and an incision is made at the site of the ureter where the stone is located. Through the resulting hole, the stone is removed from the human body. This type of operation is performed if a stone is stuck in the ureter, blocking the lumen in it. Ureterolithotomy is also performed for complications caused by the development of urolithiasis.

Home treatment and prevention

All patients wonder when they have stones in the ureter - how to remove them and how to protect themselves from this in the future? When an attack occurs, it is recommended to take pain medication to reduce colic. Then you can try to remove the stone from the ureter by preparing a diuretic infusion. It contains: bearberry, dill in seeds, horsetail. Herbs and dill seeds must be placed in a container and pour boiling water over them. Everything is infused for about half an hour. Then the infusion is filtered and drunk.

To speed up the diuretic effect after drinking the infusion, it is recommended to jump rope for 12 minutes. If the attacks recur, then it is necessary to prepare a new infusion and repeat the procedure until the stone leaves the body through urine.

To prevent the development of urolithiasis and prevent the appearance of stones in the ureter, the following conditions must be observed:

drink more water (about 2 liters per day);
reduce foods and vegetables containing oxalic acid in the diet;
use diuretic products (melons) more often, eat more fresh fruits and vegetables;
promptly treat inflammation of the bladder and remove infections from the kidneys, monitor the health of the entire genitourinary system;
use herbal infusions that have an antibacterial effect;

exercise, avoid stress, eat properly, without overusing spicy and bitter foods.

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Signs of stones in the ureter

Symptoms of stones in the ureter are caused by a blockage of the outflow of urine from the kidney. When the ureter is partially blocked by a stone, dull pain is noted in the costovertebral angle. With a complete blockade, colic develops - a severe pain attack in the hypochondrium and lower back, the pain radiates to the scrotum or labia.

Other clinical manifestations are also noted:

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Causes of stones

Most often, stones enter the ureter from the renal pelvis due to urolithiasis.

Some causes of urolithiasis: infectious and inflammatory diseases (cystitis, pyelonephritis, etc.), metabolic disorders, changes in urine pH, disruption of the colloidal state of urine and a decrease in its dissolving ability, abnormal structure of the cups and pelvis.

Stones - “removal cannot be treated” - where to put a comma?

For small stones, expectant management is used. In this case, antibacterial drugs, antispasmodics, urolitic drugs, water load (1.5-2 liters per day), and physiotherapy are prescribed. When renal colic occurs, it is treated with opioid analgesics and blockades.

Methods for removing stones from the ureter

To remove stones, endovesical methods are used - the introduction into the lumen of the ureter of drugs that improve peristalsis and facilitate the passage of stones (glycerin, papaverine, novocaine), or electrical stimulation of the urinary tract is performed.

In some cases, to remove stones from the ureter, ureterolithoextraction is used - removing stones through the channel of a ureteroscope inserted into the lumen of the ureter using special forceps.

Before removing stones with a diameter of more than 6 mm, their crushing (lithotripsy) is required.

Lithotripsy happens:

Remote – crushing of stones is carried out without surgical intervention by external influence of laser, ultrasound, electromagnetic radiation or electro-hydraulic influence.
Contact – fragmentation of stones under direct influence of physical factors (ultrasonic, pneumatic, laser crushing).

In some cases, abdominal or laparoscopic ureterolithotomy is indicated.

Treatment of the disease with folk remedies - diet and proper nutrition for stones in the ureter

If there are stones in the ureter, it is necessary to limit the consumption of salt and animal fats, and avoid fried, smoked and spicy foods. It is also recommended to exclude coffee, strong tea, chocolate, legumes, spinach, and sorrel from the diet. You can eat cereals, fruits, berries (watermelon is very healthy), vegetables and dishes made from them, lean fish and meats, dairy products, honey, marshmallows, and marmalade.

To alleviate the condition, you can take a decoction of rose hips, tea from mint, lemon balm and chamomile, or an infusion of lingonberries with honey.

How does the deletion work?

For stones with a diameter of more than 1 cm, open or laparoscopic ureterolithotomy is indicated. Surgery for stones in the ureter is also performed when there is an infection that cannot be treated with antibiotics, intractable colic, obstruction of a single kidney, or no effect from treatment with other methods.

Main stages of ureterolithotomy:

Carrying out the incision depending on the location of the stone.
Identification of the ureter, dissection of its wall.
Removing the stone with forceps.
Drainage placement, suturing.

Cavitary ureterolithotomy(removal of stone through an incision in the wall of the ureter) is now rarely performed. Most often, stones can be removed using endoscopic techniques or crushed.

Crushing stones in the ureter using a laser - pros and cons of contact lithotripsy

Laser lithotripsy is a method of crushing stones using a holmium or neodymium laser. Contact laser lithotripsy is one of the most modern methods of stone removal. The method consists of bringing a flexible light guide through the ureteroscope to the stone, exposing it to a laser beam and destroying it.

Read also: Modern methods of diagnosis and treatment of kidney hydronephrosis

Crushing stones in the ureter using ultrasound

Ultrasound lithotripsy can be performed by contact and remote methods. Contact ultrasound lithotripsy is performed in the same way as laser lithotripsy, using a ureteroscope.

Remote ultrasonic crushing is carried out by the impact of waves on the stone from the outside. Disadvantages of remote crushing: damage to the tissue around the stone during the procedure; high-density stones are not destroyed.

Endoscopic removal of stones from the ureter

If the size of the stones is less than 8 mm and they are located in the middle and lower third of the ureter, they can be removed without surgery. This method is called ureterolithoextraction. A ureteropyeloscope is inserted through the urethra and bladder into the ureter, and a lithoextractor is brought through it to the stone. The calculus is captured with lithoextractor forceps and carefully removed through the urinary tract. However, this method has a number of complications: damage to the ureteral mucosa, rupture of the wall, separation of the ureter, etc.

Prevention and consequences of removing stones from the ureter - can there be complications?

After removal of stones from the ureter, they may re-form. To prevent relapse, it is necessary to eliminate the cause of stone formation - treat pyelonephritis and other inflammatory diseases, metabolic disorders, and eliminate anatomical causes.

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The process of formation and causes of occurrence

More often, stones in the ureter are salt deposits displaced from the kidneys, less often they are primary formations that can be localized in the upper, middle, distal (lower) part of the ureter.

The basis of the stones are deposits of salts of different compositions, which are held together by protein substances. The main cause of stones in the ureter is considered to be a violation of metabolic processes, and as a result - a transformation of the composition of urine and its level of acidity. Changes in the properties of urine and precipitation of salt crystals lead to the formation of a stone core, which is gradually overgrown with cellular elements, fibrin, and blood elements.

The formation of stones in men is influenced by various factors:

genetic predisposition;
kidney inflammation of an infectious and non-infectious nature;
anomalies of the renal collecting system;
ureteral strictures;
endocrine disorders;
insufficient fluid intake;
poor nutrition;
bad habits;
stagnation of urine;
vitamin D deficiency;
prostate adenoma;
prostatitis and others.

Learn about the symptoms of apostematous pyelonephritis, as well as methods of treating the disease.

What is kidney hardening and how to treat the pathology? Read the answer at this address.

Clinical manifestations

If there is no disturbance in the outflow of urine through the ureter, then the presence of stones in it may not manifest itself in any way. Small pebbles can pass through the urinary tract on their own and asymptomatically. During the passage of formations, sharp edges can injure the ureteral mucosa and cause inflammation.

Symptoms of ureterolithiasis in men depend on the location of the stone and its mobility. If the stone is immovable, it partially blocks the lumen of the ureter, but due to the compensatory reaction, the pressure on the kidney decreases, and virtually no pain is felt. Such stones are more difficult to diagnose due to poor symptoms.

The mobility of stones becomes a provoking factor in complete obstruction of the ureter. As a result, a man may experience:

a sharp decrease in urinary outflow;
intrarenal hypertension;
swelling of the kidney tissue;
increase in kidney volume.

All this is accompanied by pain of different localization, depending on the location of the stone. If the stone is located in the upper or middle part of the ureter, the pain resembles renal colic.

Characteristic signs of colic:

sudden sharp pain that is cramping in nature and can last up to 12 hours;
localization of pain: lower back, lateral abdomen;
intoxication (loss of appetite, weakness, nausea);
protein content, high concentrations of leukocytes and erythrocytes in the urine.

As the stone changes its location, the location of the pain also changes. When it is in the lower part of the ureter, the pain is similar to inflammation of the epididymis, manifests itself intensely, radiates to the scrotum and groin.

If the stone moves through a site that passes through the bladder wall, symptoms will resemble cystitis:

pain and stinging when urinating;
frequent urge to go to the toilet;
reduction in daily diuresis;
pain in the lower abdomen;
temperature rise.

Consequences and possible complications

Stones entering the ureter obstruct urinary outflow, which can lead to the development of the following complications:

pyelonephritis;
sepsis;
hydronephrosis;
renal failure;
pathological strictures of the ureter.

Diagnostics

First, a man needs to see a urologist, a specialist will conduct an examination. Based on the localization of colic, the doctor may, upon palpation, suspect the presence of a stone in the ureter. Light tapping at the location of the stone is accompanied by increased pain.

To clarify the diagnosis, additional studies are prescribed:

biochemical and general analysis of urine and blood;
bacterial sowing;
Ultrasound of the kidneys and urinary tract;
cystoscopy;
urethroscopy;
radiography of the urinary tract;
MRI and CT.

General rules and methods of treatment

If the formations are up to 2-3 mm in size and do not interfere with the excretion of urine, then observation tactics are usually chosen. The stones may pass out on their own. The patient must adhere to a plentiful drinking regimen of at least 2.5 liters of water per day for several weeks, take diuretics, and antispasmodics.

Removing stones at home

If there is no risk of ureteral obstruction, you can expedite the removal of the stone yourself. You can resort to home treatment temporarily if you cannot quickly see a specialist.

First you need to relax the muscles of the ureter, take an antispasmodic (No-shpu, Drotaverine). If the pain is very severe, you can take analgesics or NSAIDs. To speed up the passage of the stone, you can sit in a warm bath. At the same time, you should drink diuretic decoctions of herbs (horsetail, dill, corn silk). The juice of birch, lemon, beets, and cranberries also has a diuretic effect. After half an hour spent in the bathroom, you can move actively to speed up the release of the stone.

Diet and nutrition rules

The correct diet for stones in the ureter in men is one of the key parts of treatment. The menu largely depends on the composition of the sediments. The patient needs to exclude those foods that contribute to the deposition of certain types of stones. On the other hand, you need to increase the foods in your diet that accelerate their elimination and dissolution.

With calcium salts, you need to limit the consumption of oxalic acid (spinach, cabbage, radishes, legumes). It is especially dangerous to combine them with dairy products. They contain a lot of calcium, which, when combined with oxalic acid, forms oxalates. When consuming foods high in phosphorus and alkalizing the urine, phosphates are formed. Excess uric acid in food causes urate stones.

Sticking to a long and monotonous diet is dangerous for your health. Food should be varied and balanced, this reduces the risk of forming stones of a certain chemical composition.

Surgery

If you do not seek medical help even for small stones, their passage through the ureter can damage the mucous membrane with sharp edges, cause bleeding, and cause an inflammatory process. In addition, stone removal in men is often accompanied by intense pain, which not everyone can withstand.

Methods of qualified treatment are selected based on the size of the stones, their location, and the intensity of pain.

The patient is subject to hospitalization in the following cases:

terrible pain with increased body temperature;
blood in urine;
a sharp decrease in diuresis or complete absence of urination.

A stone in the ureter can block the flow of fluid from the kidneys, which requires immediate medical attention. Usually they resort to surgical methods of removing stones:

External lithotripsy- crushing stones in the ureter larger than 6 mm with a lithotripter under the influence of laser or ultrasound beams.
Percutaneous nephrolithotomy- used for stones larger than 2 cm in diameter, which are localized in the upper part of the ureter. The patient is given general anesthesia, a tube is inserted through the urethra into the ureter, through which a contrast agent is injected. A small incision is made in the lumbar area and a nephroscope is inserted. An ultrasonic wave is applied to the stone, which crushes the formation. Crushed particles are removed using special forceps.
- a urethroscope is inserted through the urethra, the calculus is illuminated with an LED to visualize its shape and location. The formation is grasped with forceps and stones are removed from the ureter. If the formation is large, it is first crushed with a laser inserted into the lumen of the urethroscope.

Open operations to remove stones are less often used only if their size exceeds 1 cm.

Learn about the causes of urolithiasis, as well as how to treat the disease using folk remedies.

Possible complications and consequences of kidney infarction are written on this page.

Go to http://vseopochkah.com/diagnostika/analizy/bilirubin-v-moche.html and read about the norm and causes of deviations in the level of bilirubin in the urine.

Prevention measures

Most adult men have kidney stones and don't even know it.

To minimize the risk of stone formation, it is necessary to ensure compliance with preventive measures:

drink 2-2.5 liters of liquid daily;
eat a balanced diet, avoid monotony in food, excessive consumption of foods that contribute to the deposition of salts;
quit bad habits;
avoid stagnation of urine, empty the bladder on time;
promptly stop inflammatory processes in the urinary organs;
regularly diagnose the condition of the urinary system.

A specialist will tell you more about the treatment of stones in the ureter in the following video:

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Causes of stone formation in the ureter

Most of the ureteral stones encountered in practical urology are kidney stones that have dislodged from the pelvis. They can have a variety of shapes and sizes. Most often, single stones get stuck in the ureter, but multiple ureteral stones can also occur. Typically, the calculus is retained in areas of physiological narrowing of the ureter - the ureteropelvic segment, in the area of intersection with the iliac vessels or the vesicoureteral segment. For retention in the ureter, the diameter of the stone must exceed 2 mm.

The ureteropelvic segment is the site of transition of the larger diameter renal pelvis into the ureter with a lumen of 2-3 mm. Following the ureteropelvic segment, the lumen of the ureter expands to 10 mm, so a small stone can move distally - to the second physiological narrowing at the level of the iliac vessels. At this point, the ureter crosses the upper border of the pelvic inlet and again narrows to a diameter of 4 mm. The third physiological narrowing of the ureter is the vesicoureteral segment, where the diameter of the ureter is 1-5 mm.

About 25% of stones get stuck in the upper third of the ureter, about 45% in the middle, and up to 70% in the lower third. Primary stones in the ureter are rare. Their initial formation in the ureter can be facilitated by ureterocele, tumors, ectopia of the ureter, strictures, foreign bodies (ligatures, etc.). Stones of the left and right ureter are detected equally often.

Geographical and climatic factors play a certain role in the genesis of urolithiasis. Thus, in the Don and Volga basin, in the Caucasus, in Central Asia, Bavaria and Dalmatia, urolithiasis is especially common. Stone formation in the urinary tract is promoted by nutritional factors - dietary habits and quality of drinking water.

Since the formation of stones is based on a violation of phosphoric acid, oxalic acid, uric acid and other types of metabolism, the frequency of urolithiasis correlates with gout, hyperparathyroidism, osteoporosis, and bone fractures.

In the pathogenesis of stone formation, a change in the pH of urine, a violation of its colloidal state and a decrease in dissolving ability are of paramount importance. Such changes can develop under the influence of infection, primarily pyelonephritis. A certain role here is given to factors leading to urostasis - abnormal structure of the calyces and pelvis, strictures and valves of the ureter, incomplete emptying of the bladder with urethral stricture, prostate adenoma, diverticula of the urinary tract, spinal cord injuries, etc.

Symptoms of stones in the ureter

Clinical manifestations of ureteral stones develop with partial or complete blockage of urine outflow from the kidney. Therefore, in 90-95% of patients, stones in the ureter are detected only with the development of renal colic.

When the lumen of the ureter is partially blocked by a stone, the pain is dull, localized in the corresponding costovertebral angle. In the case of complete obstruction of the ureter, a sudden disruption of the outflow of urine from the kidney, overstretching of the pelvis and an increase in intrapelvic pressure develops. Disruption of microcirculation in the renal tissue and irritation of the nerve endings causes a severe attack of pain - renal colic.

An acute pain attack due to a stone in the ureter develops suddenly and is often associated with physical stress, fast walking, jolting driving or excessive fluid intake. The pain is localized in the lower back and hypochondrium, radiating along the ureter to the scrotum or labia. Acute pain forces the patient to continuously change position, which, however, does not bring relief. Renal colic can last for several hours or days, periodically subsiding and resuming again.

A painful attack due to a stone in the ureter is accompanied by reflex disorders of the gastrointestinal tract - nausea and vomiting, flatulence, stool retention, muscle tension in the anterior abdominal wall. This is due to irritation of the nerve endings of the parietal peritoneum adjacent to the blocked kidney.

Dysuric disorders with a stone in the ureter depend on the location of the stone. When the stone is localized in the lower part of the ureter, a continuous painful urge to urinate and sensations of strong pressure in the suprapubic region develop, caused by irritation of the receptors of the bladder walls.

Sometimes, when the ureter is obstructed by a stone, oliguria is observed due to the inability to remove urine from the kidney or general dehydration with severe vomiting. With stones in the ureter, macrohematuria is observed in 80-90% of cases, which often precedes a painful attack. Prolonged presence of a stone in the ureter leads to the addition of leukocyturia and pyuria.

Renal colic is accompanied by a sharp deterioration in general condition - headache, chills, weakness, dry mouth, etc. With a small stone in the ureter, renal colic can result in spontaneous passage of the stone. Otherwise, an acute attack of ureteral pain will certainly recur.

The most likely complications of stones in the ureter are obstructive pyelonephritis, hydronephrosis, and the development of renal failure (with bilateral ureterolithiasis or stones in a single kidney). In some patients with ureteral stones, the disease is aggravated by the addition of an infection - Escherichia coli, Proteus vulgaris, staphylococcus, which is manifested by acute and chronic pyelonephritis, urethritis, pyonephrosis, and urosepsis.

Diagnosis of stones in the ureter

The clinical picture of renal colic with a high degree of probability forces the urologist to assume the presence of stones in the ureter. Palpation of the projection of the kidneys is extremely painful, the reaction to the beating symptom is sharply positive. After relief of renal colic, palpation of the Tournai points, corresponding to the places of anatomical narrowing of the ureters, remains painful.

Urine tests for a stone in the ureter (general analysis, biochemical study of urine, pH determination, bacteriological culture) can provide valuable information about the presence of impurities in the urine (red blood cells, leukocytes, protein, salts, pus), the chemical structure of stones, infectious agents, etc. d.

To visualize stones in the ureter, determine their location, size and shape, a comprehensive X-ray, endoscopic and echographic examination is performed, including survey radiography of the abdominal cavity, survey urography, excretory urography, CT scan of the kidneys, ureteroscopy, radioisotope diagnostics, ultrasound of the kidneys and ureters. Based on a set of data, treatment tactics for stones in the ureter are planned.

Treatment of stones in the ureter

Conservative-wait-and-see tactics for stones in the ureter are justified in the case of a small stone size (up to 2-3 mm). In this case, antispasmodics, water load (more than 2 liters per day), urolitic drugs (ammi tooth extract, combined herbal preparations), antibiotics, exercise therapy, physiotherapy (diathermy, diadynamic currents, subaqueous baths) are prescribed. When renal colic develops, urgent measures are taken to relieve it with the help of narcotic analgesics, blockades, and antispasmodics.

Endovesical methods for removing stones include the introduction into the lumen of the ureter of special drugs (glycerin, papaverine, procaine), which enhance peristalsis and facilitate the movement of stones, or conduct electrical stimulation of the urinary tract through electrode catheters.

In some cases, to remove stones from the ureter, they resort to endourological intervention - ureterolithoextraction - removal of stones using special trap loops through the channel of the ureteroscope inserted into the lumen of the ureter. If a stone is pinched at the mouth of the ureter, it is dissected to facilitate the removal or passage of the stone. After stone extraction, the ureter is stented for better drainage of urine, sand and microscopic stone fragments.

Stones with a diameter of more than 6 mm require fragmentation before extraction, which is achieved by ultrasound, laser or electrohydraulic lithotripsy (crushing). For stones in the ureter, external ureterolithotripsy or percutaneous contact ureterolithotripsy is used.

Open or laparoscopic ureterolithotomy is indicated for stones in the ureter larger than 1 cm; infections that are not amenable to antimicrobial therapy; severe, intractable colic; non-advancing stone; obstruction of a single kidney; ineffectiveness of SWL or endourological methods.

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Ureteral stones are a significant problem that urologists around the world face every day. Urolithiasis affects patients regardless of gender and age. Modern urology has made significant progress in the treatment of this pathology, and minimally invasive operations for urolithiasis, which are used to rid the urinary tract of stones, have become routine.

Let's take a closer look at how to remove a stone from the ureter.

Table of contents:

Urolithiasis primarily occurs in the kidneys. In most cases, the stone enters the ureter from the renal pelvis. If the outflow of urine is disrupted, it manifests itself. The following symptoms are typical for it:

severe pain on the standing side of the stone;
dysuria;
decrease in the amount of urine excreted;
macro- or microhematuria;
dyspeptic disorders (with irritation of the solar plexus against the background of severe pain).

Depending on the location, the stone may be in the upper, middle or lower third of the ureter.

Why are stones formed?

Factors contributing to the development of urolithiasis are as follows:

Hereditary predisposition.
Living in endemic areas.
Improper nutrition, which contributes to stone formation.
History of diseases associated with urolithiasis.
Especially highlight:
- hyperparathyroidism;
- renal tubular acidosis,
- some gastrointestinal pathologies,
- etc.
Taking certain medications can also lead to the formation of stones. First of all, we are talking about calcium preparations, sulfonamides, vitamins C and D in high dosages.
Hypovitaminosis A and B.

There are a number of genitourinary diseases that are accompanied by stone formation.

Anomalies in the structure of the urinary system:

strictures of the ureteropelvic segment and ureter;
renal cup diverticulum;
vesicoureteral reflux;
ureterocele;
horseshoe kidney.

In some patients, long-term infection of the urogenital tract is complicated by the formation of stones.

Please note

There are several theories of stone formation, but the common one is a constant excess of stone-forming substances in the urine.

The composition and density of the stone depends on the pH of the urine.

Diagnostic measures

When talking with the patient, 80% of the time you can decide on management tactics. Palpation reveals pain on the part of the kidney and a positive symptom of effleurage. If the stone is located in the lower third of the ureter, there are complaints of frequent urge to urinate, pain, urinary incontinence, pain radiating to the groin area. The diagnosis must be confirmed by instrumental examination methods.

Differential diagnosis is carried out with the following conditions:

Modern methods of instrumental diagnostics make it possible to make a diagnosis in almost 100% of cases.

Instrumental diagnostics

Survey urography. The method is accessible, but its accuracy leaves much to be desired for X-ray negative stones. In addition, a number of factors influence the conclusion:
- excess body weight;
- fullness and ;
- quality of consumables, etc.
- The sensitivity of the method is 70%, the specificity is slightly more than 80%.
.
There are direct signs of a stone in the kidney and prevesical ureter and indirect signs. These include:
- expansion of the renal collecting system;
- expansion of the proximal and distal parts of the ureter.
An ultrasound picture allows one to assess the prevalence of the inflammatory process, the condition of the renal arteries, blood flow, swelling of the parenchyma, and the presence of purulent focal formations. The sensitivity of the method is from 78 to 93%. Specificity of 95% and above.
Excretory urography
The method provides a complete assessment of the structure and functional capacity of the kidneys and urinary tract.

Contraindications to contrast X-ray diagnostics are allergic reactions to contrast, blood creatinine levels above 200 µmol/l, myelomatosis and metformin therapy.
- a modern and informative way of research. CT allows one to assess the density and spatial location of the stone, which is important for determining further management tactics and identifying contraindications to extracorporeal lithotripsy. Sensitivity and specificity 100%.

Additional research methods include retrograde or antegrade urography, pyelography (assessment of ureteral patency throughout its entire length), and dynamic urography.

Laboratory diagnostics

Ureteral stones: treatment

To relieve renal colic, drugs from the group of NSAIDs and antispasmodics, including narcotics, are used.

According to clinical guidelines, Diclofenac reduces glomerular filtration, which is a contraindication for the treatment of patients with chronic renal failure. If kidney function is preserved and the stone is expected to pass on its own, prescribe 50 mg of Diclofenac 2 times a day, in suppositories or tablet form, for 5–7 days.

This relieves pain and reduces swelling of the ureter.

Dynamic monitoring of the patient’s condition and clinical and laboratory parameters is necessary.

The use of alpha1 adrenergic blockers (Tamsulosin, Silodosin, etc.) promotes the passage of stones from the ureters.

To prevent the inflammatory process, uroseptics and antibiotics are used.

There are good reviews about the use of herbal remedies for urolithiasis. Relatively recently appeared in the pharmacy chain herbal medicine Rowatinex.

It has the following properties:

antispasmodic;
pain reliever;
anti-inflammatory;
bacteriostatic.

Reception scheme: 1 - 2 capsules 3 times a day, for renal colic 2 - 3 capsules 4 - 5 times a day before meals.

What is the probability that the stone will come out on its own?

According to the European Association of Urology, stones up to 4–6 mm in size pass away on their own in 80% of cases.

Please note

The larger the size, the less likely it is to spontaneously pass.

Surgery for small stones is indicated in the following cases:

the existence of chronic obstruction with the likelihood of loss of kidney function;
addition of infection;
risk of developing urosepsis or 2-sided obstruction;
lack of effect from the therapy.

Crushing stones in the ureter

Before choosing surgical intervention, the severity of the inflammatory process is assessed. If the inflammation is significant, as confirmed by changes in urine analysis and bacterial culture results, they resort to drainage of the kidney by installing a stent-drainage or PPNS (percutaneous puncture nephrostomy) with the prescription of antibiotics until the condition normalizes.

Contraindications

Lithotripsy is not performed in patients with the following pathologies:

with severe heart disease,
strictures below the location of the stone,
acute processes in the genitourinary system,
CRF with loss of function more than 50%,
blood clotting disorders.

Who needs surgical treatment for ureteral stones?

Surgery is needed if the quality of life is not satisfactory, because of a stone in the ureter, kidney function suffers, the stone causes constant infection of the urinary tract.

How do stone crushing plants work?

External shock wave lithotripsy in urology is considered a minimally invasive, gentle way to get rid of stones. All lithotripters, regardless of the source of generation, produce a shock wave pulse that has an alternating effect on the calculus until it is destroyed into fragments.

Subsequently, the crushed particles are excreted naturally in the urine.

The process of focusing on the desired locus is carried out under the control of X-ray and ultrasound equipment.

Concretions having a mixed composition are more easily destroyed. The most difficult stones are cystine stones.

Let us note that at present there is a clear position on crushing stones in the ureters and kidneys, and it is the same among both Russian and Western specialists.

What interventions are performed for stones in the ureters

Depending on the size, composition and location of the stone in the ureter, the functional safety of the kidneys, the method of surgical treatment is chosen.

To get rid of a stone in the ureter, the following interventions can be used:

remote shock wave lithotripsy;
contact lithotripsy;
laparoscopic ureterolithotomy;
percutaneous nephrostomy + extracorporeal lithotripsy;
ureteroscopy + contact lithotripsy.

The disadvantages of DLT include the fact that the effect is carried out not only on the stone, but also on nearby tissues.

Local extracorporeal lithotripsy is more often performed, but ureteroscopy followed by contact exposure is equally effective.

In CLT, stones are crushed using ultrasound or laser. The laser is used for stones with high density.

With the contact method, there is no negative effect on surrounding tissues.

Contact lithotripsy is preferable in the following cases:

if after 2 sessions of DLT and litholytic therapy there are no changes;
several stones were diagnosed;
the stone remains in the ureter for a long time;
there are contraindications to DLT;
Obstruction of the ureter with stone fragments occurs after DLT.

If a uric acid stone is located in the proximal ureter, a stent is installed and litholytic therapy is prescribed; This type of stone responds well to conservative treatment.

It should be noted that several sessions of DLT are often performed. If the stone is in the ureter for a long time, is large in size and density, or is firmly “adhered” to the wall, contact lithotripsy is preferable.

If DLT and CLT are not feasible, video endoscopic surgery comes to the rescue, which is a replacement for open surgery.

According to the theses of the Russian Association of Urologists, DLT, CLT and their combinations are the most reliable way to get rid of stones in the ureters; open and laparoscopic operations are resorted to much less frequently.

What is better to choose

It should be noted that DLT and CLT are complementary ways to get rid of stones in the ureter.

After CRT, the percentage of complications is higher; its use is not always possible in men with a large prostate gland or in children.

According to various data, in 15–25% of cases after contact lithotripsy of a stone in the upper third of the ureter, the stone migrates to the kidney, which entails an additional session of DLT. But if we take into account other complications (for example, the formation of a “stone path”), then CLT successfully eliminates this complication after extracorporeal lithotripsy in 20%.

What complications can occur when crushing stones?

Note that complications are rare, since the techniques have been used for a long time and sufficient experience has been accumulated.

Side effects after DLT:

blockage of the ureter with stone fragments with subsequent development of acute inflammation,
hematoma formation.

Undesirable consequences after CLT:

damage to the mouth;
ureteral avulsion;
perforation;
acute inflammatory process in the upper and lower parts of the urogenital tract;
migration of stone to the kidney.

In case of complications, the kidney is drained, massive antibacterial therapy is carried out, open operations are rarely performed, since complications in the form of ureteral rupture occur in only 0.2% of cases.

The risk of complications increases with repeated interventions, as the topography of the retroperitoneal space changes due to scar changes.

How to prevent stone formation after surgery

After the intervention, great importance is attached to chemolysis (litholysis, dissolution) of the crushed stone.

Blemaren is used to dissolve small residues, but the drug only works for uric acid stones.

Patients with a different composition of stones are prescribed an increased drinking regimen, antispasmodics, antibiotics, and are advised to adhere to proper nutrition according to the chemical structure of the stone.