Gidronefroz – the progressing expansion cup a complex with the subsequent atrophy of a kidney parenchyma, developing owing to violation of outflow of urine from a kidney. Gidronefroz is shown by the waist pain (aching or as renal colic), a gematuriya, a painful frequent urination, arterial hypertension. Diagnostics of a gidronefroz can demand performing ultrasonography of a bladder and kidneys, a kateterization of a bladder, intravenous urography, a tsistouretrografiya, KT or MRT of kidneys, a piyelografiya, a stsintigrafiya of kidneys, a nefroskopiya. Treatment of a gidronefroz demands elimination of a cause of infringement of a passage of urine; method of emergency aid is the nefrostomiya.
Gidronefroz or hydronephrotic transformation of a kidney is a consequence of violation of a physiological passage of urine that leads to pathological expansion of cavities of a kidney, changes of interstitsialny renal fabric and an atrophy of a parenchyma. Aged from 20 up to 60 years the frequency of development of a gidronefroz is higher at women that is caused by the reasons connected with pregnancy and gynecologic oncological diseases. After 60 years develops at men, mainly against the background of adenoma of a prostate or a prostate cancer more often.
Violation of current of urine leads to increase in pressure in a mochetochnik and a lokhanok that is followed by noticeable violations of a glomerular filtration, function of tubules of a kidney, piyelolimfatichesky current, piyeloarterialny and piyelovenozny blood-groove. As an outcome of a gidronefroz serves the atrophy of kidney tubules and death of structural units of a kidney – nefron.
Classification of a gidronefroz
On development time can be primary (congenital) or acquired (dynamic). On weight of a current it is allocated easy, moderate and heavy ; on localization – unilateral and bilateral. In urology meets identical frequency the right and left kidney; bilateral hydronephrotic transformation is observed in 5-9% of cases.
The current of a gidronefroz can be sharp and chronic. In the first case at timely correction perhaps complete recovery of kidney functions; in the second – functions of kidneys are lost is irreversible. Depending on existence of an infection can develop on the aseptic or infected type.
Reasons of a gidronefroz
The causes of a gidronefroz are variable, but can be divided into two groups: caused by obstruction or an obstacle in any department of an urinary system (mochetochnik, a bladder, an urethra) or the return current of urine caused by insolvency of valves of a bladder. On localization and character of the reason of a gidronefroz can be internal, external and functional.
At the level of mochetochnik as the internal reasons of development of a gidronefroz tumors, fibroepitelialny polyps, blood clots, concrements, fungal damages of an urethra (an aspergilemm, a mitsetom), to the ureterotsela, tuberculosis, endometriosis, etc. act more often. Externally the obstacle for an urine passage in a mochetochnikovy segment can be created by a retroperitonelny lymphoma or sarcoma, pregnancy, uterus neck cancer, loss of a uterus, cysts of ovaries, pipe abscess, prostate tumors, aneurism of belly department of an aorta, the limfotsela which is abnormally located the renal artery squeezing a mochetochnik.
From a bladder as internal factors of development of a gidronefroz an urolithic disease, to the tsistotsela, the carcinoma, a bladder diverticulum, a bladder neck contracture can act. Existence of a neurogenetic bladder and a puzyrno-mochetochnikovy reflux belong to violations of a functional order. The external obstacle for outflow of urine from a bladder can arise at a pelvic lipomatoz.
Among internal damages of an urethra development of a gidronefroz is promoted by diverticulums, urethra striktura, an urethra atresia. As external obstacles the giperplaziya and a prostate cancer, as a rule, act.
At a gidronefroza defeat of an urinary path at various levels can be also caused by congenital dyskinesia and obstruction of uric ways, their injuries, an inflammation (uretrity, cystitis), injuries of a spinal cord. At localization of an obstacle for outflow of urine below a lokhanochno-mochetochnikovy segment, there is an expansion not only lokhanka, but also a mochetochnik that leads to a gidroureteronefroz.
Symptoms of a gidronefroz
Manifestations of a gidronefroz depend on localization, the speed of development and duration of obstruction of a segment of uric ways. Weight of symptomatology is defined by extent of expansion cup kidney complexes. Sharp develops promptly, at the same time there are expressed pristupoobrazny waist pains as renal colic with distribution on the course of a mochetochnik, in a hip, a groin, a crotch, area of genitals. The speeded-up desires on an urination, its morbidity, nausea and vomiting can be noted. At a gidronefroza in urine there is a blood seen by an eye (makrogematuriya) or (mikrogematuriya) defined laboratory.
Unilateral aseptic chronic the long time proceeds latentno. The discomfort in the field of a lumbar and costal corner, periodic dull aches in a waist which amplify after physical activity or reception of a large amount of liquid is in most cases noted. Over time the chronic fatigue and decrease in working capacity progresses, there is tranzitorny arterial hypertension, the gematuriya appears. At temperature increase of a body, as a rule, it is necessary to think of the infected gidronefroz and sharp purulent obstructive pyelonephritis. In this case in urine pus (piuriya) appears. Patognomonichny for a gidronefroz a sign is the preference of the patient to sleep on a stomach as such situation leads to change of intra belly pressure and improvement of outflow of urine from the affected kidney.
Complications of a gidronefroz
Chronic quite often promotes developing of an urolithic disease and pyelonephritis, hypertension which even more burden clinic of hydronephrotic transformation of a kidney. Against the background of the infected gidronefroz sepsis sometimes develops.
The current of a gidronefroz can be complicated by development of a renal failure. In this case, especially at a bilateral gidronefroz, death of the patient occurs from intoxication products of nitric exchange and violation of water and electrolytic balance. The spontaneous rupture of a hydronephrotic bag therefore occurs izlity can become the Zhizneugrozhayushchy complication of a gidronefroz wet in zabryushinny space.
Diagnostics of a gidronefroz
At a gidronefroza the diagnostic algorithm consists of collecting anamnestichesky data, carrying out fizikalny inspection, laboratory and tool researches. In the course of studying of the anamnesis at patients existence of the reasons which can promote development of a gidronefroz becomes clear. Fizikalny these maloinformativna are also not specific. At a deep palpation of a stomach the stretched bladder can be defined, children and thin adult patients have an increased kidney. Stomach percussion in the changed kidney even at a small gidronefroz reveals timpanit.
At renal colic, tension and an abdominal distension often resort to a bladder kateterization. Release through a catheter of large volume of urine can demonstrate obstruction at the level of an urethra or an output opening of a bladder.
As the defining methods of diagnostics of a gidronefroz serve radiological also ultrasonographies. Ultrasonography of kidneys is carried out polipozitsionno, investigating longitudinal, cross, slanting projections in position of the patient on a stomach and on one side. At an ekhografiya assessment of the sizes of kidneys, states cup complexes, existence of additional shadows, a condition of mochetochnik is made. If necessary ultrasonography of a bladder with determination of amount of urine, UZDG of vessels of kidneys is in addition carried out. To reveal changes in a zone of a lokhanochno-mochetochnikovy segment, and okolomochetochnikovy cellulose performance of an endolyuminalny ekhografiya allows.
For identification of a gidronefroz X-ray contrast researches, first of all, the excretory urography and a retrograde ureteropiyelografiya allowing to judge secretory function of a kidney are priority. In certain cases for definition of the reasons of obstruction of a kidney at a gidronefroza resort to a hromotsistoskopiya, a kidney angiography, a chreskozhny antegradny piyelografiya, MRT and KT of kidneys. The radio isotope dynamic nefrostsintigrafiya and a renoangiografiya are used for assessment of an organ blood-groove.
Signs of dysfunction of kidneys at a gidronefroza allow to reveal blood test and urine. Biochemical indicators of blood are characterized by increase in level of creatinine, urea, change of electrolytic balance (sodium, potassium). In the general analysis of urine the leykotsituriya, a piuriya, a gematuriya is defined. If necessary Reberg, Zimnitsky, Nechiporenko, Addis-Kakovsky's test, urine is investigated.
Gidronefroz it is necessary to distinguish from the states, similar on symptomatology, which are not complicated by hydronephrotic transformation of a kidney - a pochechnokamenny disease, a nefroptoz, a polikistoz, kidney cancer.
Treatment of a gidronefroz
Conservative therapy at a gidronefroza is inefficient. It can be directed to knocking over of a pain syndrome, prevention and suppression of an infection, decrease HELL, correction of a renal failure in the preoperative period. As method of emergency aid at a sharp gidronefroz serves the chreskozhny (perkutanny) nefrostomiya which allows to remove the saved-up urine and to reduce pressure in a kidney.
Types of surgical treatment of a gidronefroz can be various and are defined by the reason of this state. All methods of expeditious treatment of a gidronefroz share on reconstructive, organ-preserving and organoudalyashchy. As indications to reconstructive plasticity serve safety of function of a parenchyma and a possibility of radical elimination of the reason of a gidronefroz. At striktura of an urethra or striktura of mochetochnik balloon dilatation, a buzhirovaniye, an endotomiya, stenting of mochetochnik is made.
In case of the obstruction caused by a giperplaziya or a prostate cancer the prostate resection, urethra dilatation, a prostatektomiya can be carried out or to be appointed hormonal therapy. In case of an urolithic disease the lithotripsy or surgical removal of concrements from an obstruction zone is shown. Open operations are carried out at zabryushinny tumors, aneurism of an aorta, impossibility of performing endoscopic stenting or a shock and wave lithotripsy. – to removal of the changed kidney – resort to a nefrektomiya when losing its function and danger of complications.
Forecast and prevention of a gidronefroz
Bystry elimination of the reasons of a gidronefroz allows a kidney to restore the functions at the expense of great reserve opportunities. In case of long obstruction, damage of other kidney or accession of an infection the forecast of a gidronefroz serious.
Passing of periodic inspection at the urologist with performing ultrasonography of kidneys, prevention of diseases of urinary tract allows to prevent development of a gidronefroz.