Hydropyoureter

HYDROPYOURETER, hydropyoureter (empyema of the ureter), represents a dilated, chronically inflamed ureter with purulent contents. Hydropyoureter develops in the ureteral stump after the removal of a pyonephrotic, or more rarely, tuberculous kidney. Hydropyoureter arises due to an obstruction existing in the lower segment of the ureter, which can be caused either by a stone (the most frequent cause) or by a congenital or acquired stricture. The purulent contents of the inflamed ureter do not find a sufficiently free outflow into the urinary bladder and, stagnating, cause a progressive dilation of the ureteral lumen to the caliber of the small intestine. The clinical picture of hydropyoureter was first observed by Kümmell in 1911 on the basis of stones in the lower segment of the ureter, then by Verriotis in 1915 on the basis of a ureteral stricture caused by a tuberculous lesion of the latter. Of the Russian authors, cases of hydropyoureter were described by Fedorov and Kornshtein. The symptoms of hydropyoureter consist of pyuria, and sometimes also dysuria, which do not cease after the removal of the pyonephrotic or tuberculous kidney when the urinary bladder and the remaining kidney are healthy. The phenomena of pyuria can last for several years, and hydropyoureter is diagnosed with great difficulty and delay if one does not keep this disease in mind. If hydropyoureter reaches significant dimensions, it is possible to palpate a painful, elongated body in the iliac region corresponding to the location of the ureter. Upon cystoscopy, one can sometimes...

...pass a catheter only a short distance into the ureter, running into either a calculus or an existing stricture. The picture of the urinary bladder is usually little changed, and from the functioning kidney it is possible to obtain urine without an admixture of pus. If hydropyoureter is caused by a stone, it is possible to obtain its image by means of radiography. Sometimes it is possible, through a ureteral catheter introduced for 1 or several centimeters, to fill the stump with a contrast medium and obtain an accurate X-ray image of hydropyoureter (see figure). To avoid the formation of hydropyoureter, it is necessary before nephrectomy to determine the state of the ureter—whether it is dilated, and in the case of dilation, to ascertain the cause of the latter. In urolithiasis, it is necessary to pay attention to the possibility of the presence of a stone also in the lower segment of the ureter, and in tuberculosis, to the presence of a stricture. In rare cases, a congenital narrowness of the vesical orifice of the ureter may also take place. If the cited changes are clarified before the surgical intervention, then the removal of the entire ureter along with the kidney is indicated. If hydropyoureter is diagnosed some time after nephrectomy, then a secondary operation—total removal of the ureteral stump—is indicated. Access to the stump must be extraperitoneal. Due to inflammatory processes, the ureter is usually fused at the site of crossing with the vessels and with the peritoneum, and the operation for its removal presents significant technical difficulties. Conservative methods of treatment, in the form of endovesical dilation of the stricture and washings of the stump, do not yield good results.

Ya. Gotlib.