Diseases and operations on the urinary tract

diseases of the urinary tractCongenital Abnormalities

Congenital abnormalities of the kidney are not uncommon. Abnormal blood vessels enter­ing the hilus of the kidney may crowd the col­lecting pelvis and the ureter to obstruct the uri­nary flow. Occasionally a small or deformed kidney may be present. Total absence of one kid­ney is not infrequent. When there is a fusion of the two kidneys the so-called “horseshoe kid­ney” results which may mechanically impede the pelvic emptying. “Double ureters” sometimes occur. These abnormalities present since birth often demand revision by operation if they cause symptoms or if they hinder the function of the system in ridding the body of its waste products.

Injuries

Injuries to the kidney are usually the result of direct blows over the loin, but may be seen with crushing injuries and gunshot wounds. Injuries may cause simple tears of the capsule or severe fracture of the organ. Bleeding may be minor or severe internal hemorrhage. Treatment may necessitate only conservative medical care while the kidney repairs itself, or may demand opera­tion. Operation usually requires removal of the kidney (nephrectomy) although occasionally it is possible to repair the damaged organ. Injuries to the bladder are common in automobile acci­dents and result in rupture of the part with seepage of urine into the abdomen and tissues around it. Most often such fracture of the blad­der is associated with fracture of the pelvic bones. Injuries to the urethra are more common in the male, the result of vehicular accidents, direct blows to the region, and sexual abuses. Foreign bodies in the urethra are occasionally encountered. Most injuries to the urinary tract require operative repair.

Inflammations

Inflammations may occur in any part of the urinary system. A general term for inflammation of the kidney is called nephritis. (Chronic nephritis is often referred to as Bright’s disease.) Infection involving the glomeruli is known as glomerulonephritis. This may be acute, chronic, or recurrent. Inflammation involving the renal pelvis is called pyelitis. When the in­flammatory process involves both the kidney and the pelvis, it is referred to as pyelonephritis; if such should progress to produce abscesses and the entire area becomes a bag of pus, it is called pyonephrosis. These conditions usually are caused by germ infections and most often are associated with some obstruction of the uri­nary flow. Treatment is most often by medical measures, but, if obstruction is present, catheter­ization of the ureter may be necessary to drain the renal pelvis. If obstruction is marked, op­eration to relieve it may be indicated. When the kidney function is lost, nephrectomy (kid- ney-out) may be needed.

Abscesses around the kidney (perinephric abscess) caused by extension of infections of the kidney or of other parts in the vicinity al­ways require surgical drainage.

Inflammation of the urinary bladder, called cystitis or urocystitis, is very common. This may ensue from infection from without via the urethra, or from within by the flow of infected urine. It is much more common in the female, probably due to the shorter urethra. Treatment rarely entails surgery. Infection of the urethra is usually of extrinsic source and is called urethritis.

Calculus or Stone

Calculus or stone of the urinary system is a common disease. Such is formed by deposits of the salts in the urine, and are initiated by in­fections. Stones may be singular (calculus) or multiple (calculi). They may be found any­where from the kidney to the bladder, and vary in size from small granular particles called uri­nary sand or gravel to stones the size of a base­ball filling the entire bladder.

Stones in the kidney may cause few symptoms but may block the kidney function in part or in total. A large calculus filling the entire kidney pelvis and assuming the shape of this part of the collecting system is called a staghorn calculus. Stones in the ureter are usually those formed in the pelvis to pass downward. A small calculus may completely block the ureter, in which case there is sudden severe pain associated with other urinary and general symptoms. These frequently will pass to the bladder from where they will be eliminated. Stones in the bladder will usually pass via the urethra but occasionally remain to grow larger as further salt deposits occur.

Urinary calculi must be removed in order to assure an unobstructed flow of urine and to re­lieve symptoms. Their continued presence may lead to more serious conditions. Many calculi will be eliminated spontaneously or with medi­cal adjuncts, but some will require operative re­moval. When calculi are within the bladder or ureter, frequently manipulation by instruments through the cystoscope will effect their removal, but some will require open operation. Stones in the kidney and pelvis require surgical removal; this may be by nephrotomy (incision into kid­ney) or pyelotomy (incision into pelvis) or nephrectomy. Incision into the ureter is called ureterotomy and into the bladder, cystotomy.

Tumors

Tumors of the urinary tract are most infre­quent in the ureter and urethra. Benign tumors of the kidney are not commonly encountered and are less frequently seen in the bladder. Malignant growths of the kidney demand ne­phrectomy and those of the bladder require wide bladder resection, or a cystectomy (bladder- out). In more recent years, numerous new prac­tical operative procedures have been devised for allowing the ureter to drain to the surface or into another internal passageway, after blad­der removal.

Cysts

Cysts of the kidney may be singular or multi­ple. In the former case they may become large and produce symptoms so that their surgical removal is necessary. Multiple cysts of the kid­ney (polycystic kidney) usually involve both kidneys; these are treated by surgical means only if infection is otherwise not controlled.

Nephroptosis

Nephroptosis is the condition wherein the supporting structures of the kidney are at fault and with the standing position the organ falls downward from its bed. This is the so-called floating kidney. This may give rise to kinking of the ureter to obstruct this tube, much as the kinking of a garden hose impedes its flow. Surgi­cal replacement and support of the kidney is called nephropexy.

Stricture

Stricture of the ureters or urethra is a nar­rowed segment along the course of the channel, which is usually the result of infection but may be congenital. These may give rise to obstruction of the urinary flow. They are much more com­mon in the urethra than in the ureter. Urethral strictures may be treated by dilatation, or stretch­ing with instruments. But either may require operative correction.

Hydronephrosis

Dilated ureter

Hydronephrosis is dilatation and enlargement of the kidney and its pelvis by a blocking of the urinary flow at some lower portion of the system. This occurs when an obstruction has been pres­ent for some time. It is frequently the result of urinary stones lodged in the ureter, but may result from stricture or other causes. This often gives rise to pyonephrosis. Treatment is directed at relief of the offending obstruction. This may necessitate drainage of the pelvis by placing a catheter by cystoscopy up past the ob­struction into the pelvis; or nephrostomy (sur­gical placement of drainage tube from kidney or pelvis to outside). The kidney may recover so that the obstruction may be corrected, but, if the function has been lost, nephrectomy may be per­formed. Plastic revision of a deformed renal pelvis is called pyeloplasty.

Hydroureter

Hydroureter is an enlargement of the ureter caused by an obstruction to its flow. The portion below the level of the obstruction will remain of normal caliber while that above the obstruction reaches ever-increasing proportions with the in­creasing pressure of continued urine production by the kidney (Fig. 69). This condition is al­ways preceded by hydronephrosis as the capacity for stretching and distention is greater in the kidney and pelvis. If an obstruction producing hydronephrosis is not relieved, hydroureter en­sues. Again treatment is directed at relief of the obstruction with hopes of renal recovery.

Prostate Gland Enlargement

This condition may give rise to obstruction to the bladder neck in the male, so that micturi­tion cannot be accomplished. This may necessitate the surgical placement of a drainage tube into the bladder which empties the bladder contents to the surface. This is called cystostomy (bladder-opening) and may be nec­essary before or after prostate operations.

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