Ureter Flashcards
Define intrinsic UPJO
area of ureter lacking peristalsis secondary to collagen deposition or poor circular musculature; also could be due to mucosal folding
Define extrinsic UPJO
aberrant, lower pole vessel crosses anteriorly to the ureter causing it to kink
Tx of choice for UPJO in peds; adults?
Peds = pyeloplasty
Adults: endopyelotomy if etiology is not due to a lower pole vessel
What factors determine success rate for endopyelotomy for UPJO in adults
No lower pole crossing vessel
Good renal function
Stricture segment < 2cm
Mild-moderate hydronephrosis
If your surgery fails to correct the UPJO, what is the next step?
Endopyelotomy fails –> pyeloplasty or vice versa
If both fail, or pyeloplasty is failed with a long stricture, consider ureterocalicostomy
What is Dietl’s Crisis?
Someone with UPJO has renal colic secondary to diuresis, such as alcohol ingestion
What is a bifid ureter/ureter fissus?
Etiology?
It’s where 2 ureters insert the renal pelvis (duplex kidney) with a solitary, shared ureteral orifice
Due to partial division of ureteric bud prior to contacting the metaneprhogenic blastema
What is a duplicated ureter?
Etiology?
2 ureters at the renal pelvis with 2 completely separate ureters with their own UO’s
Due to complete division of the ureteric bud prior to contact with the metanephrogenic blastema
What is the Weigert-Meyer rule?
Upper pole ureter associated with ureterocele (obstructs), is ectopic, and the UO is inferior-medial
Lower pole ureter associated with VUR and UPJO, and the UO is superior-medial
What imaging test can be done to determine function of each renal unit/segment in a duplicated system?
MAG3 scan
In a duplicated system, what is the treatment if symptomatic obstruction and segment has minimal function?
Partial nephrectomy
In a duplicated system, what is the treatment if symptomatic obstruction but kidney has function?
Treat the obstruction (ureterocele ablation or pyeloplasty for UPJO)
In a duplicated system, what is the treatment if asymptomatic but kidney segment has minimal function?
Observe
Define ectopic ureter:
UO not located within bladder trigone
In females, an ectopic ureter will never directly insert into a _____ structure, but rather into associated ____ duct remnants.
promesoneprhos structure (Mullerian)
inserts into a mesonephos (Wolffian) structure
How do females commonly present with ectopic ureter?
continuous incontinence, as ureter can be distal to the spincter/bladder neck, vagina, or rectum
In males, where can ectopic ureters insert?
anywhere from bladder neck to the proximal extent of external sphincter
*males never have incontinence with ectopic ureters b/c it will always insert proximal to the external sphincter
Treatment for ectopic ureter?
Would you ever separate a duplicated or bifid ectopic ureter?
Ureteral reimplantation (ureteroneocystostomy)
NEVER separate ureters, as this will injure ureteral vasculature
Etiology of ureterocele?
Cystic dilation in a distal ectopic ureter due to persistent Chwalla’s membrane
What is a cecoureterocele?
the portion of the ureterocele that extends into the urethra
- hard to diagnose and treat
What study/test is required before surgically treating a ureterocele?
VCUG
IVP or CT urogram or CT cystogram, what is the buzzword for the appearance of a ureterocele (contrast within the ureterocele and not contrast surround it)
Cobra-head appearance
Study of choice to dx a ureterocele in pediatrics?
bladder ultrasound
- will have hydronephrosis (upper pole if duplex system)
What are the various treatment options for a ureterocele?
What should one do to the patient prior to definitive treatment?
Transurethral incision
Excision of ureterocele with ureteral reimplantation
Upper pole nephroureterectomy if non-functioning
Ureteroureterostomy
Patient should be given prophylactic antibiotics
Is a retrocaval ureter a problem with the urogenital development or problem with vascular development?
Vascular development (persistent cardinal veins)
Define megaureter:
non-specific term for severely dilated ureter > 7-8mm
Primary megaureter is due to what?
Treatment?
intrinsic ureteral abnormality leading to lack of peristalsis
Tx: majority resolve; check renal ultrasound at puberty
If primary megaureter needs surgical fixation, how should it be fixed?
distal remodeling to allow a 5:1 tunnel length-to-diameter ratio to prevent reflux; plication for moderate hydronephrosis, excision tapering for severe hydro
Divide the medial umbilical ligament (obliterated umbilical artery) as it loops lateral to posterior the ureter, thus eliminating possible ureteral obstruction
What is secondary megaureter?
megaureter due to severe VUR (grade 5), bladder outlet obstruction, neurogenic bladder
What should be given to patients with megaureter?
antibiotic prophylaxis until resolved
