Method for ultrasound diagnostics for obstruction of pyeloureteral segment

FIELD: medicine, urological ultrasound diagnostics.

SUBSTANCE: ureterectasia should be developed below prepyeloureteral department, one should cause functional obstruction in ureterovesical segment: a patients should fill urinary bladder to achieve high values of pressure in it, restrict urinary passage through ureterovesical anastomosis, perform medicinal polyuria due to intravenously introduced lasix at age dosage at simultaneous introduction of an analgesic. About 10 min after lasix introduction one should perform ultrasound testing in the course of which an increased upper third of patient's ureter enables to localize pyeloureteral segment, detect the length of obstruction and due to Doppler scanning detect either availability or absence of inferior polar vessel. The method enables to determine indications to apply open surgical techniques of hydronephrosis and endoscopic methods (endopyelotomy).

EFFECT: higher efficiency of ultrasound diagnostics.

5 dwg, 3 ex

 

The invention relates to medicine, namely to the ultrasonic diagnostic research in urology, and can be used in the preoperative diagnosis of the extent and causes of obstruction of the pelvic-ureteric segment and identify indications of endopyelotomy or public methods surgery for hydronephrosis.

It is known that the introduction of percutaneous endoscopic interventions on pyeloureteral segment when it is obstruction in the 90 years of the last century came upon the complexity of preoperative diagnosis, primarily the cause of obstruction.

Incremental nizhnesolenyi vessel is the cause of obstruction in 25-30% of cases. Consequently, the use of endopyelotomy in one quarter of cases obviously ineffective or even contraindicated. Extensive obstruction of the pelvic-ureteric segment is also a contraindication for performing endoscopic methods of treatment. The reduced effectiveness of endoscopic techniques in the treatment of obstruction pyeloureteral segment compared with open surgery, due to the use of the method in unacceptable conditions, led to the formation of the opinion of its low efficiency.

It is known that the execution of endopyelotomy (Angelsen A., Teigum H. Percutaneous pyeloplasty of ureteropelvic junction stenoses. // Tidsskrift for Den Norske Laegeforening. - 1995. - Jun.) when is bstructive pelvic-ureteric segment is not effective and is not suitable for obstructed, called incremental nijaporn vessel, a large extent of the obstruction and the large size of the pelvis. Today there is no simple, minimally invasive and reliable ways preoperative diagnosis of the extent and causes of obstruction of the pelvic-ureteric segment, which dramatically reduces the indications of endopyelotomy in the surgical treatment of hydronephrosis.

There is a method of diagnosing the extent of obstruction pyeloureteral segment (Vishnevsky EL Kazan IV, V.V. Rostov, Babanin I. New methods of diagnosis and treatment of disorders of the cross prilozhennogo Department of the ureter in children // a Guide for physicians. - Moscow. - 2000. - 22P.) using profilometry segment. This method is chosen as a prototype. The data on the cause of obstruction to obtain practically impossible, and the method vasocongestion and is associated with catheterization of the renal pelvis, with further study the relationship between the flow-pressure. In addition, in most cases, the application of this method involves using General anesthesia.

There is a method of endoluminal ultrasonography in the diagnosis of the extent and causes of obstruction of the pelvic-ureteric segment (Martov, A.; Slukova YU //Endoluminal ultrasonography in the diagnosis and treatment of diseases of the upper urinary tract. The UB is age, 2002. No. 1. - Pp.31-37). The disadvantage of this method is the need for catheterization of the renal pelvis, the execution of this study against the background of General anesthesia and age restrictions associated with the inability to use in children of early age due to the diameter of the sensor (6,2 Fr).

In light of the above there is a real need to develop a minimally invasive, simple and reliable method for preoperative diagnosis of the extent and causes of obstruction pyeloureteral segment.

The aim of the invention is a preoperative diagnosis of the causes and extent of obstruction pyeloureteral segment and identify indications for use of endopyelotomy or open surgical treatment of hydronephrosis.

This goal is achieved by creating urodynamic conditions, leading to the expansion of the ureter below the level of obstruction that allows you to visualize it by ultrasound scanning.

For the formation of ureterectomy on the first phase of the study cause functional obstruction in ureterovesicular segment. To do this, the patient is asked to fill the bladder to intense urge to urinate. The pressure in the bladder reaches high values and sharply restricted the passage of urine through ureterovesical fistula. On W the rum phase of the study used medical polyuria with lasixa, enter in the age dosage intravenously. Thus is formed an excessive amount of urine, which, falling into the ureter, causing its expansion at the expense of the formed functional obstruction ureterovesicular segment. Ten minutes after administration of a diuretic, an ultrasound is done, which extended the upper third of the ureter allows to localize the location pyeloureteral segment, to determine the length of the obstruction and using the Doppler scan region pyeloureteral segment to determine whether the extension of the polar vessel.

The results of ultrasound examination allow pre-operative diagnosis of the extent and causes of obstruction of the pelvic-ureteric segment and to determine the indications for the use of endopyelotomy or open surgery methods of hydronephrosis.

The invention “method of an ultrasonic diagnostic obstruction pyeloureteral segment is new, because it is not known from the level of medicine in the field of diagnostic ultrasound in urology.

The novelty of the invention lies in the fact that in patients with obstruction pyeloureteral segment is able to visualize the upper third of the ureter below the obstruction, the length of the obstruction and the reason the e caused, to define indications for the implementation of endopyelotomy or open surgery of hydronephrosis.

The invention “method of an ultrasonic diagnostic obstruction pyeloureteral segment involves an inventive step, since physician-urologist, is not obvious from the level of medicine ultrasound in urology cause and extent of the obstruction pyeloureteral segment hydronephrosis.

In contrast to known methods of ultrasound examination of the urinary tract when hydronephrosis proposed method for the diagnosis of the extent and causes of obstruction with hydronephrosis aims to target the identification of the main parameters obstruction pelvic-ureteric segment, determine the possibility of using endoscopy or open ways of pyeloplasty.

The proposed “method of ultrasonic diagnostics obstruction pyeloureteral segment” the original, not obvious explicitly and the level of medicine in the field of plastic urology, is not known in the available sources of information, or in CIS, neither in Russia nor abroad.

The invention “method of an ultrasonic diagnostic obstruction pyeloureteral segment is industrially applicable and can be used in health care, health-care providers in the diagnosis of PR is tsennosti and causes obstruction pyeloureteral segment hydronephrosis method of surgical correction, in particular in urological clinics involved in the correction of hydronephrosis with modern ultrasound equipment.

The method is as follows. In a patient with identified during the survey hydronephrosis on the background of obstruction pyeloureteral segment to determine the extent and cause of obstruction is created urodynamic situation, allowing to achieve expansion of the ureter below pyeloureteral segment. For this first phase of the study, the patient is asked to fill the bladder to urge for urination, close to imperative. When this develops functional block level vesicoureteral segment. When the pressure in the bladder above the systolic pressure formed in the ureter urine ceases to flow from the ureters into the bladder. The scheme of formation of the obstruction presented on the drawings (figure 1, 2).

For fast filling of the ureter below pyeloureteral segment intravenously injected lasix in age dosage with simultaneous introduction of an analgesic. Dramatically increased the flow of urine from getting into the ureter, causing its expansion due to the difficulty of the passage through the distal ureter. Schematically in the drawing shows the mechanism of formation of ureterectomy (FIG. 3).

After FD is the formation of ureterectomy able to visualize the area pyeloureteral segment, to determine the extent and severity of obstruction. After localization zone obstruction to be scanned using the Doppler sensor. In the presence of incremental nizhnespasskoe vessel it is possible to visualize and thus to clarify the cause of obstruction. The obtained data were compared with intraoperative findings.

The method of an ultrasonic diagnostic obstruction pyeloureteral segment examined 18 patients.

Examples of specific clinical application “Method of ultrasonic diagnostics pyeloureteral segment”

Example 1.

Patient M., 2000 birth entered in the urology Department of the Regional children's hospital 10.05.02, No. East. disease 5412/487 with a diagnosis of obstruction pyeloureteral segment right hydronephrosis 3 stage right. According to radioisotope renography obstructive type of curve to the right, excretory urography: the expansion and deformation of the cavity system of the right kidney, a moderate decrease in the function of the right kidney.

The patient performed an ultrasound with application of the method to diagnose the cause and extent of the obstruction of the pelvic-ureteric segment. Thus there is no reduction of the diameter of the ureter in the area of the segment (FIGURE 4).

15.05.02 the patient had an operation: lumbotomy, revision right kidney and p is loricariinae segment, resection of segment, ureteropyelostomy. During inspection of a segment revealed a high discharge of the ureter in the absence of morphological changes of the segment. Thus, intraoperative finding fully confirmed the received ultrasound data.

Example 2. Patient G., age 11 he entered the urology Department with a diagnosis of obstruction of the pelvic-ureteric segment, hydronephrosis stage 2-3 left in November 2001, № history 10572/589. When performing excretory urography revealed obstruction MEL, hydronephrosis 2-3 tbsp. left.

21.11.01 the patient is examined with the method of the ultrasonic diagnostic of the extent and causes obstruction of the LMS. At the same time revealed the extent of obstruction of 8 mm With Doppler study area obstruction identified the cause of obstruction - extension nizhnesolenyi vessel (FIGURE 5).

21.11.02 the patient underwent operation - lumbotomy, revision of the left kidney, revision LMS. The cause of obstruction was incremental nizhnesolenyi vessel. The patient underwent antenatally ureteropyelostomy. Obtained using the method of the ultrasonic diagnostic obstruction data was fully confirmed during surgery.

Example 3. Patient K., 10 years, no history of the disease 3459/428, was hospitalized in June 2002 with a diagnosis of obstr the Ktsia pyeloureteral segment to the right, hydronephrosis 3 stage right, secondary chronic pyelonephritis. The patient underwent rentgenologicheski methods of research, radioisotope studies which confirmed the presence of obstruction MEL.

The patient underwent ultrasound examination of the extent of obstruction pyeloureteral segment, showing the narrowing prilozhennogo Department of the ureter over a length of 8 mm, no signs of incremental nizhnespasskoe vessel according to the Doppler scan.

The patient underwent surgical intervention: lumbotomy right, audit kidney and prilozhennogo Department of the ureter, plastic pelvic-ureteric segment. During inspection of a segment identified dysplasia last for 10 mm Obtained using the method of an ultrasonic diagnostic of the extent and causes of obstruction of the segment data is fully confirmed intraoperatively.

Technical and economic efficiency “Method of ultrasonic diagnostics obstruction pyeloureteral segment is that, for the first time using non-invasive technology based on ultrasonic methods diagnostics extent and causes obstruction in the pelvis-ureter segment. Obtained data allow to determine the indications for the use of the open method is in surgery of hydronephrosis and endoscopic methods (endopyelotomy).

The method of an ultrasonic diagnostic obstruction pyeloureteral segment, including ultrasound, characterized in that the form ureterectomy below prilozhennogo Department of the ureter, causing functional obstruction in ureterovesicular segment: patient fills bladder to achieve the high pressures that limit the passage of urine through ureterovesical fistula, then provide medical polyuria intravenous injection of lazica in a dosage of age with the simultaneous introduction of analgesic, 10 min after the introduction of lasixa carried ultrasound, which extended the upper third of the ureter allows to localize pyeloureteral segment, to determine the length of the obstruction and on the basis of the Doppler scan region pyeloureteral segment to identify the presence or absence of nizhnespasskoe of a vessel.



 

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