Hydronephrosis of the opposite kidney

　　First, Etiology

　　Hydronephrosis of the opposite kidney in renal tuberculosis is a late complication of renal tuberculosis, caused by obstructive lesions of bladder and ureteral tuberculosis. It mainly affects the urine drainage of the opposite kidney through various pathological changes, causing hydronephrosis of the opposite kidney and ureter.

　　Second, Pathogenesis

　　1. Stricture of the ureteral orifice in tuberculous cystitis:Starting from the ureteral orifice on the affected side, it gradually spreads to the triangular area and the opposite ureteral orifice. After the lesion invades the muscular layer and causes fibrous tissue hyperplasia, the opposite ureteral orifice may develop intramural stricture due to scar formation, obstructing the urine drainage of the opposite kidney and causing hydronephrosis of the opposite kidney and ureter. The dilation of the ureter usually develops from the area near the stricture upwards gradually, and finally the entire ureter dilates and twists, which is also unfavorable for urine drainage.

　　2. Incomplete closure of the ureteral orifice:The normal ureter has a sphincter-like effect due to the oblique intramural segment in the bladder. When the bladder contracts, urine flows outwards from the inside to the outside and does not reflux into the ureter and renal pelvis. The tuberculous lesions around the ureteral orifice can lose the sphincter-like effect due to fibrosis, causing incomplete closure of the ureteral orifice. Therefore, urine in the bladder often refluxes into the contralateral ureter and renal pelvis, causing hydronephrosis of the kidney and ureter.

　　3. Severe bladder tuberculosis:In the late stage, the bladder muscle is replaced by a large amount of fibrous tissue, and finally, it is inevitable that the bladder will contract, losing its original storage and contraction function. The intravesical pressure is often in a high-pressure state, directly affecting the drainage of the contralateral kidney and ureter, thus leading to secondary hydronephrosis.

　　Narrowing of the ureteral orifice, incomplete closure of the ureteral orifice, and contracture of the bladder often coexist. During cystography, the contrast medium can reflux through the ureteral orifice into the ureter and renal pelvis.

　　4. Narrowing of the lower segment of the ureter:Due to the continuous reflux of tuberculous bacillary urine into the contralateral ureter or through the lymphatic infiltration between the sheaths, in addition to the tuberculous lesions near the orifice of the contralateral ureter, which can spread directly to the mucosal surface or infiltrate submucosally, causing a segment of the ureter above the orifice to become narrowed due to scar formation, leading to hydronephrosis of the contralateral kidney and ureter.

　　The above four types of lesions often coexist. The secondary contralateral hydronephrosis in renal tuberculosis is mainly caused by three factors: mechanical obstruction at the lower end of the ureter, retrograde urine flow, and bladder hypertension. Severe hydronephrosis can cause atrophy of the renal parenchyma, decline in renal function, and ultimately renal failure.

　　Once hydronephrosis is complicated with infection, if the obstruction is not relieved in time, the infection is difficult to cure, and the infection accelerates the destruction of the kidney, forming a vicious cycle, and even forming an abscessed kidney.

　　1. Urinary tract infection:Due to the retention of urine in the kidney and ureter, it causes bacterial growth and reproduction, thus leading to complications such as pyelonephritis, ureteritis, cystitis, or perinephritis.

　　2. Renal atrophy:Renal atrophy is the main harm caused by hydronephrosis. Due to the obstruction of urine excretion, the renal pelvis expands, the intrarenal pressure increases, the renal tissue vessels are compressed, leading to ischemic progressive atrophy and destruction of the renal tissue, and damage to renal function. In more serious cases, the kidney will become a non-functional large cyst. In patients with mild hydronephrosis, the renal pelvis shape can be restored after the obstruction of hydronephrosis is relieved; however, it is difficult to repair the atrophied renal tissue in patients with severe hydronephrosis.

　　3. Formation of kidney stones:Nephrolithiasis blocking the urethra and causing hydronephrosis, and hydronephrosis can induce the formation of stones, which are mutually causal. The bacterial flora, pus balls, and necrotic and desquamated tissue cells become the core of kidney stone formation, especially the crystallization of salt crystals in the infected urine will accumulate into stones.

　　4. Severe renal hydronephrosis:Due to the thinness of the renal parenchyma, if the intrarenal tension is too great, it is easy to cause traumatic rupture or spontaneous tensional rupture, which may be complicated with acute peritonitis, posing a serious threat to life safety.

　　The clinical symptoms of contralateral hydronephrosis in renal tuberculosis are similar to those of general advanced renal tuberculosis. Local symptoms of hydronephrosis are often not obvious, but the overall condition is often weak. The prominent manifestation is severe vesical tuberculosis symptoms, with frequent urination, urgency, dysuria, and extremely frequent urination, several times an hour, accompanied by hematuria, even urinary incontinence. A few patients have no bladder contraction, and hydronephrosis is caused solely by stenosis of the ureteral orifice, and bladder irritation symptoms are not obvious.

　　Another type of symptom is anemia, edema, acidosis, and other manifestations of renal insufficiency. If there is secondary infection, the condition will be more serious. These symptoms can only indicate that both kidneys are damaged, but cannot distinguish between bilateral renal tuberculosis or renal tuberculosis with contralateral hydronephrosis. If the patient feels one-sided lumbar pain when the bladder is full or urinating, it indicates that the patient has vesicoureteral reflux.

　　One, patients with pulmonary tuberculosis or other tuberculosis should undergo urine examination to detect renal tuberculosis early and receive early treatment. Pay attention to rest and emotional adjustment.

　　Two, renal tuberculosis patients need to supplement high-calorie and high-quality protein, and need milk; a large amount of vitamin A, B, C, and D need to be supplemented; more fresh vegetables, fruits, and various light and rich in water food should be eaten to keep the defecation smooth and enhance the diuretic effect. Long-term sick patients with physical weakness are recommended to eat tonics.

　　Avoid hot and spicy foods, as well as smoking and alcohol.

　　Three, renal tuberculosis can be cured if diagnosed early and treated positively and correctly; if found too late, the kidneys have been severely damaged or there is ureteral stenosis, surgical treatment may be required, and the prognosis is poor.

　　The fundamental measure to prevent urinary生殖系 tuberculosis is to prevent pulmonary tuberculosis. Due to the progress of molecular biology in recent years, the Centers for Disease Control and Prevention in the United States (1989) proposed a strategic plan to eliminate tuberculosis within 20 years. Humans may use new preventive, diagnostic, and treatment methods to eliminate tuberculosis. The main measures are as follows:

　　1. To prevent the development of infection into clinical disease, in the past, isoniazid 300mg per day was used for the prevention and treatment of people who had close contact with tuberculosis patients recently and other people who may develop tuberculosis. After the use, the incidence of tuberculosis decreased, reducing the spread of the disease. Through the application of short-course chemotherapy, it was found that intermittent medication can also achieve the effect of daily medication. Experimental research using rifampicin and pyrazinamide twice a week, taking medication for 2 months can effectively prevent the development of infection into tuberculosis. If this method is used for prevention and treatment, it can greatly reduce the spread of tuberculosis with only more than 10 times of medication.

　　2. The research on the species and genus specificity, surface antigens of Mycobacterium tuberculosis, the production of monoclonal antibodies, and the production of Mycobacterium tuberculosis-specific DNA probes in order to make an early diagnosis of tuberculosis.

　　3. In 1998, Cole and others determined the sequence of Mycobacterium tuberculosis DNA. Vaccines made from Mycobacterium tuberculosis DNA not only have the effect of preventing tuberculosis but can also be used for treatment, eliminating the remaining Mycobacterium tuberculosis after drug treatment. This breakthrough will accelerate the control and elimination of human tuberculosis infection.

　　1. Urine examination:Urine routine examination is acidic, with a small amount of protein and red and white blood cells. The 24-hour urine tuberculosis bacillus examination is an important method for diagnosing renal tuberculosis, and the detection of tuberculosis bacilli in urine has a decisive significance for the diagnosis of renal tuberculosis.

　　2. Phenol red renal function test:The delay in the excretion of phenol red is the earliest change in hydronephrosis on the contralateral side of renal tuberculosis, which can be used as an initial examination. After intravenous injection of 6mg of phenol red, urine samples are collected at 15, 30, 60, and 120 minutes, and the concentration of phenol red is measured. In hydronephrosis, the amount of phenol red in the urine samples at 15 and 30 minutes is very low, while the content of phenol red in the later two samples is higher, showing the phenomenon of delayed and inverted excretion of phenol red. This is different from the normal 15-minute concentration, which is the highest, followed by a gradual decrease.

　　3. Intravenous urography:Routine urography often cannot be visualized due to the solute load caused by the high dose of contrast medium itself, which can act as a diuretic, causing the hydronephrotic kidney to be fully filled. In recent years, large-dose excretory urography has been widely used, that is, 1ml of the commonly used intravenous contrast medium is injected per kilogram of body weight, which can improve the visualization in most cases. Delayed photography can also be used, and the specific time can be determined according to the excretion speed of phenol red. It is appropriate to delay the photography to 45 minutes, 90 minutes, or even 120 minutes after injection, and generally, a clearer image can be obtained.

　　4. X-ray examination:X-ray examination has a decisive significance in determining the diagnosis of renal tuberculosis, defining the location, extent, degree of lesions, and the condition of the contralateral kidney.

　　5. Ultrasound examination:This examination is simple, economical, rapid, and non-invasive, and can understand the extent of hydronephrosis on the contralateral kidney, and can measure the thickness of the cortex to estimate the renal function status. It can also be used as an accurate localization examination for puncture urography.

　　6. CT and MRI examination:For patients with acute anuria and non-opacification of the kidneys, CT or MRI examination can be performed to obtain more detailed information about renal and ureteral lesions, especially MRI can be used to understand the extent of ureteral dilation, the degree of stenosis, the location and range through the MRU (Magnetic Resonance Urography) technique of the urinary system water imaging, which provides a basis for the formulation of treatment plans, but it is relatively expensive.

　　7. Renal puncture urography:Percutaneous nephrostography is a good method for diagnosing severe renal tuberculosis and hydronephrosis with impaired renal function, which can be performed under the guidance of B-ultrasound or X-ray. Renal puncture urography can not only obtain extremely clear images of the renal pelvis and ureter, but also clearly identify the location and extent of obstruction. The urine aspirated from the renal pelvis can be subjected to routine examination and bacterial culture, and can also be tested for tuberculosis bacilli to exclude bilateral renal tuberculosis. Generally, a diluted one-time intravenous urography agent can be used for urography during renal puncture, and the amount of contrast medium injected should be less than the urine aspirated during puncture. Antibacterial drugs can also be added to the contrast medium.

　　8. Retrograde cystography:When there is a suspicion of urine reflux, contrast medium can be injected into the bladder through a catheter for retrograde urography, but it may increase the burden on the diseased kidney and cause retrograde infection, and it has been rarely used recently.

　　9. Cystoscopy:The bladder mucosa can be seen to be congested, edematous, with tuberculous nodules and ulcers, which are more obvious around the trigone and the affected ureteral orifice. In the late stage of bladder tuberculosis, the entire bladder becomes congested, edematous, and appears red all over.

　　10. Renal scintigraphy:When the renal function decreases, it is manifested as delayed excretion, even no function, and obstructive patterns appear when hydronephrosis occurs on the opposite side.

　　Renal tuberculosis patients should supplement high-calorie and high-quality protein, and need milk; a large amount of vitamin A, B, C, and D should be supplemented; eat more fresh vegetables, fruits, and various light and moisture-rich foods to keep bowel movements smooth and enhance diuresis. Patients with chronic illness and weakened bodies should consume tonics.

　　Avoid hot and spicy foods, as well as smoking and alcohol.

　　1. Treatment

　　Secondary hydronephrosis on the opposite side due to renal tuberculosis is a late complication of renal tuberculosis. The patient's general condition is poor, and the condition is complex. In patients with secondary hydronephrosis, the problems to be solved include: ① Treatment of renal tuberculosis; ② Treatment of bladder tuberculosis and bladder contraction; ③ Treatment of hydronephrosis of the kidney and ureter. Since renal tuberculosis causes hydronephrosis on the opposite side, it endangers the patient's life, so how to preserve and restore the function of the hydronephrotic kidney will be the core of the disease treatment, and the order of treatment should be decided according to the functional condition of the hydronephrotic kidney.

　　If the hydronephrosis is mild, the renal function and general condition are good, and the patient can tolerate surgery, with blood urea nitrogen below 18mmol/L (50mg/dl), nephrectomy can be performed first under anti-tuberculosis drug treatment. After the tuberculosis of the bladder improves, the hydronephrosis on the opposite side should be treated. According to the treatment results of 154 cases of hydronephrosis on the opposite side of renal tuberculosis at the First Affiliated Hospital of Beijing University of Medical Sciences, less than 1/3 of the patients gradually heal the tuberculosis of the bladder after nephrectomy of the tuberculous kidney, and the hydronephrosis improves or shows no significant change, further treatment is not required. If hydronephrosis is severe with obstruction, accompanied by renal insufficiency or secondary infection, it is necessary to first relieve the obstruction to save the renal function, and then perform nephrectomy of the tuberculous kidney after the renal function and general condition improve. However, hydronephrosis often coexists with a contracted bladder, and the tuberculosis lesions of the contracted bladder are often more severe, making it difficult to cure temporarily, which affects the treatment of hydronephrosis. In recent years, due to the use of short-course chemotherapy and anti-tuberculosis drugs, these drugs have strong bactericidal effects. Bladder contraction is not considered a contraindication for colovesical augmentation surgery when bladder infection and incomplete healing of tuberculosis are present. Dounis (1979) reported 51 cases of bladder tuberculosis contraction patients who underwent colovesical augmentation surgery, and all 51 patients still had bladder irritation symptoms, 19 had hematuria, and 14 had infection. Renal insufficiency caused by narrowing of the ureteral orifice and reflux during bladder contraction can still be treated surgically as long as the creatinine clearance rate is not less than 15ml/min, and many patients have significantly improved renal function after colovesical augmentation surgery. Urinary incontinence and stricture of the bladder neck and urethra are not suitable for colovesical augmentation surgery and should be treated with urinary diversion surgery.

　　The initial approach for colovesical augmentation surgery was to use the distal ileum, and later changed to an isolated, vascularized sigmoid colon with a contracted bladder to increase its capacity. If there is obstruction and incomplete closure at the lower end of the hydronephrotic ureter, the ureter can be cut and anastomosed to the bowel loop. In 1965, Gil-Vernet advocated using the cecum and distal ileum for bladder anastomosis. The advantage of using the ileocecal region is that the cecum or colon urination is more forceful than the ileum, with less degree of urinary stasis, less mucus secretion. When using the cecum to enlarge the bladder, the ureter transplant can take advantage of the ileocecal valve to prevent urinary reflux. In addition, the peristaltic direction of the ileocecal region is in the same direction, which is easy to locate during surgery and has no solute absorption phenomenon (Dounis, 1980). Therefore, it is now considered that using ileocecal or colonic augmentation of the bladder is a better method.

　　The patient should receive at least 4 weeks of anti-tuberculosis drug treatment before surgery. Before using the colon, a barium enema should be performed to exclude colonic diverticula. A urinary flow rate test must be performed before surgery, for women with low urinary flow rate, bladder neck dilation can be performed and the bladder neck incised at 3 and 9 o'clock; for men, the bladder neck should be incised by urethral surgery 3 weeks before surgery, and attention should be paid to avoid causing urinary incontinence during the incision of the bladder neck.

　　Preoperative bowel preparation is essential. 48 hours before surgery, take Neomycin 1g and Metronidazole (Flagyl) 200mg, three times a day, and after cleaning the colon, leave in place 500ml of 5% polyvinylpyrrolidone iodine solution (Providone-iodine). During surgery, only the top of the bladder should be removed, and the bladder should be cut as little as possible. If a ureterosigmoidostomy is to be performed, it should be done before the colovesical anastomosis, otherwise it will increase the difficulty of the surgery. 160mg of Gentamicin should be administered intravenously before the bowel resection. Intraoperatively, the omentum is commonly used to cover the anastomosis to reduce complications and urinary leakage.

　　Hydronephrosis of kidney and ureter: The treatment of hydronephrosis of the kidney and ureter depends on the cause of the obstruction. The most critical issue is whether there is bladder contraction. If there is no bladder contraction and only the orifice or lower segment of the ureter is narrow, the treatment is the same as that for lower ureteral stenosis. If there is bladder contraction, the treatment is handled according to bladder contraction.

　　Severe hydronephrosis of the kidney and ureter, renal insufficiency, or anuria, and contracted bladder not suitable for enterovesical augmentation, can be treated with urinary diversion. Common urinary diversion techniques include ureteral skin tube ostomy and nephrostomy. The surgical method is relatively simple. Before performing ureteral ostomy, a skin flap should be made from the local skin instead of placing a catheter in the ureter. Severe hydronephrosis of the ureter can cause ureteral tortuosity, which itself can cause obstruction. In this case, the tortuous ureter should be resected. Ureteral skin tube ostomy is generally permanent and cannot be restored to its original state after redirection. Nephrostomy is usually temporary, and it is treated after the excision of the tuberculous kidney and the healing of the bladder tuberculosis, and then the narrowing of the lower ureter is treated. Nephrostomy can also be used as a permanent stoma. Ileal膀胱 is a common urinary diversion method, that is, using a segment of isolated ileum, transplanting the ureter above, and making an ileal ostomy on the abdominal wall for drainage. It is generally used for patients with good general condition and poor ileal bladder ostomy drainage. In the case of only one kidney, ileal bladder is not superior to ureteral skin tube ostomy. Other urinary diversion surgeries such as ureterocolic anastomosis are no longer used due to the easy occurrence of ascending infection and hyperchloremic acidosis.

　　2. Prognosis

　　For patients with kidney tuberculosis and contralateral hydronephrosis, if there is no bladder contraction, perform ureteral orifice dilation, incision, or ureterovesical anastomosis, the prognosis is good. If the bladder lesions are severe, and there is hydronephrosis, renal insufficiency, or secondary infection, the prognosis is poor.

　　Early treatment of tuberculosis of the kidney can prevent serious tuberculous changes in the bladder and pay attention to the occurrence of this complication during the treatment process, which can achieve a good effect.