Ureteral prolapse

　　1. Etiology of the disease

　　The embryological mechanism of this disease is not yet clear, and there are several views:

　　1. Delayed rupture of the Chwalle membrane causes the distal ureteral expansion and orifice stenosis.

　　2. Delayed separation of the developing ureter from the mesonephric duct can lead to the expansion of the distal ureteral end.

　　3. Segmental embryonic arrest at the distal end of the developing ureter causes the distal ureteral muscle to develop stably, resulting in ureteral cysts.

　　Second, pathogenesis

　　1. In-situ Ureteral Cyst:Also known as simple ureteral cyst, it is more common in adults than in children. Its orifice is normal or nearly normal, and the cyst is completely located within the bladder. Small primary ureteral cysts only cause slight ureteral obstruction, do not block the bladder neck, so the affected kidney is often slightly affected or unaffected. Large primary ureteral cysts occupy most of the bladder, thereby causing obstruction of one or both ureters, and occasionally blocking the bladder neck to cause urinary retention. According to literature statistics, about 75% of large primary ureteral cysts are associated with double ureteral anomalies.

　　2. Ectopic Ureteral Cyst:It is more common in children than in adults, and about 75% of pediatric ureteral cysts belong to this type. Ericsson believes that any ectopic ureteral cyst extends into the urethra and, like some scholars, believes that it must be the ureter of the upper pole of the ipsilateral duplicated kidney. Brock and Kaplan point out that ectopic ureteral cysts can occur in both double ureteral anomalies and in the absence of double ureteral anomalies, but their orifices are ectopic. These cysts are generally larger, and their orifices can be normal circular or slit-like up to 1 cm long, and can involve the bladder neck and the proximal urethra. Since the orifices are above the external sphincter, they do not cause urinary incontinence.

　　Williams described the ectopic ureteral cyst in detail from an anatomical perspective. It is divided into three types:

　　(1) The cyst protrudes at the bladder neck, with a relatively narrow base. Cystography shows a semicircular defect shadow, and under urethroscope, a mass is seen extending to the posterior urethra, causing mild obstruction of the bladder neck but not directly affecting the other orifice of the ipsilateral double ureters.

　　(2) The cyst is located in the bladder trigone area, with a wide base and extending into the posterior urethra, like a ridge-like prominence in the midline of the posterior urethra. The ureteral orifice is large, which can cause obstruction of the bladder neck and the adjacent ureteral orifice. Since the cyst occupies most of the bladder trigone area, it is not easy to observe clearly with cystoscopy, and cystography shows a large defect shadow above the bladder neck.

　　(3) It is a variation of the second type, forming a cystic sac on the posterior wall of the posterior urethra.

　　It must be pointed out that in some cases of ectopic ureteral cysts, the bladder wall at the posterior wall of the cyst is weak, which must be paid attention to during surgery and at the same time, repair is needed.

　　3. Ureteral cyst prolapse:It is mostly a complication of ectopic ureteral cysts. It can protrude outside the urethral orifice through the bladder neck and urethra, and it mostly occurs in women. Generally, it can be复位自行复位，but it can also become incarcerated and form a large, purplish-red mass protruding from the urethral orifice. This type must be distinguished from urethral mucosal prolapse.

　　4. Blind-end type:Due to the absence of the opening at the end of the ureter, a cyst forms and protrudes within the bladder trigone area. By the third month of embryonic development, the kidneys have already started to excrete urine, so the affected kidney of this type must have been severely damaged at birth.

　　Complications of ureteral cysts with malformation or other complications:① The contralateral kidney of the affected side with double ureters is normal; ② The contralateral kidney of the affected side with incomplete double ureters; ③ Bilateral double ureters; ④ The contralateral ureteral orifice of the affected side is ectopic; ⑤ The function of the upper kidney of the affected side is good; ⑥ The upper kidney of the affected side has mild hydronephrosis; ⑦ The function of the upper kidney of the affected side is severely impaired; ⑧ The upper kidney of the affected side has developmental abnormalities with massive hydronephrosis of the ureter; ⑨ The function of the upper kidney of the affected side is severely impaired with hydronephrosis of the ipsilateral lower kidney and the contralateral kidney; ⑩ Both the upper and lower kidneys of the affected side have severely impaired function.

　　1. Pain:Due to the obstruction caused by ureteral cysts, the gradual formation of ureteral and renal hydronephrosis can cause bloating and pain in the lumbar region of the affected side.

　　2. Urinary obstruction:Ureteral cysts can block the internal orifice of the urethra, and even can extrude from the external orifice of the urethra. The extruded cyst tissue is a red mucosal cyst, which can cause difficulty in urination, interruption of urine flow, and urinary retention.

　　3. Urinary tract infection:It is easy to secondary urinary tract infection, and symptoms such as frequent urination, urgency, and dysuria occur, and they recur repeatedly.

　　4. Calculus:Cysts can be complicated with calculus, and renal colic and hematuria may occur.

　　The etiology of this disease is not clear, and it is related to autosomal recessive inheritance. It is usually related to marriage between close relatives, and there is no direct prevention for this disease. For patients with a suspected family history of chromosomal abnormalities, genetic screening should be performed to avoid the offspring suffering from this disease due to chromosomal inheritance. At the same time, attention should be paid to strengthening prenatal nutrition, reasonable diet, and avoiding adverse stimuli that affect embryonic development, such as emotional excitement.

　　1. Urinalysis:Patients with concurrent urinary tract infection or calculus have red blood cells and white blood cells.

　　2. Urinary osmolality measurement:The manifestation of impaired renal concentration function may appear in the early stage of the disease.

　　3. Renal function test:Serum creatinine and blood urea nitrogen increase progressively with the loss of renal compensatory function, and creatinine clearance rate is also a sensitive indicator.

　　4. Intravenous urography:90% of ectopic ureteral cysts occur in the upper kidney of patients with bilateral renal malformations. Due to poor renal function, they do not show up. The lower kidney showing up is displaced to the lower and outer side in the shape of a hanging lily; there is a sea snake head-like filling defect in the bladder area; and it can also understand the renal function on both sides.

　　5. Voiding cystourethrogram:50% of the patients with ureteral cysts complicated with double ureters have lower ureteral reflux, and occasionally, male patients with prolapsed ureteral cysts are prone to be confused with the posterior urethral valve.

　　6. Cystoscopy of the bladder and urethra:Define the size and opening of the cysts.

　　1. Astragalus and white grass root drink

　　Astragalus 30 grams, white grass root 30 grams, Cistanche deserticola 20 grams, watermelon skin 60 grams. Wash the four herbs and place them in a pot, add an appropriate amount of water, and boil to make a concentrated juice. Add an appropriate amount of sugar to taste. Take one dose per day, divided into two servings, which can benefit the spleen, warm the kidneys, and promote diuresis and relieve stranguria.

　　2. Lycium and Poria Tea

　　50 grams of Lycium barbarum, 100 grams of Poria cocos, appropriate amount of black tea. Grind Lycium barbarum and Poria cocos into coarse powder for storage. Take one dose per day, 10 grams of coarse powder each time, add an appropriate amount of black tea, and brew with boiling water as tea. It has the effects of invigorating the spleen and kidney, promoting diuresis and relieving stranguria.

　　3. Kidney-tonifying Porridge

　　One pig kidney, 100 grams of malva verticillata leaves, 50 grams of glutinous rice. Clean and finely chop the pig kidney, first decoct the malva verticillata leaves to get the juice, then add the pig kidney and glutinous rice, and cook into porridge. Take one dose per day, divided into two servings for warm and hot intake. It can tonify the spleen and kidney, promote diuresis and relieve stranguria.

　　Except for a few cases where the affected kidney has been irreversibly damaged, the decision to resect the affected kidney should not be made impulsively.

　　1. In-situ Ureteral Cyst:Cystotomy under cystoscopy is suitable for adults, but attention should be paid to bleeding, and electrocoagulation may be required for hemostasis. For pediatric cases, it is advisable to use the surgical approach of bladder incision above the pubic bone, expose the ureteral cyst, and incise 4-5mm downward from the ureteral orifice on the cyst; larger cysts should be resected, and the surrounding wall layer and bladder mucosa should be sutured in a circle with 4-0 intestinal suture after resection.

　　2. Ectopic Ureteral Cyst:It is incorrect to treat ectopic ureteral cysts with simple cystotomy. The choice of surgical method should be determined according to the specific case, mainly based on the severity of kidney damage on the affected side, the degree of ureteral dilation, the function of the contralateral kidney, whether there is simultaneous infection and stones, etc. The bladder is incised above the pubic bone to completely remove the cyst including the part extending to the urethra to prevent postoperative urethral obstruction; after resection, symptoms generally improve, but infection rarely disappears immediately, the dilated renal pelvis and ureter can be reduced, but it is rare to fully recover. If severe postoperative infection cannot be controlled, a second-stage total resection of the affected kidney and ureter can be performed, or if it is a duplicated kidney, partial nephrectomy including all the ureters should be performed. If there is weakness in the posterior bladder wall, it must be repaired.

　　3. Ureteral Bladder Reimplantation:If there is vesicoureteral reflux after the resection of the ureteral cyst, consideration should be given to performing a ureteral bladder anti-reflux reimplantation.

　　For any surgery, antibacterial drugs must be used effectively after surgery to control infection and achieve the goal of cure.