A guide for families about ureterovesical junction obstruction
What is ureterovesical junction obstruction?
The ureterovesical junction is the junction of the bladder and the tube-shaped ureters that carry urine from the kidney to the bladder. Ureterovesical junction obstruction describes the stenosis in this region. In the case of stenosis, the urine cannot easily empty into the bladder; As urine accumulates in the ureter, it causes enlargement of the ureter (megaureter) and enlargement of the kidney (hydronephrosis). Ureterovesical junction obstruction is the fourth most common cause of hydronephrosis in pregnancy (the first three are transient hydronephrosis, ureteropelvic junction obstruction, and vesicourethral reflux).
What causes ureterovesical junction obstruction?
It is thought that this is caused by the incomplete development of the muscle structures at the ureterovesical junction while the baby is developing in the intrauterine period. If there is no muscle tissue, the movement of the ureter to convey the urine towards the bladder does not occur, the ureter becomes wider than normal, immobile, and urine accumulates in it. Less frequently, urinary tract infections may cause narrowing in this area. Kidney stones progressing to the ureterovesical junction and obstructing, and the development of valves or abnormal tissues in this region also causes signs of obstruction.
What are the findings of ureterovesical junction obstruction?
Since ultrasound examinations during pregnancy have become widespread, most of the patients are noticed with enlargement of the kidneys and urinary tract in the intrauterine period, without any symptoms. Findings such as abdominal distension and urinary tract infection may occur in children who were not diagnosed during the intrauterine period and were diagnosed later. Older children may have back and lower back pain and kidney stones.
How is it diagnosed?
Some imaging (radiological) studies are required to show whether there is stenosis and obstruction in this region.
Urinary ultrasound is the first examination to be performed in a patient with suspected urinary anomaly. It shows whether the kidney and ureters are enlarged, the location of the kidney and whether the kidney tissue is well developed and the bladder wall thickness. It provides basic information about the urinary system of the patient to be followed.
In MAG-3 renal scintigraphy; radioactive material and diuretic drugs are given through the vein to show the duration of urinary excretion from the kidneys, whether there is any enlargement and whether there is a sign of obstruction, and how much it is affected if there is a sign of obstruction.
Voiding cystourethrogram;a contrast medium is injected into the bladder through a probe that is placed through the urethra and extends into the bladder. The structure of the bladder and urethra and whether there is leakage to the ureters are evaluated.
In selected cases, magnetic resonance imaging can provide detailed imaging of the kidney, ureter, and bladder without ionizing radiation.
How is ureterovesical junction obstruction treated?
The treatment plan is drawn according to the age of the child, the severity of the complaints and the findings. Preventive antibiotics can be started so that the child does not have a urinary tract infection. Kidney function and urine output are good, although enlargement is very prominent in some children. These patients need close monitoring. In these cases, the enlargement of the ureters may improve as the child grows. If enlargement and obstruction impair kidney function, surgical treatment is necessary. In ureterovesical junction obstruction, surgical treatment is performed to preserve kidney function.
- Ureteroneocystostomy (ureteral reimplantation): In this surgical procedure, the narrow and abnormally developing lower end of the ureter is removed. In very enlarged ureters, the diameter of the ureter is narrowed and the ureter is reconnected to the bladder in a way that will not reflux, with a new route prepared either from inside the bladder or outside the bladder. The success of surgical treatment is high and increases up to 96-98%.
At the end of the operation, a Foley catheter is placed in the bladder and a drain is placed. In some cases, a ureteral catheter may also be placed.
- Opening the lower part of the ureter to the skin: It can be preferred in cases where it is not possible to open the kidney to the skin with a catheter (percutaneous nephrostomy) and to use ureteral stents. It may be necessary to mouth the enlarged lower end of the ureter to the skin in newborn babies with very severe ureteral width and poor renal function. Thus, the flow of urine is relieved, the urine flows into the diaper and the pressure on the kidney is removed. At 18 months, the ureter is taken back into the bladder.
Are there other treatment options?
Other treatment options are ureteroneocystostomy with closed methods (laparoscopic or robotic). I successfully apply both treatment options to my patients. In these approaches, the body is entered with a camera and other instruments placed through 3-4 small holes to be opened in the abdominal wall instead of a skin incision.
The surgical method, approximate operation time and success rates are the same as in open surgery. Advantages of closed methods; small skin incision, larger and clearer image can be obtained under optical magnification, less postoperative pain, shorter postoperative hospital stay (1-2 days), faster recovery and return to normal life.
How is the care in the post-operative period?
Usually, the hospital stay is 3-4 days. In the early period, intravenous fluids, antibiotics, and painkillers are given to the child. All medications are given orally when adequate fluid intake and nutrition begin. Postoperative bladder contractions are common. If symptoms are distressing, anticholinergic drugs are used to reduce these contractions. After surgery, the urine color will be bloody. This is normal and can last up to 10-14 days. Usually, the foley catheter is removed within 2-3 days. The drain is removed one day after the Foley catheter is taken. Frequent urination, intermittent bloody urination and urinary incontinence may occur after Foley catheter removal. With the healing of the bladder, these complaints disappear within 2-3 weeks.
How is the postoperative follow-up of the patients?
The wound site is checked 7 days after leaving the hospital. Urinary system ultrasonography is planned 4-6 weeks after the operation. With this test, it is evaluated whether there is a stenosis at the surgical site. Approximately 3 months after the surgery, kidney scintigraphy is performed to evaluate whether there is stenosis again.