| disease | Renal Tuberculosis with Contralateral Hydronephrosis |
Contralateral hydronephrosis is an advanced-stage complication of renal subcutaneous node caused by bladder subcutaneous node. According to domestic data statistics, in 1959, among 1334 cases of renal subcutaneous node, 16% developed secondary contralateral hydronephrosis. In 1962, among 4748 cases of renal subcutaneous node, 13.4% developed secondary contralateral hydronephrosis.
bubble_chart Pathogenesis
(1) Ureteral orifice stenosis: When the bladder submucosal nodule develops fibrosis, the contralateral ureteral orifice may become stenotic due to scar formation, obstructing urine drainage from the contralateral kidney and leading to hydronephrosis and hydroureter.
(2) Lower ureteral stenosis: Submucosal nodule lesions near the contralateral ureteral orifice can spread directly along the mucosal surface or infiltrate the submucosal layer, causing stenosis in the segment of the ureter above the orifice due to scar formation, resulting in hydronephrosis and hydroureter on the contralateral side.
(3) Ureteral orifice incompetence: Normally, the oblique intramural segment of the ureter within the bladder wall acts as a sphincter, preventing urine reflux into the ureter and renal pelvis during bladder contraction. Submucosal nodule lesions around the ureteral orifice may lead to fibrosis, stiffening the ureter and impairing sphincter function, resulting in ureteral orifice incompetence. Consequently, bladder urine frequently refluxes into the contralateral ureter and renal pelvis, causing hydronephrosis and hydroureter.
(4) Bladder contracture: Severe bladder submucosal nodules ultimately lead to bladder contracture. Bladder contracture diminishes the bladder's ability to gradually expand its capacity during filling, maintaining normal intravesical pressure. This results in abnormally high bladder pressure, especially during inflammation, which frequently triggers bladder contractions, further increasing pressure. Chronic high intravesical pressure can obstruct urine drainage from the renal pelvis and ureter or cause vesicoureteral reflux, leading to hydronephrosis and hydroureter on the contralateral side.
These four pathological changes often coexist. Renal submucosal nodules causing secondary contralateral hydronephrosis primarily result from three factors: mechanical obstruction at the lower ureter, urine reflux, and high bladder pressure. Severe hydronephrosis can lead to renal parenchymal atrophy, decreased renal function, and an increased risk of secondary infection.bubble_chart Clinical Manifestations
The clinical symptoms of renal subcutaneous node with secondary contralateral hydronephrosis are no different from those of general advanced-stage renal subcutaneous node, primarily manifesting as severe bladder subcutaneous node symptoms, including significant urinary frequency, often accompanied by urinary incontinence, painful urination, rice-water-like urine, and varying degrees of hematuria.
When contralateral hydronephrosis reaches a considerable degree, a mass and grade I lumbago may appear in the upper abdomen, but this often goes unnoticed by the patient.
In cases of severe hydronephrosis, symptoms of chronic renal insufficiency may occur. Secondary infections may lead to symptoms of urinary tract infection.
A few cases may present with symptoms of bladder urinary reflux, such as bladder distension or a sensation of lumbar distending pain during urination.
In all cases clinically presenting as advanced stage renal subcutaneous node, especially those with severe bladder subcutaneous node, the possibility of contralateral hydronephrosis should be considered for further examination.
(1) Phenolsulfonphthalein test
Due to the dilution and prolonged retention of phenolsulfonphthalein in the dilated renal pelvis during hydronephrosis, an inversion or reduction in phenolsulfonphthalein excretion may occur. This manifests as low phenolsulfonphthalein content in the first two urine samples, while the latter two samples show relatively higher levels. In severe hydronephrosis, the total phenolsulfonphthalein excretion may also decrease.
Because of reduced renal function and the dilution of contrast medium by retained urine, conventional urography often fails to reveal the image of hydronephrosis. If the timing of X-ray imaging is adjusted based on phenolsulfonphthalein excretion, hydronephrosis can be visualized. High-dose excretory urography, if available, yields more satisfactory results.
(3) Renal puncture urography
When severe bladder lesions or ureteral orifice stenosis prevent retrograde pyelography, and excretory urography fails to produce images due to renal dysfunction, renal puncture urography becomes the only reliable diagnostic method, especially in the absence of bladder reflux. This technique allows diagnosis based on the nature of the aspirated urine and differentiates between bilateral renal subcutaneous node and unilateral renal subcutaneous node with contralateral hydronephrosis through contrast imaging.
(4) Bladder reflux urography
If vesicoureteral reflux is present, bladder reflux urography can be used to visualize the kidneys and ureters. For this examination, it is preferable to use intravenous contrast medium diluted by half, supplemented with antibiotics to prevent ascending infection.
bubble_chart Treatment Measures
(1) Treatment of renal subcutaneous node: Nephrectomy is generally required in conjunction with anti-subcutaneous node medications.
(2) Treatment of bladder subcutaneous node: After nephrectomy and anti-subcutaneous node treatment, the bladder subcutaneous node may gradually improve. However, since the bladder subcutaneous node in such patients is usually severe, it often leads to bladder contracture. Treatment involves methods to increase bladder capacity. The common approach is ileum or sigmoid colon bladder augmentation. Due to the high mucus content in urine after ileum bladder augmentation, which can easily lead to urinary tract stones, and the potential for ileum dilation affecting emptying during long-term follow-up, sigmoid colon bladder augmentation is currently preferred. If bladder contracture is complicated by urethral stricture, urinary diversion procedures such as ureterostomy, recto-bladder surgery, or ileum bladder surgery are required.
(3) Treatment of hydronephrosis and hydroureter: The treatment depends on the underlying cause of the hydronephrosis. The most critical factor is whether bladder contracture is present. If there is no bladder contracture and the obstruction is due to ureteral orifice stricture or lower ureteral stricture, the treatment is simpler and more effective. Grade I cases can undergo ureteral dilation via cystoscopy. For more severe strictures, ureteral orifice incision or ureteral reimplantation may be performed. If bladder contracture is present, sigmoid colon bladder augmentation is indicated, along with ureteral transplantation to the intestinal segment.
(4) Sequence of treatment for renal subcutaneous node and hydronephrosis: The sequence depends on the severity of hydronephrosis, the degree of renal function impairment, and the urgency of relieving the obstruction. In general cases where renal function is relatively good, nephrectomy should be performed first under anti-subcutaneous node medications, followed by treatment for hydronephrosis once the patient's condition improves. If hydronephrosis is severe, renal function is poor, or secondary infection is present, nephrostomy should be performed first on the affected side under anti-subcutaneous node medications, followed by nephrectomy once the patient's condition stabilizes.
Urinary tract stones
