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Ureterovesical obstruction/Obstructed Megaureters

Ureterovesical junction (UVJ) obstruction/Obstructed Megaureters, refers to the blockage of where the tube that drains urine from kidneys (the ureter) meets the bladder.  The obstruction impedes the urine flow down to the bladder causing urine to build into and dilate the ureters and kidneys. Often picked on maternal ultrasounds during pregnancy, it is not an uncommon prenatally obstructive disease. In situations where kidney functions are compromised, surgery is required. Treatment is often required to preserve renal function. The surgical procedure to correct UVJ obstruction is called ureteric re-implantation. 

In surgical procedure the abnormal part is removed and reduced and reconnected to the ureter. In young babies (3-6 months of age), re-implantation is done through a small incision.

Minimally Invasive surgery is an answer for children older than 6 months. 

Laparoscopic or Robotic assisted Laparoscopic approach can be taken and the reimplantation can be done. 

Advantage of Minimal Invasive Surgery 

  • Smaller cut 
  • Less visible incision
  • Quicker recovery period 

The Minimal invasive technique is not appropriate for all children. Your health care provider will guide you through and will work with you and your family closely to determine what kind of intervention would be best for the child. 

Ectopic Ureterocele 

Most of us are born with 2 ureters, the tube that drains the urine from each kidney into the bladder. But some children, are born with 2 ureters that drain a single kidney. 

In these cases, one ureter drains the upper part of the kidney and the second ureter drains the lower part of the kidney and it is called as duplicated/duplex system. 

If both ureters enter bladder and draining nicely, it is not a problem.

When, there is a cystic (balloon like) dilatation of the distal (lower part) ureter (tube carrying urine from kidney to bladder) within urinary bladder, it is called as ureterocele.

Ureterocele is common in individuals with duplex kidney.

Ureter associated with upper part/moiety of kidney, opens into bladder in an abnormal location and sometimes stenotic/obstructive. 

Ureter associated with lower part of kidney is associated few times with ureterocele. This is called as an ectopic ureterocele.

It happens when the end of ureters which enter the bladder is not developed properly. It is a birth defect. The ends of the ureteral end swells like a balloon that stops the flow of the urine into the bladder. 

Symptoms 

  • Incontinence 
  • Failure to thrive 
  • Abdominal pain 
  • Pain while passing urine
  • Difficulty urinating
  • Recurrent UTIs
  • A bulge in abdomen area 

This can cause problems like 

  • Urinary tract infection
  • Vesicoureteral reflux
  • Kidney damage 
  • Blockage in the urinary tract 

Antibiotics are often prescribed until surgery can be done. The goal of the treatment is to eliminate the blockage. Ureterocele can occur in about 1 out of every 500 to 1000 births and are more common in girls than boys.

Posterior urethral valves 

The obstructive membranes that develop in the urethra, distal to the bladder, are called posterior urethral valves. 

The extra tissues also prevent the urethra from properly carrying out urine from the bladder to the tip of penis out of the body i.e. it can obstruct or block the outflow of urine through urethra. 

Radiographic imaging with ultrasound and voiding cystourethrogram is required for a proper diagnosis of posterior urethral valves. Ultrasound will show a dilated urethra, thickened bladder with or without dilated ureter and kidneys. 

This disease only occurs in boys and can cause serious problems due to obstruction of urine flow out of the bladder through urethra. 

In fact, it is the most common urological cause of end stage renal disease/renal Failure in children. 

Most boys who have associated vesicoureteric reflux (which can be primary due to abnormal maturation of lower ureteric junction with bladder or secondary which is due to obstruction in urine outlet).

Genetic etiology of posterior valves is associated with maldevelopment of the mesonephric duct and their genetic predisposition suggests an interaction of many genes with small effects. The exact etiology of posterior urethral valve is still unknown. 

Symptoms may include 

  • Lower abdominal swelling
  • Recurrent UTI
  • Painful urination 
  • Weak urine system 
  • Urinary frequency 
  • Bed wetting 
  • Poor weight gain 
  • Difficulty in urination
  • Failure to thrive

Severe cases can lead to 

  • Kidney swelling (Hydronephrosis)
  • Bladder dysfunction 
  • Renal function impairment/Renal Failure
  • Worsening of Vesicoureteral reflux

The most common treatment is a minor surgical procedure to remove an obstructing valve and is done through a cystoscope with a camera that is inserted in the urethra. The valves are ablated away.