RU2767708C1 - Method for predicting the pathology of the ureterovesical ureter in congenital megaureter in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to pediatric urology. Ultrasound morphometry of the urinary triangle of Lieutaud is performed, for which the urethral-ureteral distance and the inter-ureteral distance are measured by determining the segment between the mouths of the ureters. Then the extent of the intramural ureter is measured for the right and left ureter. After the measurements, a comparative assessment of these parameters is carried out with a contralateral intact ureter with a unilateral megaureter, or with normal values, taking into account the age group, with a bilateral megaureter. If the normal values of the urethral-ureteral and inter-ureteral distances are exceeded, visualizing the lateralization of the ureteral mouth, in combination with shortening of the intramural ureter, the presence of a reflux variant of the pathology of the ureterovesical ureter is predicted. With a decrease in urethral-ureteral and inter-ureteral distances, indicating a medial displacement of the ureteral mouth, in combination with an elongation of the intramural ureter, an obstructive variant of the pathology of the ureterovesical ureter is predicted.

EFFECT: method makes it possible to determine anatomical changes in the intramural ureter and morphometric parameters of the intravesical triangle of Lieutaud, which justifies the differentiation of the variant of the pathological condition of the ureterovesical anastomosis and makes it possible to predict obstructive or reflux causes of primary megaureter; the study significantly improves the quality of a comprehensive urological examination of children.

1 cl, 4 dwg, 1 tbl, 3 ex

Description

The invention relates to medicine, in particular to pediatric urology, and can be used to predict a variant of the pathological condition of the ureterovesical fistula in congenital megaureter in children at the stages of an outpatient preclinical study.

The relevance of the problem of diagnosing congenital megaureter in children lies in the need to choose treatment tactics in newborns and children in the first months of life with prenatally detected dilatation of the ureter and pyelocaliceal system of the kidney. A congenital megaureter may be the result of urodynamic obstruction at the level of the ureterovesical fistula due to its anatomical narrowing, or it may be the result of a functional obstructive condition due to vesicoureteral reflux.

Currently, the diagnosis of obstructive and refluxing megaureter is carried out using a complex, as a rule, invasive diagnostic measures using X-ray (excretory urography, CT, voiding cystourethrography (VCUG), DNSG) and endoscopic techniques (under anesthesia cystoscopy).

The use of differentiated methods for the treatment of congenital megaureter of an obstructive or refluxing nature dictates the need for early diagnosis of a variant of pathological changes in the ureterovesical fistula in children.

It is known that the gold standard for the diagnosis of vesicoureteral reflux is voiding cystourethrography, performed using X-ray cystography (scopy) of the bladder with retrograde introduction using a catheter of water-soluble contrast and fixing the image in direct projection at the patient's rest and at the time of urination (in boys at the time of urination). oblique projection) [Zakharova I. N., Mumladze E. B., Voronenko O. A., Zakharkina E. V. X-ray contrast methods of research in pediatric nephrology // Attending physician].

The disadvantage of the described method is the use of the X-ray method with the presence of X-ray load, which is highly undesirable in relation to young children.

It is known that the method of confirming the obstructive state of the ureterovesical fistula is to conduct a diuretic test with the introduction of a diuretic load. So, there is a method of dynamic pyeloureterosonography with a diuretic pharmacoprobe with furosemide [Kazanskaya I.V., Sabirzyanova Z.R., Babanin I.L., Wise I.S. The role of contractile activity of the ureter in urodynamic disorders in obstructive megaureter in young children. Pediatric Surgery. - 2004. - No. 5. - S.37-40], which consists in registration by ultrasonography of the size of the pelvicalyceal system and the ureter in the prevesical department, as well as contractions of the prevesical ureter in 1 minute. The study begins 30-40 minutes after oral water loading (10 ml/kg body weight) and continues 15, 30 and 45 minutes after intramuscular administration of furosemide at a dose of 0.5 mg/kg body weight. It also evaluates the volume of the bladder at each stage of the study.

The disadvantage of this method is the negative reaction of the child and the risk of an allergic reaction after intramuscular administration of furosemide, as well as the invasiveness and the need for general anesthesia when performing cystoscopy with catheterization of the ureteral orifice, which causes difficulties in performing the study in young patients, hyperexcitable children.

There is also known a method for differential diagnosis and choice of treatment for violations of the urodynamics of the lower urinary tract in children [patent for the invention of the Russian Federation 2441596], in which a transabdominal ultrasound examination of the bladder is performed to determine the volume of residual urine in the bladder after the child urinates on his own. If a child has an age due physiological capacity of the bladder and there is no residual urine, stenosing ureterohydronephrosis is diagnosed against the background of a congenital stricture of the distal ureter located above the bladder. In the presence of residual urine of not more than 2 ml/kg of the child's weight, refluxing ureterohydronephrosis is diagnosed against the background of neurogenic dysfunctions of the bladder. When the age due physiological capacity of the bladder is exceeded by two times or more and the presence of residual urine of 5 or more ml / kg of the child's weight, a bilateral megaureter with a sharp expansion of the pelvis is diagnosed.

The disadvantage of the above method is the lack of consideration of the physiology of the child's micturition, and the duration of the study, which makes its use problematic in relation to young children. During the study, there are often difficulties in inducing urination during physiological filling, which does not correspond to the normal conditions of urination, in which there may be false large volumes of residual urine. The refluxing megaureter is assessed as secondary, from the standpoint of neurogenic dysfunctions of the bladder, and not as a primary anomaly of the ureterovesical fistula.

The closest analogue to the claimed method is the method of ultrasound examination of the ureters [Kapustin S.V., Owen R., Pimanov S.I. Ultrasonic research in urology and nephrology. Monograph. Publishing house "Smart doctor", 2nd edition, corrected and supplemented. 2017. 176 pp.], which consists in determining the ratio of the intraparietal part of the ureter with the urethral-ureteral distance in adult patients. A normally functioning ureterovesical anastomosis is determined with an equal ratio of the urethral-ureteral distance to the intramural part of the ureter. At the same time, with elongation of the submucosal section, they speak of the formation of an ureterocele-like obstructive ureterovesical anastomosis, and with shortening, vesicoureteral reflux.

The disadvantage of this method is that the variant of the pathology of the urethrovesical anastomosis is determined by the revealed ratio of the intraparietal part of the ureter with the urethral-ureteral distance, without taking into account the interureteral distance and possible displacement of the ureteral orifice. There are also no indications of the possible use of this technique in children, including infants and newborns, which sharply limits the practical application of the method for predicting the variant of the pathological condition of the ureterovesical anastomosis in congenital megaureter.

The objective of the proposed method is to provide, with the help of non-invasive ultrasound examination, an early prognosis of the variant of the pathology of the ureterovesical ureter in congenital megaureter in children.

The essence of the claimed invention lies in the fact that in a method for predicting the pathology of the ureterovesical ureter in congenital megaureter in children, including ultrasonic morphometry of the bladder triangle of Lieutaud and the intraparietal part of the ureter, determining the urethral-ureteral distance and the length of the intraparietal ureter, the urethral-ureteral distance is measured, the length of the intraparietal ureter for the right and left ureter, as well as the interureteral distance between the orifices of the ureters, while comparing these parameters with the contralateral intact ureter with a unilateral megaureter, or with the corresponding normative values, taking into account the age group, with a bilateral megaureter; when the normal values of the urethral-ureteral and interureteral distances are exceeded, indicating the lateralization of the ureteral orifice, in combination with the shortening of the intra-wall part of the ureter, the presence of a refluxing variant of the pathology of the ureterovesical ureter is predicted, and when the urethral-ureteral and interureteral distances decrease, indicating a medial displacement of the orifice of the ureter, in combination with elongation of the intraparietal ureter, an obstructive variant of the pathology of the ureterovesical ureter.

The technical result of the claimed invention is to solve the above problem. The claimed method allows to obtain an earlier and non-invasive, in contrast to known technologies, prediction of the variant of the pathology of the ureterovesical fistula in children with a diagnosis of megaureter, due to the expansion of the diagnostic approach during ultrasound examination of the bladder. The visualization of the Lieto triangle with the establishment of the absolute parameters of its faces and the determination of the length of the intra-wall part of the ureter allows, in comparison of the measured parameters with the normal ones that were established by the inventors, to give an objective prediction regarding the type of megaureter. The advantages of the proposed method are its non-invasiveness and, as a result, safety for the patient, which makes it preferable for use at the stages of early outpatient examination in newborns and young children, which allows planning the tactics of therapeutic measures, including methods of surgical correction of the identified pathology.

The method is technical and technological from the first to the last manipulation, since all the actions carried out, until, in practice, the last operation - processing the received data, are carried out using an ultrasonic device, which is proof of its industrial applicability.

The claimed invention is illustrated with the help of Fig. 1-4, which show an explanation of examples of the use of this method in clinical practice, where:

fig. 1 - Ultrasound examination of the vesical triangle and distal ureters of patient M, 1 year 9 months, where

a - ultrasound visualization of the extended interureteral distance, lateralization and "gaping" of both ureteral orifices,

b - ultrasonic visualization of the intraparietal part of the ureter on the left and the urethral-ureteral distance on the left.

Fig.2 - X-ray of the voiding cystourethrography of the patient M., 1 year 9 months.

figure 3 - Ultrasound examination of the vesical triangle and distal ureters of the patient M., 1 year old, where

a - ultrasound imaging of the dilated distal right ureter (cross section),

b – ultrasonic visualization of the intraparietal part of the ureter on the right and urethral-ureteral distance on the right;

Fig. 4 - CT scan in 3D reconstruction mode M., 1 year old, where

a front view

b - rear view.

The method is carried out as follows.

The patient is examined in the supine position by ultrasound imaging of the bladder, using a small degree of filling of the latter as an acoustic window. Determine the individual indicators of the bladder triangle of Lieto: urethral-ureteral distance, defined as the gap between the mouth of the ureter (right and left) and the internal opening of the urethra; interureteral distance - the segment between the orifices of the ureters (the base of the Lieto's triangle). The length of the intraparietal section of the ureter is also established by measuring the distance from the entrance of the ureter into the bladder to the orifice of the ureter, fixed at the place of visualization or ureteral ejection.

Then, a comparative assessment of the obtained parameters is carried out with a contralateral intact ureter with a unilateral megaureter, or with normal values, taking into account the age group, with a bilateral megaureter (established by the authors of this invention and published in the framework of EAPS 2020 “Normal parameters of the vesical trigone and ureterovesical junction in infancy and childhood according to the ultrasonic cystometry". Deryugina LA, Sukhanov SA).

With a decrease in the urethral-ureteral and interureteral distances, indicating a medial displacement of the orifice of the ureter, in combination with an elongation of the intraparietal ureter, an obstructive variant of the pathology of the ureterovesical ureter is predicted. This prediction is made based on data on the pathogenesis of primary obstructive megaureter, which is based on dysplasia of the ureter wall within the ureterovesical fistula, accompanied by a change in the orientation and chaotic arrangement of muscle fibers, an excess of collagen, severe fibrosclerosis of the ureter wall, causing a change in the above parameters relative to normal.

If the normal values of the urethral-ureteral and interureteral distances are exceeded in combination with a shortening of the intra-wall part of the ureter, the presence of a refluxing variant of the pathology is predicted based on the fact that the expansion of the ureter in this pathology is formed due to intrauterine existing vesicoureteral reflux resulting from dysplasia and impaired functioning of the valvular apparatus of the ureterovesical fistula, causing a change in the above parameters.

Example 1

In the course of conducting experimental studies on the basis of the consultative polyclinic of the SSMU. IN AND. Razumovsky, the authors examined somatically healthy children aged from 1 month to 17 years with no history of clinical and laboratory changes in the urinary system using ultrasound imaging. The study was carried out in the position of the child on the back when the bladder was filled to 30% of the individual physiological volume. The dimensions of the bladder triangle of Lieto were measured: interureteral distance, urethral-ureteral distance on the right and left, and the length of the intravesical segment of the ureters. With the complexity of differentiation of the mouths of the ureters, the location of the mouths was determined by the presence of ureteral emissions.

Under the conditions of the physiological state of the bladder, intravital measurements of the size of the vesical triangle and the intravesical segment of the ureter in children were obtained. The parameters obtained are shown in Table 1. The data in the table are presented as an average value with a standard deviation for a specific age range. Given the normal relative symmetry of the structure of the triangle and the intravesical part, these values are added for the right and left sides, and the interureteral distance, respectively, is one. These characteristics just give an idea of the arithmetic mean in this group.

Table 1 - Normal values \u200b\u200bof the bladder triangle of Lieto, depending on the age group

Patient's age, years Urethral-ureteral distance, mm Interureteral
distance, mm The length of the intraparietal part of the ureter, mm 0-1 8.57±1.53 9.83±1.67 7.52±1.82 1-3 11.75±1.62 11.88±1.88 13.81±1.53 3-6 13.46±1.76 13.53±1.67 14.74±2.23 6-9 15.37±2.6 14.98±1.54 17.04±2.71 9-12 18.28±3.7 17.11±2.15 18.67±2.89 12-18 21.71±3.29 21.47±3.85 24.79±3.66

Normally, Lieto's triangle had equal faces (isosceles), and the length of the intravesical segment (together with the submucosal tunnel) was equal to the urethral-ureteral distance. The results obtained were further confirmed radiologically by the absence of pathology of the ureterovesical anastomosis.

Clinical example 2

When conducting an ultrasound examination of a boy aged 1 year 9 months. revealed a slight expansion of the lumen of the distal right and left ureter 6-8 mm, with thickened walls (see figure 1). The following parameters were measured:

urethral-ureteral distance on the right 25 mm (average standard value 11.75±1.62 mm);

the urethral-ureteral distance on the left is 22 mm (the average standard value is 11.75±1.62 mm), shown in Fig. 1b green arrows;

interureteral distance: 27 mm (average standard value 11.88±1.87 mm), shown in figure 1 a with green arrows.

The mouths of the ureters "gape", lateralized (Fig.1 a), it is difficult to measure the intraparietal section of the ureter on the right and left, it is approximately the thickness of the bladder wall, 3-4 mm, (average standard value 13.81 ± 1.53 mm), shown in Fig. 1b with a red arrow.

A refluxing variant of the pathology of the ureterovesical anastomosis was predicted.

The prognosis was further confirmed during voiding cystourethrography (see figure 2), which was determined bilateral vesicoureteral reflux grade 4

Clinical Case 3

An ultrasound examination of a 1-year-old boy revealed an expansion of the distal ureter on the right by 7-10 mm. The following parameters were measured:

urethral-ureteral distance on the right 8 mm (average standard value 11.75±1.62 mm), shown in Fig. 3b with green arrows;

urethral-ureteral distance on the left 11 mm (average standard value 11.75±1.62 mm);

interureteral distance: 10 mm (average standard value 11.88±1.87 mm), shown in Fig. 3a;

the intraparietal section of the ureter on the right is 17 mm, on the left 11 mm (the average standard value is 13.81±1.53 mm), the borders of the section are shown in Fig. 3b with red arrows.

As a result of the study, the asymmetric structure of Lieto's triangle was established, with a decrease in the urethral-ureteral distance on the right, an increase in the length of the intraparietal part of the right ureter, and as a result, an obstructive variant of the pathology of the ureterovesical anastomosis was predicted.

The prognosis was further confirmed by computed tomography with IV contrast. The CT scan (figure 4) shows signs of expansion of the ureter on the left.

Claims (1)

A method for predicting the pathology of the ureterovesical ureter in congenital megaureter in children, including ultrasonic morphometry of the Lieto bladder triangle and the intraparietal part of the ureter, determining the urethral-ureteral distance and the length of the intraparietal ureter, characterized in that the urethral-ureteral distance is measured, the length of the intraparietal ureter for the right and left ureters, additionally determine the interureteral distance by determining the segment between the orifices of the ureters, conduct a comparative assessment of these parameters with a contralateral intact ureter with a unilateral megaureter, or with normal values, taking into account the age group, with a bilateral megaureter; when the normal values of the ureteroureteral and interureteral distances, visualizing the lateralization of the ureteral orifice, in combination with shortening of the intraparietal ureter, the presence of a refluxing variant of the pathology of the ureterovesical ureter is predicted, and when the ureteroureteral and interureteral distances decrease, indicating a medial displacement of the orifice of the ureter, in in combination with lengthening of the intraparietal ureter - an obstructive variant of the pathology of the ureterovesical ureter.

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