Ureter

If there is a stone in the kidney, its location matters a great deal. If it sits in the renal pelvis and causes dilation, it should be operated on.

If it sits in the lower calyx, it is called a “silent stone.” It may simply cause an infection, and in that case the infection is treated. Very often, if a silent stone is not causing a problem, it is left alone.

If the person is young, there is still the option of dissolving the stone with conservative treatment, and in that case this treatment is used. If the stone does not dissolve, a decision to operate has to be made. Here, too, the approach is individual.

The main criterion is where the stone is located and whether it causes swelling of the kidney (obstruction). Because a stone that has moved into the ureter can cause exactly this kind of blockage, the same criterion applies to ureteral stones. A decision not to intervene, or to use conservative treatment, is made only after an examination and on an individual basis.

RIRS is an incision-free, closed stone procedure performed with a bendable (flexible) endoscope passed through the urinary tract: the endoscope is guided to the stone, and the stone is broken up and removed.

This method is used in patients with stones in the kidney as well as in the ureter, in patients with stones in both kidneys, and for multiple small stones in the kidney.

The method is not chosen by a single size cutoff — it is decided individually based on the size, number, location and density of the stones and the anatomy of the urinary tract. For large stones, an endoscopic approach may not be enough.

Incision-free does not mean free of pain or risk: like any surgical procedure, this operation carries risks, and the method is chosen individually after an examination (see: Risks).

The most important limiting factor is the size of the stone. With large stones, scattering of the stone fragments can cause problems, and a lengthy operation increases the patient’s risk of infection and sepsis.

Because the operation is performed under general anesthesia, it cannot be used in patients who are not fit for anesthesia. A patient with a urinary tract infection must be treated first, and the procedure performed only after that.

When the closed approach is not possible for a large stone, percutaneous nephrolithotomy (through a small incision in the skin) is chosen. This method has its own risks as well; the choice is made individually after an examination.

Congenital or acquired strictures cause swelling of the kidney (hydronephrosis). Laparoscopic reconstruction can restore the flow of urine.

Like any surgical procedure, this operation carries risks; the method is chosen individually after an examination, based on the location and cause of the stricture and on kidney function.

Hydronephrosis is dilation of the collecting system (the calyces and renal pelvis) of one or both kidneys. It occurs at any age and can be congenital or acquired.

Causes include narrowing where the kidney joins the ureter (a stenosis, or an accessory blood vessel crossing it), a blockage further down (a stone, tumor or blood clot), a stricture of the ureter, and backflow of urine from the bladder (vesicoureteral reflux). Acute or chronic urinary retention — for example, due to an enlarged prostate — can also lead to hydronephrosis.

If a blockage persists for a long time, kidney function can decline significantly; that is why early diagnosis and early treatment are important.

Kidney failure can have prerenal causes, which lie before the kidney; renal causes — diseases of the kidney itself; and postrenal causes.

The postrenal form is considered the urological form: if there is some obstruction in the pathways leading out of the kidney, or some disease there, it counts as one of the urological causes.

For example, a stone may block the duct, or an enlarged prostate may cause the bladder to fill up, and this leads to hydronephrosis — dilation of the kidney. All of these are postrenal, urological causes.

If a blockage is relieved in time, this can help prevent kidney failure. Outcomes vary from person to person.

Reflux is the backward flow of urine from the bladder into the ureter. It is one of the causes of hydronephrosis.

Coming to the appointment with a full bladder helps make a more accurate diagnosis when looking for reflux and bladder growths.

This is a congenital condition: the collecting system of the kidney is divided into two parts, and two ureters drain from it. In complete duplication, each ureter opens into the bladder separately; in incomplete duplication (ureter fissus), the two ureters join along the way and continue as a single ureter.

It often causes no symptoms at all and is found incidentally on an ultrasound; when there are no symptoms, treatment is usually not needed.

An examination by a urologist (for children, a pediatric urologist) and an individual treatment plan are needed if there are recurrent urinary tract infections, backflow of urine (reflux), swelling of the kidney (hydronephrosis), a cyst-like bulge where the ureter opens into the bladder (ureterocele), or, in girls, constant dribbling of urine despite otherwise normal urination.

Diseases of the kidney itself (for example, glomerulonephritis and connective tissue diseases) and conditions that impair blood flow to the kidney (high blood pressure, diabetes, narrowing of the renal blood vessels) belong to nephrology, not urology. The urologist looks for and rules out an obstructive (postrenal) cause; if no such cause is found, the patient is referred to a nephrologist.

Although tumors of the ureter are rare, they can show up as blood in the urine and require the same follow-up principles as bladder tumors. The treatment approach is determined individually after an examination, based on the tumor’s location, size and grade.

Blood in the urine is generally one of the most alarming symptoms, and if it causes no pain and no other complaints, that makes it even more alarming. In that case a thorough workup is needed.

The workup includes cystoscopy and computed tomography, and during cystoscopy even retrograde urography, in which a contrast agent is injected. In this way any abnormality in the urinary tract is either found or ruled out. In such a case a thorough workup is essential.

Visible blood in the urine always needs to be investigated — even without pain, and even if it happened only once. Even if an ultrasound is normal, cystoscopy and imaging of the upper urinary tract (CT urography) may be needed; a tumor cannot be ruled out with an ultrasound and urinalysis alone.