The following is a medical media production from
WR AMC TV.
In selecting material for this
talk on obstruction of the ureter.
I used as a basis for the selection of
material a page from a recent
publication called Gametes and radiology,
which I'm sure you're all familiar with.
It is a comprehensive list of rick in
differential diagnosis and it is by
Maurice um reader and Benjamin Felson
with contributions by Elliott's keith
Harris,
her beauty parks and George B.
Greenfield,
the first three of these more reader,
Ben Felson and lethal virus are no strangers to this
podium that I'm standing at right now
and I am pleased to have them
as good friends over the
years.
Let us look at the list of
uh this gamut which is
number 831 in their
book and just go down the
various causes that can produce an
obstruction of the euratom.
As you will note,
these causes are divided into common and
uncommon and they are in alphabetical
order,
which means I will not necessarily present
some of these lesions in the order in which they
are here,
first of all,
in among the common we have a blood clot or
inspire stated puss calculus.
Congenital eureka row pelvic junction
obstruction that is banned vessel or adhesion
valve,
a vessel cystitis across
normal bladder with compression or obstruction of intramural
puritan inflammation and a Diemer that
is pelvic inflammatory disease,
invasion or compression by extrinsic
malignancy.
That is retro peritoneal lymphoma or
sarcoma cost normal of the pancreas,
cervix or other pelvic organs.
Post operative that is lacouture or
Diemer around the urethra pregnancy
structure.
That is congenital traumatic postoperative
radiation therapy,
inflammatory tuberculosis.
Just oh,
massages.
You re to re seal vascular compression by
normal or abnormal vessel or aneurysm.
And among the uncommon causes there are benign
eureka raw tuna that is polit papilloma,
Mesen,
Kimmel,
Touma Blatter,
diverticular um carcinoma of the Euro to
primary or metastatic endometriosis,
mega colon,
popular necrosis where they stuffed happily
pelvic lipo mitosis and finally,
retro peritoneal fibrosis or
Orman's disease.
Now,
let us look at many of these lesions
and have a little discussion on some of
the causes for obstruction
and some of the embryology and histology
behind these lesions.
First of all,
among congenital lesions causing obstruction.
We have here an interesting lesion called congenital
blind ending urata.
And you can see on this radiograph that there
is two years,
there are two.
Your it is on the left side with one
uh in the pelvic pelvis of the
left kidney above the other ending blindly at this
point right here and rather shortly
A second one is this one which is another
congenital blind ending ureter and a 35 year
old female with chronic urinary track infection.
And we see that the duplication is almost complete
with the ureter entering uh ending
blindly at this point,
very close to the pelvis itself.
Now,
what are these congenital blind ending your edges,
they are a failure in an attempt to reduce application
of the kidney.
Most of these are white type with one year to
blind the other connected with the renal pelvis.
Sometimes these inter as
single as single Eureka's into the bladder.
Therefore to your to your general office is
on the same side.
Or more frequently they are y in type
With the two joining together before they
reach the bladder.
There can be anywhere from 1-2 cm in
length,
at which time they may resemble a diverticular with the ureter.
Or they may,
as in the second case here extend
almost the complete way.
I call your attention to this appearance of a
blind ending because we will see this on several other
cases where your hands have been tied off for one cause or
another.
I know of nothing else that looks like this in the
ureter.
It looks like it ends there.
It has no relation no appearance to a
calculus or to a tumor.
It is a characteristic feature in itself
and we will see several others of a similar type as we
go along.
So much for her blind ending.
Eureka's A second type of
congenital anomaly is this case of a
retro cable ureter.
In a 27 year old male with a history of two or
three episodes of the material accompanied by
lower abdominal pain And the
latest episode having occurred just 24 hours
ago.
The patient's physical exam was negative.
His blood count was normal.
His urine showed many mucous threads traces of
bacteria,
123 red blood cells and 0 to 1
white blood cells.
This 15 minute IVP shows
gradual accumulation of
contrast material within a moderately hydro
necrotic right kidney,
a normal appearance on the left side.
In a 30 minute film we see further
accumulation and now we see filling down to the
port where the retro cable urata
has occurred.
And in the 60 minute film we see further
filling of the media in the
proximal urata.
No filling in the distal.
You're in a retrograde study was done on the same
patient immediately after the IVP.
And we see here a feeling of the lower part of
the left right urata with a
normal size,
normal diameter of this section.
And we see the typical deformity of
the retro cable.
Your edit in the film up above there.
In this particular patient's surgery was suggested the
patient preferred to defer and at last
was uh report we have not seen him
come back yet for repair of
this condition.
Another retro cable urata which is somewhat
more atypical.
Is this one with an associated incomplete
rotation of the left kidney.
Here we have a more gradual curve of the
ureter as it passes towards the midline and
downward with very little obstruction to
the euro to has shown on the previous
case.
As we discussed this,
let's look back for just a moment at the
more characteristic one and let me read you just a little
bit about how these occur.
Please play,
pay attention to this because this is a favorite
urinary track
question on the board
examinations.
According from an article by Mayor and Methods.
They state this in 18 93.
Hochstedt to first described this interesting
anomaly,
which is also called post cable or
circum cable euratom and pre your
rhetoric vena cava.
The deformity is not due to an error in
migration upward of the kidney or your data,
but it results from an abnormality of the
vascular system.
Embry a logically this condition results from the
right posterior cardinal vein failing to
undergo atrophy and persisting as the adult
vena cava.
Normally this vein disappears and the right super
cardinal vein persists as the vena
cava.
Occasionally both cardinal veins may possess the vena
cava being doubled with the ureter passing
between the two divisions.
Unfortunately,
there are no symptoms pathetic demonic of retro cable.
You're usually the symptoms of those of hydro
necrosis.
Were superimposed infection of calculus.
Heh material,
gross or microscopic has been frequently noted and
was the presenting symptoms in this case right
here.
Most patients have reached adulthood before symptoms
develop as the onset of hydrogen fibrosis is
usually insidious.
The pilot graphic finding,
which is almost pathetic.
No Monica.
Retro cable.
Eureka is the S shaped curve in the upper
ureter with displacement of the urine immediately
to all beyond the midline at the
level of the 3rd,
4th or fifth lumbar vertebra.
So much for retro cable.
Your otis.
Now another case of urethral obstruction,
secondary to a congenital abnormalities,
abnormal implantation of the Euro.
To with an associated eureka,
a seal and a female infant in this case
with a double kidney and double your.
It is on the left.
This ivp film at
45 minutes,
shows a defect in the base
of the bladder here,
which later is shown to be the rigorous seal.
It shows a filling of a
colossal system here which has the group lily
appearance of a double kidney.
It shows lateral displacement of the
uh this portion of the kidney and it shows
nothing in the upper part of the kidney.
This retrograde study of this uh
same case reveals the reason
for all of this here is the rigorous zeal
in the bladder,
causing the bladder deformity.
The ureter in this case being implanted at
at abnormally low level,
which is not uncommon with congenital yuri to
sales the Euro to,
to the upper portion of the double kidney being
implanted,
invariably in the bladder at a
lower level than the ureter to the lower
portion of the kidney.
In an article by Salmoni states that your interest
seal is a cystic dilatation of the lower end of the ureter
associated with our officials to notice
stenosis and prolapse of the cyst into
the bladder,
the wall of the uterus to reseal consists of
two layers,
The inner layer is derived from the
balloon during oral mucosa.
While the outer layer represents the vladimir
cosa carried downwards on the surface of the
prolapse ng urata.
The result of all of this is stasis urethral
dilatation and infection in the Euro.
To and in the kidney.
This still yuri to roll the treasure.
Another congenital anomaly uh of
the Euro to we have already seen at the
previous talk.
And again,
let me just amplify this by showing you
uh a longitudinal
uh sonogram of the case that we
saw earlier in the talk on pelvic masses.
Here is the distal ureter
producing this large uh
translucent mass at this point right here
and at a higher level,
producing some of this mass at this point.
Right here,
here again is the Eureka showing its very
large dilated sausage shaped
deformity,
which was the cause for the uh
mass.
And uh which resulted from
the urethral stenosis at the just
above the bladder.
In this particular case,
you can see the deformed small cystic
kidney.
This is a multi cystic kidney which has its
characteristic findings of a small
artery,
a small ureter or no urata at all,
your eternal of treasure etcetera.
We will not go further into
that description
this morning.
Now you readable
calculus.
I probably the most common form of your
federal obstruction of all.
And here are a few atypical cases of
this condition we have here a
small calculus with a very high grade obstruction,
resulting in real extra visitation of the contrast
media with the IVP.
This patient was 68 years old.
He was.
She was awakened at one a.m. with a sharp left
sided flag pain.
They close up is shown here of this very small
calculus just in the lower your,
approximate to the bladder entrance.
On this examination.
At five minutes we begin to see an accumulation of the
contrast material in the involved left side with
hydro necrosis of the left kidney,
normal findings on the right side.
At 15 minutes there,
further accumulation of the media.
And at 30 minutes we now see
the filled system
with extra visitation of some of the media media
presumably back flowing from the
what are these with dissection
downward along the kidney pelvis
and along the upper part of the your Akhter as
well.
A very characteristic appearance of extra
visitation of media from the kidney
and very commonly and not commonly but occasionally
seen in high grade obstructions
of an acute eureka
associated with an acute urinary
calculus.
The stone eventually was removed with a basket
catheter in this individual case.
Uh a complication of pregnancy is the
presence of a charitable calculus.
And here we have such a case.
This is a close up of the calculus
just adjacent to the infants.
Uh,
fetuses,
head at this point right here and a
long shot of the whole system shows
the distended
your to down to the level of the calculus
here.
The stitching above here and the hydro nephritis
kidney here.
The presence of media in the
you're too down here probably uh
excludes the possibility of the so
called ovarian vein syndrome,
which is also another.
Your it'll type obstruction associated with
pregnancy.
And we will see such a case of that in just
a few minutes.
Here's a calculus in a patient who has had an
illegal conduit uh,
secondary to a pelvic clean out for carcinoma of the
cervix,
one of the most common malignancies that will
produce a frozen pelvis and necessitates
uh a
diversion of the urinary
stream,
usually into an illegal can't do it.
On the left side,
there's normal function and the media is passing into the illegal
pouch here.
Excuse me.
This was not an illegal pouch in this case.
This was one of the old fashioned sigmoid
pouches which used to be
done.
But because of various reasons including
infection,
they are not done to any extent anymore.
The right side shows a new program,
but no feeling of media and we trace it down to this point
right here and we see a calculus in the
lower part of this respected urata,
just proximity to its entrance into the illegal
conduit.
This eventually passed and the patient was relieved of
the pain.
There's a calculus that resembles a tooth.
This is merely put in here to say that
one has to differentiate occasionally a calculus in the
ureter large calculus from a possible
tooth within a derm board of the ovary.
There are no other findings here to indicate a Dermot of the
ovary other than the presence of this
large calculus which does resemble a tooth
to some extent A far
invited within the euro to may produce similar obstructive
symptoms.
And here is one in a 23 year old female with
sickle cell anemia.
And we see two foreign
materials within the uh you're too
here at this point.
And at this point,
right here in this retrograde study and
on a drainage film,
made a short time later,
we see that there have been impregnation of
these non opaque densities
in the
uh your turn at this point
and at this point and we see uh
a rather large uh
kayla sees in the kidney superior lee
here to some extent a little bit lower here.
And obviously this is a case of papillary necrosis
and a sickle cell er who has
stuffed the potbelly.
And they have passed down the ureter causing a partial
obstruction of the urinary
so much for calculator to go now to
your Itaru tumors.
Let me very quickly give you a
classification of the tumors that may
be seen in a euratom.
And then you show you several examples of these.
First of all,
there are the epithelial tumors
and these may be benign or malignant,
The benign being the papilloma as
polyps and the adenomas and
the malignant epithelial tumors being the
transitional cell carcinomas,
squamous cell carcinomas and
adenocarcinoma.
In addition to the epithelial tumors,
there is also the occasional meta dermal uh
tumors which include among the benign the
five Roma's hemangioma is a blood vascular
tumors,
mama's limb,
Fangio mazar lymph vascular tumors
and among the malignant there maybe the occasional
sarcoma of the urine.
You read all chambers have about a
1-2% incidence of
all guiyu tumors.
They occur in male,
about 2 - one over the female.
They range anywhere from the teens and
20s up to the later years.
The 80s and the 90s.
The mean for these lesions being about 74
years The pathologist shows
75-80% being malignant and most
of these are of the epithelial origin.
The location is usually in the lower third.
In about 75% of cases,
the symptoms include about 70 to 90% of
cases with the material,
20 to 35% with pain associated
with the material,
2 to 5% short and abdominal mass.
These would have to be very large in such a case And
about 10-20% showing abdominal pain
alone in this
case.
Right here we have a
benign.
Excuse me.
In this case.
Right here we have a transition.
Excuse me,
I'll go back again.
The first case here is a urine or a polyp
in the mail with the material.
This retrograde study of the urinary track reveals a
filling defect in the lower part of the left ureter with slight
dilatation of the aorta,
just proximal to the filling defect and violation of the
euro area and the area of the filling defect,
as shown by the catheter outlining the your
laterally here.
And if then trickle of contrast.
Media,
media,
media media.
Immediately When the euro was
opened in this area,
operation out popped a small polyp on a
pinnacle about one cm in length.
Surgical findings are shown on this uh
sketch right here,
the lesion was removed and the ureter was
closed without difficulty.
A second case,
have you read the polyp is of interest?
This 64 year old male was admitted for a vascular
work up.
The initial IVP examination showed a long filling
defect in the right proximal year or two has
shown right here.
Uh huh.
There was a mile hydro necrosis of the right kidney.
Several I.
V.
P.
S over the next six weeks continued to show the filling
defect and the hydro necrosis.
And this is the last of the several examinations that were
made.
This persistent defect was thought to be on the basis of a
benign lesion of some type,
but a definite diagnosis could not be made
that operation.
The urethral polyp was found measuring about six
centimeters in length and attached by a very narrow
base,
just distal to the right you p junction.
This unusual configuration of the lesion was
probably the result of a soft tissue.
A tumour contained within a very firm loom
in the ureter with a floor of urine,
continuously washing the fixed mass and accorded
direction,
thus stretching it out in the configuration that we
see in this case
before leaving benign tumors of the
Euro.
And let me show you an entity that resembles multiple
tumors of the Euro to but it's not in
reality these lesions are related to chronic
infection.
This is a case of Eureka right assist aka
involving both your photos with a touch
of power light of cystic A.
As well.
In a 62 year old male with a long history of
chronic urinary track infection and renal
calculus.
We can very nicely see
demonstrated here the multiple,
small,
more or less uniform filling defects within
the upper half of the two thirds of the right ureter
and similar defects within the upper part
of the left ear.
To hear A
little bit about your to write assist,
Aka.
The first recorded description of you,
you read write a cystic a.
Was by our friend Morgue agony in
1761.
In a post mortem examination of an old man who had suffered
from chronic urinary obstruction,
he found in both europe is quote spherical
drops unquote of various sizes.
Cyst formation is the final stage of the
proliferated change in the mucosa,
which occurs in the renal pelvis ureter or bladder
in response to any longstanding irritation,
but usually to a chronic infection,
solid bands of epithelium become
isolated in the to look appropriate and
by meta pleasure develop into secretary
glands.
Finally,
the cyst result from retention of secretions
elaborated by these glands.
The disease usually occurs in the old age groups and is more
common in women.
There are no pathetic demonic symptoms or signs,
but almost always urinary infection is
present often with renal calculus.
I slightly material occurs very frequently and
is thought to result from spontaneous rupture of one or
more of these cysts.
The retrograde you're a gram is generally the best method of
demonstrating the disease,
although a good IVP can do it too.
The salient feature is the presence of constant small
defects in the contrast field urata or renal
pelvis.
They may be large indiscreet or multiple and
small and may occur anywhere along the
track,
including the pelvis of the kidney,
the Yoda and in the bladder tune
differential diagnosis.
Although really this can,
this looks doesn't look exactly like anything else
includes air bubbles,
multiple papilloma to tuberculosis,
granule ations,
multiple small calcula blood clots,
and possibly multiple hemangioma.
Tous formations within the irritant.
So much for benign lesions,
let's go now to the primary malignant
lesions of the aorta and as I've already mentioned,
most of these are of epithelial origin.
Here is a rather characteristic,
typical pathetic pneumonic picture of a
primary transitional cell carcinoma of the ureter
and it has rather characteristic findings.
First of all,
there is what has been described as a goblet
or wine shaped deformity of the
contrast media column within
the ureter.
Second,
there is a modern dilation of
the Euro to just below the tumor,
which is rather a constant feature,
was first described by
Bergman and is known as frequently
as Bergman's sign.
There is a high grade obstruction here,
secondary to the mass of the tumor itself,
which occupies a level through here and there
is a moderate hydro necrosis and hydro your
to approximate to this
lesion,
the kidney and ureter in this case were
removed.
A second case of interest
somewhat atypical is this patient who was
for 65 years of age And had
had a four year history of Eureka
assisted juncture obstruction.
This general was apparently treated prior to admission,
but the type of treatment was not stated.
Chief complaint was pelvic pain.
In this patient,
she was admitted.
An examination revealed papa
limiter on the wall of the bladder and up into the left your
them and the lesion was cauterized in the bladder.
Three days afterward,
the patient was dismissed from the hospital.
Three days after the patient was dismissed from the
hospital,
she had further symptoms pathology and she
was readmitted surgery at this time
included removal of the left,
your removal of the left kidney and removal of the involved
parts of the bladder.
The pathological diagnosis was superficial
transitional cell carcinoma of the bladder
with extensive papilloma ketosis of the lower ureter,
which probably was a superficial
uh involvement of the ureter in
a similar uh type of
histology that is transitional cell
carcinoma in this
patient.
Right here,
the transitional cell carcinoma began in the
kidney and was later ceded
to the euratom.
Here is a patient who has a deformity of the
upper pole of the left
kidney with an infant nebula involvement and
a superior pelvic involvement here.
Further study showed that the Euro two was normal in this
case the patient was an elderly
man with cardiovascular disease.
So it was elected to do only an effect to
me and to remove that portion of the your
took which they could get to through the
flank incision.
The best treatment of these of course,
is to remove not only that you're that you can get to that
way,
but to make a lower incision and remove the
lower part of the ureter as well along
with a cuff of the bladder and in order to
forestall seeding of the tumor downward
and re ah
development of additional metastatic
or implant lesions.
This patient later on came back and now we
see the stump of the right ureter which
was left with involvement at several
levels,
including right here with transitional cell carcinoma
and up here with transitional cell carcinoma,
the entire ureter and a portion of the bladder was
removed at this time.
Again,
I point out the bulbous
deformity of the approximately end of the ureter here
where it was tied off.
Similar to that we saw in the
blind ending your to at the earlier part of
this talk,
This patient came in for the next several years
with 10 or more admissions for additional fall durations of
tumors developing in the bladder and he eventually
died of a cardiovascular death,
not of a urinary truck death,
pelvic abnormalities causing urinal
obstructions,
including inflammations causing a Diemer,
a stricture at the offices to us in the
bladder and prostate and prostatic hypertrophy
anomalies of the bladder,
such as extra fee displacements by pro
laps adjacent lesions and so forth.
Let's look at three cases illustrating some of these
abnormalities.
First,
here is a patient with extra fee of the bladder with the
characteristic deformity of the pelvis,
a lack of a synthesis pubis.
As shown here.
If this patient was examined clinically,
one would have seen prior to surgery that the
anterior wall of the bladder was absent or
poorly developed and that the
Eureka's could be seen entering the
bladder on its posterior superior
side.
This patient was repaired and here is a tantalum
mesh over the area of repair at this point right
here.
This had not prevented the patient,
though from having an obstructed right your order at
least with a hydro necrosis
associated in the right
kidney.
Here is an interesting patient with bilateral
obstructions of the your eaters,
Secondary to bladder
calculate this was a 24 year old male
with persistent diarrhea.
The patient's history is of interest and I'll give it to you
in just a second on a plane film
examination these large opaque
calculus I was seen.
And at a closer look at these,
calculate eye,
one can see that they have a poorly
defined radio lucent center.
These were removed and examined and they were found
to have as the night us in the center of these
some paraffin and the history
uh came out that this patient
had on several occasions,
uh self instrumented his bladder with
rolled up tubes of paraffin and
evidently at one time some of these
paraffin parts broke off into the
bladder,
remained there and worthy noticed for these
large exorcised,
calculate I,
which developed at a later time.
Mm.
Here is the examination of the
patient several weeks later,
following the removal of these.
And we can see that the re Toral
obstructions which probably were
not secondary to the calcula but rather to infection
within the bladder and the Deemer of the offices
has now subsided and there is no longer
any hydro necrosis.
This is another example of a broader deformity causing
the hydro necrosis.
Here is a patient with a sister seal.
This was a 64 year old female with the material,
flank pain and temperature
104 F.
She was found to have a urinary tract infection.
She was also found by clinical examination to have
a sister seal.
A rector sealed and an epidural
seal.
A passerby was inserted as a temporary
measure.
And we can see this car didn't quite drop.
But that's all right.
We can see that the pastry uh
one week following the previous examination
has cleared up the hydro necrosis
here that the earth has now entered at a higher
level into the bladder rather than into the pull down and
stretched portions as shown on the previous film.
And that there is now relatively little if any
hydro necrosis in the
kidneys.
Uh huh.
Several examples of urinary obstruction related to
surgery here is a
patient with advanced carcinoma of the
cervix.
The patient has had a pelvic clean out and an illegal
conduit,
elio conduits,
as you're probably aware uh isolated
segments of ilium which are closed off at
one end and the other end is brought out to the
skin for drainage.
The non resected parts of the Euro.
Tas following surgery for the pelvic
clean out or implanted into this illegal
loop.
The remaining ilium of course,
which was not used for the conduit is reinvest
opposed indian for a bowel function.
It has frequently happens that there are temporary obstructions
associated with these probably due
to uh edema
around the office where the Yorkies are
implanted into the illegal conduit.
It frequently happens that this
partial obstruction clears up later.
And we have more or less normal
findings in the urinary track either on the left
or right side on both sides.
Here is a patient that had a persistent
obstruction to some extent partial in
nature which produced a mild degree
of hydro ureter and a moderate degree of hydro
necrosis uh bilaterally.
Another your obstructed
by surgery is this one in a 49
year old female.
She had a hysterectomy during which
the left ovarian artery was relegated at the
pelvic inlet.
Following surgery and abnormally small urinary
output was noted and an IvP was done
on here is shown.
We see that the left ureter is
blocked off at this point again with a bulb
ascending characteristic of a tied off
or a respected your toe.
And that there is a martyr degree of hydro
hydro necrosis.
This is a four hour film so that the right kidney
normal side has already drained out.
This patient was re admitted
uh For surgery was was re
operated upon and the lacouture
was removed from the ureter and
urinary tract function was normal.
Following thereafter
this patient was
submitted for surgery and she had a vaginal
hysterectomy.
Uh It was realized after
surgery that the urinary output which was first
three or 400 CC.
On the next postoperative day diminished to
zero an I.
V.
P.
At this time was done.
And we see here the
obstructed your actors with
bilateral hydro necrosis and
some extra visitation of contrast material
due to this high grade obstruction of an
acute nature.
Similar to that we saw on the left side caused by the
urinary calculus.
A little bit later earlier the patient was taken
to the operating room.
Following this,
she was prepped and draped in the dorsal,
the thought of my position and after adequate general
anesthesia was obtained.
Both external called Golda plastic
suitcases were located,
grasp and cut and removed.
There was noted to be almost immediate flow of urine from
the foley catheter.
Here is an example
of the ureter after it had been
dis dislocated and uh
Retrograde Catheters had been inserted
into the Euro two for the drainage.
Following the surgery,
the construction of the ureter is noted in the
left side at that point,
right there and the construction of the right
ureter was noted in the right side,
right here.
This could be an alarming thing if it was not discovered.
But fortunately in this patient,
the lesion was determined.
The cause for the obstruction was determined
and the patient was dislocated with
good results.
Mm hmm.
Finally,
some uh your edible obstructions and
displacements secondary to non
urinary tract lesions.
There are many causes for these but we want to cite just
a few of them I mentioned a
little earlier that there can be during
pregnancy.
A syndrome which is known as ovarian
vein syndrome,
in which characteristically there is a cut
off of the ureter
at the point right here where
the your two
passes over the iliac
artery and vein and the ovarian
vein and there's usually no
media distantly in the urinary
shown here,
this is thought to be due to thickening of the
right ovarian vein related
to the pregnancy.
And since the right ovarian vein drains
into the in pierre
part of the vena cava,
it is commonly a
cause,
it is occasionally it cause during pregnancy
for obstruction on the right side.
This entity does not occur on the left side
because the left ovarian vein does not enter the
inferior vena cave and thus does not obstruct the Euro
to.
But rather it is into the
uh renal vein
at the higher level on the left
side.
Here is an interesting case
that I have not seen before in a
patient with a right
urethral obstruction at about the
same level as the ovarian vein
syndrome,
which was caused by a tortuous
iliac artery.
In this case we see the
deformity of the you order at this
point right here.
In a uh an oblique view,
we see a little bit better filling and know that it is
not a tumor within the order itself,
but rather appears to be caused by
external compression and displacement.
And in this bleak view,
we see that the causes
appears to be posterior to
the here are two.
An angiogram was done on this patient and they
oughta graham where they run off into the iliac arteries.
And we see a very interesting tortuous city of the
right iliac artery at this point,
right here which corresponded identically to the
defect that we saw on the medial and
posterior aspects of the ureter at that
point,
right there
here is an example of a right
law urinal obstruction by large
endometrium,
a in the pelvic area which is not readily
demonstrated in these views.
But this rvP made because of the
pelvic mass with films in
Supan and in upright
positions shows a fairly
marked obstruction on the right side with hydro
necrosis and hydro urata.
And in the upright film,
a leveling out of the heavier
media under the urine contained
within the pelvis of and policies of the right
kidney and a tortuous city
of the kidney itself,
your to itself.
And this was proven to result from the large
endometrium in the pelvic area obstructing
the right urata to a high
grade here
is an example of Crohn's disease.
Obstructing the right ureter and causing a deformity
of the bladder.
Several articles in recent times have
indicated and have suggested
the use of the IVP in all
cases of regional underwriters,
particularly with involvement of the distal ilium
because of the presence of
fistulas tracks and thickening of
tissues and abscess formation and so on that might
obstruct one or both of the year.
It is in this case the right ureter was
obstructed and there is a mild hydro
Yoda and hydro necrosis on the right and
there is a deformity of the bladder with an upward
elevation into a testing process at this
point right here,
here is some contrast media barium which had
been given to the patient in a previous small
intestinal examination.
And here is the picture in the same patient of
the small intestine showing the
mark,
degree of involvement of the distal
ilium in this regional
enteritis.
And I believe that these areas right here are the
areas that we saw on the IVP where the
media had uh collected
and had caused
thickening and probably abscess formation in this
area.
And uh this plus surrounding non
visualized tissues caused the deformity
of the bladder itself.
A similar type can happen.
Similar type thing can happen in ovarian
and in appendix cell
abscesses which
cause uh mass
formation within the retro peritoneal area
and obstruction of the
right ureter.
Here is a patient
similar to the one we saw earlier in
which there was a retro
peritoneal.
Adn apathy again,
the curator's are partially
deformed and displaced by
these nodes in the iliac area and
in the para aortic areas.
And we see some of the deformities here again
in this classical picture caused
by the enlarged retro iliac
nodes on the left side,
particularly to the right side to some extent here
and at higher levels.
The lateral displacements of the kidneys
and the ureter is caused by the large masses of retro
peritoneal and apathy notice in this case too
that there has been some rotation of the kidneys.
And this is not an uncommon finding in
this entity.
And here is a case of the
left Eureka and the kidney
markedly displaced upward and
immediately by very large
retro peritoneal mass,
which has a relative radio loose syncing.
This mass extends all the way from the kidney,
above,
down into the pelvic area below,
and one can see in here relative radio loosest
areas with the lines of water density
here,
which represented the fibrous
tissues within a large lipo
sarcoma of the retro peritoneal
space.
Not an uncommon place to have
lipo sarcoma developed and
particularly around the urinary structures
with subsequent displacement of
these structures.
And here finally,
is a large retro peritoneal
hematoma.
In a patient with hemophilia.
And we see here the large mass
of blood accumulated in this
retro peritoneal area in this
patient with hemophilia with
subsequent mark deformity of the
ureter,
even to displacement across the midline to the
right side,
and with partial obstruction of the ureter
causing this hydra necrosis in
the right,
in the left kidney.
So these are some of the examples
of your eternal obstructions that were
mentioned in Gamut age 31
from the book.
Gametes in radiology,
I might say,
for those who don't know it,
that this is a wonderful book for
differential diagnosis and certainly one
should be on your shelf in your own
office or home.
This is my last talk to you today,
and I appreciate the opportunity
that the doctor made well.
And his staff gave me for coming to the F.
I.
P.
And giving these four talks
on the subjects of the media steinem,
the pelvic masses and the
uh your natural obstructions.
And thank all of you for your attention,
a medical media production from w.
R.
M.
C t.
V.