WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:01.010 --> 00:03.910 The following is a medical media production from 00:03.910 --> 00:05.950 WR AMC TV. 00:17.240 --> 00:19.710 In selecting material for this 00:19.720 --> 00:22.170 talk on obstruction of the ureter. 00:23.050 --> 00:25.520 I used as a basis for the selection of 00:25.520 --> 00:28.060 material a page from a recent 00:28.070 --> 00:30.640 publication called Gametes and radiology, 00:30.640 --> 00:33.040 which I'm sure you're all familiar with. 00:33.940 --> 00:36.400 It is a comprehensive list of rick in 00:36.400 --> 00:39.400 differential diagnosis and it is by 00:39.400 --> 00:41.860 Maurice um reader and Benjamin Felson 00:42.420 --> 00:45.010 with contributions by Elliott's keith 00:45.010 --> 00:45.510 Harris, 00:45.510 --> 00:47.440 her beauty parks and George B. 00:47.440 --> 00:48.160 Greenfield, 00:49.340 --> 00:51.340 the first three of these more reader, 00:51.340 --> 00:54.310 Ben Felson and lethal virus are no strangers to this 00:54.310 --> 00:56.500 podium that I'm standing at right now 00:57.040 --> 00:59.690 and I am pleased to have them 00:59.690 --> 01:02.230 as good friends over the 01:02.230 --> 01:02.950 years. 01:04.940 --> 01:07.150 Let us look at the list of 01:07.160 --> 01:09.470 uh this gamut which is 01:09.470 --> 01:12.240 number 831 in their 01:12.240 --> 01:14.920 book and just go down the 01:14.930 --> 01:17.670 various causes that can produce an 01:17.670 --> 01:19.460 obstruction of the euratom. 01:20.140 --> 01:21.020 As you will note, 01:21.030 --> 01:23.200 these causes are divided into common and 01:23.200 --> 01:25.950 uncommon and they are in alphabetical 01:25.950 --> 01:26.330 order, 01:26.380 --> 01:29.130 which means I will not necessarily present 01:29.140 --> 01:32.040 some of these lesions in the order in which they 01:32.040 --> 01:32.650 are here, 01:33.340 --> 01:33.970 first of all, 01:33.970 --> 01:36.700 in among the common we have a blood clot or 01:36.700 --> 01:38.920 inspire stated puss calculus. 01:39.440 --> 01:41.860 Congenital eureka row pelvic junction 01:41.860 --> 01:44.500 obstruction that is banned vessel or adhesion 01:44.510 --> 01:44.960 valve, 01:44.960 --> 01:47.670 a vessel cystitis across 01:47.670 --> 01:50.620 normal bladder with compression or obstruction of intramural 01:50.620 --> 01:53.500 puritan inflammation and a Diemer that 01:53.500 --> 01:55.360 is pelvic inflammatory disease, 01:55.840 --> 01:58.350 invasion or compression by extrinsic 01:58.350 --> 01:59.170 malignancy. 01:59.170 --> 02:01.580 That is retro peritoneal lymphoma or 02:01.580 --> 02:03.970 sarcoma cost normal of the pancreas, 02:03.970 --> 02:05.650 cervix or other pelvic organs. 02:06.440 --> 02:09.290 Post operative that is lacouture or 02:09.290 --> 02:11.850 Diemer around the urethra pregnancy 02:12.240 --> 02:13.180 structure. 02:13.370 --> 02:16.020 That is congenital traumatic postoperative 02:16.020 --> 02:17.400 radiation therapy, 02:17.410 --> 02:19.520 inflammatory tuberculosis. 02:19.520 --> 02:19.890 Just oh, 02:19.890 --> 02:20.660 massages. 02:21.940 --> 02:24.660 You re to re seal vascular compression by 02:24.660 --> 02:26.760 normal or abnormal vessel or aneurysm. 02:27.440 --> 02:30.260 And among the uncommon causes there are benign 02:30.260 --> 02:32.660 eureka raw tuna that is polit papilloma, 02:32.670 --> 02:33.030 Mesen, 02:33.030 --> 02:33.480 Kimmel, 02:33.480 --> 02:34.940 Touma Blatter, 02:34.940 --> 02:37.670 diverticular um carcinoma of the Euro to 02:37.670 --> 02:40.390 primary or metastatic endometriosis, 02:40.820 --> 02:41.760 mega colon, 02:42.140 --> 02:44.750 popular necrosis where they stuffed happily 02:45.340 --> 02:47.930 pelvic lipo mitosis and finally, 02:47.930 --> 02:50.550 retro peritoneal fibrosis or 02:50.550 --> 02:51.980 Orman's disease. 02:52.740 --> 02:53.080 Now, 02:53.080 --> 02:55.770 let us look at many of these lesions 02:55.770 --> 02:58.230 and have a little discussion on some of 02:58.230 --> 03:00.890 the causes for obstruction 03:00.920 --> 03:03.500 and some of the embryology and histology 03:03.500 --> 03:04.760 behind these lesions. 03:05.540 --> 03:06.320 First of all, 03:06.320 --> 03:09.020 among congenital lesions causing obstruction. 03:09.020 --> 03:12.020 We have here an interesting lesion called congenital 03:12.020 --> 03:13.660 blind ending urata. 03:14.140 --> 03:16.970 And you can see on this radiograph that there 03:16.970 --> 03:18.130 is two years, 03:18.140 --> 03:18.700 there are two. 03:18.700 --> 03:21.350 Your it is on the left side with one 03:21.360 --> 03:24.190 uh in the pelvic pelvis of the 03:24.190 --> 03:27.120 left kidney above the other ending blindly at this 03:27.120 --> 03:29.960 point right here and rather shortly 03:30.340 --> 03:33.050 A second one is this one which is another 03:33.050 --> 03:35.980 congenital blind ending ureter and a 35 year 03:35.980 --> 03:38.970 old female with chronic urinary track infection. 03:39.250 --> 03:42.140 And we see that the duplication is almost complete 03:42.260 --> 03:45.080 with the ureter entering uh ending 03:45.080 --> 03:46.250 blindly at this point, 03:46.250 --> 03:49.060 very close to the pelvis itself. 03:49.640 --> 03:49.850 Now, 03:49.850 --> 03:52.420 what are these congenital blind ending your edges, 03:52.420 --> 03:55.350 they are a failure in an attempt to reduce application 03:55.360 --> 03:56.360 of the kidney. 03:57.040 --> 03:59.740 Most of these are white type with one year to 03:59.740 --> 04:02.520 blind the other connected with the renal pelvis. 04:02.630 --> 04:05.170 Sometimes these inter as 04:05.170 --> 04:08.050 single as single Eureka's into the bladder. 04:08.060 --> 04:10.840 Therefore to your to your general office is 04:10.840 --> 04:12.020 on the same side. 04:12.440 --> 04:15.260 Or more frequently they are y in type 04:15.640 --> 04:18.100 With the two joining together before they 04:18.110 --> 04:19.750 reach the bladder. 04:21.440 --> 04:24.260 There can be anywhere from 1-2 cm in 04:24.260 --> 04:24.670 length, 04:24.670 --> 04:27.620 at which time they may resemble a diverticular with the ureter. 04:27.650 --> 04:28.900 Or they may, 04:28.910 --> 04:31.540 as in the second case here extend 04:31.540 --> 04:33.160 almost the complete way. 04:34.040 --> 04:36.830 I call your attention to this appearance of a 04:36.830 --> 04:39.750 blind ending because we will see this on several other 04:39.750 --> 04:42.590 cases where your hands have been tied off for one cause or 04:42.590 --> 04:42.980 another. 04:43.620 --> 04:46.080 I know of nothing else that looks like this in the 04:46.080 --> 04:46.690 ureter. 04:47.140 --> 04:48.830 It looks like it ends there. 04:48.830 --> 04:51.670 It has no relation no appearance to a 04:51.670 --> 04:54.210 calculus or to a tumor. 04:54.500 --> 04:57.470 It is a characteristic feature in itself 04:57.480 --> 05:00.440 and we will see several others of a similar type as we 05:00.440 --> 05:01.450 go along. 05:02.340 --> 05:04.090 So much for her blind ending. 05:04.090 --> 05:06.600 Eureka's A second type of 05:06.610 --> 05:09.250 congenital anomaly is this case of a 05:09.260 --> 05:11.110 retro cable ureter. 05:11.110 --> 05:14.100 In a 27 year old male with a history of two or 05:14.100 --> 05:17.040 three episodes of the material accompanied by 05:17.040 --> 05:19.750 lower abdominal pain And the 05:19.750 --> 05:22.360 latest episode having occurred just 24 hours 05:22.360 --> 05:22.860 ago. 05:23.390 --> 05:25.360 The patient's physical exam was negative. 05:25.360 --> 05:26.680 His blood count was normal. 05:26.680 --> 05:29.360 His urine showed many mucous threads traces of 05:29.360 --> 05:30.020 bacteria, 05:30.020 --> 05:32.940 123 red blood cells and 0 to 1 05:32.950 --> 05:34.260 white blood cells. 05:34.740 --> 05:37.100 This 15 minute IVP shows 05:37.110 --> 05:39.750 gradual accumulation of 05:39.750 --> 05:42.560 contrast material within a moderately hydro 05:42.560 --> 05:44.300 necrotic right kidney, 05:44.310 --> 05:46.860 a normal appearance on the left side. 05:47.540 --> 05:50.260 In a 30 minute film we see further 05:50.260 --> 05:52.960 accumulation and now we see filling down to the 05:52.960 --> 05:55.660 port where the retro cable urata 05:55.670 --> 05:57.050 has occurred. 05:57.440 --> 06:00.150 And in the 60 minute film we see further 06:00.150 --> 06:02.730 filling of the media in the 06:02.730 --> 06:04.280 proximal urata. 06:04.470 --> 06:05.990 No filling in the distal. 06:05.990 --> 06:08.880 You're in a retrograde study was done on the same 06:08.880 --> 06:11.740 patient immediately after the IVP. 06:11.740 --> 06:14.360 And we see here a feeling of the lower part of 06:14.360 --> 06:16.820 the left right urata with a 06:16.820 --> 06:18.190 normal size, 06:18.190 --> 06:20.090 normal diameter of this section. 06:20.240 --> 06:23.210 And we see the typical deformity of 06:23.210 --> 06:24.060 the retro cable. 06:24.060 --> 06:26.560 Your edit in the film up above there. 06:27.140 --> 06:29.990 In this particular patient's surgery was suggested the 06:29.990 --> 06:32.860 patient preferred to defer and at last 06:32.860 --> 06:35.850 was uh report we have not seen him 06:35.850 --> 06:38.610 come back yet for repair of 06:38.610 --> 06:39.700 this condition. 06:39.880 --> 06:42.790 Another retro cable urata which is somewhat 06:42.790 --> 06:44.020 more atypical. 06:44.030 --> 06:47.030 Is this one with an associated incomplete 06:47.030 --> 06:49.850 rotation of the left kidney. 06:50.240 --> 06:52.770 Here we have a more gradual curve of the 06:52.770 --> 06:55.360 ureter as it passes towards the midline and 06:55.360 --> 06:58.270 downward with very little obstruction to 06:58.270 --> 07:01.170 the euro to has shown on the previous 07:01.180 --> 07:02.100 case. 07:02.640 --> 07:03.830 As we discussed this, 07:03.830 --> 07:06.710 let's look back for just a moment at the 07:06.720 --> 07:09.650 more characteristic one and let me read you just a little 07:09.650 --> 07:11.570 bit about how these occur. 07:12.740 --> 07:13.580 Please play, 07:13.590 --> 07:16.330 pay attention to this because this is a favorite 07:16.340 --> 07:18.160 urinary track 07:18.170 --> 07:20.920 question on the board 07:20.920 --> 07:21.910 examinations. 07:22.440 --> 07:24.590 According from an article by Mayor and Methods. 07:24.590 --> 07:27.130 They state this in 18 93. 07:27.140 --> 07:29.680 Hochstedt to first described this interesting 07:29.680 --> 07:30.330 anomaly, 07:30.390 --> 07:33.030 which is also called post cable or 07:33.030 --> 07:35.600 circum cable euratom and pre your 07:35.600 --> 07:36.950 rhetoric vena cava. 07:37.640 --> 07:40.140 The deformity is not due to an error in 07:40.140 --> 07:42.530 migration upward of the kidney or your data, 07:42.730 --> 07:45.320 but it results from an abnormality of the 07:45.320 --> 07:46.460 vascular system. 07:46.910 --> 07:49.840 Embry a logically this condition results from the 07:49.840 --> 07:52.250 right posterior cardinal vein failing to 07:52.250 --> 07:55.010 undergo atrophy and persisting as the adult 07:55.010 --> 07:55.750 vena cava. 07:56.440 --> 07:59.190 Normally this vein disappears and the right super 07:59.190 --> 08:02.020 cardinal vein persists as the vena 08:02.020 --> 08:02.460 cava. 08:03.140 --> 08:06.010 Occasionally both cardinal veins may possess the vena 08:06.010 --> 08:08.180 cava being doubled with the ureter passing 08:08.180 --> 08:11.150 between the two divisions. 08:11.840 --> 08:12.810 Unfortunately, 08:12.810 --> 08:15.250 there are no symptoms pathetic demonic of retro cable. 08:15.250 --> 08:17.830 You're usually the symptoms of those of hydro 08:17.830 --> 08:18.460 necrosis. 08:18.460 --> 08:20.450 Were superimposed infection of calculus. 08:20.460 --> 08:21.490 Heh material, 08:21.490 --> 08:24.230 gross or microscopic has been frequently noted and 08:24.280 --> 08:27.100 was the presenting symptoms in this case right 08:27.100 --> 08:27.560 here. 08:28.140 --> 08:31.050 Most patients have reached adulthood before symptoms 08:31.050 --> 08:33.740 develop as the onset of hydrogen fibrosis is 08:33.740 --> 08:34.780 usually insidious. 08:35.540 --> 08:37.550 The pilot graphic finding, 08:37.550 --> 08:38.660 which is almost pathetic. 08:38.660 --> 08:39.240 No Monica. 08:39.240 --> 08:39.950 Retro cable. 08:39.950 --> 08:42.580 Eureka is the S shaped curve in the upper 08:42.580 --> 08:45.240 ureter with displacement of the urine immediately 08:45.240 --> 08:48.040 to all beyond the midline at the 08:48.040 --> 08:48.960 level of the 3rd, 08:48.970 --> 08:51.950 4th or fifth lumbar vertebra. 08:53.140 --> 08:55.110 So much for retro cable. 08:55.110 --> 08:55.660 Your otis. 08:56.640 --> 08:59.630 Now another case of urethral obstruction, 08:59.630 --> 09:02.020 secondary to a congenital abnormalities, 09:02.030 --> 09:04.370 abnormal implantation of the Euro. 09:04.370 --> 09:06.680 To with an associated eureka, 09:06.680 --> 09:09.220 a seal and a female infant in this case 09:09.400 --> 09:11.530 with a double kidney and double your. 09:11.530 --> 09:12.450 It is on the left. 09:13.240 --> 09:15.640 This ivp film at 09:15.650 --> 09:16.910 45 minutes, 09:16.920 --> 09:19.840 shows a defect in the base 09:19.840 --> 09:20.940 of the bladder here, 09:20.940 --> 09:23.860 which later is shown to be the rigorous seal. 09:24.240 --> 09:26.720 It shows a filling of a 09:26.730 --> 09:29.270 colossal system here which has the group lily 09:29.270 --> 09:31.130 appearance of a double kidney. 09:31.370 --> 09:33.930 It shows lateral displacement of the 09:33.940 --> 09:36.720 uh this portion of the kidney and it shows 09:36.720 --> 09:39.560 nothing in the upper part of the kidney. 09:40.440 --> 09:43.140 This retrograde study of this uh 09:43.150 --> 09:46.080 same case reveals the reason 09:46.080 --> 09:48.830 for all of this here is the rigorous zeal 09:49.110 --> 09:51.860 in the bladder, 09:51.890 --> 09:53.890 causing the bladder deformity. 09:53.890 --> 09:56.710 The ureter in this case being implanted at 09:56.710 --> 09:58.400 at abnormally low level, 09:58.410 --> 10:01.050 which is not uncommon with congenital yuri to 10:01.050 --> 10:03.380 sales the Euro to, 10:03.380 --> 10:06.100 to the upper portion of the double kidney being 10:06.100 --> 10:06.930 implanted, 10:06.940 --> 10:09.740 invariably in the bladder at a 10:09.740 --> 10:12.320 lower level than the ureter to the lower 10:12.320 --> 10:14.960 portion of the kidney. 10:16.740 --> 10:19.520 In an article by Salmoni states that your interest 10:19.520 --> 10:22.500 seal is a cystic dilatation of the lower end of the ureter 10:22.500 --> 10:25.210 associated with our officials to notice 10:25.220 --> 10:28.160 stenosis and prolapse of the cyst into 10:28.160 --> 10:28.690 the bladder, 10:29.540 --> 10:32.390 the wall of the uterus to reseal consists of 10:32.400 --> 10:33.350 two layers, 10:33.580 --> 10:36.220 The inner layer is derived from the 10:36.220 --> 10:38.270 balloon during oral mucosa. 10:38.280 --> 10:41.030 While the outer layer represents the vladimir 10:41.030 --> 10:43.750 cosa carried downwards on the surface of the 10:43.750 --> 10:45.160 prolapse ng urata. 10:45.940 --> 10:48.630 The result of all of this is stasis urethral 10:48.630 --> 10:50.800 dilatation and infection in the Euro. 10:50.800 --> 10:53.260 To and in the kidney. 10:54.940 --> 10:56.770 This still yuri to roll the treasure. 10:56.770 --> 10:59.750 Another congenital anomaly uh of 10:59.750 --> 11:02.390 the Euro to we have already seen at the 11:02.390 --> 11:03.560 previous talk. 11:03.570 --> 11:04.230 And again, 11:04.230 --> 11:07.090 let me just amplify this by showing you 11:07.100 --> 11:09.970 uh a longitudinal 11:09.980 --> 11:12.840 uh sonogram of the case that we 11:12.840 --> 11:15.460 saw earlier in the talk on pelvic masses. 11:15.840 --> 11:18.300 Here is the distal ureter 11:18.300 --> 11:20.630 producing this large uh 11:20.640 --> 11:23.530 translucent mass at this point right here 11:23.640 --> 11:25.040 and at a higher level, 11:25.040 --> 11:27.470 producing some of this mass at this point. 11:27.470 --> 11:28.260 Right here, 11:28.740 --> 11:31.540 here again is the Eureka showing its very 11:31.540 --> 11:33.920 large dilated sausage shaped 11:33.930 --> 11:34.950 deformity, 11:34.960 --> 11:37.600 which was the cause for the uh 11:37.610 --> 11:38.250 mass. 11:38.250 --> 11:41.010 And uh which resulted from 11:41.040 --> 11:43.760 the urethral stenosis at the just 11:43.760 --> 11:44.800 above the bladder. 11:45.340 --> 11:46.580 In this particular case, 11:46.580 --> 11:49.170 you can see the deformed small cystic 11:49.180 --> 11:49.830 kidney. 11:49.830 --> 11:52.450 This is a multi cystic kidney which has its 11:52.450 --> 11:55.370 characteristic findings of a small 11:55.370 --> 11:56.020 artery, 11:56.030 --> 11:58.650 a small ureter or no urata at all, 11:58.650 --> 12:00.960 your eternal of treasure etcetera. 12:01.440 --> 12:03.530 We will not go further into 12:03.530 --> 12:05.810 that description 12:06.120 --> 12:07.160 this morning. 12:08.340 --> 12:10.430 Now you readable 12:10.440 --> 12:11.400 calculus. 12:11.400 --> 12:14.290 I probably the most common form of your 12:14.300 --> 12:15.660 federal obstruction of all. 12:15.660 --> 12:18.360 And here are a few atypical cases of 12:18.360 --> 12:21.080 this condition we have here a 12:21.080 --> 12:23.730 small calculus with a very high grade obstruction, 12:23.730 --> 12:26.420 resulting in real extra visitation of the contrast 12:26.420 --> 12:28.450 media with the IVP. 12:29.040 --> 12:31.470 This patient was 68 years old. 12:31.470 --> 12:32.000 He was. 12:32.010 --> 12:34.800 She was awakened at one a.m. with a sharp left 12:34.800 --> 12:36.150 sided flag pain. 12:36.540 --> 12:39.180 They close up is shown here of this very small 12:39.180 --> 12:41.940 calculus just in the lower your, 12:41.950 --> 12:44.800 approximate to the bladder entrance. 12:45.240 --> 12:46.450 On this examination. 12:46.450 --> 12:49.430 At five minutes we begin to see an accumulation of the 12:49.430 --> 12:52.230 contrast material in the involved left side with 12:52.240 --> 12:54.250 hydro necrosis of the left kidney, 12:54.380 --> 12:56.660 normal findings on the right side. 12:57.140 --> 12:58.690 At 15 minutes there, 12:58.690 --> 13:00.840 further accumulation of the media. 13:00.860 --> 13:03.840 And at 30 minutes we now see 13:04.020 --> 13:06.830 the filled system 13:06.840 --> 13:09.770 with extra visitation of some of the media media 13:09.770 --> 13:12.050 presumably back flowing from the 13:12.540 --> 13:15.360 what are these with dissection 13:15.360 --> 13:17.840 downward along the kidney pelvis 13:18.240 --> 13:21.080 and along the upper part of the your Akhter as 13:21.080 --> 13:21.570 well. 13:21.710 --> 13:24.490 A very characteristic appearance of extra 13:24.490 --> 13:27.090 visitation of media from the kidney 13:27.330 --> 13:30.030 and very commonly and not commonly but occasionally 13:30.030 --> 13:32.720 seen in high grade obstructions 13:33.010 --> 13:35.830 of an acute eureka 13:35.900 --> 13:38.580 associated with an acute urinary 13:38.640 --> 13:39.610 calculus. 13:40.240 --> 13:42.710 The stone eventually was removed with a basket 13:42.710 --> 13:45.520 catheter in this individual case. 13:46.340 --> 13:49.190 Uh a complication of pregnancy is the 13:49.200 --> 13:51.150 presence of a charitable calculus. 13:51.150 --> 13:52.830 And here we have such a case. 13:53.070 --> 13:55.230 This is a close up of the calculus 13:55.240 --> 13:57.640 just adjacent to the infants. 13:57.650 --> 13:58.280 Uh, 13:58.290 --> 13:58.810 fetuses, 13:58.810 --> 14:01.680 head at this point right here and a 14:01.680 --> 14:03.900 long shot of the whole system shows 14:03.910 --> 14:06.160 the distended 14:06.640 --> 14:09.210 your to down to the level of the calculus 14:09.210 --> 14:09.940 here. 14:10.100 --> 14:12.790 The stitching above here and the hydro nephritis 14:12.800 --> 14:13.660 kidney here. 14:14.340 --> 14:17.060 The presence of media in the 14:17.740 --> 14:20.660 you're too down here probably uh 14:20.670 --> 14:23.380 excludes the possibility of the so 14:23.380 --> 14:25.250 called ovarian vein syndrome, 14:25.250 --> 14:26.360 which is also another. 14:26.360 --> 14:29.100 Your it'll type obstruction associated with 14:29.100 --> 14:29.840 pregnancy. 14:29.850 --> 14:32.730 And we will see such a case of that in just 14:32.730 --> 14:33.900 a few minutes. 14:36.540 --> 14:39.280 Here's a calculus in a patient who has had an 14:39.290 --> 14:41.070 illegal conduit uh, 14:41.080 --> 14:44.060 secondary to a pelvic clean out for carcinoma of the 14:44.060 --> 14:44.600 cervix, 14:44.610 --> 14:47.550 one of the most common malignancies that will 14:47.550 --> 14:50.550 produce a frozen pelvis and necessitates 14:50.560 --> 14:52.150 uh a 14:52.540 --> 14:54.970 diversion of the urinary 14:54.970 --> 14:55.660 stream, 14:55.840 --> 14:58.560 usually into an illegal can't do it. 14:59.040 --> 15:00.000 On the left side, 15:00.000 --> 15:02.930 there's normal function and the media is passing into the illegal 15:02.930 --> 15:03.840 pouch here. 15:03.850 --> 15:04.440 Excuse me. 15:04.440 --> 15:06.250 This was not an illegal pouch in this case. 15:06.250 --> 15:08.700 This was one of the old fashioned sigmoid 15:08.700 --> 15:11.340 pouches which used to be 15:11.340 --> 15:11.760 done. 15:11.760 --> 15:14.170 But because of various reasons including 15:14.170 --> 15:14.820 infection, 15:15.240 --> 15:17.460 they are not done to any extent anymore. 15:17.940 --> 15:20.540 The right side shows a new program, 15:20.550 --> 15:23.530 but no feeling of media and we trace it down to this point 15:23.530 --> 15:26.340 right here and we see a calculus in the 15:26.340 --> 15:29.100 lower part of this respected urata, 15:29.210 --> 15:31.980 just proximity to its entrance into the illegal 15:31.980 --> 15:32.600 conduit. 15:32.950 --> 15:35.750 This eventually passed and the patient was relieved of 15:35.750 --> 15:37.160 the pain. 15:38.240 --> 15:41.140 There's a calculus that resembles a tooth. 15:41.140 --> 15:44.060 This is merely put in here to say that 15:44.070 --> 15:46.820 one has to differentiate occasionally a calculus in the 15:46.820 --> 15:49.470 ureter large calculus from a possible 15:49.470 --> 15:51.890 tooth within a derm board of the ovary. 15:52.340 --> 15:55.320 There are no other findings here to indicate a Dermot of the 15:55.320 --> 15:58.120 ovary other than the presence of this 15:58.120 --> 16:00.790 large calculus which does resemble a tooth 16:00.790 --> 16:03.490 to some extent A far 16:03.490 --> 16:06.410 invited within the euro to may produce similar obstructive 16:06.410 --> 16:07.200 symptoms. 16:07.200 --> 16:10.180 And here is one in a 23 year old female with 16:10.180 --> 16:11.460 sickle cell anemia. 16:11.940 --> 16:14.150 And we see two foreign 16:14.150 --> 16:16.950 materials within the uh you're too 16:16.950 --> 16:18.160 here at this point. 16:18.320 --> 16:19.330 And at this point, 16:19.330 --> 16:22.310 right here in this retrograde study and 16:22.310 --> 16:23.570 on a drainage film, 16:23.570 --> 16:25.040 made a short time later, 16:25.170 --> 16:27.930 we see that there have been impregnation of 16:27.930 --> 16:30.230 these non opaque densities 16:30.520 --> 16:32.150 in the 16:32.940 --> 16:35.380 uh your turn at this point 16:35.390 --> 16:38.340 and at this point and we see uh 16:38.350 --> 16:40.650 a rather large uh 16:41.730 --> 16:44.590 kayla sees in the kidney superior lee 16:44.590 --> 16:47.270 here to some extent a little bit lower here. 16:47.640 --> 16:50.620 And obviously this is a case of papillary necrosis 16:50.620 --> 16:52.910 and a sickle cell er who has 16:52.920 --> 16:55.610 stuffed the potbelly. 16:55.610 --> 16:58.470 And they have passed down the ureter causing a partial 16:58.470 --> 17:01.060 obstruction of the urinary 17:02.940 --> 17:05.820 so much for calculator to go now to 17:05.820 --> 17:07.080 your Itaru tumors. 17:07.300 --> 17:09.480 Let me very quickly give you a 17:09.480 --> 17:12.360 classification of the tumors that may 17:12.360 --> 17:14.360 be seen in a euratom. 17:14.360 --> 17:16.860 And then you show you several examples of these. 17:18.240 --> 17:19.050 First of all, 17:19.050 --> 17:21.980 there are the epithelial tumors 17:21.990 --> 17:24.640 and these may be benign or malignant, 17:24.650 --> 17:27.240 The benign being the papilloma as 17:27.250 --> 17:30.140 polyps and the adenomas and 17:30.140 --> 17:32.750 the malignant epithelial tumors being the 17:32.750 --> 17:34.540 transitional cell carcinomas, 17:34.540 --> 17:36.840 squamous cell carcinomas and 17:36.840 --> 17:37.930 adenocarcinoma. 17:38.640 --> 17:40.710 In addition to the epithelial tumors, 17:40.710 --> 17:43.590 there is also the occasional meta dermal uh 17:43.600 --> 17:46.360 tumors which include among the benign the 17:46.360 --> 17:49.320 five Roma's hemangioma is a blood vascular 17:49.320 --> 17:49.900 tumors, 17:49.950 --> 17:51.760 mama's limb, 17:51.760 --> 17:54.220 Fangio mazar lymph vascular tumors 17:54.740 --> 17:57.310 and among the malignant there maybe the occasional 17:57.310 --> 17:59.060 sarcoma of the urine. 18:00.240 --> 18:02.510 You read all chambers have about a 18:02.510 --> 18:05.340 1-2% incidence of 18:05.340 --> 18:06.960 all guiyu tumors. 18:07.840 --> 18:09.210 They occur in male, 18:09.220 --> 18:11.600 about 2 - one over the female. 18:12.140 --> 18:14.950 They range anywhere from the teens and 18:14.950 --> 18:17.270 20s up to the later years. 18:17.270 --> 18:18.600 The 80s and the 90s. 18:19.120 --> 18:22.030 The mean for these lesions being about 74 18:22.030 --> 18:24.520 years The pathologist shows 18:24.520 --> 18:27.510 75-80% being malignant and most 18:27.510 --> 18:29.850 of these are of the epithelial origin. 18:30.640 --> 18:33.030 The location is usually in the lower third. 18:33.030 --> 18:35.130 In about 75% of cases, 18:36.120 --> 18:38.820 the symptoms include about 70 to 90% of 18:38.830 --> 18:40.220 cases with the material, 18:40.230 --> 18:43.170 20 to 35% with pain associated 18:43.170 --> 18:44.260 with the material, 18:44.330 --> 18:46.990 2 to 5% short and abdominal mass. 18:46.990 --> 18:49.870 These would have to be very large in such a case And 18:49.870 --> 18:52.680 about 10-20% showing abdominal pain 18:53.040 --> 18:55.720 alone in this 18:55.730 --> 18:56.380 case. 18:56.380 --> 18:58.560 Right here we have a 18:58.570 --> 18:59.780 benign. 19:00.540 --> 19:02.030 Excuse me. 19:02.040 --> 19:02.780 In this case. 19:02.780 --> 19:05.070 Right here we have a transition. 19:05.080 --> 19:05.810 Excuse me, 19:05.820 --> 19:06.960 I'll go back again. 19:07.740 --> 19:10.460 The first case here is a urine or a polyp 19:10.920 --> 19:12.920 in the mail with the material. 19:13.440 --> 19:16.340 This retrograde study of the urinary track reveals a 19:16.340 --> 19:19.070 filling defect in the lower part of the left ureter with slight 19:19.070 --> 19:20.190 dilatation of the aorta, 19:20.190 --> 19:23.190 just proximal to the filling defect and violation of the 19:23.190 --> 19:25.350 euro area and the area of the filling defect, 19:26.440 --> 19:28.860 as shown by the catheter outlining the your 19:28.860 --> 19:31.170 laterally here. 19:31.840 --> 19:33.580 And if then trickle of contrast. 19:33.580 --> 19:34.350 Media, 19:34.360 --> 19:35.270 media, 19:35.280 --> 19:36.590 media media. 19:36.600 --> 19:39.060 Immediately When the euro was 19:39.060 --> 19:40.340 opened in this area, 19:40.340 --> 19:42.960 operation out popped a small polyp on a 19:42.960 --> 19:45.460 pinnacle about one cm in length. 19:46.040 --> 19:48.730 Surgical findings are shown on this uh 19:48.740 --> 19:50.190 sketch right here, 19:50.200 --> 19:52.730 the lesion was removed and the ureter was 19:52.740 --> 19:54.560 closed without difficulty. 19:55.640 --> 19:56.430 A second case, 19:56.430 --> 19:58.500 have you read the polyp is of interest? 19:58.510 --> 20:01.340 This 64 year old male was admitted for a vascular 20:01.340 --> 20:01.960 work up. 20:02.440 --> 20:05.130 The initial IVP examination showed a long filling 20:05.130 --> 20:07.850 defect in the right proximal year or two has 20:07.850 --> 20:08.850 shown right here. 20:11.640 --> 20:12.260 Uh huh. 20:13.630 --> 20:16.270 There was a mile hydro necrosis of the right kidney. 20:16.840 --> 20:17.450 Several I. 20:17.450 --> 20:17.650 V. 20:17.650 --> 20:17.910 P. 20:17.910 --> 20:20.310 S over the next six weeks continued to show the filling 20:20.310 --> 20:22.360 defect and the hydro necrosis. 20:22.830 --> 20:25.810 And this is the last of the several examinations that were 20:25.810 --> 20:26.350 made. 20:26.840 --> 20:29.740 This persistent defect was thought to be on the basis of a 20:29.740 --> 20:31.070 benign lesion of some type, 20:31.070 --> 20:33.460 but a definite diagnosis could not be made 20:34.240 --> 20:35.130 that operation. 20:35.130 --> 20:37.860 The urethral polyp was found measuring about six 20:37.860 --> 20:40.600 centimeters in length and attached by a very narrow 20:40.600 --> 20:41.130 base, 20:41.140 --> 20:43.380 just distal to the right you p junction. 20:44.240 --> 20:46.730 This unusual configuration of the lesion was 20:46.730 --> 20:49.680 probably the result of a soft tissue. 20:50.050 --> 20:53.000 A tumour contained within a very firm loom 20:53.000 --> 20:55.360 in the ureter with a floor of urine, 20:55.360 --> 20:58.350 continuously washing the fixed mass and accorded 20:58.350 --> 20:59.030 direction, 20:59.300 --> 21:02.260 thus stretching it out in the configuration that we 21:02.260 --> 21:04.320 see in this case 21:06.040 --> 21:08.810 before leaving benign tumors of the 21:08.810 --> 21:09.080 Euro. 21:09.080 --> 21:11.800 And let me show you an entity that resembles multiple 21:11.800 --> 21:14.760 tumors of the Euro to but it's not in 21:14.760 --> 21:17.140 reality these lesions are related to chronic 21:17.140 --> 21:17.780 infection. 21:18.340 --> 21:20.870 This is a case of Eureka right assist aka 21:20.870 --> 21:23.500 involving both your photos with a touch 21:23.500 --> 21:25.140 of power light of cystic A. 21:25.140 --> 21:25.860 As well. 21:26.240 --> 21:29.220 In a 62 year old male with a long history of 21:29.220 --> 21:31.840 chronic urinary track infection and renal 21:31.840 --> 21:32.460 calculus. 21:33.140 --> 21:35.860 We can very nicely see 21:35.870 --> 21:37.850 demonstrated here the multiple, 21:37.850 --> 21:38.540 small, 21:38.550 --> 21:41.410 more or less uniform filling defects within 21:41.410 --> 21:44.390 the upper half of the two thirds of the right ureter 21:44.690 --> 21:47.220 and similar defects within the upper part 21:47.410 --> 21:48.520 of the left ear. 21:48.520 --> 21:51.490 To hear A 21:51.490 --> 21:53.650 little bit about your to write assist, 21:53.650 --> 21:53.900 Aka. 21:53.900 --> 21:55.980 The first recorded description of you, 21:55.990 --> 21:57.400 you read write a cystic a. 21:57.400 --> 21:59.570 Was by our friend Morgue agony in 21:59.570 --> 22:00.760 1761. 22:01.440 --> 22:04.360 In a post mortem examination of an old man who had suffered 22:04.360 --> 22:05.850 from chronic urinary obstruction, 22:05.850 --> 22:08.250 he found in both europe is quote spherical 22:08.250 --> 22:10.950 drops unquote of various sizes. 22:11.730 --> 22:14.460 Cyst formation is the final stage of the 22:14.460 --> 22:16.720 proliferated change in the mucosa, 22:16.720 --> 22:19.640 which occurs in the renal pelvis ureter or bladder 22:19.640 --> 22:22.320 in response to any longstanding irritation, 22:22.380 --> 22:24.730 but usually to a chronic infection, 22:25.480 --> 22:28.190 solid bands of epithelium become 22:28.190 --> 22:31.060 isolated in the to look appropriate and 22:31.060 --> 22:33.510 by meta pleasure develop into secretary 22:33.510 --> 22:34.210 glands. 22:34.840 --> 22:35.570 Finally, 22:35.570 --> 22:38.500 the cyst result from retention of secretions 22:38.500 --> 22:40.770 elaborated by these glands. 22:41.740 --> 22:44.560 The disease usually occurs in the old age groups and is more 22:44.560 --> 22:45.450 common in women. 22:46.040 --> 22:48.250 There are no pathetic demonic symptoms or signs, 22:48.250 --> 22:50.890 but almost always urinary infection is 22:50.890 --> 22:53.140 present often with renal calculus. 22:53.140 --> 22:56.110 I slightly material occurs very frequently and 22:56.110 --> 22:58.710 is thought to result from spontaneous rupture of one or 22:58.710 --> 23:00.410 more of these cysts. 23:01.240 --> 23:03.790 The retrograde you're a gram is generally the best method of 23:03.790 --> 23:05.110 demonstrating the disease, 23:05.110 --> 23:07.270 although a good IVP can do it too. 23:07.840 --> 23:10.600 The salient feature is the presence of constant small 23:10.600 --> 23:13.060 defects in the contrast field urata or renal 23:13.060 --> 23:13.660 pelvis. 23:14.040 --> 23:16.590 They may be large indiscreet or multiple and 23:16.590 --> 23:19.210 small and may occur anywhere along the 23:19.220 --> 23:19.690 track, 23:19.700 --> 23:21.290 including the pelvis of the kidney, 23:21.290 --> 23:23.270 the Yoda and in the bladder tune 23:24.140 --> 23:25.600 differential diagnosis. 23:25.600 --> 23:27.510 Although really this can, 23:27.520 --> 23:30.080 this looks doesn't look exactly like anything else 23:30.540 --> 23:32.350 includes air bubbles, 23:32.360 --> 23:34.840 multiple papilloma to tuberculosis, 23:34.840 --> 23:35.880 granule ations, 23:35.880 --> 23:38.860 multiple small calcula blood clots, 23:38.860 --> 23:41.070 and possibly multiple hemangioma. 23:41.070 --> 23:44.060 Tous formations within the irritant. 23:45.840 --> 23:47.510 So much for benign lesions, 23:47.510 --> 23:50.320 let's go now to the primary malignant 23:50.320 --> 23:53.210 lesions of the aorta and as I've already mentioned, 23:53.210 --> 23:55.480 most of these are of epithelial origin. 23:56.040 --> 23:58.450 Here is a rather characteristic, 23:58.460 --> 24:01.130 typical pathetic pneumonic picture of a 24:01.130 --> 24:03.910 primary transitional cell carcinoma of the ureter 24:04.840 --> 24:07.060 and it has rather characteristic findings. 24:07.540 --> 24:08.450 First of all, 24:08.450 --> 24:11.270 there is what has been described as a goblet 24:11.280 --> 24:14.210 or wine shaped deformity of the 24:14.220 --> 24:16.850 contrast media column within 24:16.850 --> 24:18.060 the ureter. 24:18.880 --> 24:19.380 Second, 24:19.380 --> 24:22.170 there is a modern dilation of 24:22.170 --> 24:24.670 the Euro to just below the tumor, 24:25.540 --> 24:27.560 which is rather a constant feature, 24:27.560 --> 24:29.500 was first described by 24:29.630 --> 24:32.490 Bergman and is known as frequently 24:32.490 --> 24:33.760 as Bergman's sign. 24:34.440 --> 24:36.660 There is a high grade obstruction here, 24:36.660 --> 24:39.230 secondary to the mass of the tumor itself, 24:39.230 --> 24:41.930 which occupies a level through here and there 24:41.940 --> 24:44.780 is a moderate hydro necrosis and hydro your 24:44.780 --> 24:47.050 to approximate to this 24:47.060 --> 24:47.960 lesion, 24:48.740 --> 24:51.730 the kidney and ureter in this case were 24:51.800 --> 24:52.670 removed. 24:54.140 --> 24:56.860 A second case of interest 24:56.870 --> 24:59.710 somewhat atypical is this patient who was 24:59.710 --> 25:02.640 for 65 years of age And had 25:02.640 --> 25:05.200 had a four year history of Eureka 25:05.200 --> 25:07.640 assisted juncture obstruction. 25:08.410 --> 25:11.210 This general was apparently treated prior to admission, 25:11.460 --> 25:13.810 but the type of treatment was not stated. 25:14.240 --> 25:15.920 Chief complaint was pelvic pain. 25:15.920 --> 25:16.760 In this patient, 25:17.340 --> 25:18.200 she was admitted. 25:18.200 --> 25:20.880 An examination revealed papa 25:20.880 --> 25:23.830 limiter on the wall of the bladder and up into the left your 25:23.830 --> 25:26.770 them and the lesion was cauterized in the bladder. 25:27.340 --> 25:28.600 Three days afterward, 25:28.610 --> 25:30.780 the patient was dismissed from the hospital. 25:30.980 --> 25:33.630 Three days after the patient was dismissed from the 25:33.630 --> 25:34.150 hospital, 25:34.150 --> 25:37.110 she had further symptoms pathology and she 25:37.110 --> 25:39.630 was readmitted surgery at this time 25:39.630 --> 25:41.100 included removal of the left, 25:41.100 --> 25:43.950 your removal of the left kidney and removal of the involved 25:43.960 --> 25:45.030 parts of the bladder. 25:45.540 --> 25:48.200 The pathological diagnosis was superficial 25:48.200 --> 25:50.920 transitional cell carcinoma of the bladder 25:51.040 --> 25:54.020 with extensive papilloma ketosis of the lower ureter, 25:54.060 --> 25:56.620 which probably was a superficial 25:56.630 --> 25:59.520 uh involvement of the ureter in 25:59.520 --> 26:01.610 a similar uh type of 26:01.610 --> 26:04.550 histology that is transitional cell 26:04.560 --> 26:07.430 carcinoma in this 26:07.430 --> 26:07.810 patient. 26:07.810 --> 26:08.420 Right here, 26:08.420 --> 26:11.230 the transitional cell carcinoma began in the 26:11.240 --> 26:14.030 kidney and was later ceded 26:14.040 --> 26:15.560 to the euratom. 26:16.240 --> 26:19.120 Here is a patient who has a deformity of the 26:19.120 --> 26:21.760 upper pole of the left 26:22.140 --> 26:24.860 kidney with an infant nebula involvement and 26:24.860 --> 26:27.450 a superior pelvic involvement here. 26:28.140 --> 26:30.790 Further study showed that the Euro two was normal in this 26:30.790 --> 26:33.450 case the patient was an elderly 26:33.450 --> 26:36.050 man with cardiovascular disease. 26:36.050 --> 26:38.810 So it was elected to do only an effect to 26:38.810 --> 26:41.690 me and to remove that portion of the your 26:41.690 --> 26:44.580 took which they could get to through the 26:44.580 --> 26:45.560 flank incision. 26:46.340 --> 26:49.140 The best treatment of these of course, 26:49.150 --> 26:52.080 is to remove not only that you're that you can get to that 26:52.080 --> 26:52.370 way, 26:52.370 --> 26:55.120 but to make a lower incision and remove the 26:55.120 --> 26:58.010 lower part of the ureter as well along 26:58.010 --> 27:00.790 with a cuff of the bladder and in order to 27:00.790 --> 27:03.480 forestall seeding of the tumor downward 27:03.790 --> 27:06.770 and re ah 27:07.240 --> 27:10.140 development of additional metastatic 27:10.140 --> 27:11.350 or implant lesions. 27:12.140 --> 27:15.100 This patient later on came back and now we 27:15.100 --> 27:17.980 see the stump of the right ureter which 27:17.980 --> 27:20.580 was left with involvement at several 27:20.580 --> 27:21.110 levels, 27:21.110 --> 27:23.940 including right here with transitional cell carcinoma 27:23.940 --> 27:26.450 and up here with transitional cell carcinoma, 27:27.450 --> 27:30.330 the entire ureter and a portion of the bladder was 27:30.330 --> 27:32.350 removed at this time. 27:32.360 --> 27:32.930 Again, 27:32.930 --> 27:35.650 I point out the bulbous 27:35.660 --> 27:38.650 deformity of the approximately end of the ureter here 27:38.650 --> 27:40.240 where it was tied off. 27:40.250 --> 27:42.840 Similar to that we saw in the 27:42.850 --> 27:45.730 blind ending your to at the earlier part of 27:45.730 --> 27:46.860 this talk, 27:47.540 --> 27:50.400 This patient came in for the next several years 27:50.400 --> 27:53.210 with 10 or more admissions for additional fall durations of 27:53.220 --> 27:56.130 tumors developing in the bladder and he eventually 27:56.130 --> 27:58.850 died of a cardiovascular death, 27:58.860 --> 28:01.560 not of a urinary truck death, 28:03.440 --> 28:05.740 pelvic abnormalities causing urinal 28:05.740 --> 28:06.580 obstructions, 28:06.580 --> 28:09.490 including inflammations causing a Diemer, 28:09.490 --> 28:12.250 a stricture at the offices to us in the 28:12.250 --> 28:14.710 bladder and prostate and prostatic hypertrophy 28:14.710 --> 28:15.950 anomalies of the bladder, 28:15.950 --> 28:18.740 such as extra fee displacements by pro 28:18.740 --> 28:20.950 laps adjacent lesions and so forth. 28:21.540 --> 28:24.250 Let's look at three cases illustrating some of these 28:24.250 --> 28:25.330 abnormalities. 28:25.580 --> 28:25.960 First, 28:25.960 --> 28:28.930 here is a patient with extra fee of the bladder with the 28:28.930 --> 28:31.800 characteristic deformity of the pelvis, 28:32.240 --> 28:34.680 a lack of a synthesis pubis. 28:34.680 --> 28:36.050 As shown here. 28:36.540 --> 28:38.510 If this patient was examined clinically, 28:38.510 --> 28:41.420 one would have seen prior to surgery that the 28:41.420 --> 28:44.150 anterior wall of the bladder was absent or 28:44.150 --> 28:46.710 poorly developed and that the 28:46.720 --> 28:49.250 Eureka's could be seen entering the 28:49.250 --> 28:51.960 bladder on its posterior superior 28:51.960 --> 28:52.560 side. 28:53.130 --> 28:56.080 This patient was repaired and here is a tantalum 28:56.080 --> 28:58.950 mesh over the area of repair at this point right 28:58.950 --> 28:59.360 here. 28:59.840 --> 29:01.450 This had not prevented the patient, 29:01.450 --> 29:04.110 though from having an obstructed right your order at 29:04.110 --> 29:06.190 least with a hydro necrosis 29:06.200 --> 29:08.800 associated in the right 29:08.810 --> 29:09.560 kidney. 29:10.840 --> 29:13.350 Here is an interesting patient with bilateral 29:13.350 --> 29:15.460 obstructions of the your eaters, 29:15.840 --> 29:18.160 Secondary to bladder 29:18.160 --> 29:21.020 calculate this was a 24 year old male 29:21.020 --> 29:22.670 with persistent diarrhea. 29:23.620 --> 29:26.610 The patient's history is of interest and I'll give it to you 29:26.610 --> 29:29.260 in just a second on a plane film 29:29.260 --> 29:31.760 examination these large opaque 29:31.760 --> 29:33.590 calculus I was seen. 29:33.600 --> 29:35.170 And at a closer look at these, 29:35.170 --> 29:35.910 calculate eye, 29:35.910 --> 29:38.410 one can see that they have a poorly 29:38.410 --> 29:40.560 defined radio lucent center. 29:41.340 --> 29:44.190 These were removed and examined and they were found 29:44.470 --> 29:47.380 to have as the night us in the center of these 29:47.390 --> 29:49.920 some paraffin and the history 29:49.930 --> 29:52.490 uh came out that this patient 29:52.500 --> 29:54.240 had on several occasions, 29:54.250 --> 29:57.220 uh self instrumented his bladder with 29:57.230 --> 29:59.940 rolled up tubes of paraffin and 29:59.940 --> 30:02.320 evidently at one time some of these 30:02.320 --> 30:04.990 paraffin parts broke off into the 30:04.990 --> 30:05.360 bladder, 30:05.360 --> 30:08.330 remained there and worthy noticed for these 30:08.330 --> 30:10.460 large exorcised, 30:10.470 --> 30:11.360 calculate I, 30:11.540 --> 30:13.670 which developed at a later time. 30:15.240 --> 30:16.050 Mm. 30:16.940 --> 30:19.590 Here is the examination of the 30:19.590 --> 30:21.190 patient several weeks later, 30:21.190 --> 30:22.600 following the removal of these. 30:22.600 --> 30:24.580 And we can see that the re Toral 30:24.580 --> 30:27.350 obstructions which probably were 30:27.350 --> 30:30.330 not secondary to the calcula but rather to infection 30:30.330 --> 30:33.240 within the bladder and the Deemer of the offices 30:33.250 --> 30:36.220 has now subsided and there is no longer 30:36.220 --> 30:38.460 any hydro necrosis. 30:41.440 --> 30:44.440 This is another example of a broader deformity causing 30:44.440 --> 30:45.510 the hydro necrosis. 30:45.510 --> 30:47.800 Here is a patient with a sister seal. 30:48.700 --> 30:51.650 This was a 64 year old female with the material, 30:51.650 --> 30:53.260 flank pain and temperature 30:54.040 --> 30:55.760 104 F. 30:55.940 --> 30:58.600 She was found to have a urinary tract infection. 30:58.600 --> 31:01.520 She was also found by clinical examination to have 31:01.520 --> 31:02.560 a sister seal. 31:02.730 --> 31:05.200 A rector sealed and an epidural 31:05.200 --> 31:05.770 seal. 31:06.340 --> 31:09.240 A passerby was inserted as a temporary 31:09.240 --> 31:09.900 measure. 31:10.050 --> 31:12.990 And we can see this car didn't quite drop. 31:13.000 --> 31:13.920 But that's all right. 31:14.040 --> 31:16.990 We can see that the pastry uh 31:17.000 --> 31:19.730 one week following the previous examination 31:19.740 --> 31:22.510 has cleared up the hydro necrosis 31:22.510 --> 31:25.270 here that the earth has now entered at a higher 31:25.270 --> 31:28.210 level into the bladder rather than into the pull down and 31:28.210 --> 31:31.110 stretched portions as shown on the previous film. 31:31.440 --> 31:34.280 And that there is now relatively little if any 31:34.290 --> 31:36.950 hydro necrosis in the 31:36.960 --> 31:37.670 kidneys. 31:40.340 --> 31:40.840 Uh huh. 31:41.640 --> 31:44.510 Several examples of urinary obstruction related to 31:44.510 --> 31:47.420 surgery here is a 31:47.420 --> 31:50.210 patient with advanced carcinoma of the 31:50.210 --> 31:51.000 cervix. 31:51.010 --> 31:53.850 The patient has had a pelvic clean out and an illegal 31:53.850 --> 31:54.560 conduit, 31:55.640 --> 31:56.710 elio conduits, 31:56.710 --> 31:59.410 as you're probably aware uh isolated 31:59.410 --> 32:02.350 segments of ilium which are closed off at 32:02.350 --> 32:05.100 one end and the other end is brought out to the 32:05.100 --> 32:06.560 skin for drainage. 32:07.110 --> 32:09.240 The non resected parts of the Euro. 32:09.240 --> 32:12.040 Tas following surgery for the pelvic 32:12.040 --> 32:14.900 clean out or implanted into this illegal 32:14.900 --> 32:15.350 loop. 32:15.940 --> 32:17.670 The remaining ilium of course, 32:17.680 --> 32:20.340 which was not used for the conduit is reinvest 32:20.340 --> 32:23.260 opposed indian for a bowel function. 32:23.840 --> 32:26.640 It has frequently happens that there are temporary obstructions 32:26.640 --> 32:28.950 associated with these probably due 32:28.950 --> 32:31.810 to uh edema 32:31.820 --> 32:34.650 around the office where the Yorkies are 32:34.650 --> 32:36.460 implanted into the illegal conduit. 32:37.540 --> 32:39.380 It frequently happens that this 32:40.440 --> 32:42.690 partial obstruction clears up later. 32:42.690 --> 32:45.550 And we have more or less normal 32:45.560 --> 32:48.540 findings in the urinary track either on the left 32:48.540 --> 32:50.270 or right side on both sides. 32:50.940 --> 32:53.140 Here is a patient that had a persistent 32:53.150 --> 32:55.750 obstruction to some extent partial in 32:55.750 --> 32:58.490 nature which produced a mild degree 32:58.490 --> 33:01.450 of hydro ureter and a moderate degree of hydro 33:01.450 --> 33:03.860 necrosis uh bilaterally. 33:05.640 --> 33:08.180 Another your obstructed 33:08.190 --> 33:11.090 by surgery is this one in a 49 33:11.090 --> 33:12.360 year old female. 33:13.040 --> 33:15.770 She had a hysterectomy during which 33:15.780 --> 33:18.730 the left ovarian artery was relegated at the 33:18.740 --> 33:19.710 pelvic inlet. 33:20.440 --> 33:23.330 Following surgery and abnormally small urinary 33:23.330 --> 33:26.230 output was noted and an IvP was done 33:26.230 --> 33:27.310 on here is shown. 33:27.940 --> 33:30.660 We see that the left ureter is 33:30.670 --> 33:33.150 blocked off at this point again with a bulb 33:33.150 --> 33:36.050 ascending characteristic of a tied off 33:36.050 --> 33:37.770 or a respected your toe. 33:38.140 --> 33:40.510 And that there is a martyr degree of hydro 33:40.840 --> 33:41.920 hydro necrosis. 33:41.920 --> 33:44.920 This is a four hour film so that the right kidney 33:45.010 --> 33:47.770 normal side has already drained out. 33:48.740 --> 33:51.160 This patient was re admitted 33:51.170 --> 33:53.950 uh For surgery was was re 33:53.950 --> 33:56.810 operated upon and the lacouture 33:56.810 --> 33:59.560 was removed from the ureter and 33:59.570 --> 34:01.520 urinary tract function was normal. 34:01.530 --> 34:02.580 Following thereafter 34:04.910 --> 34:07.680 this patient was 34:07.690 --> 34:10.610 submitted for surgery and she had a vaginal 34:10.620 --> 34:12.060 hysterectomy. 34:13.340 --> 34:15.910 Uh It was realized after 34:15.910 --> 34:18.830 surgery that the urinary output which was first 34:18.830 --> 34:20.660 three or 400 CC. 34:20.660 --> 34:23.260 On the next postoperative day diminished to 34:23.260 --> 34:24.760 zero an I. 34:24.760 --> 34:24.960 V. 34:24.960 --> 34:25.270 P. 34:25.270 --> 34:26.840 At this time was done. 34:27.010 --> 34:29.360 And we see here the 34:29.360 --> 34:31.980 obstructed your actors with 34:31.990 --> 34:34.960 bilateral hydro necrosis and 34:34.970 --> 34:37.900 some extra visitation of contrast material 34:38.340 --> 34:41.220 due to this high grade obstruction of an 34:41.220 --> 34:42.040 acute nature. 34:42.050 --> 34:44.990 Similar to that we saw on the left side caused by the 34:44.990 --> 34:45.930 urinary calculus. 34:45.930 --> 34:48.910 A little bit later earlier the patient was taken 34:48.910 --> 34:49.870 to the operating room. 34:49.870 --> 34:50.880 Following this, 34:50.890 --> 34:53.340 she was prepped and draped in the dorsal, 34:53.340 --> 34:56.250 the thought of my position and after adequate general 34:56.250 --> 34:57.500 anesthesia was obtained. 34:57.500 --> 35:00.130 Both external called Golda plastic 35:00.130 --> 35:01.300 suitcases were located, 35:01.300 --> 35:02.860 grasp and cut and removed. 35:03.490 --> 35:06.390 There was noted to be almost immediate flow of urine from 35:06.390 --> 35:07.880 the foley catheter. 35:08.440 --> 35:10.740 Here is an example 35:10.750 --> 35:13.530 of the ureter after it had been 35:13.530 --> 35:16.460 dis dislocated and uh 35:17.140 --> 35:19.790 Retrograde Catheters had been inserted 35:20.050 --> 35:22.620 into the Euro two for the drainage. 35:22.620 --> 35:23.670 Following the surgery, 35:24.040 --> 35:26.780 the construction of the ureter is noted in the 35:26.780 --> 35:28.020 left side at that point, 35:28.020 --> 35:30.880 right there and the construction of the right 35:30.890 --> 35:33.810 ureter was noted in the right side, 35:33.820 --> 35:34.750 right here. 35:35.240 --> 35:37.920 This could be an alarming thing if it was not discovered. 35:37.920 --> 35:39.780 But fortunately in this patient, 35:39.890 --> 35:42.870 the lesion was determined. 35:42.880 --> 35:45.800 The cause for the obstruction was determined 35:45.870 --> 35:48.300 and the patient was dislocated with 35:48.310 --> 35:49.970 good results. 35:52.440 --> 35:52.970 Mm hmm. 35:54.740 --> 35:55.690 Finally, 35:55.700 --> 35:58.590 some uh your edible obstructions and 35:58.590 --> 36:01.350 displacements secondary to non 36:01.350 --> 36:02.960 urinary tract lesions. 36:03.710 --> 36:06.500 There are many causes for these but we want to cite just 36:06.500 --> 36:09.320 a few of them I mentioned a 36:09.320 --> 36:11.820 little earlier that there can be during 36:11.820 --> 36:12.960 pregnancy. 36:12.970 --> 36:15.850 A syndrome which is known as ovarian 36:15.850 --> 36:17.040 vein syndrome, 36:17.630 --> 36:20.320 in which characteristically there is a cut 36:20.320 --> 36:22.450 off of the ureter 36:23.130 --> 36:25.550 at the point right here where 36:25.550 --> 36:27.980 the your two 36:27.980 --> 36:30.550 passes over the iliac 36:30.560 --> 36:33.440 artery and vein and the ovarian 36:33.440 --> 36:36.430 vein and there's usually no 36:36.430 --> 36:39.280 media distantly in the urinary 36:39.280 --> 36:40.160 shown here, 36:41.530 --> 36:44.340 this is thought to be due to thickening of the 36:44.350 --> 36:46.880 right ovarian vein related 36:46.890 --> 36:49.750 to the pregnancy. 36:50.730 --> 36:53.470 And since the right ovarian vein drains 36:53.480 --> 36:56.370 into the in pierre 36:56.370 --> 36:57.750 part of the vena cava, 36:58.430 --> 37:00.780 it is commonly a 37:00.780 --> 37:01.590 cause, 37:01.930 --> 37:04.650 it is occasionally it cause during pregnancy 37:04.990 --> 37:07.250 for obstruction on the right side. 37:08.000 --> 37:10.650 This entity does not occur on the left side 37:10.650 --> 37:13.230 because the left ovarian vein does not enter the 37:13.230 --> 37:16.140 inferior vena cave and thus does not obstruct the Euro 37:16.140 --> 37:16.400 to. 37:16.630 --> 37:18.950 But rather it is into the 37:18.960 --> 37:20.850 uh renal vein 37:21.230 --> 37:24.020 at the higher level on the left 37:24.020 --> 37:24.460 side. 37:26.930 --> 37:29.800 Here is an interesting case 37:29.800 --> 37:32.620 that I have not seen before in a 37:32.630 --> 37:35.270 patient with a right 37:35.360 --> 37:38.090 urethral obstruction at about the 37:38.090 --> 37:40.470 same level as the ovarian vein 37:40.740 --> 37:41.540 syndrome, 37:42.030 --> 37:44.820 which was caused by a tortuous 37:44.830 --> 37:46.050 iliac artery. 37:46.930 --> 37:49.470 In this case we see the 37:49.480 --> 37:52.260 deformity of the you order at this 37:52.260 --> 37:53.540 point right here. 37:54.230 --> 37:56.880 In a uh an oblique view, 37:56.880 --> 37:59.530 we see a little bit better filling and know that it is 37:59.530 --> 38:01.800 not a tumor within the order itself, 38:01.800 --> 38:04.140 but rather appears to be caused by 38:04.140 --> 38:06.650 external compression and displacement. 38:07.220 --> 38:09.210 And in this bleak view, 38:09.210 --> 38:11.590 we see that the causes 38:11.600 --> 38:14.300 appears to be posterior to 38:14.310 --> 38:16.270 the here are two. 38:17.120 --> 38:19.940 An angiogram was done on this patient and they 38:19.940 --> 38:22.640 oughta graham where they run off into the iliac arteries. 38:22.640 --> 38:25.600 And we see a very interesting tortuous city of the 38:25.600 --> 38:28.050 right iliac artery at this point, 38:28.050 --> 38:30.930 right here which corresponded identically to the 38:30.930 --> 38:33.730 defect that we saw on the medial and 38:33.730 --> 38:36.300 posterior aspects of the ureter at that 38:36.310 --> 38:36.860 point, 38:36.870 --> 38:38.340 right there 38:40.120 --> 38:43.090 here is an example of a right 38:43.090 --> 38:45.480 law urinal obstruction by large 38:45.490 --> 38:46.450 endometrium, 38:46.450 --> 38:49.030 a in the pelvic area which is not readily 38:49.030 --> 38:50.790 demonstrated in these views. 38:51.420 --> 38:54.080 But this rvP made because of the 38:54.080 --> 38:56.480 pelvic mass with films in 38:56.480 --> 38:58.990 Supan and in upright 38:58.990 --> 39:01.610 positions shows a fairly 39:01.610 --> 39:04.460 marked obstruction on the right side with hydro 39:04.460 --> 39:06.340 necrosis and hydro urata. 39:06.720 --> 39:08.910 And in the upright film, 39:08.910 --> 39:11.400 a leveling out of the heavier 39:11.400 --> 39:14.300 media under the urine contained 39:14.300 --> 39:17.050 within the pelvis of and policies of the right 39:17.060 --> 39:19.640 kidney and a tortuous city 39:19.720 --> 39:21.730 of the kidney itself, 39:21.750 --> 39:23.300 your to itself. 39:23.310 --> 39:25.910 And this was proven to result from the large 39:25.910 --> 39:28.710 endometrium in the pelvic area obstructing 39:28.710 --> 39:31.530 the right urata to a high 39:31.540 --> 39:34.330 grade here 39:34.330 --> 39:37.230 is an example of Crohn's disease. 39:37.230 --> 39:40.130 Obstructing the right ureter and causing a deformity 39:40.130 --> 39:41.450 of the bladder. 39:42.020 --> 39:44.950 Several articles in recent times have 39:45.720 --> 39:48.650 indicated and have suggested 39:49.190 --> 39:52.060 the use of the IVP in all 39:52.060 --> 39:54.650 cases of regional underwriters, 39:54.660 --> 39:57.150 particularly with involvement of the distal ilium 39:58.020 --> 40:00.680 because of the presence of 40:00.690 --> 40:03.260 fistulas tracks and thickening of 40:03.270 --> 40:06.210 tissues and abscess formation and so on that might 40:06.210 --> 40:08.180 obstruct one or both of the year. 40:08.180 --> 40:10.630 It is in this case the right ureter was 40:10.630 --> 40:13.400 obstructed and there is a mild hydro 40:13.400 --> 40:16.130 Yoda and hydro necrosis on the right and 40:16.130 --> 40:18.840 there is a deformity of the bladder with an upward 40:18.840 --> 40:21.560 elevation into a testing process at this 40:21.560 --> 40:22.530 point right here, 40:23.010 --> 40:25.920 here is some contrast media barium which had 40:25.920 --> 40:28.390 been given to the patient in a previous small 40:28.390 --> 40:29.820 intestinal examination. 40:30.310 --> 40:33.310 And here is the picture in the same patient of 40:33.310 --> 40:36.110 the small intestine showing the 40:36.120 --> 40:36.440 mark, 40:36.440 --> 40:38.770 degree of involvement of the distal 40:38.770 --> 40:41.050 ilium in this regional 40:41.050 --> 40:41.950 enteritis. 40:42.130 --> 40:44.940 And I believe that these areas right here are the 40:44.940 --> 40:47.810 areas that we saw on the IVP where the 40:47.810 --> 40:50.790 media had uh collected 40:50.850 --> 40:53.140 and had caused 40:53.610 --> 40:56.330 thickening and probably abscess formation in this 40:56.330 --> 40:56.900 area. 40:56.990 --> 40:59.960 And uh this plus surrounding non 40:59.960 --> 41:02.780 visualized tissues caused the deformity 41:02.780 --> 41:04.230 of the bladder itself. 41:04.710 --> 41:06.520 A similar type can happen. 41:06.530 --> 41:09.030 Similar type thing can happen in ovarian 41:09.040 --> 41:11.380 and in appendix cell 41:11.380 --> 41:14.300 abscesses which 41:14.310 --> 41:16.860 cause uh mass 41:16.860 --> 41:19.530 formation within the retro peritoneal area 41:19.910 --> 41:22.520 and obstruction of the 41:22.910 --> 41:24.190 right ureter. 41:26.810 --> 41:29.430 Here is a patient 41:29.440 --> 41:32.010 similar to the one we saw earlier in 41:32.010 --> 41:34.680 which there was a retro 41:34.680 --> 41:35.180 peritoneal. 41:35.180 --> 41:37.630 Adn apathy again, 41:37.640 --> 41:40.120 the curator's are partially 41:40.120 --> 41:42.650 deformed and displaced by 41:42.650 --> 41:45.520 these nodes in the iliac area and 41:45.520 --> 41:47.440 in the para aortic areas. 41:47.810 --> 41:50.410 And we see some of the deformities here again 41:50.720 --> 41:53.510 in this classical picture caused 41:53.510 --> 41:56.350 by the enlarged retro iliac 41:56.350 --> 41:57.900 nodes on the left side, 41:57.900 --> 42:00.510 particularly to the right side to some extent here 42:00.900 --> 42:02.070 and at higher levels. 42:02.070 --> 42:04.620 The lateral displacements of the kidneys 42:05.000 --> 42:07.970 and the ureter is caused by the large masses of retro 42:07.970 --> 42:10.880 peritoneal and apathy notice in this case too 42:10.880 --> 42:13.130 that there has been some rotation of the kidneys. 42:13.140 --> 42:16.060 And this is not an uncommon finding in 42:16.060 --> 42:17.430 this entity. 42:18.800 --> 42:21.590 And here is a case of the 42:21.590 --> 42:23.500 left Eureka and the kidney 42:23.700 --> 42:26.460 markedly displaced upward and 42:26.460 --> 42:29.140 immediately by very large 42:29.140 --> 42:30.800 retro peritoneal mass, 42:30.800 --> 42:33.040 which has a relative radio loose syncing. 42:33.700 --> 42:35.860 This mass extends all the way from the kidney, 42:35.860 --> 42:36.280 above, 42:36.280 --> 42:38.230 down into the pelvic area below, 42:38.600 --> 42:41.440 and one can see in here relative radio loosest 42:41.440 --> 42:43.970 areas with the lines of water density 42:43.970 --> 42:44.510 here, 42:45.000 --> 42:47.590 which represented the fibrous 42:47.600 --> 42:49.920 tissues within a large lipo 42:49.920 --> 42:52.380 sarcoma of the retro peritoneal 42:52.380 --> 42:53.060 space. 42:53.100 --> 42:55.650 Not an uncommon place to have 42:55.850 --> 42:58.240 lipo sarcoma developed and 42:58.240 --> 43:00.770 particularly around the urinary structures 43:00.790 --> 43:03.370 with subsequent displacement of 43:03.370 --> 43:04.620 these structures. 43:05.300 --> 43:06.620 And here finally, 43:06.620 --> 43:08.770 is a large retro peritoneal 43:08.770 --> 43:09.730 hematoma. 43:10.300 --> 43:13.020 In a patient with hemophilia. 43:13.700 --> 43:16.300 And we see here the large mass 43:16.520 --> 43:19.230 of blood accumulated in this 43:19.240 --> 43:21.890 retro peritoneal area in this 43:21.890 --> 43:24.590 patient with hemophilia with 43:24.600 --> 43:27.140 subsequent mark deformity of the 43:27.140 --> 43:27.810 ureter, 43:27.920 --> 43:30.740 even to displacement across the midline to the 43:30.740 --> 43:31.620 right side, 43:32.100 --> 43:34.400 and with partial obstruction of the ureter 43:34.770 --> 43:37.260 causing this hydra necrosis in 43:37.260 --> 43:38.790 the right, 43:38.800 --> 43:40.730 in the left kidney. 43:41.700 --> 43:43.910 So these are some of the examples 43:43.910 --> 43:46.870 of your eternal obstructions that were 43:46.870 --> 43:49.320 mentioned in Gamut age 31 43:50.000 --> 43:51.000 from the book. 43:51.000 --> 43:52.520 Gametes in radiology, 43:52.900 --> 43:54.280 I might say, 43:54.280 --> 43:55.620 for those who don't know it, 43:55.620 --> 43:58.150 that this is a wonderful book for 43:58.160 --> 44:01.120 differential diagnosis and certainly one 44:01.120 --> 44:04.020 should be on your shelf in your own 44:04.020 --> 44:05.430 office or home. 44:06.400 --> 44:08.570 This is my last talk to you today, 44:08.570 --> 44:11.220 and I appreciate the opportunity 44:11.220 --> 44:13.530 that the doctor made well. 44:13.530 --> 44:15.970 And his staff gave me for coming to the F. 44:15.970 --> 44:16.130 I. 44:16.130 --> 44:16.620 P. 44:17.000 --> 44:19.660 And giving these four talks 44:19.670 --> 44:22.010 on the subjects of the media steinem, 44:22.400 --> 44:24.890 the pelvic masses and the 44:24.900 --> 44:27.110 uh your natural obstructions. 44:27.470 --> 44:29.320 And thank all of you for your attention, 44:34.100 --> 44:36.430 a medical media production from w. 44:36.430 --> 44:36.710 R. 44:36.710 --> 44:37.000 M. 44:37.000 --> 44:37.580 C t. 44:37.580 --> 44:37.930 V.