What is it?
to detect evidence of scarring due to trauma
Ureteral stricture is a narrowing of the lumen
of the ureter, the ducts that carry urine from
the kidneys to the bladder, resulting in an
obstruction. Ureteral strictures may arise
from a variety of causes and are
characterized as either anastomotic or
nonanastomotic, depending on how they
develop. They may also be benign or
malignant.
Who gets it?
Any individual undergoing treatments such as
an ureteroscopy for kidney, gall or urinary
bladder stone management or urinary
diversion is at a greater risk for developing a
ureteral stricture.
What causes it?
Ureteral strictures may be caused by external
trauma or develop after treatment for another
condition. Ureteral strictures may be
inflammatory due to gonorrhea, tuberculous
urethritis, or schistosomiasis, or as a rare
complication of cancer.
Nonanastomotic ureteral strictures may
develop after stone impaction or upper
urinary tract endoscopy, as well as following
pelvic radiation therapy and a variety of open
and laparoscopic surgical procedures or other
trauma.
Anastomotic ureteral strictures may develop
as a result of a urinary diversion surgery.
What are the symptoms?
Symptoms of ureteral strictures are pain or
difficulty urinating, a weak stream, splaying
of the urinary stream, urinary retention, and
urinary tract infection. A doctor may be able
Follow-up care for a patient undergoing
or a tumor.
How is it diagnosed?
A doctor may perform a urethroscopy to
reveal the degree of narrowing of the urethra.
The patient may also undergo another
procedure, retrograde urethrogram, to
determine the site and degree of stricture.
Additional tests may be needed to
differentiate a bladder outlet obstruction due
to prostatism, impacted urethral stones,
urethral foreign bodies and tumors. If tumors
are present, the doctor will conduct additional
tests to determine if they are malignant
(cancerous) or benignant (non-cancerous).
What is the treatment?
There are a variety of minimally invasive
treatments for patients with ureteral
strictures. A doctor may perform balloon
dilation as a first step in treatment,
particularly in patients who have
nonanastomotic strictures.
For ureteral strictures that do not respond
favorably to dilation alone, endoscopic
incision is the procedure of choice for most
patients. Endoscopic incision of the stricture
can be performed or a laser may be used with
a rigid or flexible ureteroscope. A stent may
be left in place to keep the ducts open for
approximately 6 weeks.
Finally, newer techniques called are now
available that may allow for long-term relief
of a ureteral stricture if other techniques are
unsuccessful.
Self-care tips
treatment for a ureteral stricture may include
imaging testing such as renal ultrasound, IVP,
or renal scintigraphy two to four weeks after
the stent is removed.
If the patient is asymptomatic, imaging is
performed again at three months and then at
six-month intervals for the first two years
following treatment. Most ureteral stricture
recurrences are identified within the first year
after surgery.
Definition, causes and risk factors
The ureters are tubes that normally carry
urine from the kidneys to the bladder. A
ureteral stricture is a narrowing of the ureter
that results in an obstruction in the flow of
urine.
Strictures can have several origins:
They may develop after treatment for another
urologic condition. Individuals who have
undergone ureteroscopic or percutaneous
kidney treatment for stones or tumors, pelvic
radiation therapy or urinary diversion surgery
may develop ureteral strictures. After these
procedures, scar tissue may obstruct the
ureter.
Other surgeries in the vicinity of the ureters
can cause stricture formation, such as
gynecologic or vascular surgery procedures.
Strictures may occur after passage of kidney
stones or as a result of certain cancers.
External traumatic injury can cause strictures.
In children, congenital anomalies may result
in strictures (meaning that the anomaly is
present at birth).
Symptoms and diagnosis
Symptoms of ureteral strictures can include
flank and/or abdominal pain, nausea,
vomiting, fever, infection, or sometimes an
overall sensation of not feeling well.
Because ureteral strictures can have a
number of causes, your doctor will ask about
your medical history and may perform a
variety of diagnostic tests to rule out different
causes. Your doctor may visualize the
stricture using X-rays, ureteroscopy,
retrograde pyelogram or nephrostogram,
ultrasound, CT scan, or MRI.
If your doctor determines that a tumor might
be present, additional tests may be required
to determine if it is malignant or benign.
Treatment
After determining the cause and location of
your ureteral stricture, we will develop an
individualized treatment strategy. At NYU
Urology Associates, we focus on minimally
invasive treatments for ureteral strictures
whenever possible.
For strictures that develop shortly after
external injury or after surgical injury, surgery
may be the first choice of treatment. During
surgery, your doctor will remove scar tissue
and may surgically reconstruct your ureter in
a different location and reconnect it to the
kidney. Surgery may be open, laparoscopic or
robotic. If the stricture is extensive, then
tissue from another part of the body, such as
the small intestine, may be used to help
reconstruct the ureter.
For less severe or chronic strictures,
endoscopy may be recommended. Here, a
flexible tube is passed through the urethral
opening and threaded up through the bladder
into the ureters. The doctor then uses
specialized surgical instruments or lasers to
cut through the blockage. In some cases, a
balloon may be used to dilate the ureter. A
stent (a hollow tube) may be inserted to keep
the ureter open after treatment for several
weeks.
Because an obstructed ureter may lead to
fluid retention in the kidneys
(hydronephrosis), your doctor may need to
drain the fluid through a procedure known as
percutaneous nephrostomy, in which a needle
is inserted through the back into the kidney
to drain excess urine. A ureteral stent may
also be put in place; this device can help
drain urine directly from the kidney to the
bladder, bypassing the point of obstruction or
stricture.
Contraindications
The major contraindication to ureteral
stricture surgery (endoscopic or open) is an
active and untreated urinary tract infection. A
relative contraindication is uncorrected
bleeding diathesis.
When ureteral stricture surgery (endoscopic
or open) is contemplated, many patient
factors should be considered.
If the patient has a terminal malignancy, is
extremely elderly, or has a high surgical risk
and tolerates internal stenting well, long-term
stenting may be most appropriate. Chung et
al analyzed 101 patients with extrinsic
ureteral obstruction managed with indwelling
ureteral stents.4 Within 1 year, the stents
failed in 41% of the patients. Thirty percent of
patients needed percutaneous nephrostomy
tube placement at a mean of 40 days.
Predictors of stent failure included cancer, a
baseline creatinine level of greater than 1.3
mg/dL, and poststent systemic treatment.
If the affected kidney has less than 25% renal
function, balloon dilation and
endoureterotomy are more likely to fail.2
Therefore, the patient is at significant risk for
eventually requiring open surgery or
nephrectomy. Few data exist on the outcomes
of open surgery based on preoperative renal
function. Renal function may significantly
improve in some patients with poor function
due to obstruction after the obstruction is
corrected. If the renal function is less than
10%, recovery is unlikely and initial
nephrectomy may be most appropriate.
Relevant Anatomy
The ureter is a muscular tube lined by
transitional epithelium that courses from the
renal pelvis to the bladder in the
retroperitoneum.
The length of the ureter is 20-30 cm,
depending on the individual's height. The
lumen size is 4-10 mm in circumference,
depending on its location. The narrowest
areas include the UPJ, the overpass by the
ureter where it crosses over the bifurcation of
the iliac arteries, and the ureterovesical
junction (UVJ).
In both men and women, the ureter courses
posterior to the gonadal vessels and anterior
to the iliopsoas muscles, crosses the common
iliac artery and vein, and enters inferiorly into
the pelvis. In men, the vas deferens loops
anterior to the ureter, prior to the ureter
entering the bladder. In women, the ureter
courses posterior to the uterine arteries
(hence, the "water under the bridge" analogy)
and close to the uterine cervix prior to
reaching the intramural bladder.
The ureteral blood supply is provided from
multiple sources. Superiorly, branches from
the renal and gonadal arteries may
contribute. As the ureter courses through the
retroperitoneum, the aorta contributes
numerous small branches. In the pelvis, the
iliac, vesical, uterine, and hemorrhoidal
arteries also contribute to the ureteral blood
supply.
Indications
Indications for intervention include pain,
infection, or obstruction, which may threaten
a patient's renal function. Less common
indications may include stone formation
proximal to an obstruction or hematuria.
Pathophysiology
Ureteral strictures are typically due to
ischemia, resulting in fibrosis. Wolf and
colleagues define a stricture as ischemic
when it follows open surgery or radiation
therapy, whereas the stricture is considered
nonischemic if it is caused by spontaneous
stone passage or a congenital abnormality.2
Less commonly, the etiology is mechanical,
such as from a poorly placed permanent
suture or surgical clip.
Pathologic analysis of the strictures reveals
disordered collagen deposition, fibrosis, and
varying levels of inflammation, depending on
factors such as etiology and interval since the
causative insult.
The resulting ureteral obstruction may vary
widely from mild, causing only asymptomatic
proximal ureteral dilation and hydronephrosis,
to severe, causing complete obstruction and
subsequent loss of renal function.
Some patients are asymptomatic; others are
symptomatic only during periods of diuresis
or develop severe renal colic. The degree of
symptoms correlates poorly with the degree
of obstruction; at times, severe obstruction is
asymptomatic or silent. Renal failure and
azotemia may be due to bilateral strictures,
such as in cases of bilateral ureteroenteric
strictures, external compression due to
retroperitoneal malignancy, or retroperitoneal
fibrosis; recovery depends on the duration of
ureteral obstruction.
Ureteral strictures may be classified as
extrinsic or intrinsic, benign or malignant, and
iatrogenic or noniatrogenic.
Extrinsic malignant strictures include those
caused by primary or metastatic cancer.
Primary pelvic malignancies, particularly
cancers of the cervix, prostate, bladder, and
colon, frequently cause extrinsic compression
of the distal ureter. Retroperitoneal
lymphadenopathy, caused by a wide range of
malignancies, particularly lymphoma,
testicular carcinoma, breast, or prostate
cancer, may cause proximal to midureteral
obstruction.
Extrinsic benign compression due to
idiopathic retroperitoneal fibrosis may also
cause unilateral or bilateral ureteral
obstruction, leading to azotemia.
Transitional cell carcinoma (TCC) may cause
malignant intrinsic obstruction.
Malignant ureteral obstruction is
differentiated from benign ureteral
obstruction by (1) the presence of an extrinsic
mass on a CT scan or songram and (2) the
appearance of the ureter on contrast-study
images.
Ureteral TCC may manifest as ureteral
obstruction. Ureteral TCCs typically have an
irregular mucosal pattern and are associated
with dilatation of the ureter below the lesion
(goblet sign). Benign strictures are usually
smooth, without distal dilatation. In some
cases, biopsy may be required to differentiate
benign from malignant strictures. Biopsy
samples can usually be collected
ureteroscopically or with a fluoroscopically
directed ureteral brush. Ureteral tumors can
also be diagnosed during transureteral
resection of the tumor with specialized
ureteral resectoscopes.
Benign intrinsic strictures, which are the focus
of this article, may be congenital (eg,
congenital obstructing megaureter),
iatrogenic, or noniatrogenic (eg, those that
follow passage of calculi or chronic
inflammatory ureteral involvement [eg,
tuberculous and schistosomiasis]).
What Is It?
Thyroidectomy is the surgical removal of the
thyroid gland. This important gland, located in
the lower front portion of the neck, produces
thyroid hormone, which regulates the body's
production of energy. A healthy thyroid gland
is shaped like a butterfly, with right and left
lobes connected by a bridge called the
thyroid isthmus. Depending on the reason for
a thyroidectomy, all or part of the thyroid
gland will be removed. The various types of
thyroidectomy include:
Partial thyroid lobectomy (a rare procedure) ?
Only part of one thyroid lobe is removed.
Thyroid lobectomy — All of one thyroid lobe is
removed.
Thyroid lobectomy with isthmusectomy ? All
of one thyroid lobe is removed, together with
the thyroid isthmus.
Subtotal thyroidectomy — One thyroid lobe,
the isthmus and part of the second lobe are
removed.
Total thyroidectomy — The entire thyroid
gland is removed.
A thyroidectomy may be performed by using
a conventional surgical approach or a newer
endoscopic method done through very small
incisions.
What It's Used For
Conventional thyroidectomy is done for the
following reasons:
To remove malignant (cancerous) thyroid
tumors
To treat thyroid storm, a condition in which an
overactive thyroid gland produces extremely
high levels of thyroid hormone that cannot be
easily controlled
To remove all or part of a goiter (an enlarged
thyroid gland) that is pressing on neighboring
structures in the neck, especially if this
pressure interferes with swallowing or
breathing
To remove and evaluate a thyroid nodule that
on biopsy has had repeated "indeterminate"
readings
In some people, as an alternative to a
conventional thyroidectomy, an endoscopic
thyroidectomy can be done to remove small
thyroid cysts or small benign thyroid nodules
(less than 4 centimeters, or about 1? inches).
Endoscopic thyroidectomy is not used to treat
multiple thyroid nodules, thyroid cancer or
thyrotoxicosis.
Preparation
About one week before surgery, you will be
told to stop taking aspirin and other blood-
thinning medications. To reduce the risk of
vomiting during surgery, you will be told not
to eat or drink anything after midnight the
night before surgery. As part of the general
preparations for surgery, your doctor will
review your allergies and your medical and
surgical histories. If you may be pregnant,
you must tell your doctor before surgery.
Because you will be having a procedure that
involves an area above your shoulders, you
will be asked to remove all necklaces and
earrings before you are taken to the
operating room.
How It's Done
Both types of thyroidectomy are usually done
under general anesthesia. However, if general
anesthesia is too risky for a patient, local or
regional anesthesia may be used to permit
the patient to remain awake during the
procedure. An intravenous (IV) line will be
inserted into one of your veins to deliver
fluids and medications.
Conventional thyroidectomy ? In a
conventional thyroidectomy, a 3- to 4-inch
incision will be made through the skin in the
low collar area of your neck (the lower front
portion of your neck, above the collarbones
and breast bone). Next, a vertical cut will be
made through the strap-like muscles located
just below the skin, and these muscles will be
spread aside to reveal the thyroid gland and
other deeper structures. Then, all or part of
your thyroid gland will be cut free from
surrounding tissues and removed. During the
entire procedure, the surgeon will be very
careful to preserve your parathyroid glands
(two pairs of small glands located near the
thyroid) and to avoid damaging important
nerves and blood vessels in your neck. After
your thyroid gland is removed, one or two
stitches will be used to bring your neck
muscles together again. Then the deeper
layer of your incision will be closed with
stitches, and your skin will be closed with
sterile paper tapes. A small suction catheter
(tube) will be inserted near the area of your
incision to drain any blood accumulated
inside your neck. Following surgery, you will
be taken to a recovery room, where you will
be monitored for several hours until you are
stable enough to return to your hospital room.
After about 24 hours, the suction catheter will
be removed from your neck. Most patients go
home one or two days after the surgery.
Endoscopic thyroidectomy ? A viewing
instrument called an endoscope and small
surgical instruments will be inserted into your
neck through three or four small incisions.
Each incision is about 3 millimeters to 5
millimeters long (less than ? inch). Then the
surgeon will use a tiny camera on the
endoscope to guide the instruments and
remove your thyroid tissue. At the end of the
procedure, your neck incisions will be closed
with tiny stitches or surgical tape.
Follow-Up
About one week after you return home from
the hospital, you will visit your doctor for
follow-up. At this visit, your doctor will check
the healing of your incision or incisions. After
thyroid surgery, you may need periodic blood
tests to measure your thyroid hormone levels.
Calcium and phosphorus levels are checked
to evaluate the function of your parathyroid
glands, which sometimes are damaged during
thyroid surgery. If all of your thyroid gland
was removed, you can expect to take thyroid
supplements for the rest of your life. You will
have more pain after surgery if you had a
conventional thyroidectomy than if you had
an endoscopic thyroidectomy. However, most
patients are not good candidates for
endoscopic thyroidectomy because of the
type or extent of their thyroid disease.
Risks
Thyroidectomy is generally a safe surgical
procedure. However, some people have major
or minor complications. Possible
complications include:
Hemorrhage (bleeding) beneath the neck
wound ? If this occurs, the wound bulges and
the neck swells, possibly compressing
structures inside the neck and interfering with
breathing. This is an emergency.
Thyroid storm ? If a thyroidectomy is done to
treat a very overactive gland (thyrotoxicosis),
there may be a surge of thyroid hormones
into the blood. This is a very rare
complication because medications are given
before surgery to prevent this problem.
Injury to the recurrent laryngeal nerve ?
Because this nerve supplies the vocal cords,
injury can lead to vocal cord paralysis and
can produce a husky voice, either short term
or long term. In rare cases, if both vocal cords
are paralyzed, the opening of the throat may
be obstructed, causing breathing problems.
Injury to a portion of the superior laryngeal
nerve ? If this occurs, patients who sing may
not be able to hit high notes, and the voice
may lose some projection.
Hypoparathyroidism ? If the parathyroid
glands are mistakenly removed or
unintentionally damaged during a
thyroidectomy, the patient may suffer from
hypoparathyroidism, a condition in which the
levels of parathyroid hormone (a hormone
that helps regulate body calcium) are
abnormally low.
Wound infection
ow Your Thyroid Works
"A delicate Feedback Mechanism"
Your thyroid gland is a
small gland, normally
weighing less than one
ounce, located in the front
of the neck. It is made up
of two halves, called
lobes, that lie along the
windpipe (trachea) and
are joined together by a
narrow band of thyroid
tissue, known as the isthmus.
The thyroid is situated just below your
"Adams apple" or larynx. During development
(inside the womb) the thyroid gland
originates in the back of the tongue, but it
normally migrates to the front of the neck
before birth. Sometimes it fails to migrate
properly and is located high in the neck or
even in the back of the tongue (lingual
thyroid) This is very rare. At other times it
may migrate too far and ends up in the chest
(this is also rare).
The function of the thyroid gland is to take
iodine, found in many foods, and convert it
into thyroid hormones: thyroxine (T4) and
triiodothyronine (T3). Thyroid cells are the
only cells in the body which can absorb
iodine. These cells combine iodine and the
amino acid tyrosine to make T3 and T4. T3
and T4 are then released into the blood
stream and are transported throughout the
body where they control metabolism
(conversion of oxygen and calories to
energy). Every cell in the body depends upon
thyroid hormones for regulation of their
metabolism. The normal thyroid gland
produces about 80% T4 and about 20% T3,
however, T3 possesses about four times the
hormone "strength" as T4.
The thyroid gland is
under the control of
the pituitary gland, a
small gland the size
of a peanut at the
base of the brain
(shown here in
orange). When the
level of thyroid
hormones (T3 & T4)
drops too low, the
pituitary gland
produces Thyroid Stimulating Hormone (TSH)
which stimulates the thyroid gland to produce
more hormones. Under the influence of TSH,
the thyroid will manufacture and secrete T3
and T4 thereby raising their blood levels. The
pituitary senses this and responds by
decreasing its TSH production. One can
imagine the thyroid gland as a furnace and
the pituitary gland as the thermostat. Thyroid
hormones are like heat. When the heat gets
back to the thermostat, it turns the
thermostat off. As the room cools (the thyroid
hormone levels drop), the thermostat turns
back on (TSH increases) and the furnace
produces more heat (thyroid hormones).
The pituitary gland itself is regulated by
another gland, known as the hypothalamus
(shown in our picture in light blue). The
hypothalamus is part of the brain and
produces TSH Releasing Hormone (TRH)
which tells the pituitary gland to stimulate the
thyroid gland (release TSH). One might
imagine the hypothalamus as the person who
regulates the thermostat since it tells the
pituitary gland at what level the thyroid
should be set.
The thyroid hormones, thyroxine (T4) and
triiodothyronine (T3), are tyrosine-based
hormones produced by the thyroid gland. An
important component in the synthesis of
thyroid hormones is iodine. The major form of
thyroid hormone in the blood is thyroxine (T4)