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[Hydronephrosis and hydroureter in paraplegia: clinical studies and treatments].

In the clinical course of the patients after spinal cord injuries, there are many inevitable complications such as urinary infection, stone formation, hydronephrosis and vesico-ureteral reflux. The incidence of dilatation of the upper urinary tract is high and its presence is one of the most critical cause of the progressive renal damage. We have studied the clinical states and the treatment of hydronephrosis and hydroureter in the paraplegics, which could be observed and followed-up at the Osaka Rosai Hospital. The dilatation of the upper tract was found in 33 cases (37 per cent) of 89 paraplegics. This state was more frequent in the lower motor neuron lesion than in the upper. Furthermore, the bladder dysfunction was not directly related to the combination of hydronephrosis. It was noted from the study by DIP of these paraplegic patients, that the contrast medium outlining the ureter often stopped a short distance above the bladder. This was quite similar to the "notch sign" named by Hutch. However, this change could be considered as the sign which appeared in the earlier stage of paraplegics, because it was shown on the excretory urogram and in the clinical stage before the dilatation or reflux was observed. We concluded that this phenomenon was the early manifestation of dysfunction of the U-V valve mechanism and named it "stop sign". In addition, from the result that the "stop sign" faded on emptying the bladder, it was concluded that the dilatation of the upper urinary tract in paraplegics was originated from the fixation of trigonal components resulted from fibrosis and hypertrophy of trigonal musculature. For putting out the fixation of ureteral orifices, we tried to cut the trigonal muscles and named this procedure "trigonal incision". By transurethral electrocutting of the trigone, the anatomico-physiological connection between the ureter and bladder was abrupted and the flow resistance at the intramural ureter was diminished, which was followed by an improvement of hydronephrosis. We have done the "trigonal incision" for the 12 paraplegics (14 times) with hydronephrosis, and it was effective in 59%. There are two clinical states of hydronephrosis in paraplegics in general; 1) by the stenosis at the bladder neck and sphincter and 2) by the functional and/or organic obstruction at the uretero-vesical junction. We studied these two states, and the importance of the most suitable treatment and followup examination for the individual paraplegic patient with dilatation of the upper urinary tract was emphasized in this paper.