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TUBERCULOSIS STRICTURE OF PELVI —URETERIC JUNCTION IN SOLITARY KIDNEY
HG Motiwala**
Senior Registrar, Department of Urology, Institute of Postgraduate Studies and Research, BJ Medical College, Civil Hospital, Ahmedabad : 380 016.
Occurrence of tuberculous stricture at pelvi-ureteric junction (PUJ) in a solitary kidney with acute renal failure is described here. Patient had associated pulmonary tuberculosis with effusion. The case was successfully managed by Foley-Y plasty (stented) and postoperative antikoch’s therapy consisted of rifampicin/isoniazid/pyrazinamide and ethambutol.INTRODUCTION
Most of the causes of PUJ obstruction are congenital but from time to time urologist will come across cases of secondary PUJ obstruction related to surgery, infection or trauma. It is estimated that 20% of PUJ obstructions are acquired and secondary to postoperative or traumatic inflammatory fibrosis.[1] It is being rare for tuberculosis to give rise to a stricture at the PUJ, but some cases have been described.[2]
CASE REPORT
35 year old male patient was admitted in the Department with acute renal failure of sudden onset with complete anuria. On clinical examination, nothing found positive except decreased air-entry at right base of lung. On admission his BUN and serum creatinine were 110 mg/dl and 10.2 mg/dl respectively. His haemogram was normal, ESR was raised to 75 mm/hour. Urine microscopy revealed plenty of pus cells and few RBCs. Plain X-ray KUB revealed nothing abnormal. X-ray chest showed right pleural effusion. Urine culture showed no organisms. Ultrasonography detected absent left kidney and solitary kidney on right side with gross hydronephrosis with dilated pelvis. Emergency peritoneal dialysis was carried out with view to anuria. Emergency percutaneous nephrostomy was planned but patient started passing the urine through indwelling catheter. Nephrostomy was deferred in view of spontaneous recovery of acute renal failure. The report of urine for AFB was positive. Patient was kept on antituberculous drugs consisted of rifampicin 450 mg, isoniazid 300 mg, ethambutol 800 mg and pyrazinamide 750 mg twice a day. BUN and serum creatinine returned to normal within 7 days and with anti koch’s treatment of 10 days, right sided pleural effusion disappeared. Follow up ultrasonography showed regression in the size and changes in hydronephrosis but pelvis was found to be dilated with PUJ stricture. Intravenous pyelography was carried out which showed no excretion of dye on leftside with delayed function on right side with changes of hydronephrosis and pelvi-ureteric stricture causing obstruction. Patient was taken for surgery and stented Foley Y plasty was done successfully. Double J Stent was removed after 3 weeks. Postoperative IV U showed good result in terms of good renal function and correction of PUJ obstruction.
DISCUSSION
The incidence of genito-urinary tuberculosis has markedly decreased in the West but the situation is not altered much in developing countries. Tuberculosis affects many sites in uro-genital system. Ureteral strictures are one of the common presentations but the common site of ureteric stricture is at the uretero vesical junction, but they also occur at the pelviureteric junction, rarely in the middle third of ureter and very occasionally the whole ureter is stenosed, fibrotic and even calcified.[3] James Gow in his entire experience of genito-urinary tuberculosis has seen only 8 cases of PUJ stricture caused by tuberculosis.[3] The reason for spontaneous resolution of ARF in our case could be due to decreased oedema and inflammation at stricture site at PUJ. Should the patient wait for spontaneous recovery of PUJ obstruction with long term AKT? The answer is crucial one and there is no study at present available to guide. Whitefield believed that spontaneous resolution of the obstruction during the course of treatment should not be anticipated and surgery needs to be undertaken as soon as the diagnosis is made, although surgery is more difficult than in the idiopathic cases.[2] Surgery was performed after 2 weeks of AKT and I have not taken any chance in this case having solitary kidney. Much more problem in Indian set up is to maintain regular and longterm follow up because many patients on AKT will be lost for follow up.
REFERENCES
1. Scardino PL. Uretero Pelvic Lesions in H Bergman (Ed.) ‘The Ureter’ : Harper and Row, publishers, New York. 1967; 21 : 508-26.
2. Whitefield HN. Pelvi ureteric junction obstruction in WF Hendry (Ed.), Textbook of Genitourinary Surgery; Churchil Livingstone, Edinburg. 1985; 1 (22) : 297-304.
3. James G Gow. Genitourinary tuberculosis in Walsh, Gittes, Perlmutter, Stamey (Editors) : Campbell’s Urology; WB Saunders, Philadelphia. 1986; 1 (23) : 1037-69.
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