SIMULTANEOUS BOARI FLAP AND URETEROCALYCOSTOMY IN A CASE OF GUTB

A 38 year old lady presented to us with lower urinary tract symptoms and right flank pain for 15 days.She had history of undergoing left nephrectomy in 2002.The histopathological evaluation had shown granulomatous nephritis.After the surgery; she was advised scrupulous follow-up but she could not regularly visit the surgeon.On presentation to our hospital; she had deranged creatinine(2.7 mg%) with sonographic evidence of right moderate hydroureteronephrosis. Non contrast CT scan evaluation confirmed the sonographic findings.She was taken up for retrograde pyelography and stenting. The findings on RGP were hydroureteronephrosis with a stricture at pelvi-ureteric junction.The bladder capacity was small around 90 ml.She was subjected to bladder biopsy.

She underwent silicon stenting(Cook) and on follow up she had improvement of renal function to 1.7 mg%.
She underwent AKT for a period of 18 months.In the interim period she had undergone stent exchanges twice; finally she opted for reconstructive option.
This time her cystoscopic capacity was surprisingly good (around 200 ml; we suppose the initial low capacity must be because of concomitant cystitis.)But her RGP revealed additional lower ureteric stricture.

LONG SEGMENT PUJ STRICTURE

She was taken up for exploration; the pelvis was intrarenal. We didnot wish to dissect inside the renal hilum for fear of injury to the hilar vessels as this was the only kidney.
We found a thinned out parenchyma at the anterior calyceal region of the inferior pole.We made a nephrotomy there and the renal capsule and the inner mucosa were tagged in view of preventing future ureterocalycostomy closure/stenosis.

INFERIOR CALYCEAL NEPHROTOMY 

 We dissected the ureter and widely spatulated it and anastomosed to the calycotomy with 3-0 vicryl sticthes with intervening stent.

The bladder was then distended and a Boari flap was raised and tubularised over a 10 Number infant Feeding tube.This was then suture to the healthy ureter excising the lower segment of the ureter (stricture part) 

BOARI FLAP FROM THE BLADDER

GUTB: A REVIEW


Genitourinary tuberculosis is hematogeneous infection of the kidneys. The kidney being a primary organ the rest of the organs are affected by direct extension. The disease progression depends upon the host immune response.
The urologist many a times consider the GUTB as the diagnosis of exclusion. Any longstanding lower urinary tract symptoms with obvious cause detected makes the urologist suspicious about the disease.
Recurrent UTIs, frequency, dysuria, painless hematuria, painful ejaculation, anejaculation etc are the predominant symptoms.
Pathology: Tuberculosis results in development of Caseating granulomas - Langhans giant cells surrounded by lymphocytes and fibroblasts. The course of the infection depends on the virulence of the organism and the resistance of the host.
The healing process results in fibrous tissue and calcium salts being deposited, producing the classic calcified lesion. The disease because of fibrotic/calcific nature results in development of strictures,deformed calyces,small capacity bladder(so called thimble bladder).The irony of the treatment is that the starting of the antiKochs medications results in further fibrosis.This can lead to further narrowing of the strictures and / or further decrease in bladder capacity.
Small capacity bladder, nonfunctioning kidney, multiple ureteric strictures etc are the manifestations of the GUTB as in our case.