Forgotten ureteric stent:Avoidable condition

In urology stents have a special place.In almost all cases pertaining to endourology; stent placement is usually assorted to.The stent less surgery is gaining momentum but majority of the urologist including the ones in our centre are very comfortable with stented surgery.The stents have its own complications like stent related pain,dysuria,UTI etc in the immediate post-operative period.But if the stent is kept inadvertently for longer period then stent encrustation,stone formation,stent fragmentation can alos occur.Most of the cases the forgotten stent is due to poor compliance.But still the treating urologist needs to be proactive in pursuing such cases.Stent registry is a good concept as it is practically impossible to follow up each and every patient without systematic dedicated registry services.

Forgotten stents are dealt on the merit of each case.The intervention can be open surgery,URS,PCNL,Cystolithotripsy superadded with the ESWL.With the advent of LASER; almost all the cases can be dealt with endourology.

A 47 year old patient came to us with prior history of stone disease treated with ESWL and stenting 4 years back.She was suffering from recurrent UTIs.She was investigated and we saw a forgotten stent with stone formation at the both ends.She is planned for LASER cystolithotripsy and LASER URS and stent retrieval from below after cutting it at the level of the pelvi-ureteric junction.Then followed by PCNL for the partial staghorn calculus formed at the upper end of the calculus.

GENITO-URINARY TRACT TUBERCULOSIS

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 advsied 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.

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.
We therefore usually add steroids in initial management to prevent further compromise of the renal functions.
In the present case the disease had already taken a toll of left kidney.(hematogeneous route).The rest of the disease was probably because of direct extension( small bladder capacity and multiple ureteric strictures).
The treatment in our case was –stenting to safeguard the kidney function by stenting,bladder biopsy for getting final histopathological proof.The next strategy would be starting her on AKT and steroids and keep stent for 3-6 months period.Any recurrent stricture/persistence of thimbe bladder would need specific surgery.

Recurrent ovarian cyst causing left ureteric obstruction

A 40 year old lady presented with history of left flank pain of 15 days duration.There was recent exaggeration of the pain intensity.There was no history of fever,dysuria and lower urinary tract symptoms.She gave history of having been operated for ovarian cyst 3 months back.The histopathological report of the cyst was benign.

The biochemical and hematological parameters were normal.CA-125 antigen assay was also normal.The urine analysis didnot reveal any abnormality.The USG abdomen showed left hydroureteronephrosis with cyst in pelvis.The ureter could be traced only to the cyst region.She was subjected to Contrast Enhance CT scan which showed cyst compressing the ureter causing hydroureteronephrosis.

She underwent RGP and DJ stenting followed by aspiration of the cyst under USG guidance.The cytology of the aspirated cyst was essentially normal.Two weeks post-operatively the patient is doing well.We have planned a repeat CT scan after a period of 6 weeks and decide further management.Any recurrence of the cyst would then need laparotomy with cyst removal.

Complication after ileal conduit done for urinary diversion post radical cystectomy

A 65-year-old lady underwent radical cystectomy for TCC bladder 1 year back.The surgery was uneventful.The mode of diversion was ileal conduit.The post-operative histopathology read as TCC T2N0.In the post-operative follow up she had recurrent UTIs and at the end of 1 year post-op her creatinine was around 2.3 mg%.

The imaging showed no local or systemic recurrence and the upper tracts showed changes of hydroureteronephrosis.The EC scan done to reveal the pattern of drainage didnot reveal any prolonged stagnation above uretero-ileal junction.During one such episode of UTI;we decided to put the catheter in the conduit for better drainage and then we realised that there was difficulty in catheterisation because of kinking at parietes.

We perfomed dynamic contrast study under fluoroscopic guidance; it showed adequate draiange.

With every episode of UTI she usually used to get elevated RFTs and the same used to settle down after the institution of the antibiotics and the conduit catheterisation.

We revised the stoma and the conduit was released from the parietes thinking that that would relieve the blockage but it didnot.After the stomal revision also she landed up again in UTI.

We went ahead and did percutaneous nephrostomy for her on both sides for the raised creatinine and the urosepsis.After the PCN her came down and got stabilised at 1.8 mg% and also she was free from UTI for 2 months period.The patient is still on bilateral indwelling PCNs and we are planning to go ahead with nephrostogram.If the nephrostomgram reveals any stagnation then the revision of the uretro-ileal junction will be needed.

The case was brought up here to discuss the long term complication of ileal conduit.The deterioration of kidney function,recurrent urosepsis,stomal complications are possible complications of ileal conduit diversion.

RIRS: Retrograde Intra-renal Surgery ensures complete clearance of renal stone

In this case stenting and ESWL had left one residual fragment in the renal pelvis.



OUR RIRS URETEROSCOPE
In our hospitals;we routinely prestent the patient during ESWL. The reasons being two; one that stenting facilitates the passage of calculus fragments and at the same time safeguards kidney from any obstructive complications. Secondly in the event if the ESWL fails then RIRS during the stent removal can ensure complete clearance.RIRS in presented patient is comparatively easier task as the ureter is dilated and placement of ureteric access sheath becomes easier task.
Review of literature:
In RIRS; a fibre-optic tube is inserted through the urethral meatus into the kidney after passing it through bladder and the ureter. The stone is visualized and is thereafter evaporated by a laser probe. We have a 20 W Holmium LASER(Sphinx). The procedure is usually done under general or spinal anesthesia. Retrograde Intrarenal Surgery (RIRS) allows the surgeon to do surgery inside the kidney without making an incision/ and hole on the body.
The indications for RIRS include:
· Failed previous treatment attempts of ESWL
· Strictures
· Tumors
· Stones in children
· Patients with bleeding disorders
· Patients with gross obesity/KYPHOSCOLIOSIS etc

We combine the two modalities of ESWL and RIRS routinely in all patients and give 100% success rate after the procedure for all patients. The combination of these modalities ensure elimination of the need for more invasive procedures like PCNL.This is a special boon for patients having physical deformities like obesity or kyphosis.