Anuria

• 24 Feb 2020 10:02:14 AM
• |General Urology

Dear All

Comments(7)

• 

  Dr. Anil Takvani

  24 Feb 2020 01:29:21 PM

  Very interesting case.

  Gyanendra, can you please provide images of first NECT?

  On left side any attempt to look for or removal of lower ureteric stone was done?

  Was the stenting procedure completed smoothly?

  While removal of left stent check uretroscopy was done? 

  Thanks

• 

  Gyanendra Sharma

  24 Feb 2020 05:11:02 PM

  Dear Anil

  The images of First CT are not available with me

  The DJ stenting was smooth

  No URS was attempted during  DJ  removal as the CT showed no calculus

  Other than a smooth DJ stenting--No intervention done on Left Side

  Hence the cause of Stricture is difficult to explain & now its management is really challenging

  Also it is unusual to have a complete cut off at PUJ  which was the case on Right side initially

• 

  Dr. Anil Takvani

  24 Feb 2020 07:28:23 PM

  Thanks Gyanendra.

  Really very interesting, difficult to say what can be the cause or DD.

  My approach will be:

  I will attempt diagnostic as well as therapeutic ureteroscopy in this case.

  As stent was there for couple of weeks there want be any issue in reaching to the site of stenosis with rigid or flexible Ureteroscope. Will keep guide wire just little out from working channel while reaching to stenosed area. 

  Inspect the stenosed area carefully, if by chance some lesion; inflammatory or space occupying try to take biopsy.

  Passing guide wire further from stenosis part wan't be much difficult. Once the guide wire in, area can be dilated with balloon or can be cut with laser. Over the guide wire stent can be inserted and positioned. 

   

• 

  Gyanendra Sharma

  24 Feb 2020 09:03:56 PM

  The question is what caused this structure?

• 

  Ravindra Sabnis

  24 Feb 2020 09:31:24 PM

  You have mentioned that first NCCT showed mild HN & lower ureteric stone. Whether there was HN & HU also? USG /CT must clarify that. CT shows stone - means stone must be there Usually 4 mm stone causing anuria -means stricture in ureter with edema - which will result in anuria. But DJ went easily which means edema with stone likely cause of anuria. Was RGP done on left side? 

  Present situation, cut off is often misleading. It may be again due to intense edema. Was NCCT done on second time? 

  As Dr Takwani suggested, re Dj is to be attempted & it will be successful - either antegrade or retrograde 

  There is unlikely to be stricture at PUJ. Cut off is likely to be due to edema, kink. Once PCN in situ - it will all subside & DJ shoudl be successful. 

• 

  Dr Prashant Mulawkar

  25 Feb 2020 11:33:49 AM

  Dear Gyanendra,

  Thanks a lot for the interesting case.

  Let us break this down piece by piece.

  Is he diabetic?

  It is quite rare to have complete cut off at UPJ after DJ stenting alone. There must be something else

   

  What is this something else?

  1.     GW going submucosally at the time of stenting. This can happen at the site of stone impaction but is not expected at the UPJ when stone was in lower ureter.

  2.     Secondary UPJ obstruction due

  a.     Stone (??)

  b.     Infection, inflammation

  c.      Trauma (?)

  d.     Retroperitoneal fibrosis (Just listed here to complete the list)

  3.     Primary UPJ obstruction which has manifested just now, seems quite rare

   

  What can be done?

  1.     A gentle ureteroscopy just to see how is the mucosa

  2.     Attempt at left DJ stenting: an important step which give us some breathing time and an insight on the probable cause. I have a feeling that re-stenting is likwely to be possible

  3.     A contrast CT to see if there is any fibrosis around the UPJ to judge if we are expecting difficulty during pyeloplasty and we may have to resort to ureterocalicostomy

  4.     If we have to resort to pyeloplasty, histopathology of the stenotic segment

   

  What I will not do?

  1.     Endopyelotomy: antegrade or retrograde

  2.     Balloon dilatation (I do not believe in this procedure)

  3.     Laparoscopic repair (as I am not an expert. But if some expert is doing it, I do not have an objection) I am aware that it is the new gold standard

   

  What about the “missing” data

  1.     The CT scan centres (even in Government setups) have a back ups of the DICOM files and if requested, they usually provide it

  2.     It is always better to see the CT sequence on your PC rather than to read radiologist’s report.

   

  Few suggestions:

  While posting on public for a, it is better to avoid exact dates. That becomes an identifying criteria. It is better to say D1, D2, D3 etc.

   

  Thanks

   

  Prashant

   

   

   

• 

  Pankaj N Maheshwari

  27 Feb 2020 06:18:54 PM

  Dear Gyanendra,

  A very interesting case.

  Exact cause of obstruction is very difficult to guess.

  I agree that inadvertent submucosal guide wire or submucosal stent placement can happen but such anomalous placements happen at site of impaction. Even if the wire or stent goes submucosal, that should not cause stricture.

  Surely this obstruction at UPJ is neither congenital not is stone or treatment related.  

  In our country we should always keep the possibility of GU Kochs. Especially as this was an impassable narrowing, Kochs stricture is possible although there are probably no other signs of GU Kochs (Your cystoscopy did not reveal anything i presume).

  I would wait with nephrostomy draining, let creatinine settle and then reassess.

  As now this is a solitary functioning kidney, we need to be more cautious and definitive. Nephrostogram with RGP would help me decide my further plan. Would keep all options open. 

  please keep us posted with the follow-up

  Thanks