Very interesting case.
The question is what caused this structure?
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?
a lot for the interesting case.
us break this down piece by piece.
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
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
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.
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.