GUTB

• 22 Feb 2020 07:15:15 PM
• |General Urology

Indications of Stenting in GUTB ? 

Comments(4)

• 

  Ashish parikh

  22 Feb 2020 07:58:53 PM

  Indication of stenting

  A) after dilatation of ureteric structure - stent are retained for a long to stabilize the stricture-prevent further worsening of stricture by acting as a splint

  B) maintain drainage during medical therapy as to prevent stenosis/stricture.

  C) puj obstruction - initial phase of ATT

  We generally do stenting immediately during start of ATT

  No role of steroid in GUTB

  
  

• 

  Dr. Anil Takvani

  23 Feb 2020 08:53:17 AM

  It depends on at what stage of disease patient presents and how bad is the involvement of kidney, ureter and bladder.

  1. Early disease when there is mild HN , early stenting at the time of starting ATT.

  2. In patients with late presentation, DJ insertion indicated in those with; ureteric stricture is short , passable with a functioning unit (>25% split function), reasonable bladder capacity. If condition of renal units worse then mentioned double j stents are not going to serve the purpose and patients may require some short of reconstructive procedure/procedures depends on extent of disease.

  Stent need to be kept for a period of 6 to 12 months time till the strictures stabilizes. 

  Success rate with stenting and ATT is around 50%, so periodic check up evaluation is very much necessary.

  Role of steroid is controversial. May be in early acute disease with ATT to reduce inflammation and edema to reduce chances of stricture formation but in late disease with already dense stricture there is no role of steroids.

  
  

• 

  Dr. Anil Takvani

  23 Feb 2020 11:00:15 AM

  Looking at posted images :

  Start ATT 

  Cystoscopy,  bladder wall biopsy 

  RGP 

  Attempt at stenting 

  If stent don't go,  PCN + ATT 

  RGP or Antegrade study from PCN will help in deciding appropriate reconstruction if stent don't not go or stent fails to serve the purpose... 

  Thanks 

• 

  Venugopal P

  25 Feb 2020 06:47:20 PM

  Dear All,

  I place a Ureteral stent early enough when obstructive features are noted on US or other radiological evaluation. Ureteral stenting of sorts was practiced even in 1960’s. In India, as per my knowledge goes, It was Prof. Roy Chally who introduced Ureteral stenting. Those days we did not have ureteral stent as is available now. We used to place Infant feeding tube into the ureter and hope that it will remain without migrating. In difficult situations where such a tube was difficult to be negotiated, Roy used to even open the ureter and place the tube. Such Informations are historical and no one practices them anymore.

  Not all Ureteral narrowing are due to stricture formation. In many instances, the lesion in the ureter is in its early manifestation where only the mucosa is involved and the muscle being spared till then. This mucosal involvement and the accompanying inflammatory oedema will cause blockage to the free flow of urine down the ureter. A real stricture of Ureter is produced only when the muscle layers are also involved. This differentiation has therapeutic implications. When the disease is confined to the mucosa only, the medical treatment that is instituted can stop further progress of disease and can result in healing without much fibrosis and thus preventing from forming stricture. Ramnathan and M Bhandari (1998) found that that DJ stenting is successful in 41% of cases. Once the muscle layers are involved, the ureter gets fibrosed and the ensuing stricture cannot be eliminated on medical Therapy. Stenting is performed only to prevent renal deterioration due to Strictured Ureter but it will most often restricture once the stent is removed. Hence close monitoring will have to be made when stent removal is done after a period of medication.

  We are taught that Urinary TB produces multiple strictures and mostly in the lower third of Ureter. There was a teaching in the yore that a single stricture of the ureter and not in the lower third may not be Tubercular. This I find not correct as I have seen solitary strictures of the ureter and in some they were not in the lower third.

  In the past, we used Streptomycin, INAH and PAH as the treatment. The duration of treatment was prolonged. Today we have replaced it with modern AKT and it is given for a shorter period. The present treatment is more effective no doubt. But it will heal the ureter by more fibrosis and denser strictures as against Streptomycin.

  There are some who use Steroids, hopefully with a view that it may reduce the stricture formation. The role of steroids to prevent ureteral strictures in Urinary TB has remained controversial even now.

  These are some of my views and it may not be acceptable to many in the present generation.

  With warm regards,

  Venu