ureteric stone with non functioning kidney

• 11 Mar 2020 11:24:37 PM
• |Endo Urology

32/f has h/o right flank pain, dull aching, intermittent, since 1 month.

Comments(15)

• 

  Pankaj N Maheshwari

  12 Mar 2020 01:35:17 AM

  Hi

  How is the cortical thickness on USG?

  I would surely get a DTPA renogram done after the infection is treated.

  Patient is young and all attempt should be done to salvage this kidney

• 

  Ashish parikh

  12 Mar 2020 07:18:51 AM

  Sir, 

  Here I sent some images , not able to upload the image

  Pl ignore the image of stent in situ

  Thanks

  
  

  

• 

  Dr. Anil Takvani

  12 Mar 2020 07:59:02 AM

  I will prefer to put PCN first.

  Best possible decompression.

  Best possible functional recovery.

  PCN output will give best idea of renal function by quantitative and qualitative methods.

  DTPA post decompression.

  Stone management depends on functional recovery of renal unit podt PCN...

  Thanks

• 

  Sarman Ranavaya

  12 Mar 2020 07:59:06 AM

  On Behalf of Dr. Ashish Parikh Sir

  

• 

  Utsav Shah

  12 Mar 2020 08:06:54 PM

  It’s true that the Rt kidney has no excretion even at 24 hours. But at this stage, I totally agree with Anil sir. 

  
  

  PCN —> Measure urine output —> Stabilize patient —> Nuclear imaging —> Decision to preserve unit 

  
  

  Not doing a DTPA and posting the patient for nephrectomy based on a contrast imaging is very very risky and may become an issue in court of law. 

  For a pyonephrotic kidney, PCN should be preferred to drain the thick pus. Also, stenting will hinder with DTPA result. Hence PCN shud be done 

• 

  Ashish parikh

  13 Mar 2020 10:12:09 PM

  Thank you everyone

  PCN was kept. Pt discharged. With drain output 250-300/day.

  Will update on follow up

  Thanks

  Ashish

• 

  JG Lalmalani

  17 Mar 2020 04:03:03 PM

  Would straightaway do a URS and deal with the stone and place the DJ. Routinely do these cases on day care.

  Wonder what the discussion is all about.

  
  

• 

  Rahul Kapoor

  17 Mar 2020 06:27:01 PM

  No contrast seen on IVP is common. 

  We cant say its non functioning, its just a non excretory at this point. 

  I agree with Pankaj sir USG is very important... size of kidney, cortical thickness, pyonephrosis.

  
  

  One thing is these cases with large upper ureteric calculi are very good cases for Laparoscopic ureterolitiotomy... and one with laparoscopic inclination should try... 

  In case of pyonephrosis, situation changes completely. If serum creatinine is high, TLC or pt. Is having fever. Then i will do PCN and plan accordingly.. 

  
  

• 

  Dr. Anil Takvani

  17 Mar 2020 07:04:24 PM

  Rahul, 

  please take notice of USG report posted by Dr. Ashish Parikh

  

• 

  Rahul Kapoor

  17 Mar 2020 11:47:55 PM

  I missed USG report. 

  What Anil sir and Dr Utsav suggest is right way to proceed

• 

  Haresh G Thummar

  27 Mar 2020 04:58:08 PM

  Interesting case and very interesting discussion by experts.

  This kind of cases are still common in Indian scenario( compare to western world)

  What I can think,

  1. Assessment of functional status of kidney - can be done with 

       (1) IVU - non exertion RK( not accurate in 2020

        (2) PCN and assess spit GFR & UOP

    (3) DTPA renal scan - if done properly good objective assessment 

    (4) indirect evidences like chronicity of symptoms, cortical thickness, CM differentiation, status of sepsis abd so on 

  
  

  2. Reversibility of function - based on age, CMD, USG finding Paranchyma , proteinutia, duration & degree of obstruction and comorbidities 

  
  

  Based on these two,

  Priority is to control infection ( pyonrphrosis) with PCN or Dj( I would prefer PCN here, (though Margaret pearl from Texas USA, studied PCN VS DJ stent for this kind of Pt’s and found no difference 2014)

  
  

  Try to Correct all possible correctable factors 

  
  

  Assess GFR & UOP in PCN

  
  

  DTPA renal scan , maybe after 2-3 weeks to explain Pt abd relatives about prognosis and plan ( Nephrectomy decision is a major psychological trauma to Pt and family that we should understand very well)

  
  

  If it shows good function( I would save even its 10%) go for antegrade flush and retrograde URS Tech 

  
  

  Make sure urine is sterile  before intervention 

  
  

  Best of luck 

  
  

  Best regards 

  
  

  Dr Haresh Thummar 

• 

  Haresh G Thummar

  27 Mar 2020 05:00:25 PM

  One more thing, Title should be Ureteric stone with non excreting kidney (rather than non functional kidney)

  
  

  Both are different and has implication in further discussion and management 

• 

  Prabir Basu

  27 Mar 2020 08:41:42 PM

  Young female, no comorbidities, not in sepsis, afebrile , not an alarming TC, negative cs ,usg noncontributory for frank pyonephrosis , maybe IVP done during acute colic - shall go ahead with URS pneumatic under preoperative antibiotic coverage. Stone not that dense, female ureter - may get lucky just to fragment only / retro migrate and escape with a DJ. If alls well will need stent removal later under anesthesia for fragments.

  However, need to counsel for an open ureterolithotomy SOS and evaluation of renal function later. Also needs counselling regarding post procedure urosepsis.

  Rgds.

• 

  Ashish Rawandale Patil

  30 Mar 2020 05:28:36 PM

  It may be a good idea to ask the sonologist for the parenchymal thickness and then do dtpa if required .nephrectomy after a PCN at times may become sticky procedure. 

• 

  Haresh G Thummar

  01 Apr 2020 09:13:39 AM

  One more thing, Title should be Ureteric stone with non excreting kidney (rather than non functional kidney)

  
  

  Both are different and has implication in further discussion and management