A Study of Ureteric stricture in genitourinary tuberculosis

INTRODUCTION: Genitourinary Tuberculosis continues to be a significant clinical problem because of its nonspecific clinical presentation and variable radiological appearance. Nearly 15 to 20% of all new cases of Tuberculosis involve sites outside of the lung, and approximately 30% of cases of extra pulmonary Tuberculosis involve the urogenital tract, therefore Genitourinary Tuberculosis makes approximately 5% of all cases of Tuberculosis. The genitourinary tract is the second most common site for tuberculous infection after the lungs. The infection almost always affects the kidneys during the primary exposure to infection but does not manifest clinically. Hence, the study of ureteric stricture due to genitourinary tuberculosis may throw a light into this complex problem, and better understanding of the disease and management. AIM OF THE STUDY: 1. To estimate the prevalence of ureteric involvement in Genitourinary Tuberculosis in the population served by this hospital. 2. To discuss the various modes of presentations of ureteric involvement in Genitourinary Tuberculosis. 3. To determine the significance of relevant laboratory investigations in the diagnosis. 4. To compare the efficacy of various therapeutic modalities adapted. 5. To asses the impact on morbidity and mortality of Genitourinary tuberculosis. 6. To draw diagnostic and therapeutic protocols for systematic approach towards a case of Ureteric Tuberculosis. MATERIALS AND METHODS Over a period of 3 years from June 2003 to August 2005, in Our Department of Urology, Government Royapettah Hospital & Kilpauk Medical College Hospital, we have received and treated 46 cases of genitourinary tuberculosis coming from various parts of Tamil Nadu and Andra Pradesh. Patients suspected to have Genitourinary Tuberculosis were investigated with following investigations, 1. Haematocrit, 2. Total and Differential WBC Count, 3. ESR, 4. Urine investigations like albumin,sugar,deposits, 5. Three days preferably five early morning urine for AFB-smear and culture, 6. Renal parameters, 7. Ultrasound KUB, 8. Intravenous Urogram, 9. X-ray Chest, 10. Endoscopy and if necessary biopsy, 11. Antegrade studies in relevant cases. Patients diagnosed with Genitourinary tuberculosis were analysed into 1. Percentage of patients with ureteric involvement, 2. Male, Female sex ratio, 3. Presentation in various age group, 4. Various modes of clinical presentation, 5. Investigations, 6. Level of stricture involvement in the ureter, 7. Urgent treatments like DJ Stenting or PCN, 8. Medical management alone, 9. Medical management with various surgical management, 10. Role of our management in salvaging the kidney function. Patients were classified into those presenting with obstructive uropathy and without obstruction. Those presenting bladder involvement without obstructive uropathy were investigated and Antituberculous drug treatment was started. OBSERVATION: In this prospective study, over a period of 3 years from June-2003 to August-2005,cases diagnosed as GUTB were analysed Total number of cases of GUTB - 46 ( 54.3% ), Ureteric Stricture cases in GUTB - 21 (45.7%). CONCLUSION: The complication of tuberculous ureteric stricture in this population remains common and complicated. The incidence is still very high. The clinical manifestations are polymorphous, and the renal function deterioration rate is quite high. The accurate assessment is sometimes difficult because of nonvisualised system in IVU. However, a fairly confident diagnosis can be made in most instances with clinical correlation. Despite our recent efforts of supervising the patients and refining the treatment modalities, including the interventional endoscopy, our overall outcome of treatment appears modest and unsatisfactory. The socio-economic conditions may play an important role in final outcome. Genitourinary tuberculosis is a manifestation of systemic tuberculosis. The anti-tuberculous campaigns of the society need emphasis. Beware of the WHO's warning: the tuberculosis is returning