Fall 2012 - 08.pdf 725Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L 1Department of Urology, Chhatrapati Shahuji Ma- haraj Medical University, Formerly, King George Medical University, Luc- know, India 2Welcome Trust Center for Human Genetics, Univer- sity of Oxford, Oxford, UK Apul Goel,1 Anuj Goel,1 Diwakar Dalela2 Redefining Needs for Better Follow-Up in Urinary Tuberculosis Corresponding Author: Apul Goel, MS (Surg); MCh (Urol); DNB (Urol); MNAMS Department of Urology, Chhatrapati Shahuji Ma- haraj Medical University, Formerly, King George Medical University, Luc- know, 226003, India Tel: +91 983 918 1465 E-mail: goelapul1@rediff mail.com Received January 2011 Accepted March 2011 CASE REPORT Keywords: tuberculosis, urogenital, prevalence, diagnosis, ureter INTRODUCTION G enitourinary tuberculosis (GUTB) is an uncommon form of tuberculosis, and its preva- lence has shown a declining trend.(1) Tuberculous ureteral involvement is a serious problem with possible grave consequence if not detected and treated timely. Therefore, frequent intravenous urographies (IVU) are recommended both during the initial phase when anti-tuberculous treatment (ATT) is started(1) and even after the completion of therapy.(2) There is paucity in recent literature about the real behavior of ureteral involvement with the advent describe a case of GUTB, where ureteral stricture and small capacity urinary bladder developed after 1-year of completion of treatment. This case re-emphasizes the need for long-term follow-up of these cases. CASE REPORT A 40-year-old man with hematuria, dysuria, and frequency was diagnosed as GUTB on the basis of microbiologic evidences. An IVU at that time revealed bilateral normal kidneys with a round bladder and mildly dilated right lower ureter (Figure 1). There was no evidence of an immunocom- He was put on standard 9-month ATT, namely rifampicin, isoniazid, ethambutol, and pyrazina- mide. Thereafter, the patient’s symptoms, especially hematuria and dysuria, improved. An IVU done at completion of treatment revealed mild right-sided hydroureteronephrosis (Figure 2). Urine - 726 | Case Report Figure 1. Initial intravenous urogram shows normal kidneys, right lower ureteral dilation, and a round bladder. Figure 3. Intravenous urogram after 1-year of completed treat- ment shows right non-visualized kidney with small capacity irregularly scarred bladder. Figure 2. Intravenous urogram at completion of therapy shows mild right-sided hydroureteronephrosis with a round bladder and thick walls. Figure 4. Antegrade study (nephrostogram) revealed a long right lower ureteral stricture. 727Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Evolution of Genitourinary Tuberculosis | Goel et al cating cure of infection. The options of either double J stent placement or close follow-up was discussed. However, at this stage, the patient was lost to follow-up and presented after 1 year with frequency of micturition. Intravenous urogram now revealed right-sided non-visual- ized kidney with irregularly contracted bladder (Figure 3). Antegrade study revealed a long lower ureteral stricture (Fig- ure 4) while radionuclide renal scan showed 20% differential renal function. Augmentation cystoplasty with ileal replace- - brosis only. Tissue culture from the bladder wall for acid fast bacilli was not done at this time. At 2-year of follow-up, the patient is asymptomatic with stable disease (Figures 5 and 6). DISCUSSION The recommended follow-up protocol, regardless of the manifestation of GUTB, is evaluation at 3, 6, and 12 months after the course of chemotherapy.(2) During these visits, liver function tests, three early-morning urine specimens, and an IVU should be performed to ensure patency of the urinary Figure 5. Intravenous urogram 1-year after augmentation cysto- plasty and replacement of the lower ureter with ileum showing some degree of return of function of the right kidney. Figure 6. Micturating cystourethrogram showing the augment- ed bladder with bilateral vesicoureteral reflux. 728 | REFERENCES 1. McAleer SJ, Johnson CW, Johnson WD. Tuberculosis and parasitic and fungal infections of the genitourinary system. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. Vol 1. 9 ed. Philadelphia: Saun- ders Elsevier; 2007:436-70. 2. Johnson CW, Lowe FC, Johnson Jr WD. Genitourinary Tuber- culosis. In: Ball Jr TP, Marshall FF, eds. AUA Update Series. Vol 22. Houston, Texas: American Urological Association Inc.; 2003:303-7. 3. Shin KY, Park HJ, Lee JJ, Park HY, Woo YN, Lee TY. Role of early endourologic management of tuberculous ureteral stric- tures. J Endourol. 2002;16:755-8. 4. Goel A, Dalela D. Options in the management of tubercu- lous ureteric stricture. Indian J Urol. 2008;24:376-81. 5. Horne NW, Tulloch WS. Conservative management of renal tuberculosis. Br J Urol. 1975;47:481-7. 6. Gow JG. Results of treatment in a large series of cases of genito-urinary tuberculosis and the changing pattern of the disease. Br J Urol. 1970;42:647-55. 7. Prasad K, Singh MB. Corticosteroids for managing tu- berculous meningitis. Cochrane Database Syst Rev. 2008CD002244. tract.(2) If disease progression or stricture formation is seen, endourological management at an early stage may be more effective and also prevent renal loss.(3,4) Although such an intensive follow-up is recommended, there is a paucity of recent literature where deterioration has been documented on serial follow-up after completion of treat- especially in underdeveloped countries. Therefore, emphasis - plained to the patient.(4) This case highlights the dilemma faced by urologists in the treatment of tuberculous ureteral infection both at the time of starting treatment and also after apparently adequate and successful treatment in resource-poor situations. Obviously, completion of ATT; thus, underscoring the importance of prolonged follow-up even after successful treatment. Timely detection of ureteral involvement could have prevented renal deterioration; however, the patient may still need surgery for small contracted bladder. Another option, although not ac- cepted as standard, could have been the use of steroids during the initial period.(5-7) CONFLICT OF INTEREST None declared. Case Report