Posted by CLDing on February 25, 1998 at 10:10:21:
In Reply to: Re: Radiation Cystitis and Stones posted by C S Loh on February 25, 1998 at 00:52:18:
Certainly my clinical impression was was supravesical obstruction, possible causes are
those that you mentioned. When I scoped her, there was just no 'bladder' just a thimble
size cavity - if you have scoped such patients before you will know what I mean. There was
no question of stenting at all. Tumour recurrence of course is not on the cards
considering that she had been disease free for more than 10 years. Angiosarcoma maybe.
Coming to the question of oedema, irradiation cystitis is an ongoing process just like all
irradiated tissues go through, often throughout the life of the patient. This is
especially so in the female bladder because of the presumed unfortunately short urethra of
female c.f. the male and the dirty vagina next to the dirty anus!! You know what I mean.
They get cystitis and when they get cystitis they get and acute inflammation with all its
rubor, tumour, calor, dolor and functio laesa. It is interesting, though sometimes
exasperating to look after this group of patients. As I said in my lecture to the trainees
on difficult bladder bleeding. When they have cystitis and bleeding, it is not the best
time to assess bladder capacity in such patients as the oedema can reduce the capacity
tremendously. I have seen 30 cc bladders in the inflammatory phase going up to 250 cc when
things settle down. Do you get my point of oedema now?
The other interesting group of patients with irradiation damage to the pelvis presents
with recurrent lower limb oedema starting in the upper thigh, and associated with genital
oedema and oedema of the lower abdominal wall, all due to fibrosis of the lymphatics. A
burst of steroids does wonders for them. Irradiation injury is an interesting pathology.
New vessels form and sometimes just break down with the slightest trauma or even
spontaneously and this can cause a vicious cycle to start.
Coming to tuberculous ureteric strictures - I will be delighted if you can show me a paper
which shows successful treatment of established ureteric tuberculous strictures with
dilatation/ureterotomy and stenting. I do not think it works at all except for the time
the stent is in! I have reconstructed after stenting has been done by some of our
exuberant endourologist who do not believe that a transmural ureteric stricture is not
treatable that way in the long run. Steroids in tuberculous stricture is a measure of the
desperate but it has been tried and claimed to work at times. Personally I watch these
narrowing closely. My observation of this problem is that the ureteric injuries will
extend from the most proximal point of involvement, so that what is distal to the most
proximal point of tuberculous stricturing is more often than not involved with disease,
and the kidney is usually very badly involved as well in such cases. To me the option is
usually between a nephroureterectomy or a reimplantation
with a Boari flap i.e. if the bladder has not strictured off. In a few cases I had to
resort to ileocecal augmentation cystoplasty and implantation of the ureter/s into the
ileal end. Please try to change my mind by finding someone who has successfully treated
established tuberculous ureteric strictures endoscopically!!