414 J Pak Med Assoc Original Article Tubercular ureteric strictures Maneesh Sinha, K. N. Chacko, N. S. Kekre, Ganesh Gopalakrishnan Department of Urology, Christian Medical College, Vellore, India. Abstract Objective: To review the presentation of tubercular ureteric strictures and assesses the role of balloon dilatation and open surgical repair in their management. Methods: This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clinical presentation and compare the results of balloon dilatation with open surgical repair. Success was defined as adequate drainage on imaging, no worsening of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. The long term success rates were compared using the t-test for proportion. Results: Of 73 strictures, 88% had lower urinary tract symptoms. Genital abnormalities suggestive of tubercu- losis was observed in 40% male patients. Urine examination yielded aseptic pyuria in 85%, positive AFB smears in 36% and positive AFB cultures in 32%. A small capacity bladder and non-functioning renal units were the only consistent findings on intravenous urogram. Nephrectomy was performed in 37% cases due to non salvageable kidneys at presentation. The success rate of stenting fell from 93% on immediate follow up to 59% on a follow- up of 12 months. At 90% success rates on a follow-up of 7 months open surgical repair was superior (p 0.03). Long term success following balloon dilatation in renal units with good function was 78% compared to 25% for poorly functioning units. (p= 0.01) Conclusion: Open surgical repair is superior to balloon dilatation in the management of tubercular ureteric stric- tures. Renal function may predict the success of balloon dilatation (JPMA 55:414;2005). Introduction Tubercular ureteric strictures can pose dilemmas in diagnosis as well as management. 1,2 A review of the clinical presentation and results of standard clinical tests for the diagnosis of tubercular strictures revealed Balloon dilata- tion to be a safe and convenient method of management of these strictures. 3 Does this convenience justify a minimally invasive approach? How durable are it's success rates in comparison to open surgical reconstruction? Is there a sub- set of patients who may fare better than others with balloon dilatation? All these questions need an answer. This study attempts to analyze the various treatment options for tuber- cular ureteric strictures. Patients and methods This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clini- cal presentation and compare the results of balloon dilata- tion and DJ stenting with that of open surgical repair. Confirmation of tuberculosis was based on urinary smears for acid fast bacilli, urinary cultures or positive histopathol- ogy. The short and long term results of balloon dilatation and stenting were compared to that of open surgical repair. The standard procedure for balloon dilatation involved inflation with a 5 cm long 15F balloon using a uromax high pressure microvasive balloon at 14 atmospheres with the dilatation being carried out for 2 minutes. After ensuring the disappearance of waisting, the balloon was kept inflated for another 2 minutes. A 6F polyurethane stent was left in place for 6 weeks. The patients were managed under the guidance of a single consultant, who made the decision to dilate or perform open surgery. Stenting was considered for solitary, partial strictures less than 1cm long. Multiple or complete strictures; and strictures longer than 1cm underwent open repair. All patients had an imaging study (DTPA renogram or IVU) within 7 to 10 days following stent removal. Short term success was defined as adequate drainage noted during imaging. Those who had at least one imaging study a mini- mum of 3 months after stent removal were included as patients with a long term follow up. Success in this group was defined as adequate drainage on imaging, no worsen- ing of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. Patients were subdivided on the basis of a DTPA renogram into those with (>30%) and those with poor (<30%) function and the results of balloon dilatation were assessed in these two groups. Patients who were lost to fol- low up were excluded while calculating long term success rates. The long term success rates were compared using the t-test for proportion. Results There were 73 tubercular strictures in 38 males and 35 females. Their ages ranged between 11 and 62 years. At presentation, 88% had lower urinary tract symptoms, 23% flank pain, 36% haematuria, 10% weight loss and 40% of