Transcript Surgical Therapy

Urologic Tuberculosis
Xu Ha
Department of Urology, Tongji Hospital
Tuberculosis (TB)
Pathogen
Infected
— Mycobacterium tuberculosis
— one third of world's population
Organism
— lung first, through bloodstream to other
Probability
Initial
— exposure, size, and infectivity
infection — most controlled and no clinical illness
Clinical
disease — multiplication of dormant bacilli
Genitourinary
TB
Account for 10% of
tuberculosis cases
Most 20 to 40 years old
Male VS female — 2:1
Very uncommon in children
Spread of organism to kidney
through blood
Other parts become involved
by direct extension
Pathologic Features
Kidney
Caseating granuloma
Caseous abscess
Fibrosis
Calcification
 Papillary necrosis
Calyceal stem or UPJ obstruction
Autonephrectomy
Caseating granuloma
Fibrosis
Caseous abscess, Fibrosis and Calcification
Pathologic Features
Ureter
Mucosa or submucosa tubercular nodule
Stricture formation
Granuloma
Fibrosis
Ureter with calcification and stricture
formation
Pathologic Features
Bladder
Ureteral orifice inflamed and edematous
Ureteral orifice obstruction
Tuberculous ulcers
Tuberculous inflammation
Bladder wall fibrosis and contraction
Acutely inflamed ureteric orifice Tuberculous bullous granulations
Acute tuberculous ulcer
Tuberculous golf-hole ureter
severely withdrawn
Healed tuberculous lesion
Acute tuberculous cystitis
with ulceration
Clinical Manifestations
The diagnosis of genitourinary TB should be
considered in a patient presenting with vague,
longstanding urinary symptoms for which there is
no obvious cause!
Clinical Manifestations
SPECIFIC - Genitourinary tract
Lower urinary tract – 50 to 80 %
Burning , frequency , urgency , urge incontinence
 Dysuria , hematuria
 Suprapubic pain / perineal discomfort
 Decreased stream , straining, ineffective voiding
 Slough in urine

Clinical Manifestations
Upper urinary tract symptoms


Pain - kidney and ureter region
Gross hematuria- 10 %
Genital – Male
 Hematospermia - 10 %
 Azoospermia
 S/S of chronic
epididymorchitis
Genital – Female
 Menstrual
irregularities
 Pelvic pain syndrome
 Infertility – 18 %
Clinical Manifestations
Other systems
 Respiratory
 Gastrointestinal
 Lymphoreticular
- 12 % patients
- 10 %
Constitutional - 10 to 15 %
Evening rise of temperature
 Weight loss
 Anorexia

Diagnosis
Laboratory
Urinalysis and Culture

Acidic urine , sterile pyuria , microscopic hematuria

Guide for further investigation, especially in pauci-
symptomatic patients

Fastidious / slow growth – difficult to culture – at least three,
but preferably five
Diagnosis
Laboratory
Purified Protein Derivative
(PPD, Tuberculin Test, Mantoux Test)

If Positive – supports the diagnosis

If Negative – can not exclude extrapulmonary TB

Response – HIV, Immunocompromised , Post-transplant pts
Diagnosis
Laboratory
Nucleic Acid Amplification (NAA) Testing—PCR

Multiple sample

Sensitivity from 87% to 95% (VS culture)

Specificity from 92% to 99.8% (VS culture)

Resistance mutations
Diagnosis
Radiography
Plain Radiograph
Positive findings up to
50% on chest radiograph
Calcifications in 30% to
50% case on KUB
Diagnosis
Radiography
Intravenous Urography (IVU)
Traditional gold standard tool
Replaced by CT in many institutions
Early signs: calyceal erosion and papillary irregularity
Most common: hydrocalycosis, hydronephrosis, orhydroureter
Diagnosis
Radiography
Intravenous Urography (IVU)— kidney
Calyx distortion
Calyx fibration
Calyx occlusion
Calyceal destruction
Parenchymal destruction
Diagnosis
Radiography
Intravenous Urography (IVU)— ureter
Dilatation above UVJ stricture
Rigid fibration
Multiple strictures
Diagnosis
Radiography
Intravenous Urography (IVU)— bladder
Small and contracted (thimble bladder)
 Irregular with filling defects
Asymmetry
Occluded calyx
Severe calyceal and
parenchymal destruction
Stricture at the distal left ureter
Contraction of the bladder left side
Diagnosis
Radiography
Computed Tomography (CT)
Three-dimensional reconstructed images
At least the equal of IVU in identification
Findings with not specific
Computed Tomography (CT)
Calyceal abnormalities
Hydronephrosis or
hydroureter
Autonephrectomy
Amputated infundibulum
 Urinary tract calcifications
Renal parenchymal cavities
Hydronephrotic in right kidney
End-stage nonfunctioning atrophic left
kidney with calcification.
Diagnosis
Endoscopy
Cystoscopy and Biopsy
Rarely indicated in diagnosis
Must under general anesthesia
Assessing the disease extent or the response to
chemotherapy
No Biopsy advised before medical therapy
Treatment
Successful treatment
Early diagnosis
Prompt initiation of adequate drug
Rest and nutrition
Urgical treatment for advanced cases
Treatment
Medical Treatment
Multidrug treatment
 Initial 6-month regimens of rifampicin, INH,
pyrazinamide, and ethambutol
Administered in one dose
Dosage, toxicity, drug interactions
Treatment
Antituberculous Drugs
Treatment
Antituberculous Drugs
Treatment
Surgical Therapy
Adjuvant to medical therapy
 Focus on organ preservation and reconstruction
At least 4 to 6 weeks medical therapy before
Excision of diseased tissue and reconstructive
Treatment
Surgical Therapy
Excision of diseased
Nephrectomy
 Partial Nephrectomy
Abscess Drainage
Treatment
Surgical Therapy
Indications for nephrectomy
A nonfunctioning kidney with or without calcification
Extensive disease involving the whole kidney, together with
hypertension and UPJ obstruction
Coexisting renal carcinoma
Treatment
Surgical Therapy
Reconstructive Surgery
Ureteral strictures
Augmentation cystoplasty
Urinary conduit diversion
Orthotopic neobladder
Summary
Part of general tuberculosis caused by
Mycobacterium tuberculosis
 Vague, longstanding urinary symptoms with no
obvious cause
 Urinalysis and culture and radiography for
diagnosis
 Basilic medical treatment
 Adjuvant surgical therapy
