The non-functioning kidney in renal tuberculosis

The authors have found a non-functioning kidney in 117 patients, constituting more than 24 per cent of 487 patients with bacteriologically and/or histologically confirmed renal tuberculosis, treated and followed up in the last ten years. In 2/3 of the patients with non-functioning kidney and renal tuberculosis, the conditions of non-functioning had been already present from the very beginning, at the time when renal tuberculosis was established. In the remaining 1/3 of the patients, one of the kidneys has ceased to function in the course of treatment. The authors found that the main cause for the failure of the kidney function in renal tuberculosis are strictures of the draining urinary pathways. Emphasis is laid upon the necessity of a careful observation of the patients with renal tuberculosis in the course of drug treatment in view of a timely detection and treatment of the strictures in the draining urinary pathways.     

Renal malposition in patients with omphalocele

We describe a boy with a history of omphalocele who presented with gross hematuria. Subsequent evaluation revealed a cephalad right kidney malposition and the hematuria was of lower tract origin. To investigate the frequency of this radiographic finding the medical records of 15 patients with omphalocele who presented between 1979 and 1985 were reviewed. Studies of the urinary tract were performed after omphalocele closure. Of 7 cases (46 per cent) with abnormal cephalad renal displacement the kidney was on the right side only in 3 and it was bilateral in 4. The omphalocele contents consisted of gastrointestinal tract only in 9 patients, and liver and gastrointestinal tract in 6. All 6 patients with omphaloceles that included the liver had cephalad renal displacement. One patient with small bowel alone in the omphalocele had right kidney displacement. Clinicians should be aware of this variation to avoid confusion and further unnecessary evaluation.     

肾结核诊治分析(附52例报告)

目的　探讨肾结核的临床表现及诊治方法。　方法　肾结核患者 5 2例 ,临床表现膀胱刺激征 36例 (6 9% ) ,腰痛伴肉眼血尿 10例 (19% ) ,肾绞痛及无痛性肉眼血尿各 6例 (11% )。 5 2例中B超提示肾结核 2 0例 ,单侧肾积水 2 2例 ;4 7例肾图示患肾无功能 31例 ;同期尿AFB和Tb PCR检查38例 ,尿AFB阳性 13例 (34% ) ,尿Tb PCR阳性 2 1例 (5 5 % )。误诊为结石或炎症 2 7例。药物治疗 12例 (2 3% ) ,手术治疗 4 0例 (77% )。　结果　 12例药物治疗者均痊愈。 4 0例手术后病理均诊断为肾结核 ,2 3例随访 1.5～ 5 .0年均治愈 ,发生输尿管残端综合征 5例。　结论　尿AFB和Tb PCR检查仍是术前确诊肾结核的主要手段。无功能结核肾切除同时应尽可能切除患侧输尿管。     

The urological manifestations of the acquired immunodeficiency syndrome

Between 1984 and March 1987, 120 patients with either the acquired immunodeficiency syndrome or its related complex seen at our hospital were studied retrospectively for urological signs and/or symptoms. Autopsy findings also were reviewed. Of the patients 84 per cent had no complaints referable to the urinary system, 2 per cent had gross hematuria (all with a negative diagnostic evaluation) and 14 per cent had urinary infections. We conclude that only a small percentage of patients with the acquired immunodeficiency syndrome suffer from significant urological manifestations and that a full urological evaluation of such patients generally is not warranted. If the patient presents with gross hematuria excretory urography should be performed if there is no infectious etiology, and cytoscopy should be performed only if the hematuria is life-threatening or prolonged and possibly to confirm significant urographic findings.     

Long-term followup of 103 patients with bladder exstrophy

We reviewed 103 patients with exstrophy of the bladder. Followup was more than 15 years in 51 patients. Initial management consisted of primary bladder closure in 32 patients and urinary diversion in 71. Urinary continence, renal function, urinary tract infections and development of malignant lesions were evaluated. Factors leading to success or failure were analyzed. Although the highest continence rate (83 per cent) was achieved in 40 patients with ureterosigmoidostomy, renal functional deterioration was highest in this group, with 70 per cent of the evaluable renal units being abnormal. Furthermore, 10 per cent of this group died of renal failure and 23 per cent lost 1 kidney each. In 26 patients with an ileal conduit 69 per cent of the renal units evaluated were abnormal. Only 1 patient died of renal failure but 27 per cent lost 1 kidney each. Of 32 patients with primary bladder closure 31 had preservation of renal function. Twelve of 18 patients (67 per cent) in whom vesical neck reconstruction had been completed had total urinary continence and 3 (17 per cent) had partial continence. The incidence of significant urinary tract infections was highest in the ureterosigmoidostomy group (63 per cent) and next to the highest in the ileal conduit group (48 per cent). Malignant lesions developed in 8 patients (8 per cent).     

Peripheral lymph node tuberculosis: a review of 80 cases

One hundred and ninety-two patients with peripheral lymphadenopathy were screened and 80 patients with tubercular lymphadenitis were studied. Their ages ranged from 1 to 65 years; most were younger than 30 years and there was a slight female preponderance (1.2:1). Seventy per cent of patients were of low socioeconomic status. Of the 80 patients, 56 had affected cervical nodes, seven had inguinal nodes, five had axillary nodes and 12 had multiple sites of lymph node involvement. All had enlarged nodes which were matted in 44 cases and discrete in 18 cases, while the rest had either an abscess or a discharging sinus. Fifty-nine cases (74 per cent) showed a positive Mantoux test and four cases (5 per cent) had associated pulmonary tuberculosis. Fine needle aspiration cytology gave a positive diagnosis in 66 cases (83 per cent). Fifty-two cases showed a positive culture for Mycobacterium tuberculosis of human type in Lowenstein-Jensen medium. Short-term chemotherapy (9 months) consisting of rifampicin, isoniazid and ethambutol gave an excellent result. Surgery was not required in any of the cases.     

Urinary cholesterol in cancer screening

Cholesterol determinations in morning urine samples were taken in 235 selected patients with a positive test for microscopic hematuria. Values ranged from 0.2 to 76.0 mg (median 5.5) in 23 patients with urologic malignancies and from 0.1 to 33.4 mg (median 1.1) in 38 patients with various benign diseases of the kidney or urogenital tract. In the 28 patients with urinary tract infections and 146 subjects without evidence of disorders of the kidney and the urogenital system, urinary cholesterol excretion was usually normal (0.1 to 1.9 mg; median 0.35). Using 1.0 mg urinary cholesterol per morning urine as a cutoff point, sensitivity for urologic carcinomas is about 80 per cent with a comparable high specificity of 90 per cent. Therefore, subsequent measurements of urinary cholesterol in populations with microscopic hematuria could define two groups, one with high prevalence and one with low prevalence of urologic malignancies. The less complicated colorimetric instead of gas-liquid chromatographic determination of urinary cholesterol can be recommended as a screening test for urologic carcinomas in populations with microscopic hematuria.     

Traumatic lesions of the kidney

Forty-five patients who had rupture of the kidney were studied. The majority of them were young adult males. Only those cases were considered in which the kidney was ruptured by external violence without penetration of the skin. The type of renal injury varied from slight subcapsular hemorrhage to complete pulpefaction of the kidney. In some cases the ureter or renal pedicle was completely avulsed. Hemorrhage, usually perirenal, but occasionally intraperitoneal, was uniformly present, and hematuria, either gross or microscopic, occurred in 95 per cent of the cases. Leakage of urine around the kidney was common. Serious associated injuries elsewhere in the body were present in 13.3 per cent of cases. Healing may occur satisfactorily with medical treatment, or on the other hand urinary fistulas, hydronephrosis, pseudohydronephrosis, pyelonephritis, or anatomic abnormalities of varying degrees may persist or develop. A history of trauma and hemorrhage and pain are cardinal points in the diagnosis, but they should also be substantiated by intravenous urography. In general, medical treatment immediately following the injury is preferred unless contraindicated. In certain cases in which patients are treated medically, subsequent operation may become necessary.The two deaths that occurred in this series of forty-five patients were attributed to severe extrarenal trauma. Thirty-one patients were followed for a period of from four to twenty-six years following injury. Eleven patients who underwent nephrectomy are entirely free of symptoms; 73.7 per cent of those treated medically are entirely well, and the remainder of this group have mild symptoms referable to the urinary tract.     

The diagnosis of renal tuberculosis

The incidence of renal tuberculosis is today less than in the past two decades due to the reduction in the incidence of other forms of tuberculosis. It has been fully established that renal tuberculosis is secondary to tuberculous infection elsewhere in the body and that the organism is carried to the kidneys by the blood stream in most instances.The question of bilateral involvement of both kidneys, at the outset, is not fully decided; however, the work of Medlar and Sasana demonstrated 88 per cent of their guinea-pigs to have bilateral renal lesions. Clinically, Braasch and Sutton were only able to demonstrate 291 cases (13 per cent) of bilateral involvement in a total of 2,200 cases of renal tuberculosis studied.The symptoms vary from nil to those of a very painful cystitis with later pain and tenderness in the kidney region. Occasionally, hematuria may be the first symptom. A deceptive feature in some cases is the occurrence of long remissions free of painful symptoms. No symptom or train of symptoms is pathognomonic of renal tuberculosis.The urinary findings give the most important evidence of the presence of renal tuberculosis. Pus cells are regularly found and red blood cells and albumin are usually present throughout the entire course of the disease. The acid fast bacillus is found on staining the centrifuged urinary sediment in a large percentage of the cases and guinea-pig inoculations are to be employed when the smears give no decisive results.The cystoscopic appearance of the bladder is quite characteristic. Two types of lesions exist: granulations and ulceration. The function of each kidney is to be determined as well as the microscopic contents in the urine of each kidney. The presence of a few organisms in the urine from one kidney in the absence of pus cells, red blood cells and albumin may represent a contamination in passing the ureteral catheter through an infected bladder.The pyelogram is of great value. A small defect may first direct the examiner's attention to the possibility of a tuberculous infection. Cortical necrosis is demonstrated when the lesion involves the renal papilla. The excretory urogram usually does not demonstrate early defects as well as the retrograde pyelogram. However, the excretory urogram is valuable in following the course of the disease and in demonstrating disproportion in the involvement of the kidneys.     

近期泌尿系统结核诊治体会(附36例报告)

目的提高泌尿系统结核的诊治水平。方法总结了３６例患者的诊治体会。结果尿路刺激症状和血尿为最常见症状，分别为７８％和３６％。２４小时尿抗酸杆菌和尿结核ＰＣＲ的阳性率分别为２５％和４０％，ＩＶＵ，逆行尿路造影及ＣＴ的诊断符合率分别为３８％，６３％和４４％。３３例患者接受了肾及部分输尿管切除术，肾上盏结核病灶清除术１例，对侧输尿管膀胱吻合术１例及肾穿刺造瘘术１例。１例患者并发血行播散型结核死亡。结论尿沉渣染色查抗酸杆菌仍应作为泌尿系结核诊断的主要方法，ＰＣＲ法在结核诊断的意义尚需较长时间的验证。ＩＶＵ和逆行尿路造影可作为泌尿系结核诊断首选的影像学检查，对两者不能明确诊断的，可选择磁共振水成像和ＣＴ检查。对肾及输尿管结核可不做输尿管全长切除。     

非典型肾结核45例诊治分析

目的：提高对非典型肾结核临床特点的认知及诊治水平。方法：回顾性分析1979年1月～2009年12月收治的45例非典型肾结核患者的临床资料：男24例,女21例,年龄19～61岁,平均38岁,其中20～50岁者38例,占84．4％。临床表现为尿频31例（68．9％）,肉眼或镜下血尿9例（20．0％）,尿常规不正常36例（80．0%）。15例（62．5％）男性患者曾诊为慢性前列腺炎,治疗1～3年无效,后诊为肾结核;7例伴有附睾结核,其中3例已在外院行附睾切除术。治疗前行尿路造影、CT和B超检查。9例采用异烟肼加利福平加乙胺丁醇药物治疗,疗程9～12个月;36例于抗结核治疗2、3周后行患肾切除术,4例加行附睾切除。结果：尿路造影、CT和B超诊断准确性分别为21．2％、100％和88．9％。36例手术治疗者全部治愈,9例药物治疗者中,5例在6～24个月复查时,患肾损坏严重,遂行肾切除。结论：非典型肾结核的膀胱刺激症状不明显,尿常规、B超、静脉肾盂造影是主要的检查方法,CT具有较大的诊断价值;外科手术仍是肾结核无功能肾的主要治疗手段。     

Congenital renal arteriovenous malformations

Congenital arteriovenous malformations are rare lesions of the kidney. We evaluated the clinical course of 15 patients with this lesion who were seen between 1950 and 1984. There were 9 women and 6 men, and the median age at diagnosis was 48 years. Patients presented most commonly with hematuria (93 per cent) or hypertension (53 per cent). Of the 15 patients 10 underwent nephrectomy because of gross hematuria or the perceived risk of significant bleeding, or in an effort to control hypertension. None of the 10 patients has required a further operation and those who were hypertensive preoperatively remained hypertensive postoperatively. The remaining 5 patients were treated conservatively, either with observation or antihypertensive medications. All 5 patients had microscopic hematuria and none has required further therapy. It would seem that neither microscopic hematuria nor controlled hypertension is an indication alone for nephrectomy.     

Intravesical doxorubicin for prophylaxis in the management of recurrent superficial bladder carcinoma

Intermittent intravesical doxorubicin chemotherapy was given to 27 patients with multiple recurrent superficial transitional cell carcinoma of the bladder, including 12 who had become refractory to intravesical thiotepa. The starting dose was 60 mg. doxorubicin diluted in 40 to 50 ml. normal saline solution and doses were increased to 90 mg. The duration of instillation was 60 minutes. Treatments were administered every 3 weeks for a total of 8 doses, then every 6 weeks for 2 doses and then every 12 weeks for 2 doses. Therapy then ended for patients who were rendered free of disease. Cystoscopy and urinary cytology studies were performed every 3 months throughout the study. Of the patients 30 per cent had intermittent episodes of dysuria, 26 per cent had urinary frequency, 41 per cent had hematuria and 15 per cent had bladder spasms. None of these toxicities required discontinuation of the drug. Analysis of plasma samples for doxorubicin and metabolites revealed no systemic absorption and there was no myelosuppression. Of the 27 patients 15 (56 per cent) have maintained complete eradication of bladder cancer without any evidence of residual carcinoma detected endoscopically or with urinary cytology. Recurrent disease developed in 9 patients (33 per cent) while on therapy, including 3 with muscle invasion. Cystoscopy has remained grossly negative in 3 patients who have had positive class 5 cytology studies. The median duration of followup in all patients has been 12 months, with a range of 6 to 24 months. We conclude that intravesical doxorubicin is tolerated well and is effective in the management of multiple recurrent superficial transitional cell carcinoma of the bladder.     

Microscopic hematuria after blunt trauma. Is pyelography necessary?

Hematuria after blunt abdominal trauma is common with multiple organ system injuries, and many trauma centers routinely perform intravenous pyelography (IVP) on all trauma patients having any degree of hematuria. However, it has been suggested that many IVPs could be avoided if more selective criteria were used. To help determine the need for an IVP, we reviewed the records of 102 consecutive patients undergoing IVP after blunt abdominal trauma over a 17-month period. Twenty-six (25%) patients had gross hematuria. Of these, seven (27%) had abnormal IVPs, and two (7.7%) of those required urologic surgery. Seventy-six (75%) patients had microscopic hematuria. Of these, one (1.3%) had an abnormal IVP but required no urologic surgery. Thus, if IVP had been performed only when gross hematuria was present, then all surgically significant urinary tract lesions would have been recognized, and 75 per cent of these 102 patients would have been spared IVPs. We agree with others that microscopic hematuria alone is not an indication for emergency IVP in these trauma patients. However, gross hematuria or other strong clinical evidence of renal injury still mandates IVP early during the assessment of patients who have suffered blunt abdominal trauma.     

Carcinoma of the prostate: local control with external beam radiation therapy.

Local clinical control of the primary disease was evaluated in 209 patients with stage C adenocarcinoma of the prostate treated with definitive external beam radiation therapy and followed for a minimum of 2 years. Of these patients 92 per cent required no further prostatic operations for obstruction. Prostatectomy before therapy did not necessarily prevent later prostatic obstruction from occurring. Of 129 patients who had only a needle biopsy before irradiation 90 per cent had improvement of the obstructive and/or irritative symptoms as tumor regression occurred with therapy and these patients did not require a later prostatic operation for obstruction. Stricture formation occurred in 8 per cent of the patients and was not influenced by the type of preirradiation prostatic operation done. If transurethral resection was reuqired after irradiation it was technically more difficult but the morbidity was acceptable. The incidence of hematuria and incontinence was far less than that reported in non-irradiated patients with this disease. Most tumors exhibited a down-grading effect after irradiation. There were no deaths attributable to the treatment. Over-all, 83 per cent of the 209 patients had no urinary complaints after completion of therapy. From a urological viewpoint, good clinical local control is achieved in the patient with stage C adenocarcinoma of the prostate treated with external beam radiation therapy.     

Detection and significance of microscopic hematuria in patients with blunt renal trauma

Detection of hematuria is paramount in establishing injury to the urinary system. In 339 patients with blunt renal trauma in whom radiographic studies defined the severity of injury we compared the degree of microscopic hematuria determined by dipstick and microscopic urinalysis. The overall correlation between the 2 methods was low (Pearson's coefficient 0.41). However, more than 80 per cent of the urine samples with 50 to 100 red blood cells per high power field corresponded to a dipstick result of 3+. The dipstick method had greater than 97.5 per cent sensitivity and specificity for detection of microscopic hematuria. Only 7 of the 339 patients (less than 2 per cent) had a discharge diagnosis of other than renal contusion: 5 had renal artery thrombosis or avulsion of the renal vessels and 2 had minor cortical lacerations that were managed nonoperatively. Although microscopic hematuria may be quantified more accurately by microscopic analysis, it can be detected reliably with a high degree of sensitivity and specificity by dipstick analysis.     

30例晚期肾结核患者诊断分析

目的：探讨晚期肾结核的发病原因及其诊断方法。方法：回顾性分析30例经病理学诊断的晚期肾结核患者的临床症状、实验室检查和影像学检查结果。结果：临床症状表现为膀胱刺激症状(90．00％)．血尿(66．67％)，腰痛(26．67％)。病程不超过半年者7例(23．33％)．其中5例患肾功能已丧失。实验室检查尿常规100％(30／30)结果异常．红细胞沉降率81．82％(18／22)异常升高．结核杆菌及其抗体检测阳性率偏低。静脉尿路造影57．14％(16／28)患侧不显影。B超检查均提示患肾积水、结构紊乱等改变。结论：肾结核临床症状不典型以及部分患者的早期隐匿无症状，是导致晚期肾结核发生的重要原因。肾结核的正确诊断首先有待于临床上对其临床特点及其不典型的变化趋势有足够的认识和警惕．其次是应对临床症状、实验室检查及影像学检查结果进行综合分析。     

Ureteral stenting during extracorporeal shock wave lithotripsy: help or hindrance?

We retrospectively reviewed the outcome of extracorporeal shock wave lithotripsy in patients with renal calculi less than 3 cm. in size who were treated at a large multi-user lithotripsy center. Patients in whom indwelling ureteral stents were placed before lithotripsy treatment were subjected to higher levels of total power (shocks times voltage), yet the rate free of stones did not differ from those treated without a stent. In addition, the patients with internal ureteral stents experienced a significantly higher incidence of urinary urgency (43 versus 25 per cent) and hematuria (40 versus 23 per cent) than nonstented patients, respectively (p less than 0.05). Also, the duration of bladder discomfort was longer for stented patients (26 versus 13 per cent) as was the duration of urinary frequency (31 versus 16 per cent), compared to nonstented patients (p less than 0.05). The results suggest that use of an indwelling ureteral stent may not contribute to a higher rate free of stones for the treatment of small to medium sized renal calculi and, in fact, it may make the treatment more uncomfortable for the patient than performing lithotripsy without ureteral stenting. Of course, in selected cases (solitary kidney, large stone burden and aid in stone localization) ureteral stenting has a useful adjunctive role in extracorporeal shock wave lithotripsy.     

Urinary tuberculosis: ten years' experience

In this study of 26 patients, clinical features diagnosed as urinary tuberculosis in our nephrology and urology clinics between 1993 and 2002 were investigated retrospectively. Fifteen patients (52%) were male, and mean age was 43.5 (18-71). Twenty percent of the patients were asymptomatic. Frequency-dysuria (46%), flank pain (33%), and macroscopic hematuria (12%) were presenting symptoms. Physical examination was not diagnostically helpful in most patients. Hematuria and/or pyuria were detected in 80% of the patients. Eleven patients had positive urine cultures of Mycobacterium tuberculosis (42%), and 7 patients had positive smears (25%). Definitive diagnosis of urinary tuberculosis was established microbiologically in 15 patients (58%) and histopathologically in 11 patients (42%). Tuberculin skin test was positive in 60% of the patients. Eight patients had an abnormal chest roentgenogram. Hydronephrosis (majority bilateral) in 11 patients (42%), contracted bladder in 9 patients (34.6%), and renal calcification in 6 patients (23%) were detected. Two patients also had genital tuberculosis (epididymoorchitis). Although only medical treatment was applied in 13 patients for 9 months, in the rest of the patients medical therapy plus surgical intervention was carried out. End-stage renal failure developed in one patient who died on hemodialysis. Renal functions had decreased moderately in two other patients. In conclusion, the diagnosis of urinary tuberculosis was able to be established after the obstructive complications and functional losses were developed in a fair number of cases. Surgical treatment was carried out in half the patients. Urinary tuberculosis should be taken into consideration because early diagnosis and treatment is very important for the presenting of irreversible sequelae.     

Clinical study of urothelial tumors of the upper urinary tract. 2: Primary ureteral tumors

Twenty-five primary ureteral tumors treated at our University between 1963 and 1981, were reviewed retrospectively. The conclusions of this study are as follows. Sex and age distribution of the patients were 18 males and 7 females (2.6: 1), and average age was 63.04 years old. The major symptom was hematuria. The majority of the patients were admitted to our clinic within 6 months from manifestation of symptoms. The major finding of IVP was non-functioning kidney. The positive rate of urinary cytology was 63.2%. Total nephroureterectomy with bladder cuff was performed in 21 out of 23 cases. Histologically, 22 cases were transitional cell carcinoma and one case was squamous cell carcinoma. Simultaneous urothelial tumor was found in 13 cases in the bladder. Most of the ureteral tumors (63.6%) were found in the lower third segment of the ureter. Subsequent urothelial tumors were seen in 3 bladders and one urethra out of 22 cases receiving surgical treatment in the follow-up period. The 5-year survival rate by actuarial method was 39.4%. Among several factors, grade and stage of tumor were the most influencing factors for prognosis. An effective method of post-operative treatment could not be established.