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.     

Pseudotuberculous pyelonephritis associated with nephrolithiasis.

This report describes a 40-year-old man with an unusual form of granulomatous pyelonephritis, associated with nephrolithiasis, resulting in end-stage kidney disease and right pretransplant nephrectomy. The kidney specimen contained a staghorn calculus and showed chronic inflammation with confluent caseating granulomas and multinucleated giant cells, resembling renal tuberculosis. However, neither tubercle bacilli nor other microorganisms were demonstrated in the renal tissue or in urine cultures. Because these findings do not support a tuberculous etiology of the granulomatous pyelonephritis, we conclude that this patient had a pseudotuberculous reaction as a consequence of nephrolithiasis.     

结核性无功能肾的腹腔镜切除(附9例报告)

目的探讨后腹腔镜切除无功能结核肾的应用价值。方法我院2003年10月-2006年11月为9例肾结核行后腹腔镜下结核肾包膜外切除术。用超声刀游离肾脏与输尿管，Endo-GIA或Hem-o-10k阻断肾蒂，把肾放入肾袋后取出。结果9例均成功完成单纯肾切除。无一例中转开放手术，手术时间90—180min，平均110min。术中失血量20—200ml，平均94．4ml。术后住院时间3—8d，平均5．5d。术中1例肾包膜撕破造成少量干酪样脓液外渗，腹膜损伤1例。切口一期愈合。9例随访1—38个月，平均22个月，对侧肾功能正常。结论后腹腔镜结核肾切除术创伤小、出血少、恢复快，对于无功能结核肾是一种比较安全、可靠的手术方法。     

Persistent tuberculous cystitis: the most common indication for nephrectomy in the management of urogenital tuberculosis

There were 631 patients treated for proven urogenital tuberculosis in 1966-1985. Indications for nephrectomy were retrospectively analyzed in 137 (21.7%) patients operated. A badly damaged or functionless kidney was removed in 85 (62.0%) patients for the early control of persistent tuberculous cystitis; in 18 (13.1%) because of chronic, nonspecific urinary infection, dispersed calcifications with subsequent nephrolithiasis, pain or other discomfort; in 16 (11.7%) due to supposed nephrogenic hypertension, and in 3 (2.2%) because of extrarenal disease. In 15 (10.9%) patients the symptomless kidney was removed preventively. The management of renal tuberculosis by itself did not need nephrectomy.     

Meningeal tuberculosis and renal lithiasis. A case report

Urinary tuberculosis is frequent in Algeria. The discovery of the disease become difficult when one of the three criterium of the diagnostic does not allow a diagnosis of certitude. The authors reported the case of a 44 years-old patient admitted to hospital for tuberculous meningitis recovery from left nephrectomy for urinary lithiasis. The histology does not find specific lesions. Then, no antituberculous treatment is prescribed. The patient has developed renal and meningitis tuberculosis associated with urinary lithiasis. Koch's bacillus is found in the urine. The evolution under medical treatment was excellent. The urinary lithiasis has hided tuberculosis and the discovery of the disease was late.     

后腹腔镜下结核性无功能肾切除术

目的探讨后腹腔镜切除结核性无功能肾的有效性及安全性。方法2005年8月～2009年2月,对21例肾结核行后腹腔镜下肾切除术。用等离子钳游离肾脏与输尿管,Hem-o-lok阻断肾蒂,18例肾放入肾袋后取出,3例患侧下腹部取斜行切口处理输尿管及取肾。手术前后均行正规抗结核治疗。结果21例均成功完成肾切除,无一例中转开放手术,手术时间75～210min,平均105min。术中失血量40～220ml,平均100.5ml。术后住院时间4～9d,平均6.5d。术中3例肾包膜撕破造成少量干酪样脓液外渗,腹膜损伤5例。切口一期愈合20例,1例术后局部窦道形成,二次手术,输尿管残端切除术后治愈。随访3～24个月,平均12个月,6例因膀胱挛缩,术后3个月行结肠扩大膀胱术。结论后腹腔镜切除结核性无功能肾创伤小、恢复快,对于结核性无功能肾是一种安全、有效的手术方法。     

Urologische Betreuung von Patienten vor und nach Nierentransplantation

Patients with end-stage renal disease awaiting kidney transplantation require regular urological evaluation. The urologist's main task is early diagnosis and treatment of genitourinary malignancies and evaluation of the lower urinary tract. Furthermore, urologists are often confronted with the question of whether or not to perform pretransplant urological surgery, i.e., native nephrectomy for polycystic kidney disease. Urological care after kidney transplantation involves diagnosis and treatment of ureteral complications, malignancies, lower urinary tract symptoms, and last but not least erectile dysfunction, which has a prevalence of 20-50% among kidney transplant recipients.For the evaluation and follow-up of the living kidney donor, international guidelines have been developed in recent years to also help the urologist to perform a correct evaluation and follow-up of the kidney donor.     

后腹腔镜结核性无功能肾切除术的临床体会

目的:探讨后腹腔镜肾切除术治疗无功能性肾结核的临床应用价值。方法:2008年9月至2011年9月为32例肾结核患者行后腹腔镜结核性肾切除术。术中使用超声刀游离肾脏与输尿管,阻断肾蒂,切除的肾脏放入肾袋取出。手术前、后均行正规抗结核治疗。结果:32例手术均获成功,无一例中转开放手术。手术时间90～200 min,平均130 min;术中出血量30～140 ml,平均60 ml;术后住院5～9 d,平均7.1 d;术中、术后无明显并发症发生。结论:后腹腔镜肾切除术治疗结核性无功能肾安全、有效、微创,为肾结核的手术治疗提供了新途径。术前需积极进行抗痨治疗,术中科学、合理、仔细操作。     

后腹腔镜脂肪囊外结核肾切除46例报告

目的：探讨后腹腔镜脂肪囊外切除结核肾的应用价值。方法：回顾性分析2008年1月～2011年6月46例肾结核患者行后腹腔镜下结核肾脂肪囊外切除术的临床资料：男19例,女27例,中位年龄34（20～64）岁。打开侧锥筋膜和Gerota筋膜后,背侧紧贴腰大肌在脂肪囊外游离,腹侧在脂肪囊和Gerota筋膜之间游离。用Hem—O—lok（41例）或Endocutter（3例）处理。肾蒂,把肾放入肾袋后取出。结果：除早期2例因肾门处渗血视野不清中转开放外,44例均成功完成脂肪囊外肾切除。手术时间为118（80～186）min,术中失血量45．4（10～350）ml,术后住院时间为6．5（5～8）天。无腹膜损伤和脓肾破裂,围手术期无并发症,切口均一期愈合。46例随访1～43个月,平均19个月,对侧肾功能正常。结论：后腹腔镜脂肪囊外方法行结核肾切除术便于游离、创伤小、出血少、恢复快,对于结核肾是一种比较安全、可靠的手术方法。     

自发性肾脏破裂

目的 探讨自发性肾脏破裂的临床规律。方法 总结近年来经治的１６例患者;其中肾癌４例,浸润性结肠癌１例,血管平滑肌脂肪瘤２例,肾囊种、肾结石、红斑狼疮性（ＳＬＥ）肾炎、肾结核、真性红细胞增多症及门脉高压症各１例,原因不明３例。结果 ＣＴ诊断实体病为性自发性肾脏破裂明显优于Ｂ超和静脉肾孟造影。全组手术治疗１１例,其中切肾术６例,保肾术５例,病理报告与术前诊断基本相符;保守治疗５例。结论 肿瘤是自发性肾     

Therapeutic living donor nephrectomy

Therapeutic living donor nephrectomy is defined as a nephrectomy that is performed as therapy for an underlying medical condition. The patient directly benefits from having their kidney removed, but the kidney is deemed transplantable. The kidney is subsequently used as an allograft for an individual with advanced renal disease. Therapeutic donor nephrectomy can be successfully utilized for a heterogenous cohort of disease processes as both treatment for the donor and to increase the number of suitable organs available for transplantation. We describe four cases of therapeutic donor nephrectomy that were performed at our institution. Of the four cases, two patients elected to undergo therapeutic donor nephrectomy as treatment for loin pain hematuria syndrome; one after blunt abdominal trauma that resulted in complete proximal ureteral avulsion; and the fourth after being diagnosed with a small renal mass. Based on our data presented to the United Network for Organ Sharing Board of Directors (UNOS) in December 2015, living donor evaluation has been made simpler for patients electing to undergo therapeutic donor nephrectomy. UNOS eliminated the requirement for a psychosocial evaluation for these patients. As the organ shortage continues to limit transplantation, therapeutic donor nephrectomy should be considered when appropriate.     

Disseminated kidney tuberculosis complicating autosomal dominant polycystic kidney disease: a case report

Mycobacterium tuberculosis infection in patients with autosomal dominant polycystic kidney disease (ADPKD) is rare, and its diagnosis and treatment are difficult because numerous cysts are exposed to infection and antibiotics do not easily penetrate infected cysts. Here, we report the case of a 43-year-old Japanese man with disseminated urogenital tuberculosis (TB) and ADPKD without human immunodeficiency virus (HIV) infection. Delayed diagnosis and ineffective anti-TB chemotherapy worsened his condition. Finally, he underwent bilateral nephrectomy but experienced postoperative complications. In conclusion, kidney TB should be recognized as a cause of renal infection in ADPKD, and surgical treatment should be instituted without delay. The importance of early diagnosis and treatment cannot be overemphasized to prevent kidney TB deterioration.     

Role of partial nephrectomy in the treatment of kidney cancer

Incidental finding of small renal carcinoma by radiologic exams (ultrasound, computed tomography, MRI) performed for non urological purposes raises therapeutic and management problems (therapeutic abstinence and surveillance, partial or radical nephrectomy). Radical nephrectomy is recognized as a curative treatment for renal cell carcinoma. However, partial nephrectomy was suggested for renal cell carcinoma of solitary functional kidney or bilateral tumors in order to avoid dialysis or renal transplantation. The debate remains open for the small renal carcinomas with a normal controlateral kidney. Is partial nephrectomy an adequate treatment or rather perform radical nephrectomy? The present study was performed to analyse the published literature on the subject.     

Vascular obstruction of the ureter in juveniles

Seven proved cases and one probable instance of vascular ureteral obstruction in juveniles are reported. Loin pain is a frequent symptom. When infection with pyuria exists, “chronic pyelitis” is the usual diagnosis. When infection is slight or absent, the clinical diagnosis, based on urinalysis, is likely to be chronic interstitial nephritis. The existent nephritis is regularly of the toxic variety in the unobstructed organ and of the compression or back-pressure type in the obstructed kidney. This nephritis may be expected to disappear following removal or adequate treatment of the seriously diseased mate. Only by complete urological examination with urography can the diagnosis accurately be made preoperatively. Conservative surgery, chiefly vessel resection or ureteroplasty, is urged; nephrectomy is demanded with far-advanced renal destruction, infection or calculus disease. By specific example these cases serve to emphasize the great importance and necessity of the employment of modern urological methods in the diagnosis and treatment of persistent urinary tract disease in young patients.     

Acquired renal cystic disease in the end stage kidney: urological implications

A unique form of acquired renal cystic disease occurs commonly in the end stage kidneys of patients with chronic renal failure. Recent experience with 3 cases of acquired renal cystic disease has made us aware that the condition has significant urological implications. The pathogenesis of this disease is unknown but may be related to tubular obstruction, ischemia or the accumulation of toxic products. The diagnosis of acquired renal cystic disease is established by either ultrasound or computerized tomography, both of which demonstrate bilateral multiple small cysts scattered throughout the cortex and medulla of the contracted end stage kidney. Acquired renal cystic disease usually is asymptomatic but may be associated with either hemorrhage or neoplasia. Autopsy studies have revealed renal tumors in up to 45 per cent of the patients with acquired renal cystic disease. These tumors usually are small but our case 3 was a renal cell carcinoma that measured 4 cm. in diameter. Also, there have been other recent reports of large tumors and deaths of metastatic renal carcinoma in patients with acquired renal cystic disease. Patients with chronic renal failure should undergo periodic examination of the native kidneys by either ultrasound or computerized tomography. It may be difficult to distinguish benign from malignant lesions radiologically, and nephrectomy may be indicated when the diagnosis is uncertain.     

后腹腔镜结核性无功能肾切除术

目的:比较后腹腔镜结核肾切除术与开放手术的方法和疗效.方法:对7例无功能性结核肾行后腹腔镜结核肾切除术,同期11例行开放肾切除术,比较两组的手术时间、术中出血量、术后住院天数、并发症及手术疗效.结果:2组患者均顺利完成手术,平均手术时间分别为122 min(60～270 min)和96 rain(60～150 min),平均术中出血量分别为81 m1(20～400 m1)和255 ml(50～1 000 ml),平均术后住院天数分别为7天和9天,术中术后无明显并发症.结论:后腹腔镜结核肾切除术是一种安全、有效的微创治疗方法.后腹腔镜肾切除为肾结核的手术治疗提供了一条新的途径.     

Is Ipsilateral Adrenalectomy a Necessary Component of Radical Nephrectomy?

Due to the increased use of modern imaging systems during the last few years, kidney tumors are often diagnosed at an earlier and less advanced stage. This fact implies a reevaluation of the operative technique of radical nephrectomy that was recommended 30 years ago. The ipsilateral adrenal involvement during radical nephrectomy for renal cell carcinoma is assessed and the necessity of its extirpation is discussed.Between September 1987 and September 1993, we performed 299 radical nephrectomies for renal cell carcinoma and removed 285 ipsilateral adrenal glands. Eleven adrenal glands (3.8 percent) were involved with the kidney tumor and 274 (96.2 percent) were free of disease. In 7 of the adrenal gland involved cases (63.6 percent) the tumor invaded the gland by direct extension from the superior pole of the kidney. In the other 4 cases the ipsilateral adrenal gland was affected by a metastatic lesion. In all 11 adrenal gland involved cases the tumors were at an advanced stage (the lowest was stage pT3N1).Our results led us to recommend adrenalectomy during radical nephrectomy only when direct extension of the kidney tumor into the gland is suspected (upper pole or large tumors) or when the adrenal is the site of a single metastasis. Macroscopically normal adrenal glands at radical nephrectomy should not be routinely extirpated. Metastatic renal cell carcinoma (not by contiguity) in the ipsilateral adrenal gland should be regarded as a stage M+ (distant metastasis) tumor.     

Bilateral asynchronous renal cell carcinoma. Computed tomography of the contralateral kidney 10-43 years after nephrectomy.

Computed tomography (CT) was carried out in 31 patients 10-43 years after surgery for renal cell carcinoma, 10 belonging to a consecutive series of patients operated upon at one urological department 10 years previously. Twenty-eight patients were symptomless, and 3 had flank pain, severe fatigue and hematuria, respectively. Cancers in the remaining kidney were found 13-21 years after nephrectomy in 4 of 31 patients (12.9%). The 3 patients with symptoms were among these 4. An adenoma was found in 1 patient 10 years after nephrectomy. The cancers were treated by renal resection in 2 patients, multiple tumors made nephrectomy necessary in 1 patient and 1 patient was not operated upon because of disseminated disease. The adenoma indicated future checkup by CT. Three of the 4 new cancers had a dismal outcome. The renal parenchyma was found to be essentially normal in all the other 26 patients, irrespective of the widely varying time interval between nephrectomy and CT. Asynchronous bilateral renal cell carcinoma has a poor outcome which presumably can be improved by early diagnosis and aggressive treatment. CT is the method of choice for early detection and follow-up of renal tumors. It should be carried out every other year after nephrectomy for renal cell carcinoma.     

Membranous nephropathy and granulomatous interstitial nephritis due to tuberculosis

Tuberculous involvement of the genitourinary tract is well reported in the literature. However, reports of glomerular lesions of the kidney due to tuberculosis are rare. Tuberculosis has been identified as the most common infectious cause of granulomatous interstitial nephritis (GIN). We report a 23-year-old female patient with a membranous nephropathy and GIN due to tuberculosis. She presented with renal failure and nephrotic-range proteinuria, both of which resolved with the treatment of tuberculosis. There is only one report, from Japan, of a patient with membranous nephropathy and tuberculous granulomatous nephritis. Our patient is the second with tuberculous GIN and membranous nephropathy. In our patient, the close temporal relationship between the infection and glomerulonephritis, an ulcerated tuberculin skin test, the response to the treatment and the absence of any other systemic disease that might cause the glomerulonephritis suggested an association between tuberculosis and membranous nephropathy. However, a causal association can only be speculation, because membranous nephropathy could remit spontaneously. It is also possible that it might relapse at a later date when the tuberculosis is inactive. Therefore, the association might be either coincidental or causal, and could become clearer as similar patients are reported.     

Urinary tuberculosis: a review of 44 cases treated since 1963.

We are reporting on a decade of experinece with cases of renal tuberculosis treated at a large tuberculosis hospital. Most patients were men less than 50 years old. The most frequent symptoms were dysuria, back or flank pain, nocturia and hematuria. Physical examinations were generally normal and hypertension was not seen. Most patients had acid urinary pH, pyuria and/or hematuria. Excretory urograms were abnormal in 86 per cent of the cases, the most common finding being preserved function but calicectasis or abscess. Most patients had abnormal chest x-rays and nearly half of them had coexisting, active pulmonary or miliary tuberculosis. Tuberculin tests were positive in 85 per cent of the cases. In our experience urinary tuberculosis was almost always responsive to multi-drug chemotherapy, even in patients with a non-functioning, tuberculous kidney. An asymptomatic, non-functioning kidney need not be removed, provided documentation of urine culture conversion is obtained and a prolonged period of multi-drug chemotherapy is completed.