Non-surgical renal tuberculosis

We wish especially to call the attention of practitioners and urologists to the extreme and progressive frequency of this malady, both unilateral and bilateral, and to the fact that there are certain instances of this disease in which surgery as a therapeutic procedure should not be applied. We would emphasize the fact that combined medical and urological treatment in a select group of cases yields the most profitable and satisfactory results.In the three cases reported, the first one shows the incidence of an excretory renal tuberculous bacilluria without demonstrable pathological lesion in the kidney. The clinical value of this fact speaks for itself in the misleading interpretation of many diagnoses.The second case illustrates early bilateral renal tuberculosis when surgery must be applied as the best and most reasonable treatment arresting or curing the disease.The third case reported illustrates the advanced stage of bilateral renal tuberculosis, when both sides are equally involved with greatly diminished function, and when surgical treatment should not be recommended.There is no definite rule governing the solution of the clinical problem, but no kidney should be removed, particularly in doubtful cases, until after the three elements of the triangle, pointed out in this paper, are present to a marked degree and associated also with positive microscopic findings or guinea pig inoculation.Repeated urological investigations in many instances are entirely justified in an effort to discover the earliest tuberculous lesion of the upper urinary tract, and also to prevent the involvement of the second kidney. However, it is of great value to recall that genitourinary tuberculosis is a syndrome of a general body process localized in one or more of the genitourinary organs, demanding immediate attention in regard to hygienic and antituberculous treatment, i.e., the use of tuberculin, sunlight, forced diet, rest, plenty of fresh air and a peaceful life.In the light of modern urology, two distinct types of renal tuberculosis must be differentiated, the one that requires only medical treatment and the one requiring surgical treatment, when nephrectomy as a rule is indicated. But there are still certain cases in the early stage of the disease when the process is localized, involving only isolated zones of the cortical parenchyma or the medullary substance and when the lesion is walled off and does not communicate with the papillae, the calices or the pelvis, and therefore is a closed or isolated process, as we can readily see in the three distinct types shown in Figure 6. In these cases the diagnosis is most difficult, and nephrectomy should not be performed until the process is well established, i.e., after the tuberculous nodules or abscesses have broken through into the excretory apparatus producing pyuria and other marked urinary symptoms. We should not forget that not until that stage is reached can pyelographic data reveal the condition. These cases evidently require most active and efficient medical and urological treatment in order to attain a cure. But if the disease can not be arrested or cured, and the symptoms progress, the permanent cure may be obtained in from 80 to 90 per cent of the cases by early nephrectomy.On the other hand we should not wait for the incidence of an occluded renal tuberculosis, as occurs in autonephrectomy for blocking of the ureter, nor should we depend upon body resistance that the disease may continue for a long period of time. Logically it is assumed that the focus of infection is bound to develop further infection in the other kidney or in the lower urinary tract at a most serious risk. The damage that nature may cause insidiously in destroying the whole kidney parenchyma, by the tuberculous process alone, is undoubtedly worse than the traumatism of a simple nephrectomy in order to remove an organ deeply involved and functionless (Fig. 7).However, medical and urological routine treatment, as administered by the newly formed Tuberculosis Division of the Brady Urological Foundation at the New York Hospital, should be used systematically not only in postoperative or inoperable cases, but more especially in the earlier stages of the disease, for it is at this period that results are most gratifying.