Surgical management of Genitourinary TB.pptx

Dr.Ibsa Daba (urology resident)
Addis Ababa Univeristy
Genitourinary TB(Ibsa.D) 1

• Introduction
• Epidemiology
• Clinical features and classification
• KUTB and GUTB
• Diagnosis
• Culture
• Imaging
• Urethrocystoscopy
• Treatment
• Medical
• Surgical

Epidemiology
• WHO 2013 – quarter world’s population is infected with MTBC in its latent form.
• Second great imitator after syphilis
• In developing countries 90 % of GUTB occurs and
• 15% to 20% with pulmonary TB
• the GU tract is the second most common extra pulmonary site after lymph
nodes
• In developed countries, GU TB has been found 27% of extrapulmonary cases.
• USA GU TB is the third most common form after pleural and lymphatic TB
• 2-10 of cases with pulmonary TB
• Male to female ratio(2:1)
• Mean age of affection is 40 years

Pathogenesis
• Latent TB is marked by cicatrization and
granuloma calcification.
• In fewer than 5% of primary progression
• Lifetime risk of reactivation TB is
estimated at 5% to 15%.
• the risk is higher in patients with the
medical comorbidities

GUTB development
• 1.Hematogenous spread-
• principal route
• active or latency
• 2.Ascending/retrograde infection
• Second route of infection
• BCG for treatment of Bladder cancer in 0.9%
• 3.Contiguous spread
• Extension from spine and
psoas
• Entero renal and entero
vesical fistula
• 4.Direct inoculation
• Very rare

Clinical features and classification
• Nonspecific sign and symptoms.
• 8.4% of GU TB patients are
asymptomatic
• The typical TB constitutional symptoms
of present in less than 20% of patients
• 50% of only dysuria
• 50% have storage symptoms
• 33% have hematuria and
• Renal colicky in 10%
• Typical laboratory findings include
sterile pyuria and/or hematuria is
found in more than 90% of GU TB
patients in developing countries

Clinical Classification of Urogenital Tuberculosis
kidney ( GUTB) nephron tuberculosis(Kulchavenya, 2014)
• KTB 1)
• TB of kidney parenchyma
• Occasional dx
• Nondestructive form is subject to
conservative therapy.
• CTX ( anti TB)
• KTB 2
• Small-destructive form
is subject to conservative therapy,
• Reconstructive surgery is indicated
for complications only.
• Unilateral or bilateral
• Solitary or multiple
KTB 3
• From parenchyma or papillitis
• Cavernous( subcortical cavern is like renal
carbuncle
• Poly-cavernous KTB and destruction from papiltis
• surgery indicated
• KTB 4
• Widespread destructive form recovery with anti-TB
drugs only is impossible,
• surgery is necessary, basically nephrectomy
•

2.UTTB (urinary tract tuberculosis)
• TB of pelvis, ureters, bladder, and
urethra.
• Always secondary to KTB.
• Usually develops in the lower third
of ureter ,
• Strictures can also occur throughout
the ureter in a “pan-ureteral” fashion
leading to a “beaded corkscrew”
appearance.
• Urinary obstruction resulting from
strictures is an important cause of
renal failure in GU TB

Bladder
• Usually begins near the ureteral
orifices
• Implant in the urothelium and
cause a patchy cystitis.
• The dome of the bladder is the
most affected,
• whereas the trigone and neck usually
remain normal
• chronic inflammation and mucosal
scarring, bladder contracture develops
• Urinary frequency, urgency, pain, and
dysuria become prominent when bladder
capacity shrinks to less than 100 mL.
• The severely contracted “thimble”
bladder typically has a capacity of less
than 20 mL .

Kulchavenya, Divided bladder Tb in to 4 stages
• Stage 1- Tubercle infiltrative
• Stage 2- Erosive ulcerous
• Stage 3- Spastic cystitis
(bladder contraction , false
microcystitis) overactive bladder.
• Stage 4- Real microcytitis up to full
obliteration.
• The first two stages should be
treated by standard
anti-TB drugs,
• The third stage with standard
anti TB drugs and trospium
chloride.
• The fourth stage is indicated for
cystectomy with following
enteroplasty.

II. MGTB(male genital tuberculosis)
• TB epididymitis
• Unilateral ,can be bilateral in
34%
• Second most common site of
hematogenous seeding
• More affects the more
vascular globus minor
• Ulceration and tuberculous
sinus tract in 50 %
• Prostate TB (infiltrative or cavernous
forms);
• Hematogenous
• periphery and spare urethra
• Calcification and gland
hardening
• Urinary tract
• More affects the urethra and
manifests like bacterial
prostatitis
• Prostatic abscess in AIDS
patients

TB of seminal vesicles
• Cause of infertility
• Through urethra and also ejaculatory ducts
• Granulomas and further calcification
• Oligospermia,
• Azoospermia,
• Hematospermia.
• TB can rarely cause seminal vesicle abscesses

Penis and Urethra
• Involved in only 1.9% to 4.5% of GU TB
patients.
• Isolated urethral TB is very rare but has
been reported
• Urethral TB is usually associated with
prostate infection and complicated with
urethra cutaneous fistula (watering
pot perineum)
• Penile lesions begin on the skin as an
inflamed papule or a keratotic plaque (also
known as lupus vulgaris)
• ulcerate and spread to cavernous tissue
• these can be hard and mimicks malignancy and if
there is fibrosis penis can be distorted

•
Diagnosis
1.Culture
• Gold standard for the diagnosis of GU TB is urine acid fast bacilli (AFB)
culture.
• First-void urine is the best sample
• 3-5 urine samples on consecutive days
• The sensitivity is as high as 80% when done in this manner.

Cont …
• LJ (Lowenstein jansen) medium -Traditionally on solid , egg based
• Laborious and time consuming 4 to 6 weeks
• Middlebrook 7H10- Developed world in solid agar, based medium,
• Liquid based (BACTEC mycobacteria growth indicator tube (MGIT)
• Flouresence method detect MTB in as little as 10 days
• Current guidelines recommend culturing on at least one solid medium
concurrently with the liquid system to maximize yield
• ATB sensitivity to firsts line and second line can also be done

2. NEUCLIC ACID AMPLIFICATION TESTS
• Providing results in 1 to 2 days
• Can detect in low bacillary load
• Sensitivity ranges from 87% to 96%
• Lower in non sputum specimens
• Urine contains natural inhibitors that interfere with DNA/RNA amplification
• 2010,WHO enthusiastically endorsed the newest TB PCR assay on the
market, the Gene-xpert MTB/RIF
• In small study EPTB 91 urine samples ( only 5 were culture positive) and
Gene expert was 100% sensitive and 98.6% specific

3.Histopathology
• Caseating granulomas
• In patients with epididymal
nodules, fine-needle aspiration
cytology can provide a
diagnosis in 67.5% .
• Adding NAAT can further
augment diagnostic sensitivity to
tissue specimens

4.Radiography
• GU TB generates a wide
spectrum of imaging findings.
• The test of choice depends on
disease location and should be
driven by symptoms and other
clinical data.
• Imaging is often the first test
that indicates TB is the cause
of a GU disorder
• Plain radiography
• IVU
• Retrograde pyelography
• Ultrasonography
• CT scan
• MRI

Plain radiography
• Calcifications- 50%
• Lobar pattern -pathognomonic
• Globular calcifications
• Triangular ring like calcifications for
papillary necrosis
• Cement or putty kidney: the calcific
rim outlines the renal lobes
• Renal and ureteral TB-infected
stones
• Kerr’s kink
• Bladder wall calcification

Intravenous urography
• GOLD standard in imaging
of early renal TB
• Loss of sharpness and
edge irregularities
• Calyceal erosions have a
‘Moth-eaten’ appearance
• Filling defect by
tuberculomas
• Phantom calyx
• Rigid, calcified,
straightened, pipestem
ureter
• Beaded corkscrew ureter
• Hiked up pelvis
• Obstructive changes
• Cloverleaf pattern,
calyceal dilation and
distortion
• Calyceal distortion
• Infindibular
narrowing
• Hydrocalycosis
• hydroureter

Clover leaf pattern in
contracted renal pelvis

CT urography scan
• Replaced IVP
• Calcifications, scarring and signs of
obstruction
• Useful in evaluating patients with
complicated and extensive TB
• Les sensitive for detecting urothelial
thickening and subtle papillary necrosis
for which IVU is still preferred
• High dose of radiation

CT scans

Ultrasonography
• Limited use in diagnosing GU
TB
• Primary use of US is for
following Hydronephrosis in
patients who are receiving
medical treatment
• fibrosis during healing can worsen
obstruction
• Pediatrics and pregnant
• Evaluate the testis, epididymis,
seminal vesicles,
• locate abscess and cavities
• Presence of ascites,LAP or omental
caking

Retrograde pyelography
• Replaced by CTU
• However when CT cannot be
done because of renal
insufficiency or contrast allergy,
• In addition can be used with IVU
to determine cavitation's are
obstructive or nonobstructive
• Useful in pediatric and pregnant
patients
• Sensitive than IVU in showing
caliectasis and urothelial thickingin
• DWI helps In distinguishing
pyonephrosis from HN
• MRU ureteral peristalisis
MRI

5.Cytoscopy and
ureteroscopy
• Limited role Findings are
nonspecific
• Local hyperemia,
• Mucosal erosion,
• Ulceration,
• Granulomatous masses,
• Irrhole UO
• egularity of UO
• Golf

Treatment
• Medical therapy
• Combination therapy with first line ATDs
• Second line agents are reserved for
• Failed first line agents
• Side effects of first line agents
• Drug resistance for first line agents
• Treatment should start with these—namely, INH, rifampin, pyrazinamide, and
ethambutol.
• Before the start of treatment, baseline measurements should include blood
counts and liver and kidney function tests

Cont….
• Intensive phase(2 months): targeting for rapidly multiplying bacteria
• Continuation phase(6 months): to eradicate slow, sporadic multipliers
and persistent bacteria
• The role of steroid used in GUTB to prevent ureteral strictures and
bladder contraction,
• these are anecdotal and no clinical trials are further conducted

Duration of therapy
• Usually 6 months of standard short course therapy
• 9 months therapy is indicated in:
• Extensive pockets of infection
• Concurrent smear positive cavitary pulmonary disease
• CNS involvement
• Delay in positive cultures converting to negative
• If the patient is not taking Pyrazinamide for at least 2 months
• Some clinicians recommend treatment with 12 months of therapy
because of high relapse rates of 22% if given only for 6 months
29
Genitourinary TB(Ibsa.D)

• Surgical therapy
Optimal therapy for surgery is 4-6 weeks after initiation of ATDs
Operative management can be categorized in seven groups
1.Drainage for hydronephrosis (stenting or PCN insertion)1
2.Drainage for abscesses and caverns
3.Definitive local treatment of kidney tuberculosis(partial nephrectomy)
4.Reconstruction of upper UT
(calico/pyeloureterostomy, ureterolysis, ureterocystoneostomy, ureter
replacement)
5.Bladder augmentation
6.Reconstruction of urethra
7.Management of genital tuberculosis (epidiymorchidectomy)

1. Drainage for hydronephrosis (stenting or PCN insertion)
• Should be done soon in uremia and
sepsis
• Stenting, reassess after 6 weeks
• Percutaneous
nephrostomy(PCN)
• Stenting retrograde is successful
in 41%
• If that fails antegrade stenting via
PCN
• PCN should be performed.
• Risk of tuberculous cutaneous
fistula during PCN removal.
• Avoid high contrast injection
pressures during stent or PCN

2. Drainage for abscesses and caverns
• In septic cases drainage of the caverns of the kidney may be
necessary.
• Open surgical drainage of an abscess should not be attempted.
• The contents of an abscess should be aspirated in a minimally invasive
manner

3. Definitive local treatment of kidney tuberculosis
• Nephrectomy indications
1.Nonfunctional kidney and recalcitrant
or recurrent TB despite optimal medical
therapy.
2. Nonfunctional kidney and medically
resistant hypertension.
• Partial nephrectomy indications
1. Localized polar lesion that failed to
respond to intensive CTX after 6 weeks
2.Area of calcification that is slowly
increasing in size and threatening to
destroy the whole kidney.

4. Reconstruction of upper UT
Endoscopically or Open surgery
• Endoscopic management
• Upper and mid ureteric stricture
• Temporarily stenting for UPJ strictures
• Balloon dilation retrograde and antegrade access for UPJ,UVK and calyceal
infindibula
• Follow up needed
• High failure rates
• Steroid can be added
• If no improvement after 6 weeks open surgical treatment required

Open approach
• Dismembered pyeloplasty for
extrarenal pelvis
• Nondismebered pyeloplasty for
longer strictures but not feasible
because of excessive scarring
• Ureterocalicostomy (ureter to
lower pole of calyx)
• Upper and mid ureter- tension
free ureteroureterostomy
• Lower ureteric stricture-
ureteroneocystomy
• Psoas hitch— < 5cm
• Boari flap- 10 cm
• Ileal interposition in multiple
and recurrent strictures

5.Bladder augmentation
1.Augmentation cystoplasty
(ileocecum or sigmoid segments
are most suitable)
• Indicated when frequency,
nocturia, urgency and pain and
hematuria intolerable
• Bladder capacity <100ml
• 2.Thimble bladder with <20ml
capacity best managed by
• orthotopic bladder substation

6.Reconstruction of urethra
• Bladder neck contracture -transurethral incision of contracture
• Urethral strictures --endoscopically
• often require repeated procedures.
• Tuberculous urethral fistulae are treated by initiation of medical
therapy and suprapubic bladder drainage
• Delayed reconstruction is preferred

7.Management of genital tuberculosis (epidiym orchidectomy)
• Extirpative surgery for genital TB is considered only for patients in
whom medical therapy has failed.
• When epididymis infected sparing the testis, every effort should be
performed to do epidymectomy without orchidecotmy
• If testis infected scrotal orchidecotmy can be done
• Involvement of the vas deferens by TB is usually distal to the external
ring and ligation of at the level of the ring is possible and sufficient.

References
1.Books

2.Articles and journals
1.Lenk S, Naber KG, Bishop MC, Johansen TEB, Botto H, Grabe M, et al. European Urology EAU Guidelines
for the Management of Genitourinary Tuberculosis Mete C. 2005;48:353–62.
2. Abbara A, Davidson RN. Etiology and management of genitourinary tuberculosis. Nat Rev Urol
[Internet]. 2011;8(12):678–88. Available from: http://dx.doi.org/10.1038/nrurol.2011.172
3. Çalışkan S. SM Gr up Diagnosis of Genitourinary Tuberculosis. 2016;1–8.
4. Carl P, Stark L. Indications for Surgical Management of Genitourinary Tuberculosis. 1997;505–10.
5. Kulchavenya E. Urogenital tuberculosis : definition and classification. 2015;1–6.
6. Merchant S, Bharati A, Merchant N. Tuberculosis of the genitourinary system - Urinary tract
tuberculosis : Renal tuberculosis – Part II. 2013;23(1).
7. Dhangar SP, Kothawala IH, Patil S, Kumar A, Whatkar A. Radiologic signs of genitourinary tuberculosis :
An aid for earlier diagnosis. 2016;1(4):1–8.

Surgical management of Genitourinary TB.pptx

Recommended

Recommended

More Related Content

Similar to Surgical management of Genitourinary TB.pptx

Similar to Surgical management of Genitourinary TB.pptx (20)

Recently uploaded

Recently uploaded (20)

Surgical management of Genitourinary TB.pptx

Editor's Notes