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Genito urinary tuberculosis

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Genitourinary Tuberculosis
Genitourinary Tuberculosis
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Genito urinary tuberculosis

  1. 1. GENITO-URINARY TUBERCULOSIS DR. SWAPNIL S.TOPALE YASHODA SUPER SPECIALITY HOSPITAL, MALAKPET, HYDERABAD
  2. 2. INTRODUCTION  The term genitourinary tuberculosis was introduced by Wildbolz in 1937, and since then, renal and epididymal tuberculosis were considered together as the local manifestation of the same blood-borne infection  In India the estimate of TB is 168/100,000 population/year (WHO 2005 estimates) with an annual incidence of 2.2 million/year (worldwide six million new cases) and an annual death rate of 29/100,000 population/year
  3. 3.  In comparison to only pulmonary TB, which comprises around 68.4%, the incidence of combined pulmonary extrapulmonary cases and extrapulmonary TB alone comprise 12% and 20- 25% of the total disease burden respectively  Amongst extrapulmonary TB, GUTB accounts for 4% of the load  In comparison to the patient’s complaints, the sequel of genitourinary TB is volcanic and requires proper understanding
  4. 4. INCIDENCE Genital tract tuberculosis  The most common form of extrapulmonary TB is genitourinary disease  Worldwide- 27% (range, 14 to 41%)  India-18% Female genital tract tuberculosis:  1% of infertile women, aged between 20-40 years in United States and 18% in India suffer from genital TB
  5. 5. In females the genital organs commonly affected are as follows:  fallopian tube (95-100%)  endometrium (50-60%)  ovaries (20-30%)  cervix (5-15%)  myometrium (2.5%)  vulva/vagina (1%) Male genital tuberculosis:  associated with tuberculosis of the kidney and prostate, seminal vesicle, epididymis, testes as well as scrotum may occasionally be affected
  6. 6. Tuberculosis in HIV-infected patients:  India-5.2% new cases have HIV (15-49 years) and in an average  Worldwide-10% of all cases of TB are HIV-related (1999 data) Tuberculosis in post-transplant patients: 9.5-14.7% in India Tuberculosis in children with nephrotic syndrome:  in a study by Gulati et al., 9.3%, amongst a total of 300 children with nephrotic syndrome had renal tuberculosis
  7. 7. ETIOPATHOGENESIS  Tuberculosis is a chronic infection, caused by different species of Mycobacterium tuberculosis complex, such as : • M. tuberculosis • M. Canettii • M. Africanum • M. bovis, • M. microti • M. pinnipedii, • M. caprae.  Commonly, Mycobacterium tuberculosis, bovis, and africanum are Infectious While M. tuberculosis is the major cause of TB in humans  M. africanum sometimes causes pulmonary TB in humans in Africa.
  8. 8.  Tubercle bacilli can remain dormant in tissues and persist for many years. Along with the type of mycobacterial species, duration of exposure, size and infectivity of the strain are also responsible for the difference in infectivity Tuberculosis in vitamin D deficiency  There is sizeable evidence that a fall in serum 25-Ohvitamin D3 level compromises cell- mediated immune defenses, leading to the activation of latent tuberculosis
  9. 9. SOURCES OF GENITOURINARY TUBERCULOSIS  At the time of primary TB, the disseminated microorganisms through the blood stream to different organ systems remain dormant in latent foci  In 5-15% of infected patients, these dormant foci break down (liquefaction necrosis and cavitation) causing dispersion of tubercle bacilli  This secondary disease, or reactivation TB, occurs as a consequence of a decreased cellular immunity  Genitourinary TB is usually caused by reactivation of these dormant organisms, usually within the first two years following the primary infection by M. tuberculosis (90-95%) and very rarely (5-10%) by M. bovis, where the source of infection is the gastrointestinal tract
  10. 10. TB OF FEMALE GENITAL TRACT  The bacilli reach the genital tract by three principal routes: 1. The hematogenous route (90%) 2. descending direct spread or 3. lymphatic spread  rarely may occur from direct inoculation during sexual intercourse with patients with genitourinary tuberculosis  Trans-serosal exudation may give rise to pelvic inflammatory disease and subsequently in extensive pelvic diseases  Very rarely sexual transport has been reported, as 3.9% men with GUTB harbor bacilli in semen
  11. 11. TB OF MALE GENITAL TRACT: IN MEN  The sites most commonly involved are epididymis, followed by the prostate,testicular involvement is less common and usually is the result of direct extension from the epididymis  Tubercular prostatitis usually results from antegrade infection within the urinary tract  Many theories have been postulated to define the precise route of infection to the epididymis. These include - i) Infected urine theory ii) spread via lymphatic system and iii) metastatic spread through the blood stream. iv)Female to male transmission (venereal transmission of TB) is very rare.
  12. 12.  Testicular involvement is usually as a result of local invasion from the epididymis, retrograde seeding from the epididymis and rarely by hematogenous spread  Involvement of scrotal wall suggests local extratesticular extension of disease process  Male genital tuberculosis usually is associated with renal TB in 60 to 65% cases or with pulmonary TB in around 34% cases.
  13. 13. TB OF URINARY TRACT  In the kidney, hematogenous spread primarily involves the renal cortex and remains dormant  Abnormal host defense mechanism leads to reactivation of these foci with enlargement  Later, the abscess may rupture into the proximal tubule and loop of Henle with eventual development of enlarging, caseating granulomas with papillary necrosis  Spread to the renal pelvis produces pyonephrosis-like lesion, also known as a .cement. or .putty. kidney, which frequently spreads down to the ureters, bladder, or urethra, resulting into ureteric strictures and segmental dilation and Obstruction  Tuberculosis of the ureter usually starts in the ureterovesical junction.
  14. 14. IMMUNE RESPONSE IN TUBERCULOSIS  Though M. tuberculosis stimulates both the humoral and cellular immune systems, the antibodies are not protective  Activation of cellular immunity blocks and the extent of disease within four to six weeks of initial infection and elicits typical granulomas (also called tubercles), where macrophages are transformed to giant epithelioid cells  Excessive delayedtype hypersensitivity. with cytolytic T-cell activity, leads to the degeneration of the center of the lesion  In general, CD4+ cells (Helper T cells) form large aggregations dominating the granulomas while the CD8+ cells (Cytotoxic T cells) are sparse and distributed more toward the periphery of the lesion (immunosurveillance
  15. 15. PATHOLOGY OF GENITOURINARY TUBERCULOSIS Gross pathology: Renal TB:  Kidneys may be involved in two ways: 1. miliary TB-multiple cortical white nodules of around 1 mm due to hematogenous spread of bacilli, or 2. cavitary renal TB (localized ascending infection) and predominant medullary lesions
  16. 16.  The cortical granulomas may remain dormant, asymptomatic, and stable for as long as 10 to 15 years  When they coalesce, cavities are formed, which communicate with the pelvicalyceal system via erosion (moth-eaten appearance on ultrasonography), may rupture or cause part of the papillae to become necrotic, which eventually sloughs out. The end result is a destroyed, defunct calciÞ ed kidney (autonephrectomy)  At this stage, multiple surface scars are noted on the kidney along with dilated and deformed renal excretory system, Þ lled with caseous necrotic material (pyonephrosis)  Later on the only remains may be necrotic material surrounded by Þ brous tissue, commonly called cement or putty or chalk kidney
  17. 17.  Sometimes both kidneys may be slightly enlarged due to amyloidosis or diffuse proliferative glomerulonephritis secondary to TB  On the other hand, in tubercular interstitial nephritis, the kidney is generally of normal size and shows smooth contour  Even urine culture is sterile. This entity can only be diagnosed by demonstrating th granulomatous involvement in renal interstitium.
  18. 18. Ureteral TB:  Ureteral dilatation and a ragged irregular appearance of the urothelium are the first signs of ureteral TB (beaded or corkscrew ureter)  There may be obstruction at the ureterovesical junction or associated tuberculous cystitis and ureteritis  Ureteral shortening and fibrous contraction may give rise to a golf hole orifice in the bladder
  19. 19. Urinary bladder TB:  Urinary bladder TB may be induced either by local instillation of BCG, which causes a sel flimiting selflimiting, low-grade, superficial cystitis  Bladder TB affects the mucosa near the ureteral orifice to start with  In advanced infection, the bladder becomes small, irregular, contracted and calcified and eventually may lead to nonfunctional urinary bladder (autocystectomy)  Rarely fistulas may develop
  20. 20. FEMALE GENITAL TUBERCULOSIS Fallopian tube  In early phases, tube diameter is normal and changes are noted mainly in advanced disease, in the form of nodular transformation, mimicking salpingitis isthmica nodosa  Adhesion may occur between ovaries and other pelvic organs with loss of fimbrial structures  Patent ostia along with grossly diseased fallopian tube are often an indicator of tubercular salpingitis
  21. 21. Endometrium:  Diagnosis is often missed in biopsies, as the involvement can be focal  In widespread endometrial TB ulceration, caseous necrosis and hemorrhage can be seen Ovary:  Affected in 10% cases  Adhesion with the fimbria or formation of unilateral or bilateral adnexal mass can be seen  Gross caseous necrosis in ovaries is uncommon Cervicitis:  Grossly, the cervix can be normal, ulcerated or may present with a mass mimicking malignancy  External genitalia: Rarely can involve the vulva in the form of non- healing ulcers
  22. 22. MALE GENITAL TUBERCULOSIS Tubercular epididymitis:  The globus minor is affected alone in around 40% cases, owing to greater blood supply  Bilateral involvement can be noted in 34% cases  Grossly, the vas or epididymis may be beaded  Rarely, discharging sinuses may develop Prostate, testes, penis, urethra:  Prostate may enlarge and show signs of inflammation  Gross caseous necrosis is often identifiable  Testicular TB can show testicular swelling or
  23. 23. MICROSCOPIC FINDINGS Urinary tract:  In miliary renal TB, multiple small epitheloid granulomas with neutrophils and necrosis are seen, along with lymphocytes, mononuclear cells and plasma cell infiltration  In the chronic stage, extensive Þ brosis and widespread calcifications are the findings  Keratinizing squamous metaplasia may develop as a late complication in renal pelvis and may persist even after treatment of the active tuberculous lesion  This may be a potential risk factor for the development
  24. 24. GROSS PHOTOGRAPH OF KIDNEY SHOWS MULTIPLE NECROTIC AREAS INVOLVING THE MEDULLA AND AT PLACES DESTROYING RENAL CALYCES [FIGURE 1A]. CHRONIC TB PYELONEPHRITIS WITH DESTROYED RENAL CALYCES [FIGURE 1B]. EPITHELIOID CELL GRANULOMAS WITH DENSE CHRONIC INFL AMMATORY INFI LTRATE IN RENAL CORTEX. [FIGURES 1C, D, H AND E, X100]. FOCALMFORMATION OF LYMPHOID FOLLICLES [FIGURE 1E, H AND E, X40]. CROSS-SECTION OF URETER SHOWING ULCERATED UROTHELIUM BY A GRANULOMATOUS PROCESS [FIGURE 1F, H AND E, X40]
  25. 25. Female genital tract:  Similar epithelioid granulomas with Langhans giant cells with or without necrosis are noted in functional endometrial layer with ulceration of endometrial lining at some places  Gradual destruction and loss of endometrial glands are commonly seen  Metaplasia of endometrial lining or glands is not uncommon  In the absence of granulomatous inflammation, infiltration of endometrium with plasma cells and
  26. 26.  In immunecompromised patients, granulomas may be less well formed, organisms are readily demonstrated, and caseous necrosis is seen less frequent Male genital tuberculosis:  The epitheloid granulomas in the prostate are usually multiple and seen in the peripheral zones  Calcification is not uncommon  The scrotum shows variable degrees of fibrosis, epithelioid granulomata, inflammation, sinus tracts and focal micro- abscesses secondary to bacterial infections  The gradual development of scrotal tubercular abscess may give way and form ‘watermelon scrotum’
  27. 27.  In testes commonly epididymis is affected and shows features of granulomatous inflammation  Bilateral epididymal involvement and concomitant testicular lesion strongly suggest TB, especially in patients with evidence of TB elsewhere in the body and failure to respondm to conventional antibiotic therapy
  28. 28. Urinary bladder biopsy in TB:  Usually contraindicated, unless the tubercles or the ulcers are situated away from ureteral orifice
  29. 29. CLINICAL PRESENTATION AND DIAGNOSTIC APPROACH IN CASES OF GENITOURINARY TUBERCULOSIS  Kidney is usually the primary organ infected in urinary disease, and other parts of the urinary tract become involved by direct extension  Epididymis in men and fallopian tubes in women are the primary sites of genital infection  The usual frequency of organ involvement is: kidney, bladder, fallopian tube, and scrotum
  30. 30.  The GUTB has varied presentation and some of the common ways are: 1. Recurrent or resistant urinary tract infection, sterile pyuria with or without hematuria 2. Irritative voiding symptoms, i.e., frequency, urgency, and dysuria 3. An incidental diagnosis in a known case of tuberculosis.
  31. 31. 4. Renal (hydronephrosis/pyonephrosis) or epididymal Mass 5. Infertility and pelvic inß ammatory disease 6. Renal failure (Chronic kidney disease due to parenchymal infection and obstructive uropathy 7. The various other ways of presentation described are:  flank pain with acute pyelonephritis  non-healing sinuses, or fistulae (nephrocutaneous fistula or vesicovaginal fistula)
  32. 32.  The most common symptoms with which the patients have presented are in the form of irritative voiding, which are found in more than 50% of the patients  The other symptoms in GUTB can be fever, weight loss, anorexia, backache, and abdominal pain
  33. 33. KIDNEY AND URETER  asymptomatic, but may have chronic sterile pyuria  Gross hematuria-10%  microscopic hematuria-up to 50%  Acute renal pain is rare. It usually occurs secondary to luminal obstruction by blood clots, sloughed renal papilla, or flakes of calcification  Chronic dull ache may be due to infundibular, pelviureteric, or ureteric stricture  chronic renal failure which can be either due to renal parenchymal destruction secondary to infection or due to obstructive uropathy
  34. 34. URINARY BLADDER  Involvement of the bladder is usually secondary to renal infection and is found in nearly one-third of the patients  In the early stage, i.e., acute phase, bladder changes are usually non-specific which gives rise to irritative voiding symptoms  Chronic inflammation causes reduced compliance and capacity manifesting as frequency of micturition  Urgency develops if the bladder is extensively involved  Those who develop thimble bladder. (due to mural Þ brosis and contracture) may present with urinary incontinence  Chronic inflammation and extensive fibrosis at vesicoureteric junction result in Golfhole ureter
  35. 35. PROSTATE, PENIS, AND URETHRA  Tuberculous prostatitis and urethritis can cause ..beefy redness.. And superficial ulcerations on endoscopic examination  Dilatation of the prostatic urethra, and ..golf hole.. dilatation of the prostatic ducts have also been reported  Tuberculosis of the prostate may cause nodularity on digital rectal examination (DRE) mimicking malignancy  Sometimes, the diagnosis is made after histopathological examination (HPE) of transurethral prostatectomy (TURP) chips  Very rarely, fulminating prostatic involvement can cause
  36. 36. Primary involvement of the penis:  an ulcer clinically indistinguishable from sexually transmitted diseases (STDs) or malignancy  Cavernositis and cold abscess formation presenting as penile deformity or impotence Urethral involvement:  Stricture formation  Hematospermia
  37. 37. EPIDIDYMIS AND TESTES  Here, infection usually starts from the globus minor, as it has a richer vascularity  Usually presents as painful scrotal mass, which initially cannot be distinguished clinically from epididymo-orchitis  Orchitis sometimes can be difficult to differentiate from other mass lesions of the testes  Infertility due to epididymal and/or vasal obstruction  Nodular beading of the vas is a characteristic physical finding
  38. 38. PELVIC DISEASE IN FEMALES  The association of tuberculosis and pelvic disease most frequently presents as infertility, chronic pelvic pain, alterations in the menstrual pattern, or amenorrhea  Adrenal glands- Adrenocortical insufÞ ciency
  39. 39. DIAGNOSIS TESTS-URINE EXAMINATION  Sterile pyuria is the classic finding  Preferably, five consecutive early-morning specimens of urine should be examined  The yield of urine examination by smear and culture for detecting the tubercle bacillus is low, probably because of the intermittent shedding of the bacilli and is also observer- dependent  Direct smears-positive only in 30%  Urine cultures require 6 to 8 weeks in special culture media (Lowenstein-Jensen). Sensitivity- 80 -97%
  40. 40. RAPID IDENTIFICATION OF MYCOBACTERIUM Radiometric systems  Radiometric liquid culture systems (i.e., BACTEC®) [Becton Dickinson, USA]) give rapid results and are highly sensitive in the identification of mycobacterium  But these methods have some inherent diffculties in working with radioactive materials, and the necessary apparatus used are really expensive
  41. 41.  Polymerase chain reaction (PCR)  Lets the sequence of DNA fragment from just a few mycobacteria to be amplified in vitro such that the amount of amplified DNA can be visualized and identified  Rapid, with results available within few hours of DNA extraction from the sample  Specificity-up to 88% and sensitivity-94%
  42. 42. IMAGING  In spite of the fact that the definitive diagnosis of genitourinary tuberculosis is established by positive results on urine culture or histologic examination, the imaging modalities make an important part of the investigation module X-chest and spine:  to detect any pulmonary (active or old healed granuloma) or spinal involvement
  43. 43. Plain X-ray abdomen:  may show renal calcification  Calcification rarely occurs in ureter (intraluminal), bladder wall, or seminal vesicles Intravenous urography:  one of the most useful tests  provides both anatomical as well as functional details of the kidneys and ureters  The earliest radiographic changes-changes in the minor renal calyces with loss of sharpness and blunting
  44. 44.  Progression of the disease will cause – moth eaten appearance of the calyces and lost calyx due to infundibular stenosis  Ureters- initially dilated or become irregular in appearance followed by stricture formation with predilection for the infundibulum, ureteropelvic junction, and distal ureter, which are the sites for narrowing  At these states, the ureter looks like beaded or pipestem or even corkscrew conÞ guration  10 to 56% of the patients develop ureteric strictures  Involvement of ureteric orifices in the late stages, as these become Þ brotic and fixed, leads to the development of vesicoureteric reß ux (VUR).
  45. 45. Computed tomography (CT scan)  Currently, at many centers, CT is replacing IVU as an imaging modality of choice in GUTB  It is equally good at identifying calyceal and infundibular abnormalities, renal parenchymal destruction, and hydronephrosis or hydroureter  In addition, it identifies adjacent adrenal, retroperitoneal, prostatic, and seminal vesicle abnormalities
  46. 46. Cystoscopy and biopsy:  Cystoscopy is rarely indicated for diagnostic purpose  Biopsy is needed if there is suspicion of malignancy  It should be done only after 4-6 weeks of medical therapy to prevent dissemination of the disease (i.e., tubercular meningitis)  The cystoscopic findings-reduced bladder capacity and patulous ureteral orifice  The positive bladder biopsy diagnostic of GUTB can be found in up to 46% of the patients
  47. 47. Retrograde and antegrade pyelography  There are two indications for it: 1. Ureteral catheterization to obtain urine sample for culture for localization of the disease 2. To delineate the stricture of the lower ureter  Percutaneous antegrade access is required if retrograde access is unachievable or insufficient for drainage of the kidney  It also provides a route for obtaining urine samples from the renal pelvis or tuberculous cavities for culture and to assess therapeutic drug concentration at the target sites
  48. 48. Magnetic resonance imaging (MRI): Useful in patients with-  compromised renal function,  pregnancy, or  allergy to contrast media  It gives good morphological details for the kidneys as well as excellent delineation of the ureters
  49. 49.  Diagnosis of GUTB on the basis of the presence of one major and/or two minor criteria:  The major criteria- 1. granulomatous lesion on histopathology 2. AFB positivity in urine or histopathology 3. a positive PCR
  50. 50.  Minor criteria: 1. Changes suggestive of tuberculosis on IVU/CT or MRI 2. hemaruria, 3. raised ESR, and/or 4. pulmonary changes of old healed granulomas
  51. 51. SEQUEL OF GENITOURINARY TUBERCULOSIS  Tuberculosis has a significant deteriorating effect on kidney function  Though often unilateral to start with, cavitary renal TB can cause renal failure in 12% patients and hypertension in 4-12% patients  In one study it was reported that without surgery, the five-year survival rate of patients with renal TB was 15-42% while surgical intervention increased the 10-year survival rate to 50%  If proved by selective renal artery renin estimation, nephrectomy reduces the blood pressure substantially in patients complicated with hypertension  Early continuous multidrug chemotherapeutic regimens are successful in reducing mortality rate to 2.2%  Of patients who die of pulmonary TB, 60% show coexistent renal TB in autopsy
  52. 52.  Tuberculous epididymo-orchitis has a considerable effect on fertility  The sperm count and motility may be reduced due to blockage of the vas and/or secondary atrophy  The development of renal amyloidosis in TB is common  This may not only cause renal dysfunction, but if not taken care of, may lead to multiple organ failures  Development of renal dysfunction in a known case of TB is therefore a strong indication for a kidney biopsy
  53. 53. MEDICAL MANAGEMENT OF GENITOURINARY TUBERCULOSIS  In this era of evidence-based medicine, it is worthwhile to mention that the first-ever randomized controlled trial (RCT) in the history of modern medicine was conducted in the field of TB  Short-course combination chemotherapy (SCC) is the standard of care for the treatment of TB  When patients are treated with a single drug only, under the selection pressure, these drug-resistant bacilli would emerge eventually resulting in treatment-failure  But, concomitant administration of a second drug would prevent the emergence of these drugresistant bacilli and thereby averts treatment failure
  54. 54.  The two most important facets of efficacy of any combination regimen for the treatment of TB are i) rapid and complete killing of the bacillary population resulting in cure, and ii) prevention of relapse following successful cure
  55. 55.  The WHO went on to declare TB a global emergency in the year 1993 and adopted DOTS strategy to deal with the same  In India, DOTS implementation began in the year 1993 on a pilot basis, and large-scale expansion of DOTS began in 1997 under the aegis of the Revised National TB Control Programm (RNTCP)  By March 2006, 100% coverage of the nation had been achieved  Till date, more than 6.7 million patients with TB have been started on DOTS, the treatment success rate has remained consistently above the global benchmark of 85%, and about 1.2 million lives have been saved
  56. 56. DOSE MODIFICATION IN RENAL FAILURE  Doses of INH, rifampicin, and pyrazinamide need no adjustment in a patient with renal failure since these drugs are either eliminated almost entirely through biliary secretion or metabolized to nontoxic compounds  The dosing interval for ethambutol has to be doubled in patients with advanced renal failure (creatinine clearance <10 mL/min)  Patients with renal failure may develop peripheral neuropathy with INH more commonly and hence should receive pyridoxine supplementation (10 mg/day) as a preventive measure
  57. 57. WHAT IS THE ROLE OF CORTICOSTEROIDS?  The only two clinical indications for which the use of corticosteroids has been demonstrated to improve the outcome are TB meningitis and pericardial TB  Intriguingly, the benefit is evident in terms of mortality only  It seems unlikely that corticosteroids would be able to reduce the development of complications such as ureteric obstruction in patients with GUTB. This issue is worth investigating
  58. 58. EVALUATION OF A PATIENT WITH GUTB - A PHYSICIAN’S PERSPECTIVE  All patients with GUTB should be evaluated for concomitant involvement of the lungs as well as other organs  Review of symptoms such as cough, expectoration, hemoptysis, and dyspnea followed by a chest radiograph and examination of at least three sputum-smears for acid-fast bacilli is the minimum evaluation for pulmonary involvement required in all patients with GUTB  Patients should be meticulously questioned about treatment for TB in the past for a period more than one month  If present, the chances of drugresistant TB are higher, and Category II DOTS would be the appropriate treatment  In India, about 5.2% of patients with TB have underlying HIV co-infection and extra- pulmonary involvement occurs more commonly among HIV co-infected patients  All patients should therefore be offered voluntary counseling and testing services for detecting HIV co-infection
  59. 59.  The most common reason for planned treatment interruption is the development of drug-induced hepatotoxicity  Old age, malnutrition, hypoalbuminemia, and alcoholism are associated with increased risk of drug-induced hepatotoxicity  All patients should have their liver function evaluated before initiation of treatment  Liver functions have to be periodically monitored in patients with preexisting liver disease, abnormal liver function at baseline, alcoholics, and those developing symptoms suggestive of drug-induced hepatotoxicity such as anorexia,
  60. 60. APPROACH TO A PATIENT WITH UNRESPONSIVE DISEASE  A patient with GUTB or any other form of TB who fails to show improvement with treatment, of symptoms or lesions evident on imaging, is a commonly encountered situation in clinical practice  The following possibilities need to be considered - Is the regimen and dosage of drugs correct? Is the patient adherent? Was the diagnosis of Tb correct? Is it drug-resistant TB?
  61. 61.  When all these possibilities have been reasonably excluded, the most likely explanation would be a delayed response to treatment which is a common phenomenon in extrapulmonary TB
  62. 62. SURGICAL MANAGEMENT OF RENAL TUBERCULOSIS  In a patient with unexplained LUTS, urinary T B should be ruled out, as Chang had said, .The kidney is an inarticulate organ; its vocal cords are the bladder..  Tuberculosis is a great imitator of other diseases and can present as vague symptoms  The patients should be managed based on clinical and radiological findings  All patients with active or latent urinary TB require treatment with anti-TB chemotherapy
  63. 63.  The invasive or operative procedures for renal and ureteral TB can be categorized into the following groups: (1) drainage for hydronephrosis (ureteric stenting or percutaneous nephrostomy); (2) drainage of abscesses or localized collections; (3) definitive local treatment of the affected part of the kidney (cavernotomy/partial nephrectomy); (4) nephrectomy of the non-functioning tuberculous kidney (open/laparoscopic/ retro-peritoneoscopic techniques) and (5) Reconstruction of the upper urinary tract (uretero calycostomy, ureteric reimplantation, ileal ureteric replacement)
  64. 64. DOUBLE-J (DJ) STENTING  It is common in tuberculous kidneys to observe hydronephrosis secondary to stricture involving the pelvi-ureteric junction or the ureter  As these lesions heal by fibrosis, further worsening of the stricture can occur with treatment  A DJ stenting of the affected system will help in restoration of the patency of the drainage system
  65. 65.  It facilitates a passive dilatation of the ureter and prevents any further worsening by acting as a splint across the site of stricture  The strictures should be monitored with CT or IVU  If there is deterioration or no improvement after a six-week period, then surgical reimplantation or other minimally invasive procedures including balloon dilatation may be necessary
  66. 66. PERCUTANEOUS NEPHROSTOMY  Many patients have multipleinfundibular stenoses with individual calyces being dilated and non-communicating with each other  There may be a further deterioration of the renal function with chemotherapy, as the calyx may be cut off from the rest of the collecting system secondary to fibrosis  DJ stenting may not be effective in such circumstances, as the individual calyces do not communicate with each other  In such instances, a percutaneous nephrostomy, if required multiple, may be necessary, in order to protect
  67. 67. CAVERNOTOMY:  Sometimes the lesions are characterized by extensive cavitations, which usually occur at the poles of the kidney  The involved calyces do not excrete contrast medium, making it difficult to make a diagnosis of the condition  It is extremely important to have an index of suspicion in these patients, as large conglomerated, non- communicating tuberculoma formed because of infundibular stenosis may radiologically mimic a renal tumor  Ultrasound or CT abdomen usually helps us diagnose
  68. 68.  In view of ischemia to that particular segment of the kidney, the drugs may not reach the desired therapeutic levels, resulting in a persistence of the lesion even after the completion of the course of chemotherapy  When patients do not respond to medical therapy or if the disease process has gone unnoticed, the cavity containing urine may be secondarily infected to form an abscess  Previously, cavernotomy was considered an ideal option. With the advent of Pyrazinamide, which acts intracellularly, and with the availability of better imaging modalities, this procedure hardly has any place in the modern era of management
  69. 69. PARTIAL NEPHRECTOMY  Caution should be exercised if there is a calcification in the wall, as slow but insidious extension of the calcification might ultimately destroy the whole kidney  Once this process starts, it is advisable to consider partial nephrectomy  There are only two indications for  partial nephrectomy: (1) a localized polar lesion containing calcification that has failed to respond after six weeks of intensive chemotherapy; (2) an area of calcification that is slowly increasing in size and threatening to gradually destroy the entire kidney
  70. 70. CALYCORRHAPHY/INFUNDIBULOPLASTY  The non-communication of the cavity with the rest of the system necessitates a closer follow-up and if the calyx is functional may require a calycorrhaphy or infundibuloplasty  If the corresponding pole of the kidney is non- functional, polar nephrectomy is advocated. In patients with a cicatrized renal pelvis and ureter, it may be necessary to perform a lateral nephrotomy to open the infundibulum of all the major calyces, replace the ureter with ileum, and anastomose the proximal end of the ileum to the lateral border of the cavity
  71. 71. NEPHRECTOMY  Appearance of calcification in a tuberculous kidney is a sign of advanced stage of the disease and is reported in up to 50% of patients with renal tuberculosis  When a tuberculous lesion has advanced to the collecting tubules or the renal pelvis, it never heals completely because of a hindered drainage and backpressure effects  When complete healing occurs with antituberculous therapy, the tuberculous process usually is limited to the cortex and has never extended to a pyramid or collecting tubules
  72. 72.  The indications for nephrectomy in a non- functional asymptomatic tuberculous kidney are still debatable
  73. 73.  Fundamental principles while doing nephrectomy for a non-functioning tuberculous kidney:  It is preferable to approach the kidney from behind, as the kidney is more often adherent to the colon anteriorly in view of severe inflammation  It is not necessary to remove the ureter completely as the goal should be to remove as much of the diseased ureter as possible  Every effort should be taken to ligate the artery and the vein separately, in order to prevent the possibility of development of arterio-venous fistula if both are tied together
  74. 74.  Before exploring a non-functioning tuberculous kidney, it is important for the urologist to consider certain issues: (a) Is there a danger of viable tubercle bacilli in a tuberculous kidney? (b) Is salvage of a poorly functioning tuberculous kidney always possible?
  75. 75.  Ideally, percutaneous nephrostomy is the best method to assess the recoverability of renal function  It promptly decompresses the obstructed kidney and helps to estimate the creatinine clearance of the diverted urine  The limitations are that it is an invasive procedure and if the kidney is non-functioning, nephrectomy has to be done in order to prevent the occurrence of a nephro-cutaneous fistula
  76. 76.  On the other hand, if the patient.s GFR is <15 ml/min and the cortical thickness is <5 mm, associated with more proximal lesions, it is a more likely that the kidney is not worth salvaging  In such instances, it is better not to intervene, as these kidneys are less likely to improve after intervention
  77. 77. TUBERCULOSIS AND RENAL FAILURE  Tuberculous infection is 6-16 times much more frequent in patients undergoing hemodialysis than in the general population  Renal disease can be particularly occult and insidious, leading to progressive destruction and calcification of the parenchyma  Renal TB can result in end-stage renal disease by two mechanisms: (1) it can inß ict direct insult to renal parenchyma by causing obliterative endarteritis
  78. 78. of the intra-renal segmental vessels or secondary renal amyloidosis (2) by the obstruction of pelvi-ureteric junction or multiple infundibular stenoses, it can result in obstructive uropathy  The overall incidence of renal failure reported in the literature is 24%
  79. 79.  Renal TB can also result in certain biochemical abnormalities in patients with end-stage renal disease  Hypercalcemia is one such important biochemical abnormality seen in such patients  This usually occurs secondary to abnormal calcitriol production by the granulomatous tissue  This ectopic production of calcitriol by the granulomas is either unregulated or is regulated by ways different from those controlling the normal renal production of this hormone
  80. 80.  Peces et al. reported that a successful management of TB resulted in resolution of hypercalcemia and an adequate parathyroid hormone response  Any attempts at correction of hypercalcemia alone may prove detrimental to these patients  Patients with bilateral renal TB can present with acute renal failure  Conte et al. in their report suggested that any patient with acute renal failure in whom no definite cause could be identified, TB should be considered
  81. 81.  If the patient presents with obstructive uropathy, it is necessary to do an initial diversion in the form of percutaneous nephrostomy and allow sufficient time for the serum creatinine levels to reach a nadir value, before planning any form of definitive intervention  In patients with renal failure requiring a bowel interposition, a short ileal conduit is preferred
  82. 82.  Bowel interposition leads to various metabolic abnormalities and already existing renal failure could further worsen with time  Such patients need to be closely followed up as they could develop chronic renal failure necessitating dialysis and renal transplantation
  83. 83. OPTIONS IN THE MANAGEMENT OF TUBERCULOUS URETERIC STRICTURE PATHOLOGY  Site of stricture formation in decreasing order of frequency: ureterovesical junction(mc) ureteropelvic junction middle third of the ureter entire length of ureter  The length of stricture varies, but lower ureteric strictures are usually <5 cm in length  While the circular fibrosis gives rise to strictures, the longitudinal fibrosis leads to shortening of ureter, pulling up the orifice as a gaping hole -the so-called golf hole  Ureteric calcification, albeit a theoretical possibility, is rarely seen clinically
  84. 84. DIAGNOSTIC WORKUP  The specific investigations in a case of ureteric stricture are principally aimed at defining: a. the site, extent, number, and caliber of stricture, b. defining the degree and impact of backpressure changes and/or coassociated tuberculous disease on renal function c. defining the extent of involvement of urinary bladder and contralateral unit, and d. defining extent of tuberculous involvement in the segment of bowel which may be required for ureteric replacement
  85. 85. TREATMENT  Once the diagnosis of urinary TB is confirmed on investigations, the patients should be put on multidrug antituberculous drugs (ATT).  Any intervention should be done after the patient has received at least 4-6 weeks of ATT
  86. 86. TREATMENT IN EARLY DISEASE  When the investigations show early ureteric disease, every attempt should be made to place a DJ stent. If DJ stent placement is not done, these patients should be followed closely with monthly limited film IVU or renal scan  If there is no improvement or deterioration for 6 weeks then early intervention (DJ stenting or Percutaneous nephrostomy (PCN)) has to be
  87. 87.  The patients of tuberculous ureteric stricture may be grouped into two broad categories: I. Simple/uncomplicated: Short segment passable stricture with salvageable renal function and good bladder capacity II. Complex/complicated: Long segment, extensive/bilateral, or impassable stricture with or without salvageable kidney and bladder
  88. 88. ENDOUROLOGIC OPTIONS FOR MANAGEMENT OF URETERIC STRICTURE Double-J stent placement:  DJ stent placement also gives the best outcome if the ureteric stricture is short and not dense with a functioning renal unit and with reasonable bladder capacity  Subsequently, this stent can be replaced with a larger size stent  The stent can be kept for a period of 6-12 months and usually by that time the stricture stabilizes
  89. 89.  This technique is rarely definitive and usually requires repeated dilatations on a regular basis  The dilatation is repeated every 2 weeks initially, later every 1-2 months, until the upper renal tract has stabilized  Contraindications include active infection and length of stricture more than 2 cm, because dilatation alone will rarely be successful in this
  90. 90. Antegrade balloon dilation  If retrograde access fails, antegrade approach may be attempted particularly if the patient already has nephrostomy in situ
  91. 91. Endoureterotomy:  Like balloon dilation, this procedure can be done either through the retrograde or the antegrade approach Cautery wire balloon incision  This procedure is performed under fluoroscopic control  This procedure is not advocated when the stricture is in close proximity of great vessels, such as at the iliac level of the ureter  The favorable prognostic features were: length of stricture <1.5 cm, nonischemic nature of stricture, and adequate renal function
  92. 92. SURGICAL OPTION IN MANAGEMENT OF TUBERCULOUS STRICTURE  When endourologic treatment fails Ureteroureterostomy  A short defect involving the upper or midureter can be treated by ureteroureterostomy.  The anastomosis should be tension-free, hence enough ureteral mobility is essential prerequisite Ureteropyelostomy/ureterocalicostomy Psoas hitch: If the bladder capacity is normal, psoas hitch can be performed for small length strictures of the lower
  93. 93. Boari flap:  If the bladder capacity is normal, Boari flap may be employed for long lower ureteric stricture Intubated ureterotomy:  This procedure was popular for long upper and mid-ureteric strictures wherein the incised ureter was left to heal by regeneration over a stent Transureteroureterostomy:  if the other ureter is also diseased this should be attempted with caution
  94. 94. Ileal ureteral substitution  For long ureteric strictures involving almost the whole length of ureter or upper ureteric strictures require ileal replacement of ureter  The contraindications -baseline renal sufficiency with serum creatinine value of >2 mg/dl  An isoperistaltic segment of ileum is used and the lumen can reduced by tailoring
  95. 95. Autotransplantation  For proximal or multiple/pan ureteric strictures when other methods of repair fail or are not feasible, autotransplantation is an option
  96. 96. RECONSTRUCTIVE BLADDER SURGERY IN GENITOURINARY TUBERCULOSIS There are two types of lesions in the tubercular bladder:  One, which is more common, is when the bladder due to active infection has a reduced capacity of about 150-200 ml  The other type is the true or structural bladder contracture wherein the urinary bladder has permanently lost its capacity and has little or no value as a urinary reservoir  In the initial stages before cicatrisation has taken place, the dome contracts but the trigone and bladder neck are relatively spared  Antitubercular therapy is often successful in preventing disease progression and restoring normal bladder function
  97. 97.  But once the tubercular bladder shrinks to a very small size (reduced elasticity and compliance) - tubercular thimble bladder - the process may no longer be reversible and corrective(reconstructive) surgery in the form of augmentation must be performed to prevent/arrest kidney damage  The aims of the reconstructive surgery are – (1) Enlargement of the small urinary bladder to enable the patient to retain urine for a reasonable period of time (2) restoration of function as a low-pressure (less than 30 cm of water) reservoir during storage and as a high- pressure compressor during micturition
  98. 98. (3) prevention of incontinence and infection that may jeopardize upper urinary tract integrity  Before any surgical intervention, a minimum of four weeks of ATT is recommended, which allows 1. stabilization of the lesion and better planning of reconstructive surgery 2. recovery of renal function in patient, if adequate temporary urinary diversion is provided.
  99. 99. SURGICAL OPTIONS:  AUGMENTATION CYSTOPLASTY  SIGMOIDOCYSTOPLASTY (COLOCYSTOPLASTY)  ILEOCYSTOPLASTY  CAECOCYSTOPLASTY  ILEOCAECOCYSTOPLASTY  GASTROCYSTOPLASTY  ORTHOTOPIC NEOBLADDER
  100. 100. REPRODUCTIVE TRACT TUBERCULOSIS AND MALE INFERTILITY- MANAGEMENT  The primary aim is to treat the infection and requires antitubercular therapy(Rarely, in patients with an early diagnosis of the disease who have not developed bulky granulomas causing an obstruction, this therapy may result in restoration of fertility)  In the majority of cases, the presentation is late and antitubercular therapy does not improve the fertility status  Infertility here usually results from anatomic obstruction and therapy depends on the site and
  101. 101. Ejaculatory duct obstruction  While the diffuse, fibrotic type of lesions of the ejaculatory duct and seminal vesicles- not amenable to surgery  patients with discrete obstructions at the distal end of the ejaculatory duct - TURED or TUIRED Epididymal obstruction  Patients with palpable masses usually require excision of the epididymis, both for diagnosis and therapy of tuberculosis,precluding surgical reconstruction in most cases
  102. 102.  Patients who have obstructive azoospermia with normal volume, fructose-positive ejaculate-discrete obstruction either within the vas deferens or at the vaso-epididymal junction-microsurgical reconstruction(vasovasal anastomosis or vasoepididymal anastomosis) Assisted reproduction  Patients who are not amenable for surgical correction  Choices: 1. in-vitro fertilization or 2. Intracytoplasmic sperm injection (ICSI)  results comparable to those in men without this disease
  103. 103. TUBERCULOSIS IN RENAL TRANSPLANT RECIPIENTS  The reported prevalence of post transplant TB- Asia -3.1 to 15% South Africa -1.5 to 8.5%, Middle East- 1.5 to 3.5% Europe -1.7 to 5% United States- 1.5%  About 45-60% of TB occurs in the first year after transplantation  An earlier occurrence was noted with non-renal solid organ transplantation, cyclosporine, anti CD3 therapy, malnutrition secondary to prolonged dialysis, relative immunodeficiency and exposure to the organism in hospital setting
  104. 104. The major risk factors for TB are:  chronic liver disease (2times)  other coexisting infections  particularly deep mycoses  pneumocystis pneumonia  nocardia (1.6 times)  OKT3 (1.8 times)  CMV infections (2.25 times)  Cyclosporine use advances the onset to an earlier date andpatients on cyclosporine seldom develop TB later than six years
  105. 105.  The presentation of the disease differs in solid organ recipients and a high index of suspicion is important in diagnosing the problem  Rifampicin, a vital drug in the ATT regimen induces cytochrome-c P450 microsomal enzyme system which is responsible for metabolizing cyclosporine, sirolimus and prednisolone  This unpredictable interaction has led to acute rejections in 30% and graft loss is 20% and hence rifampicin should be avoided in solid organ transplantation  The dose of calcineurin inhibitors may have to be increased two- to fivefold to overcome this effect
  106. 106. Duration of therapy:  The regimens used in different centers vary in dose and duration which are not validated  authors use a four drug regimen:  pyrazinamide (3months);  ofloxacin (9 months);  INH and ethambutol (18 months)  If rifampicin has to be used for those who are not on cyclosporine, prednisolone dose has to be doubled
  107. 107.  Drug resistance and atypical mycobacterial infections are emerging problems and should be suspected in the non-responding patients

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