Reconstructive surgery for tuberculous contracted bladder: experience of a center in northern India

Long-term renal function in patients undergoing surgical reconstruction for tubercular cicatrized bladder

PURPOSE

We evaluated the long-term renal function in patients after surgical reconstruction for tuberculous contracted bladder (TBC) and determined factors associated with decreased renal function (RF) during follow up.

MATERIALS AND METHODS

We reviewed the records of 61 patients who underwent augmentation cystoplasty (AC) or orthotopic neobladder (ONB) for TBC between June 1994 and August 2019 in our institute. The estimated glomerular filtration rate (eGFR) was calculated preoperatively at initial presentation, before augmentation and at various intervals during follow up. Renal function decrease was defined as a defined as new-onset stage-3A Chronic kidney disease(CKD) or upstaging of pre-operative CKD stage 3A in follow-up. Multivariable analysis was done to evaluate the association of clinicopathological features and postoperative complications with decreased renal function.

RESULTS

We analyzed 39 patients who had a minimum follow-up of 1-year post reconstruction. At a median follow-up of 52 months (IQR 31-103 months), 16/39 patients developed RF decrease. In univariate analyses, initial eGFR, and associated ureteric stricture in contralateral renal unit were significantly associated with new-onset renal insufficiency (p < 0.001 each). On multivariable analysis, only initial presenting eGFR (p < 0.001) was an independent predictor of new-onset renal insufficiency. ROC cut-off levels for eGFR at presentation predicting the primary end point of RF decrease was 45 ml/min.

CONCLUSIONS

Decreased renal function is noted in most patients during long term follow-up after surgical reconstruction for TBC. After controlling for preoperative and postoperative risk factors, patients with initial presenting GFR < 45 ml/min are at greater risk of a decline in renal function following reconstruction.

Augmentation uretero-enterocystoplasty for refractory urinary tract dysfunction: a long-term retrospective study

Objectives

To report the long-term efficacy and complications of the augmentation uretero-enterocystoplasty (AUEC), including augmentation cystoplasty with simultaneous ureteroplasty and ureteral anti-reflux implantation in a single center.

Methods

We retrospectively reviewed clinical records, video-urodynamic data, and magnetic resonance urography of 210 patients who underwent the procedure for refractory lower urinary tract dysfunction (LUTD) from 2003 to 2019. International vesicoureteral reflux (VUR) and upper urinary tract dilatation (UUTD) grading systems were applied to assess upper urinary tract function, and post-operative complications were assessed.

Results

Mean age was 28.1 years, with a mean follow-up time of 57.4 months. A total of 338 ureters were simultaneously re-implanted, and ureteroplasty was performed on all ureters. There was a significant postoperative improvement in the bladder capacity, intravesical pressure, and compliance (P < 0.05). VUR improvement rate was 97.7% and postoperative improvement of UUTD presented in 72.5% ureters. Mean serum creatinine (Scr) level was significantly improved compared to preoperative Scr values (226.0 ± 89.4 μmol/L vs. 217.5 ± 133.9 umol/L, P < 0.05). The 1.0% patients had unacceptably postoperative urinary incontinence and 85.4% preoperative megaureters were improved. Primary complications included metabolic acidosis (9.5%), vesicoureteral anastomosis stenosis (6.2%), persistent VUR (2.7%), urinary calculi (6.6%), and intestinal dysfunction requiring laparotomy (3.3%).

Conclusion

In the study, a large series of patients treated with a complex surgical procedure was reported. It is novel, as this case series represents patients with aggressive surgical correction of VUR, ureteral tortuosity and upper tract dilation at the time of AC. AUEC was shown to have a positive role in treating patients with refractory LUTD associated with hydronephrosis and ureteral dilatation, stenosis or obstruction, with or without high- or low-pressure VUR. It was effective in improving renal function and protecting the UUT function from further deterioration in most patients with renal insufficiency.

Management of tuberculous-contracted bladder with bilateral duplex collecting system: a case report with modified robotic urinary tract reconstructive surgery

Tuberculous bladder contracture with a bilateral duplicated collecting system is rare. According to anatomic variation, the surgical treatment strategy is highly individualized. We illustrate our robotic technique of urinary tract reconstruction. A 19-year-old girl with a history of pulmonary tuberculosis (TB) as a young child presented with a complaint of increasing frequency of micturition, nocturia, urgency, and urge incontinence starting at the age of 17. Clinical and imaging examinations demonstrated tuberculous contracted bladder with a bilateral duplex collecting system. The patient underwent a robot-assisted Institute of Urology Peking University (IUPU) orthotopic ileal neobladder reconstruction. This is a modified urinary tract reconstructive method, including resection of the end of the duplex ureters and diseased contracted bladder with preservation of the proximal urethra and bladder neck, ileal harvesting and IUPU strategy to reconstruct an ileal neobladder, uretero-ileal anastomosis and neobladder-bladder neck anastomosis. The patient remained symptom-free without recurrence of TB and had improved renal function during the one-year follow-up after surgery. Thus, our robot-assisted IUPU orthotopic ileal neobladder reconstruction method is an effective approach for this benign case. It can effectively increase bladder capacity, reduce intravesical pressure, and improve symptoms such as urination frequency and urgency.

Urinary tuberculosis: still a challenge

BACKGROUND

Urinary tuberculosis (TB) is a challenging disease to cope with, as there has been no noticeable difference in basic diagnostic and therapeutic options in clinical practice over time.

PURPOSE

The aim of the current review was the critical assessment and evaluation of TB, which remains a major global health problem.

METHODS

The available literature regarding TB in the PubMed database was extensively searched.

RESULTS

New interdisciplinary team approaches such as next-generation sequencing are promising for the diagnosis and treatment of the disease. The epidemiology of the disease is changing with globalization and increasing migration events; however, the knowledge here is limited. Despite ongoing destruction, kidney functions need to be preserved as much as possible, and relatively rapid development of minimally invasive techniques relieved the surgeons in this regard. Experience is increasing in minimally invasive techniques that provide better comfort for patients compared to extensive radical surgeries.

CONCLUSIONS

Knowing the pathogenesis of urinary TB is essential for understanding the range of clinical manifestations. The onset of the disease is usually insidious. Despite modern TB drugs, reconstructive surgery, and minimally invasive procedures, progression cannot be prevented in some patients, and patient selection is essential, but we still do not have sufficient information and objective parameters to predict progression.

Medical treatment for urogenital tuberculosis (UGTB)

Urogenital tuberculosis (UGTB) should in general be treated as pulmonary TB with a four-drug regimen of Isoniazid, Rifampicin, Ethambutol and Pyrazinamide for a total of 6 months, Ethambutol and Pyrazinamide only the first two months. Some patients may need longer treatment (cavitary disease, kidney abscess/malfunction, HIV co-infection). Treatment of multi-drug resistant tuberculosis (MDR-TB) requires use of long-term intravenous treatment with aminoglycosides and other drugs with considerable toxicity for 18–24 months. Complications such as urinary tract obstruction may occur and should be treated with corticosteroids or surgery.

Urogenital Tuberculosis

Urogenital tuberculosis is the second most frequent form of extrapulmonary tuberculosis. Starting with a pulmonary focus, 2 to 20% of patients develop urogenital tuberculosis through hematogenous spread to the kidneys, prostate, and epididymis; through the descending collecting system to the ureters, bladder, and urethra; and through the ejaculatory ducts to the genital organs. Urogenital tuberculosis occurs at all age ranges, but it is predominant in males in their fourth and fifth decades. It is a serious, insidious disease, generally developing symptoms only at a late stage, which leads to a diagnostic delay with consequent urogenital organ destruction; there are reports of patients with renal failure as their initial clinical presentation. Although the condition has been long recognized by nephrologists, urologists, and infectious disease specialists, urogenital tuberculosis is still largely unknown. Even when suggestive findings such as hematuria, sterile pyuria, and recurrent urinary infections are present, we rarely remember this diagnostic possibility. Greater knowledge of the features of urogenital tuberculosis then becomes relevant and should emphasize the importance of an early diagnosis.

Urogenital tuberculosis: definition and classification

OBJECTIVES

To improve the approach to the diagnosis and management of urogenital tuberculosis (UGTB), we need clear and unique classification. UGTB remains an important problem, especially in developing countries, but it is often an overlooked disease. As with any other infection, UGTB should be cured by antibacterial therapy, but because of late diagnosis it may often require surgery.

METHODS

Scientific literature dedicated to this problem was critically analyzed and juxtaposed with the author's own more than 30 years' experience in tuberculosis urology.

RESULTS

The conception, terms and definition were consolidated into one system; classification stage by stage as well as complications are presented. Classification of any disease includes dispersion on forms and stages and exact definitions for each stage. Clinical features and symptoms significantly vary between different forms and stages of UGTB. A simple diagnostic algorithm was constructed.

CONCLUSIONS

UGTB is multivariant disease and a standard unified approach to it is impossible. Clear definition as well as unique classification are necessary for real estimation of epidemiology and the optimization of therapy. The term 'UGTB' has insufficient information in order to estimate therapy, surgery and prognosis, or to evaluate the epidemiology.

[Investigation and management of genito-urinary tuberculosis]

Genito-urinary tuberculosis is the fourth most common manifestation of the disease, but it is often underestimated by clinicians because of few and non-specific symptoms and insidious disease course. The most common urinary findings are multiple ureteral stenosis. The most common genital involvement is an epididymal nodule for men and a chronic salpingitis for women. The definite diagnosis of genito-urinary tuberculosis is obtained on the basis of culture studies. Due to the paucibacillary nature of the disease, especially of genital location in woman, a probable or presumptive diagnosis is frequently considered with several parameters including radiological imaging (abdominal CT-scan, pelvic ultrasound, pelvic MRI). Endoscopic and surgical procedures are frequently required to obtain specimens for histopathologic and bacteriological studies. Medical treatment is the method of choice, with a combination of four drugs, namely isoniazid, rifampicin, ethambutol and pyrazinamide, followed by a two-drug regimen, for a total of six month duration. Surgery might be indicated in complicated genito-urinary tuberculosis (decreased renal function, infertility, urologic complaints).

Best practice in the diagnosis and management of urogenital tuberculosis

Tuberculosis (TB) is a current public health problem, remaining the most common worldwide cause of mortality from infectious diseases. Urogenital tuberculosis (UGTB) is the second most common form of extrapulmonary TB in countries with severe epidemic situations and the third most common form in regions with a low incidence of TB. In this article we present the terminology, epidemiology and classification of UGTB, as well as describing the laboratory findings and clinical features and approaches to chemotherapy as well as surgery.

A case of extensive genitourinary tuberculosis: combined augmentation ileo-cystoplasty, ureteric ileal replacement and buccal mucosal graft urethroplasty

Genitourinary tuberculosis (GUTB) is the second most common form of extrapulmonary TB after lymph nodes. Advanced GUTB leading to strictures of ureters and urethra, and bladder contracture frequently need surgical management. These are usually treated by ileal replacement of ureter, substitution urethroplasty using buccal mucosal graft (BMG) and augmentation ileo-cystoplasty, respectively. These procedures have been well demonstrated individually but all these three procedures have never been combined as single procedure in the same patient. We report a case of advanced GUTB with ureteric and urethral strictures, and bladder contracture which was treated by the ileal replacement of ureter, augmentation ileo-cystoplasty combined with BMG substitution urethroplasty in a single sitting.