Reconstructive Surgery for the Management of Genitourinary Tuberculosis: A Single Center Experience

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.

Surgical management of tuberculous epididymo-orchitis: a retrospective study of 81 cases with long-term follow-up

BACKGROUND

Nowadays, most studies of tuberculous epididymo-orchitis (TBEO) are case reports or small sample cohort series. Our study is aimed to present the largest series of TBEO with our management experiences and long-term follow-up outcomes.

METHODS

Patients diagnosed with TBEO after surgical procedures at Department of Urology, West China Hospital from 2008 to 2019 were included. All clinical features, auxiliary examination results, treatment and histopathological findings were extracted if available.

RESULTS

Eighty-one patients (mean age 50.77 ± 16.1 years) were included. Scrotal swelling (N = 47, 58.0%) and pain (N = 29, 35.8%) were the most common presenting complaint. Pyuria and microscopic hematuria were observed in twenty-two (27.2%) and eight patients (9.9%), respectively. Urine acid fast bacilli cultures were available in 16 patients and all were negative. The mean duration between the onset of symptoms and the definite diagnosis was 6.42 ± 7.0 months. TBEO was considered in 30 (37.0%), tumors in 28 (34.6%) and nonspecific bacterial epididymo-orchitis in 23 (28.4%) patients. All patients received triple therapy of chemotherapy-surgery-pharmacotherapy and definite diagnosis was confirmed through histopathology of surgical specimens. Fifty-five patients were followed up regularly (mean follow-up 82.35 ± 36.6 months). One patient (1.2%) died from liver cirrhosis and no recurrence was observed. Postoperative complications included erectile dysfunction in 4 patients (4.9%), premature ejaculation in 5 patients (6.2%) and sterility in 7 patients (8.6%).

CONCLUSIONS

We recommend patients with advanced TBEO to receive triple therapy of chemotherapy-surgery-pharmacotherapy. Physicians should pay more attention to patients' sexual function and fertility during follow up after treatment completed.

Presentation, management and outcomes of pediatric urogenital tuberculosis: 20 years' experience from a tertiary center

BACKGROUND

Urogenital tuberculosis (UGTB) has traditionally being a diagnosis of adulthood and is supposed to be rare in children, as it is believed that the symptoms of renal tuberculosis do not appear for 10 or more years after the primary infection. While this may be true in developed countries, where childhood pulmonary tuberculosis is a rarity nowadays. In developing countries, childhood pulmonary tuberculosis is still a major issue and hence, UGTB is not an uncommon diagnosis in younger children and adolescents in these countries. Considering this dearth of data on childhood UGTB, we retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery.

OBJECTIVE

To analyze the clinical presentation, management strategies and outcomes of pediatric UGTB managed in a tertiary care center.

MATERIALS AND METHODS

Case records of children and adolescents ≤18 years diagnosed with UGTB during the period July 1998 to June 2018 at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied.

RESULTS

There were 41 children and adolescents (M: F = 22:19) identified, with a mean age of 14.8 ± 3.9 years who fulfilled the inclusion criteria. The most common presentation was flank pain and irritative storage symptoms. Mycobacterium tuberculosis was identified on urinary examination in only 17 (41.5%) cases. Six patients were lost to follow up after initial diagnosis. A total of 45 procedures (35 primary and 10 secondary) were performed in 35 children. Initial diversion in the form of PCN and DJS were done in 11 and 12 patients respectively, of which 8 were managed with stenting alone. Surgical management was done mostly in the form of nephrectomy (15), nephrectomy along with reconstruction (5) and reconstruction only (6). On univariate analysis, factors associated with nephrectomy were poor initial function and nephrostomy as initial diversion. Overall median follow-up was 25 (IQR 15.5-74.25) months. During follow up, chronic renal failure developed in nearly 53.8% of patients who underwent major reconstruction.

CONCLUSIONS

Urogenital tuberculosis presents with a wide spectrum of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of minimally invasive diversions and surgery (both ablative and reconstructive) achieve satisfactory results in the majority of cases. Children undergoing major surgical reconstruction in particular need to be followed up rigorously and counselled about possibility of development of renal failure.

Primary Urethral Tuberculosis With Urethrocutaneous Fistula in Association With Balanitis Xerotica Obliterans

We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas which was confirmed on urethrogram. He was treated with antitubercular treatment and a two stage urethroplasty.

Can kidneys be saved in patients with urinary tuberculosis? A study in the era of modern chemotherapy and surgical armamentarium

OBJECTIVE

To assess renal unit survival and factors affecting renal salvageability in a cohort of patients receiving modern medical and surgical therapy for urinary tuberculosis.

METHODS

This was a retrospective single-center study including all patients diagnosed and treated as urinary tuberculosis between 2005 and 2015 at Christian Medical College, Vellore, Tamil Nadu, India. The primary outcome was time to renal unit non-salvageability (estimated glomerular filtration rate of <15 mL/min).

RESULTS

A total of 128 patients were included in the study. The mean age was 37.7 ± 11.3 years, 33% had microbiological and 73% had histopathological confirmation in addition to radiological diagnosis. The estimated median survival of the involved renal units (n = 187) on Kaplan-Meier estimate was 75 months (95% CI 39-99). On multivariate analysis, renal units with initial split function >15 mL/min had fivefold the survival estimate as compared with those ≤15 mL/min (P < 0.001); the presence of one, two and three infundibular strictures had a 2.2-, 2.9- and fivefold higher hazard of renal unit loss respectively, and lower ureteric strictures had fivefold longer estimated survival (P = 0.015) after treatment. Renal units in the reconstruction group had 5.44-fold (95% CI 2.71-10.88, P < 0.001) longer survival than the permanent diversion group, with a mean change in split function of +0.76 (±16.11) mL/min, versus -5.61 (±10.87) mL/min respectively.

CONCLUSIONS

Loss of renal units is a function of time despite modern treatment. Baseline renal unit function, site of ureteric involvement and extent of infundibular involvement on imaging are helpful in predicting the duration of renal salvageability. When feasible, reconstruction is better at renal function preservation.

Tuberculosis of the Urogenital Tract in Adults in a Tertiary Referral Center

The genitourinary system is the main location of extrapulmonary tuberculosis. In Poland, it occupies the third place after tuberculosis of the pleura and lymph nodes. The aim of this study was to evaluate the prevalence and characteristics of tuberculosis in the urogenital tract in adult patients in a tertiary referral center in the years 2007-2015. The retrospective study included 87 patients, 42 women and 45 men. The average age was 62 ± 15 years. Changes in the urinary tract were diagnosed in 91% of women and 64% of men. Testicular tuberculosis was found in ten men, prostate tuberculosis in five, and in individual cases tuberculosis of the epididymis, scrotum, uterus, and the fallopian tube were found. The diagnosis was confirmed by bacteriological methods in 47% of patients, by histopathological in 41%, and by molecular methods in 23% of patients. In 84% of patients urological or gynecological interventions had to be applied. Patients were burdened with a number of urological diseases or diseases affecting other systems which hampered the diagnosis of tuberculosis. Antituberculosis treatment gave good results. Urogenital tuberculosis is a multivariate disease and a standard unified approach is impossible.

Aspects of Evolving Genito Urinary Tuberculosis-A Profile of Genito Urinary Tuberculosis (GUTB) in 110 Patients

INTRODUCTION

Genito Urinary Tuberculosis (GUTB) is a widespread disease seen in urology practice. The true incidence and prevalence of GUTB is difficult to estimate because a large number of patients remain asymptomatic.

AIM

To recognize typical and atypical clinical and radiological features of tuberculosis and to emphasize the need for diagnosing GUTB early.

MATERIALS AND METHODS

This was a retrospective study conducted in 110 cases of GUTB diagnosed and treated in two teaching institutions over a period of three years, from July 2002 to June 2005. A detailed history, thorough clinical examination, urine examination, culture for tubercle bacillus, imaging studies, cystoscopy and histological and serological examination were done to arrive at a diagnosis.

RESULTS

Fifty six patients (51%) were in the age group of 21-40 years. The male: female ratio was 1.4: 1. Loin pain was the most common symptom observed in 27% of the patients. Intravenous Urogram (IVU) revealed non-visulalised kidney in 25 patients (23%), hydronephrosis or hydrouretero nephrosis in 34 patients (31%) and distortion, cavitation or scarring of the calyces in 16 patients (14.5%). Five of them had thimble bladder. In 14 patients, IVU appeared normal. About 28 patients (25%) were treated conservatively with anti tuberculosis therapy. Twenty one of them (19%) underwent Nephrectomy and 10 patients had reconstructive procedures.

CONCLUSION

A peculiarity of most of our patients was a late presentation with advanced disease. Most patients were asymptomatic or ignorant. Slow but continuous infection causes a destruction of renal parenchyma and the healing process leads to renal parenchymal loss. If identified early and treated appropriately, GUTB is a curable condition.

Laparoscopic Reconstruction in Post-Tubercular Urinary Tract Strictures: Technical Challenges

BACKGROUND

Genitourinary tuberculosis still continues to plague developing countries and is a significant cause of morbidity as well as mortality in the developing world. At present, nearly 55% of the patients of genitourinary tuberculosis (GUTB) need surgical management. Owing to the presence of dense adhesions and loss of normal anatomical planes, GUTB was considered to be a contraindication to laparoscopic surgery. However, recent literature shows laparoscopy to be feasible in GUTB. Our study aimed at identifying the challenges in laparoscopic urinary tract reconstructive surgery in genitourinary tuberculosis-related urinary tract obstruction.

MATERIALS AND METHODS

The details of 6 patients who underwent different types of laparoscopic reconstructive surgery for genitourinary tuberculosis-related urinary tract obstruction from January 2014 to December 2015 were reviewed. Baseline characteristics, indications of surgery, type of surgery, operative duration, blood loss, and follow-up details were noted. All patients received antitubercular treatment before surgery as per the direct observed treatment short-course regimen followed in our country.

RESULTS

We performed one bilateral laparoscopic pyeloplasty, one unilateral laparoscopic pyeloplasty, two laparoscopic ureteroneocystostomies, and two ureteroureterostomies. Difficulty was encountered during dissection owing to the presence of adhesions, but conversion to open surgery was not done in five cases. Dense adhesions adjacent to the common iliac vessels necessitated conversion to open surgery in one of the ureteroureterostomies. Stenting was done in all the patients. All patients had uneventful postoperative recovery. Functional imaging following stent removal showed unobstructed tracer flow, showing successful operative outcome.

CONCLUSIONS

Our study showed that laparoscopic reconstructive surgery is feasible in genitourinary tuberculosis despite the presence of adhesions that may pose a challenge to dissection. This is in contrast to the previous studies which conclude that genitourinary tuberculosis is a relative contraindication to laparoscopic surgery.

Genital tuberculosis: current status of diagnosis and management

Genitourinary Tuberculosis (GUTB) is the second most common extra-pulmonary manifestation of tuberculosis (Tb) and an isolated involvement of genital organs is reported in 5–30% of the cases. Genital involvement results from primary reactivation of latent bacilli either in the epididymis or the prostate or by secondary spread from the already infected urinary organs. The epididymis are the commonest involved organs affected primarily by a hematogenous mode of spread. Tb is characterized by extensive destruction and fibrosis, thus an early diagnosis may prevent function and organ loss. The gold standard for diagnosis is the isolation and culture of mycobacterium tuberculosis bacilli and in the cases of suspected GUTB, it is commonly looked for in the urinary samples. All body fluid specimens from possible sites of infection and aspirates from nodules must also be subjected to examination. Radiologic investigations including ultrasonography and contrast imaging may provide supportive evidence. Anti-tubercular chemotherapy is the first line of management for all forms of genital Tb and a 6 months course is the standard of care. Most patients with tubercular epididymo-orchitis respond to antitubercular therapy but may require open or percutaneous drainage. Infertility resulting from the tubercular affliction of the genitalia is multifactorial in origin and may persist even after successful chemotherapy. Multiple organ involvement with obstruction at several sites is characteristic and most of these cases are not amenable to surgical reconstruction. Thus, assisted reproduction is usually required. Post treatment, regular annual follow up is recommended even though, with the current multi drug therapy, the chances of relapse are low.

Renal Tuberculosis Presenting as a Mass Lesion in a Two-year-old Girl: Report of a rare case

Genitourinary tuberculosis usually occurs in young adults and the middle-aged and is very uncommon in the paediatric population. It generally presents with haematuria, pyuria, irritative voiding symptoms and flank pain; presentation as a renal mass is highly unusual. We report a two-year-old girl who was referred to the Nil Ratan Sircar Medical College, Kolkata, India, in June 2014 with abdominal pain. Subsequent radiological investigations revealed a left renal hypoechoic mass lesion. A left nephroureterectomy was performed on suspicion of a Wilms' tumour. Histopathology indicated an epithelioid granuloma with lymphocytic infiltration, suggestive of a tubercular aetiology. A Mantoux tuberculin skin test was positive; however, there was no evidence of tuberculosis detected elsewhere in the body and the source of the infection could not be identified. A diagnosis of renal tuberculosis was made and the child was treated with antitubercular drugs. The patient was asymptomatic at a six-month follow-up.

Use of Corticosteroids for Urinary Tuberculosis Patients at Risk of Developing Ureteral Obstruction

A 77-year-old man with urinary tuberculosis developed post renal anuria two days after starting an anti-tuberculosis drug regimen. He had bilateral hydronephrosis, and his right kidney was radiologically diagnosed to be non-functioning. A transurethral catheter was placed in the left ureter. No improvement in the ureteral stricture was noted during the initial three weeks of treatment; however, the stricture did thereafter improve after the commencement of oral prednisolone. In cases of urinary tuberculosis, ureteral stricture can deteriorate and result in ureteral obstruction during anti-tuberculosis treatment. Pre-emptive administration of corticosteroids may be beneficial for preventing such stricture in patients with a pre-existing ureteral lesion.

Primary tuberculosis of urethra presenting as stricture urethra and watering can perineum: A rarity

A young man presented with irritative lower urinary tract symptoms and multiple fistulae (watering can) in the perineum since 6 months. Micturating cystourethrogram and retrograde urethrogram was performed after 12 weeks following suprapubic cystostomy which showed bulbar urethral stricture with multiple urethrocutaneous fistulae. He underwent anastomotic urethroplasty and excision of the urethrocutaneous fistulae. Histopathology of the excised fistulous tract showed granulomatous pathology suggestive of tuberculosis. Antitubercular treatment was given for 9 months. The patient is voiding well at 12 months follow-up.

Urinary Tuberculosis with Renal Failure: Challenges in Management

INTRODUCTION

India is the country with the highest burden of TB, an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million according to World Health Organization (WHO) statistics for 2013. Renal impairment in these patients is slow and due to continuous infection causing destruction of renal mass. Reconstruction of urinary tract which is frequently required for patients with Urinary TB poses significant challenges. This paper analyses these challenges.

AIM

To analyse challenges in reconstruction of urinary tract in patients with urinary tuberculosis and renal failure.

MATERIALS AND METHODS

Thirty-one patients with renal tuber-culosis were seen from August 2011 to August 2013. We faced major problem in outcomes of surgery in patients with multifocal disease.

RESULTS

Out of 31 patients 18 patients were males and 13 were females. Total 11 patients had serum creatinine more than 2mg/dl (1.5 mg/dl being upper normal range of our laboratory) at the time of presentation. These patients had simultaneous kidney, ureter and bladder involvement or with bilateral disease. Four of these patients underwent uretero-calicostomy, five patients underwent augmentation cystoplasty with bilateral ureteric reimplantation and two patients underwent ileal conduit as they were having serum creatinine of more than 2.5 mg/dl. All patients who underwent ureterocalicostomy had re stricture and failure of surgery and augmentation cystoplasty had raised creatinine requiring second procedure in the form of percutaneous nephrostomy. Patients with ileal conduit remained stable with overnight bladder drainage at bed time.

CONCLUSION

Though renal failure is not considered contrain-dication for augmentation cystoplasty, reconstruction using large segment of bowel predisposes them to metabolic complications and sepsis. Use of short segment of ileal conduit with continued drainage at night in creatinine above 2.5 mg% is reasonable option for augmentation to avoid further metabolic complications.

The surgical management of urogenital tuberculosis our experience and long-term follow-up

INTRODUCTION

Urogenital tuberculosis (TB) is common in developing countries. We present our experience of surgically managed cases of genitourinary TB (GUTB).

MATERIALS AND METHODS

We retrospectively reviewed 60 cases GUTB who underwent surgery at our center from January 2003 to January 2010. Mode of presentation, organ involvement, investigation, surgical treatment and follow-up were studied.

RESULTS

There were 38 males and 22 females with a mean age of 32.5 years. The most common symptom was irritative voiding symptoms. The most common organ involved was bladder in 33 cases, and next most common was kidney in 30 cases. Preoperative bacteriologic diagnosis was confirmed in only 19 cases. A total of 66 procedures were performed as some patients needed more than one procedure. These included 35 ablative procedures and 31 reconstructive procedures. All the patients were followed-up with renal function test (RFT) at 3, 6 and 12 months. The intravenous urography and diethylenetriamine pentaacetic acid scan were performed at 3 months when indicated. Then the patients were followed with RFT and ultrasonography 6 monthly for 3 years and then annual RFT.

CONCLUSION

Many patients of urogenital TB present late with cicatrisation sequelae. Multidrug chemotherapy with judicious surgery as and when indicated is the ideal treatment. The results of reconstructive surgery are good and should be done when possible. Rigorous and long term follow-up is necessary in patients undergoing reconstructive surgery.

Isolated urethral tuberculosis in a middle-aged man: a case report

Introduction

Urogenital tuberculosis is a frequent disease in endemic countries. It is characterized by clinical polymorphism. The isolated urethral form is exceptional, even in countries with endemic tuberculosis. We present a rare case of urogenital tuberculosis in a man revealed by urethral narrowing and multiple urethro-scrotal fistulas.

Case presentation

The patient, a Moroccan man, was 40 years old. He visited our hospital for a urology consultation and presented with dysuria, purulent discharge and a meatic penoscrotal fistula. A retrograde and voiding urethrocystography was performed and revealed an extended narrowing of the whole anterior urethra associated with multiple fistulous portions toward the scrotum and perineum. At this stage, we reached a diagnosis of nonspecific sclero-inflammatory urethral stricture with complicating fistulas. We decided to perform a urethroplasty enlargement to clear the narrowing urethral sinus tracts. The evolution was marked by delayed wound healing associated with the persistence of fistulas extending into the corpus cavernosum with purulent discharge. It was at this point in the treatment that we suspected tuberculosis. Multiple biopsies were then performed on the periurethral tissue and fistula tracts. The histological examination confirmed urethral tuberculosis and showed the presence of giant cell epithelial lesions with caseous necrosis characteristic of tuberculosis. The treatment for tuberculosis was immediately established and the evolution was marked by a localized, rapid and significant improvement. A second-stage urethroplasty was scheduled for two months after the start of his antituberculous treatment.

Conclusions

Urogenital tuberculosis is common, but isolated urethral involvement is very rare even in countries with endemic tuberculosis. We urge practitioners, and especially urologists, to consider the disease in their investigation whenever given clinical signs are declared.

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.

Reconstructive bladder surgery in genitourinary tuberculosis

Genitourinary tuberculosis (GUTB) occurs in 15-20% cases of pulmonary tuberculosis with a prevalence of 400 per 100,000 population. Reconstructive surgery for GUTB is required for cases with grossly distorted and dysfunctional anatomy that are unlikely to regress with chemotherapy alone. In the recent past, there has been a tremendous increase in the variety of reconstructive procedures for the urinary bladder, used in the management of GUTB. Augmentation cystoplasty includes the goals of increasing bladder capacity, while retaining as much of bladder as possible. Various bowel segments (from the stomach to the sigmoid colon) have been used for bladder reconstruction. The choice of material for reconstruction is purely the surgeon's prerogative--his skill, the ease, the mobility and length of mesentery (allowing bowel to reach the bladder neck without tension and maintaining an adequate blood supply). The presence or absence of concomitant reflux is of considerable importance. In the former, an ileocystoplasty with implantation of ureter to the proximal end of the isolated ileal loop and anastomosis of the distal end of the ileal loop to the bladder neck and trigone is advocated. In the latter case, the ureterovesical valve is preserved and colocystoplasty is preferred, wherein the sigmoid colon on being opened along its antimesentric border is joined to the trigone and bladder neck and then to itself to form a capacious pouch. Gastrocystoplasty reduces the risk of acidosis but is associated with complications like hypochloremic alkalosis and ‘hematuria-dysuria’ syndrome. Orthotopic neobladder reconstruction is a feasible option, suitable in cases of tubercular thimble bladder with a markedly reduced capacity (as little as 15 ml), where an augmentation alone may be associated with anastomatic narrowing or poor relief of symptoms. In this article, we review the various bladder reconstruction options used for the surgical management of GUTB, along with their indications and complications.

Clinical presentation and diagnostic approach in cases of genitourinary tuberculosis

Objective:

We herein describe the various modes of presentation in genitourinary tuberculosis (GUTB) and a simple diagnostic approach to it.

Materials and Methods:

We made a literature search through Medline database and various other peer-reviewed online journals to study the various modes of presentation in GUTB. We reviewed over 100 articles published in the last 10 years (1998 -- 2007), which were tracked through the key words like GUTB and extrapulmonary tuberculosis.

Results:

GUTB has varied presentation and the most common way of presentation is in the form of irritative voiding symptoms, which are found in more than 50% of the patients. The usual frequency of organ involvement is: kidney, bladder, fallopian tube, and scrotum. The usual tests used to diagnose GUTB are the demonstration of mycobacterium in urine or body fluid and radiographic examination. Intravenous urography (IVU) has been considered to be one of the most useful tests for the anatomical as well as the functional details of kidneys and ureters. In cases of renal failure, MRI can be used. Newer examinations such as radiometric liquid culture systems (i.e., BACTEC^®, Becton Dickinson, USA) and polymerase chain reaction (PCR) give rapid results and are highly sensitive in the identification of mycobacterium.

Conclusion:

GUTB can involve any part of the genitourinary system and presentation may vary from vague urinary symptoms to chronic kidney disease. Newer tests like radiometric liquid culture systems and polymerase chain reaction give rapid results and carry high diagnostic value.

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

OBJECTIVE

To document the management of tuberculous cicatrized urinary bladder by incorporating bowel segment and the long-term follow-up after the reconstructive surgery.

MATERIALS AND METHODS

Twenty-three patients (out of 28) were managed by augmentation cystoplasty (AC) and 5 by orthotopic neobladder (OTN) reconstruction. Sigmoidocystoplasty was performed in 11 cases, ileocystoplasty in 10 patients and ileocecocystoplasty in 2 patients. Ileal neobladder reconstruction was done in 2 patients, ileocecal neobladder reconstruction in 1 patient and sigmoid neobladder reconstruction in 2 patients, respectively. The patients were followed according to standard follow-up protocols.

RESULT

The mean age of patients who underwent AC was 32.5 years and of those who underwent OTN reconstruction was 31 years. The mean pre-operative bladder capacity in patients with AC was 70 ml (range 40-100 ml) and of patients with OTN reconstruction was 14 ml (range 10-20 ml). The mean postoperative bladder capacity at 3 months following AC was 427 ml (range 450-500 ml) and following OTN reconstruction it was 430 ml (range 350-450 ml). The mean follow-up in patients who underwent AC was 43.3 months (range 12-90 months) and in those who underwent OTN reconstruction it was 35.6 months (16-60 months). None of the patients had upper urinary tract deterioration following the reconstructive surgery.

CONCLUSION

Urinary bladder rehabilitation either by AC or OTN reconstruction increases the bladder capacity and storage time and also preserves the upper tracts.

Genitourinary tuberculosis in pediatric urological practice

OBJECTIVE

Genitourinary tuberculosis is a form of secondary tuberculosis with vague symptoms and presentation, and is rare in children. Antitubercular therapy is the cornerstone of treatment, although surgical intervention is required in a minority of the cases. We retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery.

MATERIALS AND METHODS

Case records of 17 children diagnosed and admitted with genitourinary tuberculosis at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied.

RESULTS

There were 11 male and six female children with a mean age of 11.6 years, admitted during the period July 1990 to June 2005. The most common presentation was storage lower urinary tract symptoms. The most commonly involved organ was the ureter in seven (41%) cases. Mycobacterium tuberculosis was identified on urinary examination in only five (29%) cases. A total of 28 procedures, including 15 endoscopic, four ablative and five reconstructive, were performed with some children requiring more than one procedure. Renal functional parameters stabilized or improved in four of five children (80%) in whom they were deranged at presentation.

CONCLUSIONS

Genitourinary tuberculosis presents with a wide variety of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of surgery achieve satisfactory results in the majority of cases. With improved drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. Children undergoing surgical procedures and reconstruction in particular need to be followed up rigorously.

Surgical management of renal tuberculosis

Tuberculosis (TB) is one of the major health problems that our country is facing today. Despite active interventions by our government, control of TB still remains to be achieved. The emergence and exponential growth of the human immunodeficiency virus and drug-resistant strains threaten to further complicate the TB situation in our country. Even in this era of advanced chemotherapy, many lives are lost every day in our country. Tuberculosis of the urinary tract, despite being one of the commonest forms of extra-pulmonary TB, is generally overlooked. Most patients present with vague lower urinary symptoms typical of urinary tract infection. In this article, we shall highlight the various issues related to the surgical management of renal and ureteral tuberculosis.

Current survey of urinary tuberculosis in Hokkaido, Japan

Urinary tuberculosis has been rare in recent years and its diagnosis is difficult because there are no disease-specific symptoms. We tried to clarify the occurrence of urinary tuberculosis in recent years in our area. During the past 5 years, there were 12 patients with urinary tuberculosis in the clinics that participated in this study. Their chief complaints were frequent voiding in 7 patients and gross hematuria in 3 patients. They were diagnosed by nucleic acid amplification tests and imaging modalities such as excretory urography, computed tomography, and/or cystoscopy. Most of the patients received multidrug treatment and had relatively favorable treatment outcomes. There has been a small but neglected number of patients with urinary tuberculosis in recent years. We should keep this rare and difficult-to-diagnose disease in mind and suspect it when patients complain of longstanding urinary symptoms with no obvious cause.