Multidetector CT urography in urogenital tuberculosis: use of reformatted images for the assessment of the radiological findings. A pictorial essay

Urogenital tuberculosis (UGTB) is the most common form of extrapulmonary TB and is responsible for a destructive inflammation of the renal parenchyma and urinary tract often leading to the loss of kidney function. For these reasons, the early diagnosis of this disease, once considered disappeared in developed countries, is very important to establish a prompt and efficient treatment. However, the subtle and non-specific symptoms, often represented by recurrent and persistent lower urinary tract symptoms, can confound and delay the diagnosis. Therefore, an adequate and comprehensive imaging study is necessary in patients with persistent urinary tract infections not responding to the antibiotics and can suggest the hypothesis although bacteriological and/or histologic analysis is required for a definitive diagnosis. In the past years, intravenous urography (IVU) has allowed a comprehensive study of the urinary excretory tract, promoting the knowledge of the radiological findings of this disease. Nowadays, computed tomography urography (CTU), with the implementation of multidetector (MD) technology, has replaced IVU in all its indications; the MDCTU improves the assessment of renal and urinary tract lesions using reformatted images [such as multiplanar reconstruction (MPR) and maximum intensity projection (MIP)]. Therefore, our paper aims to provide a guide for radiologist for searching the classic signs of UGTB on MDCTU, encouraging the use of the MPR and MIP reformatted images.

[The epidemiological situation of urogenital tuberculosis in Siberia and the Far East]

INTRODUCTION

Tuberculosis remains one of the most important problems of our time. Late diagnosis of urogenital tuberculosis (UGT) results from a lack of a clinician awareness, paucity of pathognomonic symptoms and suboptimal therapy for urinary tract infections while UGT often manifests under their disguise.

AIM

To determine the incidence of urogenital tuberculosis and its structure in an epidemiologically unfavorable region.

MATERIAL AND METHODS

The study compared the temporal changes in the structure of UGT morbidity from 1999 to 2015 in the Siberian and Far Eastern Federal Districts and analyzed outpatient medical records of 456 UGT patients.

RESULTS

The highest (46%) proportion of UGT in the structure of extrapulmonary disease was found in 2003, the lowest (22.9%) in 2014. According to outpatient medical records, the proportions of patients with stage 1, stage 2 and cavernous forms of nephrotuberculosis ranged from 21.2 to 37%, 26 to 53.5% and 21.6 to 37%, respectively. The incidence of prostate tuberculosis ranged from 0 in 2003 and 7.1% in 2008 to 54.2% in 2013, averaging to 33.9%.

CONCLUSIONS

Currently, it is impossible to estimate the true prevalence of UGT, we can only speak about the detection rate. Every fourth UGT patient was under the medical supervision with a wrong diagnosis for 5 or more years. The proportion of UGT in the structure of morbidity from all forms of extrapulmonary TB reached a minimum (22.9%) in 2014 but went up again. Introducing new technologies has led to an improvement of bacteriological verification of UGT and increased prostate tuberculosis detection rate to 35.7%.

Imaging findings of urinary tuberculosis on computerized tomography versus excretory urography: through 46 confirmed cases

BACKGROUND

Imaging findings of urinary tuberculosis (TB) on excretory urography (IVP) and CT have been reported to be nonspecific although CT may provide detailed informations. We performed a retrospective study of patients with proven urinary TB to compare imaging findings on IVP and CT and to make a systemic approach to imaging analysis of urinary TB.

METHODS

Urinary TB was diagnosed in 46 patients who had IVP and CT examinations prior to definitive diagnosis and treatment. They were 30 females and 16 males with a mean age of 43.6 ys. We assessed the presence and frequency of urinary tract calcifications, autonephrectomy, renal parenchymal masses, renal parenchymal scarring, moth-eaten calices, amputated infundibulum, renal parenchymal cavities, hydrocalycosis, hydronephrosis, hydroureter and thick urinary tract walls.

RESULTS

CT was most sensitive in detecting any renal parenchyma cavities (p=0.01), hydronephrois (p=0.0005), ureteral stricture (p=0.03) and walls thickening of the renal pelvis / ureter (p< 0.0001). Four imaging patterns were noted in 20 IVPs (43%) and 34 CTs (74%) with multiple findings. They were hydrocalycosis, hydronephrosis or hydroureter du to multiple stricture sites, ureteral stricture with thick wall, autonephrectomy combined with at least 1 other type of imaging finding and thick wall of renal pelvis or ureters and bladder with at least 1 other type of imaging finding.

CONCLUSIONS

Renal parenchymal cavities, hydronephrosis, ureteral stricture and thickened urinary tract walls were significantly more common on CT than on IVP. Multiple findings on CT were more common and very useful for TB diagnosis. Thus, we recommend CT as the standard exam in patients with suspicion of urinary TB.

[Radical nephrouretercystectomy]

The results of radical nephrouretercystectomy (NUCE) are presented for 13 patients (9 males and 4 females, age 44-70 years, mean age 58 +/- 1.7 years). One-stage NUCE was made in 11 patients, two- or three-stage--in 2 patients. Indications for NUCE were the following: urothelial cancer, urogenital tuberculosis, microcystis, neurogenic dysfunction of the urinary bladder complicated by definite renal dysfunction. Postoperative complications arose in 3 patients. Lethal outcomes were absent. The results presented say in favour of extended surgery in involvement of the kidney, ureter, urinary bladder, prostate, urethra. Radical NUCE is primarily indicated in cancer of the renal pelvis, ureter with muscular invasion into the bladder wall, non-functional kidney due to ureteral obstruction with a tumor or scar.

A rare case of granulomatous prostatitis caused by Mycobacterium tuberculosis

We report a rare case of infective granulomatous prostatitis caused by Mycobacterium tuberculosis that may be mistaken for prostatic carcinoma, both on clinical examination and transrectal sonography (TRUS). A large hypoechoic mass was detected in the prostate of a 46-year-old man during TRUS and histopathologic examination after TRUS-guided biopsies reported the diagnosis of tuberculous prostatitis. We herein describe the clinical and TRUS findings of this case.

Role of imaging in predicting salvageability of kidneys in urinary tract tuberculosis

OBJECTIVE

To study the role of imaging in predicting salvageability of kidneys and the role of early nephrectomy in urinary tract tuberculosis (TB).

METHODS

This was a retrospective study of 103 cases managed between 1990 to 1998. Intravenous urograms (IVUs) were reviewed and based on the IVU findings. Patients were stratified into three groups. Treatment consisted of immediate surgery, defined as nephrectomy within six weeks of starting anti-TB treatment (ATT) and delayed as nephrectomy done after completion of ATT. Chi square test was applied to find the significance of early nephrectomy. Logistic regression analysis model was used to identify factors predicting salvageabilty of the nephron mass.

RESULTS

Of the 103 cases, 23 had early nephrectomy and all of them achieved cure and had good renal function at follow up. Of the 76 who received only ATT, 43 were cured and the remaining 33 deteriorated symptomatically with high serum creatinine and decreasing GFR. Of the 33 who deteriorated, radiological and biochemical deterioration was seen in 24, two developed flank sinus and one developed multi drug resistant TB. On sub-grouping of the patients based on IVU, it was found that those with major renal lesion alone (group A) or with bladder involvement (group C) required either early or delayed nephrectomy and those who had minor lesion (group B) or bladder involvement with or without minor lesion (group C) did well on ATT alone. Logistic regression model showed cavitory lesions, GFR < 20ml/min/m2 and gross hydronephrosis as statistically significant unfavourable factors and ureteric stricture as a favourable factor.

CONCLUSION

In the era of modem ATT, nephrectomy is still an essential procedure. We recommend early nephrectomy for patients with major renal lesion with or without bladder involvement, gross hydronephrosis and for those who have GFR of < 20 ml/min/m2. Lower ureteric strictures and renal units with GFR of > 20 ml/min/m2 are favourable factors and salvage procedures are successful in these cases. It is likely that nephrectomy removes a large focus of disease and possibly dormant bacteria. With continuance of ATT, this further helps in improved patient outcome.

Laparoscopy-assisted ileal ureter creation for multiple tuberculous strictures: report of two cases

We describe in detail the technique of laparoscopy-assisted ileal ureter creation for multiple tuberculous ureteral strictures in two patients. The proximal anastomosis included an ileocalicostomy in the first patient and an ileopyelostomy in the second patient. The first patient had bowel entrapment behind the mesentery of the ileal loop, but the second patient had an uneventful postoperative recovery. Short-term follow-up showed good patency of the ileal loop. The variations in the technique that can cause postoperative problems are discussed, and the future of this technique is postulated.

Case Report: Tubercular Cold Abscess of Seminal Vesicle: Minimally Invasive Endoscopic Management

BACKGROUND

Tubercular cold abscess of the seminal vesicle is very rare, and only a few cases are reported in literature. Preoperative diagnosis is difficult and to the best of our knowledge has not been reported.

CASE REPORT

A 35-year-old man presented with a 7-year history of blood in the semen and a reddish brownish discharge per urethra while defecating. On rectal examination, a soft fluctuant mass was felt above the prostate. Abdominal ultrasonography showed cystic swelling of the right seminal vesicle bulging into the posterior bladder wall. Semen examination showed abundant pus cells and 90% immotile sperm with normal morphology. Acid-fast bacilli were not seen, but acid-fast bacilli were found in a 24-hour urine specimen. Cystoscopy showed tubercles in the urethra and brownish discharge from the orifice of the right ejaculatory duct on per-rectal compression of the mass. The abscess cavity was incised with a Collings' knife. Brownish material was evacuated, and the abscess cavity was seen. An 18F Foley catheter was placed for 3 days. Antitubercular therapy was instituted. Ultrasonography repeated after 3, 25, 45, and 75 days showed gradual regression of the abscess cavity. Semen examination after 75 days was normal, with 75% motility, and cystoscopy 45 days postoperatively showed complete healing of the wound.

CONCLUSION

The incision connecting the bladder with the abscess cavity facilitated evacuation of pus and complete resolution of the abscess.

Virtual cystoscopy: reality in imaging of bladder tuberculosis

We present a case of urinary tuberculosis investigated initially by ultrasound and multidetector computed tomography (MDCT). The MDCT-derived volumetric data were used to generate virtual cystoscopy (VC) images, which revealed a bladder ulcer. The presence of this ulcer was confirmed by conventional cystoscopy-guided biopsy and there was good agreement regarding various features of the ulcer, such as the site, size and shape, as detected by virtual and conventional cystoscopies. VC, a result of simple postprocessing of preacquired MDCT data, proved valuable in the characterization of the bladder lesion in conjunction with CT and ultrasound images. Although a larger study is warranted, in our case these en face VC representations of the ulcer served as useful precursors to conventional cystoscopic biopsy.

Bladder augmentation for the treatment of chronic tuberculous cystitis. Clinical and urodynamic evaluation of 25 patients after long term follow-up

AIMS

Clinical and urodynamic evaluation of the late outcome of 25 patients with chronic tuberculous cystitis who underwent bladder augmentation.

PATIENTS AND METHODS

Twenty men and five women with median age of 40 years were evaluated. The tubularized ileocecal segment was used in 8 cases, the detubularized sigmoid in 13, and the tubularized sigmoid in 4. Patients underwent a postoperative clinical and urodynamic evaluation. Miccional diurnal frequency of more than 2 hr together with patient satisfaction as assessed by the quality of life question of the ICSmaleSF questionnaire was considered a good result.

RESULTS

The average postoperative follow-up was of 11.1 +/- 9.1 (1 to 36) years. A good result was seen in 80% of the patients. Bad results occurred statistically in the cases using tubularized sigmoid and in patients with prostatitis. Patients with good results showed augmented bladders with normal sensation (P = 0.03) and greater capacity (P < 0.01) and compliance (P < 0.01) than did those with bad results. There was no statistically significant difference in the frequency of involuntary contractions (P = 0.27) but in the good result patients, the contractions started with greater bladder filling volume (P = 0.02).

CONCLUSIONS

The sigmoid should be detubularized but the ileocecal segment may be used in its original tubularized form to augment the bladder with chronic tuberculous cystitis. Augmented bladder with capacity of more than 250 ml, good compliance, and normal sensation are necessary for diurnal frequency of more than 2 hr. The presence of involuntary contractions does not lead to a decrease in the diurnal frequency.

Genitourinary tuberculosis

Although uncommon, genitourinary tuberculosis is the most common site of extrapulmonary tuberculosis infection. Its diagnosis is often difficult. This article provides an overview of the pathologic and radiologic findings of this disease process.

Modern imaging of tuberculosis in children: thoracic, central nervous system and abdominal tuberculosis

Tuberculosis (TB) can affect any organ in the body. Children are a high-risk group for contracting the disease and pose a constant challenge to clinicians with regard to making a definitive diagnosis. Radiologists are playing a more active role in diagnosing TB, and armed with more accurate diagnostic investigations such as CT and MRI, they must face the cost implications as well as technical limitations. This review aims to guide the reader through the modern imaging techniques useful for diagnosing TB of the thorax, central nervous system and abdomen in children. The more specific features of each modality in the particular anatomical regions are highlighted.

Spectrum of high-resolution sonographic features of urinary tuberculosis

OBJECTIVE

To evaluate the high-resolution sonographic features of urinary tuberculosis.

METHODS

During a period of about 3 years 6 months, there were 45 patients with sonographic features of urinary tuberculosis that was subsequently proved by urine culture or biopsy. The clinical symptoms, urinalysis findings, sonographic features, urine smear findings, and biopsy findings were recorded.

RESULTS

The most common symptoms were dysuria and frequency of micturition. Sonographic features included parenchymal masses, cavities, mucosal thickening of the collecting system and urinary bladder, stenosis of the collecting system, a contracted urinary bladder, vesicoureteric reflux, and calcifications. The proof of tuberculosis was by urinalysis, culture, and biopsy.

CONCLUSIONS

High-resolution sonography in appropriate clinical situations is useful in diagnosis of urinary tuberculosis. The various high-resolution sonographic findings in urinary tuberculosis are illustrated. The distinguishing features are visualization of involvement of multiple sites and multiple stages of disease in the same patient.

[Unexpected complication in an elderly lady suffering from rheumatoid arthritis]

A 66-year old female suffering from rheumatoid arthritis was treated with methotrexate and intra-articular steroid injections. She had gone through pulmonary tuberculosis at the age of 2 years, also, surgery had been performed 2 years ago because of perforated sigmoid diverticulitis. The patient now presented with episodes of abdominal pain and diarrhea as well as occasional night sweats. Laboratory investigation (normal BSR, CRP and white blood cell counts) did not indicate the presence of an inflammatory process, such as reoccurrence of diverticulitis. However, leukocyturia was repetitively found in this patient with the conventional urine culture yielding no significant bacterial growth. Further urine investigation did not indicate infection with Chlamydia trachomatis or Neisseria gonorrhoeae. Ziehl Neelson stains of morning urinary samples did not show acid-fast rods, however, Mycobacterium tuberculosis was finally isolated by culture. Thus, urogenital tuberculosis was finally diagnosed in this patient. Infection, hematogenic dissemination, and spontaneous remission of pulmonary tuberculosis had occurred more than 60 years ago. After a long latent period, reactivation of tuberculosis happened during drug-induced immunosuppression. The patient was successfully treated with an anti-tuberculosis triple-drug therapy during 2 months followed by a double-drug therapy during 4 months.

[A rare cause of urinary obstruction: urogenital tuberculosis]

The authors reported a rare cause of urogenital tuberculosis complicated by an obstructive acute renal failure in 44 years old man with solitary anatomic kidney. The authors insisted of using the upper urinary tract opacification by percutaneous nephrostomy for diagnosis, the urogenital tuberculosis with this exploration, we can suspected the tuberculosis by abnormalities of the radiologic imagine, and confirmed the koch bacilli urinary into urinary tract. The upper chance of positives of finding koch bacilli in higher than urinary bladder.

Imaging findings of urinary tuberculosis on excretory urography and computerized tomography

PURPOSE

We performed a retrospective study to analyze findings on excretory urography (IVP) and computerized tomography (CT) in patients with urinary tuberculosis.

MATERIALS AND METHODS

In a 16-year period 53 patients with a total of 47 IVP and 33 CT examinations were diagnosed with urinary tuberculosis at our hospital. IVP and CT were reviewed and compared for certain imaging findings, including moth-eaten calices, renal parenchymal masses, an amputated infundibulum, autonephrectomy, thick urinary tract walls, urinary tract calcifications, renal parenchymal cavities, hydrocalycosis, hydronephrosis or hydroureter due to stricture, extra-urinary tubercular manifestations and renal parenchymal scarring.

RESULTS

The most common finding on IVP was hydrocalycosis, hydronephrosis or hydroureter due to stricture, whereas renal parenchymal scarring was the most common finding on CT. Imaging findings of renal parenchymal masses and scarring, thick urinary tract walls and extra-urinary tubercular manifestations were significantly more common on CT than on IVP. Three imaging patterns were noted on all 44 IVPs (100%) and 31 of 33 CTs (94%) with multiple imaging findings, including multiple stricture sites, a single stricture with 1 other imaging finding and autonephrectomy with another imaging finding other than stricture.

CONCLUSIONS

When the 3 imaging patterns are shown on IVP and CT, tubercular cultures or biopsies are suggested to make the definite diagnosis of urinary tuberculosis. Thus, treatment can be initiated as early as possible.

Retroperitoneoscopic extirpation for adult multicystic calcified dysplastic kidneys with contralateral ureteral abnormalities mimicking genitourinary tuberculosis

PURPOSE

To identify adult multicystic calcified dysplastic kidneys (AMCDK) with contralateral ureteral abnormalities mimicking urinary tuberculosis and to evaluate the feasibility and efficacy of retroperitoneoscopic extirpation in their management.

PATIENTS AND METHODS

We retrospectively identified a group of adult patients who were referred to us as having unilateral nonfunctioning kidney containing calcified cystic masses with a contralateral normally functioning kidney along with segmental dilation of ureter. Two patients had histories of treatment elsewhere with antitubercular drugs on the basis of imaging studies, before being referred to our center for retroperitoneoscopic nephrectomy with a diagnosis of nonfunctioning left kidneys and urinary tuberculosis. The other two cases with similar findings on imaging studies were detected incidentally while the patients were undergoing investigations for vague abdominal symptoms.

RESULTS

All these patients had AMCDK on the left side and a contralateral normally functioning kidney with ureteral abnormality. Retroperitoneoscopic extirpation of the nonfunctioning left renal unit was carried out uneventfully with a mean operating time, blood loss, and hospital stay of 124 minutes, 80 mL, and 3 days, respectively. There were no complications. The dissection in these cases was difficult, as the dysplastic calcified kidney was plastered in the retroperitoneum.

CONCLUSION

Unilateral AMCDK with contralateral segmental dilation of the ureter may be separate entity or a coincidental finding, and it should not be confused with urinary tuberculosis unless there is microbiological and radiologic or histopathologic evidence of infection. Minimally invasive surgery in the form of retroperitoneoscopic extirpation is feasible, safe, and effective in such cases, although difficult, and it requires skills as well as experience.

Urinary tuberculosis in a two-year-old boy

The authors describe a case of genitourinary tuberculosis hitherto unobserved in early childhood.

Relief of urinary tract obstruction in tuberculosis to improve renal function. Analysis of predictive factors

OBJECTIVE

To assess the effect of the relief of obstruction on the ultimate function of the affected renal unit in urinary tuberculosis, and to identify predictors of functional recoverability.

PATIENTS AND METHODS

Of a total of 82 patients with urinary tuberculosis presenting over 7 years, 38 with evidence of upper tract obstruction were analysed. All patients were assessed with pre-operative excretory urography, urinary mycobacterial cultures and serum chemistry. Patients with subnormally functioning kidneys were assessed with baseline renal scans. Preliminary intervention in the form of JJ stenting or percutaneous nephrostomy (PCN) was carried out in patients with reasonable renal function. Function was reassessed after 4 weeks to detect evidence of improvement and factors which could affect the outcome were determined.

RESULTS

Thirty-eight patients had documented upper tract obstruction, of whom six had bilateral obstruction (total of 44 renal units). Ten renal units were not functioning at presentation, with a mean (SD) glomerular filtration rate (GFR) of 3.0 (5.73) mL/min, and no preliminary intervention was performed. In the remaining 34, preliminary intervention was carried out before definitive surgery (JJ stenting in 14, PCN in 15 and PCN followed by antegrade JJ stenting in five); 21 of these renal units were salvaged but 13 were lost despite overcoming the obstruction. Three of the 13 units deteriorated from having acceptable pre-treatment GFRs to becoming non-functional. Good renal cortical thickness, a low grade of renal involvement (Semb 1 or 2), the presence of more distal disease in the form of ureteric stricture and a GFR of > 15 mL/min were good predictors of renal recovery after diversion.

CONCLUSIONS

The loss of some renal units seems inevitable in patients with urinary tuberculosis, despite advances in chemotherapy. Having pre-operative predictors of renal recovery may ensure optimal patient selection, thereby reducing the number of procedures and economic burden on the patient who does not require intervention.

[A case of prostatic tuberculosis: usefulness of transrectal ultrasound in diagnosis]

A case of prostatic tuberculosis is reported. A 61-year-old male visited our clinic complaining of urinary retention. On digital rectal examination, the prostate was found to be enlarged, hard, and uneven. Transrectal ultrasound revealed a large hypoechoic lesion in the posterior aspect of the prostate. Transrectal ultrasound guided systematic biopsies of the prostate were performed. The specimens obtained from the hypoechoic lesion, were diagnosed histopathologically as prostatitis with epithelioid granuloma, Langhans' type giant cells, and caseous necrosis. Mycobacterium tuberculosis was detected in the physiological saline solution injected into the urethra after prostatic massage. The patient was diagnosed as having prostatic tuberculosis and underwent antituberculotic therapy with INH and RFP. Transrectal ultrasound seemed to be useful in detecting histopathological changes associated with tuberculosis in the prostate.

[Aspects of evolving urogenital tuberculosis. 60 cases]

Based on the results of a retrospective study of 60 patients treated between January 1984 and December 1994, the authors review the current clinical features of urogenital tuberculosis. The sex-ratio shows a male predominance of 65%. The mean age is 48 years. Cystitis and low back pain are the main symptoms of the disease. IVU, performed in all patients, showed pathological images in 98.3% of cases. Urine culture was positive in 23 out of the 50 cases in which it was performed. Serious forms were relatively frequent, with bilateral lesions in 12 cases, associated with renal failure in 4 of them, or unilateral renal destruction in 43 cases. All patients were treated with triple- or quadruple-agent tuberculostatic therapy. 54 patients required one or several surgical procedures: 43 nephrectomies, 7 ureterovesical reimplantations, 11 augmentation enterocystoplasties, 1 Bricker ureteroileostomy, 3 ureterostomies, 1 ureteric resection and 4 epididymectomies. Two patients admitted in a context of deterioration of the general state died during the days following admission. 56 patients were reviewed with a minimum follow-up of 6 months. Two were cured by medical treatment alone. Among the 54 operated patients, clinical improvement was obtained in 43 patients (91%) and radiological improvement was obtained in 33 of the 36 cases in which IVU was performed (91%). In conclusion, despite the various anti-tuberculosis campaigns, urogenital tuberculosis remains a serious disease, essentially because of the delayed diagnosis.

CT features of genitourinary tuberculosis

The genitourinary system is the most common site of extrapulmonary tuberculous infection. The diagnosis is difficult and often delayed. In this essay, we illustrate the CT features of the kidneys, ureters, bladder, prostate gland, and seminal vesicles caused by tuberculosis.

Imaging of tuberculosis. II. Abdominal manifestations in 112 patients

PURPOSE

To describe the radiological findings of tuberculosis (TB) of the abdomen as reflected at our hospital.

MATERIAL AND METHODS

The radiological files of 503 patients (referred to our institution mainly because of a clinical suspicion of malignancy, and found to have culture- or biopsy-proven TB) were reviewed in order to analyze the spectrum of the TB manifestations in this group of patients.

RESULTS

Abdominal manifestations were found in 112 patients, in 1/3 abdominal disease was the only evidence of TB. More than half of the patients also had chest TB. The most common abdominal TB manifestations were peritonitis and lymph node enlargement, each occurring in about 1/3 of the patients. Also 1/3 had genitourinary TB manifestations. About 1/5 had TB of the liver, spleen or pancreas or in the gastrointestinal tract, respectively. Multiple organ involvement was common.

CONCLUSION

The need to consider TB in the differential diagnosis in patients with obscure abdominal symptoms, especially with multiple organ involvement, is stressed.

Sonographic features of tuberculous peritonitis with female genital tract tuberculosis

Our aim was to illustrate the sonographic features of tuberculous peritonitis with female genital tract tuberculosis in an attempt to facilitate the recognition of the disorder preoperatively. Transabdominal and transvaginal sonographic features and the findings from laparotomy/laparoscopy, endometrial biopsy and microbiology were reviewed and compared in 15 patients with tuberculous peritonitis with female genital tract tuberculosis. Of the 15 patients, 12 had wet tuberculosis and three had dry (adhesive) tuberculosis. Sonographic features of wet tuberculosis were categorized as follows: septated ascites (ten patients), particulate ascites (two patients), loculated fluid (two patients), thickened peritoneum (eight patients), thickened omentum (eight patients), adnexal mass (11 patients), adhesions (seven patients) and endometrial involvement (five patients). Adnexal masses, adhesions and loculated fluid were found to be present in the dry type. When sonographic findings were compared with those of laparotomy and/or laparoscopy and/or endometrial biopsy, ultrasound was able to identify aspects of tuberculosis infection as follows: ascites/loculated fluid, 13/13 (100%); adnexal mass, 12/13 (93%); peritoneal thickening, 9/13 (69%); omental thickening, 8/13 (61%); and endometrial involvement, 5/6 (83%). We conclude that awareness of the sonographic changes associated with tuberculosis infection may improve diagnostic accuracy, and avoid clinical mismanagement and surgical explorations in the wet type of tuberculosis.

Concomitant ceco-appendicular and urinary tuberculosis. Description of two rare cases: physiopathological and diagnostic remarks

Two cases of specific tubercular processes in the ceco-appendicular zone and the urinary system in men aged 25 and 30 years are described. Both patients reported abdominal pain and persistent fever that did not respond to treatment. Surgery revealed ulcerated appendix, intraperitoneal serous exudate, ascitic liquid, peritoneal ulcerocaseous nodules, and fibrous adhesions. Histological sections revealed a tubercular puchet in the ceco-appendicular zone. Subsequent x-ray test in response to reports of frequent painful urination showed specific lesions in the papillae and renal ureteral ampullae, and urine cultures were positive for Koch's bacillus. Treatment with streptomycin, followed by isoniazid, rifampicin, ethambutol, and morinamid for 2 years, was effective.

[Tuberculous calcifications of the bladder wall in children]

A case of tuberculous urinary bladder calcifications in a 13 year old boy is reported. The lesion is rare in adults and no case is published in the literature as occurring in children.

Urogenital tuberculosis in children

The clinical and radiological features of 16 children with urogenital tuberculosis are reviewed. The possibility of urinary tract involvement should be considered in all children with evidence of past or active pulmonary tuberculosis, or who are primary contacts.

Radiological imaging of urogenital tuberculosis in children with emphasis on ultrasound

Radiological recognition of tuberculosis in children ist uncommon as the initial lesions are occult. The appearances of our last 12 cases of renal TB have been tabulated. When the condition becomes radiologically evident the bladder is usually involved and the lesions can be detected ultrasonically. Ultrasonography as a primary method of diagnosis is described.

Primary genitourinary tuberculosis: rapid progression and tissue destruction during treatment

We report a case of primary genitourinary tuberculosis associated with severe progressive scarring, and obstruction of the left collecting system and proximal ureter, a contracted bladder with persistent vesicoureteral reflux and a bulbar urethral stricture. Scarring commenced soon after initiation of medical therapy, and resulted in left nephrectomy and reconstruction with colocystoplasty, right ureteral reimplantation and urethroplasty. The rapidity of disease progression and severity of tissue destruction in this case suggest that patients with genitourinary tuberculosis require close supervision starting at initiation of drug treatment. When complications do arise appropriate surgical intervention may become mandatory to decrease morbidity and to conserve renal function. The pathophysiology, clinical manifestations, radiological findings and treatment of genitourinary tuberculosis are reviewed.

[Role of computed tomography in extrapulmonary tuberculosis]

A retrospective evaluation of 65 computed tomographic investigations on 27 patients with proven disseminated extrapulmonary tuberculosis showed no CT changes characteristic for tuberculosis, except for a higher density of tubercular abscesses. In the majority of cases the extent of tubercular manifestations could only be exactly established after the CT investigation. With the aid of this information together with the clinical course of the disease, the timing, type and extent of operative measures could be determined. Finally, in comparison with conventional X-ray and sonography, computed tomography has proved to be superior for control of therapeutic procedures.

Six-month chemotherapy for urogenital tuberculosis

Rifampicin (RMP, 600 mg), isoniazid (INH, 300 mg) and pyrazinamide (PZA, 1,000 mg) administered daily in the hospital for a duration of 2 months was followed at home by daily administration of 600 mg RMP and 300 mg INH for a duration of 4 months. 113 patients with previously untreated and bacteriologically proven urogenital tuberculosis were admitted to the study. Therapy was completed and evaluated in 106 (94%) patients. No failure of chemotherapy was observed during the treatment; one bacteriologically proven relapse occurred after completion of treatment within the 45- to 63-month follow-up. This 6-month chemotherapy seems as efficient as the standard treatment which lasted for 18-24 months.

Changing patterns in pulmonary tuberculosis

We reviewed the initial chest roentgenograms of 182 consecutive adult patients with proven active tuberculosis. Less than 50% of all cases were known or suspected at the time of initial presentation. There is a low degree of correlation between radiologically discernible active pulmonary tuberculosis and extrapulmonary tuberculosis. A high percentage of cases represent uncommon pulmonary locations. We present the frequency of occurrence of four common pulmonary patterns.

[Surgical therapy of urogenital tuberculosis]

The surgical therapy of genitourinary tuberculosis is important as adjuvant treatment besides an appropriate anti-tuberculous drug therapy. During the years 1966-1983 surgical treatment was necessary in 46.1% (330 cases) of 715 patients. Cases, not treated properly for a long time, still have a high incidence of nephrectomy. Since 1976 more reconstructive operations and partial kidney resections have been carried out, resulting in a 5,6% rate of secondary nephrectomy. In up to 92.3% of the patients with these operations, renal function was not reduced or had improved. In cases with progressive tuberculosis of the upper urinary tract reconstructive surgical treatment is also recommended with good late results.

The treatment of urinary tuberculosis

During the last 7 years we treated 92 patients with tuberculosis of the urinary tract. Patients with tuberculous infection were divided into 3 groups according to treatment: group 1--no surgical treatment (18 patients), group 2--ablative surgery (45 patients) and group 3--reconstructive surgery (29 patients). Antituberculous drugs, consisting of rifampin, pyrazinamide, isoniazid and ethambutol, were given according to the severity and extent of the infection process. The results of medical and surgical treatment were most gratifying. Surgical morbidity was low and there was no immediate mortality.