Pan-caliceal ileoneocystostomy--a new operation for intrapelvic tuberculotic strictures of the renal pelvis

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.

Long-term results of percutaneous endourologic management of renal infundibular stricture

PURPOSE

The long-term result of percutaneous endourologic management in the relief of infundibular stricture is not clear. We reviewed the long-term efficacy in our series of patients.

PATIENTS AND METHODS

Twenty-seven patients underwent percutaneous endourologic management between August 1990 and February 1996. This study included the 21 who could be followed for more than 2 years (mean 4.8 years). The causes of stricture were tuberculosis (N = 18; 86%) and stone (N = 3; 14%). We made a cold-knife incision in eight patients; the others underwent only dilation with fascial dilators from 20F to 30F. Success was defined as symptomatic improvement and radiographic resolution of obstruction.

RESULTS

The overall success rate was 76% (16 of 21). Seven of the eleven patients (64%) with concomitant ureteral stricture had a successful result. In the nine patients with multiple infundibular strictures, five procedure (56%) were successful. The success rates of the cold-knife or fascial dilator were 88% (7 of 8) and 69% (8 of 13), respectively. In the five patients in whom the procedure failed, ureteral stricture was associated in four and multiple infundibular strictures in four. All of them had tuberculous infundibular strictures. No significant difference in the success rate was observed according to the duration of indwelling catheter. There was no significant complication except pyelonephritis in four patients, which was controlled with conservative treatment.

CONCLUSIONS

Percutaneous endourologic management is an effective and safe procedure to treat renal infundibular stricture. Risk factors for failure are multiple infundibular strictures and concomitant ureteral stricture. If the procedure does fail, other treatments have not been compromised. Cold-knife incision seems to be more effective than dilation.

Endoscopic infundibulotomy in tuberculous renal infundibular stricture

To salvage the renal parenchyma, percutaneous endoscopic infundibulotomy was performed in 10 patients with a tuberculous renal infundibular stricture. Followup ranged from 12 to 31 months. The sites of stricture were the upper calix in 6 patients and the lower calix in 4. A cold knife was used to incise the stricture and a stent was retained for 6 to 8 weeks. Postoperative excretory urography revealed marked shrinkage of the dilated calix in 5 patients, moderate shrinkage in 3 and no change in 2 (success rate 80%). Of 2 failed cases partial nephrectomy was done in 1 and 1 is being followed. There was no significant complication except for 2 cases of pyelonephritis that was controlled with conservative treatment. In conclusion, endoscopic infundibulotomy is a safe, less invasive, successful and parenchyma salvageable procedure to treat tuberculous renal infundibular stricture.

Endocalicotomy in tuberculous renal caliceal stricture

The stricture of the calix, renal pelvis, or ureter secondary to renal tuberculosis has been managed by nephrectomy, partial nephrectomy, ureteroileoneocystoplasty, or even pancaliceal-ileoneocystoplasty. To salvage the renal parenchyma, percutaneous endocalicotomy with or without endopyelotomy was performed in 10 patients. The main sites of stricture were an upper calix in six cases and a lower calix in four. A cold knife was used to incise the stricture, and a stenting two-section 14F endopyelotomy catheter was retained for 6 to 8 weeks. Postoperative intravenous urography revealed marked shrinkage of the dilated calix in seven cases, moderate shrinkage in one, and no change in two (success rate 80%). One of the patients in whom the procedure failed underwent partial nephrectomy, and the other is being followed. The only significant complication was one case of pyelonephritis. Endocalicotomy is a safe, less invasive, successful (in cases that a guidewire could pass), and parenchyma-saving procedure. Retrograde pyelography is mandatory just before the surgery because stricture can worsen during antituberculosis chemotherapy.

Acquired infundibular stenosis

Acquired infundibular stenosis is an unusual complication resulting in pancalyceal obstruction. We have cared for 6 patients with acquired infundibular stenosis not associated with tuberculosis. All patients had urinary diversion with ileal conduits for a minimum of eleven years and documented ileal-ureteral reflux and chronic urinary tract infections. The clinical, radiographic, and pathologic characteristics of this syndrome are described and therapeutic guidelines suggested.

Ileal conduit diversion from a bivalved kidney

We report 2 successful cases of ileal conduit diversion from a bivalved kidney. Both patients had a single kidney and were in chronic renal failure. Cutaneous diversion had malfunctioned because of intrarenal obstruction of tuberculous origin. The kidney was bivalved and anastomosed to an isolated ileal segment. The lower end of the ileal segment was brought to the abdominal skin as a stoma. Postoperatively, renal function was aggravated temporarily. During the followup periods of 2 years and 1 year 6 months neither patient had evidence of renal deterioration. This type of urinary diversion seems acceptable for relieving infundibular stricture with chronic renal failure.

Pan-caliceal ileoneocystostomy: indications, modifications and further evaluation

During the last 4 years we treated 11 patients with obstructed kidneys and intrapelvic strictures, which were owing to tuberculosis in 9 and renal stone surgery in 2. Pan-caliceal ileoneocystostomy was performed in all 11 cases. The entire caliceal system was anastomosed to an ileal ureter and, thus, relieved the obstruction. The result of this operation was most gratifying. Although 1 patient died of anastomotic leakage and sepsis the morbidity was low.

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.