An evaluation of the current therapeutic regimen for renal tuberculosis

Role of routine nephrectomy for non-functioning kidneys due to genitourinary tuberculosis: Data from an Indian subcontinent

Objective:

To evaluate the role of routine nephrectomy for tuberculous non-functioning kidney (TNFK) after receiving anti-tubercular therapy (ATT) by demonstrating whether live tubercle bacilli persist in nephrectomy specimens after treatment or not.

Materials and methods:

Patients with TNFK who underwent nephrectomy after completion of at least 6 months of ATT were included in this prospective cohort study. We sent tissue/pus from a nephrectomy specimen for acid-fast bacilli (AFB) staining, polymerase chain reaction (PCR) and culture to look for live bacilli. Bacilli were considered alive only if AFB culture was positive.

Results:

Twenty-four patients underwent nephrectomy for TNFK between April 2015 and October 2017 (18 laparoscopic and 6 open nephrectomy). Laparoscopic nephrectomy was associated with lower blood loss (225 ml versus 408 ml, p = 0.0003) and shorter hospital stay (3 versus 3.8 days, p = 0.06) compared with open nephrectomy; however, mean operative time and overall complications were similar. Eight specimens were AFB smear and/or tuberculosis PCR positive, out of which three showed viable bacilli upon culture. Drug sensitivity testing showed multi-drug resistant strain in all three patients who were treated with second-line ATT.

Conclusion:

It is preferable to do routine nephrectomy for TNFKs as they are more likely to harbour live bacilli and lead to disease recurrence. Viability testing for AFB must be performed on all operated specimens to identify drug resistant bacilli so that patients may be treated with second-line therapy if required.

Level of evidence:

4.

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.

Imaging of renal tuberculosis in eastern Taiwan: correlation with clinical course and different communities

Hualien, located in eastern Taiwan, is a relatively isolated district. The population is composed of different ethnic communities. Our hospital is the only medical center in eastern Taiwan, so is the most important referral hospital for epidemic diseases. After reviewing our collected cases of renal tuberculosis (TB), we observed a great diversity in staging and outcomes. The aim of this study was to classify different imaging presentations and clinical outcomes in the ethnic communities represented by these cases (non-aboriginal and aboriginal). We retrospectively reviewed 22 cases from 1991 to 2001. We reviewed laboratory data, radiologic reports, and clinical outcomes. Before TB was proved by biopsy or culture, patients were not treated with an anti-TB regimen. Roentgenography showed that 68% of patients had renal calcification, 59% had dilated calyces, 55% had lung involvement, and 41% had auto-nephrectomy. The proportion of mild and severe forms was significantly different between aboriginal and non-aboriginal groups (0.05 > p > or = 0.00409). From this series, we recommend routine plain film roentgenography, including chest roentgenography and kidney, ureter, and bladder or abdominal roentgenography, followed by intravenous urography or computerized tomography as investigative tools for renal TB. Based on the significantly different outcomes of the disease between aboriginal and non-aboriginal groups, a stronger health education program for the isolated district in eastern Taiwan is necessary.

Treatment of tuberculous epididymitis by intratunical rifampicin injection

The results of treating 4 patients with tuberculous epididymitis by rifampicin injection into the tunica vaginalis sac were compared with the results in another 4 patients treated with the common oral antituberculous drugs. Oral treatment consisted of daily administration of rifampicin (600 mg), isoniazid (300 mg), and ethambutol (25 mg/kg body weight). Rifampicin (600 mg) was injected intratunically every 4 to 6 days. Treatment continued for 6 months in both groups, with 3 months follow-up thereafter. Periodic clinical assessment as well as semen and hydrocele fluid examination were performed. In the intratunical injection group, epididymal swellings disappeared in 3 to 6 months; semen and hydrocele fluid became sterile in 4 months. The oral group showed partial diminution of the epididymal mass in one patient only; one patient developed scrotal fistula. Semen remained positive for tubercle bacilli, and hydrocele fluid became negative in one patient only. The satisfactory results with the intratunical rifampicin administration seem to be due to the drug reaching the epididymis in high concentrations. The tunica vaginalis is a part of the peritoneum and, like it, is believed to have a high absorptive power. Furthermore, the intratunical injection treatment uses a single drug, in contrast to the oral therapy, which, by its multidrug administration, enhances the incidence of side effects.

The changing pattern of renal tuberculosis

The authors present a series of 2,173 patients with renal tuberculosis seen between 1950 and 1979. This is group 1, serving only to show the incidence of renal tuberculosis during the antibiotic era. The fact is that the incidence of renal tuberculosis is going down slightly but constantly in the last years because the resistance of patients is increasing and the virulence of the TB bacillus is decreasing. The second group consists of 128 patients completely examined and the conclusion is that certain forms of very active TB have disappeared; high fever, very active forms of renal TB with deep and limited ulcerations in the kidney do not occur anymore. The third group is formed of 208 patients reviewed in order to demonstrate the residues after long antituberculotic treatment. It has been found that certain residual changes in the parenchyma are minimal but present as the remnants of antibiotic treatment indicating that probably the bilateral forms of renal TB are more common than we supposed before, in full agreement with Cibert's claim.

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.

Genito-urinary tuberculosis in Glasgow 1970 to 1979: a review of 230 patients

Two hundred and thirty patients with genito-urinary tuberculosis presenting between 1970 and 1979 were reviewed. In 22 per cent there was a history of previous tuberculosis and a family history in 14 per cent. Night sweats and weight loss were uncommon. The mean duration of medical treatment was 17 months. Surgery was necessary in 49 per cent of patients but reconstructive procedures were only performed in 7 per cent of cases. The mean follow-up period after diagnosis was 46 months. Patients with initial renal calcification were followed-up for a similar time to those with no calcification. Complications during follow-up were no more common in those with initial renal calcification than in those without this feature. With the exception of 1971 and 1972, there was a steady incidence of 20 or so new cases of genito-urinary tuberculosis per year in Glasgow.

The surgical management of non-functioning tuberculous kidneys

During the last 3 years we have explored all cases of non-functioning tuberculous kidneys in patients seen at our hospital. The operative, pathological and bacteriological findings are presented. In 89.3 per cent of the cases (25 of 28) the kidneys and ureters were destroyed and nephrectomy was done. In 10.7 per cent (3 of 28 cases) a reconstructive operation was possible with gratifying results. In 17.9 per cent (5 of 28 cases) the caseous material was positive for acid-fast bacilli on direct smear. It is concluded that surgical exploration should be done on all patients with non-functioning tuberculous kidneys to, 1) salvage kidneys before they are damaged totally by the obstructive lesions, 2) remove a potential source of infection with viable organisms and 3) shorten convalescence.

Role of nephrectomy in the treatment of non-functioning or very poorly functioning unilateral tuberculous kidney

We reviewed 300 consecutive cases of genitourinary tuberculosis at Wrightington Hospital from 1961 to 1978. There were 73 patients with non-functioning or poorly functioning kidneys who underwent nephrectomy after at least 6 weeks of intensive chemotherapy with 3 antituberculous drugs. Three of 4 patients with unilateral non-functioning kidneys who did not have a primary nephrectomy had delayed complications. Late complications of in situ non-functioning tuberculous kidneys included draining flank sinuses, abscesses and hypertension. These complications can occur years after completion of chemotherapy, even in sterile organs. The incidence of hypertension in this series was 11.3 per cent. The incidence of hypertension in patients with unilateral non-functioning or poorly functioning tuberculous kidneys was 23.2 per cent (p less than 0.005). Two-thirds of the hypertensive patients with severe unilateral tuberculous nephropathy benefited by a decrease in blood pressure after nephrectomy. Removal of these kidneys does not cause a significant loss of renal function. The perioperative morbidity and mortality of the procedure should be minimal in a generally younger population. It is concluded that primary nephrectomy is an important adjunct in the comprehensive management of the unilateral non-functioning kidney.

Genitourinary tuberculosis: a 7-year review

Since 1970 short course regimes of chemotherapy have been adopted for the treatment of 87 patients suffering from genitourinary tuberculosis. The response to chemotherapy, the effect of surgery, the importance of hypertension and the relapse rate have been studied. It is concluded that all cases of genitourinary tuberculosis will respond to a short intensive course of chemotherapy, which need not be given for longer than 6 months.