[Urethral microbiome in patients with pulmonary tuberculosis]

INTRODUCTION

Treatment of tuberculosis involves long-term intake of several antimicrobial drugs, including that with a wide spectrum of action, which may affect the microflora of the urinary tract.

AIM

To determine the effect of long-term combination of antibiotic drugs on the microbiome of male urethra.

MATERIALS AND METHODS

A total of 75 men were included in an open, prospective, non-comparative study, including 63 patients with pulmonary tuberculosis who received anti-tuberculosis therapy for at least 3 and no more than 5 months without urinary tract infections (main group) and 12 patients with non-infectious urological diseases (urolithiasis, benign prostatic hyperplasia) and normal urinalysis (comparison group). All patients underwent urethral swab with a sterile cotton after cleaning of genital area. The identification of pathogens and the quantitative assessment of composition of the microbiota in the obtained samples was performed by the method of real-time polymerase chain reaction (RT-PCR). The quantitative results are presented in the number of genomic equivalents in 1 ml (GE/ml), which are proportional to the microbial contamination of the samples.

RESULTS

"Classical" pathogenic microflora in the urethral swab was detected in 1/3-1/4 patient with tuberculosis. Enterobacteriaceae spp./Enterococcus spp. in a titer of 103-104 GE/ml was identified in 16 (25.4%) patients. Staphylococcus spp. was found in the titer of 103-106 GE/ml in 20 males (31.7%). In the comparison group, Staphylococcus spp. was present in half of the cases (n=6), and Enterobacteriaceae spp./ Enterococcus spp. were isolated in every third patient (n=4) with a titer of 103-105 GE/ml. In patients with tuberculosis, Corynebacterium spp. was most commonly detected (n=31, 49.2%), while in the comparison group this pathogen was isolated only in 3 (25.0%) patients. At the same time, the detection rate of Candida spp. in urethral swab was not significantly different between two groups (7.9 and 8.3%, respectively).

CONCLUSION

Patients with tuberculosis receiving combination of chemotherapeutic drugs for at least 3 months, and male without signs of urinary tract infections have significant differences in the spectrum of the urethral microflora.

[Surgical treatment of patients with renal tuberculosis, complicated by ureteral tuberculosis]

INTRODUCTION

Late diagnosis of renal tuberculosis leads to complications that cannot be eliminated by treatment.

CLINICAL CASE

A clinical observation of patient Ch., born in 1976, who was admitted to TB Research Institute of Ministry of Health of Russia on 17.02.2020. A diagnosis was cavernous renal tuberculosis. Tuberculosis of the ureter. MBT (-). Right ureteral stricture (obliteration), complicated by ipsilateral hydronephrosis. Right nephrostomy tube (2018). Clinical cure of disseminated pulmonary tuberculosis. He underwent planned laparoscopic bowel substitution of the right ureter on 10.03.2020. In the postoperative period, pyelonephritis developed, which was resolved by drug therapy.

CONCLUSION

In this case, there is the correct tactics of outpatient urologists. When hydronephrosis was diagnosed, a nephrostomy tube was put, which allowed to preserve the kidney, Then the patient was immediately referred to a phthisiatrician to exclude urogenital tuberculosis. In the local TB dispensary, the patient did not have the opportunity to receive necessary treatment, and he was transferred to the TB Research Institute of Ministry of Health of Russia, where a reconstructive laparoscopic procedure was performed.

[Surgical treatment of patients with urogenital tuberculosis]

Despite the modest positive trends in the epidemic situation for tuberculosis, the incidence of extrapulmonary tuberculosis is not consistent. The relevance of urogenital tuberculosis remains high, as well as its social significance. Tuberculosis of the kidneys and urinary tract is often diagnosed late, when drug therapy is not enough and surgical treatment is required. A total of 78 national and foreign publications dedicated to surgical treatment of patients with urogenital tuberculosis were analyzed. Various surgical techniques for renal and bladder tuberculosis are described with a comparison of their advantages and disadvantages. Tuberculosis of the urinary system, like any infectious disease, can and must be cured with drug therapy. Unfortunately, there are complicating subjective (low alertness of doctors regarding tuberculosis, low adherence to national and international guidelines) and objective (absence of pathognomonic symptoms of urogenital tuberculosis, which results in late diagnosis, increased drug resistance of the pathogen, high comorbidity) factors. The advancements in surgical techniques and modern drugs for neoadjuvant therapy give patients the opportunity to receive minimally invasive treatment that saves not only life, but also provides them acceptable quality of life.

[Current approach to diagnosis of chronic prostatitis]

INTRODUCTION

The problem of chronic prostatitis is still to be resolved.

AIM

to compare the frequency of the main symptoms (pain, dysuria, sexual dysfunction) in patients with chronic bacterial and abacterial prostatitis, as well as prostate tuberculosis (PTB); to determine the prevalence of latent infectious prostatitis in patients with chronic abacterial prostatitis (CAP).

MATERIALS AND METHODS

A total 73 men who were followed with a diagnosis of chronic prostatitis for at least two years and had a history of at least three exacerbations per year were included in the study. A microbiological study of expressed prostate secretions (EPS) was carried out using both routine and molecular genetic methods.

RESULTS

Chronic bacterial prostatitis (CBP) was diagnosed in 27 patients (37.0%). 36.7% of pathogens were resistant to antibiotics. In 46 patients (63%) no microflora was not isolated at the first examination. In some patients with CBP, prostate tuberculosis (PTB) was diagnosed. Thus, in the total cohort of patients, only 17 (23.3%) had isolated CBP, and other 10 (13.7%) had CBP in combination with PTB. All patients with CAP received longidaza rectal suppositories for diagnostic purposes. In 23 men (50.0% of patients with CAP), uropathogens were isolated from EPS after administration of longidaza, and 56.9% of them were resistant to antibacterial drugs. Five patients from this group also had PTB, and 18 (24.6%) had CBP, which was not diagnosed by standard methods. There were no significant differences in the frequency of pain and urinary disorders. However, sexual dysfunction more often developed in patients with CAP and PTB (p<0.05); hemospermia, on the other hand, was not typical for patients with CAP, occurred in few cases with CBP and latent CAP, but was present in two-thirds of patients with PTB.

CONCLUSION

As a mask of CAP, both latent CPB and PTB can present. Although CBP, CAP, latent CBP and PTB have a number of significant differences in the clinical manifestations, no pathognomonic symptoms have been identified for these subgroups of chronic prostatitis. Considering that half of patients with CAP actually have latent CBP, it is necessary to use rectal suppositories of the drug longidaza for diagnostic purposes with repeated analysis of expressed prostate secretions. To identify pathogens, molecular genetic diagnostics should be used along with routine methods. PTB can manifest as chronic bacterial or abacterial prostatitis. It is necessary to carefully study the patient's history, epidemic history, and, if indicated, to perform an appropriate examination to exclude PTB.

[Surgical treatment of patients with renal tuberculosis, complicated by ureteral tuberculosis]

Late diagnosis of renal tuberculosis leads to complications that cannot be eliminated by treatment. A clinical observation of renal tuberculosis, complicated by total ureteral obliteration, in a comorbid patient is presented. He underwent planned bowel substitution of the right ureter. In the postoperative period, pyelonephritis developed, which was resolved by drug therapy. In this case, there is the correct tactics of outpatient urologists. When hydronephrosis was diagnosed, a nephrostomy tube was put, which allowed to preserve the kidney, Then the patient was immediately referred to a phthisiatrician to exclude urogenital tuberculosis. In the local TB dispensary, the patient did not have the opportunity to receive necessary treatment, and he was transferred to the TB Research Institute of Ministry of Health of Russia, where a reconstructive laparoscopic procedure was performed.

[Overactive bladder in a complicated patient: which drug to choose?]

A literature review, including 60 national and foreign publications, was carried out. The review focuses on aspects of the pathogenesis and pathophysiology of overactive bladder (OAB). The effect of OAB on a woman's sexual function is described, as well as the features of OAB treatment in comorbid patients and complications of using anticholinergics drugs. The analysis showed that currently available drugs are highly effective, but have some adverse effects. A combination of various M-anticholinergics or M-anticholinergic drugs with -blockers or 3-adrenoceptor agonists can be used. Trospium chloride is preferrable drug for older patients, especially with cognitive impairment and dementia, as well as for patients receiving drugs metabolized by the cytochrome P450 for concomitant diseases or those with bladder tuberculosis.

[The features of the recurrence of urogenital tuberculosis]

INTRODUCTION

Tuberculosis is an infectious disease, which can result in self-cure, chronic process or relapse course.

AIM

To analyze the incidence of recurrence of urogenital tuberculosis and to identify the features of patients with recurrent disease.

MATERIALS AND METHODS

Specially developed questionnaires on the structure of the incidence of extrapulmonary tuberculosis in the Siberian Federal District and the Far Eastern Federal District were analyzed. We also studied 140 outpatient medical records of patients with tuberculosis of the urinary tract and male reproductive system, who was followed at the Novosibirsk Regional TB Outpatient Department. The medical records of patients with recurrent disease were analyzed in detail.

RESULTS

In 2019, 563 patients with isolated extrapulmonary tuberculosis in the Siberian Federal District and the Far Eastern Federal District were identified, and 14.4% of them had urogenital tuberculosis. In 99 (17.6%) patients, the present state was a relapse, while urogenital tuberculosis occupied 8.1%, and all patients were HIV-negative. In the Novosibirsk Region, 127 out of 140 patients were diagnosed with urogenital tuberculosis for the first time, and in 13 (9.3%) had recurrent disease. Among patients with relapse, male predominated (61.5%). The primary focus of tuberculosis was located in the genitourinary system in 53.9% of patients, which supports the theory of reactivation of dormant foci. In addition, 38.5% of patients with primary episode of tuberculosis were smear-positive. The average relapse time after successful cure of tuberculosis was 9.1 years. Among patients with recurrent urogenital tuberculosis, mycobacteriuria was recorded in 23.1% of cases, and in one case drug resistance of the pathogen to streptomycin and isoniazid was seen. In general, the kidneys were the most susceptible to relapses and were involved in 69.2% of cases.

CONCLUSIONS

Nearly 8.1-9.3% of patients with genitourinary tuberculosis had previously tuberculosis and were successfully cured. When urogenital tuberculosis recurs, the kidneys are affected in 69.2% of cases. The overwhelming majority (61.5%) of patients with recurrent genitourinary tuberculosis are men, therefore gender can be considered a predictor of recurrence. HIV infection was found in isolated cases in patients with both newly diagnosed and recurrent urogenital tuberculosis.

[Method for evaluating the efficiency of treatment of urogenital tuberculosis]

INTRODUCTION

Methods for evaluating the efficiency of treatment which were developed for pulmonary tuberculosis (absence of bacterial transmission and closure of cavities) are not suitable for urogenital tuberculosis.

AIM

To evaluate the use of scoring system for assessing the efficiency of treatment of urogenital tuberculosis.

MATERIALS AND METHODS

A pilot simple open-label prospective noncomparative cohort study was carried out, which included 15 patients with urogenital tuberculosis. All patients completed the urogenital tuberculosis score upon admission and after 1 month, along with standard clinical, laboratory and X-ray examinations. We developed this score to objectify evaluate the efficiency of antituberculosis therapy and it includes clinical and laboratory manifestations of urogenital tuberculosis.

RESULTS

Eleven (73.3%) patients responded well to standard therapy, and 4 (26.7%) required therapy correction. Considering that the correction of therapy was carried out in a timely manner, the final result of the treatment was satisfactory. The efficiency of the proposed score has been demonstrated by clinical results.

CONCLUSION

Using the urogenital tuberculosis score for assessing the results of treatment of urogenital tuberculosis allows timely correction of therapy according to objective criteria.

[Nephrotuberculosis and urolithiasis]

INTRODUCTION

Urolithiasis and nephrotuberculosis, due to the similarity of the radiographic patterns, share the same differential diagnosis list. The study aimed to analyze the incidence of co-occurrence of nephrotuberculosis and urolithiasis and to determine the impact of urolithiasis on the clinical course of renal tuberculosis.

MATERIAL AND METHODS

This open cohort retrospective study comprised 843 patients with renal tuberculosis and 245 patients with urolithiasis. 1088 medical records were analyzed to identify cases with co-occurrence of these two diseases and determine the clinical presentation of renal tuberculosis, urolithiasis, and the comorbid state. Also, patients with pulmonary tuberculosis (44), urogenital tuberculosis (17), and chronic nonspecific pyelonephritis (12) were tested for serum concentration of total calcium and phosphorus.

RESULTS

Of 843 patients with renal tuberculosis, 39 (4.6%), had concomitant nephrolithiasis. The combination of urolithiasis with nephrotuberculosis manifested by more severe symptoms; these patients had a more than two-fold risk of tuberculosis recurrence. Except for the incidence of renal colic and dysuria, the clinical manifestations of urolithiasis and nephrotuberculosis did not differ statistically significantly. Prolonged infectious and inflammatory process in the kidneys resulted in an increase in the excretion of oxalates, which was more pronounced in patients with nonspecific pyelonephritis (p<0.05). A three-month course of antituberculosis chemotherapy resulted in a 36.2% increase in the excretion of oxalates in patients with urotuberculosis (p<0.05). Excretion of uric acid also significantly increased after a three-month intake of antituberculosis drugs.

CONCLUSION

In our study, the incidence of concomitant urolithiasis and urogenital tuberculosis was low (4.6%), but comorbidity significantly complicated the clinical course of the disease and worsened the prognosis of nephrotuberculosis. Antituberculosis polychemotherapy increases the risk for formation of urinary stones. Prevention of urolithiasis in patients with urogenital tuberculosis warrants further investigation.

[Masks of urogenital tuberculosis as the cause of diagnostic errors]

Urogenital tuberculosis does not have pathognomonic symptoms, so diagnostic errors are quite common. This systematic review of literature was conducted to identify the causes and estimate the incidence of erroneous diagnoses. We critically evaluated some articles in which the authors describe observations of urogenital tuberculosis as rare and unusual because they never encountered this disease, but in fact that were typical manifestations of genitourinary tuberculosis. The authors analyzed and illustrated the features of urinary tuberculosis in patients with pulmonary tuberculosis, differential diagnosis of urogenital tuberculosis and kidney cancer and male genitourinary organs, described errors in the diagnosis of urethral, testicular, penile, prostatic and epididymal tuberculosis. Urolithiasis was described as a mask and concomitant disease of urogenital tuberculosis. Really rare forms of bladder tuberculosis as the cause of diagnostic errors are described. Examples of fatal outcomes of urogenital tuberculosis are given. The authors analyzed cases of granulomatous interstitial nephritis due to tuberculosis infection and tuberculosis of the renal artery as the cause of renovascular hypertension. The most common causes of late diagnosis of urogenital tuberculosis are the absence of a typical pattern and the tendency to manifest under the guise of other diseases.

[Cancer and genitourinary tuberculosis (literature review and clinical observations)]

Tuberculosis has been regarded as a counter-regulatory process to cancer. The development of tumors in the kidney that is affected by tuberculosis is considered as extremely rare, almost impossible case. The analysis of the literature on combined/sequential damage of urogenital organs by tuberculosis and cancer, and own clinical observation were performed. The case history of 72-year-old patient who sought medical advice for violation of urination is described. Previously he suffered from tuberculosis of the lungs and prostate cancer, and he was healed. The PSA level was 11 ng / mL. Urethroprostatogram showed a large cavity with calcification in the prostate. Biopsy of the prostate gland was performed; histologically solid-glandular cancer, Gleason 7 (3 + 4) was confirmed. There were no signs of tubercular inflammation. Radical prostatectomy was caried out; in the section, prostate caverns were filled with large fragments calcified caseation.Pathomorphological evaluation of surgical material has revealed proliferative glandular prostate cancer with invasion into the capsule of both lobes. In seminal vesicles invasion into muscle layer was detected. Tuberculosis can predetermine conditions for the development of a malignant tumor. In any case, the increase in PSA levels is an indication for prostate biopsy, especially if the patient had a history of long-term infectious inflammation of the prostate gland.

[Diagnosis of tuberculosis of bladder]

A comparative analysis of cystoscopic and pathologic patterns in 190 patients hospitalized for differential diagnosis or treatment of genitourinary tuberculosis in 2008-2011 was performed. All patients underwent polyfocal biopsy followed by pathologic examination of biopsy specimens. Furthermore, a comparison of results ofpathomorphological studies of tissue obtained by biopsy and after cystectomy was conducted. Cystoscopy in all patients with tuberculosis of the bladder (TB) revealed the reduced bladder capacity in contrast to patients with other urological diseases. Deformation of orifices, trabecularity and contact bleeding were observed in 66.7 to 94.4% of cases in patients with TB, which were significantly more common than in other diseases. Polymorphism of pathological pattern and the lack of specific changes in the majority of patients with TB were noted; multinucleated Pirogov-Langhans cells were found only in 11.8% of cases, and only in biopsies, whereas in the tissues obtained after cystectomy in same patients, lymphocytic infiltration and fibrosis were observed. The algorithm of diagnosis of tuberculosis of the bladder is suggested.

[Bladder tuberculosis stage 4: how to restore urination?]

Reconstructive surgery for contracted bladder (bladder tuberculosis stage 4) was performed in 21 patients: women underwent cystectomy, and men underwent cystectomy and cystprostatectomy. The artificial bladder was formed using segment of the ileum by the Studer method with the implementation of ureteral-intestinal anastomosis by Nesbit or Wallace methods. Criteria for determining the bladder tuberculosis 4 stage, requiring the implementation of reconstructive surgery were as follows: bladder capacity of 100 ml or less (including general anesthesia); bladder volume--150 ml or less in the presence of vesicoureteral reflux. A good results were obtained in 17 (80.9%) patients. Results of 3 (14.2%) patients were regarded as satisfactory; one patient developed a stricture of ureterovaginal-reservoir anastomosis, which required re-anastomosis; 1 patient formed a stricture of membranous urethra, which recurred after optical urethrotomy and required the implementation of anastomotic urethroplasty; and 1 patient had difficulty urinating, requiring intermittent catheterization. Poor result was recorded in 1 (4.7%) patient who was diagnosed with chronic renal failure progression, despite the lack of evidence of retention of the urinary tract and vesicoureteral reflux in the presence of spontaneous urination, and satisfactory bladder capacity. This fact was attributable to the antiretroviral therapy for HIV infection.

[The use of laser vaporization for the treatment of benign prostatic hyperplasia]

Results of use of UroBeam laser diode in 72 patients with benign prostatic hyperplasia (BPH) were analyzed. Average prostate volume was 67.29 +/- 26.72 cm3, the duration of vaporization--69.2 +/- 23.7 min. Blood loss was minimal. In the period from 2 weeks to 4 months after surgery, 9 patients have developed acute urinary retention. In the early postoperative period, acute prostatitis was diagnosed in 7 patients and was jugulated using drug treatment. The laser vaporization of BPH led to a three-fold reduction in the severity of urinary disorders and increase the urinary flow rate. The combination of laser vaporization of the prostate with transurethral resection of the prostate allow to improve the recovery of urination after surgery.

[Urogenital tuberculosis today]

In order to analyze the structure of urogenital tuberculosis, retrospective analysis of medical records of 131 patients with newly diagnosed urogenital tuberculosis observed in the Novosibirsk Regional TB Dispensary from 2009 to 2011 was performed. The renal tuberculosis is main form in the structure is urotuberculosis, detected in 75% of patients, and widespread destructive forms of the disease were diagnosed in more than half of cases. Isolated nephrotuberculosis was more often diagnosed in women--56.8%. 15.9% of patients had asymptomatic nephrotuberculosis; one-third of patients complained of pain in the lumbar region and frequent painful urination (35.2 and 39.8%, respectively); symptoms of intoxication were present in 17% of patients, renal colic--in 9.1%, and gross hematuria--in 7.9% of patients. Mycobacteriuria in isolated nephrotuberculosis was detected in 31.8% of cases. Acute tuberculous orchiepididymitis developed in 35.7% of patients, hemospermia was observed in 7.1% of patients, dysuria was in 35.7% of patients. The pain in the perineum, frequent painful urination (both by 31.6%), hemospermia (26.3%) were main complaints in prostate tuberculosis. Mycobacteria was detected in 10.5% of cases. It was found that urogenital tuberculosis has no pathognomonic symptoms; the most alarming manifestations include long-term dysuria, hematuria, hemospermia.

[A comparative study of efficacy of 2-, 3- and 4-glass tests in patients with chronic prostatitis]

To compare informative value of three tests (2-, 3- and 4-glass) in diagnosis ofprostatitis we examined 177 patients with chronic prostatitis (CP) who were randomized into 4 groups. Group 1 patients (n = 33) were examined with standard 4-glass test (Mearls and Stamey), patients of subgroup 2a (n = 42) were examined with 2-glass test before finger rectal test (FRT), FRT was made in subgroup 2b (n = 45) before urine collection (2 portions), group 3 (n = 57) was examined by an original technique proposed by the authors. While performing the latter test special focus was given to urination continuity, then the secretion obtained at FRT was studied. Efficacy of each of the tests was assessed by comfort of the procedure for the patient and the doctor, a proportion of false-positive results. The 3-glass test proved most informative and significant. Also, it is sensitive in detection of urogenital tuberculosis. The 4-glass test is not comfortable for both the patient and the doctor. The 2-glass test often produced false-positive results.

[Approaches to raising efficacy of treatment of patients with chronic prostatitis associated with intracellular infections]

The efficacy of indigal plus containing indol-3-carbinol, epigallocatexin-3-gallat and Serenoa repens extract in combination with sparfloxacin was studied in a trial with participation of 30 patients with chronic infectious prostatitis associated with intracellular agents. Group 1 (n=15) received indigal plus (2 capsules twice a day for 3 months) and sparfloxacin (200 mg twice a day for 1 month). Group 2 including 15 matched controls received sparfloxacin alone according to the same schedule. The examination included questionnaire survey (IPSS, QoL, NIH-CPSI), blood count, urinalysis, PSA test, microscopy, bacteriological study of prostatic secretion, uroflowmetry, transrectal ultrasound investigation of the prostate with residual urine assay, laser doppleroflowmetry. The examinations were performed on the treatment day 30, 60 and 90. After the antibacterial treatment chlamidia, ureaplasma and E.coli were detected in 13.3, 6.7 and 26.7% patients of the control group, in 6.7, 6.7 and 6.7% patients of the study group, respectively. Thus, the addition of a pathogenetic drug indigal plus to sparfloxacin treatment promoted normalization of apoptosis of the infected cells, led to more effective bacterial eradication, enhanced regression of the symptoms. It is recommended to include indigal plus in a basic scheme of treatment of patients with chronic infectious prostatitis.