1 Urologic TuberculosisXu Ha Department of Urology, Tongji Hospital

2 Tuberculosis (TB) Pathogen — Mycobacterium tuberculosisInfected — one third of world's population Organism — lung first, through bloodstream to other Probability — exposure, size, and infectivity Initial infection — most controlled and no clinical illness Clinical disease — multiplication of dormant bacilli

3 Genitourinary TB Account for 10% of tuberculosis casesMost 20 to 40 years old Male VS female — 2:1 Very uncommon in children Spread of organism to kidney through blood Other parts become involved by direct extension

4 Pathologic Features Kidney Caseating granuloma Caseous abscessFibrosis Calcification Papillary necrosis Calyceal stem or UPJ obstruction Autonephrectomy Caseating granuloma

5 Fibrosis

6 Caseous abscess, Fibrosis and Calcification

7 Ureter with calcification and stricture formationPathologic Features Ureter Mucosa or submucosa tubercular nodule Stricture formation Granuloma Fibrosis Ureter with calcification and stricture formation

8 Pathologic Features Bladder Ureteral orifice inflamed and edematousUreteral orifice obstruction Tuberculous ulcers Tuberculous inflammation Bladder wall fibrosis and contraction

9 Acutely inflamed ureteric orifice Tuberculous bullous granulations

10 Tuberculous golf-hole ureterseverely withdrawn Acute tuberculous ulcer

11 Acute tuberculous cystitiswith ulceration Healed tuberculous lesion

12 Clinical ManifestationsThe diagnosis of genitourinary TB should be considered in a patient presenting with vague, longstanding urinary symptoms for which there is no obvious cause!

13 Clinical ManifestationsSPECIFIC - Genitourinary tract Lower urinary tract – 50 to 80 % Burning , frequency , urgency , urge incontinence Dysuria , hematuria Suprapubic pain / perineal discomfort Decreased stream , straining, ineffective voiding Slough in urine

14 Clinical ManifestationsUpper urinary tract symptoms Pain - kidney and ureter region Gross hematuria- 10 % Genital – Male Hematospermia - 10 % Azoospermia S/S of chronic epididymorchitis Genital – Female Menstrual irregularities Pelvic pain syndrome Infertility – 18 %

15 Clinical ManifestationsOther systems Respiratory % patients Gastrointestinal % Lymphoreticular Constitutional to 15 % Evening rise of temperature Weight loss Anorexia

16 Diagnosis Laboratory Urinalysis and CultureAcidic urine , sterile pyuria , microscopic hematuria Guide for further investigation, especially in pauci-symptomatic patients Fastidious / slow growth – difficult to culture – at least three, but preferably five

17 Diagnosis Laboratory Purified Protein Derivative(PPD, Tuberculin Test, Mantoux Test) If Positive – supports the diagnosis If Negative – can not exclude extrapulmonary TB Response – HIV, Immunocompromised , Post-transplant pts

18 Diagnosis Laboratory Nucleic Acid Amplification (NAA) Testing—PCRMultiple sample Sensitivity from 87% to 95% (VS culture) Specificity from 92% to 99.8% (VS culture) Resistance mutations

19 Diagnosis Radiography Plain RadiographPositive findings up to 50% on chest radiograph Calcifications in 30% to 50% case on KUB

20 Diagnosis Radiography Intravenous Urography (IVU)Traditional gold standard tool Replaced by CT in many institutions Early signs: calyceal erosion and papillary irregularity Most common: hydrocalycosis, hydronephrosis, orhydroureter

21 Diagnosis Radiography Intravenous Urography (IVU)— kidneyCalyx distortion Calyx fibration Calyx occlusion Calyceal destruction Parenchymal destruction

22 Diagnosis Radiography Intravenous Urography (IVU)— ureterDilatation above UVJ stricture Rigid fibration Multiple strictures

23 Diagnosis Radiography Intravenous Urography (IVU)— bladderSmall and contracted (thimble bladder) Irregular with filling defects Asymmetry

24 parenchymal destructionOccluded calyx Severe calyceal and  parenchymal destruction

25 Stricture at the distal left ureter Contraction of the bladder left side 

26 Diagnosis Radiography Three-dimensional reconstructed imagesComputed Tomography (CT) Three-dimensional reconstructed images At least the equal of IVU in identification Findings with not specific

27 Computed Tomography (CT) Calyceal abnormalities Hydronephrosis or hydroureter Autonephrectomy Amputated infundibulum Urinary tract calcifications Renal parenchymal cavities Hydronephrotic in right kidney End-stage nonfunctioning atrophic left kidney with calcification.

28 Diagnosis Endoscopy Cystoscopy and BiopsyRarely indicated in diagnosis Must under general anesthesia Assessing the disease extent or the response to chemotherapy No Biopsy advised before medical therapy

29 Treatment Successful treatment Early diagnosisPrompt initiation of adequate drug Rest and nutrition Urgical treatment for advanced cases

30 Treatment Medical Treatment Multidrug treatmentInitial 6-month regimens of rifampicin, INH, pyrazinamide, and ethambutol Administered in one dose Dosage, toxicity, drug interactions

31 Antituberculous DrugsTreatment Antituberculous Drugs

32 Antituberculous DrugsTreatment Antituberculous Drugs

33 Treatment Surgical Therapy Adjuvant to medical therapyFocus on organ preservation and reconstruction At least 4 to 6 weeks medical therapy before Excision of diseased tissue and reconstructive

34 Treatment Surgical Therapy Excision of diseased NephrectomyPartial Nephrectomy Abscess Drainage

35 Treatment Surgical Therapy Indications for nephrectomyA nonfunctioning kidney with or without calcification Extensive disease involving the whole kidney, together with hypertension and UPJ obstruction Coexisting renal carcinoma

36 Treatment Surgical Therapy Reconstructive Surgery Ureteral stricturesAugmentation cystoplasty Urinary conduit diversion Orthotopic neobladder

37 Summary Part of general tuberculosis caused by Mycobacterium tuberculosis Vague, longstanding urinary symptoms with no obvious cause Urinalysis and culture and radiography for diagnosis Basilic medical treatment Adjuvant surgical therapy

38 THANK YOU