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Hematuria in Renal Tuberculosis
Vol. 99, Jan. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1968 by The Williams & Wilkins Co.
HElVIATURIA IN RENAL TUBERCULOSIS EGGERT BREKKAN From the Department of Surgery I, Sahlgrenska sjukhuset, Goteborg, ancl the Ravlancla Sanatorium, Ravlancla, Sweden
Investigators in various countries have reported a considerable difference in the incidence of hematuria accompanying urinary tract tuberculosis. Cosbie Ross found hematuria in 46 per cent of his male, and 35 per cent of female patients with renal tuberculosis. 1 Obrant and associates found hematuria in 13 per cent of patients afflicted with renal tuberculosis.2 Borthwick reported hematuria in 11.1 per cent of 700 cases of renal tuberculosis. 3 Puigvert stated in his monograph on male urogenital tuberculosis that hematuria is a constant symptom. He estimated that 80 to 90 per cent of his patients had gross hematuria and that microscopic hematuria may persist even after a clinical cure. 4 Hematuria in cases of urinary tuberculosis can be classified by origin, as vesical or renal; by quantity, as gross or microscopic; and by occurrence, as total or terminal, which usually accompanies other symptoms of tuberculous cystitis. The clinical signs tend to disappear in a relatively short time following chemotherapy. However, in some cases microscopic hematuria may persist for several months after treatment is begun. Ne have had 2 patients with renal tuberculosis in whom gross hematuria and severe kidney pain were so persistent following chemotherapy that an operation became inevitable.
at various sanatoria for pulmonary tuberculosis. In 1946 a left thoracoplasty was done. In 1950 it was believed that the patient was cured. X-rays revealed a typical deformity in the lower pole of the right kidney with a suspect cavity behind the lowermost calyx, which was constricted. Chemotherapy was instituted. Positive guinea pig tests of the urine confirmed the clinical diagnosis of renal tuberculosis. After 14 months of chemotherapy the patient was discharged from the hospital. During the final months of hospitalization he complained of pain in the right loin and had constant microscopic to gross hematuria. Shortly after discharge he had severe renal colic. Excretory urography revealed no urinary tract obstruction. Nevertheless the pain and attacks of renal colic persisted and he was readmitted to the hospital. Since his pain ,vas no longer endurable and the hematuria persisted, a right nephrectomy was clone. Convalescence was uneventful and the hematuria ceased promptly. No signs of relapse have been noted (fig. 1). Gross examination of the kidney revealed 2 communicating cavities filled with blood clots pressing through an extremely constricted calyx into the renal pelvis (fig. 2). No specific lesions were noted on histological examination and only a slight non-specific inflammatory reaction was seen with granulation and ulceration in the cavities. Case 2. A 36-year-old man had a lower urinary tract infection for a year. The guinea pig tests of the urine were positive and the patient was admitted to the hospital. X-ray studies revealed left renal tuberculosis with cavity formation and constriction of the calyx in the upper portion of the kidney. After 2 months of chemotherapy a guinea pig test of urine was negative. Nevertheless, after 16 months of chemotherapy (fig. 3) the patient still had microscopic to gross hematuria, and during the final months of hospitalization, he had moderate to severe pain in the left loin. A partial left nephrectomy was done because of the patient's discomfort. Convalescence was un-
CASE REPORTS
Case 1. A 37-year-old man was admitted to the hospital because of urethritis and epididymitis. Between 1941 and 1950 the patient was treated Accepted for publication January 12, 1967. 1 Ross, J.C.: Management of tuberculous bacilluria. Proc. Roy. Soc. Med., 46: 434, 1953. 2 Obrant, 0., Frimann-Dahl, J., Franzas, F. and Semb, C.: Treatment of renal tuberculosis. Acta Chir. Scand., 110: 3, 19i55. 3 Borthwick, W. Iii.: Genito-urinary tuberculosis. Tubercle, 37: 120, 1956. 4 Puigvert, A. C.: La Tuberculosis U rinaria y Genital Masculin. Barcelona, 1958, p. 135. 18
ID
HEiVIATURIA I!\ RENAL TUBERCULOSIS
Op. nephrectomy
Case l
t
Guinea pig test Haemoturia
.A -
PAS+ INH
Chemotherapy -t
+ + -
+
0
2
4
6
8
12
10
14
16
18
20
Time in
0
22 months
Fm. L Renal tuberculosis with stable conversion and negative g11inea pig tests of urine, following months of chemotherapy. AHer 1.~ months of treatment, patient still had microscopic to macroscopic hematuria. Nephrectomy was done because of pain and hernat.nria, HJ m,ml.hs ,tfter treatment.
Fm . .2. Case 1. Operative specimen revealed cavities in lower pole, filled with blood clots, a constricted calyx. Op. partial nephrectomy
Case 2
l
__j '------------· PAS+INH+STREPTOMYCIN
Chemotherapy Guinea pig tests Haematuria
+
rt
.! 0
2
4
6
8
10
12
14
16
•
Time in
18 months
Fm. :3. Renal tuberculosis with stable conversion and negative guinea pig tesls after .2 months of tren.t: ment. Partial nephrectomy was done following 16 months of chemotherapy because of hematnrin, nnd loin pain. and the hcnrnturia ceased promptly. is Yrnll and has no signs of relapse. As in case 1, gross examination of the specimen showed a cavity system filled with blood clots pnossing through a constricted calyx into the renal pelvis. Histological studies revealed no specific but a slight inflammatory reaction with ulceration and granulation in the cavities.
JJJSCUSSIO:N
J'\ rare complication made an operation neces-sary in two almost identical cases of renal tuber·· culosis. Although persistence of hematuria after successful medical treatment is noi, common, it is a factor to be considered. 1'he tuberculous process, as such, had healed. Both patients had negative guinea pig tests of urine at
20
BREKKAN
intervals for more than a year. Histological studies of the operative specimens showed no specific tuberculous lesions, but a non-specific inflammatory reaction with granulation and ulceration was present. In both cases, during the period of chemotherapy, studies for nonspecific urinary tract infections were negative. The histological picture agrees with former experience that during chemotherapy, the specific lesions change histologically to non-specific before ultimate healing. 5- 7 It is not known whether prolonged chemotherapy in these 2 cases would have made an operation superfluous, but the persistent hem5 Domagk, G.: Chemotherapie der Tuberkulose mit den Thiosemikarbazonen. Stuttgart: Thieme,
1950, p.127.
s Hansson, H.: Cited by 0. Obrant. 2 Fritjofsson, A. and Ahren, C.: Effect of chemotherapy on locally destructive renal tuberculosis. A pathologicoanatomic and clinical study. Acta Chir. Scand., suppl., 280, p. 17, 1961. 7
aturia and the patients' great discomfort gave us no choice. CONCLUSION
The indications for surgical treatment of renal tuberculosis are extremely limited; in fact, the only indication now is a non-functioning or a gravely impaired kidney. In 2 cases we encountered a late complication following otherwise successful medical treatment, i.e. persistent hematuria and renal pain, that made operative intervention imperative. SUMMARY
Two cases of renal tuberculosis are herein reported. In both, chemotherapy resulted in early stable conversion and negative guinea pig tests of urine, but severe renal pain and persistent hematuria eventually necessiated operation. Histological studies of the surgical specimens revealed no specific lesions.
THE JOURNAL OF UROLOGY
Copyright © 1968 by The Williams & Wilkins Co.
HElVIATURIA IN RENAL TUBERCULOSIS EGGERT BREKKAN From the Department of Surgery I, Sahlgrenska sjukhuset, Goteborg, ancl the Ravlancla Sanatorium, Ravlancla, Sweden
Investigators in various countries have reported a considerable difference in the incidence of hematuria accompanying urinary tract tuberculosis. Cosbie Ross found hematuria in 46 per cent of his male, and 35 per cent of female patients with renal tuberculosis. 1 Obrant and associates found hematuria in 13 per cent of patients afflicted with renal tuberculosis.2 Borthwick reported hematuria in 11.1 per cent of 700 cases of renal tuberculosis. 3 Puigvert stated in his monograph on male urogenital tuberculosis that hematuria is a constant symptom. He estimated that 80 to 90 per cent of his patients had gross hematuria and that microscopic hematuria may persist even after a clinical cure. 4 Hematuria in cases of urinary tuberculosis can be classified by origin, as vesical or renal; by quantity, as gross or microscopic; and by occurrence, as total or terminal, which usually accompanies other symptoms of tuberculous cystitis. The clinical signs tend to disappear in a relatively short time following chemotherapy. However, in some cases microscopic hematuria may persist for several months after treatment is begun. Ne have had 2 patients with renal tuberculosis in whom gross hematuria and severe kidney pain were so persistent following chemotherapy that an operation became inevitable.
at various sanatoria for pulmonary tuberculosis. In 1946 a left thoracoplasty was done. In 1950 it was believed that the patient was cured. X-rays revealed a typical deformity in the lower pole of the right kidney with a suspect cavity behind the lowermost calyx, which was constricted. Chemotherapy was instituted. Positive guinea pig tests of the urine confirmed the clinical diagnosis of renal tuberculosis. After 14 months of chemotherapy the patient was discharged from the hospital. During the final months of hospitalization he complained of pain in the right loin and had constant microscopic to gross hematuria. Shortly after discharge he had severe renal colic. Excretory urography revealed no urinary tract obstruction. Nevertheless the pain and attacks of renal colic persisted and he was readmitted to the hospital. Since his pain ,vas no longer endurable and the hematuria persisted, a right nephrectomy was clone. Convalescence was uneventful and the hematuria ceased promptly. No signs of relapse have been noted (fig. 1). Gross examination of the kidney revealed 2 communicating cavities filled with blood clots pressing through an extremely constricted calyx into the renal pelvis (fig. 2). No specific lesions were noted on histological examination and only a slight non-specific inflammatory reaction was seen with granulation and ulceration in the cavities. Case 2. A 36-year-old man had a lower urinary tract infection for a year. The guinea pig tests of the urine were positive and the patient was admitted to the hospital. X-ray studies revealed left renal tuberculosis with cavity formation and constriction of the calyx in the upper portion of the kidney. After 2 months of chemotherapy a guinea pig test of urine was negative. Nevertheless, after 16 months of chemotherapy (fig. 3) the patient still had microscopic to gross hematuria, and during the final months of hospitalization, he had moderate to severe pain in the left loin. A partial left nephrectomy was done because of the patient's discomfort. Convalescence was un-
CASE REPORTS
Case 1. A 37-year-old man was admitted to the hospital because of urethritis and epididymitis. Between 1941 and 1950 the patient was treated Accepted for publication January 12, 1967. 1 Ross, J.C.: Management of tuberculous bacilluria. Proc. Roy. Soc. Med., 46: 434, 1953. 2 Obrant, 0., Frimann-Dahl, J., Franzas, F. and Semb, C.: Treatment of renal tuberculosis. Acta Chir. Scand., 110: 3, 19i55. 3 Borthwick, W. Iii.: Genito-urinary tuberculosis. Tubercle, 37: 120, 1956. 4 Puigvert, A. C.: La Tuberculosis U rinaria y Genital Masculin. Barcelona, 1958, p. 135. 18
ID
HEiVIATURIA I!\ RENAL TUBERCULOSIS
Op. nephrectomy
Case l
t
Guinea pig test Haemoturia
.A -
PAS+ INH
Chemotherapy -t
+ + -
+
0
2
4
6
8
12
10
14
16
18
20
Time in
0
22 months
Fm. L Renal tuberculosis with stable conversion and negative g11inea pig tests of urine, following months of chemotherapy. AHer 1.~ months of treatment, patient still had microscopic to macroscopic hematuria. Nephrectomy was done because of pain and hernat.nria, HJ m,ml.hs ,tfter treatment.
Fm . .2. Case 1. Operative specimen revealed cavities in lower pole, filled with blood clots, a constricted calyx. Op. partial nephrectomy
Case 2
l
__j '------------· PAS+INH+STREPTOMYCIN
Chemotherapy Guinea pig tests Haematuria
+
rt
.! 0
2
4
6
8
10
12
14
16
•
Time in
18 months
Fm. :3. Renal tuberculosis with stable conversion and negative guinea pig tesls after .2 months of tren.t: ment. Partial nephrectomy was done following 16 months of chemotherapy because of hematnrin, nnd loin pain. and the hcnrnturia ceased promptly. is Yrnll and has no signs of relapse. As in case 1, gross examination of the specimen showed a cavity system filled with blood clots pnossing through a constricted calyx into the renal pelvis. Histological studies revealed no specific but a slight inflammatory reaction with ulceration and granulation in the cavities.
JJJSCUSSIO:N
J'\ rare complication made an operation neces-sary in two almost identical cases of renal tuber·· culosis. Although persistence of hematuria after successful medical treatment is noi, common, it is a factor to be considered. 1'he tuberculous process, as such, had healed. Both patients had negative guinea pig tests of urine at
20
BREKKAN
intervals for more than a year. Histological studies of the operative specimens showed no specific tuberculous lesions, but a non-specific inflammatory reaction with granulation and ulceration was present. In both cases, during the period of chemotherapy, studies for nonspecific urinary tract infections were negative. The histological picture agrees with former experience that during chemotherapy, the specific lesions change histologically to non-specific before ultimate healing. 5- 7 It is not known whether prolonged chemotherapy in these 2 cases would have made an operation superfluous, but the persistent hem5 Domagk, G.: Chemotherapie der Tuberkulose mit den Thiosemikarbazonen. Stuttgart: Thieme,
1950, p.127.
s Hansson, H.: Cited by 0. Obrant. 2 Fritjofsson, A. and Ahren, C.: Effect of chemotherapy on locally destructive renal tuberculosis. A pathologicoanatomic and clinical study. Acta Chir. Scand., suppl., 280, p. 17, 1961. 7
aturia and the patients' great discomfort gave us no choice. CONCLUSION
The indications for surgical treatment of renal tuberculosis are extremely limited; in fact, the only indication now is a non-functioning or a gravely impaired kidney. In 2 cases we encountered a late complication following otherwise successful medical treatment, i.e. persistent hematuria and renal pain, that made operative intervention imperative. SUMMARY
Two cases of renal tuberculosis are herein reported. In both, chemotherapy resulted in early stable conversion and negative guinea pig tests of urine, but severe renal pain and persistent hematuria eventually necessiated operation. Histological studies of the surgical specimens revealed no specific lesions.