Restoration of Function after Apparent Tuberculous Autonephrectomy

Vol. 106, Octobe,. Printed in U.S.A.

THE JouRNAL OF UROLOGY

Copyright© 1971 by The Williams & Wilkins Co.

RESTORATION OF FUKCTIOK AFTER APPARENT TUBERCULOVS AUTONEPHRECTOJ\IY Y. TAGUCHI

",ND

J. P. EMOND

From the Department of Urology, Royal Victoria Hospital and The Royal Edward Chest Hospital, Montreal, Canada

Lattimer's campaign indiscriminate in cases of renal tuberculosis has found a wide and receptive audience. 1 However, his crusade has been "'''"-·"~-,~,--! by some as a general indictment against all forms of surgical intervention in genitourinary tuberculosis and has overshadowed the more modest claims of those who have maintained that more nephrons be salvaged the application of the scalpe).2- 4 Herein is reported a case that reinforces this latter of view. V.UCV"JUU

CASE R}]PORT

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man, c011sulted his in :\1:arch 1968 with complaints and The symptoms abated when sulfonamide therapy was given but the urine conti,rned to show acid pyuria. Subsequently, morning urine specimens were tested for acid-fast bacilli. The smears were but Lowenstein cultures yielded modertuberculosis on 3 of successive occasions. Triple was started and the patient was referred for follovrnp. An excretory urogram (IVP) in October showed rather marked dilatation of the left drainage system with stricture formation at the upper and lower ends of the ureter (fig. 1, A). About a month later ureteral dilatation seemed worse and an to dilate the ureter failed. On 7, 1969 there was no excretion of contrast medium on IVP 1, B). On 10, with the urine converted, the

left kidney and upper ureter were through a transverse subcostal incision. The renal substance The kidney was mobilized and its vessels cleared to their junction with the aorta and vena eava. By displacing the kidney rtffmnnrn we could remove and bridge the strictured segment of the upper ureter without further mobilization of the ureter. The distal ureter then vvas approached through a separate Gibson incision. By suturing the dome of the bladder to the psoas muscle, we could the defect that would be created upon removal of the strictured segment of distal ureter. A dismembered pyeloplasty was done above and a mucosato-mucosa anastomosis was constructed below (fig. 2). No splints were used but suction drainage tubes* were placed adjacent to both anastomoses. Convalescence was uneventful. IVPs obtained at 12 2 months and 9 months revealed progressive (fig. 3). The patient is in excellent health more than l year later.

for publication December 1970. J. K., Uson, A. C. and Melicow, M. M.: Tuberculous infections and inflammations of the urinary tract. In: Edited by M. F. Campbell. Philadelphia: W. Saunders Co., vol. p. 409, 1963. W. K., Gale, G. L. and Peterson, K. S.S.: Reconstructive surgery for genitourinary tuberculosis. J. Urol., 101: 254, 1969. 3 Gow, J. G.: The surgery of genito-urinary tuberculosis. Brit. J. , 53: 210, 1966. 4 Hanley, H. G.: surgery in renal tuberculosis, including renal cavernotomy. Brit. J. Surg., 48: 415, 1961. 485

DISCUSSION

A succinct review of current management in genitourinary tuberculosis has been lished. 5 We favor 2 years of with 1 gm. streptomycin, intramuscularly, twice 100 gm. isoniazid, 3 times a · 5 gm. paraaminosalicylic acid (PAS), 3 times a and 50 gm. pyridoxine (B6), twice a When the intramuscular administration of streptomycin poses problems, we substitute 250 rag. cycloserine, twice a and when PAS cannot be tolerated, we use 25 mg. per kg. ethambutol for 3 weeks and then decrease the to 15 mg. per kg. For patients who undergo re-treatment we substitute 250 mg. c,u,uv•uu,,w,~~ 3 times a for the PAS and test for Hemovacs, Baxter Laboratories. Lattimer, J. K., Wechsler, H., Ehrlich, IL M. and Fukushima, K.: Current treatment for renaJ tuberculosis. J. Urol., 102: 2, 1969. * 5

486

TAGUCHI AND EMOND

Fm. 1. A, 60-minute IVP demonstrates stricture formation at upper and lower ends of ureter. B, 60-minute IVP demonstrates non-functioning left kidney.

!~ constricted areas of ureter resected

Fm. 2. Schematic representation of findings at exploration and surgical repair.

Kanamycin and pyrazinamide are not used in routine cases. Diagnosis is made by smears and Lowenstein cultures of 3 consecutive morning urine samples. When the laboratory does not confirm the clinical diagnosis we repeat the study, test repeat 24-hour urine collections and request guinea pig inoculations. One patient who had uremia had a positive culture after 12 collections.

The frequency of IVPs is individualized. When progressive strictures make frequent examinations necessary, we carry out modified IVPs, taking only 2 to 3 radiographs. We have been unsuccessful in dilating ureteral strictures. It may be that we are somewhat timid in forcing the catheters. On 1 occasion we attempted to dilate a ureter from above at exploration. The ureteral catheter readily and repeatedly perforated the inflamed wall of the ureter. The role of nephrectomy in the management of renal tuberculosis remains highly controversial. Lattimer stated that the only remaining indication for nephrectomy in tuberculosis is intractable pain and fever 1 and he has not found ablative operations necessary in the past 13 years. 5 Kerr noticed a decline in the number of nephrectomies in his series but he believes that diseased and non-functioning organs should be removed and has found nephrectomy necessary in at least 25 per cent of his cases. 2 Marshall argued that patients can be returned to a full and active life earlier by widening the indications for surgical extirpation. 6 6 Beck, A. D. and Marshall, V. F.: Is nephrectomy obsolete for unilateral renal tuberculosis? J. Urol., 98: 65, 1967.

487

GENITOURINARY TUBERCULOSIS

successful management of tuberculous strictures of the ureter with and intubations hiis been reported. 7 Gow reviewed 502 with genitourinary tuberculosis. in 821 There were 14 reimplantations (8 direct and into a, Iloari flap) and 2 dismembered plasties. 3 A report of a simultaneous and reimplantation has not been found. Our case demonstrates that if the abdominal ureter is not mobilization and resection of the upper and lower ends of the ureter arn without ischemic tions. Tuberculous autonephrectomy failure of the involved medium administered Creternl obstruction accounts for the loss of function in many cases. Kerr noted that in 59 of 63 autonephrectomies there were occluded urete:·s. 2 Barrie analyzed 61 nephrectomies for tuberculosis and found J 1 cases had obstructed ureters as the main cause of renal destruction and a:1 additional 18 of 25 cases with intrarenal stricture had uretcral obstruction. 8 correction of the stenosis in selected int;tance~ may restore renal function in a number of the:3e

of the obstructed ureter m Plustic tuberculosis 18 uncommon. In 711 cases of renal tuberculosis Kerr and associates did 12 and 2 open ureteral intubations, both of which \Vere unsuccessfuL2 However,

7 J\1oore, C. A. and L.: Manageto tnbercv_ ~ ment of ureteral stricture . J. Urol., 102: 176, 1969. H.J., W. K. and Gale, G.

and

of tuberculot,s J. Urol., 584,