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Tuberculous Renocolic Fistula: A Report of Two Cases
THE JOURNAL OF UROLOGY
Vol. 85, No. 5 May 1961 Copyright © 1961 by The Williams & Wilkins Co. Printed in U.S.A.
TUBERCULOUS RENOCOLIC FISTULA: A REPORT OF TWO CASES IAM BHISITKUL
AND
HARRY M. BURROS
From the Department of Urology, Graduate Hospital and Graduate School of Medicine of the University of Pennsylvania, Philadelphia, Pa.
The incidence of renal tuberculosis has not decreased in recent years, in spite of effective chemotherapy. However, renocolic fistula of tuberculous origin is rare. There has not been a case reported in the literature within the last 10 years. The purpose of this paper is to report two unusual cases of renal tuberculosis, each showing fistulous tracts to the colon. CASE REPORTS
Case 1. B. S. (No. 274116), a 67-year-old Negress, was admitted to The Graduate Hospital on October 14, 1959 because of general weakness, anorexia, constipation and progressive weight loss for about 2 months prior to admission. During the present illness she had had crampy pain in the lower abdomen associated with frequency on urination, occasional burning and nocturia 5-6 times. The pain would be relieved by a bowel movement or by passing flatus. The past history revealed that she was admitted to the hospital in 1946 because of lower abdominal pain and burning on urination. Cystoscopy at the time showed cystitis; an exudate was seen coming from the right ureteral orifice. The physical examination revealed a chronically ill, malnourished woman. The temperature was lOOF. The blood pressure was 122/68. Few crepitant rales were detected at both lung bases. There were systolic murmurs at aortic and mitral areas. The abdomen was distended and slightly tender in the right lower quadrant. It was impossible to determine any palpable mass due to abdominal distention. Rectal and vaginal examination was negative. The urine was acid, contained 1 plus albumin, 400-500 white blood cells and was loaded with bacteria. Urine culture was positive for Pseudomonas. The culture for acid-fast bacilli was negative. The blood urea was 9 mg. per cent. The hemoglobin was 8.3 gm. per cent. The white blood count and differential count were within normal limits. Occult blood (1 plus) was found in the stool. A barium enema revealed Accepted for publication September 22, 1960.
a short segment of narrowing in the distal portion of the ascending colon (fig. 1, A). Chest x-ray, gastrointestinal series and x-ray of lumbar and thoracic spines were normal. The barium e1;ema was reported to show obstructing carcinoma of the ascending colon. On October 27, 1959, an exploratory laparotomy through a midline abdominal inciRion revealed a large retroperitoneal mass in the region of the right kidney involving ascending colon, hepatic flexure and retroperitoneum. The 8ecum and distal ileum were also bound do,vn by an adhesive inflammatory process. Several enlarged mesenteric lymph nodes were observed in the region of distal ileum. It was impossible to separate the mass from the surrounding tissue due to extensive adhesions. An ileo-transverse colostomy was performed to relieve obstruction of the colon. A biopsy obtained from the mesenteric lymph nodes and distal ileum was reported as a tuberculous lesion. A postoperative intravenous urogram revealed a normal left upper urinary tract. No contrast material was observed in the right renal area. Cystoscopy was done on November 5, 1959. The right lateral wall of the bladder was deformed and scarred. Fibrosis was present in the region of the right ureteral orifice. The orifice was seen as a small dimple in this area. The trigone was pulled toward the right by a scar on the right lateral wall. The left orifice was seen just to the right of the midline. A size 6 ureteral catheter was passed up the left ureter to the renal pelvis with ease. On the right side, moderate resistance was encountered on advancing the catheter. No urine was obtained from the right kidney. A retrograde pyelogram showed a normal left upper urinary tract. The right pelviocalyceal system was markedly deformed. A fistulous tract communicating the right kidney to the distal ascending colon was demonstrated (fig. 1, B). Thick, purulent material was obtained from aspiration of the right retroperitoneal space. The stain of this material was positive for acid-fast bacilli.
716
TUBERCULOUS REKOCOLIC FISTULA
7
FIG. 1
The patient took streptomycin, 1 gm. twice a week, para-aminosalicylic acid, 4 gm. 4 times a day and isoniazid, 100 mg. 3 times a day. She was clinically improved and was discharged to be followed in the outpatient clinic. Right nephrectomy and colon resection will be considered after 6 months of medical therapy. Case 2. L. S. (No. 258593), a 60-year-old Negress, was admitted to The Graduate Hospital in February 1959, because of persistent vomiting and tarry stools 4 weeks in duration. The symptoms had progressed in severity until she was not able to take anything by mouth during the few days before she ,vas admitted to the hospital. Bowel movements at that time were frequent and tarry. These symptoms were associated with burning on urination, frequency and nocturia 5-6 times. She had no pain during the present illness. The past history revealed that she had undergone hysterectomy followed by penumonia in 1927. She was admitted to the hospital in 1957 because of superficial thrombophlebitis of the J.ower extremities. The patient had been treated with digitalis by the cardiac clinic since 1955 because of congestive heart failure. Physical examination revealed an acutely and chronically ill, cachectic woman. The temperature was lOlF. The blood pressure was 90/74. The patient was dehydrated and slightly dyspneic. Few rhonchi were heard in both lung bases.
A systolic murmur was audible over the area. A freely movable, nontender mass was palpated in the right upper abdominal quadrant It could be moved from the lumbar to the umbilical area. In the left upper quadrant there was a questionable mass extending down to the ]eh, lumbar area. Pelvic examination was negative. A tarry stool was obtained from rectal examination. The urine was acid and loaded with leuko. cytes. The hemoglobin was 11.8 gm. per cent . white blood cells 11,000 with 91 per cent neutrophiles, 4 per cent lymphocytes, 3 per cent monocytes and 2 per cent eosinophils. The blood 1Jrea, nitrogen was 14 mg. per cent. An excretory urogram showed a malrotatecl 1 ptotic right kidney and an otherwise normal right upper tract. No contrast material was ob. served in the left renal area. A small calcific shadow was seen in this area. A retrograde pyelogram demonstrated a deformed left pelviocalycea! system with a fistula between the left kidney and the proximal descending colon (fig. 2, A) A barium enema revealed lateral displacernent of the middle third of the descending colon by ,,, soft tissue mass in the region of the left kidney (fig. 2, B). An exploratory laparotomy was contemplatec( but the patient refused operation and was discharged to be followed in the outpatient clinic. In December 1959, the patient was again admitted because of repeated vomiting, diarrhea
718
BHISITKUL AND BURROS
FIG. 2
and tarry stools. She had lost about 20 pounds since her last admission; the frequency, clysuria and nocturia had continued. She was found to be acidotic and was in electrolyte imbalance. On this admission the urine culture was positive for acid-fast bacilli. The diagnosis was tuberculous left kidney with renocolic fistula. Streptomycin 1 gm. twice a week, isoniazid, 100 mg. 3 times a day and para-aminosalicylic acid 4 gm. 4 times a day were prescribed. On December 10, 1959, a transverse colostomy was performed because of continued colonic bleeding and diarrhea. N ephrectomy and colon resection will be considered after 6 months of antituberculous therapy. DISCUSSION
Renal fistula is a rare condition, and yet it is a serious and formidable problem. Tuberculosis is a frequent cause of renal fistula. Abeshouse, in 1949, was able to collect 89 cases of renal fistula, 25 of which were tuberculous in origin. The lesion results from a late and extensive process of the disease. The primary lesion is always in the kidney; no primary bowel lesion causes this condition. No case has been reported of an associated malignant lesion in the kidney. Early diagnosis and treatment give the best possible prognosis to the patient with renal tuberculosis. The massive lesion can not be healed by chemotherapy. Any lesion that can be definitely visualized by pyelogram is very difficult
to heal by chemotherapy. The correct or positive diagnosis is based on finding tubercle bacilli and/or pyelographic findings. In renocolic fistula, retrograde pyelography is the most valuable procedure for obtaining correct diagnosis, accurate location and the extent of the lesion. Intravenous pyelography may not be of any value if the renal damage is massive. Barium enema is not necessary and usually is of little help. There is no definite rule of treatment that can be applied to every case of renal tuberculosis. Within recent years, the treatment has changed considerably. The treatment of choice should be considered according to the extent of renal lesions. It has been demonstrated that a small or minimal lesion can be cured by proper chemotherapy. The most effective chemotherapy is the combined treatment of streptomycin, paraaminosalicylic acid and isoniazicl, which must be continued without interruption for 2 years, regardless of negative urine culture. Should the urine be positive at the encl of treatment, medical therapy should be continued for another one or two years. No drug should be given singly in the treatment of renal tuberculosis. This would lead to early resistance of the bacteria to the drug and the benefit of treatment decreased. Supportive treatment (bed rest, high protein and high vitamin diet) is essential for obtaining the best result. The patient should be semiambulatory for at least the first six months of therapy.
7Hl
TUBERCULOUS REKOCOLIC FISTULA
Before the antibiotic era, the treatment of renal tuberculosis was always surgical. In recent years, the medical therapy with modern antituberculous drugs has given promising results, but is not always effective. Surgery is still indicated in certain types of renal tuberculosis. In advanced or fibrocaseous unilateral renal tuberculosis as well as autonephrectomized kidney, the treatment of choice is nephrectomy, provided that the patient is in a favorable general condition. Surgery is also indicated in tuberculous pyonephrosis especially when secondarily infected. The economic and social status of the patient is important, since certain ones are unable to stay on medical therapy for a long period of time. In this instance, surgery will shorten the course of the disease. Partial nephrectomy has been reported as a treatment of choice in localized lesions that failed to heal by medical therapy. Less than 5 per cent of renal tuberculosis, however, is suitable for partial resection. Any type of surgery should be in conjunction with medical treatment. The best results are obtained by giving the patient preoperative streptomycin1 isoniazicl and paraaminosalicylic acid for at least 4 to 6 months. This will minimize the incidence of postoperative miliary spread, serious wound infection, and fistula formation. In order to complete the course of treatment, the patient is given medical therapy for a full 2 years. The operation should be clone at the most suitable time, i.e. when the patient has the greatest possible resistance to the disease. Disposition of the ureteral stump in nephrectomy for renal tuberculosis is important. The incidence of wound infection, abscess and fistula resulting from infected stump is as high as 25 per cent. This serious complication can be obviated by either removal (nephro-ureterectomy), or exteriorization of the ureteral stump. SUMMARY
Renocolic fistula of tuberculous origin is rare. The diagnosis is best established by retrograde pyelography. Intravenous pyelography and barium enema are of little help. The condition results from far advanced or long standing renal tuberculosis. The primary lesion is always renal in origin. X either malignant disease of the kidney
nor primary disease of the bowel causing reno colic fistula has been reported. The treatment of choice is nephrectomy. CONCLUSION
Two cases of tuberculous renocolic fistula are reported. The diagnosis and treatment of renal tuberculosis are briefly described.
419 S. 19th St., Philadelphia 46, Pa. (H. M. REFERENCES ABESHous:EJ, B. S.: Renal and ureteral fistula of the visceral and cutaneous types: A of four cases. Urol. & Cutan. Rev., 53: 674, 1949. CoLBY, F. H.: Tuberculous infection and mflammation of urinary tract. In Urology, edited by Campbell. Philadelphia and London· W. B. Saunders Co., 1954, vol. 1, pp. 525-,557. DONOVAN, J. H.: Disposition of the ureteral stump after nephrectomy for tuberculosis. A study of 81 cases. J. Urol., 76: 365-370, 1956. DEAN, A. L.: Treatment of tuberculosis of genitourinary organs by drugs. J. Urol., 73: 599-608, 1955. FINDLAY, H. V.: Renocolic fistula. Calif. 11.focL, 70: 207-209, 1949. HowARD, T. L.: The management of the ureter in tuberculous lesions of the kidney. J. UroL, 42: 1003-1009, 1939. How ARD, T. L.: Renal tuberculosis and its treatment. In: Dodson's Urological Surgery. St. Louis: The C. V. Mosby Co., 1956, pp. 186-HJ7. LATTIMER, J. K.: The treatment of tuberculous infections of the genitourinary tract. J. UroI., 74: 291-300, 1955. LATTIMER, J. K., LERMAN, F., LERMAN, P. AND SPIVAK, L. L.: Streptomycin, PAS and isonia zid in renal tuberculosis. J. Urol., 69: 745--752, 1953. LATTIMER, J. K.: Partial resection of kidney for tuberculosis. J. Urol., 73: 455--459, 1955. LATTIMER, J. K. AND SPIRITO, A. L.: The current status of the chemotherapy of renal tuberculosis. J. Urol., 75: 375--379, 1956. LATTIMER, J. K.: Tuberculosis in a solitary kidney. J. Urol., 81: 379-381, 1959. LATTIMER, J. K., VASQUEZ, G. AND WECHSLER, H .. J. U rol., 83: 493-497 1960. LJUNGGREN, E.: Indications for nephrectomy, nephro-ureterectomy and partial nephrectomy in renal tuberculosis. J. Urol., 78: '199-50:{, 1957. RATLIFF, R. K. AND BARNES, A. C.: reno-colic fistula; report of two cases. J. 42: 311-316, 1939. RINKER, J. R.: Surgical resection of tuberculous kidney. J. Urol., 66: 498-499, 1956. Ros'l', G. S., CooPER, D., KNouF, C E., FERGUSON, P. AND lVlcCRARY, A.: J. Urol., 75: 787-792, 1956. VERMOOTEN, V. AND lVIcKEOWN, R. lVI.: Reno .. colic fistula. Am. J. Surg., 21: 242-246, 1933. 1
Vol. 85, No. 5 May 1961 Copyright © 1961 by The Williams & Wilkins Co. Printed in U.S.A.
TUBERCULOUS RENOCOLIC FISTULA: A REPORT OF TWO CASES IAM BHISITKUL
AND
HARRY M. BURROS
From the Department of Urology, Graduate Hospital and Graduate School of Medicine of the University of Pennsylvania, Philadelphia, Pa.
The incidence of renal tuberculosis has not decreased in recent years, in spite of effective chemotherapy. However, renocolic fistula of tuberculous origin is rare. There has not been a case reported in the literature within the last 10 years. The purpose of this paper is to report two unusual cases of renal tuberculosis, each showing fistulous tracts to the colon. CASE REPORTS
Case 1. B. S. (No. 274116), a 67-year-old Negress, was admitted to The Graduate Hospital on October 14, 1959 because of general weakness, anorexia, constipation and progressive weight loss for about 2 months prior to admission. During the present illness she had had crampy pain in the lower abdomen associated with frequency on urination, occasional burning and nocturia 5-6 times. The pain would be relieved by a bowel movement or by passing flatus. The past history revealed that she was admitted to the hospital in 1946 because of lower abdominal pain and burning on urination. Cystoscopy at the time showed cystitis; an exudate was seen coming from the right ureteral orifice. The physical examination revealed a chronically ill, malnourished woman. The temperature was lOOF. The blood pressure was 122/68. Few crepitant rales were detected at both lung bases. There were systolic murmurs at aortic and mitral areas. The abdomen was distended and slightly tender in the right lower quadrant. It was impossible to determine any palpable mass due to abdominal distention. Rectal and vaginal examination was negative. The urine was acid, contained 1 plus albumin, 400-500 white blood cells and was loaded with bacteria. Urine culture was positive for Pseudomonas. The culture for acid-fast bacilli was negative. The blood urea was 9 mg. per cent. The hemoglobin was 8.3 gm. per cent. The white blood count and differential count were within normal limits. Occult blood (1 plus) was found in the stool. A barium enema revealed Accepted for publication September 22, 1960.
a short segment of narrowing in the distal portion of the ascending colon (fig. 1, A). Chest x-ray, gastrointestinal series and x-ray of lumbar and thoracic spines were normal. The barium e1;ema was reported to show obstructing carcinoma of the ascending colon. On October 27, 1959, an exploratory laparotomy through a midline abdominal inciRion revealed a large retroperitoneal mass in the region of the right kidney involving ascending colon, hepatic flexure and retroperitoneum. The 8ecum and distal ileum were also bound do,vn by an adhesive inflammatory process. Several enlarged mesenteric lymph nodes were observed in the region of distal ileum. It was impossible to separate the mass from the surrounding tissue due to extensive adhesions. An ileo-transverse colostomy was performed to relieve obstruction of the colon. A biopsy obtained from the mesenteric lymph nodes and distal ileum was reported as a tuberculous lesion. A postoperative intravenous urogram revealed a normal left upper urinary tract. No contrast material was observed in the right renal area. Cystoscopy was done on November 5, 1959. The right lateral wall of the bladder was deformed and scarred. Fibrosis was present in the region of the right ureteral orifice. The orifice was seen as a small dimple in this area. The trigone was pulled toward the right by a scar on the right lateral wall. The left orifice was seen just to the right of the midline. A size 6 ureteral catheter was passed up the left ureter to the renal pelvis with ease. On the right side, moderate resistance was encountered on advancing the catheter. No urine was obtained from the right kidney. A retrograde pyelogram showed a normal left upper urinary tract. The right pelviocalyceal system was markedly deformed. A fistulous tract communicating the right kidney to the distal ascending colon was demonstrated (fig. 1, B). Thick, purulent material was obtained from aspiration of the right retroperitoneal space. The stain of this material was positive for acid-fast bacilli.
716
TUBERCULOUS REKOCOLIC FISTULA
7
FIG. 1
The patient took streptomycin, 1 gm. twice a week, para-aminosalicylic acid, 4 gm. 4 times a day and isoniazid, 100 mg. 3 times a day. She was clinically improved and was discharged to be followed in the outpatient clinic. Right nephrectomy and colon resection will be considered after 6 months of medical therapy. Case 2. L. S. (No. 258593), a 60-year-old Negress, was admitted to The Graduate Hospital in February 1959, because of persistent vomiting and tarry stools 4 weeks in duration. The symptoms had progressed in severity until she was not able to take anything by mouth during the few days before she ,vas admitted to the hospital. Bowel movements at that time were frequent and tarry. These symptoms were associated with burning on urination, frequency and nocturia 5-6 times. She had no pain during the present illness. The past history revealed that she had undergone hysterectomy followed by penumonia in 1927. She was admitted to the hospital in 1957 because of superficial thrombophlebitis of the J.ower extremities. The patient had been treated with digitalis by the cardiac clinic since 1955 because of congestive heart failure. Physical examination revealed an acutely and chronically ill, cachectic woman. The temperature was lOlF. The blood pressure was 90/74. The patient was dehydrated and slightly dyspneic. Few rhonchi were heard in both lung bases.
A systolic murmur was audible over the area. A freely movable, nontender mass was palpated in the right upper abdominal quadrant It could be moved from the lumbar to the umbilical area. In the left upper quadrant there was a questionable mass extending down to the ]eh, lumbar area. Pelvic examination was negative. A tarry stool was obtained from rectal examination. The urine was acid and loaded with leuko. cytes. The hemoglobin was 11.8 gm. per cent . white blood cells 11,000 with 91 per cent neutrophiles, 4 per cent lymphocytes, 3 per cent monocytes and 2 per cent eosinophils. The blood 1Jrea, nitrogen was 14 mg. per cent. An excretory urogram showed a malrotatecl 1 ptotic right kidney and an otherwise normal right upper tract. No contrast material was ob. served in the left renal area. A small calcific shadow was seen in this area. A retrograde pyelogram demonstrated a deformed left pelviocalycea! system with a fistula between the left kidney and the proximal descending colon (fig. 2, A) A barium enema revealed lateral displacernent of the middle third of the descending colon by ,,, soft tissue mass in the region of the left kidney (fig. 2, B). An exploratory laparotomy was contemplatec( but the patient refused operation and was discharged to be followed in the outpatient clinic. In December 1959, the patient was again admitted because of repeated vomiting, diarrhea
718
BHISITKUL AND BURROS
FIG. 2
and tarry stools. She had lost about 20 pounds since her last admission; the frequency, clysuria and nocturia had continued. She was found to be acidotic and was in electrolyte imbalance. On this admission the urine culture was positive for acid-fast bacilli. The diagnosis was tuberculous left kidney with renocolic fistula. Streptomycin 1 gm. twice a week, isoniazid, 100 mg. 3 times a day and para-aminosalicylic acid 4 gm. 4 times a day were prescribed. On December 10, 1959, a transverse colostomy was performed because of continued colonic bleeding and diarrhea. N ephrectomy and colon resection will be considered after 6 months of antituberculous therapy. DISCUSSION
Renal fistula is a rare condition, and yet it is a serious and formidable problem. Tuberculosis is a frequent cause of renal fistula. Abeshouse, in 1949, was able to collect 89 cases of renal fistula, 25 of which were tuberculous in origin. The lesion results from a late and extensive process of the disease. The primary lesion is always in the kidney; no primary bowel lesion causes this condition. No case has been reported of an associated malignant lesion in the kidney. Early diagnosis and treatment give the best possible prognosis to the patient with renal tuberculosis. The massive lesion can not be healed by chemotherapy. Any lesion that can be definitely visualized by pyelogram is very difficult
to heal by chemotherapy. The correct or positive diagnosis is based on finding tubercle bacilli and/or pyelographic findings. In renocolic fistula, retrograde pyelography is the most valuable procedure for obtaining correct diagnosis, accurate location and the extent of the lesion. Intravenous pyelography may not be of any value if the renal damage is massive. Barium enema is not necessary and usually is of little help. There is no definite rule of treatment that can be applied to every case of renal tuberculosis. Within recent years, the treatment has changed considerably. The treatment of choice should be considered according to the extent of renal lesions. It has been demonstrated that a small or minimal lesion can be cured by proper chemotherapy. The most effective chemotherapy is the combined treatment of streptomycin, paraaminosalicylic acid and isoniazicl, which must be continued without interruption for 2 years, regardless of negative urine culture. Should the urine be positive at the encl of treatment, medical therapy should be continued for another one or two years. No drug should be given singly in the treatment of renal tuberculosis. This would lead to early resistance of the bacteria to the drug and the benefit of treatment decreased. Supportive treatment (bed rest, high protein and high vitamin diet) is essential for obtaining the best result. The patient should be semiambulatory for at least the first six months of therapy.
7Hl
TUBERCULOUS REKOCOLIC FISTULA
Before the antibiotic era, the treatment of renal tuberculosis was always surgical. In recent years, the medical therapy with modern antituberculous drugs has given promising results, but is not always effective. Surgery is still indicated in certain types of renal tuberculosis. In advanced or fibrocaseous unilateral renal tuberculosis as well as autonephrectomized kidney, the treatment of choice is nephrectomy, provided that the patient is in a favorable general condition. Surgery is also indicated in tuberculous pyonephrosis especially when secondarily infected. The economic and social status of the patient is important, since certain ones are unable to stay on medical therapy for a long period of time. In this instance, surgery will shorten the course of the disease. Partial nephrectomy has been reported as a treatment of choice in localized lesions that failed to heal by medical therapy. Less than 5 per cent of renal tuberculosis, however, is suitable for partial resection. Any type of surgery should be in conjunction with medical treatment. The best results are obtained by giving the patient preoperative streptomycin1 isoniazicl and paraaminosalicylic acid for at least 4 to 6 months. This will minimize the incidence of postoperative miliary spread, serious wound infection, and fistula formation. In order to complete the course of treatment, the patient is given medical therapy for a full 2 years. The operation should be clone at the most suitable time, i.e. when the patient has the greatest possible resistance to the disease. Disposition of the ureteral stump in nephrectomy for renal tuberculosis is important. The incidence of wound infection, abscess and fistula resulting from infected stump is as high as 25 per cent. This serious complication can be obviated by either removal (nephro-ureterectomy), or exteriorization of the ureteral stump. SUMMARY
Renocolic fistula of tuberculous origin is rare. The diagnosis is best established by retrograde pyelography. Intravenous pyelography and barium enema are of little help. The condition results from far advanced or long standing renal tuberculosis. The primary lesion is always renal in origin. X either malignant disease of the kidney
nor primary disease of the bowel causing reno colic fistula has been reported. The treatment of choice is nephrectomy. CONCLUSION
Two cases of tuberculous renocolic fistula are reported. The diagnosis and treatment of renal tuberculosis are briefly described.
419 S. 19th St., Philadelphia 46, Pa. (H. M. REFERENCES ABESHous:EJ, B. S.: Renal and ureteral fistula of the visceral and cutaneous types: A of four cases. Urol. & Cutan. Rev., 53: 674, 1949. CoLBY, F. H.: Tuberculous infection and mflammation of urinary tract. In Urology, edited by Campbell. Philadelphia and London· W. B. Saunders Co., 1954, vol. 1, pp. 525-,557. DONOVAN, J. H.: Disposition of the ureteral stump after nephrectomy for tuberculosis. A study of 81 cases. J. Urol., 76: 365-370, 1956. DEAN, A. L.: Treatment of tuberculosis of genitourinary organs by drugs. J. Urol., 73: 599-608, 1955. FINDLAY, H. V.: Renocolic fistula. Calif. 11.focL, 70: 207-209, 1949. HowARD, T. L.: The management of the ureter in tuberculous lesions of the kidney. J. UroL, 42: 1003-1009, 1939. How ARD, T. L.: Renal tuberculosis and its treatment. In: Dodson's Urological Surgery. St. Louis: The C. V. Mosby Co., 1956, pp. 186-HJ7. LATTIMER, J. K.: The treatment of tuberculous infections of the genitourinary tract. J. UroI., 74: 291-300, 1955. LATTIMER, J. K., LERMAN, F., LERMAN, P. AND SPIVAK, L. L.: Streptomycin, PAS and isonia zid in renal tuberculosis. J. Urol., 69: 745--752, 1953. LATTIMER, J. K.: Partial resection of kidney for tuberculosis. J. Urol., 73: 455--459, 1955. LATTIMER, J. K. AND SPIRITO, A. L.: The current status of the chemotherapy of renal tuberculosis. J. Urol., 75: 375--379, 1956. LATTIMER, J. K.: Tuberculosis in a solitary kidney. J. Urol., 81: 379-381, 1959. LATTIMER, J. K., VASQUEZ, G. AND WECHSLER, H .. J. U rol., 83: 493-497 1960. LJUNGGREN, E.: Indications for nephrectomy, nephro-ureterectomy and partial nephrectomy in renal tuberculosis. J. Urol., 78: '199-50:{, 1957. RATLIFF, R. K. AND BARNES, A. C.: reno-colic fistula; report of two cases. J. 42: 311-316, 1939. RINKER, J. R.: Surgical resection of tuberculous kidney. J. Urol., 66: 498-499, 1956. Ros'l', G. S., CooPER, D., KNouF, C E., FERGUSON, P. AND lVlcCRARY, A.: J. Urol., 75: 787-792, 1956. VERMOOTEN, V. AND lVIcKEOWN, R. lVI.: Reno .. colic fistula. Am. J. Surg., 21: 242-246, 1933. 1