Comparison of Transperitoneal and Retroperitoneal Laparoscopic Nephrectomy for Nonfunctional Tuberculous Kidneys: A Single-Center Experience.

OBJECTIVES: To compare the effectiveness and safety between retroperitoneal laparoscopic nephrectomy (RLN) and transperitoneal laparoscopic nephrectomy (TLN) for nonfunctional tuberculous kidneys (NTK). METHODS: From March 2013 to February 2016, 24 patients with NTK underwent laparoscopic nephrectomy in our department. Eleven patients underwent RLN, and 13 underwent TLN. The demographics and perioperative outcomes were compared retrospectively. RESULTS: Characteristics, including gender, age, body mass index, and location, were similar in these two groups. All operations were successfully completed in the RLN group, while 1 case in the TLN group was converted to open surgery due to severe adhesions and excessive bleeding (1 of 13 patients). Time to oral intake after surgery in the TLN and RLN group was 43.85 ± 6.01 hours and 27.45 ± 6.83 hours (P < .05). No notable differences were found between two groups in terms of estimated blood loss, operative time, days of drain removal, and postoperative hospital stay. No local or disseminated recurrence was identified during the follow-up period. CONCLUSION: Taking the same safety and effectiveness into consideration, TLN can be an alternative choice for experienced surgeons to deal with NTK. Also, further studies with a larger sample size should be performed to confirm this finding.

Renal tuberculosis in the modern era.

Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. The disease remains as an important public health problem in developing countries. Extrapulmonary TB became more common with the advent of infection with human immunodeficiency virus and by the increase in the number of organ transplantation, which also leads to immunosuppression of thousand of persons. Urogenital TB represents 27% of extrapulmonary cases. Renal involvement in TB can be part of a disseminated infection or a localized genitourinary disease. Renal involvement by TB infection is underdiagnosed in most health care centers. Most patients with renal TB have sterile pyuria, which can be accompanied by microscopic hematuria. The diagnosis of urinary tract TB is based on the finding of pyuria in the absence of common bacterial infection. The first choice drugs include isoniazide, rifampicin, pirazinamide, ethambutol, and streptomycin. Awareness of renal TB is urgently needed by physicians for suspecting this disease in patients with unexplained urinary tract abnormalities, mainly in those with any immunosuppression and those coming from TB-endemic areas.

Tuberculosis and tubulointerstitial nephritis: an intriguing puzzle.

Classical renal tuberculosis is a well-known cause of urinary tract scarring and calcification, and sometimes renal dysfunction. In the past two decades there have been reports, particularly from the United Kingdom among immigrants from the Indian subcontinent, of a more insidiously progressive form of renal disease. Ultrasound shows small smooth kidneys, and histology reveals tubulointerstitial nephritis including granulomas but not acid-fast bacilli. Evidence is mounting that the underlying cause may be tuberculosis, but the mechanism remains obscure.

Presentation, diagnosis, and treatment outcome of tuberculous-mediated tubulointerstitial nephritis.

Insidious Mycobacterium tuberculosis infection causing tubulointerstitial nephritis is a rare disorder. Here we report on a single-center case series of patients with tubulointerstitial nephritis due to tuberculosis, addressing clinicopathologic features and treatment outcome. Twenty-five adult patients with clinical evidence of tuberculosis and significant renal disease were assessed, 17 of whom had a kidney biopsy and were subsequently diagnosed with chronic granulomatous tubulointerstitial nephritis as the primary lesion. All patients were given standard antitubercular treatment, with some receiving corticosteroids, and showed a good response in clinical symptoms and inflammatory markers. Nine of the 25 patients, however, started renal replacement therapy within 6 months of presentation. Of the remaining 16, renal function improved for up to a year after presentation but subsequently declined through a median follow-up of 36 months. This case series supports that chronic tubulointerstitial nephritis is the most frequent kidney biopsy finding in patients with renal involvement from tuberculosis. Thus, a kidney biopsy should be considered in the clinical evaluation of kidney dysfunction with tuberculosis since tubulointerstitial nephritis presents late with advanced disease. A low threshold of suspicion in high-risk populations might lead to earlier diagnosis and treatment, preserving renal function and delaying initiation of renal replacement therapy.

[SPECIFIC IMMUNE RESPONSE AND PROTECTIVE FACTORS OF NEUTROPHIL GRANULOCYTES IN PULMONARY AND EXTRAPULMONARY TUBERCULOSIS].

An immune response and protective factors of neutrophil granulocytes were comparatively studied in 61 patients with pulmonary tuberculosis, 70 with nephrotuberculosis, and 45 with tuberculous spondylitis. It was shown that there were elevated serum levels of neutrophil cationic proteins in both pulmonary and extrapulmonary tuberculosis. Lower content of intracellular cationic proteins along with suppressed cellular immunity was observed in pulmonary tuberculosis patients with disseminated actively progressive changes. This combination may be regarded as a poor predictor. Higher values of a specific cellular immune response and elevated levels of intracellular cationic proteins of neutrophils were found in extrapulmonary tuberculosis. This was also seen in patients with severe clinical manifestations of the disease. Thus, there is reason to believe that there is a regulatory association of the protective factors of neutrophil granulocytes with cellular immunity in tuberculosis.

[Relationship of the course of nephrotuberculosis in patients to various combinations of genetic markers].

To examine the body's responsiveness in different forms of nepthrotuberculosis, 237 patients underwent comprehensive clinical laboratory studies. To reveal various combinations of genetic markers, the authors determine the phenotypes of haptoglobin, the activity of red blood cell glucose-6-phosphate dehydrogenase, the type of inactivation of isonicotinic acid hydrazide. According to the combinations of a complex of these genetic markers, the authors identified 4 combinations: poor, good, relatively poor, and relatively good. The studies indicated the high incidence of common forms of nephrotuberculosis in subjects with poor and relatively poor combinations of genetic markers. The determination of various chronic renal failure-associated combinations of genetic markers may be used to identify risk groups for this disease.

[Ultrasound evaluation of intrahepatic hemodynamic disorders in patients with renal tuberculosis].

Seroechography, duplex, color, and energy Doppler studies were used to examine 50 patients with different forms of renal tuberculosis. The nature of renal blood flow was shown to depend on the magnitude of pathomorphological changes in tuberculous lesion. Spectral and energy Doppler studies revealed enhanced blood flow in the area of tuberculous infiltration. In all forms of nephrotuberculosis, there was an increase in peripheral vascular resistance, which was associated with vasoconstriction, obliteration, and diminished elasticity of vascular walls. Ultrasound angiography used in destructive forms of renal tuberculosis makes it possible to define treatment policy. The data of Doppler study were compared in relation to the glomerular filtration rate. The study ascertained that there was a reduction in glomerular filtration rates as the velocity characteristics of blood flow decreased and peripheral vascular resistance increased. The threshold values of renal hemodynamic parameters were determined to estimate renal filtration function. The reduction in end-diastolic blood flow velocity at different levels of the renal artery was of the greatest diagnostic informational value for diminished renal filtration function.

[Extrapulmonary tuberculosis: case of a 70-year-old woman suffering from cutaneous lymph node, renal and bone tuberculosis ]. / Gruzlica pozaplucna: przypadek 70-letniej kobiety z rozsianym procesem gruzliczym skóry, wezlów chlonnych, nerek i kosci.

We have described a case of a 70-year-old woman, treated for a pancreas cancer, which was diagnosed for many months because of atypical skin lesions, lymphadenopathy and progressing cachexia. Despite many autoimmunological, serological, histopathological, bacteriological and mycological examinations there was no diagnosis. Finally the case of extrapulmonary tuberculosis involving skin, lymph nodes, kidneys and bones was diagnosed. After the introduction of antituberculotic therapy we are observing some clinical improvement and regression of symptoms.

[Clinical and epidemiological characteristics of renal tuberculosis in children and adolescents]. / Diagnostika i lechenie tuberkuleza perifericheskikh limphaticheskikh uzlov u detei i podrostkov.

The clinical manifestations of renal tuberculosis under the present conditions were studied. Seventy one patients with active renal tuberculosis treated at the Moscow Research Institute of Phthisiopulmonology and at the Pediatric Department, Yekaterinburg Research- and Production Association Phthisiology were followed up. The morbidity rate of urinary tuberculosis was found to directly depends on whether early detection of the disease is organized. Urinary tuberculosis afflicts children and adolescents in all age groups. However, its higher rates are detected in the first decade of life. Renal tuberculosis is accompanied by manifestations of the urinary syndrome in 70.4% of cases and by the presence of Mycobacteria tuberculosis in 100%. A limited renal tuberculous process was detected in 80% of cases in the period of primary infection or in the following 2 years. A generalized renal tuberculous process involving other systems in a child was accompanied by few clinical urinary symptoms and it did not depend on the duration of infection.

[Significance of the CT scan in renal tuberculosis].

OBJECTIVE: To elucidate the features and clinical significance of CT scan in the diagnosis of renal tuberculosis. METHODS: The CT findings and the clinical characteristics of 42 cases with renal TB were retrospectively analyzed. RESULTS: Unilateral renal TB was found in 34 cases, bilateral in 8 cases. The typical CT features were characterized by one or more cysts surrounding the calyx with thin adjacent cortex (34/50), thickened wall of ureters and calyx, hydronephrosis (22/50) and kidney calcification (8/50). Atypical features presented with single or multiple low density nodes in the renal parenchyma (6/50). 30 patients receiving contrast enhanced CT scan showed that intensified Hu (by 20 approximately 120 HU) in the affected kidney. Multiple lymph nodes calcification in abdomen was found in 2 patients, calcification and low density nodes in spleen and liver in 4 patients, vertebral damage and paravertebral abscess in 6 patients and post-abdominal abscess in 1 patient. CONCLUSION: CT scan examination is not only useful in the diagnosis of renal tuberculosis, but also of significance in assessing the severity of the disease, renal function and the involvement of other organs in the abdomen.

Laparoscopic nephrectomy for nonfunctioning tuberculous kidney.

BACKGROUND AND PURPOSE: Although laparoscopic nephrectomy for benign renal disease has been widely accepted, use of the operation for tubercular pyelonephritic kidney is relatively contraindicated because of difficulties in dissecting the dense fibrotic adhesions and the risk of spillage of caseous materials with subsequent dissemination of the disease. However, with the accumulation of experience, laparoscopic surgery is expanding its applications. In this study, we tried to evaluate the efficacy and safety of the laparoscopic nephrectomy for renal tuberculosis. PATIENTS AND METHODS: At three centers, 13 laparoscopic nephrectomies were performed between April 1996 and March 1999. The patients consisted of eight men and five women with a mean age of 44.8 years (range 37-51 years). All patients had known renal tuberculosis with a nonfunctioning kidney and underwent nephrectomy after at least 3 months of chemotherapy with four antituberculous drugs. Nine patients underwent the transperitoneal approach and four patients, the retroperitoneal approach. The follow-up was from 2 to 35 months with a mean of 15.8 months. RESULTS: Kidneys were removed laparoscopically in 12 patients (92%). The mean operative time was 268 minutes (range 190-500 minutes), and the mean estimated blood loss was 227 mL. Although there had been some difficulties releasing the adhesions, no significant intraoperative and postoperative complications were observed. Conversion to open surgery was needed in only one patient. The mean hospital stay was 4 days, and the patients returned to normal activity within 10 days. Neither local recurrence nor distant dissemination of the disease was observed during the follow-up period. CONCLUSION: Laparoscopic nephrectomy for renal tuberculosis was safe and effective with minor complications. Therefore, tuberculosis should not be a contraindication to a laparoscopic approach.

[Radionuclide diagnosis of the ureteral motor function and urodynamics in renal tuberculosis and other diseases of the urinary system]. / Radionuklidnaia diagnostika motornoi funktsii mochetochnikov i urodinamiki pri nefrotuberkuleze i razlichnykh zabolevaniiakh mochevydelitel'noi sistemy.

Radionuclide methods (a new technique of infusion dynamic ureteroscintigraphy and standard techniques of dynamic and static scintigraphy of the kidneys, radionuclide renography) were used to examine 134 patients with nephrophthisis, 61 patients with other urological diseases and 51 controls. It is shown that nephrophthisis brings urodynamic disorders and impairment of ureteral contractility. Three types of the contractile disorders are distinguished. A decline in motor function and urodynamic defects occurred also in other urological affections. Sensitive radionuclide techniques are thought valuable in examination of the urinary system and objective evaluation of urodynamic disorders.

[Functional system of secretion in renal tuberculosis]. / Funktsional'naia sistema vydeleniia pri nefrotuberkuleze.

Data are given on the study of functional correlations of the pairs of organs (kidneys-liver and kidneys-lungs) that participate in provision of the functional system of secretion. The correlation of these pairs of organs contribution to the total secretion of metabolites as renal insufficiency grows is characterized by the S-shaped dependence, i.e. by a compensatory increase of the conjoined functions at the early stages and its depression at the graver stages of renal insufficiency. This approach makes it possible to determine the character, terms and significance of the participation of various organs in provision of metabolic homeostasis maintenance long before its failure and to reveal the main links in the pathogenesis of functional disorders of secretion.

[Reticulohistiocyte system activity of the liver in patients with nephrotuberculosis]. / Aktivnost' retikulogistiotsitarnoi sistemy pecheni u bol'nykh nefrotuberkulezom.

The reticuloendothelial system of the liver was studied in 27 patients with nephrotuberculosis by means of radionuclide hepatography with colloid solution of Au-198. It was found that all these patients showed a reduction of the activity of stellate reticuloendotheliocytes of the liver. These conclusions were made on the basis of distinctly changed values of the period of half-purification of the blood, constants of blood purification, coefficient of liver retention, etc. There was also a distinct reduction of fractional blood flow of the liver.