• Bladder urine normal and symptom absent.
Kidney & Ureter
• Basic lesion——Tubercle foci(结核结节) • Epithelioid reticulum(上皮样网) • Peripheral giant cells
• Heal by fibrosis(纤维化).
• Excretory urograms: • Ureteral stricture with secondary dilatation. • Absence of function of the kidney. • Retrograde Urography
MRU or CT
Diagnosis: Instrumental Exams
Diagnosis: Lab Findings
• Persistent pyuria(脓尿) without organism on culture. But acid-fast stains: 60%(+). • Culture for TB (1st morning urine): • (+) percentage very high. • Tuberculin test(结核菌素试验): • (-) against TB.
• Cystoscope(膀胱镜): • Tubercles & ulcers, contraction(孪缩) • Cystogram(膀胱造影): • Ureteral reflux(输尿管返流)
Differential Diagnosis 鉴别诊断
• Chronic nonspecific cystitis 慢性膀胱炎 • Epididymitis 附睾炎 • Multiple small renal stones and medullary sponge kidneys(海绵肾) • Urinary bilharziasis(血吸虫病) • Bladder stones or cancer.
• Combination of drugs(1st line):
• • • • • 1. Isoniazid (INH, 异烟肼) 200~300mg/d 2. Rifapin (RFP, 利福平) 450~600mg/d 3. Ethambutol (EMB, 乙胺丁醇) 15mg/kg/d 4. Streptomycin (STM, 链霉素) 1g/d im 5. Pyrazinamide (PZA, 吡嗪酰胺) 1.5~2g/d
Diagnosis: Signs(体征)
• Kidney——no enlargement / tenderness(触痛) • External genitalia(外生殖器): • thickened, nontender epididymis(附睾) • chronic scrotal draining sinus(阴囊窦道) • Induration/nodulationof prostate & seminal vesicles(前列腺/精囊硬结)
Pathology(病理)
Kidney & Ureter (输尿管)
• Grossly: a soft, yellowish localized bulge (隆起).
• On section: involved area filled with cheesy material (caseation, 干酪样物质).
Lt Renal Dysfunction on Radioisotope Scan(同位素扫描)
Calcification (钙化)
Bladder
• Tubercle form: white/yellow raised
nodules(结节) surrounded by a halo of hyperremia(充血). • Tubercles break downdeep ragged ulcers bladder irritable.
Diagnosis: Symptoms(症状)
• No classic clinical picture of renal TB.
• Most are vesical in-origin(膀胱起源):
burning, frequency(尿频) & nocturia(夜尿),
hematuria(血尿)
Kidney & Ureter
• Walls of pelvis, calyces and ureter thickened. Ulceration(溃疡形成) in calyces.
• Complete ureteral stenosis(输尿管狭窄) Autonephrectomy(肾自截).
膀胱结核，多个粟粒样黄色小结节
膀胱结核，结核性溃疡
Diagnosis(诊断)
• Just saying you had turned a corner doesn’t make it so. • Just saying there is massive destruction doesn’t make it so. __John Kerry • Just saying there is TB also doesn’t make it so. • We must provide…… • Demonstration of tubercle bacilli in urine by culture.
Diagnosis: X-ray Findings
• Excretory urograms(排泄性尿路造影): • “Moth-eaten”(蚤咬) appearance of ulcerated calyces. • Obliteration of 1/more calyces. • Dilation of calyces. • Abscess cavities connecting with calyces.
Treatment: Renal TB
• Nephrectomy(肾切除) :
• 1. After 3 m, urine culture still (+) and gross involvement radiologically evident. • 2. Severe sepsis(脓毒症), pain or bleeding from 1 kidney. • 3. Marked advanced on 1 side and minimal damage on the other.
Diagnosis: X-ray Findings
• Chest film • Plain film(平片):
• • Enlargement of 1 kidney Obliteration(消失) of the renal & psoas (腰大肌) shadow • Renal stones(肾结石) 10%
Tuberculosis(TB) of the Genitourinary Tract 泌尿生殖系结核
瑞金医院泌尿外科
Urinary TB
• A disease of young adults. 60% between 20~40y.
• Infecting organism — Mycobacterium tuberculosis (结核分支杆菌，结核杆菌), Tubercle bacilli •
Pathogenesis(发病机理)
• Tubercle bacilli hit the renal cortex(肾皮质):
• Normal resistance(抵抗力): organism destroyed • Sufficient virulence(致病力): clinical infection established.
Treatment (治疗)
TB must be treated as a generalized disease!
• Basic treatment——Medical 药物
• Surgical excision(外科切除) —— merely adjunct
Treatment: Renal TB
Pathogenesis
• TB of kidney: progresses slowly, 15~20y to destroy a kidney with good resistance.
• No clinical disturbance until the calyces / pelvis(肾盏/肾盂) involved.
• Left kidney: autonephrectomy • Right Kidney: hydronephrosis & ureteral reflux (肾 积水&输尿管返流) • Contraction of the bladder (膀胱孪缩)
左肾萎缩
萎缩肾外观
Caseation & Fibrosis
Kidney & Ureter
• TB is a combination of caseation(干酪样
变), cavitation(空洞形成) and healing by fibrosis &scarring(纤维化和疤痕愈合). • Depending on virulence vs resistance. • Calcification(钙化): strongly suggestive of TB. Secondary renal al TB
• Prefer —— INH + RFP + EMB
• • • • • • Resistance to 1st line drugs: Aminosalicylic acid (氨基水杨酸) Capreomycin (卷须霉素) Cycloserine (环丝氨酸) Ethionamide (乙硫异烟胺) Viomycin (紫霉素)