Copyright, 1944 b,y The American Journal of Surgery, Inc.

A PRACTICAL JOURNAL BUILT ON h,IERIT

FiJty-third Yew of Continuous Publication

NE\lr SERIES VOL. LX111 MARCH, 1944 NUMBER ‘I’HIIEI‘

SURGICAL RENAL TUBERCULOSIS

I NASMUCH as the latest statistics show that tuberculosis in general is on the increase since war created pro-

found changes in living standards through- out the worId, it is reasonable to expect that this increase wiII be observed in renaI as well as in other forms of this disease. It is accordingly worth whiIe to emphasize the importance of the earl\ diagnosis of this condition, and the possi- bility of its complete eradication 63 surgical treatment, when it has reached the open stage.

Albarran, in the beginning of this century, was the first to introduce this principIe of modern uroIogy, pointing out that removal of the one kidney affected would result in compIete cure. Although he had no urographic means of diagnosis, he was able, in the face of opposition and destructive criticism, to demonstrate b! results that this principle was sound. His work in this field is essentially the basis of what we know today of the solu- tion of this fascinating problem.

Renal tuberculosis, which is a blood- borne infection from some other primary focus, is unilateral in 80 to 90 per cent of cases, the original lesion being in the lungs, Iymphatics or bony system, in which it may have become quiescent but has later produced manifestations in the kidneys or genitourinary tract. Once in

this tract, it falls into two main groups, the one medica1, or closed, the other, surgical, or open. The medica group comprises the cases of miliary tuberculosis and tubercuIous nephritis, both char- acterized by presence of tuberculous bacil- Iuria. So long as the Iesions remain closed, that is, isolated within the renal paren- chyma and expressed only in a bacilluria, without other symptoms in the urinary tract, they may hea1. Such cases do not require surgical treatment. Once they have opened into the excretory apparatus, however, no treatment wiI1 be effective except nephrectomy. It is these open cases which constitute the recognized entity of tubercuIosis of the kidney. It is called surgical renal tubercuIosis because its only. cure is by surgical means. By the time a case becomes open, the pathologic process is well established and has de- stroyed the parenchyma of the kidney, forming typica caverns such as are seen in pyonephrosis. The kidney as a rule drains its caseous contents into the calices, renal pelvis and ureter, producing pyuria, hematuria, and other marked urinary dis- turbances, characterized by bladder symp- toms for which the patient is referred for urological consideration,

The diagnosis is readily made in these urographic days, and is based on ( I) cystoscopic data, (2 j catheterization of

302 American Journal of Surgery EditoriaI

both ureters in the differentia1 renaI test, (3) roentgenographic and pyeIo-urographic evidence of a weII estabIished Iesion, and (4) laboratory data based on positive smear for Koch’s baciIlus in the urine, or positive culture, or positive guinea pig inocuIation. With these fundamenta1 data one is in a position to estabIish a correct diagnosis for renaI tuberculosis. Upon these data and the verilication of a normal pyelogram of the kidney of the opposite side, one may always fee1 assured that the indication is present for nephrectomy of the diseased kidney.

In the surgical management of renal tuberculosis it is also important today to consider not onIy the pathoIogic condition of the kidney, but aIso the surgica1 lesions that may invoIve the ureter and urinary bladder, which will demand further treat- ment. There are two types of surgical renal tubercuIosis with Iesions of the ureters which can be established uro- graphicaIIy previous to operation. The first is the type of hydro-ureter, or megaIo- ureter, or the ureter in which there is a vesico-uretero-renal refl ux. The second is the group of cases in which the ureter is infiltrated, with marked ureteritis, and indurated to such an extent that it can be detected by recta1 or vagina1 paIpation. In these two types, demonstrabIe before operation, a combined ureteronephrectomy by two separate incisions is the procedure of choice. In those instances, however, in which an advanced lesion of the ureter has not been properly recognized in ad- vance, and is discovered only in the course of a nephrectomy, the Iumbar incision should be proIonged to include a ureter- ectomy. This total and radica1 procedure is simple, and assures a permanent cure. It is important, from a surgical point of view, to emphasize that if the ureter is not removed in toto when it is tuber- culous, it may produce a uropuruIent lumbar fistuIa, or a persistent cystitis, which will demand a subsequent secondary ureterectomy. Electrocoagulation or ful- Puration of a tubercuIous ulcer of the

bladder wiI1 be useIess if the stump of a tubercuIous ureter has not been removed at the time of the nephrectomy. In the past, many faiIures foIIowing nephrectomy have been attributabIe to thus oversight on the part of the surgeon who has not removed this tubercuIous focus, which inevitabIy infects the bIadder and may also cause ascending infection of the other kidney.

In the surgical probIem of biIatera1 renaI tubercuIosis, present in IO to 20 per cent of cases, we are again confronted with two principal types: In one of these the pyelographic data and differential renal functiona tests reveal destruction of the papiIIa, calices and renal parenchyma, whiIe the urographic studies of the kidney of the opposite side show that this organ is stiI1 normaI, even though the cathe- terized specimen discIoses an excretory tubercuIous baciIIuria. Here nephrectomy is obviously indicated. In the other group, the destructive pathologic process is far advanced and can be demonstrated in the retrograde pyeIogram of both kidneys. In such cases no surgery seems to be indicated, except in those in which a large pyonephrotic kidney is present, which calls for drainage by a simpIe Iumbar nephrostomy, to reIieve symptoms and proIong life. This principle also applies in the exceptional case of an acquired single kidney in which the tubercuIous disease is far advanced.

It is we11 to emphasize that the sulfa drugs, which have come to be regarded as a panacea for a11 infections, have no effect upon the tubercIe baciIlus. For this reason a persistent pyuria and dysuria, with marked nocturia and bIadder tenes- mus, should be promptly investigated from the urological angle without wasting time in the use of these new chemo- therapeutic measures or other forms of paIIiative treatment.

It should be borne in mind, however, that nephrectomy is only the first step in the general management of tuberculosis of the kidney. After operation the patient

must be submitted for a considerable period of time to a proper dietetic regimen, suitable hygiene, medica care and rest, preferably in the quiet of a sanatorium, in order to build up bodiIy resistance against the toxins of the Koch bacihus, which mav still be present in the Iungs or bIood stream. There wiI1 be no permanent cure of renal tuberculosis unti1 the primary focus within the kidney has been removed. The few isolated cases that have been reported of so-called heaIed tubercuIosis of the kidney are not convincing, since in most of these the malady has recurred with all its annoying bIadder symptoms; and in some there has been anatomopatho- logic proof at autopsy of the persistence of the tubercuIous lesion in the kidney. Even in cases of so-caIIed autonephrectomy or complete calcification or caseation of the whole organ, in which the patient has

gained in weight and strength temporariIy, the specimen removed at operation has revealed actual caverns and obviously active tubercuIous Iesions.

The convenience and faciIity of spinal anesthesia, the improvement in surgicaI technic and in the pre- and postoperative care of these tubercuIous patients have aII contributed to the lowering of the morbid-

ity and mortality, and hat\re assured bctt.er curative results.

The curability after nephrectomy is high, the operative mortaIity very low, depending of course upon the condition of the patient, the stage of the disease and whether the primary lesion in the kidney is uniIatera1 or bilateral. The prognosis is on the whole excellent with this train of treatment for obtaining a permanent cure.

In addition it can be said that the surgical treatment of renaI tuberculosis offers to the community and to the world at large a better controJ of the propagation of this age-long scourge of humanity, removing a source of contamination for which medical science has as yet found no specific cure.

The enormous experience and abundant clinical data which have been accumulated in this accurate cystoscopic and urographic era prove the sound wisdom of establishing in renal tubercuIosis an early diagnosis, foIlowed by an early nephrectomy. For the discovery and application of this principIe, which is one of the greatest achievements of modern uroIogy, we are forever indebted to its originator, the great Albarran.

ROBERT GUTIEKHEZ, M.D.