The Surgical Intervention in Genitourinary Tuberculosis

THE SURGICAL INTERVENTION IN GENITOURINARY TUBERCULOSIS MOHAMMAD SALAHUDDIN FARUQUE1, AKM ANWARUL ISLAM1, AKM KHURSHIDUL ALAM1 1Department of Urology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh Abstract Introduction: Genitourinary tuberculosis (GUTB) is the leading cause of morbidity and mortality worldwide especially in developing countries. Surgery is an essential management modality in genitourinary tuberculosis when indicated. Objective: This study aims to document the role of surgery for genitourinary tuberculosis according to the organ involved. Materials and Methods: Retrospective review of 33 GUTB cases was done that underwent surgery at department of urology, Bangabandhu Sheikh Mujib Medical University from January 2008 to December 2014. Patient’s baseline characteristics, mode of presentation, organ involvement, investigation, surgical intervention and follow up were studied. Results: Among enrolled patients, mean age at presentation was 31.5 years and 64% (21, 33) were male. The most common presentation was irritative voiding symptoms. Kidney was the most common organ involved in 39% (13, 33) cases, and next common site was bladder in 30% (10, 33) cases. Preoperative bacteriologic diagnosis was confirmed only in 21% (7, 33) cases. A total of 41 surgical procedures were performed as some patients needed more than one procedure. These included 13 endoscopic, 6 temporary diversion, 19 ablative procedures and 3 reconstructive procedures. Post surgical follow up of all the patients were given after 3, 6 and 12 months. Then the patients were followed with RFT and ultrasonography 6 monthly for 3 years and then annually. The intravenous urography and diethylenetriamine pentaacetic acid scan were performed when indicated. Conclusion: Multidrug chemotherapy with judicious surgery when indicated is the ideal treatment. Surgery plays an important role in symptomatic relief and helps to lead a normal life. The results of reconstructive surgery are good and should be done when possible. Rigorous and long term follow up is necessary in patients undergoing reconstructive surgery. Key Words: Tuberculosis, reconstructive surgery, urogenital. Bangladesh J. Urol. 2016; 19(2): 69-73 Introduction: Tuberculosis (TB) is a major public health problem in developing as well as de-veloped countries. The recent surge in reported cases of TB is mainly attributable to Human Immunodeficiency virus (HIV) infection, emergence of resistant bacilli and human migration [1]. The World Health Organization (WHO) estimates that 9.27 million new cases of TB occurred in 2007, compared with 9.24million new cases (140 per 100,000) in 2006. An estimated 1.37million (14.8%) of the cases in 2007 were HIV-positive. Pulmonary sites account for 10% of tuberculosis cases. Genitourinary TB accounts for 30% to 40% of all extrapulmonary TB, second only to lymphonodal affection. In developed countries, urogenital tuberculosis occurs in 2% to 10%of cases of pulmonary tuberculosis, while in developing countries it occurs in as many as 15% to 20% of cases[2]. Correspondence: Dr Mohammad Salahuddin Faruque, Assistant Professor, Department of Urology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh, E-mail: Diagnosis of genitourinary tuberculosis (GUTB) are not straight forward and the low yield of current available investigations, the disease remains subclinical for long 69 Bangladesh J. Urol. 2016; 19(2): 69-73 The Surgical Intervention in Genitourinary Tuberculosis time before initiation of chemotherapy, that leads to distorted and dysfunctional anatomical changes in the genitourinary tract. Therefore, Surgery still continues to play a major role despite effective chemotherapy for tuberculosis. It is estimated that approximately 55% of patients with GUTB require surgical intervention[3]. In this study, we assessed the role of surgical intervention in GUTB. Both ablative and reconstructive surgery have role to eradicate the disease and prevent relapse as well as to preserve or to restore the function of the organs. Materials and methods This retrospective study was conducted in Department of Urology of our institution, a tertiary care center of Dhaka, Bangladesh. A total of 33 patients diagnosed as GUTB were admitted and undergone surgery for different indication, from January 2008 to December 2014. Evaluation included detailed clinical history and physical examination, followed by a complete blood count, renal function test (RFT) and liver function tests. Urine examination, including bacterial cultures, was performed. Urine for acid-fast bacteria (AFB) smear was done on 3 consecutive days, and mycobacterial culture was obtained. Radiological evaluation included chest Xray, X-ray of kidneys-ureters-bladder (KUB) was performed in all cases and intravenous urogram when serum creatinine was normal. Gene Xpert test for urine and body fluid was also done in selected cases. A voiding cystourethrogram, nephrostogram and retrograde pyelogram, ultrasound study of KUB region and computerized tomography were obtained when necessary. Cystoscopy and bladder biopsy were done wherever indicated. Fine needle aspiration cytology (FNAC) was performed in cases with epididymal nodule. Biopsy from fistulous or sinus tract were also taken when indicated. Renal dynamic scans were used selectively to ascertain renal function in compromised kidneys. Polymerase chain reaction (PCR) was done in cases to assist in diagnosis. All patients received antitubercular drug therapy with 4 drugs (rifampicin, ethambutol, isoniazid and pyrazinamide) for 2 months followed by 2 drugs (rifampicin and isoniazid) for 4-7 months. Temporary urinary diversion was performed in case of obstruction. The operative procedure was selected depending upon the organ involved, the extent of disease, functional status of the involved organs and overall renal function. Followup included history, physical examination and investigations like complete blood count, liver function Bangladesh J. Urol. 2016; 19(2): 69-73 tests and RFT at 3and 6 months. The intravenous urography and diethylenetriamine pentaacetic acid (DTPA) scan were performed when indicated. Then the patients were followed with RFT and ultrasonography 6 monthly for 3 years and then annually. Data were collected from departmental register in a predefined proforma. Analyses were done with SPSS version 19. Results: There were 21 males and 12 females. Mean age of the patients was 31.5 years with a range of 15-57 years. The most common symptom was irritative voiding symptoms in all 33 patients, 20 had constitutional symptoms, 15 patients had haematuria, 12 had sterile pyuria , 3 had discharging scrotal sinus 1 had nephrocuteneous fistula 3 had renal failure [Table 1]. The most commonly involved organ was the kidney cases 13, followed by the bladder in 10, ureteral lesions were found in 09 cases, epidydmis in 05 and complex lesions in 04 cases [Table 2]. (...truncated)