NEW SERIES, VOL. V AUGUST, 1928 No. 2 NON4URGICAL RENAL TUBERCULOSIS* ROBERT GUTIERREZ, A.B., M.D. NEW T HE probIem of non-surgica1 renal tubercuIosis is aIways of great interest, not onIy in regard to its unlimited scope, but aIso in regard to its correct diagnosis and proper treatment. Since the frequency of this maIady has steadiIy increased unti1 it has become one of the most common and serious of a11 pathoIogica1 infections of the kidney, it wiII aIways be necessary to determine the most accurate method of differentiating between the types of infec- tion best treated by medicine or by surgery. Under the titIe of non-surgica1 renaI tubercuIosis, I shaI1 discuss the most important features of this maIady from a tripIe viewpoint, nameIy, diagnosis, prog- nosis, and treatment. The earIy stages of this infection undoubtedIy deserve more carefuI cIinica1 attention and further uro- IogicaI investigation. The Iater and more comphcated stage, when the disease has become biIatera1, is the other phase of interest in which adequate treatment shouId be established in an effort to improve prognosis. I shaI1 iIIustrate this paper with the report of three cases. The first is a case of non-tubercuIous kidney in which the pres- ence of Koch’s baciIIus occurred in the urine obtained by catheterization. The other two iIIustrate the incidence of biIatera1 renaI tubercuIosis. YORK ConsiderabIe confusion arises in the earIy stage of renaI tubercuIosis when urinary symptoms appear and particuIarIy when there is not a definite Iesion estab- Iished in the kidney, although there are tubercIe baciIIi in the urine. Many authors have shown that Koch’s baciIIus may occur in the urine obtained in a catheterized specimen from the kidney whiIe the kidney on that side has no definite pathoIogica1 Iesion of tubercuIosis (Fig. I). The discovery of the tubercIe baciIIi in the urine upon routine examination has great significance in regard to the diagnosis when it corresponds with the clinica and functiona renaI tests and when the case is studied by modern uroIogica1 methods, but no Iaboratory test can be considered of great vaIue if it does not correspond with the cIinica1 condition of the patient. A definite diagnosis shouId not be made unti1 a positive urographic examination is obtained, combined with the diminished renaI functions in regard to urea secretion and phthaIein eIimination. Moreover, not unti1 the diagnosis can be based upon this triangIe of cIinica1 data, nameIy, kidney functiona tests, pyeIographic studies and the presence of the tubercIe baciIIi in the urine, are we certain of a positive diagnosis of tubercuIous nephrosis. It is important to emphasize the we& known principIe that in 80 to 90 per cent * Read before Section of Genito-Urinary Surgery, New York Academy of Medicine, February 15, 1928. From the Department of Urology (James Buchanan Brady Foundation) of the New York Hospital. 99
Transcript
NEW SERIES, VOL. V AUGUST, 1928 No. 2
NON4URGICAL
RENAL TUBERCULOSIS* ROBERT GUTIERREZ, A.B., M.D.
NEW
T
HE probIem of non-surgica1 renal tubercuIosis is aIways of great interest, not onIy in regard to its unlimited scope, but aIso in regard to its correct diagnosis
and proper treatment. Since the frequency of this maIady has steadiIy increased unti1 it has become one of the most common and serious of a11 pathoIogica1 infections of the kidney, it wiII aIways be necessary to determine the most accurate method of differentiating between the types of infec- tion best treated by medicine or by surgery.
Under the titIe of non-surgica1 renaI tubercuIosis, I shaI1 discuss the most important features of this maIady from a tripIe viewpoint, nameIy, diagnosis, prog- nosis, and treatment. The earIy stages of this infection undoubtedIy deserve more carefuI cIinica1 attention and further uro- IogicaI investigation. The Iater and more comphcated stage, when the disease has become biIatera1, is the other phase of interest in which adequate treatment shouId be established in an effort to improve prognosis.
I shaI1 iIIustrate this paper with the report of three cases. The first is a case of non-tubercuIous kidney in which the pres- ence of Koch’s baciIIus occurred in the urine obtained by catheterization. The other two iIIustrate the incidence of biIatera1 renaI tubercuIosis.
YORK
ConsiderabIe confusion arises in the earIy stage of renaI tubercuIosis when urinary symptoms appear and particuIarIy when there is not a definite Iesion estab- Iished in the kidney, although there are tubercIe baciIIi in the urine. Many authors have shown that Koch’s baciIIus may occur in the urine obtained in a catheterized specimen from the kidney whiIe the kidney on that side has no definite pathoIogica1 Iesion of tubercuIosis (Fig. I).
The discovery of the tubercIe baciIIi in the urine upon routine examination has great significance in regard to the diagnosis when it corresponds with the clinica and functiona renaI tests and when the case is studied by modern uroIogica1 methods, but no Iaboratory test can be considered of great vaIue if it does not correspond with the cIinica1 condition of the patient. A definite diagnosis shouId not be made unti1 a positive urographic examination is obtained, combined with the diminished renaI functions in regard to urea secretion and phthaIein eIimination. Moreover, not unti1 the diagnosis can be based upon this triangIe of cIinica1 data, nameIy, kidney functiona tests, pyeIographic studies and the presence of the tubercIe baciIIi in the urine, are we certain of a positive diagnosis of tubercuIous nephrosis.
It is important to emphasize the we& known principIe that in 80 to 90 per cent
* Read before Section of Genito-Urinary Surgery, New York Academy of Medicine, February 15, 1928. From the Department of Urology (James Buchanan Brady Foundation) of the New York Hospital.
99
100 American Journal of Surgery Gutierrez-Renal TubercuIosis Aucus~, 1928
of the cases of renaI tubercuIosis the infec- tion in the beginning is uniIatera1. The conception estabIished by AIbarran’ and
FIG. I. Drawing of a pyelogram showing toxic nephritis or pyelonephritis in early stage of renal tubercutosis, due to tuberculous bacilluria and lack of drainage without tuberculous Iesion in kidney parenchyma, as in case herein reported. The pyelogram shows only shagginess or sIight distortion of the upper and lower calices, the kidney function being normal in regard to urea and phthalein elimination. This case shows early stage of non-surgical renaI tuberculosis.
Israe12 that earIy diagnosis shouId be foIIowed by nephrectomy for curing or arresting the disease wiI1 remain one of the greatest accompIishments of uroIogy.
The etioIogica1 study in the Iast decade, through exhaustive and repeated animal experimentation by many different authors and investigators, has shown that the hematogenous route of invasion is the most usuaI, and this theory is the one most commonIy accepted. But infection through the lymphatics as we11 as ascending infec-
tion from the bIadder undoubtedIy occur. Infection by direct route and infection by contiguity may come about or a combina- tion of these methods may occur.
Peter3 and CaImette,d foIIowed since by other authors and investigators, have decIared that in miIiary tubercuIosis, when baciIIemia exists, the baciIIi are excreted in the urine, the kidney serving as a filter. Rafrn,5 for exampIe, stated that the urine of 50 per cent of a11 cases of puImonary tubercuIosis contained Koch’s baciIIus. A primary infection of the kidney is considered a rare condition because in the great majority of cases post mortem examination reveals active or arrested Iesions IocaIized in other organs, principaIIy in the Iungs or the Iymphatics. Thus the primary focus has been found very com- monIy as a Iatent Iesion somewhere eIse in the body.
BaciIIuria in renaI tubercuIosis may be due to intermittent bIood invasion by bacteria, producing showers of germs in the urine without Ieaving any apparent Iesion in the kidney. It may also resuIt from mixed infection and Iack of proper drain- age. But just as important are the predis- posing causes of a Iater anatomica Iesion in the tubercuIous process of the kidney. Any of the etioIogica1 factors, such as the method of invasion, might expIain the cause of tubercuIous baciIIuria. It must be admitted that the kidneys might be the gIands of maximum excretion even of pathoIogica1 microorganisms without pro- ducing any definite histoIogica1 Iesion in the epitheIia1 ceIIs of the tubules or paren- chyma of the organs.6,7
In the case that I am reporting, the series of histoIogica1 studies of different sections show regressive changes of the epitheIia1 Iining with proliferation and hyaline degeneration of connective tissue. GIomeruIar Iesions as we11 as definite inflammatory processes, invoIving here and there the principa1 eIements that form the renaI tissue, as can be seen beIow in the pathoIogica1 report, give evidence of an acute process of nephritis or tubuIar
NEW SERIES VOL. V, No. 1 Gutierrez-Rena1 TubercuIosis American Journal of surgery ro I
nephritis produced by the toxin or the germs themseIves during tubercuIous baciI- Iuria. In many instances when baciIIuria does occur, it is very IikeIy to Ieave ana- tomical or histologica Iesions, producing what Castaignes has described as toxic or acute nephritis, which may be responsi- bIe for the phenomena of essentia1 excre- tory baciIIuria.
The experimenta work done on animaIs by Albarran and Baumgarteng as we11 as by Chauffard,‘O Jousset,” and Bernard and SaIomon, l2 has proved that injecting cuItures of Koch’s baciIIus intravenousIy or directIy into the renaI artery has in many instances produced, by means of the toxin or the baciIIus itseIf, compIex Iesions in the kidney parenchyma, histoIogicaIIy characteristic of earIy tubercuIous Iesions. In some other instances the pathoIogica1 findings have been those of atypical Iesions corresponding with the Iesions of an acute tubercuIous nephritis, or mereIy a toxic nephritis.
ConsiderabIe work has been done in studying the urine of patients with puI- monary tuberculosis in which no urologica symptoms were present in order to discover whether or not, in a routine investigation, these patients have tubercIe baciIIi in the urine. In the Iast decade severa writers have caIIed attention to the fact that Koch’s baciIIus may appear in the urine without any Iesion in the genitourinary tract. Among the first, Fournier and Beaufumel” reported the findings of normal kidneys at post mortem in cases of puI- monary tubercuIosis in which Koch’s baciIIus had been found in the urine. AIso Brown14 of Saranac Lake, in studying 156 cases of puImonary tubercuIosis, has found positive resuIts in 13 of such cases. Cun- ningham’s of Boston found the presence of Koch’s baciIIus by means of anima1 inocuIation six times in 66 patients suffering with puImonary tubercuIosis. Schapira, Wittenberg and SpiegeIberg”j of the Sea View HospitaI state in a more recent articIe that in a study of 600 cases they found that in a group of 60 cases the
presence of the baciIIi in the urine was the only indication of tubercuIosis in the urinary tract.
Thus in a thorough and compIete uro- IogicaI investigation, this group of cases showed no definite pathoIogica1 Iesion. Therefore, it can be concIuded that tubercIe baciIIi are often found in the urine without subjective symptoms or apparent Iesions in the urinary organs.
Morse and Braasch,” and very recentIy Thomas and KinseIIa,ls have come to the concIusion that renaI tuberculosis is a part of a generaIized disease and that nephrec- tomy shouId not be advised unti1 the pyeIographic evidence of a gross Iesion in one kidney is we11 established (Fig. 2),
together with assurance of good compensat- ing function of the other kidney, aIIowing the patient at the same time opportunity to buiId up resistance against tubercuIous infection.
Many interesting papers, such as those of Morse and Braasch,” Beer?g and Heitz- Boyer,20 have been pubIished on the possibiIity of contamination of the urine and on the different sources from which the baciIIi couId come. Other writers, as WegeIin and WiIdboIz,21 Legueu, Papin and VerIiac,22 and others have emphasized having found heaIed Iesions or arrested processes in the histopathoIogica1 study of tubercuIous kidney. However, one of the interesting points in regard to the case I am reporting (Case I) is the fact that because of the pyeIographic findings we were treating this case cystoscopicaIIy in the routine manner of diIating the ureter and irrigating the kidney peIvis, unti1 the positive report of the guinea pig inocuIa- tion arrived which prompted us to remove the organ. Later histopathoIogica1 study determined it to be a non-tubercuIous kidney.
This patient is somewhat improved, gaining in weight, and is under the proper care and attention for her genera1 condition in our postoperative and non-surgica1 tubercuIosis cIinic.
The host satisfactory resuIt that one
102 American Journal of Surgery Gutierrez-Rena1 Tubercdosis AUGUST. rgz8
FIG. Z. Case of renal tuberculosis with positive findings, such as diminished renaI function, Koch’s baciIIus urine, pyeIogram shagginess, distortion with dilation and Ming defect of calices and pelvis. In this type case nephrectomy always should be done for permanent cure.
in of
NEW SERIES VOL. V, No. z Gutierrez-Rena1 TubercuIosis American Journal of surgery 103
may obtain in the treatment of those cases
in our tubercuIosis clinic has been reported
by Wang and DeIze1123 in a recent article.
CASE I. Rena1 tubercuIous baciIIuria in a catheterized uretera specimen without tubercu- Ious Iesion in the kidney.
L. B., femaIe, aged eighteen, was referred to the UroIogicaI CIinic of the New York Hospital on JuIy 30,1925. The patient came accompanied by her mother. She compIained particuIarIy of pain in the Ieft Iumbar region, frequency of urination day and night, sIight burning and dysuria. The famiIy history was irrelevant. There was no history of tubercuIosis or any other disease in the famiIy. In earIy childhood the patient developed scarIet fever and diph- theria and at a Iater date had the tonsiIs removed for recurring attacks of tonsiIIitis. There was no history or sign of any venerea1 disease. The menstruation started at eIeven years of age, this being reguIar unti1 the Iast four months when the menstrua1 period stopped; for this reason her mother brought her to the hospita1 for an examination.
The present iIIness was characterized mainly by intermittent pain in the Ieft kidney region for a period of about four months, irradiating aIong the course of the ureter to the bladder. The pain was a duI1 aching rather than a sharp knife-Iike pain, but was persistent and getting worse as time passed. It was associated with a miId frequency and occasionaIIy a sIight hematuria, but was noted by the patient onIy in the form of dark cIoudy urine which was thought to be bIoody in appearance. During the past haIf year, she had Iost 40 pounds.
On physica examination the patient was seen to be a young woman somewhat anemic, paIe and sIightIy emaciated but apparentIy not acutely III. Her bIood pressure was normal and the Wassermann test negative. The abdo- men, chest and heart were apparently norma except that the Ieft kidney was sIightIy enIarged and paIpabIe. The urine anaIysis showed acid reaction and a specific gravity of 1022; the appearance was cIoudy with the presence of a faint trace of aIbumin and microscopic pus and bIood ceIIs. The patient was subjected to a compIete uroIogica1 investigation in order to arrive at a definite diagnosis.
On August 2, 1926, the patient was cysto- scoped for the first time and a bIadder mucosa normal throughout was found. UreteraI ori- fices were norma in Iocation, shape and appear-
ante, the vesica1 orifice aIso being normaI. Both ureters were catheterized without diffl- cuIty with a No. 6 French catheter. Speci- mens were coIIected from each kidney and from the bIadder and sent to the Iaboratory for culture and microscopica examination; specr- mens were aIso coIIected from each kidney for urea estimation and for a guinea pig inocula- tion. One C.C. of phenoIsuIphonphthaIein in- jected intravenousIy appeared on the right side in seven mmutes and on the Ieft side in ten min- utes. The tota amount was coIIected for a period of ten minutes for functiona estimation, which was 8 per cent for the right and 6 per cent for the left kidney.
LABORATORY REPORT OF URETERAL SPECIMENS
Right Left
Character. Bloody * BIoody * Urea .._............ g+$gm.perL. II gm.perL.
PHENOLSULPHONPHTHALEIN
Appeared. 7 mins. Percent............ Time.
I I
I0 mins. 8 6
I0 mins. I0 mins.
MICROSCOPIC EXAMINATION OF SEDIMENT
Wet specimen. Much bIood Much blood Oct. epitheIia1 Much debris
cells Some debris
CuItures of urine show right and left ureters and bladder steriIe.
* ApparentIy due to a traumatism caused by the catheter.
One week Iater, on August 9, 1926, the patient was cystoscoped again. The bIadder mucosa was found norma throughout. Cathe- ters were passed to both kidney peIves and after coIIecting specimens for cuIture and microscopic examinations, pIain roentgen-ray pictures with instrument and catheters in position were taken, and aIso pyeIograms and ureterograms in the usua1 manner, about 15 C.C. of a soIution of sodium iodide, 20 per cent, being injected.
The report of this urographic examination showed kidneys norma in size and position and no shadows indicative of stone anywhere in the urinary tract. The Ieft pyeIogram showed a definite shagginess in both upper and Iower caIices, and a stricture or a narrowing at the ureteropeIvic junction.
104 American Journal of Surgery Gutierrez-Renal TubercuIosis Aucus~, Igz(l
The impression that one gathered in this case was that of infection of the Ieft kidney, which had some of the appearance of tubercuIosis, and a contraction or a stricture of the upper portion of the ureter at the ureteropeIvic junction.
The importance of this case is that whiIe we were waiting for the report of the guinea pig inocuIation, we were treating the patient in the routine weekly manner by diIating her ureters through the cystoscope and irrigating each kidney pelvis with a solution (I to 1000) of acriff avine.
This patient undoubtedIy was improving under this treatment, as she stated that her kidney pain and urinary symptoms were greatIy diminished, but after six weeks of treatment, we were notified by the laboratory of the presence of Koch’s baciIIus and the posi- tive guinea pig inocuIation from the Ieft kid- ney. Without any further investigation the patient was advised to enter the hospita1 for an operation to remove her Ieft kidney for tubercu- ous infection of that organ.
Nephrectomy of the Ieft kidney was carried out through the ordinary Iumbar incision, exposing the organ, tying the ureter and then the pedicIe and cIosing the wound in the usua1 manner. The patient had an uneventfu1 recovery and went home on the fourteenth day after her operation.
To our surpriseythe kidney during operation was apparentIy normaI. Later the pathoIogi- ca1 report of the microscopica study of the specimen showed onIy the features of a chronic pyeionephritis with no evidence of tubercuIous Iesion. The examination made of further sections showed a moderate amount of regres- sive change in the epitheIia1 Iiningof the tubuIar parenchyma. The tubuIar Iumina con- tained a granuIar pinkish materia1 in some parts. Here and there a gIomeruIus was found replaced by hyaline connective tissue and surrounded by a mononucIear round ceI1 inHtration of the stroma. Bowman’s capsuIe appeared dis- tended in some instances and a pink homoge- nous substance was seen in the perigIomeruIar space, suggesting the presence of aIbumen.
The appearance was that of a normal kidney measuring g by 6 by 5 cm. The capsuIe showed no foca1 Iesions and couId be stripped easiIy, Ieaving a smooth surface. The peIvic mucosa appeared wrinkled, grayish-white in color. The definite statements of our pathoIo- gist, after a careful study, was that no evidence of tubercuIous Iesion was found in the sections
examined from this specimen. It is evident that in this case the predisposing factors observed in earIy life were Iargely present and that a definite toxemia also was present, act- ing favorabIy to protect the tubercuIous baciIIuria, which was responsibIe for the urinary symptoms and the inflammation and infection sufficient to produce the pathoIogica1 lesions in the kidney that were characteristic of the condition of acute toxic nephritis.
RfiSUMk
The case showed evidence of toxic nephritis with pyeIonephritis, due undoubtedIy to the baciIIemia from tubercuIous bacilIi that were found in catheterized specimens taken from the left kidney. I think we may say that a distinct lack of proper drainage, due to a slight obstruc- tion at the ureteropeIvic junction, cIearIy shown in the pyelogram, and the presence of a focus of infection somewhere eIse in the body, were the combined causes of the secondary infection of the kidney. It is assumed that the parenchyma of this organ did not show any tubercuIous Iesion.
We fee1 that in a case of this sort, without treatment, sooner or Iater infection wiI1 set in, getting worse in many instances so that an occIuded kidney is bound to result.
BILATERAL RENAL TUBERCULOSIS
The frequency of renaI tubercuIosis is greater than is ordinariIy suspected, but the invoIvement of both kidneys is not so commonly seen. AIthough there is not much difference in regard to symptoms and clinica aspect in the earIy stages of the disease, it is more characteristic in biIatera1 kidney disease to fmd invoIvement of some other viscus in the body. This has been well Xustrated by Young and Davis”” in the study of 32 cases of bilateral renaI tubercuIosis. Young found that whenever both kidneys are affected, it is aIways possibIe to find pathoIogica1 Iesions invoIv- ing one or various of the other genitouri- nary organs, and that in addition to the advanced stage of puImonary tubercuIosis that may exist, the urinary bIadder is invariabIy invoIved, if not by definite pathologica Iesions at Ieast by symptoma- tic disturbances, as a complication arising from the general tubercuIous processes.
NEW SERIES VOL. V. No. 2 Gutierrez-Renal TubercuIosis American Journal of Surgery 105
Not many cases of biIatera1 renaI tubercuIosis (Figs. 3 and 4) have ever been pubIished in the Iiterature but more recentIy a few authors (Rousseau,2” Keyes, 26 Marion,27 Braasch and SchoI128) have caIIed attention to the importance of this, so-considered, hopeless cIinica1 prob- Iem in an effort to establish correct thera- peutic procedure.
Legueu2g quoted from the Iiterature 87 cases of biIatera1 renaI tubercuIosis and added six persona1 observations, studying a tota of 93 cases. His concIusions were most encouraging. After the poorest func- tioning kidney has been removed the bIadder symptoms often disappear and the tubercuIous Iesion of the remaining kidney has been arrested or cured, reIieving the active pathoIogica1 condition and proIonging Iife. Legueu quoted the work of IsraeI, stating that the tubercuIous process of the second kidney occurred in the proportion of 29.2 per cent in the cases in which no operation for the earIy maIady was performed, and that in 1022 cases of nephrectomy the second kidney was Iater invoIved onIy in 13 patients, in the pro- portion of onIy 1.6 per cent. The thesis of Barrie30 is aIso of vaIue in showing inter- esting figures in regard to this probIem. ProportionateIy, biIatera1 renaI tubercu- Iosis is not so commonIy seen cIinicaIIy, since the figures reach onIy 14.6 per cent, but it is surprisingIy increased in post- mortem findings, the figures reaching 47.9 per cent of the cases. The resuIts of these investigations mean, therefore, that uniIatera1 kidney disease varies from 85.9 per cent to 52.1 per cent, showing con- sequentIy that with the better media of diagnosis and more accurate investigations that we have at our disposa1 today, we can prevent by earIy nephrectomy the invasion of the other kidney, arresting the disease or curing it even in the earIy cases of biIatera1 infection.
In some instances, aIbuminuria, hema- turia or other urinary symptoms are due to the toxic infection produced by the baciIIus in the non-affected kidney, or independent
of the tubercuIous process which is onIy an inffammation of the tubuIes or a gIomeruIitis, as in the parenchymatous
FIG. 3. In cases of bilateral renal tuberculosis, with good function in one kidney and very much dimin- ished function on opposite side as indicated with the aid of the pyelogram, remova of more seriousIy affected kidney is recommended, as iIIustrated in case herein reported.
nephritis which has been brought to Iight by AIbarran31 and other writers.
Rovsing,32 among other investigators* has emphasized the vaIue of kidney func- tion for a differential diagnosis in earIy renaI tubercuIasis, particuIarIy by sys- tematicaIIy undertaking quantitative and partia1 anaIysis of urea. The norma secre- tion of urea is a safe criterion of a sufI?cient amount of kidney tissue capabIe of func- tioning. At the same time, of course, one must have in mind the hyper-compensating function as we11 as the reduced secretion,
* 33, 34, 35.
106 American Journal of Surgery Gutierrez-Renal TubercuIosis AUGUST, 1928
inasmuch as the Iatter directIy or indirectly and chemica1 urine examination. Ger- can be due to the diseased kidney; directIy aghty,36 and aIso workers at the Mayo ‘by a pureIy refIex effect, as the reno-renaI Clinic, give more credit to phthaIein aIone,
FIG. 4.‘Cases of non-surgical biIatera1 renaI tuberculosis, in which instances the functional tests are equaIIy poor in both kidneys, which is IargeIy evidenced by the pyelogram, shouId receive medica treatment and sanitarium care for most beneticial resuIts. This type is iIIustrated in Case III.
reff ex, and indirectIy by the disease though we advocate the combined methods influencing the functions of the whoIe of phthaIein and urea secretion in both .organism. However, urea estimation in uniIatera1 and biIatera1 disease. The uni- routine examination is of decided vaIue and versa1 routine cystoscopic examination perhaps is as important in regard to the with the catheterization of both ureters, kidney work and functiona activity as any the combined coIor dye test and urea other test, even as the simpIest microscopic eIimination and pyeIography is undoubt-
NEW SERIES VOL. V. No. z Gutierrez-Rena1 TubercuIosis American J~urnaI of Surgery 107
edly the most accurate, skiIIfu1 and perfect method of diagnosis, accompanied aIways by the guinea pig inocuIation in an effort to detect Koch’s bacilIus. In some instances of biIatera1 disease, Achard’s methyIene bIue or Voelker’s indigo carmine test also is vaIuable in addition to the phenoI- suIphonphthaIein test so often used.
To arrive at a sound diagnosis and prognosis, we should aIways base our investigations on the triangIe of principIes above mentioned, cIinica1 data, kidney functiona tests and pyeIographic studies. In doubtfu1 cases it is obvious that the entire investigation shouId be repeated in order to arrive at a more concIusive diag- nosis, particuIarIy in biIatera1 disease. There is a definite value in routine blood chemistry examination, * incIuding esti- mation of urea, creatin, creatinine and co2 concentration power, which it is not necessary to emphasize in this paper. However, in urinary surgery the combined method of bIood chemistry and renaI tests are invaIuabIe. It was accepted as a uni- form criterion by many authorities during the discussion heId at the 1927 meeting of the InternationaI Congress of Uro1ogy.l’
Progress in conservative treatment in renaI tuberculosis has been marked in the Iast two decades.42l43
Conservative surgery44.45 shouId be con- sidered particuIarIy in anomaIies of the kidneys and when onIy haIf of the organ is invoIved, for it can be controIled by the pyeIograms and functiona tests, as has been SatisfactoriIy proved by different surgeons. 46,47 For exampIe, a few cases have been reported of heminephrectomy in tubercuIous horseshoe kidney in which the other half of the organ was normaI, not onIy cIinicaIIy and pathoIogicaIIy but in regard to bacterioIogica1 examinations, functiona tests and pyeIogram examina- tions. This refined and advantageous method, which perfects diagnosis and makes conservative kidney surgery pos- sibIe, is undoubtedIy due to the era of the cystoscope and a deveIoped urography,
* 37, 38, 399 40.
for which we owe much to the genius of AIbarran.
Furthermore, conservative cure by hemi-
FIG. 5. In types of anomalies of biIatera1 renaI tubercu- Iosis, conservative surgery is indicated in some instances.
With the aid of the pyeIogram and functiona tests, the case above iIIustrates an instance in which hemi- nephrectomy in the upper pole of a double tuberculous kidney can be accomplished, and in a second operation nephrectomy of the opposite functionIess tubercrdous kidney can be done with benefit to the patient, assuring the maintenance of life with one-haIf of a kidney. This type is seen in cases reported by Legueu, Papin and Marion.
nephrectomy in a few cases of doubIe kidney and doubIe ureter invoIvement has been obtained,48,*g as we11 as in our cases of biIatera1 renaI tubercuIosis upon which partia1 nephrectomy was performed (Fig. 3). HaIf of the doubIe kidney on one side was removed and Iater, in a second opera- tion, nephrectomy of the other tubercuIous kidney was performed, both operations being successfuIIy carried out, assuring
108 American Journd of Surgery Gutierrez-Renal TubercuIosis AUGUST, 1928
reIief from symptoms and proIongation of
the patient’s life. BiIateraI renaI tubercuIosis can be
arrested or perhaps cured in these days of
modern diagnosis when the disease is
discovered in its earIiest inception and when the second kidney has enough parenchyma and enough function to main-
tain Iife. In a carefu1 study of such cases, earIy nephrectomy should be the indication
of choice, understanding that postoperative care and proper medica treatment resuIt in
greatest benefit.
CASE REPORTS
CASE II. SurgicaI biIatera1 renaI tubercuIosis. C. H., an Irishman, aged thirty, was
admitted to the UroIogicaI Service of the New York HospitaI, October 9, 1924, with compIaint of extreme urgency and frequency of urination, hematuria and very marked nycturia. The famiIy history was negative for tubercuIosis. He had had the ordinary diseases of chiIdhood. Genera1 condition had aIways been good. His present iIIness commenced in June, 1924, when nycturia, frequency and urgency were noticed which steadiIy increased in severity. Two months Iater the first hematuria was noticed and since then it has been intermittent and aIarming as time went on. The patient Iost over 30 Ibs. On physica examination patient appeared a we11 deveIoped man 5 ft., IO in. in height, and weighed 168 Ibs. which was reduced, at the time of admission, to 142 Ibs. On genera1 examination the head, eyes, nose, mouth, neck, thorax, and heart were normaI. The abdomen was soft, no masses or tender areas were made out. There was present on pressure a sIight pain over Ieft kidney, and the kidney was easiIy paIpabIe. ExternaI genitaIia, extremities and reflexes were also normaI. The Wassermann test was negative. BIood pressure 130 systoIic, 72 diastoIic. The urine anaIysis showed much pus and acid reaction; specific gravity, 10 17.
The cystoscopic and pyeIographic examina- tions reveaIed tubercuIosis of the kidney; function on the Ieft side was much diminished compared with the right and the guinea pig inocuIation showed a positive tinding for renaI tubercuIosis. Left nephrectomy was per- formed, October 14, 1924, under paravertebra1 anesthesia, which we have been using in these cases very SatisfactoriIy.
The pathoIogica1 report of the specimen removed showed tubercuIous kidney with superimposed pyogenic infection.
The patient was discharged from the hospi- taI, November 3, 1924, with his kidney wound heaIed but stiI1 complaining of considerabIe frequency and painful urination for which we advised continuation of treatment in our tubercuIosis clinic.
RhUMh
When the patient came to the hospita1 in October, 1924, with severe urinary symptoms, in bad genera1 condition and suffering with biIatera1 renal tuberculosis, he was submitted to left nephrectomy foIIowed by intensive hygienic and heIiotherapeutic genera1 anti- tubercuIous treatment weekIy in our tuber- cuIosis cIinic. On October 26, 1927, or three years after his operation, the patient was stiI1 aIive and his genera1 condition very much improved. His weight increased from 142 to 154 Ibs. His temperature was 98, puIse 96. He was feeIing very weI1, had no frequency of urination either day or night; he had onIy occasiona sIight burning at urination. He is stiI1 under the proper care and treatment in our cIinic for his tuberculous condition. He has had a most happy convaIescence and the resuIt after this Iong treatment is apparentIy that of permanent cure.
CASE III. Non-surgica1 biIatera1 renaI tubercuIosis.
C. P., an ItaIian, aged twenty-four, married, was referred to the UroIogicaI Service of the New York Hospital, January 25, 1926, com- pIaining of urinary symptoms which began in October, 1925, with duI1 aching pain across her back and sIight frequency of urination. In January, 1926, the pain radiated to the Ieft side of the back over the kidney region. She had burning on urination, and frequency every thirty minutes. She had nycturia and had attacks of hematuria. She had sIight Ioss of strength, weighing upon admission 10255 Ibs. FamiIy history was negative and the past persona1 history was irrelevant. Genera1 phys- ica1 examination was negative except that there was an oId inactive tubercuIous Iesion in the right Iung IocaIized in the posterior upper right apex.
The patient was submitted to a compIete uroIogica1 examination. Cystoscopy showed edema and congestion of both uretera orifices.
NEW SERIES VOL. V, No. 2 Gutierrez-Rena1 TubercuIosis American journal of SWWY 109
No definite uIcers were seen. Both ureters were catheterized without dificu1t.y. Speci- mens were coIIected from each kidney for urea, microscopic and bacterioIogica1 examination and for guinea pig inocuIation. One C.C. of phenoIsuIphonphthaIein was injected intrave- nousIy and appeared in five minutes on the Ieft and in nine minutes on the right, and was coIIected for ten minutes for estimation. Roent- gen-ray fiIms and pyeIograms were taken in the usua1 manner.
REPORT OF URETERAL SPECIMENS
Right Left
Character. i Clear Clear Urea.................. .I 6 gm. per L. I gm. per L. ___ __ _ .__
The urographic report showed considerabIe distortion with marked dilatation and shaggi- ness of both caIices and peIvis of Ieft kidney, giving the impression of tubercuIosis.
One week Iater cystoscopy was repeated with functiona tests and pyeIogram of right side was taken. It showed a great distortion and raggedness of the upper, Iower and middIe caIices and marked distortion of the kidney peIvis, on account of which the suggestion of tubercuIosis of the right kidney was made. The kidney function was much diminished on both sides in regard to urea and phthaIein eIimination. AIso Koch’s baciIIus was detected and the guinea pig inocuIation with the specimens coIIected from each kidney was positive for tubercuIosis. Therefore, the diag- nosis of biIatera1 renaI tubercuIosis with equaIIy diminished function on both sides was made.
The patient has been receiving treatment and specia1 medica attention in our tubercu- Iosis cIinic as an inoperabIe case of biIatera1 renaI tubercuIosis. This patient has improved somewhat in her genera1 condition and partic- uIarIy as regards her tubercuIous uroIogica1 pathoIogy. She is feeIing better but stiI1 com- pIains of frequency of urination. Her weight has increased from 10235 to 126 Ibs. Indeed
at present no surgica1 treatment for the type of this group of advanced cases shouId be appIied. However, one shouId be prepared for what may occur, because in some instances when marked pyuria, pain, fever and genera1 symptoms deveIop, an occIuded or functionIess kidney may resuIt and therefore surgica1 reIief shouId be considered, i.e., a paIIiative proce- dure, as a nephrotomy, in an attempt to secure drainage and finaIIy possibIy a better prognosis.
SUMMARY
We wish especiaIIy to caI1 the attention of practitioners and uroIogists to the extreme and progressive frequency of this maIady, both uniIatera1 and biIatera1, and to the fact that there are certain instances of this disease in which surgery as a thera- peutic procedure shouId not be appIied. We wouId emphasize the fact that com- bined medica and uroIogica1 treatment in a seIect group of cases yieIds the most profitabIe and satisfactory resuIts.
In the three cases reported, the first one shows the incidence of an excretory renaI tubercuIous baciIIuria without demonstra- bIe pathoIogica1 Iesion in the kidney. The cIinica1 vaIue of this fact speaks for itseIf in the misIeading interpretation of many diagnoses.
The second case iIIustrates earIy biIatera1 renaI tubercuI&is when surgery must be appIied as the best and most reasonabIe treatment arresting or curing the disease.
The third case reported iIIustrates the advanced stage of biIatera1 renaI tubercu- Iosis, when both sides are equaIIy invoIved with greatIy diminished function, and when surgica1 treatment shouId not be recommended.
There is no definite ruIe governing the soIution of the clinica probIem, but no kidney shouId be removed, particuIarIy in doubtfu1 cases, unti1 after the three eIe- ments of the triangIe, pointed out in this paper, are present to a marked degree and associated aIso with positive microscopic findings or guinea pig inocuIation.
Repeated uroIogica1 investigations in many instances are entireIy justified in an effort to discover the earliest tubercuIous
ii0 American Journal of Surgery Gutierrez-Rena1 TubercuIosis Aucus~, 1928
Iesion of the upper urinary tract, and aIso to prevent the invoIvement of the second kidney. However, it is of great vaIue to
FIG. 6. This drawing shows the three stages of early renaI tubercuIosis most diffkult of diagnosis; miliary, nodular, and abscess or cavernous types. In these three conditions the initial Iesion is IocaIized in the parenchyma without communicating with caIices or pelvis. SIight urinary symptoms are present, but the triangular factors of diagnosis in many instances may be absent. The treatment shouId be preopera- tive, medica and uroIogica1, as iIIustrated in Case I.
recaI1 that genitourinary tubercuIosis is a syndrome of a genera1 body process Iocal- ized in one or more of the genitourinary organs, demanding immediate attention in regard to hygienic and antitubercuIous treatment, i.e., the use of tuberculin, sun- Iight, forced diet, rest, pIenty of fresh air and a peacefu1 Iife.
In the Iight of modern uroIogy, two distinct types of renaI tubercuIosis must be differentiated, the one that requires onIy
medica treatment and the one requiring surgica1 treatment, when nephrectomy as a ruIe is indicated. But there are stiI1 certain cases in the earIy stage of the disease when the process is IocaIized, invoIving onIy isoIated zones of the cortica1 parenchyma or the meduIIary substance and when the Iesion is waIIed off and does not communicate with the papiIIae, the calices or the peIvis, and therefore is a closed or isoIated process, as we can readiIy see in the three distinct types shown in Figure 6. In these cases the diagnosis is most diffIcuIt, and nephrectomy shouId not be performed unti1 the process is we11 estabIished, i.e., after the tubercuIous noduIes or abscesses have broken through into the excretory apparatus producing pyuria and other marked urinary symp- toms. We shouId not forget that not unti1 that stage is reached can pyeIographic data revea1 the condition. These cases evidentIy require most active and efficient medica and uroIogica1 treatment in order to attain a cure. But if the disease can not be arrested or cured, and the symptoms progress, the permanent cure may be obtained in from 80 to 90 per cent of the cases by earIy nephrectomy.
On the other hand we shouId not wait for the incidence of an occIuded renaI tubercu- Iosis, as occurs in autonephrectomy for bIocking of the ureter, nor shouId we depend upon body resistance that the disease may continue for a Iong period of time. LogicaIIy it is assumed that the focus of infection is bound to deveIop further infection in the other kidney or in the Iower urinary tract at a most serious risk. The damage that nature may cause insidiousIy in destroying the whoIe kidney parenchyma, by the tubercuIous process alone, is undoubtedIy worse than the trau- matism of a simpIe nephrectomy in order to remove an organ deepIy invoIved and functionIess (Fig. 7).
However, medica and uroIogica1 routine treatment, as administered by the newI) formed TubercuIosis Division of the Brady UroIogicaI Foundation at the New York
NEW SERIES VOL. V, No. 2 Gutierrez-Renal Tubercdosis American J~urd of surgery I I I
FIG. 7. Case of occIuded renaI tuberculosis showing pyohydronephrosis or “pyronephrosis” in which the disea: kidn ey was functionIess, as is we11 evidenced in the pyeloureterogram. The organ removed at operation show corn1 Aete distortion of whole kidney parenchyma. In those cases having good function of opposite kidnl neph lrectomy is indicated.
;ed red PYT
I I2 American Journal of Surgery Gutierrez-Rena1 TubercuIosis Aucusr. 1928
HospitaI, shouId be used SystematicaIIy not onIy in postoperative or inoperabIe cases, but more especiaIIy in the earIier stages of the disease, for it is at this period that resuIts are most gratifying.
CONCLUSIONS
From the cIinica1 study as we11 as from the observation of a Iong series of pyeIo- grams in a11 types of cases of renaI tuber- cuIosis, we may draw the foIIowing concIusions :
I. In renaI tubercuIosis we are deaIing in the great majority of cases with a hematogenous infection that has been IocaIized in the kidney.
2. TubercuIous baciIIuria may indicate the Iatency of a IocaIized focus of tuber- cuIosis somewhere eIse in the body.
3. TubercuIous baciIIuria does not aIways mean renaI tubercuIosis. Therefore, routine and repeated uroIogica1 examina- tions, particuIarIy in earIy stages, shouId aIways be made.
4. Nephrectomy shouId be advised onIy when the cIinica1 data are in accordance with a positive pyeIogram and the report of the Iaboratory and when the kidney function IS diminished in regard to urea secretion and phenoIsuIphonphthaIein eIim- ination, providing aIso that the other kidney has function to maintain Iife.
3. Rena1 tubercuIosis is accepted as a uniIatera1 disease, but the incidence of biIatera1 renaI tubercuIosis is more common than has ever been suspected cIinicaIIy.
6. In biIatera1 renaI tubercuIosis when the genera1 condition of the patient is favorabIe and there is good kidney function on one side and a diminished function on the opposite side, the more seriousIy effected kidney shouId be removed, pro- viding that the remaining organ has enough good parenchyma and sufficient function to maintain Iife.
7. Conservative surgery is indicated in renaI tuberculosis, particuIarIy in anoma- Ious cases when they can be controIIed by pyeIographic studies. Heminephrectomy
and partia1 nephrectomy in some instances shouId be recommended.
8. The azotemie index, or the study of bIood chemistry in regard to CO2 concen- tration power, urea, creatin and creatitine, shouId aIways be made in order to deter- mine the degree of nephrosis and in an effort to determine a better prognosis.
9. When the pyeIogram shows pyeIo- nephritis, sIight degree of hydronephrosis, narrowing or stricture at the ureteropeIvic junction or kinks in the ureter sufficient to int.erfere with good drainage, and when there is fairIy good kidney function without any apparent Iesion of the bIadder mucosa, these cases shouId be treated cysto- scopicaIIy by the routine methods of catheterization and diIation of the ure- ters and irrigations of the kidney peIvis with an antiseptic soIution, such as acri- ffavine, I to 1000. This treatment shouId b e given week1 y. The patient at the same time shouId be pIaced in the best hygienic surroundings and appropriate medica treatment instituted in order to aIIow him to buiId up resistance against infection.
IO. EarIy tubercuIous Iesions in the kidney, which in many instances start in the papiIIae or in the caIices for Iack of proper drainage, may be cured, heaIed or arrested when the above method of treat- ment is used.
I I. HistoIogicaI signs of cure, such as heaIing Iesions and inactive IocaIized proc- esses in the kidney parenchyma, often found, are simiIar to those commonIy observed in Iung tissues, and therefore emphasize the fact that cure is possible under intensive medica and uroIogica1 treatment.
12. When a gross Iesion is visuaIized by a positive pyeIogram coincident with the absence or diminution of renaI function, the treatment shouId aIways be nephrec- tomy, providing that such patients go afterwards for a long period of time to a sanitorium or continue to receive medica attention with the usua1 treatment for tubercuIosis.
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