Pretransplant Antitubercular Therapy how long?

To define a safe duration of antitubercular therapy in patients on dialysis awaiting a kidney transplant. Patients with chronic renal failure are more prone to develop tuberculosis than the general population. Continuing dialysis till completion of antitubercular therapy [ATT] has its problems both in terms of morbidity and finances. Since most patients in developing countries have to pay for their dialysis, it is transplantation which balances the risk of flare up of tuberculosis important to define a safe duration of ATT prior to renal with the problems of prolonged dialysis. Retrospective. Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India. Materials and methods: Records of 1360 patients who had received renal allograft at our hospital were reviewed retrospectively. Patients who were found to have tuberculosis prior to transplantation and received therapy according to our hospital protocol were assessed for the duration of pre transplant ATT and their outcome after transplantation. Out of 96 patients who received ATT starting at a mean of 122 +/- 82 days before transplant, only one developed tuberculosis in the post transplant period. Of the 96 patients, a subgroup of 23 patients had received an allograft between six to eight weeks after initiating ATT, that. At a mean follow up of 29 months post transplant, none of these while the rest were transplanted at varying periods after23 patients developed recurrence of tuberculosis. This compares favorably with a 13.3% incidence of post transplant tuberculosis among those patients who did not have the disease preoperatively. Renal transplantation after 6-8 weeks of ATT is probably associated with a minimal risk of flare up of the disease in the post transplant period

Role of Imaging in predicting Salvageability of Kidneys in Urinary Tract Tuberculosis

To study the role of imaging in predicting salvageability of kidneys and the role of early nephrectomy in urinary tract tuberculosis [TB]. This was a retrospective study of 103 cases managed between 1990 to1998. Intravenous urograms [IVUs] were reviewed and based on the IVU findings. Patients were stratified into three groups. Treatment consisted of immediate surgery, defined as nephrectomy within six weeks of starting anti-TB treatment [ATT] and delayed as nephrectomy done after completion of ATT. Chi square test was applied to find the significance of early nephrectomy. Logistic regression analysis model was used to identify factors predicting salvageabilty of the nephron mass. Of the 103 cases, 23 had early nephrectomy and all of them achieved cure and had good renal function at follow up. Of the 76 who received only ATT, 43 were cured and the remaining 33 deteriorated symptomatically with high serum creatinine and decreasing GFR. Of the 33 who deteriorated, radiological and biochemical deterioration was seen in 24, two developed flank sinus and one developed multi drug resistant TB. On sub-grouping of the patients based on IVU, it was found that those with major renal lesion alone [group A] or with bladder involvement [group C] required either early or delayed nephrectomy and those who had minor lesion [group B] or bladder involvement with or without minor lesion [group C] did well on ATT alone. Logistic regression model showed cavitory lesions, GFR<20ml/min/m[2] and gross hydronephrosis as statistically significant unfavourable factors and ureteric stricture as a favourable factor. In the era of modern ATT, nephrectomy is still an essential procedure. We recommend early nephrectomy for patients with major renal lesion with or without bladder involvement, gross hydronephrosis and for those who have GFR of <20 ml/min/m[2]. Lower ureteric strictures and renal units with GFR of >20 ml/min/m[2] are favourable factors and salvage procedures are successful in these cases. It is likely that nephrectomy removes a large focus of disease and possibly dormant bacteria. With continuance of ATT, this further helps in improved patient outcome

Tubercular ureteric strictures

To review the presentation of tubercular ureteric strictures and assesses the role of balloon dilatation and open surgical repair in their management. This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clinical presentation and compare the results of balloon dilatation with open surgical repair. Success was defined as adequate drainage on imaging, no worsening of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. The long term success rates were compared using the t-test for proportion. Of 73 strictures, 88% had lower urinary tract symptoms. Genital abnormalities suggestive of tuberculosis was observed in 40% male patients. Urine examination yielded aseptic pyuria in 85%, positive AFB smears in 36% and positive AFB cultures in 32%. A small capacity bladder and non-functioning renal units were the only consistent findings on intravenous urogram. Nephrectomy was performed in 37% cases due to non salvageable kidneys at presentation. The success rate of stenting fell from 93% on immediate follow up to 59% on a follow-up of 12 months. At 90% success rates on a follow-up of 7 months open surgical repair was superior [p 0.03]. Long term success following balloon dilatation in renal units with good function was 78% compared to 25% for poorly functioning units. [p= 0.01]. Open surgical repair is superior to balloon dilatation in the management of tubercular ureteric strictures. Renal function may predict the success of balloon dilatation

Tubercular ureteric strictures

To review the presentation of tubercular ureteric strictures and assesses the role of balloon dilatation and open surgical repair in their management. This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clinical presentation and compare the results of balloon dilatation with open surgical repair. Success was defined as adequate drainage on imaging, no worsening of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. The long term success rates were compared using the t-test for proportion. Of 73 strictures, 88% had lower urinary tract symptoms. Genital abnormalities suggestive of tuberculosis was observed in 40% male patients. Urine examination yielded aseptic pyuria in 85%, positive AFB smears in 36% and positive AFB cultures in 32%. A small capacity bladder and non-functioning renal units were the only consistent findings on intravenous urogram. Nephrectomy was performed in 37% cases due to non salvageable kidneys at presentation. The success rate of stenting fell from 93% on immediate follow up to 59% on a follow-up of 12 months. At 90% success rates on a follow-up of 7 months open surgical repair was superior [p 0.03]. Long term success following balloon dilatation in renal units with good function was 78% compared to 25% for poorly functioning units. [p= 0.01]. Open surgical repair is superior to balloon dilatation in the management of tubercular ureteric strictures. Renal function may predict the success of balloon dilatation

Urethral diverticulum as a sequele of instrumentation for transurethral resection of prostate [TURP]

We present a case of acquired urethral diverticulum following transurethral resection of the prostate. He developed the symptoms of urinary incontinence, passing urine by straining and squeezing the scrotal swelling nine months after surgery. Diverticulectomy was done successfully.Acquired urethral diverticulum is a rare complication following transurethral resection of the p rostate. To our knowledge this is not mentioned as a complication in the literature

Isolated metastasis of renal cell carcinoma into the spermatic cord

Renal cell carcinoma is known as a ubiquitous tumor because of its unusual presentation and metastatic profile. We report an isolated metastasis of clear cell renal cell carcinoma into the spermatic cord

Cerebral vascular changes in experimentally induced hypertensive rats

To study the pathogenesis of cerebral vascular changes in hypertension, especially those predisposing to hemorrhage, we set out to produce a hypertensive rat model by the Goldblatt [2 kidney-1 clip] method. Materials and Fifty rats were rendere d hypertensive by the Goldblatt method in which the left renal artery was ligated surgically. The animals, together with 18 control rats, were divided into three groups as follows: a] on normal diet and water, b] on normal diet and 1% salt water and c] on normal diet and drinking water containing 0.12% of the lathyrogen beta a m i n o p roprionitrile [BAPN]. Slices of brain were examined both macroscopically and microscopically for morphological changes in the cerebral vessels. Mean arterial blood pressures achieved were only moderate [170 mmHg] and corresponding cerebral vascular changes were mild to moderate. None of the s e v e re lesions [hemorrhages, fibrinoid necrosis, microaneurysms, etc.] known to be associated with severe or long-standing hypertension were demonstrated in this study. A few vessels in six animals showed fibrin deposition in the wall, although these could not be directly related to the severity of hypertension or duration of survival of the animal. The six, as well as three additional animals, also showed immunoglobulin G [IgG] deposition in the vessel walls and perivascular tissues within the brain. We have successfully established a rat model for the study of hypertension-related cerebral vascular changes. The deposits of fibrin and IgG in the vessel wall and surrounding tissues re p resent early changes, which appear to occur even in the absence of severe hypertensive vascular disease. Further studies are required to determine the relevance of these changes to other known morphological changes of the cerebral vasculature in hypertension