84例肾结核患者的临床特点

Clinical Characteristics of Renal Tuberculosis:a Report of 84 Cases

目的:探讨肾结核的临床特点及治疗手段。方法:回顾分析2004年4月—2012年9月84例肾结核患者的临床资料。其中,3例病灶局限者行抗结核药物保守治疗,行患侧肾切除者43例,行患侧肾、输尿管全切除者36例,行部分肾切除者2例。所有患者术前、术后均联合抗结核药物治疗。结果:84例肾结核患者中,男性36例,女性48例;平均年龄(46.1±13.8)岁;平均病程(21.2±27.6)个月(2周～10年)。其中,左肾结核39例,右肾结核44例,双肾结核1例;一侧肾结核合并对侧肾输尿管积水6例。因下尿路刺激症状就诊37例(44.0%),因腰腹痛、肾积水、血尿等非特异性表现就诊47例(56%)。70例(83.3%)尿液常规检查有不同程度的血尿、脓尿;13例(15.5%)有明确的肺结核或结核性胸膜炎病史;尿找抗酸杆菌阳性率31.0%(18/58)。B超确诊率45.2%(38/84),26.2%(22/84)误诊为尿路结石;腹部平片(KUB)+静脉肾盂造影(intrave-nous urography,IVU)确诊率54.2%(26/48),尿路不显影者占43.8%(21/48);CT确诊率85.1%(57/67),肾积水、肾盏囊样扩张、输尿管狭窄伴管壁增厚是最常见的CT表现。84例患者平均随访(23.9±13.8)个月(4～60个月);随访期间,3例上盏局限性肾结核经保守治疗痊愈,1例尿道狭窄行尿道内切开术,1例因输尿管狭窄行回肠代输尿管术,2例因膀胱挛缩行回肠膀胱扩大术,1例双肾切除者行透析治疗,2例肾功能不全需长期留置肾造瘘管或定期更换双J管;全部患者未见结核复发。结论:肾结核具有起病隐匿、临床症状无特异性、较少合并肺结核病史、尿细菌学阳性率低、影像学表现多样性的特点。早期诊断、正规抗结核药物治疗、恰当的外科干预是减少肾切除、避免复杂重建手术的关键。

Objective： To investigate the clincical characteristics and treatment of renal tuberculosis. Methods：The clinical data of 84 patients with renal tuberculosis from Apr. 2004 to Sep. 2012 was analyzed retrospectively. Among 84 cases,3 cases with focal lesions received antituberculosis conservative therapy, 43 cases underwent nephrectomy, 36 cases underwent nephroure-terectomy, and the other 2 cases underwent partial nepherectomy. Standard antituberculosis drug treatment was administered before and after surgery. Results： There were 36 males and 48 females in the cohort, with the mean age of （46. 1 ±13. 8） years. The mean course of disease was （21.2 ± 27.6） months （1 weeks-10 years）. Among the 84 cases,39 cases had renal tuberculosis on left side, 44 cases had renal tuberculosis on right side, and 1 case bad lesion on both sides. And 6 cases had renal tuberculosis on one side and contralateral hydronephrosis. Among the 84 cases,37 cases （44.0 0/oo） had moderate to severe low er urinary tract symptoms, and 47 cases （56.0%） remainder had nonspecific symptoms such as backache, hydronephrosis, hematuria. Seventy cases （83.3 %）had pyuria and hematuria of varying degrees in routine urianalysis and only 13 cases （15.5 % ） had definite history of pulmonary tuberculosis or pleural tuberculosis. The positive rate of urine acid-fast bacilli was 31.0 % （18/58）. The positive diagnostic rate of renal tuberculosis was 45.2 % （38/84） in B-ultrasonography, 54. 2 % （26/48） in KUB combined with intravenous urography（IVU）, and 85.1 % （57/67） in CT. About 26.20/oo（22/84） were misdiagnosed as urinary calculi by B-ultrasonography, and 43.8% （21/48） of those who underwent KUB and IVU failed to show contrast filling in upper urinary tract. The most common presentations of renal tuberculosis in CT images were hydronephrosis, stenosis-rela- ted dilatation of calyces, ureteral stricture and dilatation, combined with thickening of fibrosis ureteral wall. The average fol- low-up period was （23.9 ± 13.8） months （4±60 months）. During the follow-up period, 3 cases of upper calyces focal tuberculosis were cured by antituberculosis conservative therapy; 1 case of strictures of the urethra underwent endoscopic urethrotomy;replacement of ureter with ileum was performed in 1 case because of ureteral strictures; bladder augmentation was done in 2 cases with contracture of tuberculous bladder; 1 case was treated with dialysis due to nephrectomy in both sides, 2 cases needed drainage for hydronephrosis by percutaneous nephrostomy or ureter stenting due to renal insufficiency. And all of those underwent surgery recovered without relapse. Conclusions： Insidious onset,nonspecific symptoms, infrequent history of pulmonary tuberculosis, low positive rate of urine bacteriologic examination, polymorphic or variable radiological findings were the characteristics of renal tuberculosis in rencent years. Diagnosis at early stages, standard antituberculosis drug treatment, appropriate urological intervention can reduce the necessity of nephrectomy and complicated reconstruction surgery.