Renal tuberculosis may run a painless course, or it may be accompanied by a severe renal colic or renal crises, the latter sometimes due to plugging of the ureter with cheesy debris. Pyuria may be masked by hematuria, the latter trifling, apparently spontaneous, and occurring even during repose.
More accurate diagnosis can be rarely made without resort to the cystoscope and catheterization of the ureters. When in the cystoscopic image the ureteral orifice is enlarged, congested, and even hemorrhagic or ulcerated, it may be regarded as evidence of tuberculous disease in the corresponding kidney. Meyer has claimed that in the descending form of tuberculosis the mouth of the ureter is ulcerated, while in the ascending form it is apparently healthy. When both outlets are apparently healthy, and urinalysis indicates renal disease, the case must be one of ascending lesion. Fenwick has described what he calls a “golf-hole ureter,” the orifice being dilated and patulous, and the appearance being to him pathognomonic.
Ureteral catheterization is perhaps less necessary on the suspected side than it is to prove the healthfulness of the kidney on the opposite side. The disease is more common in the female, and usually occurs in early adult life. It is more often a descending than an ascending affection.
Fig. 635
Renal tuberculosis as seen on section. Papillary granulomata seen at T. (Israel.)
Treatment.—Radical treatment of renal tuberculosis is possible only when the lesion is limited to one organ. What shall be done with the kidney involved, when exposed and the disease revealed, may depend to some extent upon the actual degree of involvement. More and more surgeons are agreeing that anything like partial nephrectomy is of questionable value, and that an organ distinctly tuberculous should be removed. In other words, partial nephrectomy is of doubtful merit. Of course, the kidney should be opened before its removal, unless from its exterior it is seen to be hopelessly involved. A further question of great importance is that of involvement of the ureter. With a few associated lesions in the kidney the ureter may easily escape, but with a kidney thoroughly degenerated, and with infected urine or tuberculous debris passing constantly down through the ureter it cannot escape contamination. It is not a difficult procedure, nor does it add to the gravity of the operation, to extend the incision sufficiently to permit not only the delivery of the kidney but the exposure at least of the upper portion of its ureter. In this way the renal pelvis may be opened and the ureter itself examined. When thus involved, and especially if it be determined to sacrifice the kidney, as much of the ureter should be removed with it as can be reached. While theoretical considerations would always require these measures to be combined, many mild tuberculous lesions of the ureter undergo spontaneous retrocession after removal of the diseased kidney from which it has become contaminated.
The incision intended to expose the ureter should begin about a half-inch forward and in front of the lower costal cartilage, parallel with the last rib, and terminate on a level with the anterior superior spine, about one inch toward its inner side. This incision will then be about four inches in length. The use of a pillow is of assistance in the easy performance of this operation. The body should be rolled as far as possible without losing negative pressure upon the abdomen. The more abdominal fat there is present the further over the patient should be rolled; a stout patient should have the hips raised from the table by a cushion, in order that the abdomen may be pendent, while the foot of the table is somewhat elevated and the operator is facing the abdomen. After exposing the fat which is adherent to the peritoneum, and the knife is laid aside, the peritoneum is separated from the abdominal wall until the kidney and the perinephritic fascia are recognized. Then with a short retractor the posterior edge of the wound below the ribs is elevated, after which, under the influence of gravity, the cavity opens widely, the fascia may be torn through, and the kidney exposed and freed. The retractor is then removed, the anterior edge of the wound pressed backward, and the kidney is easily delivered from the abdominal cavity; or if its delivery be impracticable, it may be at least so drawn up that the renal vessels are easily exposed, tied, and divided. After their division care should be given that the weight of the kidney does not drag injuriously upon the ureter. The latter is then cleared of peritoneum, especially to its outer side, by blunt dissection, after which a medium-width Sims speculum, with a long bill, may be passed downward between the peritoneum and the abdominal wall and made to draw the latter upward. Thus an extensive view of the ureter is afforded, while its lower portion may be still further freed toward the base of the broad ligament. By a continuation of this process of separation and exposure it is possible to release the ureter almost to its junction with the bladder, where it is tied, its stump being disinfected with pure carbolic.
Syphilis and Actinomycosis.
—These lesions may be briefly dismissed so far as they pertain to the kidneys. Gummas are rare, renal syphilis being usually of a disseminated type, which should be treated by internal therapy, except when abscess results or when there arises some peculiar surgical complication. Actinomycosis is rare in the kidneys, and is not recognized until the peculiar fungi are found in the urine, or until some granuloma, developing toward the surface, breaks down and discharges its characteristic products.