泌尿系结核PPT课件

Tuberculosis(TB)oftheGenitourinaryTract泌尿生殖系结核瑞金医院泌尿外科UrinaryTB•Adiseaseofyoungadults.60%between20~40y.•Infectingorganism—Mycobacteriumtuberculosis(结核分支杆菌，结核杆菌),Tuberclebacilli•InfectingRoute(感染途径)•Hematogenousroute(血行途径)fromthelungs.•Primarysites(初发部位):Kidney,Prostate(前列腺)•Otherorgansinvolved:directextensionPathogenesis(发病机理)•Tuberclebacillihittherenalcortex(肾皮质):•Normalresistance(抵抗力):organismdestroyed•Sufficientvirulence(致病力):clinicalinfectionestablished.Pathogenesis•TBofkidney:progressesslowly,15~20ytodestroyakidneywithgoodresistance.•Noclinicaldisturbanceuntilthecalyces/pelvis(肾盏/肾盂)involved.Pathology(病理)Kidney&Ureter(输尿管)•Grossly:asoft,yellowishlocalizedbulge(隆起).•Onsection:involvedareafilledwithcheesymaterial(caseation,干酪样物质).Kidney&Ureter•Wallsofpelvis,calycesandureterthickened.Ulceration(溃疡形成)incalyces.•Completeureteralstenosis(输尿管狭窄)Autonephrectomy(肾自截).•Bladderurinenormalandsymptomabsent.Kidney&Ureter•Basiclesion——Tuberclefoci(结核结节)•Epithelioidreticulum(上皮样网)•Peripheralgiantcells•Healbyfibrosis(纤维化).Kidney&Ureter•TBisacombinationofcaseation(干酪样变),cavitation(空洞形成)andhealingbyfibrosis&scarring(纤维化和疤痕愈合).•Dependingonvirulencevsresistance.•Calcification(钙化):stronglysuggestiveofTB.Secondaryrenalstonesin10%.•Leftkidney:autonephrectomy•RightKidney:hydronephrosis&ureteralreflux(肾积水&输尿管返流)•Contractionofthebladder(膀胱孪缩)左肾萎缩萎缩肾外观Caseation&FibrosisLtRenalDysfunctiononRadioisotopeScan(同位素扫描)Calcification(钙化)Bladder•Tubercleform:white/yellowraisednodules(结节)surroundedbyahaloofhyperremia(充血).•Tuberclesbreakdowndeepraggedulcersbladderirritable.膀胱结核，多个粟粒样黄色小结节膀胱结核，结核性溃疡Diagnosis(诊断)•Justsayingyouhadturnedacornerdoesn’tmakeitso.•Justsayingthereismassivedestructiondoesn’tmakeitso.__JohnKerry•JustsayingthereisTBalsodoesn’tmakeitso.•Wemustprovide……•Demonstrationoftuberclebacilliinurinebyculture.Diagnosis:Symptoms(症状)•NoclassicclinicalpictureofrenalTB.•Mostarevesicalin-origin(膀胱起源):burning,frequency(尿频)&nocturia(夜尿),hematuria(血尿)Diagnosis:Signs(体征)•Kidney——noenlargement/tenderness(触痛)•Externalgenitalia(外生殖器):•thickened,nontenderepididymis(附睾)•chronicscrotaldrainingsinus(阴囊窦道)•Induration/nodulationofprostate&seminalvesicles(前列腺/精囊硬结)Diagnosis:LabFindings•Persistentpyuria(脓尿)withoutorganismonculture.Butacid-faststains:60%(+).•CultureforTB(1stmorningurine):•(+)percentageveryhigh.•Tuberculintest(结核菌素试验):•(-)againstTB.Diagnosis:X-rayFindings•Chestfilm•Plainfilm(平片):•Enlargementof1kidney•Obliteration(消失)oftherenal&psoas(腰大肌)shadow•Renalstones(肾结石)10%Diagnosis:X-rayFindings•Excretoryurograms(排泄性尿路造影):•“Moth-eaten”(蚤咬)appearanceofulceratedcalyces.•Obliterationof1/morecalyces.•Dilationofcalyces.•Abscesscavitiesconnectingwithcalyces.•Excretoryurograms:•Ureteralstricturewithsecondarydilatation.•Absenceoffunctionofthekidney.•RetrogradeUrographyMRUorCTDiagnosis:InstrumentalExams•Cystoscope(膀胱镜):•Tubercles&ulcers,contraction(孪缩)•Cystogram(膀胱造影):•Ureteralreflux(输尿管返流)DifferentialDiagnosis鉴别诊断•Chronicnonspecificcystitis慢性膀胱炎•Epididymitis附睾炎•Multiplesmallrenalstonesandmedullaryspongekidneys(海绵肾)•Urinarybilharziasis(血吸虫病)•Bladderstonesorcancer.Treatment(治疗)TBmustbetreatedasageneralizeddisease!•Basictreatment——Medical药物•Surgicalexcision(外科切除)——merelyadjunctTreatment:RenalTB•Combinationofdrugs(1stline):•1.Isoniazid(INH,异烟肼)200~300mg/d•2.Rifapin(RFP,利福平)450~600mg/d•3.Ethambutol(EMB,乙胺丁醇)15mg/kg/d•4.Streptomycin(STM,链霉素)1g/dim•5.Pyrazinamide(PZA,吡嗪酰胺)1.5~2g/dTreatment:RenalTB•Prefer——INH+RFP+EMB•Resistanceto1stlinedrugs:•Aminosalicylicacid(氨基水杨酸)•Capreomycin(卷须霉素)•Cycloserine(环丝氨酸)•Ethionamide(乙硫异烟胺)•Viomycin(紫霉素)Treatment:RenalTB•Nephrectomy(肾切除):•1.After3m,urineculturestill(+)andgrossinvolvementradiologicallyevident.•2.Severesepsis(脓毒症),painorbleedingfrom1kidney.•3.Markedadvancedon1sideandminimaldamageontheother.Treatment:VesicalTB•Tendstohealwhentreatmentforthe“primary”infectionisgiven.•Ulcers:trans-urethralelectrocoagulation(经尿道电凝)•Extremebladdercontraction:urinarydiversion(尿流改道);augmentationcystoplasty(节段性膀胱成形术)Treatment:GeneralMeasures•Optimalnutrition:important•Irritablebladder:bladdersedatives(镇静剂)•tolterodine,oxybutyninPrognosis(预后)•Relapse(复发):•Ureteralstenosis;•VesicalcontractionPrognosis•Overallcontrolrate:98%at5years•Urinestudy:every6mduringtreatment;everyyearfor10years.CaseReport•A56ymalewithleftabdominalmass&anemia(贫血).•X-rayshowedalargestoneinLtkidneywithseverehydronephrosis.Physician,Surgeon&Pathologist•Physiciansknoweverythingbutdonothing.•Surgeonsdoeverythingbutknownothing.•PathologistsknoweverythinganddoeverythingBUT……•IT’STOOLATE!谢谢