Currently, the contingent of patients with tuberculosis of the genitourinary system is divided from the point of view of therapy into the following subgroups.
1. Patients with renal tuberculosis, subject exclusively to drug therapy (tuberculosis of the renal parenchyma, tuberculosis papillitis).
2. Patients with tuberculosis of one or both kidneys who are subject to long-term drug therapy in preparation for organ-preserving surgery, the nature of which is specified after a certain period of conservative treatment (cavernotomy, cavernectomy, resection of the affected segments of the kidney, various types of surgery for plastic restoration of ureteral patency). This group includes patients with limited destructive tuberculosis of the kidney (kidney) with their normal total function, patients with destructive tuberculosis of the kidney in combination with tuberculosis of the ureter.
3. Patients, obviously subject to organ-preserving surgical interventions – resection of the kidney (kidney), cavernectomy, cavernotomy, restoration of patency of the ureter. This group includes patients with calcified caverns (tuberculomas), turned off caverns, extensive foci of destruction of the renal parenchyma located in one of the segments of the kidney, persistent scarring of the ureter with preserved kidney function.
4. Patients subject to radical surgical operations – nephrectomy, nephrourerectomy (tuberculous pyonephrosis, polycavernous tuberculosis of the kidney, cavernous tuberculosis of the kidney with multiple ureteral strictures, mistaken tuberculous kidney).
5. Patients with post-tuberculosis diseases of the urinary system, subject to plastic corrective surgery (intestinal plastic of the bladder, plastic of the ureter, pelvis).
The use of modern anti-TB drugs makes it possible to successfully operate on both kidneys, to operate with a combination of kidney tuberculosis and tuberculosis of other organs.
The principles of drug treatment of tuberculosis of the genitourinary system are not much different from the principles of treatment of tuberculosis of other localizations. The duration of treatment depends on the form of the tuberculosis process, the drug resistance of the tuberculous mycobacteria secreted by the patient, and the individual tolerance of the drugs. All forms of renal tuberculosis are subject to preliminary antibacterial treatment for 3-6 months with streptomycin D in combination with PASK or isonicotinic acid hydrazide preparations. After such preparatory therapy, it seems possible to develop further therapeutic tactics in relation to this patient. If the question of the indication for radical kidney surgery is usually resolved in the course of preparatory therapy, then the terms of organ-preserving operations are established after dynamic monitoring of the effectiveness of drug therapy after 8-12 months of continuous treatment. For the first 3-5 months of drug treatment, patients receive daily injections of streptomycin in combination with one or two drugs. Subsequently, in the presence of a visible clinical effect or with pronounced poor tolerability of the drugs, they switch to intravenous drip or intermittent administration (streptomycin after one or two days with a daily intake of two drugs inside). Patients with renal tuberculosis in the process of drug treatment are subject to systematic urological observation with the aim of timely diagnosis and treatment of possible complications (stricture of the ureter, obliteration of the mouth of the ureter). In the presence of specific changes in the ureter, treatment with anti-tuberculosis drugs is combined with the appointment of corticosteroids, hyaluronidase against the background of a systematic mechanical expansion of the lumen of the ureter.
One of the important features of the treatment of patients with renal tuberculosis is the dependence of the dosage of anti-TB drugs on the functional ability of the kidney and weight. With normal secretory and evacuation functions of the kidneys, the optimal daily doses of drugs are prescribed (streptomycin 1 g, PASK 9-12 g, tubazide 10 mg per kg of body weight). With a reduced total kidney function or if the patient has a single kidney due to the danger of cumulation of drugs in the body, their daily dose, especially streptomycin, is reduced by half. In such patients, it is advisable to conduct intermittent antibacterial therapy. Treatment with anti-TB drugs is combined, as a rule, with complex vitamin therapy. Patients subject to prolonged drug therapy, as well as patients in the postoperative period, are sent for sanatorium treatment to special urological sanatoriums for patients with tuberculosis of the genitourinary system. The sanatorium regime and climatotherapy are an important additional therapeutic factor for the treatment of patients with tuberculosis of the genitourinary system.
In connection with the use of a large arsenal of new anti-TB drugs and organ-preserving operations, a new category of patients with metatuberculous diseases of the urinary system appeared: patients with chronic post-tuberculous pyelonephritis, nonspecific hydronephrosis, hydrocalix, hydroureter. The indicated group of patients is subject to treatment, the nature and extent of which is determined by the quality of microflora and the presence of pain factor. Post-tuberculous disturbance of urinary dynamics with varying degrees of expansion of the upper urinary tract is an indication for reconstructive surgery. Patients with chronic post-tuberculous pyelonephritis receive systematic treatment with drugs with a wide antibacterial spectrum. Unlike patients with tuberculosis, kidneys, which, with rare exceptions, are not prescribed a special diet, patients with chronic pyelonephritis receive a sparing diet with the exception of extractive foods and spices. Timely use of tuberculostatic drugs contributes to the complete clinical and anatomical cure of the initial manifestations of bladder tuberculosis during the preparatory therapy. In more advanced cases of ulcerative tuberculosis of the bladder, along with the anti-tuberculosis therapy, patients with tuberculosis of the bladder receive instillations of sterile fish oil, PASK solutions, tibone, saluside into the bladder, and with severe pain, ion galvanization with dicain and streptomycin to the bladder area. Solitary tuberculous ulcers of the bladder mucosa respond well to treatment with streptomycin in combination with cortisone and novocaine through a cystoscope using a special flexible needle. In a number of patients with bladder tuberculosis, a good therapeutic effect is achieved by the use of an alcoholic solution of vitamin D2 at 25 LLC-30 LLC ED per day for 3-4 months in combination with streptomycin therapy. With a wrinkled scar microbubble and satisfactory functions of the kidney (kidney), surgical treatment is indicated – intestinal plastic bladder, which leads to an increase in its capacity and elimination of vesicoureteral reflux.