Prognosis and outcome of renal tuberculosis after nephrectomy

Prognosis and outcome of renal tuberculosis after nephrectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Prognosis and outcome of renal tuberculosis after nephrectomy Shun Wang, Yuan Tian, Qing Wang, Kehua Jiang, Fa Sun, Tao Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4886961/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Researches has proved that nephrectomy combine with anti-tuberculosis therapy were effective methods for renal tuberculosis, but whether it could also reduce the complications after one year later or longer has never been reported. Methods The clinical data, anti-tuberculosis strategy and the occurrence and management of renal tuberculosis related long-term complications (including bladder contracture, contralateral hydronephrosis, lower urinary tract symptoms [LUTS] and tuberculosis recurrence) were reviewed and analyzed. Meanwhile, the logistic regression analysis was used to explore the impactors of long-term complications. Results A total of 146 patients were successfully followed up. Among them, 3 cases developed bladder contracture after nephrectomy whose life quality was significantly improved after bladder augmentation. 9 patients showed contralateral hydronephrosis, with four cases were diagnosed preoperatively and five postoperatively. The preoperative symptoms of tuberculosis toxicity significantly increased the incidence of postoperative contralateral hydronephrosis. 17 patients suffered from severe LUTS, with 11 individuals occurred preoperatively and six developed postoperatively, and the elevated preoperative white blood cell counts and globulin level significantly influenced the new-onset LUTS risk. 2 patients experienced postoperative recurrence of pulmonary tuberculosis and cured by another regular anti tuberculosis treatment. 12 patients experienced postoperative flank pain, of which 7 cases were new-onset and five were pre-existing. The older age increased the risk of postoperative flank pain. Conclusion Preoperative symptoms of tuberculosis toxicity significantly increased the risk of the postoperative renal hydronephrosis, while elevated white blood cell counts and reduced globulin levels before surgery increased the risk of new-onset postoperative LUTS, and the older the patient, the higher the risk of postoperative flank pain. Health sciences/Diseases Health sciences/Medical research Health sciences/Signs and symptoms Health sciences/Urology Renal tuberculosis Nephrectomy Complication Prognosis Introduction There are approximately 1.3 million new tuberculosis cases each year in China, with pulmonary tuberculosis accounting for 90% and genitourinary tuberculosis representing 27% for the extra-pulmonary cases [ 1 – 3 ] . The kidney is the most commonly affected organs in genitourinary system [ 4 ] ; however, the Mycobacterium tuberculosis will latent for a long time in kidney. Thus, the progression of renal tuberculosis is extremely slow, and the symptoms usually appear only in the late stage and is lacking specificity. When the tuberculosis foci involve renal collecting system, the M. tuberculosis will flow into pelvis, ureters, bladder, urethra, seminal vesicles, and testes, which residing into the tissues and impairing organs to induce related symptoms including frequency, urgency, odynuria, pyuria, hematuria, and flank pain [ 5 – 7 ] ; while all these are atypical and extremely difficult to diagnose. The typical tuberculosis symptoms like low fever or night sweats are less than 10%, more than 50% patients are accidentally found due to physical examination or other urinary diseases [ 5 ] . Thus, the early diagnosis is difficult and more patients have developed with serious kidney damage before consulting a doctor. As we know, nephrectomy combine with anti-tuberculosis therapy is more recommended for patients with clinical or advanced renal tuberculosis to prevent the M. tuberculosis releasing and further damaging other genitourinary organs [ 8 ] . To date, researches proved that these were effective methods for renal tuberculosis, but most of them focused on the perioperative indicators. Whether nephrectomy combine with anti-tuberculosis therapy could also slow, prevent, or reverse the mycobacterium induced lesion progression, thus reducing the long-term complications of renal tuberculosis has never been reported; meanwhile, few investigations tracking the development of bladder contracture, contralateral hydronephrosis, severe LUTS, or tuberculosis recurrence, after one year later or longer. We retrospectively summarized the clinical data of renal tuberculosis patients receiving nephrectomy and analyzed their long-term disease prognosis and outcome, aim to providing a strategy for postoperative treatment and follow-up for such patients. Materials and methods Clinical data The clinical data of patients who underwent unilateral nephrectomy due to renal tuberculosis in our hospital between 2015 and 2021 were collected. These data included sex, age, past history of tuberculosis, clinical manifestations, laboratory tests (erythrocyte sedimentation rate [ESR], T-cell spot test for tuberculosis infection [T-SPOT], antibodies against the 16 and 38 kDa mycobacterial antigens and lipoarabinomannan, polymerase chain reaction [PCR] identification of tuberculosis infection, acid-fast staining of tissue, assessment of deoxyribonucleic acid [DNA] in urine, routine urine analysis, and preoperative and postoperative routine blood measurements). Further information on anti-tuberculosis treatment, occurrence of bladder contracture, contralateral hydronephrosis, LUTS, tuberculosis recurrence, flank pain, and treatment status were followed up via phone calls. Then, the correlations between the parameter and complications were followed-up and analyzed by SPSS software. All methods were performed in accordance with the relevant guidelines and regulations. Inclusion and exclusion criteria Inclusion criteria: Patients who underwent unilateral nephrectomy due to renal tuberculosis at our hospital and were diagnosed with renal tuberculosis by postoperative pathology between 2015 and 2021. Exclusion criteria: Patients with incomplete records; patients with non-tuberculous diseases causing symptoms such as bladder contracture, contralateral hydronephrosis, LUTS, flank pain, and hematuria; patients using anticoagulant drugs needing discontinuation or already discontinued but not meeting the standard discontinuation time; patients with severe hematological diseases and cardiopulmonary insufficiency who could not tolerate surgery. Statistical analysis Statistical analysis was performed using SPSS 22 software. Normally distributed continuous variables are described as mean ± standard deviation, and non-normal continuous numerical variables are described as “median (interquartile range)”. Non-parametric tests (Spearman correlation analysis or Fisher’s exact test) were employed for univariate analysis of the occurrence of bladder contracture, contralateral hydronephrosis, LUTS, and postoperative flank pain symptoms in relation to preoperative clinical manifestations, anti-tuberculosis treatment, tuberculosis history, and laboratory tests. When P < 0.2, the indicator was included in the logistic regression model for correlation analysis, and P < 0.05 was considered statistically significant. Results 146 patients were followed up, and data on anti-tuberculosis drug treatment were collected for 100 patients. The median duration of preoperative anti-tuberculosis treatment was 4 (2, 9) weeks, while that for postoperative treatment was 34 (26, 52) weeks. Among them, 12 patients received a two-drug anti-tuberculosis regimen, 18 received a three-drug regimen, and 70 received a four-drug regimen. Of the 146 patients, three (2.05%) developed bladder contracture, with two patients diagnosed before surgery and one two years after surgery. Two patients diagnosed with bladder contracture before surgery returned to hospital for bladder enlargement after 6 months anti-tuberculosis treatment and recovered well after surgery. The new-onset bladder contracture patient had obvious LUTS and flank pain before surgery, combined with pulmonary and bladder tuberculosis. Subsequently, the patient underwent bladder enlargement surgery, and the symptoms were significant improvement. Due to the limited number of cases with bladder contracture, no correlation analysis was performed. In this study, nine (6.16%) patients showed postoperative contralateral hydronephrosis, with four cases diagnosed preoperatively and five postoperatively. Among the four patients diagnosed preoperatively, the contralateral hydronephrosis were significantly improved in two patients after nephrectomy, and no aggravation was observed in other two patients. All the five new-onset contralateral hydronephrosis patients had regular follow-up, showing normal renal function and no worsening of hydronephrosis. The results of regression analysis revealed that preoperative symptoms of tuberculosis toxicity significantly increased the risk of postoperative hydronephrosis (OR = 11.619, 95% CI [1.948-509.159], P = 0.015) (Table 1 ). Table 1 Factor associated with new-onset contralateral hydronephrosis after operation Feature P value OR 95% CI Symptoms of tuberculosis poisoning 0.015 11.619 1.949-509.159 OR, odds ratio; CI, confidence interval Among the patients followed up postoperatively, 17 (11.64%) had accompanying LUTS, with 11 cases occurring preoperatively and 6 cases developing postoperatively. Among the 11 patients with preoperative LUTS, three experienced recurrences after the LUTS disappearance, while preoperative LUTS continued after surgery in the remaining eight patients albeit with significantly reduced severity. Among the six patients who developed new-onset LUTS postoperatively, two patients had significant alleviation of the LUTS symptoms by further treatment. Patients with new-onset LUTS have significantly higher white blood cell and neutrophil counts compared to others, but preoperative globulin levels were opposite ( P < 0.05). Regression analysis revealed that elevated preoperative white blood cell counts (OR = 3.959, 95% CI [1.452–10.794], P = 0.007) and globulin levels (OR = 0.654, 95% CI [0.431–0.992], P = 0.046) significantly influenced the risk of new-onset LUTS (Table 2 ). Table 2 Factors associated with new-onset LUTS after operation Feature P value OR 95% CI Preoperative WBC 0.007 3.959 1.452–10.794 Preoperative Glb 0.046 0.654 0.431–0.992 LUTS, lower urinary tract symptoms; OR, odds ratio; CI, confidence interval; WBC, white blood cell; Glb, globulin Two (1.37%) confirmed cases of recurrent pulmonary tuberculosis were identified. One patient showed a recurrence in one year after discontinuation of postoperative oral anti-tuberculosis medication, and the other patient experienced pulmonary tuberculosis recurrence in the fourth year postoperatively, both were cured after another year of medication. Since only two cases of tuberculosis recurred in the 146 follow-up patients, no correlation analysis of risk factors for recurrence was performed. 12 (8.22%) experienced postoperative flank pain among the 146, of which seven cases were new-onset and five were pre-existing. None of the 12 patients with flank pain received treatment. Subsequent regression analysis indicated that older age increased the risk of postoperative flank pain (OR = 1.106, 95% CI [1.015–1.206], P = 0.021) (Table 3 ). Table 3 Factor associated with new-onset flank pain after operation Feature P value OR 95% CI Age 0.021 1.106 1.015–1.206 OR, odds ratio; CI, confidence interval Discussion Renal tuberculosis cases are mostly secondary to pulmonary tuberculosis [ 9 ] . As described previously, the M. tuberculosis from kidney can continuously stimulate and damage other urinary organs. Firstly, the released mycobacterium invades ureters to induce local specific inflammatory response, the inflammatory scar heals but might accompanied with ureterostenosis which finally leads hydronephrosis and renal dysfunction [ 10 , 11 ] . Meanwhile, the mycobacterium attacks the bladder to induce mucosal congestion, edema, and tuberculous nodules formation; when the lesion involving the deeper muscle layer, the fibrosis and scar contraction in the bladder wall will occur while the bladder loses tension and capacity, which eventually leading bladder contracture. Moreover, the fibrosis and scar contraction can spread to the contra ureteral bladder opening site to contribute the stenosis or incomplete closure of contralateral ureteral orifice, which finally result contralateral hydronephrosis and even uremia. In addition, patients with renal tuberculosis can also develop to severe LUTS or suffered from tuberculosis recurrence even with timely and normative treatments. Thus, we must pay attention to the long-term complications (bladder contracture, contralateral hydronephrosis, severe LUTS, and tuberculosis recurrence) for individuals with renal tuberculosis. M. tuberculosis , carried by the urine, invades the bladder, leading to extensive fibrosis and cicatricial contraction of the bladder wall as the deep lesions heal. This results in the loss of bladder wall elasticity and a significant decrease in bladder capacity (less than 50 ml), known as tuberculous bladder contracture. The main symptoms include frequent urination, urgency, pain in the pubic area, and urinary incontinence [ 6 ] . Bladder enlargement surgery can significantly increase bladder capacity and alleviate LUTS in patients with tuberculous bladder contracture. However, for patients with bladder contracture accompanied by pain in the pubic area during urination, simple bladder enlargement may not be effective for relieving pain. This might be due to the compression of the bladder wall nerves by the proliferating scar tissue, necessitating the removal of most of the bladder tissue affected by contracture for symptom relief [ 12 ] . In our study, three patients who underwent bladder enlargement surgery experienced a significant relief of LUTS, and in patients with concomitant contralateral hydronephrosis, renal function was preserved. This indicates the positive therapeutic effect of bladder enlargement surgery on tuberculous contracture bladder, effectively preventing secondary LUTS and damage to the contralateral kidney. The pathogenesis of contralateral hydronephrosis involves ureteral obstruction, urinary reflux, and high pressure in the bladder. For upper ureteral strictures, ureteropyeloplasty can be performed; mid-segment strictures are mainly treated by incision within the narrow segment. If obstruction persists, autologous kidney transplantation can be considered. Anti-reflux ureteral bladder reimplantation surgery has a significant therapeutic effect on patients with ureteral orifice strictures, incomplete closure, or lower ureteral strictures. Additionally, bladder enlargement surgery can effectively increase bladder capacity, reduce intravesical pressure, and treat vesicoureteral reflux and renal hydronephrosis. Our research results indicate a significant correlation between preoperative symptoms of tuberculous intoxication and postoperative contralateral renal hydronephrosis. For patients in this category, communicating the risks beforehand is advisable but excessive anxiety is unnecessary. If postoperative hydronephrosis does not worsen, no specific treatment is required. About 46% of the patients with renal tuberculosis in this study presented with LUTS [ 13 ] . Regression analysis found a significant correlation between postoperative LUTS and elevated preoperative white blood cell counts as well as decreased globulin levels. Early LUTS is related to direct stimulation of the urinary tract by M. tuberculosis , while late-stage complications such as bladder contraction and nonspecific urinary tract infections exacerbate LUTS symptoms. Further analysis revealed no significant correlation between postoperative LUTS and preoperative symptoms, suggesting that regardless of the severity of preoperative symptoms, patients with renal tuberculosis generally respond well to systematic, regular treatment. Even if residual or new-onset LUTS symptoms persist after surgery, most of these can be alleviated by further anti-tuberculosis therapy. Anti-tuberculosis drugs are the first-line treatment for tuberculosis, and most patients with early-stage renal tuberculosis can be cured with anti-tuberculosis drugs, avoiding surgical intervention [ 14 , 15 ] . Studies have reported recurrence rates of 80% with single-drug anti-tuberculosis therapy, 25% with dual-drug therapy, and 10% with triple-drug therapy; thus, the most conservative approach is to initiate a quadruple-drug regimen, namely isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin [ 3 ] . However, if after 6–9 months of drug therapy, the urine remains positive for tuberculosis bacilli or if there is severe renal parenchymal damage, surgical removal of the affected kidney should be considered, with at least two weeks of preoperative anti-tuberculosis treatment and postoperative continuation for at least 6 months [ 16 ] . Studies have found that appropriate prolongation of the course of anti-tuberculosis drugs can effectively reduce the recurrence rate of tuberculosis but carries the risk of the development of drug resistance [ 10 ] . Two patients in this study who experienced tuberculosis recurrence also had preoperative pulmonary tuberculosis lesions that recurred after surgery, suggesting a possible correlation between postoperative urinary tuberculosis recurrence and a history of pulmonary tuberculosis. Therefore, thorough follow-up chest CT is essential for patients with a history of pulmonary tuberculosis, and anti-tuberculosis treatment should be initiated promptly if signs of tuberculosis recurrence appear. Flank pain is a common clinical manifestation of renal tuberculosis and a major reason for patients to seek medical attention [ 17 , 18 ] . It is considered that postoperative flank pain is mainly caused by invasion of the kidney by M. tuberculosis , secondary urinary system lesions (renal hydronephrosis), and surgery-related injuries. M. tuberculosis infection in the kidney initially presents as atypical renal tuberculosis, with flank pain being the most common clinical manifestation. When M. tuberculosis invasion causes bladder urine reflux and ureteral obstruction, leading to renal hydronephrosis, flank pain may occur. Flank pain may also occur with concurrent nonspecific upper urinary tract infections [ 15 ] . During nephrectomy for renal tuberculosis, it is necessary to separate the surrounding tissues of the kidney. If adhesions are severe and the tissue structures are unclear, damage to the surrounding tissues is inevitable, which may lead to postoperative flank pain. The results of the regression analysis in this study showed that the older the patient, the higher the risk of postoperative flank pain. This study has several limitations. It was a single-center analysis of renal tuberculosis data. Retrospective studies are prone to selection bias, and the success rate of follow-up was low. There were few positive outcome events among follow-up cases; hence, it was unable to stratify the risk factors for the identified positive indicators. It is necessary to conduct prospective multicenter studies on the use of nephrectomy for renal tuberculosis and track postoperative complications, renal function, and tuberculosis recurrence. Conclusions Patients with renal tuberculosis who underwent nephrectomy combined with regular anti-tuberculosis treatment were found to have a lower incidence of postoperative complications, such as bladder contraction, contralateral renal hydronephrosis, LUTS, and tuberculosis recurrence. Preoperative symptoms of tuberculosis toxicity significantly increased the risk of the postoperative development of renal hydronephrosis, while elevated white blood cell counts and reduced globulin levels before surgery increased the risk of new-onset postoperative LUTS, and the older the patient, the higher the risk of postoperative flank pain. Declarations Ethical approval and consent to participate The study was approved by the Ethics Committee of Affiliated hospital of Guizhou medical university. Informed consent was obtained from all patients, if patients are under 16, from a parent and/or legal guardian. Competing interests The authors declare that they have no competing interests. Funding This manuscript was funded by National Nature Science Foundation of China (No. 82360295 and 82060276), the Doctor Start-up Fund of Affiliated Hospital of Guizhou Medical University (gyfybsky-2023-03), the Science and Technology Department of Guizhou Province (QianKeHeJiChu-ZK [2021] YiBan382), and the Science and Technology Foundation Project of Guizhou Provincial Health Commission (gzwkj2024-150). The funding agencies and donors had no role in any aspect of this study. Author Contribution WS and WQ wrote the manuscript and collected the data, JKH, LT and TY collected the data and analysis, SF and JKH study design, study supervision and edited the manuscript, all authors reviewed the manuscript. Acknowledgements Not applicable. Data Availability Records and data pertaining to this study are available from the corresponding author on reasonable request. References Kulchavenya, E., Kholtobin, D. & Shevchenko, S. Challenges in urogenital tuberculosis[J]. World J. Urol. 38 (1), 89–94 (2020). Global tuberculosis control. key findings from the December 2009 WHO report[J]. Wkly. Epidemiol. Rec . 85 (9), 69–80 (2010). Figueiredo, A. A., Lucon, A. M. & Srougi, M. Urogenital Tuberculosis[J]. Microbiol. Spectr. , 5 (1). (2017). Schubert, G. E., Haltaufderheide, T. & Golz, R. Frequency of urogenital tuberculosis in an unselected autopsy series from 1928 to 1949 and 1976 to 1989[J]. Eur. Urol. 21 (3), 216–223 (1992). MEDLAR E M & SPAIN D M HOLLIDAY R W. Post-mortem compared with clinical diagnosis of genito-urinary tuberculosis in adult males[J]. J. Urol. 61 (6), 1078–1088 (1949). Ponnayyan, N., Ganapath, A. & Ganapathy, V. Spectrum of tuberculosis in urology: Case series and review of the literature[J]. Urol. 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Altintepe, L. et al. Urinary tuberculosis: ten years' experience[J]. Ren. Fail. 27 (6), 657–661 (2005). Cek, M. et al. EAU guidelines for the management of genitourinary tuberculosis[J]. Eur. Urol. 48 (3), 353–362 (2005). Li, C. et al. Retroperitoneal laparoscopic nephroureterectomy with distal and intramural ureter resection for a tuberculous non - functional kidney[J]. Int. Braz J. Urol. 44 (6), 1174–1181 (2018). Chen, Y. et al. Comparison of Transperitoneal and Retroperitoneal Laparoscopic Nephrectomy for Nonfunctional Tuberculous Kidneys: A Single-Center Experience[J]. J. Laparoendosc Adv. Surg. Tech. A . 28 (3), 325–329 (2018). Krishnamoorthy, S. et al. Aspects of Evolving Genito Urinary Tuberculosis-A Profile of Genito Urinary Tuberculosis (GUTB) in 110 Patients[J]. J. Clin. Diagn. Res. 11 (9), C1–C5 (2017). Das, P., Ahuja, A. & Gupta, S. D. Incidence, etiopathogenesis and pathological aspects of genitourinary tuberculosis in India: A journey revisited[J]. Indian J. Urol. 24 (3), 356–361 (2008). Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4886961","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":357080002,"identity":"28af35b0-4f7b-4b48-9f67-40a617d3928e","order_by":0,"name":"Shun Wang","email":"","orcid":"","institution":"Affiliated hospital of Guizhou medical university","correspondingAuthor":false,"prefix":"","firstName":"Shun","middleName":"","lastName":"Wang","suffix":""},{"id":357080003,"identity":"13de021c-f7ec-4788-b549-938d6c017bf6","order_by":1,"name":"Yuan Tian","email":"","orcid":"","institution":"Affiliated hospital of Guizhou medical university","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Tian","suffix":""},{"id":357080004,"identity":"450e9483-e393-455e-9efa-04af35b05a46","order_by":2,"name":"Qing Wang","email":"","orcid":"","institution":"Guizhou provincial people’s hospital","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Wang","suffix":""},{"id":357080005,"identity":"3db29634-f7b4-41df-a49d-16a004ed8195","order_by":3,"name":"Kehua Jiang","email":"","orcid":"","institution":"Guizhou provincial people’s hospital","correspondingAuthor":false,"prefix":"","firstName":"Kehua","middleName":"","lastName":"Jiang","suffix":""},{"id":357080006,"identity":"771b2648-cbf7-437f-8d1d-9a6b98f5249b","order_by":4,"name":"Fa Sun","email":"","orcid":"","institution":"Affiliated hospital of Guizhou medical university","correspondingAuthor":false,"prefix":"","firstName":"Fa","middleName":"","lastName":"Sun","suffix":""},{"id":357080007,"identity":"ae4479cf-9f05-4ebd-8de2-367379f6774f","order_by":5,"name":"Tao Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYBACPmYQWSABJBgbH374YcPDz8x8+AE+LWzMID0GEkA9zM3Gkj1pMpLtbGkGeLUwgLUwALWwtwnwsB2yMTjPoyCBVws7/8EPHwws6vjbG9sYJHgO8Bgf5gEaUWMTjcdhzJIzgA6TOHOw7UGBxR0es8O8Bx4wHEvLbcDjF2kekF9uJLYbSPA8A2rhSzBgbDiMTwvzb5AW+RuJbRI8bId5jJuBXAJa2MC2GMC0GDAT1mJmCfSL5MYzB8GBzCNxGBjICXj8ws9/8PGNDxV1/HLH2x+CotKev//w4QcfamxwasEBEkhTPgpGwSgYBaMADQAAcm5OR3yK+wkAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated hospital of Guizhou medical university","correspondingAuthor":true,"prefix":"","firstName":"Tao","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-08-09 12:06:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4886961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4886961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79804254,"identity":"630c7872-e476-4e57-8937-6d50edc43fce","added_by":"auto","created_at":"2025-04-03 05:01:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":562518,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4886961/v1/8b08187f-2f42-45a9-9898-5cf72efe550d.pdf"},{"id":66061461,"identity":"a9e70cf0-47e6-4315-b708-fadc7b1b8d9a","added_by":"auto","created_at":"2024-10-07 10:20:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20296,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-4886961/v1/ba29aa7b3562bc288a85230a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prognosis and outcome of renal tuberculosis after nephrectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere are approximately 1.3\u0026nbsp;million new tuberculosis cases each year in China, with pulmonary tuberculosis accounting for 90% and genitourinary tuberculosis representing 27% for the extra-pulmonary cases\u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The kidney is the most commonly affected organs in genitourinary system\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e; however, the \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e will latent for a long time in kidney. Thus, the progression of renal tuberculosis is extremely slow, and the symptoms usually appear only in the late stage and is lacking specificity. When the tuberculosis foci involve renal collecting system, the \u003cem\u003eM. tuberculosis\u003c/em\u003e will flow into pelvis, ureters, bladder, urethra, seminal vesicles, and testes, which residing into the tissues and impairing organs to induce related symptoms including frequency, urgency, odynuria, pyuria, hematuria, and flank pain\u003csup\u003e[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e; while all these are atypical and extremely difficult to diagnose. The typical tuberculosis symptoms like low fever or night sweats are less than 10%, more than 50% patients are accidentally found due to physical examination or other urinary diseases\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Thus, the early diagnosis is difficult and more patients have developed with serious kidney damage before consulting a doctor.\u003c/p\u003e \u003cp\u003eAs we know, nephrectomy combine with anti-tuberculosis therapy is more recommended for patients with clinical or advanced renal tuberculosis to prevent the \u003cem\u003eM. tuberculosis\u003c/em\u003e releasing and further damaging other genitourinary organs\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. To date, researches proved that these were effective methods for renal tuberculosis, but most of them focused on the perioperative indicators. Whether nephrectomy combine with anti-tuberculosis therapy could also slow, prevent, or reverse the mycobacterium induced lesion progression, thus reducing the long-term complications of renal tuberculosis has never been reported; meanwhile, few investigations tracking the development of bladder contracture, contralateral hydronephrosis, severe LUTS, or tuberculosis recurrence, after one year later or longer. We retrospectively summarized the clinical data of renal tuberculosis patients receiving nephrectomy and analyzed their long-term disease prognosis and outcome, aim to providing a strategy for postoperative treatment and follow-up for such patients.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eClinical data\u003c/h2\u003e \u003cp\u003eThe clinical data of patients who underwent unilateral nephrectomy due to renal tuberculosis in our hospital between 2015 and 2021 were collected. These data included sex, age, past history of tuberculosis, clinical manifestations, laboratory tests (erythrocyte sedimentation rate [ESR], T-cell spot test for tuberculosis infection [T-SPOT], antibodies against the 16 and 38 kDa mycobacterial antigens and lipoarabinomannan, polymerase chain reaction [PCR] identification of tuberculosis infection, acid-fast staining of tissue, assessment of deoxyribonucleic acid [DNA] in urine, routine urine analysis, and preoperative and postoperative routine blood measurements). Further information on anti-tuberculosis treatment, occurrence of bladder contracture, contralateral hydronephrosis, LUTS, tuberculosis recurrence, flank pain, and treatment status were followed up via phone calls. Then, the correlations between the parameter and complications were followed-up and analyzed by SPSS software. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eInclusion criteria: Patients who underwent unilateral nephrectomy due to renal tuberculosis at our hospital and were diagnosed with renal tuberculosis by postoperative pathology between 2015 and 2021.\u003c/p\u003e \u003cp\u003eExclusion criteria: Patients with incomplete records; patients with non-tuberculous diseases causing symptoms such as bladder contracture, contralateral hydronephrosis, LUTS, flank pain, and hematuria; patients using anticoagulant drugs needing discontinuation or already discontinued but not meeting the standard discontinuation time; patients with severe hematological diseases and cardiopulmonary insufficiency who could not tolerate surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS 22 software. Normally distributed continuous variables are described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and non-normal continuous numerical variables are described as \u0026ldquo;median (interquartile range)\u0026rdquo;. Non-parametric tests (Spearman correlation analysis or Fisher\u0026rsquo;s exact test) were employed for univariate analysis of the occurrence of bladder contracture, contralateral hydronephrosis, LUTS, and postoperative flank pain symptoms in relation to preoperative clinical manifestations, anti-tuberculosis treatment, tuberculosis history, and laboratory tests. When \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.2, the indicator was included in the logistic regression model for correlation analysis, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e146 patients were followed up, and data on anti-tuberculosis drug treatment were collected for 100 patients. The median duration of preoperative anti-tuberculosis treatment was 4 (2, 9) weeks, while that for postoperative treatment was 34 (26, 52) weeks. Among them, 12 patients received a two-drug anti-tuberculosis regimen, 18 received a three-drug regimen, and 70 received a four-drug regimen.\u003c/p\u003e \u003cp\u003eOf the 146 patients, three (2.05%) developed bladder contracture, with two patients diagnosed before surgery and one two years after surgery. Two patients diagnosed with bladder contracture before surgery returned to hospital for bladder enlargement after 6 months anti-tuberculosis treatment and recovered well after surgery. The new-onset bladder contracture patient had obvious LUTS and flank pain before surgery, combined with pulmonary and bladder tuberculosis. Subsequently, the patient underwent bladder enlargement surgery, and the symptoms were significant improvement. Due to the limited number of cases with bladder contracture, no correlation analysis was performed.\u003c/p\u003e \u003cp\u003eIn this study, nine (6.16%) patients showed postoperative contralateral hydronephrosis, with four cases diagnosed preoperatively and five postoperatively. Among the four patients diagnosed preoperatively, the contralateral hydronephrosis were significantly improved in two patients after nephrectomy, and no aggravation was observed in other two patients. All the five new-onset contralateral hydronephrosis patients had regular follow-up, showing normal renal function and no worsening of hydronephrosis. The results of regression analysis revealed that preoperative symptoms of tuberculosis toxicity significantly increased the risk of postoperative hydronephrosis (OR\u0026thinsp;=\u0026thinsp;11.619, 95% CI [1.948-509.159], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactor associated with new-onset contralateral hydronephrosis after operation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms of tuberculosis poisoning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.949-509.159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eOR, odds ratio; CI, confidence interval\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the patients followed up postoperatively, 17 (11.64%) had accompanying LUTS, with 11 cases occurring preoperatively and 6 cases developing postoperatively. Among the 11 patients with preoperative LUTS, three experienced recurrences after the LUTS disappearance, while preoperative LUTS continued after surgery in the remaining eight patients albeit with significantly reduced severity. Among the six patients who developed new-onset LUTS postoperatively, two patients had significant alleviation of the LUTS symptoms by further treatment. Patients with new-onset LUTS have significantly higher white blood cell and neutrophil counts compared to others, but preoperative globulin levels were opposite (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Regression analysis revealed that elevated preoperative white blood cell counts (OR\u0026thinsp;=\u0026thinsp;3.959, 95% CI [1.452\u0026ndash;10.794], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007) and globulin levels (OR\u0026thinsp;=\u0026thinsp;0.654, 95% CI [0.431\u0026ndash;0.992], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046) significantly influenced the risk of new-onset LUTS (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with new-onset LUTS after operation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative WBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.452\u0026ndash;10.794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Glb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.431\u0026ndash;0.992\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eLUTS, lower urinary tract symptoms; OR, odds ratio; CI, confidence interval; WBC, white blood cell; Glb, globulin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwo (1.37%) confirmed cases of recurrent pulmonary tuberculosis were identified. One patient showed a recurrence in one year after discontinuation of postoperative oral anti-tuberculosis medication, and the other patient experienced pulmonary tuberculosis recurrence in the fourth year postoperatively, both were cured after another year of medication. Since only two cases of tuberculosis recurred in the 146 follow-up patients, no correlation analysis of risk factors for recurrence was performed.\u003c/p\u003e \u003cp\u003e12 (8.22%) experienced postoperative flank pain among the 146, of which seven cases were new-onset and five were pre-existing. None of the 12 patients with flank pain received treatment. Subsequent regression analysis indicated that older age increased the risk of postoperative flank pain (OR\u0026thinsp;=\u0026thinsp;1.106, 95% CI [1.015\u0026ndash;1.206], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactor associated with new-onset flank pain after operation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.015\u0026ndash;1.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eOR, odds ratio; CI, confidence interval\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRenal tuberculosis cases are mostly secondary to pulmonary tuberculosis\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. As described previously, the \u003cem\u003eM. tuberculosis\u003c/em\u003e from kidney can continuously stimulate and damage other urinary organs. Firstly, the released mycobacterium invades ureters to induce local specific inflammatory response, the inflammatory scar heals but might accompanied with ureterostenosis which finally leads hydronephrosis and renal dysfunction\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, the mycobacterium attacks the bladder to induce mucosal congestion, edema, and tuberculous nodules formation; when the lesion involving the deeper muscle layer, the fibrosis and scar contraction in the bladder wall will occur while the bladder loses tension and capacity, which eventually leading bladder contracture. Moreover, the fibrosis and scar contraction can spread to the contra ureteral bladder opening site to contribute the stenosis or incomplete closure of contralateral ureteral orifice, which finally result contralateral hydronephrosis and even uremia. In addition, patients with renal tuberculosis can also develop to severe LUTS or suffered from tuberculosis recurrence even with timely and normative treatments. Thus, we must pay attention to the long-term complications (bladder contracture, contralateral hydronephrosis, severe LUTS, and tuberculosis recurrence) for individuals with renal tuberculosis.\u003c/p\u003e \u003cp\u003e \u003cem\u003eM. tuberculosis\u003c/em\u003e, carried by the urine, invades the bladder, leading to extensive fibrosis and cicatricial contraction of the bladder wall as the deep lesions heal. This results in the loss of bladder wall elasticity and a significant decrease in bladder capacity (less than 50 ml), known as tuberculous bladder contracture. The main symptoms include frequent urination, urgency, pain in the pubic area, and urinary incontinence\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Bladder enlargement surgery can significantly increase bladder capacity and alleviate LUTS in patients with tuberculous bladder contracture. However, for patients with bladder contracture accompanied by pain in the pubic area during urination, simple bladder enlargement may not be effective for relieving pain. This might be due to the compression of the bladder wall nerves by the proliferating scar tissue, necessitating the removal of most of the bladder tissue affected by contracture for symptom relief\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. In our study, three patients who underwent bladder enlargement surgery experienced a significant relief of LUTS, and in patients with concomitant contralateral hydronephrosis, renal function was preserved. This indicates the positive therapeutic effect of bladder enlargement surgery on tuberculous contracture bladder, effectively preventing secondary LUTS and damage to the contralateral kidney.\u003c/p\u003e \u003cp\u003eThe pathogenesis of contralateral hydronephrosis involves ureteral obstruction, urinary reflux, and high pressure in the bladder. For upper ureteral strictures, ureteropyeloplasty can be performed; mid-segment strictures are mainly treated by incision within the narrow segment. If obstruction persists, autologous kidney transplantation can be considered. Anti-reflux ureteral bladder reimplantation surgery has a significant therapeutic effect on patients with ureteral orifice strictures, incomplete closure, or lower ureteral strictures. Additionally, bladder enlargement surgery can effectively increase bladder capacity, reduce intravesical pressure, and treat vesicoureteral reflux and renal hydronephrosis. Our research results indicate a significant correlation between preoperative symptoms of tuberculous intoxication and postoperative contralateral renal hydronephrosis. For patients in this category, communicating the risks beforehand is advisable but excessive anxiety is unnecessary. If postoperative hydronephrosis does not worsen, no specific treatment is required.\u003c/p\u003e \u003cp\u003eAbout 46% of the patients with renal tuberculosis in this study presented with LUTS\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Regression analysis found a significant correlation between postoperative LUTS and elevated preoperative white blood cell counts as well as decreased globulin levels. Early LUTS is related to direct stimulation of the urinary tract by \u003cem\u003eM. tuberculosis\u003c/em\u003e, while late-stage complications such as bladder contraction and nonspecific urinary tract infections exacerbate LUTS symptoms. Further analysis revealed no significant correlation between postoperative LUTS and preoperative symptoms, suggesting that regardless of the severity of preoperative symptoms, patients with renal tuberculosis generally respond well to systematic, regular treatment. Even if residual or new-onset LUTS symptoms persist after surgery, most of these can be alleviated by further anti-tuberculosis therapy.\u003c/p\u003e \u003cp\u003eAnti-tuberculosis drugs are the first-line treatment for tuberculosis, and most patients with early-stage renal tuberculosis can be cured with anti-tuberculosis drugs, avoiding surgical intervention\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Studies have reported recurrence rates of 80% with single-drug anti-tuberculosis therapy, 25% with dual-drug therapy, and 10% with triple-drug therapy; thus, the most conservative approach is to initiate a quadruple-drug regimen, namely isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. However, if after 6\u0026ndash;9 months of drug therapy, the urine remains positive for tuberculosis bacilli or if there is severe renal parenchymal damage, surgical removal of the affected kidney should be considered, with at least two weeks of preoperative anti-tuberculosis treatment and postoperative continuation for at least 6 months\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Studies have found that appropriate prolongation of the course of anti-tuberculosis drugs can effectively reduce the recurrence rate of tuberculosis but carries the risk of the development of drug resistance\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Two patients in this study who experienced tuberculosis recurrence also had preoperative pulmonary tuberculosis lesions that recurred after surgery, suggesting a possible correlation between postoperative urinary tuberculosis recurrence and a history of pulmonary tuberculosis. Therefore, thorough follow-up chest CT is essential for patients with a history of pulmonary tuberculosis, and anti-tuberculosis treatment should be initiated promptly if signs of tuberculosis recurrence appear.\u003c/p\u003e \u003cp\u003eFlank pain is a common clinical manifestation of renal tuberculosis and a major reason for patients to seek medical attention\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. It is considered that postoperative flank pain is mainly caused by invasion of the kidney by \u003cem\u003eM. tuberculosis\u003c/em\u003e, secondary urinary system lesions (renal hydronephrosis), and surgery-related injuries. \u003cem\u003eM. tuberculosis\u003c/em\u003e infection in the kidney initially presents as atypical renal tuberculosis, with flank pain being the most common clinical manifestation. When \u003cem\u003eM. tuberculosis\u003c/em\u003e invasion causes bladder urine reflux and ureteral obstruction, leading to renal hydronephrosis, flank pain may occur. Flank pain may also occur with concurrent nonspecific upper urinary tract infections\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. During nephrectomy for renal tuberculosis, it is necessary to separate the surrounding tissues of the kidney. If adhesions are severe and the tissue structures are unclear, damage to the surrounding tissues is inevitable, which may lead to postoperative flank pain. The results of the regression analysis in this study showed that the older the patient, the higher the risk of postoperative flank pain.\u003c/p\u003e \u003cp\u003eThis study has several limitations. It was a single-center analysis of renal tuberculosis data. Retrospective studies are prone to selection bias, and the success rate of follow-up was low. There were few positive outcome events among follow-up cases; hence, it was unable to stratify the risk factors for the identified positive indicators. It is necessary to conduct prospective multicenter studies on the use of nephrectomy for renal tuberculosis and track postoperative complications, renal function, and tuberculosis recurrence.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePatients with renal tuberculosis who underwent nephrectomy combined with regular anti-tuberculosis treatment were found to have a lower incidence of postoperative complications, such as bladder contraction, contralateral renal hydronephrosis, LUTS, and tuberculosis recurrence. Preoperative symptoms of tuberculosis toxicity significantly increased the risk of the postoperative development of renal hydronephrosis, while elevated white blood cell counts and reduced globulin levels before surgery increased the risk of new-onset postoperative LUTS, and the older the patient, the higher the risk of postoperative flank pain.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was approved by the Ethics Committee of Affiliated hospital of Guizhou medical university. Informed consent was obtained from all patients, if patients are under 16, from a parent and/or legal guardian.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis manuscript was funded by National Nature Science Foundation of China (No. 82360295 and 82060276), the Doctor Start-up Fund of Affiliated Hospital of Guizhou Medical University (gyfybsky-2023-03), the Science and Technology Department of Guizhou Province (QianKeHeJiChu-ZK [2021] YiBan382), and the Science and Technology Foundation Project of Guizhou Provincial Health Commission (gzwkj2024-150). The funding agencies and donors had no role in any aspect of this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWS and WQ wrote the manuscript and collected the data, JKH, LT and TY collected the data and analysis, SF and JKH study design, study supervision and edited the manuscript, all authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eRecords and data pertaining to this study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKulchavenya, E., Kholtobin, D. \u0026amp; Shevchenko, S. Challenges in urogenital tuberculosis[J]. \u003cem\u003eWorld J. 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Urol.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e (3), 207\u0026ndash;217 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNovikov, B. I. et al. [Clinical and morphological parallels in the validation of surgical treatment of nephrotuberculosi][J]. \u003cem\u003eUrologiia\u003c/em\u003e, (6):47\u0026ndash;53. (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuneer, A. et al. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features[J]. \u003cem\u003eNat. Rev. Urol.\u003c/em\u003e \u003cb\u003e16\u003c/b\u003e (10), 573\u0026ndash;598 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePurves, J. T. \u0026amp; Hughes, F. J. Inflammasomes in the urinary tract: a disease-based review[J]. \u003cem\u003eAm. J. Physiol. Ren. Physiol.\u003c/em\u003e \u003cb\u003e311\u003c/b\u003e (4), F653\u0026ndash;F662 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZumla, A. \u0026amp; James, D. G. 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Res.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e (9), C1\u0026ndash;C5 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas, P., Ahuja, A. \u0026amp; Gupta, S. D. Incidence, etiopathogenesis and pathological aspects of genitourinary tuberculosis in India: A journey revisited[J]. \u003cem\u003eIndian J. Urol.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (3), 356\u0026ndash;361 (2008).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Renal tuberculosis, Nephrectomy, Complication, Prognosis","lastPublishedDoi":"10.21203/rs.3.rs-4886961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4886961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eResearches has proved that nephrectomy combine with anti-tuberculosis therapy were effective methods for renal tuberculosis, but whether it could also reduce the complications after one year later or longer has never been reported.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe clinical data, anti-tuberculosis strategy and the occurrence and management of renal tuberculosis related long-term complications (including bladder contracture, contralateral hydronephrosis, lower urinary tract symptoms [LUTS] and tuberculosis recurrence) were reviewed and analyzed. Meanwhile, the logistic regression analysis was used to explore the impactors of long-term complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 146 patients were successfully followed up. Among them, 3 cases developed bladder contracture after nephrectomy whose life quality was significantly improved after bladder augmentation. 9 patients showed contralateral hydronephrosis, with four cases were diagnosed preoperatively and five postoperatively. The preoperative symptoms of tuberculosis toxicity significantly increased the incidence of postoperative contralateral hydronephrosis. 17 patients suffered from severe LUTS, with 11 individuals occurred preoperatively and six developed postoperatively, and the elevated preoperative white blood cell counts and globulin level significantly influenced the new-onset LUTS risk. 2 patients experienced postoperative recurrence of pulmonary tuberculosis and cured by another regular anti tuberculosis treatment. 12 patients experienced postoperative flank pain, of which 7 cases were new-onset and five were pre-existing. The older age increased the risk of postoperative flank pain.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePreoperative symptoms of tuberculosis toxicity significantly increased the risk of the postoperative renal hydronephrosis, while elevated white blood cell counts and reduced globulin levels before surgery increased the risk of new-onset postoperative LUTS, and the older the patient, the higher the risk of postoperative flank pain.\u003c/p\u003e","manuscriptTitle":"Prognosis and outcome of renal tuberculosis after nephrectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-07 10:20:31","doi":"10.21203/rs.3.rs-4886961/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e0b655f5-4f19-498a-936d-027d5e343008","owner":[],"postedDate":"October 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":37988055,"name":"Health sciences/Diseases"},{"id":37988056,"name":"Health sciences/Medical research"},{"id":37988057,"name":"Health sciences/Signs and symptoms"},{"id":37988058,"name":"Health sciences/Urology"}],"tags":[],"updatedAt":"2025-09-15T23:08:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-07 10:20:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4886961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4886961","identity":"rs-4886961","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}