上泌尿道惡性腫瘤病患接受部分腎切除手術及卡介苗灌注導致開放性肺結核
莊梓昱1、邱逸淳1,2、程威銘1,2、洪士奇1、邱文祥1,2
1台北市立聯合醫院忠孝院區外科部 泌尿科；2國立陽明大學醫學院泌尿學科
Active tuberculosis infection after upper tract urothelial carcinoma patient treated by partial nephrectomy with adjuvant bacillus Calmette-Guérin instillation therapy
Tzu-Yu Chuang1、Yi-Chun Chiu1,2、Wei-Ming Cheng1,2、Shyh-Chyi Hung1、Allen W. Chiu1,2
1Division of Urology, Department of Surgery, ZhongXiao Branch, Taipei City Hospital, Taipei, Taiwan
2Department of Urology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
Introduction
The incidence of upper tract urothelial carcinoma (UTUC) is relatively high in Taiwan. Radical nephroureterectomy with bladder cuff excision is the gold-standard management of UTUC, although an organ-sparing approach may be beneficial in selected patients. Herein, we reported a patient with high-grade renal pelvis urothelial carcinoma infected with tuberculosis after robotic partial nephrectomy with adjuvant bacillus Calmette-Guérin (BCG) instillation.
Case Presentation
A 80-year-old female patient has a history of muscle-invasive bladder urothelial carcinoma treated by radical transurethral resection of bladder tumor and full courses of intravesical BCG instillation seven years ago. She presented to our department with hematuria. Urine cytology reported suspicious for malignancy. Enhanced computed tomography was arranged and revealed a 1.8cm irregular filling defects at lower infundibulum of left kidney. (Figure 1) Twice retrograde ureteropyeloscopy was performed with flexible instruments, and the lesion is subsequently ablated using Ho:YAG laser. After endoscopic management, progressly enlargement of tumor was still seen by imaging, so surgical intervention was considered. The renogram of left and right kidney were 92 ml/min and 136 ml/min, respectively. Therefore, she underwent left robotic partial nephrectomy, and received 1st dosage of upper tract BCG instillation 3 weeks later.
She presented with low-grade fever and fatigue 2 weeks later, and computed tomography reported a 17cm urinoma embedded in lower pole of left kidney with peripheral fat stranding. (Figure 2) Immediate percutaneous drainage and antibiotics were suggested, and urine specimen from pigtail were positive for tuberculosis by both acid-fast stain and polymerase chain reaction. Sputum acid-fast stained smears also reported positive in one of three specimens. Isoniazid, rifampicin and ethambutol were prescribed orally thereafter. Later, she was discharged with stable conditions.
Conclusions
Despite the extensive use of intravesical BCG instillations, complications of BCG infection have been reported with an incidence of 10–15%. Also, physicians should be aware of the possibility of active tuberculosis infection and life-threatening adverse events.