|Year : 2003 | Volume
| Issue : 1 | Page : 71-72
Tubercular autocystectomy with vesicocolic fistula - a case report
Hemendra N Shah, Anjali A Bokil, Percy Jal Chibber
Department of Urology, Sir JJ Hospital, Mumbai, India
Percy Jal Chibber
Department of Urology, Sir JJ Hospital, Byculla, Mumbai - 400 008
Source of Support: None, Conflict of Interest: None
Keywords: Genitourinary tuberculosis, cystocolic, fistulae.
|How to cite this article:|
Shah HN, Bokil AA, Chibber PJ. Tubercular autocystectomy with vesicocolic fistula - a case report. Indian J Urol 2003;20:71-2
| Case Report|| |
A 52-year-old male, previously diagnosed as a case of abdominal Kochs, presented with acute retention of urine. As a urethral catheter could not be passed, a suprapubic catheterization was done. He had a serum creatinine of 2.4mg/dL and an ultrasound showed bilateral gross hydroureteronephrosis and a thick bladder wall. The patient later had an internal urethrotomy for a discrete bulbar stricture. He was asymptomatic for 6 months postoperatively, after which he presented with acute renal failure and symptoms of passing urine perrectum. Urethral catheterization failed.
Ultrasound showed bilateral pyonephrosis with dilated ureters. The urinary bladder could not be demonstrated. Bilaternal percutaneous nephrostomies (PCN) were performed. Ascending urethrogram revealed an irregular dilated posterior urethra opening into a very small bladder from which there was prompt reflux up the left ureter and leak of contrast into the sigmoid colon [Figure - 1]. On left nephrostogram a vesico-colic fistula was demonstrated between the sigmoid colon and the bladder. Right nephrostomy was draining pus approximately 50cc/day. Panendoscopy revealed normal anterior urethra, but the bladder could not be identified and irrigating fluid filled the rectum easily. His serum creatinine stabilized at 1.6mg/dL after bilateral nephrostomy drainage. CT scan of abdomen and pelvis showed right hydronephrotic kidney with the PCN tube insitu. There was no excretion of contrast on the right side while the left side was normal. The bladder could not be identified in the pelvis. His colonoscopy was normal. On exploration no bladder tissue was identified. The posterior urethra opened into a small cavity, which had a fistulous communication with sigmoid colon. A right nephroureterectomy was done and left ureter anastomosed into an ileal conduit. The fistulous tract was excised and the sigmoid colon was closed primarily with a proximal transverse loop colostomy. Histopathological examination of the excised fistulous tract showed fibrosis with typical tuberculous granuloma. He received anti Koch's treatment and the colostomy was closed after 3 months. Patient is on regular follow-up for the last 3 years and has a stable renal function with a serum creatinine of 1.4 mg/dL and a healthy urinary stoma.
| Comments|| |
This case represents a rare variety of genitourinary Koch's where the patient developed total destruction of bladder over a period of 7 months to the extent that intraoperatively it was completely replaced by dense fibrous tissue. This occurred after starting medical therapy for abdominal tuberculosis. There was spontaneous vesicocolic fistula with sigmoid colon.
Tuberculous autonephrectomy is a well described entity where there is complete destruction of the kidney; usually silent and asymptomaitc. Auto-prostatectomy has been described in literature; however this entity is extremely rare. Thimble bladder is commonly seen in genitourinary tuberculosis, especially after antitubercular treatment has been started and frequently requires surgical treatment, either augmentation cystoplasty or urinary diversion. However to our knowledge there has been no reported case of complete destruction of the bladder; for which we suggest the term tuberculous autocystectomy.
Psihrams reported a case of primary genitourinary tuberculosis associated with severe progressive scarring and destruction of left kidney with contracted bladder, persistent vesicoureteral reflux and bulbar urethral stricture where scarring started after initiation of medical therapy.  A close supervision was advised after initiation of therapy for genitourinary tuberculosis. Pereiva-Arias et al described a case of advanced genitourinary tuberculosis and recommended early diagnosis and treatment in order to avoid the irreversible sequelae. 
| References|| |
|1.||Psihrams KE, Donahoe PK. Primary genitourinary tuberculosis - rapid progression and tissue destruction during treatment. J Urol 1986; 135(5): 1033. |
|2.||Pereira-Arias TG, Gallego Sanchez JA, Larvinage-Simon J, PrietoUgidos-N, Gonzalez-Ibarluzea-J, Bernuy Malfaz-C. Advanced tubercular disease of urogenital tract. Arch Esp Urol 1997; 50(4): 396. |
[Figure - 1]