Even in the era of modern anti-TB drugs, nephrectomy is still an essential procedure. It was recommended to perform early nephrectomy for patients with major renal lesion with or without bladder involvement, gross hydronephrosis and for those who have glomerular filtration rate (GFR) of <20 ml/min/m². Lower ureteral strictures and renal units with GFR of >20 ml/min/m² are favourable factors and salvage procedures are successful in these cases. It is likely that nephrectomy removes a large focus of disease and possibly dormant bacteria. With continuance of chemotherapy, this further helps in improved patient outcome (Viswaroop et al. 2006).

The surgical exploration should be done on all patients with non-functioning tuberculous kidneys to, (1) salvage kidneys before they are damaged totally by the obstructive lesions, (2) remove a potential source of infection with viable organisms and (3) shorten convalescence. Wong and Lau (1980) in 89.3 % of their UGTB patients have diagnosed complicated KTB 4th stage and performed them nephrectomy. In 10.7 % a reconstructive operation was possible with gratifying results (Wong and Lau 1980).

In a study of Fischer and Flamm (1990) of the 72 patients with urinary tuberculosis, 21 received exclusively conservative treatment, while 16 underwent conservative surgery and the remaining 35, ablational surgery. The high nephrectomy and overall operation rate was explained by the high percentage of advanced state of disease and a large number of patients referred to authors for nephrectomy following long-term conservative treatment. A retrospective justification for this procedure is found in the fact that 52 % of the surgical specimens showed florid tuberculosis, though the patients had been receiving standardized chemotherapy for an average of 9 months (Fischer and Flamm 1990).

Among 167 new-revealed UGTB patients 70 % were cured by chemotherapy, and surgery was indicated for the rest 30 %; as a whole 85.1 % recovered (Nguyen Phuc Cam Hoang et al. 1994). Other authors were not so optimistic. In their study 51 % of UGTB patients underwent surgery and in 73 % it was nephrectomy. Relatively in-time diagnostic allowed performing organ-saving operations to 9.4 % of patients only (Batyrov et al. 2004).

The organ-removing operations were performed in 73 % of UGTB patients (Batyrov et al. 2004). It was found that such eradicative techniques as nephrectomy and nephruretherectomy still prevail. Early drainage of the kidney for its decompression allows preservation of the kidney and following reconstructive surgery in 70.6 % of cases. The number of early and later complications considerably decreased (Zuban’ et al. 2008).

Hemal et al. (2000) compared results of retroperitoneoscopic nephrectomy with open surgery for TB nonfunctioning kidneys. They performed retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys to nine patients, and to another nine patients – open nephrectomy. Retroperitoneoscopic nephrectomy was successful in seven of the nine patients. Although two of the patients required conversion to open surgery, the remaining seven successfully underwent retroperitoneoscopic nephrectomy after modifying the technique. The authors concluded that TB has been considered a contraindication to retroperitoneoscopic nephrectomy due to a high conversion rate. However, they believe that their modified technique of retroperitoneoscopic nephrectomy is a viable option for managing TB nonfunctioning kidneys (Hemal et al. 2000).

Lee et al. (2002) performed laparoscopic nephrectomy successfully on 30 patients with KTB as well as on 44 patients without TB (control group). The two groups showed comparable perioperative and postoperative parameters, except for mean operative time, which, at 244 min for the tuberculosis group, was significantly greater than the 216 min for the control group (P < 0.05). No significant intraoperative or postoperative complications were observed in either group.

The results of this study indicate that laparoscopic nephrectomy for renal tuberculosis is a safe, effective, and less invasive treatment modality. Therefore Lee et al. (2002) suggested that the renal tuberculous nonfunctioning kidney should be approached initially using the laparoscopic approach.

Gupta et al. (1997) described a case of KTB 4th stage with a nonfunctioning kidney in which laparoscopic nephrectomy was attempted. The kidney was very difficult to mobilize due to dense perinephric adhesions (that is common for KTB 4th stage) and subsequently the procedure was converted to an open nephrectomy. The authors think KTB 4th stage is a relative contraindication to laparoscopic approach as its dissection is difficult and fraught with potential complications such as leakage of caseous material into the peritoneal cavity and systemic dissemination of the disease (Gupta et al. 1997).

Suárez-Grau et al. (2012) described their experience of laparoscopic surgery of an enterovesical fistula of tuberculous origin (terminal ileum and sigmoid colon).

Due often to co-morbidity of KTB and stone disease, in a patient diagnosed with ureterolithiasis, a thorough history and physical examination, with specific attention to HIV and tuberculosis predisposing factors, should be carried out and preoperative screening tests considering the possibility of urinary tuberculosis are required. Finally, if urinary tuberculosis is detected, extracorporeal shock-wave lithotripsy must be postponed until after appropriate treatment of tuberculosis (Tourchi et al. 2014).

I would like to present a case of co-morbidity of KTB 4th stage, bladder TB 4th stage as well as horny-like staghorn kidney stone. A female patient, 54 years of age, survived treatment and managed to be a typical patient with urolithiasis and chronic pyelonephritis for 10 years, and her urograms (Fig. 6.1) were interpreted as stone disease. Secondary to stone recurrent pyelonephritis was diagnosed with severe dysuria, pyuria, growth of Enterobacter spp10⁷ CFU/ml in urine, first sensitive to all antibiotics. The patient was treated with fluoroquinolones and amicacin with a very short “cold” period with fast relapse of the disease. Lithotripsy was scheduled, but concerning IVU picture KTB was suspected, but bacteriology didn’t reveal Mtb. It was not surprising, as she received in total 34 courses of antibiotics – mostly non-optimal antibiotics. Due to resistance to the therapy, the patient was admitted into the Urogenital Clinic of Novosibirsk Research TB Institute, and complex examination confirmed UGTB by clinic and laboratory tests; Mtb was found once by PCR.

The patient had bladder volume 40 ml with day frequency of urination 30–35, and nocturia 10–12 – but without incontinence.

The anti-TB chemotherapy was started, and in 2 months nephruretercystectomy on the right was performed with following enteroplastic (operation material is shown in Fig. 6.2). After surgery ChT was continued for 10 months with good efficiency. Follow up is 3 years, the patient retains wellbeing, dysuria and pyuria are absent, and function of urinary reservoir is satisfied.

It was the good fortune of our patient that extracorporeal shock-wave lithotripsy was not made before anti-TB ChT as haematogenous dissemination of undiagnosed urinary tuberculosis after performing extracorporeal shock-wave lithotripsy is high probable (Tourchi et al. 2014).

Urinary tract TB is a complication of kidney TB which requires reconstructive surgery – if it is not done in time, results of the complex therapy are poor.