Incidental encounter of intraperitoneal tuberculosis during renal surgeries: A surgeon's dilemma

Tuberculosis is a major healthcare burden in India, which accounts for the maximum number of cases worldwide. Due to its non-specific features, peritoneal tuberculosis has been dubbed as the great mimicker of various other abdominal pathologies. This case series highlights the importance of incidental intra operative detection of peritoneal tuberculosis in cases being operated for renal pathologies. Diagnostic and therapeutic dilemma is bound to occur when surgeon is faced with such an unexpected finding. Incidental peritoneal tuberculosis was defined as peritoneal tubercular lesions (ascites or tubercles) detected intraoperatively in patients being operated for non-tuberculosis related indications and no prior preoperative suspicion of abdominal tuberculosis. We here review 3 cases with different renal pathologies and no prior history or exposure to tuberculosis in which intraperitoneal tuberculosis was encountered incidentally at the time of surgery. Case 1 was a suspected case of right renal cell carcinoma and underwent right robotic nephron sparing surgery. Case 2 underwent robotic assisted lap simple nephrectomy for a right nonfunctioning kidney due to obstructive ureteric calculus. Case 3 was a suspected case of left upper tract urothelial carcinoma who underwent robotic nephroureterectomy with bladder cuff excision. In all 3 cases, on encountering the peritoneal lesions, an intraoperative decision to continue with the proposed surgery was made after frozen section biopsies from the multiple peritoneal and omental deposits revealed no malignant cells. Histopathology of these lesions in all 3 cases revealed caseating granulomas consistent with a diagnosis of disseminated peritoneal tuberculosis. None of the resected specimen had features suggestive of tuberculosis. ATT was started and on follow up the patients are doing well. Peritoneal tuberculosis although uncommon is not a rare presentation of active tuberculosis. Surgeons on encountering such lesions during non-related surgeries should always have a high suspicion of tuberculosis. Despite the existing literature favoring abandoning the procedure in such situations, we successfully completed the proposed surgeries.