Cystectomy and Urinary Diversion for Non-malignant Bladder
Disorders: Our Early Experience
Cathbert Mudimu MBCHB, MMED UROLOGY
Urological Surgery
Parirenyatwa Group of Hospitals
Email: cathberm@gmail.com
Daud Athanasius Dube, FRCS
CONSULTANT UROLOGIST AND SENIOR LECTURER FMHS-UZ
Parirenyatwa Group of Hospitals
Email:
daud.dube@gmail.com
Corresponding Author
Cathbert Mudimu
Department of Surgery, FMHS-UZ, PO BOX A128, Avondale, Harare Zimbabwe
Phone +263773461972
e-mail:
cathbertm@gmail.com
50 key word clinical message
Chronic urinary schistosomiasis affects mainly the bladder and ureters.
Early recognition and correction of obstructive uropathy during
follow-up is fundamental in order to preserve renal function in patients
with schistosomal obstructive uropathy. Simple cystectomy and orthotopic
neobladder is a viable treatment option in patients with a severely
contracted bladder and good renal function.
INTRODUCTION
Radical cystectomy and urinary diversion for bladder cancer dates back
to the 1920s.1 It was only until the latter part of
the 20th century that cystectomy became an acceptable
surgical option for patients with benign bladder
disorders2. Data regarding perioperative morbidity and
long term follow-up after simple or partial cystectomy is derived mainly
from small case series and case reports. We report our experience with a
patient whom we closely followed-up and managed for chronic progressive
schistosomal obstructive uropathy. Emphasis is made on adequate
preoperative assessment, counselling, and functional outcomes and on the
postoperative long-term follow-up of patients undergoing cystectomy and
urinary diversion.
THE CASE
A 55-year-old male was referred by his General practitioner for lower
urinary tract symptoms. He had a chronic history of suprapubic pain,
urinary frequency and pain after sexual intercourse. His symptoms had
failed to improve on several courses of antibiotics. He had a positive
history of having been treated for schistosomiasis in childhood. He also
admitted to treatment of a sexually transmitted infection in the past.
His examination findings were unremarkable. USS showed a left
hydroureteronephrosis, normal bladder capacity and an insignificant PVR.
A baseline DTPA renogram showed split renal function of 17% in the left
kidney. He underwent an urethrocystoscopy and bladder biopsy and left
double-J stenting. Noted on cystoscopy were extensive sandy patchy
appearances and areas with erythematous lesions. During follow-up, his
split renal function in the left kidney did not improve despite the
relief of obstruction. He also continued to have recurrence of his LUTS
and left flank pain. In view of this a left simple nephrectomy was done
for a silent symptomatic kidney. He was under surveillance every 6
months. His lower urinary tract symptoms continued to recur. After 10
years of follow-up, he had evidence of a severely contracted bladder and
right hydroureteronephrosis. His DTPA renal scans showed deteriorating
function of the solitary right kidney. A simple cystectomy for extensive
bladder schistosomiasis, noncompliant bladder (contracted bladder) and
deteriorating renal function was done. A Hartmann W pouch was fashioned
from the distal ileum and an ureteroneocystoplasty was accomplished. The
postoperative recovery was uneventful. The patient required intermittent
catheterisation and regular bladder washout in the early months
postoperatively.
The patient is now more than 15 years post urinary diversion. The
quality of life according to the patient is satisfactory. He no longer
has bothersome LUTS. His recent USS showed compensatory hypertrophy of
the right kidney with no evidence of hydronephrosis nor hydroureter. The
bladder volume improved remarkably over the years from 200 cm3 to a
maximum of above 500cm3. The post void urine residual has remained
insignificant over the years. His electrolytes are within normal limits
and the estimated GFR was 80ml/min.
TABLE 1: SPLIT RENAL FUNCTION FROM FIRST PRESENATION TO NEPHRECTOMY