DISCUSSION

Chronic urinary schistosomiasis is characterised by fibrosis in the distal ureters and bladder wall. Fibrosis is a result of immune reaction to egg deposition in the wall of the bladder and ureters. The resulting lesions are ureteric strictures in the pelvic part of the ureter leading to obstructive uropathy. In the bladder this may result in progressive ischaemia and muscle degeneration ultimately causing a non-compliant bladder. The presented patient had initially left ureteric obstructive uropathy and eventually developed a non-compliant bladder.

In a severely contracted bladder (i.e. bladder volume less than 100 cm3), augmentation cystoplasty is indicated^3,4. Simple cystectomy with urinary diversion for a contracted bladder secondary to chronic schistosomiasis has been described in the literature by Ghoneim et al⁴. Continent or incontinent forms of diversion are chosen depending on the patient’s underlying pathology and its method of treatment. As much as offering a functional benefit, orthotopic urinary diversion also offers psychological benefits for the patient⁵. Decision for orthotopic neobladder was based on the patient’s underlying disease and its form of treatment. Our patient was young, well-motivated, had good renal function and was compliant to treatment follow-up. Adequate pre-operative assessment, investigations and patient preparation were carried out. With proper pre-operative counselling and patient preparation, patient satisfaction is usually achieved in most patients regardless of the type of diversion employed^5,6.

The aims of urinary diversion in our patient can be summarized as follows: preservation of the upper urinary tract, achievement of urinary continence, adequate reservoir emptying and avoidance of urinary tract infections and other complications. The neobladder initially had low reservoir volume and high post void residual. Episodes of cystitis were encountered and managed with antibiotics after urine cultures. They had to initially undergo clean intermittent catheterization. Endoscopy was done every six months. The post void residual significantly dropped over time and now the patient can completely void as evidence by the latest ultrasound scan results. The creatinine and glomerular filtration rates improved remarkably after urinary diversion and remains relatively constant more than 10 years after the procedure was done.

Another important functional outcome in neobladder patients is that of continence. The age of the patient and preservation of autonomic innervation during surgery are key determinants of urinary continence. Overall daytime continence in large series is achieved in about 95% of patients whilst 66 to 93% will achieve night time continence at one year follow up^6–8. Continence is more likely achieved with age less than 50 years as compared with age greater than 70 years⁶. Our patient was less than 50 years old at the time of urinary diversion. Urinary continence has been achieved in our patient; both day and night time continence.

Urinary retention also occurred in our patient especially early on in the first few months following surgery. This was successfully managed with clean intermittent catheterization; follow up endoscopy and ultrasound scan and early treatment of urinary tract infections. Other complications known to occur in neobladder patients and may cause urinary retention are urethral anastomotic stricture, ileal valve and subtotal resection of the prostate. None of these were noted on follow up endoscopy in our patient.

The terminal ileum remains the preferred bowel segment in orthotopic urinary diversion. It is associated with less metabolic consequences and dysentery, easier surgical technique, better nocturnal continence rate and a better functional protection of the upper urinary tract. The extent of metabolic problems in neobladder patients decreases over time⁹. It is thus prudent in the early postoperatively period to adequately hydrate the patient and monitor acid-base and electrolyte balance.

Compromised sexual function is a cause for concern following cystectomy and continent urinary diversion. Just like continence, nerve sparing surgery and age strongly correlates with sexual function after surgery. In nerve sparing cystectomy, 62% of men less than 50 years achieved sexual function compared to only 20% of men aged 70 to 79 years⁶. Our patient was young and had reported satisfactory sexual function on the IIEF score.

CONCLUSION

Continent urinary diversion yields excellent functional outcomes in carefully selected patients. It is thus important to know the type of continent urinary diversion suitable for each patient. Pre-operative evaluation and patient education are prudent if the goals of diversion are to be achieved. Orthotopic bladder substitution has good functional outcomes and also improves quality of life of the patient.