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