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 indicated3,4. 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
employed5,6.
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 up6–8. 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.