Bilharzial hydronephrosis: a clinicoradiological study

The epidemiology and chemotherapeutic approaches to the control of urinary schistosomiasis in school-age children (SAC): a systematic review

BACKGROUND

Human schistosomiases are acute and chronic infectious diseases of poverty. Currently, epidemiological data of urinary schistosomiasis (US) in school-age children (SAC) and adults are often reported together making it difficult to ascertain the true status of the disease. Based on this premise, we set out to carry out this review.

METHOD

To achieve this aim, we carried out a computer-aided search of PubMed, Web of Science, Science Direct, African Journals OnLine (AJOL) and the database of World Health Organization. However, the information obtained from these sources was supplemented with additional literatures from Mendeley, Research Gate, and Google.

RESULTS

The search yielded 183 literatures of which 93 full text research, review and online articles were deemed fit for inclusion. Our key findings showed that: (1) of all World Health Organization (WHO) Regions, Africa is the most endemic zone for US, with Kenya and Senegal recording the highest prevalence and mean intensity respectively; (2) SAC within the range of 5-16 years contribute most significantly to the transmission cycle of US globally; (3) gender is a factor to watch out for, with male often recording the highest prevalence and intensity of infection; (4) contact with open, potentially infested water sources contribute significantly to transmission; (5) parental factors (occupation and education status) predispose SAC to US; (6) economic vis a vis ecological factors play a key role in infection transmission; and (7) in the last decade, a treatment coverage of 45% was never achieved globally for SAC or non-SAC treatment category for urinary schistosomiasis.

CONCLUSION

In view of the WHO strategic plan to eliminate schistosomiasis by 2020 and the findings from this review, it is obvious that this goal, in the face of realities, might not be achieved. It is imperative that annual control programmes be scaled up marginally, particularly in the African region of WHO. While US-based researches should be sponsored at the grass-root level to unveil hidden endemic foci, adequate facilities for Water, Sanitation, and Hygiene (WASH) should be put in place in all schools globally.

Urinary schistosomiasis: urographic features and significance of drooping kidney appearance

The purpose of the study was to analyse the urographic features of schistosomiasis and to see the theurapeutic implications of "drooping kidney" appearance for the urologists. Over a period of one year, 1636 patients undergoing intravenous urography (IVU) were analysed to look for urographic features of schistosomiasis. A total of 136 patients revealed the classical urographic feature such as ureteric strictures, vesical and ureteric calcification and calculi etc. 131 of these patients were of Egyptian origin. In addition to above mentioned classical features, 8 patients (6%) with urinary schistosomiasis revealed "drooping kidney" appearance. In the remaining patients with no evidence of clinical or urographic features of urinary schistosomiasis, only one patient (0.07%) showed similar bilateral appearance. Renogram in 6 to 8 patients with "drooping kidney" revealed poorer renal function on the affected side. Ureteroscopy (URS) revealed more florid ureteritis cystica on the side with "drooping kidney" in 6 out of 8 patients compared with the normal side. URS also confirmed the presence of a kink and more difficulty with insertion of J stents. "Drooping kidney" a new urographic feature of urinary schistosomiasis may have theurapeutic implications for the urologists and should be looked for on the I.V.U. of patients with urinary schistosomiasis.

Long-term results of endourologic and percutaneous management of ureteral strictures in bilharzial patients

We have managed 164 bilharzial ureteral strictures endourologically. The site was at the pelviureteral junction in 4, at the pelvic inlet in 22, juxtavesical in 78, and intramural in 60. These lesions were categorized according to the line of management. Type I or simple stricture, present in 116 cases, was managed by retrograde bougie dilation to 16F. Dilation was preceded by transurethral ureterotomy in 54 cases. Type II or difficult strictures (24 cases) were managed by percutaneous antegrade dilation. Type III or complicated strictures (24 cases) were managed by antegrade placement of a guidewire down to the bladder followed by transureteral meatotomy and bougie dilation in one sitting under C-arm fluoroscopy. Three types of stenting procedures and diversion were used according to the length of the stricture and the quality of renal function. After 6 to 72 months, an overall successful clinical outcome with decompression of the upper urinary system and improved drainage pattern was achieved in 87.8% (144 cases) v only 50% in patients with strictures longer than 2 cm. Postoperative reflux was seen in 21 cases (18%) of Type I strictures compared with 4 (17%) of Type II and 13 (54%) of Type III strictures. We concluded that this scheme of combined endourologic management for ureteral strictures is safe, simple, and less traumatic and produces excellent results. It should be the approach of choice, although it needs special equipment and operator experience. Open surgery should be restricted to the lesions that prove undilatable on both retrograde and antegrade procedures.

Specific investigations in chronic urinary bilharziasis

Seventy-two patients with histologically confirmed chronic urinary bilharziasis were studied for the reliability of some specific investigative tools in diagnosing this disease, namely urinalysis, serology, urography, and cystoscopy. Of the 72 patients 36 (50%) had hematuria and only 3 (4%) had ova of Schistosoma haematobium on urinalysis. Sixty-two patients (86%) had features of bilharziasis on intravenous urography (IVU). Of the remaining 10 patients with negative urography 6 underwent serology and all had positive results. Of the total patients 52 underwent serology and 49 had significant bilharzial antibody titer (94.2%). At cystoscopy all patients (100%) had features of bilharziasis. It is concluded that the most reliable diagnostic tools in chronic urinary bilharziasis are cystoscopy, serology, and to a lesser extent urography. Unlike early bilharziasis, chronic bilharziasis can be missed if total reliance is placed on urinalysis for screening a population at risk.

Bilharzial vesicoureteric reflux and bladder neck stenosis: fact or fiction?

A group of 47 patients with histologically confirmed chronic urinary bilharziasis underwent micturating cystourethrography to look for vesicoureteric reflux (VUR) and bladder neck stenosis (BNS); 13 patients were found to have VUR of varying grades (8 unilateral and 5 bilateral). None had evidence of BNS. Urinary tract infection (UTI), loin pain, hydroureter and renal failure were compared in patients with and without VUR. Of the 13 patients with reflux, 3 had UTI, loin pain was present in 8, 11 had an ipsilateral hydroureter and 2 presented with renal failure. In the 34 patients without reflux, 8 had UTI, loin pain was present in 22, 30 had hydroureter and 3 presented with renal failure. It was concluded that the incidence of UTI, loin pain, hydroureter and renal deterioration associated with bilharzial VUR was not significantly different from that found in bilharzial patients without VUR. Thus the clinical significance and the need for surgical correction of isolated VUR in bilharziasis are questionable.

99mTc DTPA diuretic renography in the evaluation of surgery in chronic schistosomal and non-schistosomal obstructive uropathy

The selection of patients with chronic obstructive uropathy for surgery is difficult because of problems in identifying true obstruction in a grossly dilated urinary tract. This is especially so in schistosomal (bilharzial) obstructive uropathy. A prospective study of 90 patients (68 with chronic schistosomal and 22 with non-bilharzial obstructive uropathy) was carried out. All patients underwent pre-operative and post-operative radionuclide 99mTc DTPA diuretic renography (RDR). The aims were to assess the value of RDR in the pre- and post-operative management of these patients and whether it could predict the outcome of surgery. Distinctive renogram patterns were identified in patients who required surgical management. These were found useful in monitoring the results and in predicting the outcome of surgery.

Evaluation of surgical procedures for bilharzial strictures of the ureter

A series of 35 patients, with unilateral hydronephrosis complicating bilharzial stricture of either the upper or the middle third of the ureter, was divided into 2 groups. Group A, comprising 21 patients, was treated by resection anastomosis. Group B, comprising 14 patients, was treated by other reparative procedures without resection of the stricture. The results of the surgical correction, assessed clinically and radiologically, showed that significantly better results were achieved with resection anastomosis than with the other procedures.

The continuing challenge of bilharzial ureteric stricture

The commonest urologic complication in 176 cases of chronic urinary bilharziasis was ureteric stricture (87 ureters in 55 patients), with the lower third of the ureter affected in 87% of the cases. Other complications included squamous-cell carcinoma of the bladder, urinary calculi and bladder calcification. Intravenous urography and cystoscopy were the most useful diagnostic methods in 76% of the cases. Post-micturition erect urography and frusemide intravenous urography gave great help in distinguishing between true mechanical and non-mechanical ureteric obstruction in patients with dilated pelvicalyceal system on conventional urograms. Only 17 of 68 dilated ureters were truly obstructed and required excision and ureteroneocystostomy. Postoperative vesicoureteric reflux developed in four of these cases. No deterioration of renal function occurred in the remaining, conservatively treated patients.

Balloon dilatation of bilharzial ureteric strictures

Balloon dilatation was performed in nine patients with bilharzial ureteric strictures. In six patients a percutaneous, antegrade approach was used and in three a balloon catheter was introduced into the ureter via a cystoscope. In another four patients, negotiation of the strictured area with a guide wire failed. In all dilated patients, symptomatic and urographic relief of the obstruction was obtained during follow-up periods of 3 to 38 months (mean 19). One patient was re-dilated after 24 months and has remained symptom-free for a further 18 months. Balloon dilatation seems to be a promising method of treating this condition.

Long-term ureterostomy with suprapubic intravesical drainage used to bypass severe schistosomal obstructive uropathy--preliminary report

Severe obstructive uropathy due to infection with S. hematobium often requires reconstructive surgery. Recent reports, have emphasized that many lesions will disappear after specific chemotherapy given the necessary time. Time for effective chemotherapy may be impossible to allow in severe obstruction. The necessary surgical procedures range from ureteric dilatation to ureteric resection with ileal loop replacement. We suggest that temporary long-term bypass of the diseased ureter using silastic tubes may offer an alternative to resection in many cases while the effect of specific chemotherapy is awaited. One case is described in which ureterostomy with suprapubic intravesical drainage adequately bypassed the diseased and obstructed lower two thirds of the left ureter. In the following six months specific chemotherapy had encouraging effects on the bypassed area.

Surgical Intervention in Dilated Bilharzial Ureters

Surgery has often been performed for presumed obstruction in dilated bilharzial ureters but with unrewarding results. In this report 55 non-refluxing dilated bilharzial ureters were studied. Perfusion pressure flow studies and diuresis renography with washout technique were used to diagnose the presence or absence of obstruction. Surgery was performed only when obstruction was proven by PPFS and diuresis renography; thus patients were spared an operation when the obstruction could not be confirmed. Antegrade ureteropyelographic findings, evaluation of peristalsis and transport of urine were the basis for the selection of operation performed. The various surgical procedures are discussed.