Bilharzial Hydronephrosis: A Clinicoradiological Study

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THE

Vol. 126, August Printed in U.S.A.

JOURNAL OF UROLOGY

Copyright© 1981 by The Williams & Wilkins Co.

BILHARZIAL HYDRONEPHROSIS: A CLINICORADIOLOGICAL STUDY B. C. UMERAH From the Department of Radiation Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria

ABSTRACT

I have studied 68 patients with hydronephrosis. Except when complicated by infection, calculosis, cancer and severe strictures, function at excretory urography was relatively good even in advanced cases of hydronephrosis. In Zambia, Central Africa the intensity of infection and the disordered ureteral motility are the most important factors in the pathogenesis of bilharzia! hydronephrosis. In other countries strictures, calculosis, ureteroceles, vesicoureteral reflux and bladder cancer apparently are more significant in these cases. Since reimplantation of the ureters usually fails because of fibrosis conservative treatment is advocated with periodic dilation of troublesome stricture(s). This is especially true since supra-infection is rare even after repeated surgical procedures. The importance of geographical variations of the disease and the relevance to clinical management are stressed. Cystoscopic findings were available in 21 patients. In all, schistosomial sandy patches were found. Granulomas were found in 3 patients and carcinoma in 1. Efflux was not in gushes as found in the normal examination but was either a slow steady or intermittent dribble into a static pool of urine. 2• 3 Ureteral catheterization was difficult at the ureteral orifices in a significant number of the cases. In 29 patients periodic surgical instrumentation was done during a IO-year interval, especially cystoscopy, ureteral catheterization and dilation of strictures. Obstructive factors in bilharzial hydronephrosis include disordered ureteral peristalsis, associated calculi, vesicoureteral reflux, bilharzial ureteral strictures, outflow obstruction from chronic bilharzial prostatitis, associated ureteroceles and associated squamous carcinoma of the bladder.

Schistosomiasis is rife, affecting >200 million people in the world. Lesions in the urinary tract are varied, frequently florid and show marked geographical variations. Hydronephrosis is a serious common sequela. Obstructive changes were found in as many as 25 per cent of patients with urinary schistosomiasis in Saudi Arabia. I Some features of bilharzial hydronephrosis and the relevance to clinical management are discussed. MATERIALS AND METHODS

All 68 patients had hydronephrosis secondary to schistosomiasis, were Zambian Africans and were treated between 1974 and 1977. There were 54 men and 14 women, ranging in age from 23 to 65 years. All patients underwent excretory urography (IVP) and 18 also were screened with fluoroscopy to observe ureteral motility during the examination. Results of urinalysis, blood urea, creatinine clearance and cystoscopic findings were available in a number of cases.

DISCUSSION

All patients had frank clubbing of the calices and pyelectasis. Patients with minimal hydronephrosis showing only flattening of calices were excluded since this condition is reversible. Infection. Occult urinary infection is seen in many patients previously exposed to the disease but now living in nonendemic areas of the world, such as North America and Europe.I In these patients the disease usually is limited to the bladder and does not progress to hydronephrosis and hydroureters. It appears that sustained infection or reinfection is necessary to produce the pathological lesions that can progress to hydronephrosis. Causes of back pressure changes. The concept that bilharzial hydronephrosis usually is caused by mechanical obstruction from strictures4 has been questioned. 5• 6 This study confirms the previous observation that disturbance of ureteral peristalsis appears to be the primary cause of back pressure changes in the urinary tract in this disease. The incidence of strictures generally is low-3.1 per cent in Rhodesia 7 and 7 per cent in Zambia. 6 In this series only 1 case ofhydronephrosis was caused primarily by a bilharzia! stricture at the pelvioureteral junction. Strictures in 6 other patients were in the lower ureters. They were contributory but not the major cause of stasis, which usually was bilateral. In 1 patient atonic segmental ureterectasis in the distal ureter was the cause of back pressure changes. Obstruction of this nature can be likened to that seen in the colon in Hirschsprung's disease and appears to be pathognomonic of bilharziasis. The role of vesicoureteral reflux in the pathogenesis of bilharzial hydronephrosis has been emphasized elsewhere 8 but does not appear to be as important in Central Africa. The contracted bladder and outflow obstruction caused by prostatic enlargement are common in Egypt but were not

RESULTS

The condition was bilateral in 53 patients and unilateral in 15. Excretion of contrast medium occurred in <5 minutes from 76 kidneys, between 5 and 10 minutes from 38, between 10 and 25 minutes from 15, at 25 minutes in 9 and after >30 minutes in 9. Of the 3 patients with kidneys that did not show radiological function 1 had amorphous calcification in the affected kidney on a plain radiograph and pyonephrosis at operation, 1 had a large calculus at the lower end of the ureter and 1 had advanced carcinoma of the bladder. A voiding cystogram was done in 11 patients with bilateral hydronephrosis and ureteral reflux was found in 2 only. In 1 patient reflux was unilateral, although hydronephrosis was bilateral. The other patient had a ureterocele in the affected ureter. Strictures were seen in 8 patients, at the pelvioureteral junction in 1 and at the lower third of the ureter in the others. Of the 18 patients who underwent fluoroscopy 12 had diminished or absent ureteral peristalsis. Two of the remaining 4 patients with normal ureteral motility had ureteroceles. In 1 patient atony was restricted to a short dilated segment in the distal third of the ureter. No functional or organic lesion was seen in the remaining 3 patients. Of the 7 patients in whom creatinine clearance tests were done the values were normal. Blood urea was within normal limits in 14 of 19 patients examined. In the remaining 5 cases the values were 90, 88, 80, 80 and 79 mg. per cent. The blood specimen was taken during the IVP under dehydrated conditions in 2 patients and the values may not be valid. Accepted for publication August 8, 1980. 164

165

BILHARZIAL HYDRONJEPHROSIS

Frequency of surgical instrumentation in 10 years in 29 patients with schistosomial hydronephrosis No. Pts.

No. Cystoscopies

No. Ureteral Dilations

2

11 8 9

7 6 3 4 3

6 2 9

3

-

7 6

Total Surgical Instrumentations

Postop. Urinary Infection

18 14 12 11 9

teral reflux with or without ureteroceles, contracted bladder and bladder cancer. Function. The progressive destruction of renal parenchyi:na associated with hydronephrosis in this condition does not pear to be as serious or rapid as in the mechanically kidney. It is likely that the insidious nature of the disease and low pressure in the collecting system are responsible for the relative preservation of renal parenchyma. Excretion of contrast medium, therefore, was good even in the gTotesque ':!l~:.:·.::·.:-,;c,.. cated hydronephrosis. As shown in the 3 patients wi.th pyone phrosis, lower u:reteral calculus and bladder carcinoma the situation appears to reverse with rapid deterioration of function when complications supervene (see figure). Clinical management. Despite the marked stasis evident from urographic and cystoscopic findings additional infection was rare, even after repeated surgical instrumentation" The fear that repeated dilation of strictures would be an invitation to infection is from expectation rather than results and is not substantiated by our experience (see table)" In view of the insidious nature of the disease and poor results of the operation because of pre-existing and on-going as well as established functional derangement of ureteral motility, reimplantation of the ureters usually fails and should be reserved for patients with ureteroceles and associated troublesome reflux. Stenosis at the site of anastomosis invariably recurred within 18 months in >60 patients who had undergone ureteral reimplantation. Conservative measures with periodic dilation of troublesome strictures appear to be the logical regimen in the management of bilharzia! hydronephrosis, a major operation being indicated only in patients with complicating factors, such as bladder cancer, contracted onephrosis, calculosis and bladder outflow obstruction prostatic enlargement. 0

REFERENCES

Hydroneplrrotic right kidney. Left kidney does not excrete contrast medium. Note calcification in left renal area. At operation pyonephrosis was found in nonfunctioning left kidney.

encountered in this series, although bilharzia! prostatitis is endemic in Zambi.a. 9 The contracted bladder is not unknown in Zambia but is exceedingly rare. Two cases were seen within a 10-year period. These discrepancies emphasize the marked geognphical variations found in different parts of the world. The causes of stasis in bilharziasis of the urinary tract are many, the most important being functional disturbance of ureteral Other causes that are variably significant include mechanical obstruction from complicating strictures, giranulomas in the ureters, calculi, a.tonic segmental ureterectasis, outflow obstmction caused chronic prostatism, vesicoure-

1. Wallace, n M.: Urinary schistosomiasis in Saudi Arabia. Ann. Roy. Coll. Engl., 61: 265, 1979" 2. Can-uthers, R.: Department of Surgery, University Teaching Hospital, Lusaka, personal communication, 1976. 3. Dubey, K.: Department of Urology University Teaching Hospital, Lusaka, personal communication, 1976. ,t Badenoch, A. W.: Manual of Urology, 2nd ed. Chicago: Year Book Medical Publishers, p. 225, 1974. 5. Young, S. W., Khalid, K. H., Farid, Z. and Mahmoud, A. IL Urinruy tract lesions of Schistosoma haematobium with detailed radiographic consideration of the ureter. Radiology, 111: 81, 1974. 6. Umerah, B. C.: Evaluation of the physiological function of the ureter by fluoroscopy in bilharziasis. Radiology, 124: 645, 1977, 7. Gelfand, H.: Schistosomiasis in South Central Africa. A dinicopathological Study. Capetown and Johannesburg: Juta & Co, Ltd., 1950" 8. Umernh, B. C. and Naik, K. G.: The pattern of prostatic diseases in the Zambian with special reference to prostatic calculi, Med. Zambia, HI: 135, 1976" 9" Al-Ghorab, M., El-Badawi, A. and Effat, H.: Vesico-ureteric reflm: in urinary bilharziasis. A clinico-radiological study. Clin. Rad., 17: 41, 1966,