Schistosomiasis: An Unusual Cause of Hematuria in the Ileal Neobladder

Abstract

Bladder substitution using bowel has improved the quality of life of cystectomy patients. However, late complications are not rare and may include deterioration of the upper tract, malignancy or stricture of the retained urethra, stone formation and spontaneous rupture of the neobladder.' We report a unique complication of severe hematuria due to schistommiasis of the ileal neobladder. CASE REPORT A 39-year-old man underwent radical cystectomy and creation of an orthotopic ileal neobladder in February 1991. Definitive histopathology showed grade 2 TP3aNOMO squamous cell carcinoma. Schistosoma haematobium eggs were present in the cystectomy specimen. The patient had a history of exposure and unknown treatment of schistosomiasis 3 years before cystectomy. At that time he complained of dysuria and terminal hematuria, which improved after antibilharzial treatment. There was no history of exposure to schistosomiasis after that course of treatment and no evaluation for schistosomiasis was performed before or after cystectomy. The patient did well until January 1994, when he complained of gross hematuria. The kidneys and ureters were normal on excretory urography and ultrasonography. UMalysis revealed active S. haematobium eggs and urine culture yielded no growth. Panendoscopy demonstrated a normal urethra and ileo-urethral junction, and extensive submucod hemorrhagic areas with multiple mucosal ulcerations in the ileal neobladder. Biopsy showed partial ulceration of the ileal mucosa with calcified bilharzial ova surrounded by diffuse mononuclear cellular infiltrate (see figure). Anti-bilhanial treatment was given orally (60 mg&. praziquantel in 2 divided doses daily) in conjunction with a total dose of 60 mgkg. oxamniquine given orally in 6 divided doses (twice daily for 3 days). There was dramatic improvement after anti-bilharzial therapy and the patient was free of hematuria 8 months after treatment. Repeat urinalysis was normal. DISCUSSION Schistosomiasis is an endemic dieease that inf man and animals. A total of 1,ooO million people is at risk and approximatelv 200 million are infected throughout the Partial ulceration of ileal muwa with calcified.bilharzial ovum (arrow) surrounded by diiTuse mononuclear cellular mfiltrate. H & E, reduced from X250. In tropical areas intestinal schistmomiasis could be a cause of hematuria in patients with substitution of the bladder by a bowel segment. Patients in these areas should undergo a thorough evaluation for schistosomiasis before surgery. We suggest urinalysis for S. haematobium eggs (characteristic terminal spine) and stool analysis for S. mansoni eggs (characteristic lateral spine). An indirect hemagglutination test must be performed to detect circulating antischistosomal antibodies. All patients in whom stool analysis and indirect hemagglutination testing fail to show the presence of infection should undergo biopsy of the rectal mumsa to reveal any signs of egg deposits or schistosomal granulomas. Infected patients must be treated as described. Repeat urine and stool analyses with indirect hemagglutination testing should prove the resolution of the infection before surgery. F'urthermore, a bowel mucosal biopsy must be obtained intraoperatively and examined for schismmiasis.