A 39-year-old woman with a personal history of pulmonary tuberculosis, repeated renal colic and stress urinary incontinence.
She attended the emergency department for low back pain and pollakiuria. Abdominal ultrasound showed bilateral ureterohydronephrosis with preserved left renal parenchyma and right kidney with thin, unstructured cortical tissue, as well as renal function with serum creatinine of 1.98 mg/dl. Therefore, a urinary diversion by percutaneous nephrostomy of the left kidney was decided.
A diagnosis of genitourinary tuberculosis was made due to a positive Lowestein culture in the urine evacuated by the nephrostomy and medical treatment was started with Rifampicin, Isoniazid and Pyrazinamide for 2 months and Isoniazid and Rifampicin for a further 4 months. During the outpatient follow-up, a renal scan was performed showing a non-functioning right kidney and the left kidney with preserved morphology and discrete ectasia of the upper calyceal system. An abdominal ultrasound was also obtained which corroborated the findings of the renal scan. The patient discontinued antibiotic treatment and follow-up consultations after 6 months, due to social problems, despite persistent disease in the cultures.
One year after diagnosis, medical treatment was restarted and continued for one year with adequate clinical follow-up. Intravenous urography was performed, with a diagnosis of right mastic kidney and stenosis of the last few cms of the left ureter. A right nephrectomy was performed and left uretero-vesical reimplantation was attempted, during which the left ureter was disinserted 1 cm below the pyeloureteral junction, so a permanent left urinary diversion (racket nephrostomy) was decided.
For three years he maintained good renal function and periodic changes of racquet nephrostomy with the evident limitation and affectation of his quality of life. After this time and given the patient's good physical condition and age, reconstruction of the excretory tract with ileum was considered. The preoperative evaluation confirmed complete bladder retraction, so simultaneous replacement of this organ was considered.
The surgical technique consisted of freeing and defunctionalising 60 cm of ileum with opening of the left mesocolon to allow anastomosis of the proximal end of the ileum to the pelvis of the left kidney, with loose sutures and a double J tutor catheter. Subsequently, cystectomy and hysterectomy of the myomatous uterus was performed because the anastomosis between the neobladder and urethra was difficult, with detubulation of 30 cm of distal ileum in isoperistaltic position, forming a "U" shaped neobladder with modified Camey type folding of the final 20 cm.
The postoperative period was uneventful with good clinical evolution and removal of the ureteral tutor 21 days after surgery. Cystogram showing that the bladder suture was watertight, although the presence of vesico-ureteral reflux was observed, with high pressure. After removal of the nephrostomy and bladder catheter, the patient was discharged from hospital with hourly urination and leaks between micturitions, requiring compresses and the Credé manoeuvre to empty the bladder.
Six months later, cystography showed a larger bladder capacity and little reflux, but night-time incontinence persisted.
During the periodic check-ups performed every 6 months, the patient expressed her satisfaction with the results obtained after surgery and her improved quality of life, as she no longer has urinary diversion and urine leaks are scarce and nocturnal.
At present, 4 years after the last surgery, she has urination every 2-3 hours with daytime continence and a night-time pad, bladder emptying at the expense of the Credé and Valsalva manoeuvre without subsequent residue, requiring 1 g daily of oral bicarbonate for adequate metabolic control and a plasma Creatinine of 1.1 mg/dl7.
