Management of bilharzial strictures of the lower ureter

Ureteral strictures are serious and frequent complications of chronic bilharziasis of the urinary tract are seen. To determine which corrective surgical procedures are most successful, we compared the results of those most commonly done. We retrospectively analyzed our experience with mucosa to mucosa ureterovesical anastomosis (68 ureters), transvesical ureteral meatotomy (30 ureters) are submucosal tunnel ureteroneocystostomy, (UNC; 10 ureters). Complete follow-up data are available for 102 patients (108 ureters); half of these cases were followed for 4 years or even more. It is to be noted that, in our series, only 10 ureters were suitable for submucosal tunnel anastomosis: bilharzial ureters are usually fibrotic, noncompressible, and the vesical mucosa is adherent to the muscular layer - which renders creation of a tunnel difficult or impossible. However, this procedure produced the best results. The conclusion was reached that, whenever possible, antireflux procedures suitable for the bilharzial bladder and ureter should be attempted. Based on this analysis, a prospective clinical trial was carried out, which compared Boari flap UNC (30 ureters), triangular flap ureterovesicoplasty of Girgis et al. (30 ureters), and ileal loop replacement of the pathologic segment (30 ureters). The average period of follow-up was 20 months. Triangular flap and Boari flap were found to be superior to ileal replacement. Ileal replacement is consistently followed by vesicoileal reflux and commonly by persistent urinary tract infection. In consequence, the latter operation must be reserved for cases with extensive ureteral loss or destruction. Antireflux procedures still remain the most desirable methods whenever technically possible.