Tumour formation within intestinal segments transposed to the urinary tract

Carcinoma arising in ileal conduit or orthotopic ileal neobladder reconstruction: A 20-year single institute experience

CONTEXT

Carcinomas found in urinary diversion specimens are uncommon, particularly new primary tumours. New primary tumours primarily occur when the large intestine is utilised, whereas the occurrence is infrequent with the use of the ileum. These tumours include both the recurrence of primary malignancy or the development of a new primary malignancy originating from the small intestine.

DESIGN

A search was performed within the pathology laboratory system to identify cases of malignancies involving ileal conduit/reconstruction from 2002 to 2022. Data on demographics, clinical details, pathology and management was recorded.

RESULTS

A total of 13 male patients, with a mean age of 67 years (range = 49-81 years) were included in the study. The initial procedure performed included cystoprostatectomy (n = 10, including one case with right nephroureterectomy) and cystectomy (n = 3, including one case for bladder exstrophy) for initial diagnoses including urothelial carcinoma (n = 11; conventional, 6; sarcomatoid, 1; glandular 1; plasmacytoid, 1; micropapillary, 2) and adenocarcinoma (n = 1). The initial management included radical surgery with neoadjuvant chemotherapy/immunotherapy (n = 1), adjuvant chemotherapy (n = 3), intravesical adjuvant BCG (n = 2) and intravesical adjuvant chemotherapy (n = 1). Malignancies in ileal conduit or orthotopic ileal neobladder included recurrent urothelial carcinoma (n = 10) and new secondary adenocarcinomas (n = 3), which developed as early as 3 months (usually recurrence) and up to 13, 33 and 45 years (new primary malignancy) following primary resection.

CONCLUSIONS

Utilising the ileum as conduit/neobladder presents a viable alternative for urinary diversion with a reduced malignancy risk compared to using a segment of the large intestine. However, there remains a potential for malignancy, either tumour recurrence or a new primary malignancy. In our study, tumour recurrence occurred up to 4 years following the initial diagnosis and the development of a new primary malignancy occurred up to 45 years after the initial diagnosis. Consequently, it is crucial to prioritise long-term follow-up for these patients undergoing this procedure.

Transition to adulthood with a bladder augmentation: histopathologic concerns

Aim:

To investigate the histopathologic changes in native bladder and gastrointestinal segment, the relation between histopathologic changes, type of operation and the period passed over operation in patients with bladder augmentation.

Materials and methods:

Twenty consecutive patients were enrolled in this study. Histopathologic evaluation of the cystoscopic mucosal biopsies from native bladder and enteric augment was performed in all patients.

Results:

Active or chronic non-specific inflammation of various degrees was found in all specimens except two. Metaplastic changes were detected in 3 patients. Two patients had squamous metaplasia (one focal, one extensive) and one patient had intestinal metaplasia. All metaplastic changes were found in native bladder specimens. The type of augmentation in patients with metaplastic changes were ileocystoplasty and sigmoidocystoplasty. No signs of malignancy were detected in any patient.

Conclusion:

The complexity of the disorders requiring bladder augmentation does not let the surgeons to draw a clear line between different groups of complications including malignancy formation. However, due to challenging course of the augmentation procedure itself, surgeons should be well aware of the possibility of malignancy development.

Efficacy and safety of continent anal urinary diversion for complicated bladder exstrophy in children by using modified Duhamel's procedure

BACKGROUND

A high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence and a miserable life even after a well-performed staged reconstruction in specialized centers. Most of those children usually have a normal anal sphincter allowing construction of a neobladder from the rectum, so they are continent without an abdominal stoma, and do not require frequent catheterization, which greatly contribute to a favorable body image.

OBJECTIVE

In this study a modified Duhamel's rectal pouch done for 19 children, with implication of suitable stapler adopted to construct a rectal bladder with a non-refluxing urterorectostomy, there is a theoretical advantage in our procedure of avoiding a mix of urine and feces. All patients were followed for up to 6 years (2-8 years) for efficacy, safety, subsequent renal complications, and surveillance for any rectal neoplastic changes in this new diversion.

STUDY DESIGN

Assessment of electrolytes, acid base balance, and renal function were carried out regularly and all data were analyzed using the SPSS 9.0.1 statistical package and compared using a paired t test; data were considered significant if p < 0.05. Proctoscopy was performed 6 monthly in the first year then annually thereafter, and at any time if there was any rectal bleeding.

RESULTS

In this group of patients, follow-up revealed no neoplastic changes in the rectal bladder, deterioration in renal function, or major electrolytes disturbance. They can hold up to 400 mL (350-550 mL) of urine and all are continent during the daytime with an emptying frequency of 3-5 h; three patients had infrequent (4 episodes/month) nocturnal enuresis; and four cases developed pyelonephritis controlled with medical treatment.

CONCLUSION

The continent rectal bladder created by using the principles of the Duhamel pull-through is feasible, easy to perform, successful in the immediate short term with low complications after 6 years of follow-up and appropriately accepted by the children and their families with marked improvement in quality of life regarding continence; longer-term follow-up is requested to rule out rectal neoplastic changes. A comparative review of the complications, patient's acceptance, and longer-term follow-up with other well-known procedures, such as Mainz II, is required.

Intestinal adenocarcinoma in an augmented ileocystoplasty

We present a case of a 67-year-old patient with a history of augmentation ileocystoplasty 31 years ago following genitourinary tuberculosis. Radiological investigations performed due to asymptomatic microscopic haematuria revealed three contrast-enhancing polyps within the neobladder. The patient had enterocystoprostatectomy and histopathological examination of the neobladder revealed mucinous adenocarcinoma in all three polyps, together with a prostatic adenocarcinoma Gleason 7 (3+4). After adjuvant chemotherapy and 1 year of follow-up, he had no sign of clinical or radiological recurrence. Taking into consideration this rare case, we discuss the development of malignant tumours after the incorporation of intestinal segments in a urinary tract reconstruction, showing what relationship exists between secondary neoplastic growth, the primary disease and the type of urinary diversion utilised.

[Secondary malignancies in urinary diversions]

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[Tumors following urinary diversions. Results of a multicenter study]

BACKGROUND

The risk estimation of secondary tumors after different types of urinary diversion with intestinal segments has as yet been possible only for ureterosigmoidostomy.

METHOD

We analyzed the operative records of 44 German clinics for urinary diversions performed from 1970 to 2007 and registered all reported secondary tumors up to 2009.

RESULTS

In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (2.58%) and cystoplasty (1.58%) is significantly higher than in other continent forms of urinary diversion (p<0.0001). The risk in orthotopic (ileo)colonic neobladders (1.29%) is significantly higher (p=0.0001) than in ileal neobladders (0.05%). The difference between ileocecal pouches (0.14%) and ileal neobladders is not significant (p=0.46).

CONCLUSION

Ureterosigmoidostomies, cystoplasties, and orthotopic (ileo)colonic neobladders necessitate regular endoscopic evaluation from at least the fifth postoperative year. After ileal neobladders, conduits, and catheterizable ileocecal pouches regular routine endoscopy is not imperative.

Metastatic transitional cell carcinoma of the bladder arising in a patient with bladder autoaugmentation

We report a case of a metastatic transitional cell carcinoma of the bladder in a 20-year-old patient who had previously undergone resection of posterior urethral valves, clean intermittent catheterization, bladder autoaugmentation, and later renal transplantation. To our knowledge, this is the first report of transitional cell carcinoma following bladder autoaugmentation. We also review the literature on bladder autoaugmentation and transitional cell carcinoma.

Ultrastructural changes in colorectal mucosa after chronic contact with urine

Ultrastructural changes in the colorectal mucosa in response to chronic contact with the urine were demonstrated in outbred albino rat experiments. Oral correction with slightly alkaline sodium hydrocarbonate solution reduced the destructive effect of the urine on rat colorectal mucosa.

Long-term outcome of ureterosigmoidostomy: an analysis of patients with >10 years of follow-up

STUDY TYPE

Therapy (case series).

LEVEL OF EVIDENCE

4.

OBJECTIVE

To examine our long-term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long-term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques.

PATIENTS AND METHODS

We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow-up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (< or =30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention.

RESULTS

The median (range) follow-up was 15.7 (10.0-45.4) years and the median age at surgery was 58.8 (0.4-79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study.

CONCLUSIONS

USS is associated with long-term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.

[Perspectives in urinary diversion]

"Perspectives in Urinary Diversion" was the title of a presentation held during the opening session of the 56th annual meeting of the German Urological Association in Hamburg on September 21, 2006. It focused on the balance between obstruction and reflux of ureters implanted in diverted intestinal segments, the choice of intestinal segments for orthotopic pouches, orthotopic diversion in the female, the status of rectal diversions, and alternatives to the use of intestinal segments.

Glycosylation of the two O-glycosylated domains of human MUC2 mucin in patients transposed with artificial urinary bladders constructed from proximal colonic tissue

Transposition of intestinal segments is frequently used for bladder reconstruction. Following transposition, bowel segments continue to produce mucus and a correlation between excessive mucus production and complications such as urinary tract infection or catheter blockage has been observed for a long time. However, no information is currently available on the change of mucin expression and glycosylation under these abnormal conditions. In this study, the variable number tandem repeat region and the irregular repeat domain of human MUC2 were isolated as two glycopeptide populations after reduction and trypsin digestion followed by gel chromatography from urine of patients transposed with urinary bladders. After alkaline borohydride treatment, the oligosaccharides released from the whole MUC2 mucin and the two glycosylated domains were investigated by nanoESI Q-TOF MS/MS (electrospray ionization quadrupole time-of-flight tandem mass spectrometry). More than 60 different glycans were identified, mainly based on sialylated core 3 structures. Some core 1, 2 and 4 oligosaccharides were also found. Most of the structures were acidic with NeuAc residues mainly alpha2-6 linked to the N-acetylgalactosaminitol and sulphate residues exclusively 3-linked to galactose. No expression of blood group A and B or Sda/Cad determinants was observed. Similar patterns of glycosylation were found in the tandem repeat region and the irregular repeat domain and the level of expression of the major oligosaccharides were in the same order of magnitude. The most interesting feature of this study was that sialyl-Tn antigen, which is considered as a tumour antigen, was the oligosaccharide most highly expressed. This result suggests that mucins from intestinal transposed segments are abnormally glycosylated.

Modified ureterosigmoidostomy (Mainz Pouch II): a nonrefluxing stented vs unstented laparoscopic porcine model

OBJECTIVE

To describe a rapid and reproducible pure laparoscopic cystectomy and nonrefluxing modified continent urinary diversion (Mainz Pouch II), and to determine whether ureteric stenting decreases ureteric obstruction after surgery.

MATERIALS AND METHODS

After institutional review and approval, six female pigs (51-55 kg) had a laparoscopic cystectomy and urinary diversion using a modified Mainz Pouch II. Imbricating bowel over the extra-intestinal ureteric segment created the nonrefluxing mechanism. All pigs had the same bowel preparation before a standard four-port transperitoneal laparoscopic procedure, but three pigs received bilateral J ureteric stents and three did not. Body weights, radiographic imaging, serum electrolytes and renal function were monitored during the 6-week survival period.

RESULTS

One stented pig developed bilateral pyelonephritis, renal obstruction and was killed. Including this pig, four of 12 renal units were obstructed, occurring more often in the stented pigs. There were no significant differences between the serum electrolytes before and after surgery or between the stented or unstented pigs. The surgery was quicker as experience increased. No pig developed hyperchloraemic metabolic acidosis. The nonrefluxing modification appeared to be effective, as reflux was only present in one renal unit.

CONCLUSIONS

Laparoscopic ureterosigmoidostomy, specifically the modified Mainz Pouch II, represents a viable and reasonable continent urinary diversion. The results suggest that there was no benefit in stenting in this pig model.

Complications of treatment of obstetric fistula in the developing world: gynatresia, urinary incontinence, and urinary diversion

OBJECTIVE

To provide a comprehensive review of the pathophysiology, evaluation, and treatment of gynatresia and urinary incontinence, 2 conditions that can arise following the repair of obstetric fistulas. The article discusses relevant issues with respect to urinary diversion in the treatment of obstetrical fistula and associated urinary incontinence.

METHODS

A review was conducted of the existing literature and of the expert recommendations issued at the Gates Institute fistula meeting held in July 2005 at the Johns Hopkins Bloomberg School of Public Health.

RESULTS

Gynatresia and urinary incontinence develop in approximately 10% and 16% of patients, respectively, after the first repair. Urinary diversion may be necessary when fistulas cannot be closed vaginally or in cases of severe urinary incontinence following successful closure. Gynatresia, urinary incontinence, and urinary diversion are all associated with morbidity, and they require surgical and nonsurgical expertise for proper management.

CONCLUSIONS

Closing the anatomical fistula is not always sufficient, and treatment paradigms must shift toward the prevention and repair of gynatresia and urinary incontinence at the time of the primary operation.

Tubular adenoma with high-grade dysplasia in the ileal segment 34 years after augmentation ileocystoplasty: report of a first case

Neoplasms of the urinary bladder following augmentation ileocystoplasty are rare. We present the case of a 39-year-old male with a tubular adenoma with high-grade dysplasia in the ileal segment 34 years after augmentation ileocystoplasty to enlarge a post-chemoradiation-induced shrunken bladder. He presented with gross hematuria. Cystoscopy revealed a papillary tumor at the site of ileovesical anastomosis, and transurethral resection was performed. Histologic examination revealed a tubular adenoma with high-grade dysplasia. There are only two previous reports of tubulovillous adenoma in ileal segment after ileocystoplasty, both without high-grade dysplasia. Our observation supports the hypothesis that an ileal neobladder may undergo all the morphologic and molecular changes observed in the development of gastrointestinal adenocarcinoma. Therefore, patients who had an ileal neobladder created should be closely followed.

Colonic adenocarcinoma in an Indiana pouch successfully treated by endoscopic mucosal resection

We report the case of a 76-year-old woman who developed a colonic adenocarcinoma and a stone in an Indiana pouch 15 years after the urinary diversion. The colonic adenocarcinoma was treated endoscopically and we were able to preserve the Indiana pouch. To our knowledge, this is the sixth case of colonic adenocarcinoma in an Indiana pouch.

Urinary diversion: options, patient selection, and outcomes

Improved survival following radical cystectomy for bladder cancer as a result of advancements in combination chemotherapy and surgical technique has resulted in a philosophical change in the surgeon's approach to urinary diversion selection. Aims have evolved from the mere diversion of urine to a functional bowel conduit such as an ileal conduit or ureterosigmoidostomy, to providing the optimal diversion for the patient's quality of life. While quality of life is important, one must also consider the stage of cancer and individual patient comorbidities. Which diversion provides the best local cancer control, the lowest potential for complications (short and long term), and the easiest emotional adjustment in lifestyle while still allowing the timely completion of chemotherapy and therapeutic goals? A multidisciplinary approach to diversion selection that includes the patient, the medical oncologist, radiation oncologist, internist, and surgeon is ideal. We describe the three most commonly used types of diversions today, including conduits, continent cutaneous reservoirs, and orthotopic urethral diversions, as well as issues relative to patient selection and functional outcomes in patients undergoing radical cystectomy for the treatment of bladder cancer.

Adenocarcinoma of ileal neobladder 20 years after cystectomy

We present the case of a 67-year-old man with adenocarcinoma of the ileal neobladder 20 years after radical cystoprostatectomy for Stage pT2 transitional bladder cell cancer. A MEDLINE research revealed 9 other cases of the development of a neoplasm in the ileal part of an ileocystoplasty. This observation supports the hypothesis that in an ileal neobladder morphologic and molecular changes can be observed similar to those in the development of colorectal carcinoma. Patients who had an ileal neobladder created are at risk of glandular malignancy and should be closely followed up.

Ureterosigmoidostomy and obstructive uropathy

BACKGROUND

A 19-year-old mentally retarded man with failed exstrophy repair and ureterosigmoidostomy urinary diversion presented with high fever, vomiting and right-flank pain of 2 days' duration. Past medical history was notable for a left nephrectomy to treat an infected staghorn calculus in a poorly functioning kidney. Physical examination revealed pyrexia and right-flank tenderness.

INVESTIGATIONS

Physical examination, renal function tests, electrolyte and metabolic assessment, urine and blood cultures, abdominal CT, ANTEGRADE PYELOURETEROGRAPHY, sigmoidoscopy and histopathology.

DIAGNOSIS

Ureterosigmoidostomy complicated by acute pyelonephritis, obstructive uropathy, recurrent urinary tract infections, renal impairment and the development of renal stones and metabolic acidosis.

MANAGEMENT

Fluids, intravenous antibiotics, bicarbonate and potassium supplementation, and rediversion of ureterosigmoidostomy to an ileal conduit.