Carcinoma in the defunctionalized bladder: report of a case and review of the literature

Adenocarcinoma of the urinary bladder presenting as locally advanced endometrial carcinoma. Case report and review of the literature

BACKGROUND

Carcinoma of the urinary bladder that occurs after urinary diversion is a rare entity. We report a case of an adenocarcinoma arising in a defunctionalized bladder that presented as locally advanced endometrial carcinoma.

CASE

A 77-year-old presented with postmenopausal bleeding and mucous vaginal discharge. She had a prior history of urinary diversion via a Koch pouch. Examination revealed a mass protruding through the cervix and possibly involving the bladder anteriorly. The patient underwent anterior pelvic exenteration for a locally advanced mucinous carcinoma thought to be arising from the uterus and invading into the bladder. Final pathology, however, was consistent with a primary bladder carcinoma.

CONCLUSION

Carcinoma developing in the bladder after urinary diversion presents at an advanced stage and has associated poor overall survival.

Tumour formation within intestinal segments transposed to the urinary tract

Patients and their urologists are quite rightly concerned about the possibility of neoplastic change within intestinal segments transposed to the lower urinary tract. This fear arises from the occurrence of latent adenocarcinoma arising from the urocolic anastomosis in approximately 10% of patients who underwent ureterosigmoidostomy in childhood. The present text provides an update of previous reviews and details work published since 1990 on epidemiological, experimental and clinical studies. Consideration of the collected evidence confirms the increased risk of colonic neoplasia following mixing of the faecal and urinary stream by ureterosigmoidostomy or its more recent variants. In contrast, the occurrence of tumours within transposed intestinal segments appears more likely to be related to the underlying urinary tract disease for which the surgery was performed rather than exposure of the intestinal mucosa to urine. This conclusion is, however, based on low level evidence and, despite the reassuring findings, caution is advised until more robust data are available to provide a confident risk assessment.

The defunctionalized bladder

Supravesical urinary diversion without cystectomy is a common procedure performed to manage a variety of lower urinary tract pathologies. The purpose of this article is to review the complications associated with the bladder left in situ and to relate this to the female patient. Complications related to the defunctionalized bladder include pyocystis, hemorrhage, pain/spasm and neoplastic transformation. The defunctionalized bladder also has implications for sexual function, pregnancy and undiversion. The risk factors for complications are chronic infection, inadequate drainage, interstitial cystitis and previous irradiation. The incidence of neoplastic change in the defunctionalized bladder is low, but long-term follow-up is advised, as carcinoma could develop many decades after diversion. Sexual function following urinary diversion is better preserved when the bladder is retained.

Laparoscopic surgery for bladder carcinoma

Recent utilization of laparoscopy in urology has led to the performance of several pelvic procedures. The successful performance of laparoscopic diverticulectomies and cystectomies for benign pathology has led to speculation about, and utilization of, the laparoscopic approach in the treatment of bladder cancer. Herein, we relay our experience with the laparoscopic approach for bladder surgery and discuss the pros and cons of its current status in the treatment of bladder cancer.

Mucinous adenocarcinoma in defunctionalized bladders

Primary adenocarcinoma of the bladder accounts for less than 2% of all bladder cancers. There is no report of such a case in a defunctionalized bladder. All reported cases of carcinoma in defunctionalized bladders were either squamous cell, signet ring cell, or transitional cell carcinoma, detected within an average of 5 years after urinary diversion, and all have been associated with chronic inflammation of the bladder. We report on 2 cases of adenocarcinoma that developed in defunctionalized bladders 30 and 8 years after ileal loop diversion for prune belly syndrome and neurogenic bladder, respectively.

Laparoscopic cystectomy: initial report on a new treatment for the retained bladder

The retained bladder of a 27-year-old paraplegic woman suffering from recurrent pyocystis was removed laparoscopically. Operative time was 130 minutes. Postoperative hospital stay was 5 days, which was significantly less than that in 5 similar patients undergoing open cystectomy for vesical empyema in whom the mean hospital stay was 20.6 days. We believe that laparoscopic cystectomy represents a plausible, minimally invasive alternative to standard cystectomy for the symptomatic bladder left behind after supravesical urinary diversion.

The fate of the remaining bladder following supravesical diversion

A retrospective study of 30 adults who underwent supravesical diversion for a variety of benign and malignant conditions was done with special attention to the fate of the residual bladder. Diversion was performed for diverse conditions, including radiation cystitis, cyclophosphamide cystitis, interstitial cystitis, incontinence and trauma. All groups experienced significant morbidity from the remaining in situ bladder. Over-all, 80% of the patients experienced at least 1 complication, chief among which were pyocystis (67%), hemorrhage (23%), severe pain (13%), and unremitting feelings of incomplete emptying and spasm (17%). Complications of sufficient severity to require rehospitalization occurred in 43% of the patients. Several patients required multiple rehospitalizations. Reoperation requiring general or regional anesthesia was necessary in 9 patients (30%) and included 4 cystectomies. Serious consideration should be given to performing primary cystectomy at the time of supravesical diversion in any patient in whom subsequent undiversion is not anticipated.

Adenocarcinoma in the defunctionalized bladder

A case of adenocarcinoma appearing in the bladder six years after supravesical urinary diversion is reported. The reason for the diversion was chronic bladder inflammation, as in all but one of the 11 earlier reported cases of carcinoma in defunctionalized bladder. The theory that chronic bladder inflammation favors the development of, or possibly leads to malignancy is reviewed,. The conclusion is a recommendation for periodic cystoscopy of the bladder "left behind", and possibly for cystectomy at the time of urinary diversion in patients with a long history of bladder inflammation.

Urothelial hyperplasia and neoplasia: a response to chronic urinary tract infections in rats

The rat was used as an animal model to examine the effect of foreign bodies and long term infection (24 weeks) on bladder epithelium. Stainless steel wire implants and multiple injections of Escherichia coli were compared to control rat bladders by gross observation, light microscopy and scanning electron microscopy. Hyperplastic alterations, (papilloma, von Brunn's nests), dysplasia (squamous metaplasia, microvilli) and early lesions consistent with neoplasia occurred in rats with bladder implants and multiple bacterial injections but not in controls. Epithelial changes were not associated with sterile bladder implants. Bladder papillomata could be observed as early as 2 weeks in rats having both an implant and an infection, but the majority of hyperplastic and early neoplastic-like changes occurred after 6 weeks. Long-term infections, both with and without a bladder implant, can lead to lesions consistent with neoplasia in bladder epithelium.

Mucinous adenocarcinoma of bladder. Case associated with extensive intestinal metaplasia of urothelium in patient with nonfunctioning bladder for twelve years

A mucin-secreting adenocarcinoma of the bladder arose in a fifty-one-year-old man twelve years after he had an ileal conduit and urinary diversion for a neurogenic bladder which was due to a myelomeningocele. The patient presented with a mucinous penile discharge, and cystoscopy showed several papillary tumors with mucoid material coating the intervening mucosa. Examination of the resected bladder showed almost total intestinal metaplasia of the urothelium with numerous foci of dysplasia, adenocarcinoma in situ, papillary and invasive adenocarcinoma. The clinical and pathologic features of this case and the risk of carcinoma developing in a nonfunctioning bladder are discussed.

Carcinoma in the defunctionalized urinary tract

Carcinoma developing in the lower urinary tract diverted from the urinary stream, although uncommon, does occur and must be sought carefully in the presence of intractable pyocystis. Our experience with this condition is presented with emphasis on early diagnosis and treatment.