Case Report: Urothelial Hyperplasia Causing Recurrent Obstruction after Ureteral Metal Stent Placement in Treatment of Ureteroenteric Anastomotic Stricture

Initial experience utilizing metal stents in the treatment of ureteroenteric anastomotic strictures has yielded promising results. However, the long-term efficacy of metal stent placement remains unknown. Further, there is a paucity of literature to describe the technical considerations associated with the surgical management of obstruction after metal stent failure. We report the case of a 67-year-old man undergoing bilateral ureteral metal stent removal and ileal conduit creation following stent failure and recurrent obstruction.

Solitary ureteral metastases of renal cell carcinoma

Metachronous presentation of metastatic renal cell carcinoma (RCC) to the ureter is extremely rare. We report a solitary metachronous metastatic RCC in the contralateral ureter 14 months after right radical nephrectomy for Fuhrman grade 2 pT3a clear cell disease after the patient re-presented with gross hematuria. The proximal left ureteral lesion was excised followed by ileal-ureteral interposition. Pathologic examination confirmed metastatic RCC. To date, only 51 cases of metastatic RCC to the ureter have been reported, with only 6 occurring metachronously in the contralateral ureter. Also, we report the presence of focal extramedullary hematopoiesis occurring within this metastatic lesion.

Complications after cystectomy and urinary diversion in patients previously treated for localized prostate cancer

OBJECTIVES

To assess the morbidity associated with radical cystectomy in patients who had previously undergone definitive treatment of prostate cancer.

METHODS

A retrospective review was undertaken, identifying 35 patients undergoing radical cystectomy with a previous history of radical prostatectomy and/or radiotherapy for prostate cancer. The clinical and surgical information was analyzed to assess patient outcomes. Specific attention was given to the rate, severity, and time course of the postoperative complications. In addition, outcomes after orthotopic and continent cutaneous diversion in this patient cohort were examined.

RESULTS

An overall complication rate of 76% was seen in this patient cohort, with 47% of patients experiencing a complication that presented later than postoperative day 30. Radiotherapy was associated with a slightly greater complication rate compared with radical prostatectomy monotherapy (77% versus 71%). Continent urinary diversion (n = 14) was associated with increased morbidity compared with ileal conduit diversion (n = 21). However, a greater percentage of the complications occurring in patients undergoing ileal conduit diversion were major (80% versus 67%).

CONCLUSIONS

Our experience has suggested that radical cystectomy in patients previously treated for prostate cancer with radiotherapy and/or radical prostatectomy may be associated with a greater level of morbidity than previously reported. This finding may be, in part, because a significant portion of complications present in a delayed fashion and, as such, have not been seen in previous reports with limited follow-up. For this reason, careful consideration of these risks is necessary when counseling this patient cohort regarding the decision to undergo radical cystectomy.

Simplifying laparoscopic partial nephrectomy: Technical considerations for reproducible outcomes

OBJECTIVES

To present our technique, modifications, and experience of laparoscopic partial nephrectomy (LPN). Nephron-sparing surgery is an increasingly accepted treatment for selected T1a kidney tumors. Because of the more complex surgical technique involved, LPN is evolving more slowly than laparoscopic radical nephrectomy.

METHODS

The data of 41 consecutive patients with T1a tumors who had undergone LPN from October 2002 to March 2004 were retrospectively reviewed. Four main considerations in our surgical technique were consistently used: (a) LPN was performed in the transperitoneal approach, (b) a suture traction system was placed on the kidney when tumor visualization was challenging, (c) sutures and bolsters were preloaded on the abdominal wall, and (d) hemostasis and closure of the renal defect was performed using Lapra-Ty clips, eliminating knot-tying.

RESULTS

The mean patient age was 63.1 years. The mean warm ischemia time was 29.7 minutes, and the mean surgical time was 226.5 minutes. In 26 of 41 patients, the collecting system was entered and repaired. The median estimated blood loss was 150 mL, with a mean tumor size of 2.2 cm. Three cases were converted to open surgery. Five complications (13.2%) occurred. The median hospital stay was 2 days. Of the 41 specimens, 11 were benign. All surgical margins were negative. The mean follow-up was 7.5 months.

CONCLUSIONS

Although technically challenging, LPN is emerging as an alternative to open partial nephrectomy. With several easily applied technical considerations, we have simplified LPN, making the procedure more efficient. We believe that the technical considerations we describe can increase the feasibility and ease of LPN for Stage T1a exophytic renal tumors.

Neobladder-vaginal fistula after cystectomy and orthotopic neobladder construction

OBJECTIVE

To determine the potential surgical and clinical factors that contribute to the development of neobladder-vaginal fistula (NVF) after cystectomy and orthotopic neobladder (ONB) construction in women.

PATIENTS AND METHODS

Of 37 patients who had vaginal-sparing cystectomy, the records of four who developed a NVF after radical cystectomy and ONB construction were reviewed. Retrospective clinical and surgical information was collected, including patient demographics, tumour pathology, surgical technique, presenting symptoms, and method and efficacy of surgical repair.

RESULTS

In two of the four patients who developed a NVF a small injury to the anterior vaginal wall was noted during surgery and closed primarily. All patients presented with severe urinary incontinence. The NVF was diagnosed after cystoscopy and/or speculum examination. Three of the four patients had an attempted surgical repair, including one obturator flap interposition, one rectus flap interposition, and one primary two-layer closure. To date, one patient is fistula-free and two were subsequently converted to an ileal conduit or continent cutaneous diversion because the fistula recurred. The fourth patient developed a NVF in association with local tumour recurrence and underwent conversion to an ileal conduit.

CONCLUSION

The development of a NVF is a significant complication after cystectomy. Inadvertent injury to the vaginal wall is an important predisposing factor to subsequent NVF development. The repair of a NVF is often difficult; upon diagnosis, conversion to a continent cutaneous urinary diversion may be considered.

Percutaneous Placement of Permanent Metal Stents for Treatment of Ureteroenteric Anastomotic Strictures

PURPOSE

To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy.

PATIENTS AND METHODS

Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits.

RESULTS

At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients.

CONCLUSIONS

Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.

Long-Term Results of Endoureterotomy and Open Surgical Revision for the Management of Ureteroenteric Strictures After Urinary Diversion

PURPOSE

Prior studies have demonstrated that while endoureterotomy offers a reasonable initial treatment option, open anastomotic revision should remain the gold standard for managing ureteroenteric strictures. However, to our knowledge the results of contemporary endoureterotomy series have not been compared with those of open anastomotic revision, and no study has assessed the morbidity or success rate of secondary open anastomotic revision after failed endoureterotomy.

MATERIALS AND METHODS

Between May 1997 and August 2002 a total of 31 renal units in 22 patients were treated for ureteroenteric strictures after radical cystectomy and urinary diversion. A total of 16 renal units were treated endoscopically, including 9 on the left and 7 on the right side, and open revision was performed in 15 renal units, including 9 on the left and 6 on the right side. Success was defined as radiological improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

At a median followup of 35 months (range 17 to 62) for endoureterotomy and 34 months (range 5 to 54) for open revision the success rate of endoureterotomy and open revision was 50% (8 of 16 renal units) and 80% (12 of 15), respectively. One of the 3 patients in whom open revision failed underwent prior pelvic external beam radiation and the other 2 underwent prior endoureterotomies. Overall interventions for right strictures were more successful 85% or 11 of 13 cases than those on the left side (50% or 9 of 18) (p = 0.037). Average operative time was longer and average estimated blood loss was higher in patients treated with open repair after failed endoureterotomy (p = 0.009 and 0.016, respectively). No complications developed in patients following endoureterotomy.

CONCLUSIONS

Open revision remains the gold standard for the management of ureteroenteric strictures. Left strictures are considerably more resistant to management. Patients with left anastomotic strictures should be cautioned that endoureterotomy might have a lower success rate, and failure may limit the success and increase the morbidity of subsequent open anastomotic revision.

Detection of alpha-methylacyl-coenzyme A racemase in postradiation prostatic adenocarcinoma

OBJECTIVES

To assess the utility of alpha-methylacyl-coenzyme A racemase (AMACR), also known as P504S, immunohistochemistry in the detection of postradiation prostatic adenocarcinoma in surgical specimens. Pathologic diagnosis of postradiation prostate cancer is difficult because of the radiation-induced cytologic changes in benign and malignant epithelial cells. AMACR/P504S is a recently identified molecular marker for prostatic adenocarcinoma. It has been demonstrated that AMACR is overexpressed in the vast majority of prostatic adenocarcinoma cases by cDNA microarray, RNA analysis, Western blotting, and immunohistochemistry.

METHODS

A total of 80 prostate glands, including 40 irradiated prostate specimens (28 with adenocarcinoma and 12 benign prostates) and 40 nonirradiated prostate specimens (20 with adenocarcinoma and 20 benign prostates), were examined. The specimens were obtained after salvage radical prostatectomy (n = 25), transurethral resection (n = 4), or needle biopsy (n = 11). All samples were immunohistochemically analyzed for AMACR.

RESULTS

All 48 carcinoma cases (28 of 28 irradiated and 20 of 20 nonirradiated specimens) showed strongly positive AMACR/P504S immunostaining. AMACR immunostaining was negative for all irradiated (n = 12) and nonirradiated (n = 20) benign prostates, as well as the irradiated benign glands adjacent to carcinoma. 34betaE12 confirmed the presence of basal cells in all benign prostates (32 of 32) and the absence of basal cells in carcinoma (0 of 48).

CONCLUSIONS

Our results demonstrate that AMACR is a highly specific and sensitive indicator of postradiation prostate cancer. AMACR immunostaining facilitates the challenging differentiation between prostatic adenocarcinoma and radiation-induced atypia in benign prostatic epithelium and may be of exceptional value in limited needle biopsies.

Primary amyloidosis of the bladder treated with partial cystectomy

A 56-year-old man presented with a 1-year history of intermittent gross, painless hematuria. Extensive evaluation revealed primary localized amyloidosis of the urinary bladder. Despite several endoscopic resections and fulgurations, the patient continued to have episodes of significant hematuria due to recurrent amyloid deposition. He was then successfully treated with partial cystectomy. At 60 months following surgery, the patient remains free of recurrent or systemic disease.

Novel modification of partial nephrectomy technique using porcine small intestine submucosa

INTRODUCTION

To describe a novel partial nephrectomy technique that uses small intestine submucosa (SIS) to ensure a watertight closure of the collecting system and minimize parenchymal bleeding. The indications for nephron-sparing surgery have increased in recent years. The most prevalent complications after partial nephrectomy include urinary leakage/fistula and parenchymal bleeding. Porcine SIS has been used in animal models to reconstruct portions of the urinary tract successfully.

TECHNICAL CONSIDERATIONS

Twenty-two consecutive patients underwent 24 partial nephrectomies that required entry into the collecting system for presumed renal cell carcinoma. After temporary occlusion of the renal vessels and renal hypothermia, the tumor and a margin of normal parenchyma were excised. The cut surface was cauterized with an argon beam coagulator, and visible vessels were suture ligated. The collecting system was reapproximated with interrupted, absorbable sutures. A multilayer piece of hydrated SIS was sutured in place over the exposed collecting system and parenchymal defect with several figure-of-eight chromic sutures. With a mean follow-up of 18.4 months, none of the 22 patients experienced postoperative urinary leaks/fistulas or postoperative hemorrhage requiring transfusion. The serum creatinine returned to within 0.2 mg/dL of baseline in all patients after surgery.

CONCLUSIONS

We describe a novel technique of partial nephrectomy using SIS, which, we believe, aids in closure of the collecting system and decreases parenchymal bleeding.

Distal ureteral replacement with tubularized porcine small intestine submucosa

Extensive ureteral injury can result from renal stone disease, iatrogenic injury, or penetrating trauma. A significant ureteral stricture can be repaired using various techniques, including the psoas hitch, Boari flap, transureteroureterostomy, ileal ureter, or renal autotransplantation. We describe a woman with a 5-cm, ischemic uretero-Indiana pouch stricture that developed after cystectomy and urinary diversion. Severe pelvic fibrosis prevented adequate mobilization of the ureter and Indiana pouch and would not permit any of the above-mentioned procedures. We report the first human use of tubularized small intestine submucosa to successfully replace a 5-cm strictured segment of distal ureter.

Artificial urinary sphincter placement in men after cystectomy with orthotopic ileal neobladder: continence, complications, and quality of life

OBJECTIVES

To review our experience regarding the overall efficacy and safety of an artificial urinary sphincter (AUS) in men with stress urinary incontinence (SUI) after cystoprostatectomy with an orthotopic ileal neobladder.

METHODS

We performed a retrospective review of 5 men who underwent placement of an AUS (AMS 800) for severe SUI after radical cystectomy with an orthotopic ileal neobladder. Incontinence symptoms and quality of life were quantified using two validated continence questionnaires (Urogenital Distress Inventory Short Form and Incontinence Impact Questionnaire Short Form) and a brief addendum questionnaire. The degree of continence, perioperative and postoperative complications and infections, symptom distress, quality of life, and patient satisfaction were compared before and after AUS placement.

RESULTS

Complete (0 pads per day) or social (1 pad or less per day) continence was reported in 5 of 5 patients after AUS placement. The average pad usage significantly decreased from 6.2 to 0.6 per day (P <0.001). No significant perioperative or postoperative complications or infections were noted. Symptom distress, quality of life, and patient satisfaction were significantly improved after AUS placement (P < 0.01, < 0.0001, and < 0.001, respectively).

CONCLUSIONS

With short-term follow-up and a limited number of patients, the placement of an AUS for treatment of SUI after bladder substitution is well tolerated and reliable and has a positive impact on patients' quality of life.

Long-term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures

OBJECTIVES

To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion.

METHODS

Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-micrometer holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures.

CONCLUSIONS

Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate.

Therapeutic options and treatment of muscle invasive bladder cancer

Carcinoma of the bladder is the second most common genitourinary malignancy. Although several treatments exist, the gold standard therapy for muscle invasive bladder cancer (> or = stage T2) is cystectomy with urinary diversion. We review various surgical treatments for muscle invasive bladder cancer, focusing on the reported survival rates, complications, advantages and disadvantages of each therapeutic modality.

Medical management of patients with refractory carcinoma in situ of the bladder

Bladder cancer is a common genitourinary malignancy and carcinoma in situ (CIS) of the bladder exists as a potentially aggressive variant of the superficial form of the disease. Treatment must reflect the unpredictable nature of this disease entity. In 1976, the use of intravesical Bacillus Calmette-Guerin (BCG) was described for the management of early stage bladder cancer. A subsequent report demonstrated efficacy in a cohort of patients with CIS of the bladder. Since this time, intravesical BCG has been recognised as the initial therapy for CIS of the bladder. Although a 6-week treatment with intravesical BCG has been established as standard therapy in patients with CIS, there has been no consensus as to the subsequent treatment for patients in the setting of failure to initial management with BCG. In addition, a number of reports have demonstrated an increased potential of adverse effects after repeated treatment with intravesical BCG. A variety of alternative immunological and chemotherapeutic agents have been developed in response to the limitations of BCG for patients with refractory CIS of the bladder. At present, valrubicin remains the only agent that is approved by the US Food and Drug Administration for the specific indication of CIS of the bladder unresponsive to intravesical BCG. Although these agents appear promising, the most efficacious therapy remains to be determined. The specific treatment protocol for refractory CIS of the bladder remains elusive. It is ultimately the combined decision of the clinician and patient to determine which course of management is most beneficial.

Complications of cystectomy in patients with a history of pelvic radiation

OBJECTIVES

To compare the complications occurring during the first year of follow-up after radical cystectomy in two groups, one with and one without a history of pelvic radiation. Radical cystectomy and urinary diversion is the treatment of choice for invasive bladder cancer.

METHODS

One hundred ninety-four cystectomies were performed between January 1995 and June 2000 by a single surgeon. Twenty-three patients were identified with a history of external beam radiotherapy to the pelvis (EBRT group), and 23 additional patients without a history of pelvic radiation were randomly selected to serve as the control group.

RESULTS

Although the overall risk of having a complication was not statistically different in the EBRT group (48%) than in the control group (30%; P = 0.183), complications directly related to surgery were higher in the EBRT group than in the control group (48% versus 26%; P = 0.045). The patients in the EBRT group were more likely to require an invasive procedure (39% versus 9%; P = 0.018). In addition, 5 (22%) of 23 patients in the EBRT group had a symptomatic fluid collection, which was diagnosed as a urine leak (n = 2) or an abdominal abscess (n = 3). In contrast, no patient in the control group developed a symptomatic fluid collection.

CONCLUSIONS

Cystectomy after pelvic radiation is associated with acceptable morbidity; however, compared with cystectomy performed in a nonirradiated pelvis, the risk of complications that will require invasive intervention is increased. A history of prior pelvic radiation significantly increases the risk of a symptomatic fluid collection.

Correlation between biopsy and radical cystectomy in assessing grade and depth of invasion in bladder urothelial carcinoma

OBJECTIVES

To assess the degree of correlation between the pathologic characteristics of the specimens obtained from biopsy and radical cystoprostatectomy. The stage and grade of bladder urothelial (transitional cell) carcinoma are important predictors of prognosis.

METHODS

We retrospectively identified 169 cases of urothelial carcinoma from 222 radical cystectomies performed at University of Chicago Hospitals from 1992 to 1999.

RESULTS

For all the cases in this study, the histologic grade, using the 1998 World Health Organization and International Society of Urological Pathologists (WHO/ISUP) classification, was identical when the biopsy specimen and radical cystectomy specimen were compared. However, when the same cases were assessed using the traditional three-grade system, the histologic grade increased or decreased by one grade in 19 (11%) and 8 (5%) of 169 cases, respectively. Patients with invasion of the lamina propria on biopsy had tumor extending outside the bladder in 15 (27%) of 55 cases. Patients with invasion of the muscularis propria on biopsy had tumor extending outside the bladder in 47 (49%) of 96 cases, including nodal metastasis in 22 (23%) of 96 cases. Overall, bladder biopsy underestimated the true extent of the disease in 78 (46%) of 169 cases.

CONCLUSIONS

Using either the WHO/ISUP (1998) classification or the traditional three-grade system, the histologic grade of the biopsy specimen is a fairly good predictor of the final histologic grade. The preoperative biopsy tends to understage bladder cancer. Patients with muscularis propria invasion demonstrated by biopsy have a significantly higher risk of non-organ-confined disease than those with lamina propria invasion.