Patients With Spina Bifida and Bladder Cancer: Atypical Presentation, Advanced Stage and Poor Survival

Augmentation cystoplasty and risk of neoplasia: fact, fiction and controversy

PURPOSE

We determined if ileal/colonic bladder augmentation performed in patients with congenital bladder abnormalities is an independent risk factor for bladder malignancy.

MATERIALS AND METHODS

We reviewed a registry of patients with bladder dysfunction due to neurological abnormalities, exstrophy and posterior urethral valves. Individuals treated with augmentation cystoplasty were matched (1:1) to a control group treated with intermittent catheterization based on etiology of bladder dysfunction, gender and age (±2 years).

RESULTS

We evaluated 153 patients with an ileal/colonic cystoplasty and a matched control population. There was no difference (p=0.54) in the incidence of bladder cancer in patients with augmentation cystoplasty (7 patients [4.6%]) vs controls (4 [2.6%]). In addition, there was no difference between the 2 groups regarding age at diagnosis (51 vs 49.5 years, p>0.7), stage (3.4 vs 3.8, p>0.5), mortality rate (5 of 7 [71%] vs 4 of 4 [100%], p>0.4) or median survival (18 vs 17 months, p>0.8). Irrespective of augmentation status patients with a history of renal transplant on chronic immunosuppression had a significantly higher incidence of bladder cancer (3 of 20 [15%]), compared to patients who were not immunosuppressed (8 of 286 [2.8%], p=0.03).

CONCLUSIONS

In patients with congenital bladder dysfunction ileal/colonic bladder augmentation does not appear to increase the risk of bladder malignancy over the inherent cancer risk associated with the underlying congenital abnormality. In addition, immunosuppression irrespective of bladder treatment is an independent risk factor for malignancy in this patient population.

Urothelial carcinoma of the sarcomatoid variant in a young patient with spina bifida: a case report and review of the literature

INTRODUCTION

Patients with neurogenic bladder due to spina bifida are considered to be at increased risk for aggressive bladder cancer. We present a unique case of a 32-year-old woman with spina bifida diagnosed with sarcomatoid urothelial carcinoma of the bladder and report diagnosis and management.

CASE PRESENTATION

A 32 year old woman with neurogenic bladder managed with intermittent self catheterisations, presented with gross hematuria. On cystoscopy, she had a bulky bladder mass on the posterior bladder wall. Bladder biopsies revealed sarcomatoid variant of bladder transitional cell carcinoma. Treatment included radical cystectomy with ileal conduit diversion and adjuvant chemotherapy with excellent intermediate term follow up.

CONCLUSION

Patents with neurogenic bladder managed with intermittent self catheterisations need periodical follow up due to increased risk for aggressive bladder cancer. Immediate radical cystectomy with adjuvant chemotherapy is the suggested treatment approach.

Bulbar urethral ligation for managing persistent urinary incontinence in young men with myelomeningocele

OBJECTIVE

To report our experience with ligation of the bulbar urethra for treating refractory stress incontinence in a selected group of young men with neuropathic bladders secondary to myelomeningocele (MM), in whom primary anti-incontinence procedures had failed.

PATIENTS AND METHODS

Persistent urethral incontinence leading to chronic perineal skin ulceration can occur in these patients, despite aggressive medical and surgical efforts to decrease wetting by increasing bladder capacity, compliance and outlet resistance. Four young men with MM had bulbar urethral ligation; all had undergone a previous ileocystoplasty and functioning continent catheterizable channels (CCC, three appendicovesicostomies, one Monti procedure). Three patients had primary bladder neck procedures using rectus fascia slings, and secondary attempts were made at urethral bulking in two patients. All patients had persistent incontinence through their native urethra, with dry intervals of <2 h.

RESULTS

The bulbar urethra was ligated through a small midline perineal incision at 1 year after augmentation, and successfully resolved incontinence in all four patients. All reported satisfaction with their bladder regimen at a mean (range) follow-up of 49 (20-93) months. There were no perineal wound infections. While one patient developed bladder calculi, no patient developed urethral stones, febrile urinary tract infections, fistulae or bladder perforations.

CONCLUSIONS

We report the results of bulbar urethral ligation for resolution of incontinence in patients with MM in whom anti-incontinence bladder neck procedures had failed. Ligation of the urethra is effective, and can be considered an alternative treatment for refractory urinary incontinence in patients with a functional CCC in whom previous bladder neck-supporting procedures have failed.