Bladder adenocarcinoma following gastrocystoplasty

Gastric Adenocarcinoma Arising in Gastrocystoplasty

Gastric cancer is a rare long-term complication in gastrocystoplasty. We report 2 cases of gastric adenocarcinoma and review the literature for similar cases. A total of 14 cases are identified. The majority of patients are males, presented with hematuria, and developed cancer at a younger age, more than 10 years after gastrocystoplasty. Long-term follow up information was limited, but 5 patients (36%) died within 5 years of diagnosis. Annual surveillance for malignancy may not be effective due to its rarity. However, symptomatic patients, particularly those 10 years after the surgery, warrant detailed evaluation to rule out neoplastic transformation.

Secondary Tumors After Urinary Diversion

It has been known that urinary diversions juxtaposing the urinary and intestinal tracts lead to increased incidence of secondary malignancies. Although tumorigenesis in ureterosigmoidostomies follows the typical course from adenomas to adenocarcinomas, secondary malignancies arising from isolated intestinal diversions are much more heterogeneous. Research over the last half century has unveiled patterns of incidence and progression, while also uncovering possible mechanisms driving the neoplastic changes. In this review, we summarize the current understanding of these unique tumors, with the hope that the knowledge gained may shed light on the etiologies of other cancers arising from the urinary and intestinal tracts.

What is the outcome of paediatric gastrocystoplasty when the patients reach adulthood?

OBJECTIVE

To document the long-term outcomes of paediatric augmentation gastrocystoplasty (AGC) in terms of preservation of renal function and maintenance of dryness, and to analyse the rate of complications.

PATIENTS AND METHODS

The medical records of children who had undergone AGC between 1992 and 2000 (minimum time interval of 15 years) were reviewed retrospectively. The following data were collected: age at surgery, the cause of bladder dysfunction, functioning of the AGC, any complications, and the long-term outcome of the patients. All of the patients were re-contacted by telephone.

RESULTS

A total of 11 AGCs were carried out between 1992 and 2000, at a median (range) age of 11 (6.5-14) years. The diagnosis of patients undergoing AGC included myelomeningocele (four), bladder exstrophy (four), posterior urethral valves (one), irradiated bladder (one), and Prune Belly syndrome (one). The median [interquartile range (IQR)] follow-up was 17 (15-19.5) years. Renal function was preserved or improved in seven of the 11 patients and nine patients were dry after AGC. Seven of the 11 patients reported symptoms linked to haematuria-dysuria syndrome, which was resistant to treatment in one case and requiring excision of the gastric patch. Three of the 11 patients developed a tumour on the gastric graft after a median (range) delay of 20 (11-22) years after the initial procedure. All had gastric adenocarcinoma of which two were metastatic at the time of diagnosis requiring pelvectomy with pelvic lymph node dissection and adjuvant chemotherapy. Seven of the 11 patients underwent excision of the gastric patch after a median (IQR) time of 11 (8.5-20.5) years.

CONCLUSIONS

Our long-term data confirmed that most patients undergoing AGC had preservation of their renal function and were continent. However, long-term, AGC was associated with a significant risk of malignant transformation and a high rate of surgical re-intervention involving removal of the gastric patch. These results question the use of this technique for bladder augmentation, irrespective of the indication. We highlight the importance of strict endoscopic follow-up of all patients already having undergone an AGC and the need to inform and educated patients about tumour-related symptoms.

Management of bleeding-associated severe gastritis of the gastric mucosa in a patient with a gastrocystoplasty

Gastrocystoplasty is a form of bladder augmentation (neobladder), where a segment of the stomach is surgically attached to the urinary bladder to increase bladder capacity and compliance. Although bleeding and malignant complications of gastrocystoplasty have been reported, the risks of these complications in the setting of gastrocystoplasty are not known. We describe the case of a 58-year-old African American woman with a history of a congenital solitary kidney, chronic kidney disease, and status postgastrocystoplasty and catheterizable umbilical stoma 21 years ago for neurogenic bladder presented with gross hematuria. To the best of our knowledge, this is the first reported case of gastrocystoplasty with a bleeding complication that has endoscopic pictures before and after treatment with proton pump inhibitor.

Adenocarcinoma arising from tubulovillous adenoma in a native bladder following gastrocystoplasty

Gastrocystoplasty is a surgical form of bladder augmentation which improves bladder capacity and compliance. Patients who undergo bladder augmentation with a gastric remnant are at increased risk for malignancy. The most common types of tumors in this situation were adenocarcinoma and urothelial carcinoma. Most of the adenocarcinomas arise in the gastric remnant or anastomotic site, and adenocarcinomas arising in the residual native bladder are extremely rare. We report on a patient who received gastrocystoplasty 16 years ago. She suffered from recurrent urinary tract infections for a year and cystoscopy showed a tumor in the bladder trigone. Pathologic examination showed tubulovillous adenoma with malignant transformation to adenocarcinoma. The tumor consisted of intact adenomatous architecture from low-grade dysplastic gland to adenocarcinoma, which suggested that the pathogenesis might be related to intestinal metaplasia and dysplasia. The unique location and immunohistologic findings of the tumor suggested that it originated in the bladder mucosa.

Experimental gastrocystoplasty in rats: risk of developing ECLoma

OBJECTIVE

There are no clinical reports on the risk of carcinoids in the gastric segment following gastrocystoplasty. The aim of the present study was to examine whether gastric carcinoids could develop in a rat model of gastrocystoplasty.

MATERIALS AND METHODS

Rats were subjected to gastrocystoplasty in which 10% of the oxyntic part of the stomach was removed (i.e. 10% fundectomy), gastrocystoplasty with 90% fundectomy (known to induce hypergastrinemia), sham operation, or no operation, and were followed up for 6 months. Tissue specimens of bladder and stomach were analyzed by means of pathology and immunohistochemistry.

RESULTS

Atrophy of gastric glands in the augmented bladders was found after gastrocystoplasty with either 10% or 90% fundectomy. Gastrocystoplasty with 90% fundectomy resulted in hyperplasia of the oxyntic mucosa, enterochromaffin-like (ECL) cell hyperplasia and ECLoma in the remnant stomach, and atrophy of the oxyntic mucosa and ECLoma in the gastric segment of the bladder.

CONCLUSIONS

ECLoma could develop in the gastric segment of the bladder after gastrocystoplasty, particularly in the setting of hypergastrinemia. The tumorigenesis of ECLoma seems to follow the same pathological pathway regardless of whether the oxyntic mucosa is located in the stomach or the bladder.

Complications after use of gastric segments for lower urinary tract reconstruction

PURPOSE

We retrospectively reviewed our experience with the use of gastric segments for lower urinary tract reconstruction with an emphasis on long-term complications.

MATERIALS AND METHODS

A total of 29 patients underwent reconstruction of the lower urinary tract using gastric segments between 1993 and 2000. Diagnoses included neurogenic bladder (21), cloacal exstrophy (5), solitary kidney/ectopic ureter (1), posterior urethral valves (1) and rhabdomyosarcoma of prostate (1). Gastric segment was used as gastrocystoplasty (21), composite gastroenteric cystoplasty (6), demucosalized gastrocystoplasty (1) and continent gastric reservoir (1).

RESULTS

Mean followup was 13.9 years (range 9 to 16.5). Complications were seen in 15 (51.7%) patients. Seven patients had the hematuria-dysuria syndrome, which was intractable in 1 and necessitated excision of the gastric patch. Due to severe complications necessitating major reoperations 3 patients underwent re-augmentation with enteric segments without excision of the gastric tissue (composite). One patient who underwent demucosalized gastrocystoplasty had excision of the gastric tissue and re-augmentation with enteric segment due to contraction of the gastric patch. A stone developed in 1 patient with a composite gastroenteric reservoir. Malignancy developed in the reservoir in 3 patients 11, 12 and 14 years after gastrocystoplasty, and all 3 died of metastasis.

CONCLUSIONS

We do not recommend the use of gastric segments for reconstruction of the lower urinary tract due to the high incidence of reoperations and complications. In patients in whom gastric segments were used in the past for lower urinary tract reconstruction, regular surveillance and close followup are strongly advocated.

Re-epithelialization of demucosalized stomach patch with tissue-engineered urothelial mucosa combined with Botox A in bladder augmentation

Re-epithelialization demucosa stomach patch is important to prevent the patch being exposed to urine that might cause patch shrinkage and fibrosis formation due to urine-derived chemical irritation. Additionally, Botox A acts by blocking the transmission of nerve impulses to smooth muscles and so paralysing the muscles, which is commonly used to relax muscle for treatment of oesophageal achalasia due to overactive smooth muscle and sphincters of gastrointestinal tract. We fabricated in vitro tissue engineered urothelial mucosa with multi-layers of urothelium and smooth muscle layers seeded on SIS scaffold and then used this cell-scaffold construct to cover nuke gastro patch combining with Botox A for gastrocystoplasty in a canine model.

OBJECTIVE

To evaluate the demucosalized stomach patch covered with tissue-engineered urothelium for gastrocystoplasty and to determine whether or not injections of Botox A into the re-epithelialized stomach patch can protect the graft from contraction in a canine bladder reconstruction model.

MATERIALS AND METHODS

Gastrocystoplasty was performed in 10 adult beagles after hemi-cystectomy using five types of stomach patch (n = 2 per group): entire stomach patches (group I); demucosalized patches (group II); demucosalized patches covered with cell-free small intestinal submucosa (SIS) (group III); demucosalized patches with urothelial and smooth muscle cell-seeded SIS (group IV); and demucosalized patches with the cell-seeded SIS combined with injections of Botox A (group V). The bladder volume/pressure and the graft sizes were measured before surgery and again 10 weeks after bladder augmentation. The graft tissues were examined both histologically and using immunohistochemistry.

RESULTS

All dogs survived and their gastric grafts were all vital with a good blood supply. Gastric metaplasia of urothelium appeared on the top of stomach mucosa patches in two animals in group I. There was calcification formation at the centre of the graft in one animal in group II. As compared with urothelium that was partially covered over with stomach patches in groups II and III, stratified urothelium completely covered the demucosalized gastric patches in groups IV and V. There was less shrinkage of the stomach grafts in groups I and V, which shrank to half of their original size, than of the stomach grafts in groups II, III, and IV, which shrank significantly to one-quarter of their original sizes.

CONCLUSIONS

Botox A injections appear to protect the graft contraction in the re-epithelialized stomach flaps. The gastrocystoplasty using demucosalized patches covered with tissue-engineered urothelial mucosa combined with an injection of Botox A could have clinical potential for use in bladder reconstruction.