SECONDARY MALIGNANCIES IN DIFFERENT FORMS OF URINARY DIVERSION USING ISOLATED GUT

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Squamous cell and urothelial carcinomas in an ileal neobladder

Introduction

In cases of ileal neobladder following radical cystectomy for the treatment of bladder cancer, tumor development in the isolated gut segment is extremely rare. Herein, we report a case of squamous cell and urothelial carcinomas in the ileal neobladder 23 years after radical cystectomy.

Case presentation

A 71‐year‐old man was referred to our hospital for further examination of a solitary tumor in an ileal neobladder. At the age of 48 years, he underwent radical cystectomy with ileal neobladder reconstruction. Transurethral resection of the bladder tumor was performed, and histopathological findings showed squamous cell carcinoma with high‐grade urothelial carcinoma.

Conclusion

To our knowledge, this is the first report of squamous cell and urothelial carcinomas in an ileal neobladder. While secondary tumor development in an ileal neobladder is rare, it is a cause for concern as a late postoperative adverse event. Therefore, long‐term follow‐ups are recommended.

Secondary malignancy after urologic reconstruction procedures: a multi-institutional case series

Urinary diversion and reconstructive urologic procedures are most often performed by incorporating various intestinal segments into the urinary tract. Although the risk of malignancy, among other complications, is well recognized and occurs most frequently after ureterosigmoidostomies and cystoplasties, data on the histopathologic and immunohistochemical characteristics of these tumors are scant. This study aims to evaluate the clinicopathological features of secondary tumors arising after urologic reconstruction procedures. Eleven cases were identified among five collaborating academic institutions. The average age was 51.7 years, and the M:F ratio was 8:3. Surgical procedures included 7 ileal conduits, 2 gastrocystoplasties, 1 augmentation cystoplasty not otherwise specified (NOS), and 1 Indiana pouch. Median time from reconstruction to malignancy was 36 years. Malignancy included adenocarcinoma in 10 patients (intestinal type in 6, gastric in 2, signet-ring cell in 1, undetermined type after neoadjuvant treatment in 1) and squamous cell carcinoma in 1. By immunohistochemistry, the adenocarcinomas were CK7 (45%), CK20 (89%), CK903 (78%), CDX2 (89%), SATB2 (67%), and beta-catenin (100%) positive. GATA-3 was negative in all cases. Pathologic stage was T1 (30%), T2 (40%), T3 (20%), and T4 (10%). Regional lymph node and distant metastasis were present in 60% and 20%, respectively. Treatment included multimodality therapy in most patients. On follow-up (mean, 27.4 months), 2 patients were dead (1 of disease), 3 were alive with disease, 4 were alive without disease, and 2 were lost to follow-up. Secondary malignancy arising within urologic reconstruction is rare, most frequently has adenocarcinoma morphology, presents late, and behaves aggressively.

Adenocarcinoma mucinosum of extrophy bladder: A rare case report

INTRODUCTION

Bladder exstrophy is a rare congenital anomaly while, bladder adenocarcinoma mucinous type is a rare type of bladder cancer, with aggressive behavior and inadequate response to radiation and chemotherapy. In extremely rare cases, untreated bladder exstrophy could transform into bladder mucinous adenocarcinoma.

CASE PRESENTATION

We report a case of a 41-year-old male with untreated bladder exstrophy that transformed into mucinous adenocarcinoma. The patient also had epispadias and a right inguinal hernia. Joint procedures were conducted to perform radical cystectomy, total penectomy and W-Pouch continent urostomy, inguinal hernia repair, osteotomy, and keystone and scrotal flap by split-thickness skin graft (STSG) for wound closure. The patient progressed well after surgery, two months after initial procedure, nephrostomies were conducted due to pouches stenosis. Due to the government's limited transportation and lockdown policy, as the Covid-19 pandemic occurred, the patient could not come to the hospital for routine follow-up and died nine-month after surgery.

CLINICAL DISCUSSION

Bladder exstrophy is one of the risk factors of bladder cancer. Transformation of bladder exstrophy into mucinous adenocarcinoma is extremely rare, as the case is the first case to be discovered in Indonesia. Surgery, followed with a strict follow-up regime, is mainstay of treatment in this type of malignancy.

CONCLUSION

Adenocarcinoma of mucinous type is a scarce type of bladder exstrophy malignancies. A multidiscipline approach is mandatory in these cases. Strict and regular follow up are suggested for these cases.

Laparoscopic ileal ureteral replacement to preserve the natural anti-reflux system: An initial case report

INTRODUCTION

Ileal ureteral replacement is one of the treatment options for long ureteral strictures. Most ileal ureteral replacements anastomose the distal side of the ileal segment directly to the bladder. We have reported here an initial case of laparoscopic ileal ureteral replacement for preserving the natural anti-reflux system.

CASE PRESENTATION

A 29-year-old male presented with right flank pain, and his imaging results revealed multiple strictures of the right upper-middle ureter. Hence, we performed a laparoscopic ileal ureteral replacement surgery. The normal distal ureter was preserved, and the distal side of the ileal segment was anastomosed to it. As such, the natural anti-reflux system could be completely preserved. Following this, the renal function was maintained, and no urinary tract infection was recorded.

CONCLUSION

Laparoscopic ileal ureteral replacement, which preserves the natural anti-reflux system, can be considered as a treatment option for refractory upper-middle ureteral strictures.

Mixed histology bladder cancer as a complication of clam ileocystoplasty

A 58-year-old woman with a previous clam ileocystoplasty was referred to the urology department for the investigation of haematuria. CT urogram showed a large left-sided soft tissue mass arising from the bladder. Histological analysis of the shavings from transurethral resection revealed a G3pT2 transitional cell carcinoma and T4N1Mx adenocarcinoma. The patient was referred to oncology for the discussion of palliative chemotherapy; however, in the interim she deteriorated and was admitted to hospital with a post-renal acute kidney injury. A right-sided nephrostomy was inserted relieving her obstruction and she subsequently made a good recovery. This case report illustrates the difficulties in the long-term follow-up of patients having undergone what is now a rarely performed procedure. In the absence of regular cystoscopic follow-up post ileocystoplasty, malignancy may present late and with complications from advanced disease.

Rare gastrointestinal stromal tumor in an ileal conduit detected by recurrent massive bleeding from the stoma

INTRODUCTION

The development of secondary tumors is a well-known late adverse event after urinary diversion. However, the frequency of secondary tumors after an ileal conduit is the lowest compared to other methods used for urinary diversion. We observed a rare case of a gastrointestinal stromal tumor in an ileal conduit detected by recurrent massive bleeding from the stoma.

CASE PRESENTATION

An 87-year-old female was hospitalized at our hospital due to recurrent bleeding from a stoma 22 years after radical cystectomy. Contrast-enhanced computed tomography revealed a 5-cm mass in her ileal conduit. She underwent a complete resection of the tumor, a histological examination of which revealed it to be a gastrointestinal stromal tumor. The condition of the patient has been good showing no recurrence or metastases 4 years after surgery.

CONCLUSION

We report a rare secondary tumor, a gastrointestinal stromal tumor, arising from an ileal conduit.

De Novo Secondary Adenocarcinoma in the Colon Used as Urinary Diversion Not in Contact with the Fecal Stream: Systematic Review and Meta-analysis

BACKGROUND

A systematic review with a meta-analysis was performed to determine the prevalence and risk factors for secondary de novo adenocarcinoma in the colon used as a urinary diversion not exposed to the fecal stream.

METHODS

The systematic review of the literature identified 47 patients with secondary adenocarcinoma in a colonic urinary diversion not exposed to the fecal stream.

RESULTS

The diagnosis of secondary adenocarcinoma was determined due to the presence major local symptoms and because the cancer in half of the patients was detected at an advanced stage. Diagnosis at an earlier stage was associated with long-term cancer-free survival.

CONCLUSIONS

The authors concluded that cystoscopy-colonoscopy screening as suggested by the American Gastroenterology Society for the general population should be applied to patients who have colon urinary diversion not exposed to the fecal stream. For patients with active high-grade inflammation, difficulty with self-catheterization, or symptoms, cystoscopy should be performed earlier. Resection of the tumor at an early stage offers better clinical outcomes with longer survival rates.

Clam augmentation enterocystoplasty as management of urge urinary incontinence and reduced bladder capacity

Objectives: Third line treatment of urge urinary incontinence (UUI) and/or reduced bladder capacity is bladder augmentation. The aim of this study was to investigate whether clam enterocystoplasty (CECP) was an efficient treatment for patients who were refractory to conservative treatments of UUI and small functional bladder capacity and secondly if there was a difference in outcome in patients with neurogenic and non-neurogenic bladders.Methods: We evaluated 118 patients retrospectively treated in the period 2006-2018 at a single university hospital. Data were collected retrospectively. Patient groups were compared with Wilcoxon signed-rank test and Fisher's exact test.Results: Overall, 76% became continent with 92% using clean intermittent self-catherization (CISC) of patients with neurogenic bladder, 82% became continent and 100% were using CISC, whereas of patients with non-neurogenic bladder 64% became continence and 77% were using CISC. The median overall improvement of capacity was 296.5 mL (IQR: 142-440), 310 mL (186-467) in the neurogenic group and 214 mL (IQR: 126.8-361.5) in non-neurogenic (p = 0.01).Conclusion: CECP is an efficient treatment in UUI and reduced bladder capacity. Difference in outcome was seen with neurogenic patients having a bigger functional capacity and a higher rate of continence compared to the non-neurogenic.

Carcinoma in a Colonic Conduit Post Esophagectomy: a Case Report

Colon Conduit is a commonly used form of reconstruction post esophagectomy either for malignancy, strictures due to caustic acid ingestion, or other benign conditions. Carcinoma of the Colon Conduit following esophagectomy is a complication with an extremely low incidence and the management options are not clear. Thorough search of literature showed only 16 such cases. Hence, we report a case of a patient who underwent colon conduit reconstruction for a gastroesophageal (GE) junction tumor and developed a recurrence 4 years after the initial surgery.

Hypoxic changes to the urothelium as a bystander of end-stage bladder disease

INTRODUCTION

Urothelial cells harvested from benign diseased bladders have a compromised capacity to propagate or differentiate in vitro, potentially limiting their application in autologous tissue engineering approaches. The causative pathways behind this altered phenotype are unknown. The hypothesis is that hypoxic damage to the urothelium occurs as a bystander to chronic or recurrent episodes of infection and inflammation.

OBJECTIVE

The aim of this study was to assess immunohistochemically detected nuclear hypoxia-inducible factor 1 alpha (HIF-1α) and vascular endothelial growth factor in the urothelium when exposed to hypoxia.

STUDY DESIGN

Human bladder sections from a total of 29 adult and paediatric patients, representing a variety of different pathologies including neuropathy (n = 15), were analysed. Tissues from adults with bladder outlet obstruction secondary to prostatic disease (n = 1), urothelial carcinoma (n = 1) and tonsil (n = 1) were used as positive tissue controls for immunohistochemistry. Hypoxia-inducible factor 1 alpha-labelled sections were scanned using a Zeiss AxioScan Z1 slide scanner. Analysis of urothelial nuclear HIF-1α labelling was performed using HistoQuest image analysis software (TissueGnostics). Comparison of nuclear HIF-1α labelling between neuropathic and non-neuropathic sections was performed using one-way analysis of variance with the post hoc Tukey honestly significant difference (HSD) test. Patient urodynamic studies performed before tissue sample harvest were evaluated and correlated to the HIF-1α intensity using Spearman's rank correlation.

RESULTS

Hypoxia-inducible factor 1 alpha appeared more intense in the urothelial compartment from neuropathic bladder samples (n = 15) than in the control tissues, including non-obstructed samples (n = 9). Image analysis supported this; median nuclear HIF-1α labelling was 29.98 ± 3.10 (standard deviation [SD]) (n = 9) in controls and 74.29 ± 7.55 (SD) in neuropathic samples (n = 15). A statistically significant difference between the control and neuropathic tissue groups was shown (P < 0.05). Of the 15 neuropathic samples, 11 had traceable urodynamic studies. Both initial and maximum detrusor pressures indicated a positive relationship when plotted against HIF-1α labelling. Spearman's rank correlation, with no missing events, confirmed significant correlations between both initial or maximum detrusor pressure and nuclear HIF-1α labelling intensity (median score); P ≤ 0.046 and P ≤ 0.05, respectively. The null hypothesis was accordingly rejected.

CONCLUSIONS

This study indicates that urothelial nuclear HIF-1α may be a biomarker of hypoxia and a common feature in end-stage bladder disease associated with high-pressure systems.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

Revisiting Ureterosigmoidostomy, a Useful Technique of Urinary Diversion in Functional Urology

Ureterosigmoidostomy has largely been disregarded in recent times but has now seen a resurgence of interest because of its potential applicability to newer, minimally invasive surgical techniques. The advantages of ureterosigmoidostomy over intestinal conduits are urinary continence (obviating the need for stoma and external appliances), ease, and rapidity of performance as well as acceptance by patients. Ureterosigmoidostomy has been characterized by good continence outcomes and it offers good quality of life. Possible complications are anastomosis stenosis, coloureteral reflux, electrolyte imbalance, hydronephrosis, pyelonephritis, chronic renal failure, colorectal cancer, and others. Ureterosigmoidostomy is therefore only advisable for patients ready to accept long-term follow-up.

Management of advanced adenocarcinoma in Indiana Pouch urinary diversion

Adenocarcinoma is a rare finding following urinary diversion with gastrointestinal segments. This report describes an 80-year-old woman with a history of bladder cancer who subsequently developed a pT4 adenocarcinoma 8 years following her radical cystectomy and Indiana Pouch continent urinary diversion. An en bloc resection of the pouch and affected small bowel was performed and the patient underwent conversion to an ileal conduit diversion. We use this case to highlight a mechanism for possible pathogenesis and the management of adenocarcinoma in urinary diversions including the need for regular surveillance and the surgical approach.

Adenocarcinoma in a Koff Urinary Ileal Diversion

The use of an ileal conduit as a means of treatment for bladder cancer or dysfunction is widely used and understood. However, long term surveillance of that conduit has not been strongly established and set forth as a means of screening. We present a 76yo female with a history of neurogenic bladder secondary to paraplegia who underwent the formation of a “Koff” pouch as a conduit. Nineteen years later she presents with hematuria and was found to have adenocarcinoma originating in her conduit.

Adenocarcinoma in Continent Anal Urinary Diversion: Is a Sigma Rectum Pouch a Surgical Option After Failed Ureterosigmoidostomy?

OBJECTIVE

To report our experience of radical resection of secondary cancers after ureterosigmoidostomy. Ureterosigmoidostomy was the most common continent urinary diversion before the era of continent cutaneous diversion and neobladders, specifically in children. When performed for bladder exstrophy, patients will live with this kind of diversion for quite a long time. As a result, urologists will be confronted with patients presenting with an adenocarcinoma in their ureterosigmoidostomy. In most cases reported in the literature, an ileal conduit was used for urinary conversion. However, nowadays an ileal loop must not be the only solution for patients with a long life expectancy.

MATERIALS AND METHODS

Between 2004 and 2015, 6 patients were treated for an adenocarcinoma in their ureterosigmoidostomy. All patients underwent radical resection of the tumor-bearing sigmoid colon. After thorough preoperative informed consent concerning the choice of future urinary diversion, such as conversion to an ileal conduit, construction of a continent catheterizable pouch, or repeat continent anal diversion, 4 patients chose a repeat continent anal urinary diversion.

RESULTS

Up to this date, no complications or recurrences were seen after a median follow-up of 35 months.

CONCLUSION

In patients with secondary malignancy of the colon, radical resection of the tumor-bearing bowel segment is mandatory. A repeat continent anal urinary diversion appears to be a feasible alternative to secondary urinary diversion after resection of the tumor-bearing sigmoid colon. However, a longer follow-up is required to determine whether the risk of secondary malignancy remains unchanged, and whether the risk is increased or decreased.

Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer

AIM

In advanced pelvic cancer it may be necessary to perform a total pelvic exenteration. In such cases urinary tract reconstruction is usually achieved with the creation of an ileal conduit with a urinary stoma on the right side of the patient's abdomen and an end colostomy separately on the left. The potential morbidity from a second stoma may be avoided by the use of a double-barrelled wet colostomy (DBWC), as a single stoma. Another advantage is the possibility of using a vertical rectus abdominis muscle flap for perineal reconstruction.

METHOD

All patients undergoing formation of a DBWC were included.

RESULT

A DBWC was formed in 10 patients. One patient underwent formation of a double-barrelled wet ileostomy.

CONCLUSIONS

In this technical note we present our early experience in 11 cases and a video of DBWC formation in a male patient.

Current standards of care in bladder and prostate rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common soft tissue tumor in children, and 15% to 20% arise from the genitourinary tract. Multicenter collaborative studies have improved survival substantially, and in addition to excellent oncologic control, current treatment focuses on organ preservation and minimization of late treatment effects. The multiple modalities needed to treat RMS dictate that treating physicians must be familiar with the disease as well as the goals and possible sequelae of treatment with chemotherapy, radiotherapy, and surgery. This article discusses the current standards of care for bladder and prostate RMS.

Carcinoma arising in enteric diversion or rectal neobladder for bladder exstrophy

Bladder exstrophy is a rare malformation. Ureteral diversion, such as ureterosigmoidostomy or a neorectal bladder, has been described. When the patients reach adulthood, cancer may arise in these reconstructions. Our aim was to perform a systematic review (all languages) of the published literature on neoplasia after urinary diversion and suggested management in cases of cancer. PubMed and Cochrane library were searched for relevant articles published within the last 20 years. All identified articles were reviewed for inclusion. Carcinoma occurring in the bladder and unreconstructed exstrophy were excluded. Out of 47 articles found, 12 matched our search criteria. The outcomes of 23 patients (including 2 from the authors' institution) were reported. Twenty-two patients with adenocarcinoma and 1 with carcinoid tumour were identified. Median age at urinary diversion was 3 (range 1-13) years. There were 20 ureterosigmoidostomies and 2 neorectal bladders. Cancer was diagnosed subsequently at a median of 31 (range 5-55) years after urinary diversion still in place (n = 18) or 21 years (range 1-30) after incomplete excision of ureteric stump when re-diverted (n = 5). The long-term outcomes of 15 patients were available. Ten died due to colorectal adenocarcinoma, and 5 were disease-free at 3 years. Patients with enteric diversion for bladder exstrophy, including those with subsequent reconstruction, are at risk of adenocarcinoma during adulthood. It is important to provide adequate surveillance. If lesions suggestive of carcinoma are seen, complete excision of the receptive bowel and urinary diversion are mandatory.

Primary Squamous Cell Carcinoma Arising From a Cutaneous Ureterovesical Stoma (Modified Mitrofanoff): Case Report and Review of Literature

Squamous cell carcinoma arising from a urinary stoma is exceedingly rare, and none so far is reported from a cutaneous ureterovesical stoma. Squamous cell carcinoma usually occurs as a late complication of urinary diversion, and we report the first such case in a cutaneous ureterovesical stoma with a review of published literature.

Renal Transplantation in the Setting of Prior Urinary Diversion: A Case of Poorly Differentiated Adenocarcinoma in an Ileal Conduit

Though rare, renal transplantation into a bowel containing urinary diversion is necessary in select clinical situations. Compared to renal transplant patients with functional native bladders, patients with urinary diversion have comparable long-term graft and patient survival rates. However, compounding the increased risk of malignancy in those on chronic immunosuppression are the inherent risks of urinary diversion. We present a case report of a high grade adenocarcinoma with neuroendocrine differentiation arising in an ileal conduit and discussion on the pathophysiology, management, and screening of this highly select population.

Tubulovillous Adenoma in a Urethral Neobladder Anastomosis

We present a case of a tubulovillous adenoma arising in a neobladder that was managed by cystoscopic resection. A 64 year-old male underwent a cystectomy with creation of an ileocolic neobladder urinary diversion for T2 urothelial carcinoma of the bladder. Nine years following his surgery, the patient noted several episodes of gross hematuria. Cystoscopic evaluation revealed the rare occurrence of a 3 cm tubulovillous adenoma with high-grade dysplasia at the neck of the neobladder.

Bladder Regeneration Using a Smart Acellular Collagen Scaffold with Growth Factors VEGF, FGF2 and HB-EGF

Tissue engineering may become an alternative to current bladder augmentation techniques. Large scaffolds are needed for clinically significant augmentation, but can result in fibrosis and graft shrinkage. The purpose of this study was to investigate whether smart acellular collagen-heparin scaffolds with growth factors (GFs) VEGF, FGF2, and HB-EGF enhance bladder tissue regeneration and bladder capacity in a large animal model of diseased bladder. Scaffolds of bovine type I collagen with heparin and VEGF, FGF2, and HB-EGF measuring 3.2 cm in diameter were prepared. In 23 fetal sheep, a bladder exstrophy was surgically created at 79 days of gestation. One week after birth (at full term), the bladder was reconstructed by primary closure (PC group) or using a collagen-heparin scaffold with GFs (COLGF group) and compared to a historical group reconstructed with a collagen scaffold without GFs (COL group). Functional (video urodynamics) and histological evaluation was performed 1 and 6 months after bladder repair. The overall survival rate was 57%. Cystograms were normal in all animals, except for low-grade reflux in all groups. Urodynamics showed no statistically significant differences in bladder capacity and compliance between groups. Histological evaluation at 1 month revealed increased urothelium formation, improved angiogenesis, and enhanced ingrowth of smooth muscle cells (SMCs) in the COLGF group compared to the COL group. At 6 months, improved SMC ingrowth was found in the COLGF group compared to the COL group; both scaffold groups showed normal urothelial lining and standard extracellular matrix development. Bladder regeneration using a collagen-heparin scaffold with VEGF, FGF2, and HB-EGF improved bladder tissue regeneration in a large animal model of diseased bladder. Larger GF-loaded constructs need to be tested to reach clinically significant augmentation.

Oncologic Concerns in An Exstrophied Urinary Bladder - An Indian Scenario

Exstrophy of the urinary bladder is a rare congenital anomaly which if untreated causes bladder carcinoma and intestinal tumours noted if urinary diversion is performed. It is seen that 50% of all persons afflicted with exstrophy are dead by their tenth year and 66-67% are dead by their twentieth year. It is thus a great rarity to see a case of ectopia vesicae in adulthood. Still more uncommon is to see a case of exstrophy complicated by carcinoma. Here, we report a case of papillary adenocarcinoma of ectopic urinary bladder in a 42-year-old male patient. In view of locally advanced disease, patient was given neoadjuvant chemotherapy. The case is being reported on account of its rarity to sensitise clinicians about rising incidence of carcinoma if mismanaged due to lack of protocol in oncological screening.

Intestinal seromuscular tunneling: a novel method for ureteral replacement--an experimental design

BACKGROUND

Long-segment ureteral injuries may have different etiologies. Although multiple procedures have been previously used for ureteral replacement, none of them had optimum results, and replacement of long segments of injured ureter is still a challenging surgical problem. In this article, we have hypothesized that it may be possible to use intestinal seromuscular tunneling as a novel method for ureteral replacement.

METHODS

This experimental study was conducted on eight dogs. After cutting the ureter at about its mid-part and ligating the distal part, a 10-cm tunnel was made in the seromuscular layer of small intestine using a metallic probe, and a catheter was passed through it. Proximal and distal ends of the tunnel were anastomosed to proximal end of ureter and urinary bladder, respectively. After 8 weeks, the dogs were killed, and their whole urinary system was sent for histopathologic examinations.

RESULTS

No complication was noted during the post-op period. Histopathologic examinations confirmed that the seromuscular tunnel was well patent, lined by pseudostratified transitional epithelium and without any inflammatory reaction.

CONCLUSION

Our study shows that ureteral replacement by intestinal seromuscular tunneling is anatomically possible at least in animal model. However, more well-designed prospective studies are needed to confirm its long-term functional results.

[Continent urinary diversion following anterior exenteration]

BACKGROUND

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir).

RESULTS

Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field.

CONCLUSION

Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction

AIMS

To investigate the functional outcome after supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

Retrospective follow-up investigation in a single spinal cord injury rehabilitation center. In 29 patients, urodynamic data before and after supratrigonal cystectomy and augmentation ileocystoplasty, clinical outcome and post-operative complications were evaluated.

RESULTS

The median age of the 29 patients at the time of surgery was 31 years, a median 14 years after NLUTD had occurred. At the last follow-up visit (median 2.4, range 0.4-9.0 years post-operatively), 20/29 patients (69%) were continent compared to 2/29 pre-operatively (P = 0.001). Furthermore, 16 patients required no or less detrusor relaxation therapy after augmentation ileocystoplasty. Augmentation cystoplasty resulted in a significant (P = 0.001) increase in the median bladder capacity (from 240 ml to 500 ml) and compliance (from 13 ml/cm H2 O to 50 ml/cm H2 O). The median maximum detrusor pressure had decreased significantly (P = 0.001) from 38 cm H2 O to 15 cm H2 O. Significantly (P = 0.001) fewer patients presented with a risk for renal damage (1 vs. 15 with maximum detrusor pressure >40 cm H2 O and 1 vs. 12 with detrusor compliance <20 ml/cm H2 O) at the last follow-up. The following complications were observed in 11/29 (38%) patients: paralytic and obstructive ileus, impaired bowel function, bladder stones, dehiscence, metabolic acidosis and autonomic dysreflexia.

CONCLUSIONS

Protection of renal function, adequate bladder capacity and low detrusor pressure can be achieved using supratrigonal cystectomy and augmentation ileocystoplasty in patients suffering from refractory NLUTD.

[Follow-up care - consequences of urinary diversion after bladder cancer]

Radical cystectomy is the standard of care for muscle-invasive bladder cancer. Continent urinary diversions utilizing both small and large bowel are becoming more prominent: therefore, the postoperative follow-up has to focus on different aspects. In the first instance after radical cystectomy functional issues with respect to potential stenosis, post-void residual urine and micturition disorders are important. In the early phase the oncological follow-up aims to detect local, urethral and systemic recurrences and new data show the importance of the first 3 years after surgery. Long-term follow-up focuses on metabolic aspects, such as cobalamin or bile acid deficits, acidosis and disorders of calcium and bone metabolism. Follow-up care should consider specific complications of different types of urinary diversions; however to date standardized follow-up guidelines are lacking.

First case of invasive squamous cell carcinoma in a stoma of a Monti ileovesicostomy

We report a very rare case of invasive squamous cell carcinoma (SCC) in the abdominal stoma of a Monti ileovesicostomy. Our patient underwent an uncomplicated Monti ileovesicostomy at age 16 for a neurogenic bladder. She presented 10 years later with difficulty catheterizing the stoma. A biopsy of peristomal tissue showed moderately differentiated SCC. A cystoscopy did not reveal any bladder tumours or suspicious lesions. A computed tomography (CT) scan of the abdomen and pelvis did not demonstrate metastasis. The patient underwent a complete en bloc resection of the stomal site, the Monti, a partial cuff of bladder, and 2 loops of bowel that were adherent to the Monti. Final pathology revealed pure invasive SCC arising around the stoma and negative surgical margins. Six months later, a follow-up CT scan showed no evidence of malignancy, while a cystoscopy revealed a small erythematous area in the posterior bladder wall. Urinary cytology was positive for SCC. Transurethral resection of the erythematous lesion with random bladder biopsies showed SCC in situ in the erythematous lesion and right lateral bladder wall. Staging workup was negative. The patient subsequently underwent a radical cystectomy and ileal conduit diversion with bilateral pelvic lymph node dissection. Final pathology on cystectomy specimen was SCC in situ without evidence of invasive carcinoma. The patient has remained in remission at the 3-year follow-up.

Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients

OBJECTIVES

To assess whether the detubularised isolated ureterosigmoidostomy (DIUS) technique is safe for urinary diversion after radical cystectomy.

PATIENTS AND METHODS

The study included 10 patients (mean age 61.8 years) with invasive bladder tumour, operated at the Alexandria University, Egypt. The diversion in all patients was through a DIUS, with ureteric reimplantation by an antirefluxing procedure, using an embedded-nipple technique. The patients were evaluated before and after surgery using radiological and manometric studies, and the results analysed statistically using Student's t-test.

RESULTS

Nine of the 10 patients could differentiate between urinary and stool sensation, and evacuate them separately. The mean (range) daytime frequency was 4.1 (3-5) and the mean night-time frequency was 0.5 (0-1). Before and after surgery, the respective mean resting anal pressure was 71 and 74 cm H2O (P = 0.004), the volume at first desire to defecate was 54 and 72 mL (P = 0.004) and the maximum tolerable volume was 140 and 160 mL (P < 0.001). The anorectal inhibitory reflex was lost in all patients after surgery. The mean (SD, range) basal pouch pressure was 5 (3.33, 0-10) cmH2O, and the end pressure was 13.2 (4.42, 9-20) cmH2O.

CONCLUSION

Although the Mainz II pouch has a documented efficacy for urinary diversion after radical cystectomy, the modifications we applied to the DIUS improved that method of diversion, by separating urine and stool evacuation, maintaining continence, and with a low frequency and better protection of the upper urinary tracts, resulting in an improvement in the patients' quality of life.

[Complications and their management after urinary diversion]

BACKGROUND

Bladder cancer is a common disease. It is predicted that 11,900 men and 4,500 women in Germany will be diagnosed with invasive bladder cancer in 2014. The cystectomy, which is standard treatment in muscle-invasive bladder cancer, requires urinary diversion.

PURPOSE

The goal of this article is to present the complications associated with urinary diversions and their management.

METHODS

Based on a selective literature search in PubMed and our own clinical experience, the options for urinary diversion and their management are discussed.

RESULTS

In patients treated with curative intent, orthotopic bladder replacement is preferred. In patients with palliative intent, incontinent cutaneous urinary diversion is commonly used. The present work shows the variety of early and late complications, peri-/postoperative mortality, and the management of these patients.

CONCLUSION

After cystectomy, various methods for urinary diversion are available, which can be used in curative and/or palliative intent. Crucial to the success and the long-term satisfaction of the patients is selection of the right urinary diversion method.

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

CONTEXT

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

OBJECTIVE

To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper.

EVIDENCE SYNTHESIS

Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option.

CONCLUSIONS

Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

Adenocarcinoma of the Ileal Conduit in a Patient Born With Classic Bladder Exstrophy

Bladder exstrophy is a rare birth defect that typically requires patients to undergo multiple surgical procedures throughout the course of their childhood. Many ultimately undergo operations that use segments of bowel for the reconstruction and/or augmentation of the urinary tract, which imparts an increased risk of malignancy in these patients. We present the case of a 59-year-old man with a history of bladder exstrophy managed with ureterosigmoidostomies revised to an ileal conduit who developed a large adenocarcinoma in the ileal conduit that extended into small bowel, sigmoid colon, and ureter.

Long-term consequences of posterior urethral valves

Posterior urethral valves (PUV) are the most common congenital cause of bladder outlet obstruction in infancy, and it is the effect of this obstruction on the bladder and the kidneys that will decide a patient's prognosis. With the improvements in diagnosis and treatments, what was previously a poor prognosis for boys with PUV has improved, and more patients will encounter the long-term sequelae of PUV during puberty and adulthood. In these patients the long-term prognosis in terms of renal and bladder function and fertility, as well as the risk of malignancy in those whose bladders were augmented with gastrointestinal segments, is still a matter of great concern and all of these topics will be discussed in this article.

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.