Adenocarcinoma following urinary diversion

Abstract

The use of bowel segments in urinary diversions has been associated with an increased risk of neoplasia. This report describes three cases of intestinal adenocarcinoma following urinary diversion. In the first case, a 73-year-old woman developed moderately-differentiated colonic adenocarcinoma in her Indiana pouch 10.5 years after cystectomy. The second case involved a 77-year-old man with well-differentiated adenocarcinoma in his Indiana pouch 9 years after radical cystoprostatectomy and en bloc urethrectomy. The third case involved a 38-year-old man with moderately-differentiated adenocarcinoma arising in his ileal conduit 33 years after the creation of the conduit. These cases highlight the diagnostic signs of adenocarcinoma arising in urinary diversions and emphasize the importance of lifelong surveillance in these patients. IntroductionExposure of intestinal mucosa to urine has been associated with an increased risk of tumorigenesis.1 Although the pathogenesis of these tumours has not been well-established, many possible explanations exist. First, in patients with ureterosigmoidostomy, the blending of fecal and urinary materials is thought to increase the production of nitrosamines at the site of the uretero-colonic anastamosis.2 Second, in the absence of fecal and urinary blending, chronic inflammation, irritation, presence of stones and elevation of a variety of substances have been implicated in carcinogenesis within the intestinal segment.1 The carcinogenic substances currently being investigated include nitrosamine, reactive oxygen species, epidermal growth factor, transforming growth factor, cyclo-oxygenase, mucin and ornithine transcarbamylase.1 Many of these substances have also been suggested as potential causes of adenocarcinoma in not only Indiana pouches and ileal conduits, but also in neobladders. In the absence of mixing of the urinary and fecal streams, there does not appear to be any increased risk per se in a urinary diversion beyond that inherent in the bowel segment in a non-diverted patient. Third, de novo adenocarcinoma may develop in any bowel segment, including the portion used in urinary diversions.3 Thus, the origin of these tumours is likely to be multifactorial. The following uncommon presentations of adenocarcinoma following urinary diversion surgery emphasize the diverse circumstances in which these malignancies can develop. Case 1A 73-year-old female with a history of recurrent non-muscle invasive urothelial carcinoma of the bladder came to urology clinic. Her chief complaint was hematuria 10.5 years after radical cystectomy, extended lymph node dissection and continent urinary diversion with an Indiana pouch. Final pathology of the cystectomy showed a pTaG2 urothelial carcinoma of the bladder and carcinoma in situ. She had been in continuous follow-up postoperatively without evidence of recurrence. Magnetic resonance imaging (MRI) of the abdomen demonstrated a solid 2.5-cm mass localized in the posterior-inferior wall inside the Indiana pouch (Fig. 1, panel A). Endosco...

Tubular Adenoma in the Indiana Pouch of a Patient With a History of Bladder Exstrophy

“… 1 Prior cases of tumor formation in Indiana Pouches involve patients over the age of 60. 2 , 3 , 4 The current patient had Indiana Pouch construction at the age of 18 secondary to her history of bladder exstrophy. The average time between pouch creation and tumor detection was 8.9 years in the previous cases reported by Jian et al, while in this case the pouch was in place 24 years before any polyp was detected.…”

“…In addition, unlike previously reported cases of adenocarcinoma in an Indiana Pouch, the current finding was not preceded by gross hematuria or other symptoms. 2 , 3 , 4 Instead it was found incidentally. If left untreated, the tubular adenoma would eventually have progressed to adenocarcinoma.…”

“…One such substance, nitrosamine, is increased with the mixing of feces and urine. 2 The lack of similar mixing in diversions such as the Indiana Pouch help explain why tumors are rarely reported in these cases. The following case is the first report of a tubular adenoma with high grade dysplasia arising in an Indiana Pouch constructed for management of bladder exstrophy after cystectomy.…”