• • Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy ~ r ANTHONY ELISCO, DO J\ \ LEONARD H. FINKELSTEIN, DO ( \ \

Bladder tumors develop after the The pertinent radiologic findings, definitive diagnosis of upper urinary tract carcinoma therapy, and postoperative results are discussed, in approximately 20% of cases, whereas the and three conclusions regarding the diagnostic incidence of upper urinary tract tumor after dilemma in the asymptomatic patient are present­ the diagnosis of bladder cancer is low, approx­ ed, along with technical difficulties associated with imately 2%. In a 64-year-old man who had the surgical management. undergone cystoprostatectomy treatment of Upper urinary tract tumors, that is, those involv­ bladder carcinoma 6 years previously, with ing the hollow collecting system of the kidneys the sigmoid conduit used for supravesicle including the ureters, are an uncommon occurrence. diversion, a transitional cell carcinoma that Review of the literature revealed that the incidence developed in the conduit was not revealed of upper urinary tract tumors after diagnosis of with intravenous pyelography at regular fol­ bladder carcinoma was 2.2%.1 This is strikingly low-up intervals. The patient had only hema­ slight in comparison with the 20% incidence report­ turia. After an obstructed left kidney, left ed for antecedent bladder cancer after upper uri­ ureteral stricture, and a filling defect in the con­ nary tract transitional cell carcinoma. duit were observed radiologically and biop­ In patients with transitional cell carcinoma of sy revealed a transitional cell cacinoma at the the upper urinary tract after cystectomy, follow-up ureterosigmoid junction, the patient under­ is particularly difficult. Hastie and associates2 went left nephroureterectomy, partial resec­ reported that IVP after cystectomy is of low yield in tion of a third of the sigmoid conduit, and asymptomatic patients. When a diagnosis of upper right ureteral reimplantation. The occurrence urinary tract disease is made, treatment should of upper urinary tract carcinoma after treat­ consist of nephroureterectomy with partial resec­ ment of bladder cancer should be considered tion of the neobladder cuff. even in light of intravenous pyelography that In the age of ureterosigmoidostomies, when the shows no abnormality; and when such carci­ mixing of feces and urine was commonplace, patients nomas occur in this situation, disease involv­ had an increased risk of colon carcinoma, which ing the conduit should be ruled out. was well documented by Golomb and associates.3 (Key words: Transitional cell carcinoma, With the advent of new techniques, the separation radical cystoprostatectomy, sigmoid conduit, of urine and feces is now standard. However, Shaa­ nephroureterectomy, ureteral carcinoma) ban and associates4 described an increased risk of colon carcinoma from chronic inflammatory changes. Transitional cell carcinoma of the upper uri­ We report a case of upper urinary tract transition­ nary tract after radical cystectomy is an uncom­ al cell carcinoma in a patient 6 years after radical mon finding, developing in only 3% to 8% of cases. cystoprostatectomy. In a man in his 60s, transitional cell carcinoma was discovered protruding into the sigmoid conduit 6 Report of case years after cystoprostatectomy. Routine intravenous A 64-year-old man was admitted to the urologic service pyelography (IVP) during the 6 years of follow-up for evaluation of gross hematuria. His urologic history failed to detect the pathologic condition. Hematuria had been consistent with transitional cell carcinoma of the developed. urinary bladder for approximately 14 years. During that time, the patient underwent treatment by way of transurethral resection, laser ablation, and intravesicle administration ofthiotepa. Six years before admission, a From the Division of Urology, Department of Surgery, Philadel­ recurrence was found to have progressed from patholog­ phia College of Osteopathic Medicine, Philadelphia, Pa. Dr Elis­ co is a resident in urology; Dr Finkelstein is professor, Division ic grade II to grade III, with involvement of the distal of Urology. portion of the left ureter and resultant hydronephrosis. Correspondence to Leonard H. Finkelstein, DO, President, After percutaneous nephrostomy, and negative evaluation Philadelphia College of Osteopathic Medicine, 4170 City Ave, for metastasis, the patient underwent radical cysto­ Philadelphia, PA 19131-1694. prostatectomy with the sigmoid conduit used for the

Case reports • Elisco and Finkelstein JAOA • Vol 95 • No 10 • October 1995 • 613 Figure 2. Radiograph of the sigmoid loop shows a filling defect at the ureterosigmoidostomy, representing the large intrasig­ moid tumor.

biopsies as well as endoscopic examination of the con­ Figure 1. Anterior nephrostographic view reveals stricture at duit. Right retrograde ureteropyelography revealed the ureterosigmoidjunction. This stricture was found to be a high­ right-side system to be normal. Pathologic evaluation grade transitional cell carcinoma. revealed a high-grade transitional cell carcinoma at the ureterosigmoid junction. A filling defect in the conduit supravesicle diversion. This particular diversion was cho­ near the region of the left ureterosigmoidostomy was sen because the left ureter was short as a result of involve­ seen at radiography of the sigmoid colon (Figure 2). Com­ ment of the distal portion. After resection, analysis of a puted tomography of the abdomen and pelvis, as well as frozen section of the ureter revealed the distal end to be bone scanning, failed to reveal any metastatic spread. free of tumor. The postoperative course was favorable, The patient underwent left nephroureterectomy with and the patient was discharged, with follow-up to pro­ partial resection of the sigmoid conduit and right ureter­ ceed on an outpatient basis. Final pathologic evaluation al reimplantation. At the time of surgery, the sigmoid revealed a high-grade malignancy of the bladder, with­ conduit was opened, and a large mass measuring approx­ out involvement of the lymph nodes. As noted, a small focus imately 3 cm in diameter was visualized protruding from involved the distal portion of the left ureter, which was the left ureteric orifice into the conduit. The mass did resected. not appear to involve the conduit. Approximately a third Renal scanning at the time the patient was seen for of the conduit was resected. The patient tolerated the evaluation of hematuria demonstrated an obstructed left procedure well. Pathologic evaluation revealed a high­ kidney. A percutaneous nephrostomy tube was placed, grade transitional cell carcinoma ofthe distal portion of and anterior nephrostography was performed (Figure 1), the left ureter protruding into, but not involving, the sig­ which demonstrated a stricture of the ureter at the moid conduit (Figure 3). No metastatic nodes or tumor was ureterosigmoid junction. The patient underwent brush found outside the ureter. The mucosa and wall of the

614· JAOA • Vol 95 • No 10 • October 1995 Case reports • Elisco and Finkelstein Figure 3. Histologic specimen from ureterosigmoid junction. Eval­ Figure 4. At 3 months after surgery, intravenous pyelogram shows uation confirmed high-grade transitional cell carcinoma. normal right ureter. conduit revealed chronic inflammation but no tumor diagnosis was 72 months (range, 54 to 91 months)!. involvement. The right ureter was free of tumor. With these data in mind, it appears that metachro­ Three months after surgery, routine IVP revealed a nous tumor of the left ureter developed in this normally functioning right kidney and ureter, with no patient well Within the time period reported in the identifiable filling defects (Figure 4) _ literature. Further evidence suggesting a metachro­ nous lesion is that the tumor was of high grade and Discussion involved the left ureter, which resulted in further Synchronous and metachronous transitional cell car­ resection of that segment. cinoma of the urinary tract has been well docu­ Mter cystoprostatectomy, the patient under­ mented. However, the incidence of metachronous went follow-up IVP regularly, and readings were bladder carcinoma with involvement of the upper negative before symptoms appeared. Hastie and urinary tracts is much different than metachro­ associates2 reported that in more than 400 post­ nous upper urinary tract transitional cell carci­ cystectomy patients, routine IVP failed to detect noma to the urinary bladder. Yousem and associ­ any upper urinary tract tumors when the patients ates! found that in nine studies, the average were asymptomatic. They concluded that routine incidence of upper urinary tract tumor after a IVP in evaluation for upper urinary tract tumors diagnosis of bladder carcinoma was 2.2%, rang­ in patients postcystectomy are oflittle value ifthe ing from 0% to 6.4%.2 The average interval between patient is asymptomatic. diagnosis was 77 months, with a range of 0 to 132 A question arose as to whether the distal mar­ months. A review of the literature by the same gin of resection of the left ureter had microscopic inva­ group found that in 14 studies, the prevalence of sion. Our patient clearly had ureteral disease at antecedent bladder tumors after a diagnosis of the time of cystectomy_ However, pathologic evaluation upper tract transitional cell carcinoma was 20% revealed tumor-free margin after further resection (range, 6% to 40%). The average interval between of the distal portion of the left ureter. Whether

Case reports • Elisco and Finkelstein JAOA • Vol 95 • No 10 • October 1995 • 615 microscopic invasion was undetected at the time of because of the low diagnostic yield of routine cystectomy is the question. Linker and Whitmore5 IVP. clearly demonstrated an 8.8% incidence of carcino­ • In doing nephroureterectomy for recurrent upper ma in situ in the remaining portions of ureter in urinary tract disease, a cuff containing at least patients after cystectomy. They found no greater 2 cm of normal bowel should be removed from risk for later development of upper urinary tract the conduit to rule out residual disease involv­ tumors because of the presence of carcinoma in situ ing the conduit. in the distal ureter. In our patient, the diagnosis • If there is a question of involvement ofthe con­ was a filling defect in the distal portion of the left duit near the other ureteral anastomosis, reim­ ureter, hydronephrosis, and a nonfunctioning left kid­ plantation may be advised. ney. Our patient underwent what is considered the Finally, although they are uncommon, malig­ "gold standard" of care, a left nephroureterectomy nant changes of the colonic conduit should be ruled with partial conduit resection and right ureteral out, particularly adenocarcinoma, because of the reimplantation. Mufti and associates6 reviewed six chronic mucosal inflammation caused by urine. cases and arrived at the same conclusion as Link­ er and Whitmore.5 They state that in performance of a nephroureterectomy after cystectomy, part of the References cuff at the ureter conduit anastomosis should be 1. Yousem DM, Gatewood OB, Goldman SM, et al: Synchro­ resected because of the high rate of recurrence (16% nous and metachronous transitional cell carcinoma of the uri­ to 64% of ureteral stump carcinoma after nephro­ nary tract: Prevalence, incidence, and radiographic detection. ureterectomy) . Radiology 1988;167:613-618. 2. Hastie JK, Hamcly MC, Collins MC, et al: Upper tract tumors following cystectomy for bladder cancer: Is routine intravenous Comment urography worthwhile? Br J Urol 1991;67:29-31. The case described here represents an uncommon 3. Golomb J , Klutke CG, Raz S: Complication of bladder sub­ occurrence of transitional cell carcinoma of the upper stitution and continent urinary diversion. Urology 1989;34:329- urinary tract, protruding into a sigmoid conduit 6 years 338. after radical cystectomy. Routine follow-up failed 4. Shaaban AA, Sheir KZ, El-Baz MZ: Adenocarcinoma in an iso­ to demonstrate any abnormality until the patient lated rectosigmoid bladder: Case report. J Urol1992;147:457- 458. became symptomatic (hematuria). Mter review of 5. Linker DG, Whitmore WF: Ureteral carcinoma in situ. J the literature, we came to several conclusions: Urol1975;113:777-779. • Although recurrence in an upper urinary tract 6. Mufti GR, Gove JRW, Riddle PR: Nephroureterectomy after is uncommon, it presents a difficult dilemma radical cystectomy. J Urol 1988;139:588-589.

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