Colonic Adenocarcinoma: A Delayed Complication of Ureterosigmoidostomy

THE JOURNAL OF UROLOGY

Copyright © 1977 by The Williams & Wilkins Co.

ADENOCARCINOMA: DELAYED COMPLICATION URETEROSIGMOIDOSTOMY CHARLES D. PARSONS, MICHAEL H. THOMAS

AND

ROBERT A GARRETT

From the Department of Urology, Indiana University Medical Center, Indianapolis, Indiana

ABSTRACT

Two cases a:re reported of adenoca:rcinoma of the colon developing 26 and 33 years after the had undergone ureterosigmoidostomy. The literature is reviewed and the clinical "''-""''···~c, tions are discussed. .,v""'".,,u

urinary diversion by ureterosigmoidostomy has a popular and reliable procedure despite its recogof anastomotic obstruction nized potential for cv,.uµ,u
Case 1. R. H., a 29-year-old white man, had undergone

bilateral ureterosigmoidostomy for exstrophy of the bladder in 1947, when he was 3 old. The patient required a right 4 years and the left ureterosigmoidostomy to a left ureteral ileal conduit for pyelonephritic ~v,u,,,u~vu,,v,,,~ in 1957. The ureterosigmoid anastomoses were situ and the patient did well clinically until 1973, when he had complaints of abdominal distension and n~.:!·':r11;;~g A barium enema demonstrated a large bowel obwhich to be a non-resectable poorly differenof the colon and appeared to arise the ureterosigmoid anastomosis (figs. l and 2). metastatic disease was found at exploration and died of the colonic carcinoma. R. K., a 35-year-old white man, had undergone bilateral ureterosigmoid urinary diversion for exstrophy of the bladder in 1941, when he was 18 months old. The patient did well. and, subsequently, was lost to followup. In 1974 the patient was seen for intermittent lower abdominal cramping, and occasional blood in the stool generally, was continuing to feel quite well. Evaluation included an excrnto_r; urogram (IVP), which demonstrated non-function of the right kidney and failure of any contrast material to rise above the sigmoid flexure into the descending colon (fig. 3, A). A contrast study of the col.on confirmed the presence of a large core" lesion in the sigmoid colon consistent with carcinoma (fig. 3, B). Exploratory laparotomy revealed a partially obstructing carcinoma of the sigmoid colon lymphatic metastases (Duke's C). The patient was managed with aggressive colonic resection but, subsewidespread metastatic disease developed. The patient now in the terminal stages of the illness. Pathological examination of the resected tissue confirmed the location of the tumor at the site of the previous ureterosigmoid anastomosis 4). .,u,.,u,.a,,.uu November 24, 1976.

Fm. 1. Case 1. Barium enema shows complete large bowel obstruc-·

tion.

Fm. 2. Case 1. Biopsy near ureterosig-moidostomy shows infiltrating adenocarcinoma. Reduced from x 100.

mscussmN Development of adenocarcinoma of the colon at the site the ureterosigmoid anastomosis has been "'""''"''uL,cc~ and ported on numerous occasions. Excluding cases which tumor appeared to be of transitional cell histology and

meeting of North Central Section, American "'~'""·'"'"w", Palm Beach, Florida, October 17-24, 1976.

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PARSONS, THOMAS AND GARRETT

Fm. 3. Case 2. A, IVP of non-functioning right kidney. B, barium enema illustrates "apple core" lesion of sigmoid colon

Fm. 4. Case 2. Section of colon illustrates adenocarcinoma

bly arose from urothelial origin there are at least 25 cases of adenocarcinoma in the colon in the current literature (see table). 1 ~ 20 These carcinomas have been recognized from 6 to 46 years after the procedure. The average interval between diver-

sion and diagnosis was approximately 25 years when the diversion was done for benign disease and 8 years when it was done for pelvic carcinoma. The mean age of patients was 34.3 years and 60.5 years when diverted for benign and malignant disease, respectively. Since the majority of these diversions was performed in children for bladder exstrophy the carcinomas are being found in relatively young adults. Inasmuch as carcinoma of the colon is predominantly a neoplasm of the elderly, its peak incidence being in the seventh decade, the finding of malignancy in the younger age group suggests some carcinogenic influence. Furthermore, the frequent location of such neoplasms at or adjacent to the ureterosigmoid anastomosis further suggests a probable relationship between the procedure and the subsequent carcinogenesis. Several theories relating the potential carcinogenic effect of ureterosigmoid urinary diversion have been offered. The possibility of a carcinogen in the urine inducing the neoplastic change in the colonic mucosa has been raised. However, one would anticipate a generalized effect in the distal colonic mucosa rather than the local changes in the anastomotic site that have been observed. Furthermore, the appearance of carcinoma in the anastomotic site after subsequent ileal diversion, as illustrated in our first case and 3 cases in the literature, would seem to suggest that a urinary carcinogen is less likely. 12• 15• 16 A second theory suggests that the transitional cell epithelium of the distal ureter may undergo adenomatous

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COLONIC ADENOCARCINOMA

Colonic adenocarcinomas following ureterosigmoidostomies

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Reference Hammer 1 Dixon and Weismarn12 Wilson' M.G.H. 4 Amar' Aldis 6 Scheinma:n7 Kozak and associates 8 Urdaneta and associates" Urdaneta and associates' Urdaneta and associates 9 Kille and Glick 10 Richter and Ginsberg'' and associates" """'"- ,___ and associates 13 'Nhitaker and associates" Brekkan and associates 14 Brekkan and associates'' Brekkan and associates" Rivard and associates i .s Tank and associates 16 Carswell and associates 17 and associates 18 and associates 19 Present report Present report

---:L:-a---------------------------

Original Condition 60M

33-M 47-F 63-M 64-M 33-F 51-M 17-M 40-F

64-M 34-F 26-M 24-F

23-M 57-M 22-M 23-F

42-M 47-M 38-M 55-M 27-F 21-F 34-M 22-M

29-M 35-M

tency (yrs.)

Exstrophy Exstrophy Congenital incontinence Transitional cell Ca, bladder Transitional cell Ca, bladder Exstrophy Transitional cell Ca, bladder Exstrophy Interstitial cystitis Squamous cell Ca, bladder Exstrophy Incontinence owing to epispadias Exstrophy Exstrophy Exstrophy Post-traumatic urinary fistula Exstrophy Exstrophy Exstrophy Exstrophy Exstrophy Exstrophy Exstrophy Trauma to bladder Persistent urinary fistula Exstrnphy Exstrophy

adenocarcinoma seems ,-m"""VA''"''~'" examination of the reported cases has suggests a colonic mucosal of pv,ocn,cnc explanation has been the mucosal fold at the anastomotic site, degeneration to carcinoma in response to chronic irritation from the and fecal We have observed 3 such adenomatous from the HY'Atc>1m<11

our current concern. 'hc>rc,torc> we a resection should be done and an ileal conduit should be created if an adenomatous is found at the ureterocolonic anastomosis. Regardless of the pathogenesis the high incidence of carcinoma in patients who had had ureterosigmoid diversion far exceeds the expected incidence of carcinoma of the colon in the general population. Our 2 cases are among 29 diverted to ureterosigmoidostomy for greater than 10 for disease. Urdaneta calculated that the inciof carcinoma after ureterosigmoidostomy is 13,300 per cases. 9 Our incidence is at least per 100,000 cases Urdaneta's since many of our been lost to This incidence is substangreater than the c1c.1u,:uc:u incidence in the of 24 per 100,000 cases. there would appear to a 280 and 550-fold increase in the incidence of who have these patients often age than the general 0 ~--"·~~ of this reanastomosis is performed in situ or must be considered as a

10

30

31 8 6

15 9

15 17 9

30 15 22

23 27 15

20 36 41 19

46 24 17

26 15

26 33

Description of Tumor Colloid Ca Polypoid adenoca. Anaplastic Ca, colon Polypoid low grade adenoca. Mucinous adenoca. Anaplastic Ca Mucinous adenoca. Mucin-producing adenoca. Mucinous Ca Adenoca., colon Infiltrating undifferentiated Ca Polypoid adenoca. Infiltrating adenoca. Adenoca., colon Adenoca., undetermined origin Polypoid mucus-secreting adenoca. Low grade polypoid Ca and another anaplastic Ca Infiltrating adenoca., colon Infiltrating mucinous Ca Low grade polypoid adenoca. and adenomatous polyp Adenoca., bilat. Mucinous adenoca. Adenoca. Mucinous adenoca. Iviucinous adenoca. Adenoca. Adenoca.

lowup examinations in these patients renal scans may be as informative clinically with much less radiation. Also of ex·· treme importance is detecting any history of change in bowel habits, since this may be the first clue to a neoplasm. In view of the potential complications of barium reflux into the ureters some investigators have suggested the use of water soluble contrast medium 23 Presently, we are using barium contrast agents and have had no difficulties. Sigmoidoscopy and colon·· oscopy may be helpful although the anastomoses are difficult to visualize endoscopically on occasions. Any late development of ureterocolonic obstruction, as noted on an IVP or- renal scans, should prompt contrast study of the colon, since neoplasia rather than delayed anastomotic fibrosis may be underly· ing the change. At present we do not recommend abandon" ment of colonic urinary diversions. In pelvic malignancy its use remains helpful in palliation. Ureterosigmoidostomy in the child may well have to be reconsidered as a long--term method of management. Early ureterosigmoidostomy with subsequent conversion to the ileal loop has the advantage continence without appliance in the psychically fonnative years. However, the results in case 1 suggest that even this plan may be hazardous. SUMMARY

The development of adenocarcinoma at the site of a urete.rosigmoid anastomosis in a 29 and a 35-year-old white man 26 and 33 years after the ureterosigmoid urinary diversion for bladder exstrophy, focuses our attention on this late complication ofureterocolonic anastomosis. The location of such tumors at the site of anastomosis and the relatively earlier age of patients with this malignancy make the relationship between ureterosigmoid diversion and the development of carcinoma almost certain. We must express our concern regarding this possible long-term complication in view of the recent enthusiasm for ureterocolonic conduits for supravesical urinary diversions. We urge the careful followup and evaluation of such patients. REFERENCES 1. Hammer, E.: Cancer du colon sigmoide dix ans apres implantation des ureteres d'une vessie extrophiee. J. d'Urol., 28: 260,

1929. 2. Dixon, C. F. and Weismann, R. E.: Polyps of the sigmoid occur·

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3. 4.

5. 6. 7. 8. 9.

10. 11. 12.

PARSONS, THOMAS AND GARRETT

ring 30 years after bilateral ureterosigmoidostomy for exstrophy of the bladder; report of a case. Surgery, 24: 1026, 1948. Wilson, L. L.: Carcinomatous ureteric obstruction 30 years after ureterosigmoidostomy. Aust. New Zeal. J. Surg., 27: 158, 1957. Massachusetts General Hospital; Case No. 44052. New Engl J. Med., 258: 244, 1958. Amar, A. D: Neoplastic obstruction of the ureterosigmoid anastomosis. J. Urol., 86: 334, 1961. Aldis, A. S.: Carcinoma of colon following transplantation of the ureters, and at the site of the transplantation. Proc. Roy. Soc. Med., 54: 159, 1961. Scheinman, L. J.: Tumor at site of ureterosigmoidostomy nine years postoperatively. J. Urol., 85: 934, 1961. Kozak, J. A., Watkins, W. E. and Jewell, W. R.: Neoplastic stomal obstruction: a complication of ureterosigmoidostomy. J. Urol., 96: 691, 1966. Urdaneta, L. F., Duffell, D., Creevy, C. D. and Aust, J.B.: Late development of primary carcinoma of the colon following uretensigmoidostomy; report of three cases and literature review. Ann. Surg., 164: 503, 1966. Kille, J. N. and Glick, S.: Neoplasia complicating ureterosigmoidostomy. Brit. Med. J., 4: 783, 1967. Richter, R. M. and Ginsberg, S. A.: Late development of colonic carcinoma complicating ureterosigmoidostomy. Amer. J. Surg., 113: 843, 1967. Oetjen, L. H., Jr., Campbell, J. L., Thomley, W. W. and Parsons, R. L.: Carcinoma of the colon following ureterosigmo-

idostomy. Report of a case. J. Urol., 104: 536, 1970. 13. Whitaker, R. H., Pugh, R. C. B. and Dow, D.: Colonic tumors following ureterosigmoidostomy. Brit. J. Urol., 43: 562, 1971. 14. Brekkan, E., Colleen, S., Myrvold, H., duRietz, B., Schniirer, L.-B. and Fritjofsson, A.: Colonic neoplasia: a late complication ofureterosigmoidostomy. Scand. J. Urol. Nephrol., 6: 197, 1972. 15. Rivard, J-Y., Bedard, A. and Dionne, L.: Colonic neoplasms following ureterosigmoidostomy. J. Urol., 113: 781, 1975. 16. Tank, E. S., Karsch, D. N. and Lapides, J.: Adenocarcinoma of the colon associated with ureterosigmoidostomy: report of a case. Dis. Colon & Rectum, 16: 300, 1973. 17. Carswell, J. J., III, Skeel, D. A., Witherington, R. andOtken, L. B., Jr.: Neoplasia at the site of ureterosigmoidostomy. J. Urol., 115: 750, 1976. 18. Shapiro, S. R., Baez, A., Colodny, A. H. and Folkman, J.: Adenocarcinoma of colon at ureterosigmoidostomy site 14 years after conversion to ileal loop. Urology, 3: 229, 1974. 19. Preissig, R. S., Barry, W. F., Jr. and Lester, R. G.: The increased incidence of carcinoma of the colon following ureterosigmoidostomy. Amer. J. Roentgen., 121: 806, 1974. 20. Hanley, H. G.: Personal communication to Gillman. 22 21. Willis, R. A.: The Borderland of Embryology and Pathology. London: Butterworth & Co., Ltd., 1958. 22. Gillman, J. C.: Adenomatous polyp of bowel following ureterocolic anastomosis. Brit. J. Urol., 36: 264, 1964. 23. Goodwin, W. E.: Discussion of paper by Urdaneta and associates.9