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Late ureteral conduit urinary leak as a presentation of urothelial carcinoma of the ureter
CASE REPORT
LATE URETERAL CONDUIT URINARY LEAK AS A PRESENTATION OF UROTHELIAL CARCINOMA OF THE URETER ALAN SO, LIAM HICKEY,
AND
RICHARD NORMAN
ABSTRACT Urinary leakage at the ureteroenteric anastomosis in patients with urinary diversion is a rare complication that usually occurs in the early postoperative period, regardless of the indication for surgery. To our knowledge, ureteroenteric urinary leaks that occur late in the postoperative period have not been described. We present a unique case of a late ureteroenteric anastomotic leak within an ileal conduit that occurred as a result of recurrent urothelial carcinoma of the ureter at the site of anastomosis. UROLOGY 59: 946iv–946v, 2002. © 2002, Elsevier Science Inc.
A
72-year-old man, who had undergone radical cystectomy (for Stage pT2a urothelial carcinoma [UC]) with ileal conduit urinary diversion 9 years prior, presented with fever, chills, and peristomal abdominal pain of 8 days’ duration. The pathologic studies at the time of the initial surgery had revealed negative resection margins at both ureters and bladder. His course since surgery had been uneventful; he was not taking medication and had no other medical problems. The physical examination revealed peristomal tenderness with minimal guarding and good bowel sounds. The urinary stoma appeared healthy and patent. The laboratory studies revealed hematuria and pyuria, mildly elevated creatinine (170 mol/L) and urea (10 mmol/L), and leukocytosis with left shift. Abdominal ultrasonography revealed right hydronephrosis and a fluid collection in the right lower quadrant. A nephrostomy tube was placed with ultrasound guidance percutaneously in the right kidney, and this revealed pus. The patient improved clinically after drainage and intravenous antibiotics, and 5 days later, a nephrostogram was performed revealing a urinary leak at the site of the right ureteral anastomosis (Figs. 1 and 2). A loopFrom the Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada Address for correspondence: Alan So, M.D., Department of Urology, Dalhousie University, Room 294- 5 South, QEII Health Sciences Centre, VG Site, 1278 Tower Road, Halifax, NS B3H 2Y9 Canada Submitted: November 29, 2001, accepted (with revisions): January 24, 2002
946iv
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. Anterograde nephrostogram showing normal proximal and mid-right ureter with early extravasation at the distal ureter.
ogram of the conduit was also performed. It revealed no reflux up the right ureter, but contrast refluxed into the left ureter, and this anastomosis appeared healthy. At laparotomy, a mass at the right ureteral conduit anastomosis was found; this was apparently the site of the urinary leakage. The mass, consisting of approximately 4 cm of the conduit and both distal ureteral segments was resected from the conduit. Using the remaining ileal segment, the con0090-4295/02/$22.00 PII S0090-4295(02)01554-6
FIGURE 2. Late-phase anterograde nephrostogram showing normal right renal collecting system and prominent extravasation of contrast from the right distal ureter.
duit was reconstructed, and bilateral end-to-side reanastomosis was performed. Histologic studies of the mass revealed right distal, muscle-invasive, ureteral UC. This tumor had invaded the conduit mucosa and lymphatics. The ureteral resection margins were negative. COMMENT Early postoperative urinary leakage at the ureteral conduit anastomosis has been reported to occur in approximately 2% of cases with ileal conduits and is attributed to technical error.1 To our knowledge, we present the first case of a late urine leak of an ileal conduit at the site of a ureteral conduit anastomosis due to recurrence of UC in the ureter. Ureteral UC occurs in 2% to 4% of patients with bladder UC2 and most commonly pre-
UROLOGY 59 (6), 2002
sents in the distal ureter.3 The most common symptoms of ureteral tumors include gross hematuria and flank pain, two symptoms that our patient did not have. Urinary ascites is a rare complication of ureteral tumors and has never been documented at the site of ureteroenteric anastomosis in patients who have undergone previous cystectomy for bladder cancer.4 Interestingly, upper tract tumors in patients with bladder tumors usually present at a median of 40 to 170 months.2 UC of the ureter is exceedingly rare in patients with ileal conduits. Tumors of the bowel used in urinary diversion are estimated to occur in up to 29% of cases.5 These tumors occur most commonly when ureterosigmoidostomy is performed, and, not surprisingly, most malignant tumors are adenocarcinomas.5 Local invasion and even tumor seeding from upper tract UC may also occur. In our case, UC spread from the ureter, invaded the conduit, and compromised the anastomosis, allowing urinary leakage. Obviously, there is a theoretical risk for the patient to develop tumor seeding into the abdomen and peritoneum secondary to the urine leak. However, the tumor is more likely to recur locally at the new ureteroenteric anastamoses—in the ileal conduit or remaining urothelium. Thus, annual urinary cytologic analysis from the ileal conduit and intravenous urography will be essential components of our patient’s follow-up to evaluate for tumor recurrence. REFERENCES 1. Skinner DG, Crawford ED, and Kaufman JJ: Complications of radical cystectomy for carcinoma of the bladder. J Urol 123: 640 – 643, 1980. 2. Oldbring J, Glifberg I, Mikulowski P, et al: Carcinoma of the renal pelvis and ureter following bladder carcinoma: frequency, risk factors and clinicopathological findings. J Urol 141: 1311–1313, 1989. 3. Yousem DM, Gatewood OM, Goldman SM, et al: Synchronous and metachronous transitional cell carcinoma of the urinary tract: prevalence, incidence, and radiographic detection. Radiology 167: 613– 618, 1988. 4. Walsh PC, Retik AB, Vaughan ED Jr, et al (Eds): Campbells’ Urology, 7th ed. Philadelphia, WB Saunders, 1998. 5. Fichtner J. Follow-up after urinary diversion. Urol Int 63: 40 – 45, 1999.
946v
LATE URETERAL CONDUIT URINARY LEAK AS A PRESENTATION OF UROTHELIAL CARCINOMA OF THE URETER ALAN SO, LIAM HICKEY,
AND
RICHARD NORMAN
ABSTRACT Urinary leakage at the ureteroenteric anastomosis in patients with urinary diversion is a rare complication that usually occurs in the early postoperative period, regardless of the indication for surgery. To our knowledge, ureteroenteric urinary leaks that occur late in the postoperative period have not been described. We present a unique case of a late ureteroenteric anastomotic leak within an ileal conduit that occurred as a result of recurrent urothelial carcinoma of the ureter at the site of anastomosis. UROLOGY 59: 946iv–946v, 2002. © 2002, Elsevier Science Inc.
A
72-year-old man, who had undergone radical cystectomy (for Stage pT2a urothelial carcinoma [UC]) with ileal conduit urinary diversion 9 years prior, presented with fever, chills, and peristomal abdominal pain of 8 days’ duration. The pathologic studies at the time of the initial surgery had revealed negative resection margins at both ureters and bladder. His course since surgery had been uneventful; he was not taking medication and had no other medical problems. The physical examination revealed peristomal tenderness with minimal guarding and good bowel sounds. The urinary stoma appeared healthy and patent. The laboratory studies revealed hematuria and pyuria, mildly elevated creatinine (170 mol/L) and urea (10 mmol/L), and leukocytosis with left shift. Abdominal ultrasonography revealed right hydronephrosis and a fluid collection in the right lower quadrant. A nephrostomy tube was placed with ultrasound guidance percutaneously in the right kidney, and this revealed pus. The patient improved clinically after drainage and intravenous antibiotics, and 5 days later, a nephrostogram was performed revealing a urinary leak at the site of the right ureteral anastomosis (Figs. 1 and 2). A loopFrom the Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada Address for correspondence: Alan So, M.D., Department of Urology, Dalhousie University, Room 294- 5 South, QEII Health Sciences Centre, VG Site, 1278 Tower Road, Halifax, NS B3H 2Y9 Canada Submitted: November 29, 2001, accepted (with revisions): January 24, 2002
946iv
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. Anterograde nephrostogram showing normal proximal and mid-right ureter with early extravasation at the distal ureter.
ogram of the conduit was also performed. It revealed no reflux up the right ureter, but contrast refluxed into the left ureter, and this anastomosis appeared healthy. At laparotomy, a mass at the right ureteral conduit anastomosis was found; this was apparently the site of the urinary leakage. The mass, consisting of approximately 4 cm of the conduit and both distal ureteral segments was resected from the conduit. Using the remaining ileal segment, the con0090-4295/02/$22.00 PII S0090-4295(02)01554-6
FIGURE 2. Late-phase anterograde nephrostogram showing normal right renal collecting system and prominent extravasation of contrast from the right distal ureter.
duit was reconstructed, and bilateral end-to-side reanastomosis was performed. Histologic studies of the mass revealed right distal, muscle-invasive, ureteral UC. This tumor had invaded the conduit mucosa and lymphatics. The ureteral resection margins were negative. COMMENT Early postoperative urinary leakage at the ureteral conduit anastomosis has been reported to occur in approximately 2% of cases with ileal conduits and is attributed to technical error.1 To our knowledge, we present the first case of a late urine leak of an ileal conduit at the site of a ureteral conduit anastomosis due to recurrence of UC in the ureter. Ureteral UC occurs in 2% to 4% of patients with bladder UC2 and most commonly pre-
UROLOGY 59 (6), 2002
sents in the distal ureter.3 The most common symptoms of ureteral tumors include gross hematuria and flank pain, two symptoms that our patient did not have. Urinary ascites is a rare complication of ureteral tumors and has never been documented at the site of ureteroenteric anastomosis in patients who have undergone previous cystectomy for bladder cancer.4 Interestingly, upper tract tumors in patients with bladder tumors usually present at a median of 40 to 170 months.2 UC of the ureter is exceedingly rare in patients with ileal conduits. Tumors of the bowel used in urinary diversion are estimated to occur in up to 29% of cases.5 These tumors occur most commonly when ureterosigmoidostomy is performed, and, not surprisingly, most malignant tumors are adenocarcinomas.5 Local invasion and even tumor seeding from upper tract UC may also occur. In our case, UC spread from the ureter, invaded the conduit, and compromised the anastomosis, allowing urinary leakage. Obviously, there is a theoretical risk for the patient to develop tumor seeding into the abdomen and peritoneum secondary to the urine leak. However, the tumor is more likely to recur locally at the new ureteroenteric anastamoses—in the ileal conduit or remaining urothelium. Thus, annual urinary cytologic analysis from the ileal conduit and intravenous urography will be essential components of our patient’s follow-up to evaluate for tumor recurrence. REFERENCES 1. Skinner DG, Crawford ED, and Kaufman JJ: Complications of radical cystectomy for carcinoma of the bladder. J Urol 123: 640 – 643, 1980. 2. Oldbring J, Glifberg I, Mikulowski P, et al: Carcinoma of the renal pelvis and ureter following bladder carcinoma: frequency, risk factors and clinicopathological findings. J Urol 141: 1311–1313, 1989. 3. Yousem DM, Gatewood OM, Goldman SM, et al: Synchronous and metachronous transitional cell carcinoma of the urinary tract: prevalence, incidence, and radiographic detection. Radiology 167: 613– 618, 1988. 4. Walsh PC, Retik AB, Vaughan ED Jr, et al (Eds): Campbells’ Urology, 7th ed. Philadelphia, WB Saunders, 1998. 5. Fichtner J. Follow-up after urinary diversion. Urol Int 63: 40 – 45, 1999.
946v