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Nephroureterectomy after Radical Cystectomy
0022-534 7/88/1393-0588$2.00/0 Vol. 139, March Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
NEPHROURETERECTOMY AFTER RADICAL CYSTECTOMY G. R. MUFTI, J. R. W. GOVE
AND
P. R. RIDDLE
From St. Peter's Hospitals and Institute of Urology, London, England
ABSTRACT
We report 6 cases of upper tract transitional cell carcinoma that developed after total cystectomy with ileal loop diversion. We conclude that if nephroureterectomy is to be used as treatment, excision of the ureteroileal anastomoses should be done. (J. Ural., 139: 588-589, 1988) The conventional treatment of upper urinary tract transitional cell tumor in a patient with an intact bladder and a healthy contralateral renal unit is nephroureterectomy with excision of a cuff of bladder mucosa. Should an upper tract transitional cell tumor develop in a patient who has· already undergone radical cystectomy for urothelial neoplasia, further surgical management can be problematic. If nephroureterectomy is indicated one must determine the extent of ureteral excision. From 1971 to 1985, 188 patients underwent radical cystectomy for carcinoma of bladder. Of these patients upper urinary tract transitional cell carcinoma developed in 16 during followup. We report 6 of these cases in which nephroureterectomy was performed. CASE REPORTS
Case 1. C. F., a 58-year-old man, underwent radical cystectomy with ileal loop diversion (Wallace 2 technique) for multifocal grade 2, stage PIS and Plb transitional cell carcinoma of the bladder. In the Wallace type of diversion a single anastomosis is made between the vertically opened and conjoined lower ends of the ureters and the back end of the loop. The Wallace type 2 procedure involves placement of the lower ends of both ureters in opposite directions (head to tail). 1 After 15 months he presented with peritonitis and laparotomy revealed perforation of left pyonephrosis into the peritoneal cavity. The left kidney and most of the left ureter were excised. Histological examination demonstrated multiple grade 2, stage Pla tumors in the pelviocaliceal system and ureter. Obstruction of the right upper tract at the ureteroileal junction occurred 2½ years later (fig. 1). At re-exploration a tumor was excised, which included the left ureteral stump, part of the ileal loop and the distal right ureter. The proximal right ureter was reimplanted into the remaining ileal conduit. Histological examination revealed a grade 3, stage Plb solid, transitional cell tumor arising from the left ureteral stump. The patient died of metastatic disease 5 months later. Case 2. R. D., a 67-year-old man, was treated for multiple grade 2, stage Pla bladder tumors by radical cystourethrectomy and ilea! loop diversion (Wallace 1 technique). In the Wallace type 1 procedure the lower ends of both ureters lie in the same direction. 2 A year later re-exploration was performed for multiple tumors in the right upper tract. Right nephroureterectomy with excision of the ureter as close to the ureteroileal anastomosis as possible was done. Histology showed multifocal papillary tumors in the entire upper tract. A year later re-exploration for a dilated left upper tract revealed a 2 cm. mass at the ureteroileal anastomosis in the conjoined common ureter. The entire anastomosis, including part of the loop, was excised and the left ureter was reimplanted. Histology showed a grade 2, stage Pla transitional cell tumor Accepted for publication July 17, 1987.
FIG. 1. Case 1. Excretory urogram 2½ years after left nephroureterectomy shows right hydroureteronephrosis owing to obstruction at ureteroileal junction.
arising from the ureteral epithelium and from the transitional epithelium around the ureteroileal anastomosis. The patient was well 8 years later. Case 3. C. B., a 67-year-old man, underwent radical cystourethrectomy with an ilea! conduit (Wallace 2 technique) for multifocal grade 2, stage Plb transitional cell tumors of the bladder. A left upper caliceal tumor was detected 2 years later, and left nephrectomy and subtotal ureterectomy were performed. Histological examination confirmed multifocal carcinoma in situ and grade 2, stage Pab disease in the pelvis, calices and ureter. The distal ureteral resection showed changes of carcinoma in situ. A large, para-aortic mass developed with obstruction of the right upper tract 15 months later, which was presumed to be local recurrence. The patient was treated with palliative chemotherapy and radiotherapy but he died of metastatic disease 8 months later. Case 4. J. S., a 37-year-old man, underwent radical cystoprostatectomy with an ileal conduit (Wallace 1 technique) for
588
NEPHROURETERECTOMY AFTER RADICAL CYSTECTOMY
multifocal grade 2, stage Pab cancer and carcinoma in situ of the bladder. At followup 7 years later investigations confirmed the presence of tumors in the left upper calix and the lower end of the left ureter. Left nephroureterectomy was performed. The specimen consisted of the left kidney, left ureter, ureteroileal anastomosis, back end of the loop and distal right ureter. Histological examination confirmed the presence of partially papillary, partially solid grade 2, stage Plb transitional cell carcinoma in the left upper calix and the ureteroileal anastomosis. Tumor recurred in the right lower calix 2 years later, which was treated by right lower pole nephrectomy. The patient died of renal failure 2½ years later. Case 5. E. P., a 67-year-old woman, underwent anterior pelvic exenteration with formation of an ileal conduit (Wallace 2 technique) for anaplastic stage P3 transitional cell carcinoma of the bladder. Left nephrectomy and partial ureterectomy were performed 3 years later for a grade 2, stage Pl and PIS transitional cell tumor in the left renal pelvis. A year later urinary cytology was positive and a loopogram showed a filling defect in the left ureteral stump (fig. 2). The back end of the loop was excised together with the lower ends of both ureters, and the right ureter was reimplanted into the loop. However, no tumor was identified on histological examination of the specimen. Soon thereafter a tumor was detected in the right upper calix, which is being treated currently with laser therapy. Case 6. C. B., a 67-year-old man, underwent radical cystourethrectomy with ileal loop diversion (Wallace 2 technique) for multiple superficial grade 2, stage Plb transitional cell tumors of the bladder. Soon thereafter a transitional cell tumor was confirmed in the left renal pelvis. After a course of interferon, left nephrectomy with partial ureterectomy was performed. Histological examination revealed a grade 2, stage P3a tumor
589
in the renal pelvis but the end of the ureter was free of tumor. A course of radiotherapy (40 Gy) was administered to the renal bed, and the patient was well 3 years later with no evidence of recurrent disease. DISCUSSION
The association of upper tract transitional cell tumors with bladder tumors is well documented. 3 - 6 The occurrence of an upper urothelial tumor after cystectomy for bladder tumors, although uncommon, is not rare. Zincke and associates reported an incidence of 3.3 per cent in their series of 425 patients. 7 In our patients the incidence was higher (8.5 per cent). Careful followup of the upper tracts is mandatory in these patients particularly in those with multifocal disease. If nephroureterectomy is indicated for the upper tract lesion, one is tempted to excise the ureter as low as possible without actually taking down the ureteroileal anastomosis. In 3 of our 6 patients recurrence developed in the ureteral stump and/or ureteroileal anastomosis after nephrectomy and subtotal ureterectomy for the upper tract tumor. In case 4, in which the operative procedure included excision of the anastomosis along with the kidney and ureter, presence of a tumor at the ureteroileal anastomosis was proved on histological examination. In case 5 a filling defect in the stump led to further laparotomy, albeit with a negative result. From our clinical material it is apparent that surgical therapy should entail excision of the entire ureter with the ureteroileal anastomosis and part of the ileal loop, particularly if a doublebarrelled (Wallace) 1• 2 ureteroileal anastomosis was performed after radical cystectomy or if the indication for cystectomy was multifocal transitional cell carcinoma of bladder. The incidence of recurrent disease of the ureteral stump after nephroureterectomy ranges from 16 to 64 per cent. 4 • 8 - 11 This incidence rate does not appear to be markedly different if the stump is left in the ileum rather than in the bladder. REFERENCES
FIG. 2. Case 5. Loopogram shows filling defect in left ureteral stump.
1. Wallace, D. M.: Uretero-ileostomy. Brit. J. Urol., 42: 529, 1970. 2. Wallace, D. M.: Ureteric diversion using a conduit. A simplified technique. Brit. J. Urol., 38: 522, 1966. 3. Williams, C. B. and Mitchell, J. P .: Carcinoma of the renal pelvis: a review of 43 cases. Brit. J. Urol., 45: 370, 1973. 4. Kakizoe, T., Fujita, J., Murase, T., Matsumoto, K. and Kishi, K.: Transitional cell carcinoma of the bladder in patients with renal pelvic and ureteral cancer. J. Urol., 124: 17, 1980. 5. Grabstald, H., Whitmore, W. F. and Melamed, M. R.: Renal pelvic tumors. J.A.M.A., 218: 845, 1971. 6. Booth, C. M., Cameron, K. M. and Pugh, R. C.: Urothelial carcinoma of the kidney and ureter. Brit. J. Urol., 52: 430, 1980. 7. Zincke, H., Garbeff, P. J. and Beahrs, J. R.: Upper urinary tract transitional cell cancer after radical cystectomy for bladder cancer. J. Urol., 131: 50, 1984. 8. Nocks, B. N., Heney, N. M., Daly, J. J., Perone, T. A., Griffin, P. P. and Prout, G. R., Jr.: Transitional cell carcinoma of renal pelvis. Urology, 19: 472, 1982. 9. Kimbale, F. N. and Ferris, H. W.: Papillomatous tumor of the renal pelvis associated with similar tumors of the ureters and bladder. J. Urol., 31: 257, 1934. 10. Strong, D. W., Pearse, H. D., Tank, E. S., Jr. and Hodges, C. V.: The ureteral stump after nephroureterectomy. J. Urol., 115: 654, 1976. 11. Wallace, D. M.A., Wallace, D. M., Whitfield, H. N., Hendry, W. F. and Wickham, J.E. A.: The late results of conservative surgery for upper tract urothelial carcinomas. Brit. J. Urol., 53: 537, 1981.
THE JOURNAL OF UROLOGY
Copyright© 1988 by The Williams & Wilkins Co.
NEPHROURETERECTOMY AFTER RADICAL CYSTECTOMY G. R. MUFTI, J. R. W. GOVE
AND
P. R. RIDDLE
From St. Peter's Hospitals and Institute of Urology, London, England
ABSTRACT
We report 6 cases of upper tract transitional cell carcinoma that developed after total cystectomy with ileal loop diversion. We conclude that if nephroureterectomy is to be used as treatment, excision of the ureteroileal anastomoses should be done. (J. Ural., 139: 588-589, 1988) The conventional treatment of upper urinary tract transitional cell tumor in a patient with an intact bladder and a healthy contralateral renal unit is nephroureterectomy with excision of a cuff of bladder mucosa. Should an upper tract transitional cell tumor develop in a patient who has· already undergone radical cystectomy for urothelial neoplasia, further surgical management can be problematic. If nephroureterectomy is indicated one must determine the extent of ureteral excision. From 1971 to 1985, 188 patients underwent radical cystectomy for carcinoma of bladder. Of these patients upper urinary tract transitional cell carcinoma developed in 16 during followup. We report 6 of these cases in which nephroureterectomy was performed. CASE REPORTS
Case 1. C. F., a 58-year-old man, underwent radical cystectomy with ileal loop diversion (Wallace 2 technique) for multifocal grade 2, stage PIS and Plb transitional cell carcinoma of the bladder. In the Wallace type of diversion a single anastomosis is made between the vertically opened and conjoined lower ends of the ureters and the back end of the loop. The Wallace type 2 procedure involves placement of the lower ends of both ureters in opposite directions (head to tail). 1 After 15 months he presented with peritonitis and laparotomy revealed perforation of left pyonephrosis into the peritoneal cavity. The left kidney and most of the left ureter were excised. Histological examination demonstrated multiple grade 2, stage Pla tumors in the pelviocaliceal system and ureter. Obstruction of the right upper tract at the ureteroileal junction occurred 2½ years later (fig. 1). At re-exploration a tumor was excised, which included the left ureteral stump, part of the ileal loop and the distal right ureter. The proximal right ureter was reimplanted into the remaining ileal conduit. Histological examination revealed a grade 3, stage Plb solid, transitional cell tumor arising from the left ureteral stump. The patient died of metastatic disease 5 months later. Case 2. R. D., a 67-year-old man, was treated for multiple grade 2, stage Pla bladder tumors by radical cystourethrectomy and ilea! loop diversion (Wallace 1 technique). In the Wallace type 1 procedure the lower ends of both ureters lie in the same direction. 2 A year later re-exploration was performed for multiple tumors in the right upper tract. Right nephroureterectomy with excision of the ureter as close to the ureteroileal anastomosis as possible was done. Histology showed multifocal papillary tumors in the entire upper tract. A year later re-exploration for a dilated left upper tract revealed a 2 cm. mass at the ureteroileal anastomosis in the conjoined common ureter. The entire anastomosis, including part of the loop, was excised and the left ureter was reimplanted. Histology showed a grade 2, stage Pla transitional cell tumor Accepted for publication July 17, 1987.
FIG. 1. Case 1. Excretory urogram 2½ years after left nephroureterectomy shows right hydroureteronephrosis owing to obstruction at ureteroileal junction.
arising from the ureteral epithelium and from the transitional epithelium around the ureteroileal anastomosis. The patient was well 8 years later. Case 3. C. B., a 67-year-old man, underwent radical cystourethrectomy with an ilea! conduit (Wallace 2 technique) for multifocal grade 2, stage Plb transitional cell tumors of the bladder. A left upper caliceal tumor was detected 2 years later, and left nephrectomy and subtotal ureterectomy were performed. Histological examination confirmed multifocal carcinoma in situ and grade 2, stage Pab disease in the pelvis, calices and ureter. The distal ureteral resection showed changes of carcinoma in situ. A large, para-aortic mass developed with obstruction of the right upper tract 15 months later, which was presumed to be local recurrence. The patient was treated with palliative chemotherapy and radiotherapy but he died of metastatic disease 8 months later. Case 4. J. S., a 37-year-old man, underwent radical cystoprostatectomy with an ileal conduit (Wallace 1 technique) for
588
NEPHROURETERECTOMY AFTER RADICAL CYSTECTOMY
multifocal grade 2, stage Pab cancer and carcinoma in situ of the bladder. At followup 7 years later investigations confirmed the presence of tumors in the left upper calix and the lower end of the left ureter. Left nephroureterectomy was performed. The specimen consisted of the left kidney, left ureter, ureteroileal anastomosis, back end of the loop and distal right ureter. Histological examination confirmed the presence of partially papillary, partially solid grade 2, stage Plb transitional cell carcinoma in the left upper calix and the ureteroileal anastomosis. Tumor recurred in the right lower calix 2 years later, which was treated by right lower pole nephrectomy. The patient died of renal failure 2½ years later. Case 5. E. P., a 67-year-old woman, underwent anterior pelvic exenteration with formation of an ileal conduit (Wallace 2 technique) for anaplastic stage P3 transitional cell carcinoma of the bladder. Left nephrectomy and partial ureterectomy were performed 3 years later for a grade 2, stage Pl and PIS transitional cell tumor in the left renal pelvis. A year later urinary cytology was positive and a loopogram showed a filling defect in the left ureteral stump (fig. 2). The back end of the loop was excised together with the lower ends of both ureters, and the right ureter was reimplanted into the loop. However, no tumor was identified on histological examination of the specimen. Soon thereafter a tumor was detected in the right upper calix, which is being treated currently with laser therapy. Case 6. C. B., a 67-year-old man, underwent radical cystourethrectomy with ileal loop diversion (Wallace 2 technique) for multiple superficial grade 2, stage Plb transitional cell tumors of the bladder. Soon thereafter a transitional cell tumor was confirmed in the left renal pelvis. After a course of interferon, left nephrectomy with partial ureterectomy was performed. Histological examination revealed a grade 2, stage P3a tumor
589
in the renal pelvis but the end of the ureter was free of tumor. A course of radiotherapy (40 Gy) was administered to the renal bed, and the patient was well 3 years later with no evidence of recurrent disease. DISCUSSION
The association of upper tract transitional cell tumors with bladder tumors is well documented. 3 - 6 The occurrence of an upper urothelial tumor after cystectomy for bladder tumors, although uncommon, is not rare. Zincke and associates reported an incidence of 3.3 per cent in their series of 425 patients. 7 In our patients the incidence was higher (8.5 per cent). Careful followup of the upper tracts is mandatory in these patients particularly in those with multifocal disease. If nephroureterectomy is indicated for the upper tract lesion, one is tempted to excise the ureter as low as possible without actually taking down the ureteroileal anastomosis. In 3 of our 6 patients recurrence developed in the ureteral stump and/or ureteroileal anastomosis after nephrectomy and subtotal ureterectomy for the upper tract tumor. In case 4, in which the operative procedure included excision of the anastomosis along with the kidney and ureter, presence of a tumor at the ureteroileal anastomosis was proved on histological examination. In case 5 a filling defect in the stump led to further laparotomy, albeit with a negative result. From our clinical material it is apparent that surgical therapy should entail excision of the entire ureter with the ureteroileal anastomosis and part of the ileal loop, particularly if a doublebarrelled (Wallace) 1• 2 ureteroileal anastomosis was performed after radical cystectomy or if the indication for cystectomy was multifocal transitional cell carcinoma of bladder. The incidence of recurrent disease of the ureteral stump after nephroureterectomy ranges from 16 to 64 per cent. 4 • 8 - 11 This incidence rate does not appear to be markedly different if the stump is left in the ileum rather than in the bladder. REFERENCES
FIG. 2. Case 5. Loopogram shows filling defect in left ureteral stump.
1. Wallace, D. M.: Uretero-ileostomy. Brit. J. Urol., 42: 529, 1970. 2. Wallace, D. M.: Ureteric diversion using a conduit. A simplified technique. Brit. J. Urol., 38: 522, 1966. 3. Williams, C. B. and Mitchell, J. P .: Carcinoma of the renal pelvis: a review of 43 cases. Brit. J. Urol., 45: 370, 1973. 4. Kakizoe, T., Fujita, J., Murase, T., Matsumoto, K. and Kishi, K.: Transitional cell carcinoma of the bladder in patients with renal pelvic and ureteral cancer. J. Urol., 124: 17, 1980. 5. Grabstald, H., Whitmore, W. F. and Melamed, M. R.: Renal pelvic tumors. J.A.M.A., 218: 845, 1971. 6. Booth, C. M., Cameron, K. M. and Pugh, R. C.: Urothelial carcinoma of the kidney and ureter. Brit. J. Urol., 52: 430, 1980. 7. Zincke, H., Garbeff, P. J. and Beahrs, J. R.: Upper urinary tract transitional cell cancer after radical cystectomy for bladder cancer. J. Urol., 131: 50, 1984. 8. Nocks, B. N., Heney, N. M., Daly, J. J., Perone, T. A., Griffin, P. P. and Prout, G. R., Jr.: Transitional cell carcinoma of renal pelvis. Urology, 19: 472, 1982. 9. Kimbale, F. N. and Ferris, H. W.: Papillomatous tumor of the renal pelvis associated with similar tumors of the ureters and bladder. J. Urol., 31: 257, 1934. 10. Strong, D. W., Pearse, H. D., Tank, E. S., Jr. and Hodges, C. V.: The ureteral stump after nephroureterectomy. J. Urol., 115: 654, 1976. 11. Wallace, D. M.A., Wallace, D. M., Whitfield, H. N., Hendry, W. F. and Wickham, J.E. A.: The late results of conservative surgery for upper tract urothelial carcinomas. Brit. J. Urol., 53: 537, 1981.