Abstract
PURPOSE: The occurrence of neoplasia after ureterosigmoidostomy is well-documented in the literature. Because of its rarity, few general surgeons will gain significant exposure to this entity, and colorectal surgeons are likely to be involved with the care of these patients. The purpose of this article is to apprise colorectal surgeons about the management of neoplasia after ureterosigmoidostomy and to familiarize them with the unique anatomy of the reconstructed pelvis. METHODS: We performed a MEDLINE search to identify articles on ureterosigmoid tumors. The theories regarding the cause and pathology of these tumors were critically analyzed. A consensus was developed for screening patients with ureterosigmoidostomy and for treatment of neoplasia. RESULTS: The incidence of carcinoma after ureterosigmoidostomy ranges from 2 to 15 percent. Polyps are more common, and it seems that these tumors also follow the sequence of adenocarcinoma that is seen in the common variety of colorectal neoplasia. Neoplastic changes begin with the interaction of urine and feces and the healing colonic mucosa. Both production of nitrosamines by the action of bacteria on urine and DNA damage caused by reactive oxygen radicals produced by neutrophils at the healing anastomosis have been implicated in the pathogenesis of neoplasia. The latent period between formation of ureterosigmoidostomy and the appearance of carcinoma is between 20 and 26 years. Obstructive urinary symptoms that develop more than two years after ureterosigmoidostomy should be viewed with suspicion. The patient should be investigated with a CT scan and colonoscopy, and a barium enema may be required to delineate the anatomy further. If a benign tumor is encountered during colonoscopy, it may be removed by snare polypectomy. For a malignant tumor the segment of colon with ureteric implants should be excised, along with its lymphatic drainage. Bowel continuity is restored primarily, and the ureters are implanted in an ileal conduit. CONCLUSIONS: Patients with ureterosigmoidostomy should be followed closely for the rest of their lives. The aim of screening is to identify and treat neoplasia before malignancy develops. Furthermore, early detection of neoplasia by close screening will improve survival. Although urine cytology and occult blood are inexpensive tests, colonoscopy remains the criterion standard for follow-up of these patients. Annual colonoscopic surveillance should be started soon after the ureterosigmoidostomy but not later than five to six years after the procedure. Patients who are noncompliant with the vigorous follow-up schedule should be offered the option of resection of the colonic segment at risk with urinary diversion.
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References
Simon J. Operation for directing the orifices of ureters into the rectum; temporary success, subsequent failure; autopsy. Lancet 1852;2:568–70.
Coffey RC. Physiologic implantation of the severed ureter or common bile-duct into the intestine. JAMA 1911;56:397–403.
Hammer E. Cancer du colon sigmoide dix ans pres implantation des ureters d'une vessu extrophi. J Urol (Paris) 1929;28:260–3.
Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950;30:1511–21.
Bissada NK, Morcos RR, Morgan WM, Hanash KA. Ureterosigmoidostomy. Is it a viable procedure in the age of continent urinary diversion and bladder substitution? J Urol 1995;153:1429–31.
Koo HP, Avolio L, Duckett JW Jr. Long-term results of ureterosigmoidostomy in children with bladder exstrophy. J Urol 1996;156:2037–40.
Kamidono S, Oda Y, Hamami G, Hikosaka K, Kataoka N, Ishigami J. Urinary diversion: anastomosis of the ureters into a sigmoid pouch and end-to-side sigmoidorectostomy. J Urol 1985;133:391–4.
Bissada NK, Morcos RR, Morgan WM, Hanash KA. Ureterosigmoidostomy. Is it a viable procedure in the age of continent urinary diversion and bladder substitution? [see comments] J Urol 1995;153:1429–31.
Kroovand RL. Isolated ureterosigmoidostomy and isolated vesicorectal anastomosis. The rectal bladder. Urol Clin North Am 1991;18:603–8.
Gill RW. Urocolonic tumors. J Urol 1988;139:1330.
Husmann DA, Spence HM. Current status of tumor of the bowel following ureterosigmoidostomy: a review. J Urol 1990;144:607–10.
Sugg WL. Tumor at site of ureterosigmoidostomy: report of a case and review of the literature. Ann Surg 1962;155:572–6.
Higgs B, Ineson NR. Transitional cell carcinoma arising at the site of ureterosigmoidostomy. Brit J Urol 1983;55:451–2.
Shokeir AA, Shamaa M, el-Mekresh MM, el-Baz M, Ghoneim MA. Late malignancy in bowel segments exposed to urine without fecal stream. Urology 1995;46:657–61.
Chiang MS, Minton JP, Clausen K, Clatworthy HW, Wise HA 2d. Carcinoma in a colon conduit urinary diversion. J Urol 1982;127:1185–7.
Davis CP, Cohen MS, Anderson MD, Gruber MB, Warren MM. Urothelial hyperplasia and neoplasia. II. Detection of nitrosamines and interferon in chronic urinary tract infections in rats. J Urol 1985;134:1002–6.
Stewart M, Hill MJ, Pugh RC, Williams JP. The role of N-nitrosamine in carcinogenesis at the ureterocolic anastomosis. Br J Urol 1981;53:115–8.
Brauers A, Baron J, Jung P,et al. Expression of cytochrome P-450 2E1 messenger ribonucleic acid in adenocarcinoma at ureterosigmoidostomy site after bladder exstrophy. J Urol 1998;159:979–80.
Kalble T, Tricker AR, Berger M,et al. Tumor induction in a rat model for ureterosigmoidostomy without evidence of nitrosamine formation. J Urol 1991;146:862–6.
Weitzman SA, Weitberg AB, Clark EP, Stossel TP. Phagocytes as carcinogens: malignant transformation produced by human neutrophils. Science 1985;227:1231–3.
Cerutti P, Friedman J, Zimmerman R. A role for active oxygen induced DNA damage in tumor production. In: Rydstrom J, Montelius J, Bengtsson M, eds. Extrahepatic drug metabolism and chemical carcinogenesis: proceedings of the international meeting on extrahepatic drug metabolism and chemical carcinogenesis. New York: Elsevier, 1983:499–506.
Dull BJ, Gittes RF, Goldman P. Nitrate production and phagocyte activation: differences among Sprague-Dawley, Wistar-Furth and Lewis rats. Carcinogenesis 1988;9:625–7.
Urdaneta LF, Duffell D, Creevy CD, Aust JB. Late development of a primary carcinoma of the colon following ureterosigmoidostomy: report of three cases and literature review. Ann Surg 1966;164:503–13.
Leadbetter GW Jr, Zickerman P, Pierce E. Ureterosigmoidostomy and carcinoma of the colon. J Urol 1979;121:732–5.
Gittes RF. Carcinogenesis in ureterosigmoidostomy. Urol Clin North Am 1986;13:201–5.
Eraklis AJ, Folkman MJ. Adenocarcinoma at the site of ureterosigmoidostomies for exstrophy of the bladder. J Pediatr Surg 1978;13:730–4.
Zabbo A, Kay R. Ureterosigmoidostomy and bladder exstrophy: a long-term followup. J Urol 1986;136:396–8.
Stewart M. Urinary diversion and bowel cancer. Ann R Coll Surg Engl 1986;68:98–102.
Starling JR, Uehling DT, Gilchrist KW. Value of colonoscopy after ureterosigmoidostomy. Surgery 1984;96:784–90.
Harford FJ, Fazio VW, Epstein LM, Hewitt CB. Rectosigmoid carcinoma occurring after ureterosigmoidostomy. Dis Colon Rectum 1984;27:321–4.
Badalament RA, Cirulli C, Zerick W, Lucas JG, Drago JR. Colon carcinoma associated with ureterosigmoidostomy. J Surg Oncol 1990;45:207–11.
Zander M, Böcker R. Tumors of the colon following ureterosigmoidostomy [in German]. Urologe A 1983;22:215–8.
Weber TR, Westfall SH, Steinhardt GF, Webb L, Sotelo-Avila C, Connors RH. Malignancy associated with ureterosigmoidostomy: detection of mucosa ornithine decarboxylase. J Pediatr Surg 1988;23:1091–4.
Strachan JR, Rees HC, Cox R, Woodhouse CR. Mucin changes adjacent to carcinoma following ureterosigmoidostomy. Eur Urol 1987;13:419.
Kalble T, Mohring K, Waldherr R, Staehler G. Screening study for early detection of intestinal tumors after urinary diversion. Helv Chir Acta 1992;59:507–11.
Urdaneta LF, Duffell D, Creevy CD, Aust JB. Late development of a primary carcinoma of the colon following ureterosigmoidostomy: report of three cases and literature review. Ann Surg 1966;164:503–13.
Strachan JR, Woodhouse CR. Malignancy following ureterosigmoidostomy in patients with exstrophy. Br J Surg 1991;78:1216–8.
Weinstein T, Zevin D, Kyzer S,et al. Adenocarcinoma at ureterosigmoidostomy junction in a renal transplant recipient 15 years after conversion to ileal conduit. Clin Nephrol 1995;44:125–7.
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Azimuddin, K., Khubchandani, I.T., Stasik, J.J. et al. Neoplasia after ureterosigmoidostomy. Dis Colon Rectum 42, 1632–1638 (1999). https://doi.org/10.1007/BF02236220
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DOI: https://doi.org/10.1007/BF02236220