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New England Section of the American Urological Association

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Adenocarcinoma of a Continent Urinary Conduit: A Case Report and Review of the Literature
Michael E. Goltzman, MD1, Richard T. Kershen, MD2.
1UConn Health, Farmington, CT, 2Tallwood Institute of Urology, Hartford Healthcare Medical Group, Hartford, CT.

BACKGROUND: Colonic segments are routinely utilized by Urologists for bladder augmentation as well as urinary neobladder formation. Colonic adenocarcinoma is the third most common cancer diagnosed in the U.S. affecting roughly 4% of both genders.[1] While the increased risk of developing colonic adenocarcinoma is well known in patients who have undergone ureterosigmoidostomy, adenocarcinoma arising in an Indiana pouch is extremely rare.[2] We aim to report a case of adenocarcinoma in an Indiana pouch treated with trans-stomal endoscopic resection, and address the screening, diagnostic and treatment-related issues surrounding this rare disease including a review of the literature.

METHODS: An extensive literature search on PubMed/MEDLINE was conducted. The keywords “Indiana pouch”, “carcinoma”, “adenoma”, and “adenocarcinoma” were used to find case reports and case series. Data were gathered and tabulated in regard to age, sex, tumor pathology, presence or absence of metastatic disease, therapy, and outcomes.

RESULTS: The patient is a 68-year-old man with a history of high-grade prostate cancer who underwent an aborted radical prostatectomy in 2009 due to extensive extra prostatic disease. He was subsequently treated with brachytherapy and external beam radiation therapy resulting in successful oncological control but suffered debilitating refractory lower urinary tract symptoms related to posterior urethral stenosis, mixed incontinence and retention. In 2017, he underwent a simple cystectomy with creation of an Indiana pouch. Two years after the procedure, the patient presented for surveillance pouchoscopy and was found to have a polypoid mass within his pouch (Figure 1A). He subsequently underwent endoscopic resection of this mass via a trans-stomal technique utilizing a cystoscope and a “hot” snare (Figure 1B). Pathologic investigation of the mass revealed a tubular adenoma with multifocal high-grade dysplasia/intramucosal carcinoma without invasion of the submucosa. Repeat endoscopic biopsy and pathologic investigation revealed no evidence of residual disease. Literature review revealed that adenocarcinoma was by far the most common tumor arising within the Indiana pouch (Table 1). While small tumors and/or polyps could be managed endoscopically, larger more extensive lesions required open resection and/or pouchectomy.

CONCLUSIONS: While large and/or invasive adenocarcinomas arising in an Indiana pouch may require partial or total resection of the pouch, small, non-invasive lesions may be managed endoscopically allowing pouch preservation. Given this fact, we advocate for regular (yearly) endoscopic surveillance of Indiana pouches as early detection of malignant lesions may enable less invasive management strategies and potentially better oncologic outcomes should a tumor or polyp be discovered. Adenocarcinoma continues to be a rare, but serious, complication of Indiana pouch urinary diversion.
[1] Key Statistics for Colorectal Cancer. The American Cancer Society.
[2] Austen M, Kälble T. Secondary malignancies in different forms of urinary diversion using isolated gut. J Urol. 2004;172(3):831-8. f Urethral Bulking Agents for Stress Urinary Incontinence: An Extensive Review Including Case Reports. Female Pelvic Med Reconstr Surg. 2018;24(6):392-398.

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