HYU Onc - Bladder and Upper Tract Flashcards
Microhematuria definition
> or = 3 RBCs/hpf on microscopic evaluation of a single, properly collected urine specimen
Evaluation should not change based on presence or absence of AC/anti-plt meds
Microhematuria: Low-Risk
Must meet ALL of the following criteria:
Women < 50yo
Men < 40yo
<10 pack-years
3-10 RBCs/hpf
No prior episodes of MF
No other risk factors
Microhematuria: Intermediate Risk
If you meet ANY of the following criteria:
Women 50-59 yo
Men 40-59 yo
11-30 pack years
11-25 RBCs/ hpf
Presence of additional risk factors
Previously low-risk without prior evaluation and 3-25 RBCs/hpf
Microhematuria: Intermediate Risk
If you meet ANY of the following criteria:
Women 50-59 yo
Men 40-59 yo
11-30 pack years
11-25 RBCs/ hpf
Presence of additional risk factors
Microhematuria: High Risk
If you meet ANY of the following criteria:
Man or woman >60yo
>30 pack years
>25 RBCs/hpf
History of gross hematuria
Previously low-risk without prior evaluation and >25 RBCs/hpf
Management of low-risk microhematuria
Shared decision making
Can repeat UA within 6 months or
Cysto + US
Management of intermediate-risk microhematuria
Cysto + RUS
Management of high-risk microhematuria/gross hematuria
Cysto (for all)
CTU > MRU > retrograde pyelograms and noncon axial imaging or RUS
Additional risk factors for urothelial carcinoma
Irritative LUT voiding symptoms
History of cyclophosphamide of ifosfamide chemotherapy
Family history of US or lynch syndrome
Occupational exposure to benzene chemicals or aromatic amines
History of chronic indwelling foreign body in the urinary tract
Imaging when microhematuria in a patient with family history of RCC or known genetic renal tumor syndrome
Perform upper tract imaging regardless of risk stratification
When use urine cytology and markers in MH patients?
Do not use in initial MH evaluation
Can use cytology for patients with persistent MH + irritative LUTS or RFs for CIS after a negative initial MH workup
MH follow-up after negative evaluation
Repeat UA in 12 months
If UA negative, discontinue further evaluation
If UA persistent MH, shared decision making regarding need for initial evaluation
After negative evaluation, initiate further evaluation if new gross hematuria, increasing degree of MH, or new urologic symptoms
Bladder Cancer Staging
Tis = mucosa
T1 = lamina propria
T2 = Muscularis propria
- a = inner
- b = outer
T3 = Perivesical tissue/fat
- a = microscopic
- b = macroscopic
T4 = Extravesical
- a = adjacent organs
- b = body wall
Ta: This refers to noninvasive papillary carcinoma. This type of growth often is found on a small section of tissue that easily can be removed with TURBT.
Low risk bladder cancer
LG solitary Ta less than or = to 3 cm
PUMLUMP
Intermediate Risk Bladder Cancer
Recurrence of LG Ta within 1 year
Solitary LG Ta >3cm
Multifocal LG Ta
HG Ta < or = to 3 cm
Any LG T1
High Risk Bladder Cancer
HG T1
Any Recurrent HG Ta
HG Ta > 3 cm or multifocal
Any CIS
Any BCG failure in HG patient
Any variant histology (micropapillary, sarcomatoid, plasmacytoid)
Any LVI
Any HG prostatic urethral involvement
Positive cytology with normal cysto in a patient with a history of NMIBC
Consider upper tract imaging, prostatic urethral biopsies, blue light cysto, ureteroscopy, random bladder biopsies
Variant histology, extensive squamous or glandular differentiation, + LVI
Obtain GU pathologist review
Offer restaging TURBT 4-6 weeks after diagnostic TURBT (if attempting to spare bladder)
Or, offer up front radical cystectomy
When is the use of urine markers appropriate?
For NMIBC, can use biomarkers to assess response to BCG and to adjudicate equivocal cytology
- Should NOT use in lieu of cytology
- Should NOT use for surveillance of low risk patients with with normal cytology
- SHOULD use cytology with surveillance cystoscopy for IR and HR disease
When do you perform a restaging TURBT?
Within 6 weeks of initial TURBT
If incomplete resection
If pathology is high-risk HG Ta OR HG T1
Must get muscle in specimen
Single dose intravesical MMC or gemcitabine use?
Postop
Consider in suspected/known LG disease within 24 hours of TURBT, except in cases of suspected perforation or extensive resection
When do you use BCG?
Don’t use in LR
Consider in IR
Use in HR
If it works, maintenance BCG (3 weekly doses starting 3 months after induction) for 1 year in IR and 3 years in HR
What is maintenance BCG dosing/timing?
If it works, maintenance BCG (3 weekly doses starting 3 months after induction) for 1 year in IR and 3 years in HR
What do you do for persistent/recurrent NMIBC s/p 1 induction course of BCG?
- Ta?
- CIS?
- HG T1?
Ta - Second induction course of BCG
CIS - Second induction course of BCG
RC w/o NAC also an option for both of these
HG T1 - RC
Persistent/recurrent HG or CIS within 6 months of 2 induction courses BCG or induction + maintenance BCG?
No more BCG
Unwilling or unfit for RC after 2 courses of BCG with recurrence within 12 months –> clinical trial vs other intravesical therapy (valrubicin, gemcitabine, docetaxel), vs. systemic pembro for CIS
Cystoscopy follow-up for bladder cancer patients
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months
If this is negative, the frequency of subsequent surveillance cysto (w/ cytology if IR/HR) varies based on risk stratification
Low-risk NMIBC surveillance cysto schedule
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months
Next cysto 6-9 months later
Then yearly
Shared decision making after 5 years
*In-office fulguration is an option for LG Ta disease with <1cm papillary recurrence
Intermediate-risk NMIBC surveillance cysto schedule
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months
Cysto/cytology q3-6 months x2 years
q6-12 months x2 years
Then yearly
Consider surveillance upper tract imaging every 1-2 years
High-risk NMIBC surveillance cysto schedule
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months
Cysto/cytology q3-4 months x2 years
q6 months x2 years
Then yearly
Consider surveillance upper tract imaging every 1-2 years
Treatment for BCG sepsis
- MOA for the drugs?
Corticosteroids + NSAIDs + Isoniazid 300mg + Rifampin 600mg + Ethambutol 1200mg daily
Isoniazid inhibits mycobacterial cell wall formation
Rifampin inhibits RNA polymerase
Ethambutol inhibits mycobacterial cell wall formation
Pyridoxine (B6) is administered with Isoniazid to prevent peripheral neuropathy
Persistent fever without sepsis or UTI following BCG
Isoniazid x 3 months
Timing of BCG and TURBT
Don’t give BCG until >1 week after TURBT due to risk of BCG sepsis
Can you give BCG in immunocompromised patients?
BCG is safe in immunocompromised patients
- Including patients with autoimmune disease, transplant patients, and patients undergoing systemic chemotherapy
BCG is dependent on an intact immune system, so use MMC (DNA x-linker) for intravesical therapy in patients on immunosuppression (chronic steroids for RA or anti-TNFa for Crohn’s)
Urothelial CIS of the prostatic urethra during TURP?
Repeat BCG Tx to reduce recurrence of CIS
Positive cytology and negative cysto?
Prostatic urethral biopsies should include at 5 and 7 o’clock positions, where the ejaculatory ducts insert
These are most common sites of occult disease
Granulomatous prostatitis
Common following iBCG
No intervention needed
mBCG can continue
Valrubicin uses
Valrubicin is FDA approved for BCG-refractory CIS and HR disease in a non-cystectomy candidate
Recurrent tiny (<1cm) low grade Ta after BCG
fulgurate and observe
Persistent CIS after induction in a high risk patient
Repeat induction BCG
Best method for detecting recurrent CIS after induction BCG
blue-light cysto
Hexaminolevulinate
BCG-unresponsive
Persistent/recurrent NMIBC must undergo iBCG + at least one mBCG to be ‘BCG-unresponsive’
Anktiva
IL-15 superantagonist - used with BCG in BCG- unresponsive CIS +/- Ta/T1
Side effects of MMC
9% rash (contact dermatitis)
6-41% chemical cystitis
How to optimize MMC effectiveness
Void/CIC prior
Dehydration to prevent dilution
Alkalinization with Na-bicarb
Increase drug concentration (want 40mg/20mL)
Not helpful: abx, NSAIDs, antimuscarinics
T1 tumors with aggressive features
(>3 cm, micropapillary/variant histology, concomitant CIS, LVI)
Up front cystectomy without NAC
When do you treat asymptomatic ileal conduit urine cultures?
Asymptomatic IC cultures are >75% positive
Only need to be treated if culture grows proteus or pseudomonas due to risk of stone formation
Risk of LN metastasis at time of RC performed for recurrent T1 or CIS
10-15%
Nephroureterectomy in a patient with one kidney and prior RC/IC
Leave IC in place for use with future renal transplant
Persistent disease (any) on mid-cycle TURBT during chemoradiation
Proceed to RC
Urine Assay: UroVysion FISH
Detects aneuploidy from chromosome 3, 7 and 17 and homozygous loss of chromosome 9p21
Can adjudicate equivocal urine cytology
Urine Assay: ImmunoCyt
Immunohistochemistry for urothelial antigens
Can adjudicate equivocal cytology
Urine Assay: BladderCheck
Enzyme innunoassay for NMP22
Used with cytology for Dx and surveillance
Urine Assay: BTA
Enzyme immunoassay for bladder tumor antigen
Nephrogenic Adenoma
- What is it?
- Sxs?
- Tx?
Rare benign metaplastic response to urothelium injury
Hematuria and irritative voiding sxs
Cystoscopy looks like low-grade papillary tumor
TUR + > or = 1 years of antibiotic suppression
Inverted papilloma of the ureter
Can behave malignantly, so survey bladder and upper tracts
Conservative management with surveillance for at least two years is recommended
Instillation of periop chemo after complete TURBT only works if given within how long?
24 hours after surgery
5mm filling defect in distal ureter + biopsy shows LG UC
Ureteroscopic tumor ablation
Risk of upper tract UC in patient with bladder Ca diagnosis?
10%
Risk of bladder cancer in patients with UTUC diagnosis?
~40%
How to follow cystitis glandularis?
Could have risk of transformation to adenocarcinoma
Survey with cysto or UA
Lit: SWOG 8216
1991
Intravesical BCG > Doxorubicin for preventing NMIBC recurrence
RCT
BCG = immune system activator
Doxorubicin = DNA intercalator
Lit: BCG Complications
1992
Intravesical BCG is generally well tolerated but can lead to serious adverse effects
2.9% fever
0.9% granulomatous prostatitis
0.7% PNA/hepatitis
0.5% arthralgias
1% hematuria
0.3% rash
0.3% ureteral obstruction
0.4% epididymitis
0.2% contracted bladder
0.1% renal abscess
0.4% sepsis
0.1% cytopenia
Management of BCG-related complications?
- Fever >38.5C
- Allergic reaction
- Acute severe illness
- Sepsis
Fever >38.5C: Isoniazid 300mg daily for 3 months
- Can resume BCG when asymptomatic
Allergic reaction: Isoniazid 300mg daily for 3 months
- Further BCG if benefits outweigh risks
Acute severe illness: Isoniazid 300mg, rifampin 600mg, ethambutol 1200mg daily for 6 months
- No further BCG
Sepsis: Isoniazid 300mg, rifampin 600mg, ethambutol 1200mg daily for 6 months
- Also consider prednisone 40mg
Lit: Post-TURBT MMC
1996
Post-TURBT MMC decreases risk of recurrence
RCT
5-year follow-data favored MMC over nothing
Lit: SWOG 8507
2000
Maintenance BCG doubles RFS compared to induction BCG alone in HR NMIBC
RCT
Similar 5-yr OS
Lit: Valrubicin for BCG-refractory CIS
2000
FDA-approved for treatment of BCG-refractory CIS in non-cystectomy candidates
Phase III trial
Valrubicin = anthracycline chemo - DNA intercalation
Lit: EORTC 30692
2013
3 years (vs. 1 year) of mBCG is helpful in HR (but not IR) NMIBC
RCT
Lit: SWOG S0337
2018
Immediate post-TURBT Gemcitabine reduces recurrence of low-risk NMIBC
RCT
Gemcitabine = DNA synthesis inhibitor
Lit: KEYNOTE 057
2021
Pembrolizumab is approved for use in BCG-unresponsive NMIBC
Single arm
Lit: Nadofaragene Firadenovec for BCG-unresponsive NMIBC
2021
CIS unresponsive to BCG may have durable response to nadofaragene
Phase III trial
Nadofaragene = delivers IFN-alpha/2beta cDNA to bladder epithelium and activates immune system
FDA approved in 2022
BCG: MOA
Immune system activator
MMC: MOA
Alkylating chemotherapy - DNA cross-linker
Valrubicin: MOA
Anthracycline chemotherapy - DNA intercalation
Gemcitabine: MOA
DNA synthesis inhibitor
Pembrolizumab: MOA
IgG4-mAb to PD-1
Decreases T-cell suppression
Increases T-cells killing cancer cells
This is IV/systemic
Nadofaragene: MOA
Delivers IFN alpha/2beta to bladder epithelium
Activates immune system
BCG Shortage recommendations: 2020
Don’t use BCG in LR disease
For IR disease, use intravesical chemo (MMC, gemcitabine, epirubicin, docetaxel)
Use the available BCG for HR NMIBC induction
- If needed, BCG dose can be reduced to 1/2 or 1/3rd strength
If enough BCG is available to offer mBCG - reduce to 1/3rd strength and limit to one year of maintenance
If BCG shortage –> prioritize iBCG for HR over mBCG
If BCG is unavailable –> MMC is the preferred alternative
Newly diagnosed CIS and BCG is unavailable
MMC
HR bladder cancer patients with HR features (HGT1 + CIS, LVI, PUI, variant histology) who are surgical candidates and who are unwilling to take any oncologic risk by using a non-BCG regimen
Offer radical cystectomy
Workup for patients with suspected UTUC
Cystoscopy
Cross-sectional imaging of upper tracts with contrast and with delays
Also, diagnostic URS with washings and biopsy of any concerning lesions identified
If bladder and upper tract tumors discovered during evaluation of upper tracts?
Deal with bladder lesions in same sitting as upper tract eval
If upper tract is difficult to access due to stricture?
Minimize risk of ureteral injury by using gentle dilation techniques such as ureteral stenting
Don’t use a sheath or try to dilate
In cases where ureteroscopy cannot be safely performed or is not possible, but UTUC is suspected?
An attempt at selective upper tract
washing or barbotage for cytology may be made and pyeloureterography performed in cases where good quality imaging such as CT or MR urography cannot be obtained
Should you inspect both sides when one UT is concerning for cancer? Or only one?
At the time of ureteroscopy for suspected UTUC, clinicians should not perform ureteroscopic inspection of a radiographically and clinically normal contralateral upper tract.
For patients with suspected/diagnosed UTUC, when do you send them to genetic counseling?
If they have a personal or family history of Lynch Syndrome
(colorectal, ovarian, endometrial, gastric, biliary, small bowel, pancreatic, prostate, skin and brain cancer)
Favorable low-risk UTUC features
Biopsy Low-grade
Negative cytology
No invasion
No obstruction
Normal nodes
Unifocial, papillary in appearance
No lower tract involvement
Treatment: Ablation preferred, no systemic therapy
Unfavorable Low-Risk UTUC features
Biopsy Low-grade
No HGUC on cytology
No invasion
Can have obstruction
Normal Nodes
Multifocal
Papillary appearance
Can have bladder involvement
Ablative therapy can be offered, No systemic therapy
Favorable High-Risk UTUC features
Biopsy high-grade
Any cytology
No invasion
No obstruction
Normal nodes
Unifocal
Papillary appearance
No lower tract involvement
Ablative therapy in rare, selected cases
Recommend neoadjuvant or adjuvant systemic therapy
Unfavorable High-Risk UTUC features
Biopsy high-grade
HGUC on cytology
Invasion
Obstruction
Suspicious nodes
Multifocal
Sessile or Flat lesions
Lower tract involvement
Ablation for palliation
Recommend neoadjuvant or adjuvant systemic therapy
Initial management option for patients with LR favorable UTUC
Tumor ablation
Initial management option offered to patients with LR unfavorable UTUC and select patients with HR favorable disease who have low-volume tumors or who cannot undergo Radical Nephroureterectomy
Tumor ablation
Tumor ablation - retrograde or antegrade? Next endo eval?
Tumor ablation may be accomplished via a retrograde or antegrade percutaneous approach and repeat endoscopic evaluation should be performed within three months
Role of intravesical or pelvicalycel chemo in UTUC ablation?
Following ablation of UTUC tumors and after confirming there is no perforation of the bladder or upper tract, clinicians may instill adjuvant pelvicalyceal chemotherapy (Conditional Recommendation; Evidence Level: Grade
C) or intravesical chemotherapy (Expert Opinion) to decrease the risk of urothelial cancer recurrence.
Pelvicalyceal therapy with BCG may be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS)
Pelvicalyceal therapy with BCG may be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS)
When do you perform NephU in LR UTUC?
When tumor ablation is not feasible or evidence of risk group progression is identified in patients with LR UTUC,
surgical resection of all involved sites either by RNU or segmental resection of the ureter should be offered
Choice therapy for patients with HR UTUC?
Clinicians should recommend RNU or segmental ureterectomy for surgically eligible patients with HR UTUC.
Make sure to also give a single dose of chemo intravesically
Best treatment option for surgically eligible patients with HR and unfavorable LR UTUC cancers endoscopically confirmed as confined to the lower ureter in a functional renal unit
Distal ureterectomy and ureteral reimplantation is the preferred treatment
Make sure to also give a single dose of chemo intravesically
When performing NU or distal ureterectomy, the entire distal ureter including the intramural ureteral tunnel and ureteral orifice should be excised, and the urinary tract should be closed in a watertight fashion
LND in UTUC surgery?
For patients with LOW RISK UTUC, clinicians MAY perform LND at time of NU or ureterectomy
For patients with HIGH RISK UTUC, clinicians SHOULD perform LND at time of NU or ureterectomy
When to consider neoadjuvant chemo in UTUC management?
Clinicians should offer cisplatin-based NAC to patients undergoing RNU or ureterectomy with HR UTUC, particularly in those patients whose post-operative eGFR is expected to be less than 60 or those with other
medical comorbidities that would preclude platinum-based chemotherapy in the post-operative setting
When to us adjuvant chemo in UTUC management?
Clinicians should offer platinum-based adjuvant chemotherapy to patients with advanced pathological stage (pT2–T4 pN0–N3 M0 or pTany N1–3 M0) UTUC after RNU or ureterectomy who have not received neoadjuvant platinum based therapy
Adjuvant nivolumab therapy may be offered to patients who received neoadjuvant platinum-based chemotherapy (ypT2–T4 or ypN+) or who are ineligible for or refuse perioperative cisplatin (pT3, pT4a, or pN+).
Metastatic UTUC patients treatment?
In patients with metastatic (M+) UTUC, RNU or ureterectomy should not be offered as initial therapy
Patients with clinical, regional node-positive (cN1-3, M0) UTUC should initially be treated with systemic therapy. Consolidative RNU or ureterectomy with lymph-node dissection may be performed in those with a partial or complete response
Upper tract CIS with low tolerance for nephrol loss (eg CKD, history of stones)
PCN with antegrade BCG instillation is more effective than ureteral stent placement and bladder instillation
Upper tract UC before age 55
Genetic counseling if positive for lynch syndrome (HNPCC)
Balkan Nephropathy
Long-term consumption of aristolochic acid increases the risk of UTUC and ESRD
Lit: (don’t) POUT (it worked)
Peri-operative chemotherapy vs. surveillance in Upper Tract UC
2020
Adjuvant systemic gem/cis improves DFS over placebo after NUx for advanced, non-metastatic UTUC
This was surveillance vs. adjuvant gem/cis
RCT
Lit: OLYMPUS
2022
MMC gel injected into upper tract weekly works to destroy low-grade UTUC but is associated with ureteral stenosis in almost 50% of patients
Phase III
6 weekly instillations of Jelmyto - retrograde
Complete responders eligible for monthly maintenance instillation
Need to stage non-metastatic muscle invasive bladder cancer prior to recommending treatment. How?
CT Urogram
CBC
CMP
Chest imaging
Bone imaging if clinical suspicion (increased ALP) or symptoms of bone mets
Role of NAC and AC in MIBC (non-metastatic)
Generally, patients should get cisplatin-based NAC followed by RC within 12 weeks of NAC
Neoadjuvant carboplatin-based chemo should NOT be used (if cisplatin ineligible –> up front RC vs. clinical trial)
Cisplatin-based adjuvant chemo if non-organ confined disease at cystectomy (T3, T4 or N+)
Cystectomy for M0 disease
Do bilateral pelvic lymph node dissection (BPLND) (at least external/internal iliac and obturator nodes)
Remove bladder, prostate, SVs in med
Remove bladder +/- adjacent organs in women
Consider sexual function preserving procedures depending on extent of disease
When creating a neobladder, verify a negative urethral margin first
Medications to use in cystectomy periop period
mu-opioid antagonists (alvimopan) unless contraindicated
Pharmacologic VTE prophylaxis should be used
Bladder preservation in non-metastatic MIBC
Maximal TURBT
Radiosensitization (cisplatin of 5-FU/MMC)
EBRT
Surveillance cysto
RC for MIBC recurrence
TURBT or RC for NMIBC recurrence
Radiation monotherapy should not be offered
Follow-up for non-metastatic muscle invasive bladder cancer
Chest imaging
Cross-sectional AP imaging q6-12 months x 3 years and then annually
Labe q3-6 months for 3 years and then annually
Monitor urethral remnant if present
MIBC, chemo type, and timing
Most patients with MIBC should get cisplatin-based NAC prior to RC
Contraindications to cisplatin-based chemotherapy
Poor performance status
CrCl <60
Significant hearing loss
Significant peripheral neuropathy
NYHA Class 3+ HF
Muscle invasive small cell carcinoma treatment
Muscle invasive small cell carcinoma responds well to cisplatin based neoadjuvant chemo followed by surgery OR radiation
(Cure rate 40-60% vs. 5-20% without NAC)
Cisplatin + ETOPOSIDE (not gemcitabine) is the standard regimen
Treatment for pure variant histology (micropapillary, squamous, adenocarcinoma (colonoscopy required in workup), plasmacytoid, and sarcomatoid) tumors
Pure variant histology tumors should generally be treated with upfront cystectomy (no NAC)
MIBC in conjunction with variant histology should (generally) be managed how?
NAC prior to local treatment
Neoadjuvant chemo and NON-MIBC?
NAC has NOT been found to be of benefit in patient undergoing RC for non-muscle invasive disease
Major metabolic anomaly with ileum or colon diversion
HYPERchloremic metabolic acidosis
- Due to absorption of ammonium ions (absorbed with Cl-) in exchange for carbonic acid and water (secreted)
Major metabolic anomaly with ileum or colon diversion - treatment?
Treat with:
1. Decreased transit time (CIC)
2. Alkalinizing agents (bicrab, citrate)
3. Inhibitors of Cl- transport (chlorpromazine, nicotinic acid)
Ureterosigmoid (colon) vs. ileal conduit
- Metabolic derangements?
- Risks?
Both create a hyperchloremic metabolic acidosis
- Risk of colon cancer with colon conduit
- Risk of worse (more frequent and more severe) metabolic derangements with colon
Osteomalacia is most likely with colonic continent diversions
- MAc gets buffered by bone with release of Ca++
- Mineralized bone is reduced and osteoid component becomes excessive
- Lethargy, joint pain, proximal myopathy, elevated alk phos
– Treat by correcting acidosis with K-cit and Ca++ supplementation
Major metabolic abnormality seen after RC/IC
HYPER-Cl
HYPO-K
Metabolic acidosis
Jejunal conduit metabolic derangement
Also ACIDOSIS
But with opposite electrolyte derangements
So, HYPO-Cl and HYPER-K
Treat by rehydrating and alkalinizing (PO hydration, NaCl and bicarb (NaHCO3))
Stomach conduit metabolic derangement and treatment
Stomach conduit abnormalities are like vomiting
Metabolic alkalosis (lose your stomach acid)
HYPO-Cl
HYPO-K
Tx:
Rehydration with NS
KCl replacement
H2 blockers
PPI
How does B12 deficiency present? When does it happenin Urology/bladder Ca?
B12 deficiency presents with anemia and neurologic abnormalities (numbness and postural hypotension)
Nutritional problems (B12 deficiency and bile acid salt absorption) are less with colon when compared to ileum as long as ileocecal valve is left intact
B12 is a coenzyme in the metabolism of homocysteine
- Homocysteine will build up in serum in absence of adequate B12
Ileal conduit and ‘water under the bridge’
IC should be formed “under” (inferior to) the bowel anastomosis
Most accurate way to assess renal function s/p ileal conduit
FeNa
Next step: decreased UOP and increased drain output 4 days after RC/IC
Place a catheter in stoma
Urinary ammonium excreted by the kidneys (collecting duct) is absorbed by intestinal conduit…
What can happen next?
Treatment?
If symptoms are relatively mild?
The liver metabolizes the ammonia to urea (via ornithine cycle)
If liver function is decreased, can lead to increased ammonia buildup and you can go into ammoniagenic coma
Treat with oral neomycin or lactulose to reduce absorption in GI tract
*If sxs are milder (lethargy with increased transaminases), start with continuous drainage of urinary diversion
Necrotic looking stoma. Next step?
Loop endoscopy with or without diagnostic lap to determine extent of ischemic segment prior to operative intervention
If just very distal conduit is involved, can consider stoma revision alone without resection of the entire conduit
Next step?: Enteral-conduit fistula –> feculent urine
Start with catheter in conduit + low residue diet
Surgical intervention PRN
Largest risk factor for parastomal hernia
Stoma placement lateral to the rectus abdominus
Next step?: Pyocystis s/p ileal conduit w/o cystectomy
First line treatment is bladder irrigations
If persistent problems like sepsis, vesicovaginostomy formation improves symptoms without morbidity of cystectomy
Bowel prep needed for small bowel diversion?
No, mechanical bowel prep is NOT indicated for most patients having a diversion with small bowel
Next step: Calculus in ileal conduit?
Most will pass spontaneously
- Initial observation is preferred in an asymptomatic patient in absence of hydronephrosis or other evidence of conduit obstruction
Next step?: Suspicious or positive urethral wash s/p RC/IC for BCG-refractory CIS
Staging imaging
Urethrectomy if imaging negative
Next step?: New hydronephrosis in patient with RC/IC
Loopogram to determine presence/absence of reflux
If no reflux, get lasix renogram to determine level of obstruction
- Consider CTU to evaluate for extrinsic vs. intrinsic mass at site of obstruction prior to nephrostomy tube placement
+/- nephrostomy tube
Endoscopic +/- laparoscopic management
Ureteroenteric anastomotic strictures: Work-Up?
First rule out malignant cause of stricture (ureteroscopy +/- biopsy +/- cytology)
The assess kidney function (renogram)
Then consider length of strictures
- If <2cm could try endoscopic procedure
If > 2cm, open repair is best
Causes of early vs. late ureteroenteric anastomotic strictures?
Early = <1 year after surgery
- Usually due to devascularization of the distal ureter or extreme angulation of the left ureter at the IMA (more common on left side)
Late = usually a fibrotic response at the UE junction
Open or endoscopic repair for:
early UEA strictures?
Late UEA strictures?
Long?
Short?
Short - can be managed endoscopically in first year or so after surgery
Open surgical repair most effective
Open repair typically needed for longer (>2 cm) or strictures that occur >1 yr after surgery
What do you do for obstructed, nonfunctional kidney after RC/IC?
NephU should be considered because these units cannot be surveyed for upper tract recurrence using cytology
Diarrhea after >40cm but <100cm of ileal resection and RC/IC?
Due to decreased ileal bile salt absorption, so there is increased bile salt delivery to the colon
Colonic irritation and increased bicarb and water secretion (secretory diarrhea)
Treat with cholestyramine (bile-acid sequestrant in the GI tract) and decreased fat intake
Diarrhea after ileocecal valve or colon resection?
Decreased bowel transit time + osmotic diarrhea
Treat with oral bulking agents and loperamide
Contraindications for orthotopic ileal neobladder
Inability/unwillingness to catheterize
Urethral stricture disease
SUI
GFR <50
Severe liver disease
Positive urethral margin
IBD (crohn’s)
Short bowel syndrome
Maneuvers to do if there is difficulty reaching the urethral stump with neobladder
Reduce Trendelenburg
Incise peritoneum over the neobladder mesentery
Staple the medial/proximal mesentery while avoiding ischemia
Release ileum around ileocecal junction
Convert to ileal conduit or sigmoid neobladder
Abdominal pain over continent diversion and explosive urinary leakage
Pouchitis
Urine culture and empiric abx
First line treatment is regular pouch irrigation
Second line is prophylactic abx or urine acidification
Why?: Isolated nocturnal incontinence s/p RC/NB
Associated with loss of afferent input from the detrusor to CNS, which normally causes a reflex rise in urethral pressure during reservoir filling
What is bowel segment of choice in neobladder? Why?
Detubularized ileum
Superior compliance
Lowest likelihood of generating intermittent high-pressure contractions
Next step?: Urethral recurrence in neobladder
If invasive disease –> urethrectomy + urinary diversion
If superficial, can try to TUR or do intraurethral BCG
Urethral recurrence after Studer (U-shaped) NB?
Urethrectomy + conversion of afferent limb into ileal conduit
Omentum blood supply
Right gastroepiploic artery
First branch off of the internal iliac
Umbilical artery
- This gives off the superior vesical arteries before becoming the obliterated umbilical artery (medial umbilical ligament)
Ureter passes medial to the medial umbilical ligament to reach the bladder
Vas deferens enters the pelvis lateral to the epigastrics and then passes medially, anterior to the ureter, to reach the base of the prostate
Branches of the External Iliac Artery
Inferior epigastric
Deep circumflex iliac
Femoral (gives rise to superficial and inferior external pudendal arteries, which supply blood to rhe penile and lateral scrotal skin, respectively)
Posterior branches of the Internal Iliac Artery
Iliolumbar, lateral sacral, superior gluteal
Ligation of the internal iliac should only be done distal to the posterior branch to avoid devascularization
Anterior branches of the Internal Iliac Artery
Umbilical
Obturator
Inferior Gluteal
Uterine (F)
Vaginal (F)
Inferior vesical (blood supply to prostate via prostatic and capsular branches)
Middle Rectal
Superior Vesical (blood supply to vas deferens via vesiculodeferential)
Internal pudendal
Celiac Artery Branches
Left Gastric artery
Common Hepatic artery
Splenic artery
