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					                                                          ISSN 1391-6343




SLJU
THE SRI LANKA JOURNAL OF UROLOGY
Established 2000

Volume 10, No. 1, December 2009




                                           JOURNAL OF
                                  THE SRI LANKA ASSOCIATION OF
                                     UROLOGICAL SURGEONS


                                  Editors: S. A. S. Goonewardena
                                           A. M. Abeygunasekera
                                                        UROLOGICAL CHALLENGES IN RENAL TRANSPLANTATION                 1



Sri Lanka Journal of Urology, 2009, 10, 1-11
Review Article


Urological challenges in renal transplantation

N. Seneviratne and N. D. Perera
Department of Urology and Renal Transplantation, National Hospital of Sri Lanka, Colombo, Sri Lanka.




Urological evaluation is an essential component of the       exhausted. Hence the true incidence of technical graft
pre-transplantation assessment of any potential renal        loss due to urological complications is infrequent.
recipient. The main objective is to identify structural
and functional abnormalities of the native urinary tract     Pre transplantation assessment
that may preclude transplantation or threaten patient or
                                                             1. Upper urinary tract
graft survival. Mainly the assessment should be tailored
to determine the need for pre transplant nephrectomy         Probably the most frequent pre-transplant surgical
and the suitability of the lower urinary tract to receive    consideration of the upper tracts of the renal system is the
the graft. Meticulous measures taken to harvest a healthy    need of nephrectomy with or without ureterectomy. The
ureter which is properly implanted with a non refluxing      goals of nephrectomy are to clear a potential nidus for
                                                             septicemia which becomes an issue during immuno-
method is mandatory since ureteric complications could
                                                             suppression, to ameliorate hypertension and to eliminate
arise at any time and could be an unforgiving threat to
                                                             a potential neoplastic focus (1). Table 1 summarizes the
the graft viability or even patient survival. These post
                                                             indications for pre-transplant nephrectomy.
operative complications are now increasingly managed
by endourological or percutaneous image guided               Whenever possible the procedure should be limited to
techniques which have become a part and parcel of            a unilateral nephrectomy to allow continued erythro-
modern urological practice. As a result, reoperation is      poietin and urine production by the remaining kidney
rarely required unless all other resources have been         to buy time before the transplantation.




                             Table 1. Indications for pre-transplant nephrectomy

    Indication                 Rationale                                    Pathology

    (a) Mandatory              Ongoing infection                            Staghorn calculus
                                                                            Renal cortical abscess
                                                                            Resistant organisms in urine culture

                               Malignant hypertension                       Renovascular disease
                                                                            Idiopathic unresponsive to
                                                                              medical therapy

                               To rule out malignancy                       Renal Mass
                                                                            Acquired cystic kidney disease

    (b) Preferable             Eliminate potential infection                History of pyelonephritis
                               Persistent pain                              Polycystic kidney disease
                               Haemorrhage requiring transfusion
2      N. SENEVIRATNE AND N. D. PERERA



Laparoscopy (total or hand assisted) should be and            before transplantation. Voiding cystourethrography is
rightfully considered as the method of choice (‘Gold          a reliable method of detecting significant abnormalities
standard’) for pretransplant nephrectomy. The high            and has been shown to be a cost efficient means of
success rate, low morbidity, early recovery all are           initial investigation (9).
considered as real advantages for this patient population
(2). However, in the era of laparoscopy, bilateral simul-     Older renal transplant candidates, particularly men
taneous nephrectomy should be considered, minimizing          above 50 years, also have an increased incidence of
the waiting time and the duration between nephrectomy         abnormalities of the urinary tract, although these are
and transplantation. As Lap-donor nephrectomy is              generally acquired. In this situation PSA estimation,
considered as an advanced technique which should be           sonographic evaluation of the prostate as well as non
practised towards the end of the learning curve of a          invasive measurement of the voiding efficiency by
laparoscopist, presence of an experienced general or          means of uroflowmetry will be invaluable initial base
preferably a urological surgeon could minimize                line investigations.
complications during organ harvesting (3).
                                                              Potential recipients with underlying urological problems
High grade vesicoureteric reflux (VUR) that is left           or whose screening investigations are suspicious
untreated post transplantation is associated with             obviously require more detailed studies. Additional
increased urinary tract infections, even when urinary         imaging should be undertaken to establish the cause of
tract infections were not a problem prior to trans-           any ureteric dilatation and hydronephrosis, which in
plantation (4). Surgical options are reimplantation or        many cases requires an assessment of vesical function.
nephroureterectomy. Endoscopic collagen injection has         The storage and emptying properties of the bladder are
been successful in children prior to transplant which         studied in more detail by formal advanced urodynamics
reduces the morbidity of surgery (5). Generally,              supported by a cystoscopy.
ureterectomy is indicated in the presence of VUR grade
III or above or presence of primary renal infections          It is of prime importance that the assessment of bladder
due any degree of reflux disease. If ureterectomy is          function is considered early in the management of
contemplated the entire ureter has to be excised upto
                                                              the patient approaching end-stage renal failure. Vesical
the bladder. However, the decision for ureterectomy
                                                              function deteriorates in most patients on dialysis. Many
should not be made lightly since post transplant necrosis
                                                              develop small-capacity bladders with low voiding rates.
or long strictures of the donor ureter are most easily
                                                              Male haemodialysis patients are most affected, with a
replaced with the native ureter (6). Dilated donor ureters
                                                              median bladder capacity of 180 ml and maximal flow
could also be used for bladder augmentation in children
                                                              rate of 5 ml/sec, compared to 300 ml and 14 ml/sec in
prior to transplantation.
                                                              patients on peritoneal dialysis (10). The majority
                                                              improve within 3 months of transplantation. An average
2. Lower urinary tract                                        increase in excess of 50% in both bladder capacity and
The ideal bladder for implantation of the transplant          maximal flow rate is seen (11). Unfortunately, it is
ureter is a continent, sterile, low-pressure reservoir that   difficult to predict bladder function after transplantation
empties completely. Basic evaluation should be a good         in an oliguric patient. However, those with pre-transplant
history and physical examination on irritative or voiding     bladder capacities of less than 100 ml and a history of
symptoms, urinary tract infection and haematuria              urinary infection have a poor outcome and worse graft
followed by urine analysis, sonogaphic assessment of          survival (10). It is critical, therefore, that patients with
bladder volume and the post void residual volume. It is       chronic renal impairment in whom there may be
routine to do a X-ray KUB in places where stone disease       potential concerns with respect to bladder function have
is endemic as in ours as well as it gives a clue into         this formally assessed prior to transplantation.
calcified vessels (7). In the absence of a past urological
history with initial evaluation being negative further        As the age of the transplant patients increase, more
investigations are generally not required. However, two       male patients exhibit benign prostate enlargement. Prior
groups at extremes of age are at additional risk despite      to transplant these patients have small urine outputs
the initial screening and need further evaluation.            which are probably inaccurate to address the bladder
                                                              outlet obstruction. In general it is preferable to perform
30-40% of paediatric renal transplant recipients in           a transurethral resection (TURP) after successful trans-
contrast to 6% of adults have end stage renal disease         plantation as lack of transurethral urine tends to
(ESRD) secondary to or associated structural genito-          predispose bladder neck stricture formation which
urinary abnormalities (8). Therefore, formal assessment       would be an additional burden prior to transplantation.
of the lower urinary tract should be done in all children     Additional advantage of a delayed prostatic surgery is
                                                          UROLOGICAL CHALLENGES IN RENAL TRANSPLANTATION                 3



that with a post transplant diuresis some of the lower         which is common among the ageing transplant
urinary tract symptoms such as poor flow could                 population. Problems of recurrent urinary infection and
markedly improve.                                              chronic retention can be avoided in such patients with
                                                               regular and complete bladder emptying by clean
                                                               intermittent self catheterization.
Lower urinary tract reconstruction – bladder
augmentation or urinary diversion
Many ESRD patients have defunctionalized bladders
and generally of low capacity (12). Of the adult
population 6% have lower urinary tract anomalies.
Generally they are small bladders with detrusor irritability
                                                                                                            B
or large volumes with poor emptying. In this group
voiding cystourethogram and advanced urodynamics                                              C

become key investigations to get an idea of the nervous
and/or muscular response to volume expansion (13). But
in majority of patients with abnormal vesical function,
the surgically unmodified bladder can still be rehabilitated
                                                               Figure 1. End stage renal failure due to neuropathic
and used for transplantation with a planned strategy
                                                               thick walled bladder (B) augmented with caecum and
involving intermittent self-catheterization and/or
                                                               right colon (C).
anticholinergic therapy (if required), with good long-
term results (8). Self catheterization has been far more
superior and less in morbidity when compared to                Predominantly children with neurological and anato-
surgery.                                                       mical derangements affecting the detrusor/sphincter
                                                               mechanism, in a very few, the entire bladder is deemed
On the other hand, patients with small nondistensible          an unsuitable reservoir. In this case simple urinary
fibrotic bladders are unlikely to become an adequate           diversion in the form of conduit of ileum, sigmoid or
reservoir post transplant. Therefore, bladder augmen-          the caecum has been used and the transplanted ureter
tation should be done prior to transplantation which           has been anastomosed to it (17). Although historically
employs a detubularized segment of caecum (Figure 1),          the initial approach to this problem was anastomosis of
right colon, ileum or sigmoid colon (14). Urinary tract        the ureters to the sigmoid colon (by Coffey), the
infections are the most common complication of the             procedure was abandoned due to the development of
augmented bladders. Regulated timed voiding and double         metabolic and infective complications. Since then ileal
voiding will reduce the occurrence of infections though        conduits, have become more widely utilized procedure.
others believe low-dose antibiotic prophylaxis will
prevent symptomatic urine infections (15). Electrolytes        Continent urinary diversion and neo bladder recons-
and metabolic abnormities are not so uncommon.                 truction are alternatives to conduit diversion and are
Acidosis should be treated due to its contribution to          being used increasingly (18). The major concern of using
metabolic bone disease. This favours gastric segments          long bowel segments, was that it could result in bicar-
to be employed in children hoping that secretion of acid       bonate loss causing hypercholoremic acidosis which
into the urinary tract offsets metabolic acidosis of           in turn inhibits renal resorption of calcium and
chronic renal failure and may decrease the risk of urine       production of 1-25 dihydrocholecalciferol, leading to
infection. However, gastric acid production can also           bone demineralization. This could exacerbate the
cause problems when stomach is interposed in the               existing clinical bone disease in post transplant recipients
urinary tract. The use of small bowel additionally will        treated with steroids and calcineurin inhibitors.
give rise to nutritional deficiencies such as B12 as well
as excessive mucous related problems. Regular                  Whenever possible, urinary tract reconstruction,
drainage of augmented bladder and irrigation to remove         particularly if prosthetic devices are to be used, should
mucous are recommended to prevent symptomatic                  be completed before transplantation, to reduce the risk
urine infections. All these complications can be               of infection during immunosuppression.
overcome if redundant dilated lower ureter is used, if
available, for augmentation of the bladder in the uraemic      Perioperative concerns
patient (16).
                                                               1. Ureteric harvesting
The other form of dysfunctionalized bladder is the             Transplant ureter has a proclivity toward complications,
hypotonic/ atonic bladders resulting from diabetes and         because it receives its entire blood supply from the
other causes of peripheral or autonomic neuropathy             vessels that emanate in the hilar and upper periureteral
4      N. SENEVIRATNE AND N. D. PERERA



areolar tissue, sites that are vulnerable to injury during     any substantial need to attempt a nonrefluxing anas-
donor nephrectomy. Therefore, caution has to be                tomosis. The incidence of reflux on voiding cysto-
exercised during harvesting the ureter to avoid                graphy is similar in both tunneled and non-tunneled
dissection of the perihilar fat and preserving periureteric    implants (23% v 29%). Urinary tract infections occur
fat and areolar tissue by limiting the dissection medial       with similar frequency in patients with or without reflux
to the gonadal vein. In addition if the ureteral segment       into the transplanted ureter (27). Despite this, it has
is either too long and redundant or too short and under        been suggested that reflux may be associated with
tension may compromise the blood supply.                       poorer graft survival independent of infection.

To reduce the magnitude of the donor operation in terms        Despite well established ureteroneocystostomy
of convalescence and improved cosmetic results                 techniques, Whelchel and Cosmi in 1975 and Hughes
laparoscopic donor nephrectomy was introduced in               in 1987 advocated the use of ureteropyelostomy
1995 (20). Though the initial ureteric complications           connecting the ipsilateral recipient native ureter to the
during harvesting was 11% lately it has dropped down           donor renal pelvis (28). This created a wide anastomosis
to less than 2% almost reaching the conventional open
                                                               with less chance of stricture or obstruction. However,
figures which is less than 1% (19,20).
                                                               the major complication of ureteropyelostomy being
                                                               infected urinoma and the greater risk of vascular
2. Ureteric anastomosis                                        disruption owing to extension of infection into hilar
Implantation of the transplant ureter is usually done by       vessels rendered this technique to be used sparingly.
one of two techniques. Choice of technique appears             Alternatively, Hamburger in 1962 introduced uretero-
largely related to institutional preference. In the            uretostomy where donor ureter is anastomosed to
Leadbetter-Politano technique, which is an intravesical        the native lower ureter (29). These two alternative
method requires a larger anterior cystotomy to visualize       techniques are particulary useful if ureteroneo-
interior of the bladder, creation of a 2-3 cm long             cystostomy is not feasible owing to a shortened donor
submucosal tunnel hence requiring a longer length of           ureter due to a surgical misadventure during organ
the donor ureter dissection (21). Implantation of the ureter   procurement.
is done superior-medial to the native ureteric orifice
over the trigone rendering the accessibility of endos-         3. Stenting the anastomosis
copic instrumentation and stenting when indicated. This
is probably of less importance in the present era with         A double-pigtail polyurethane stent is inserted during
the availability of interventional radiological techniques     the ureterovesical anastomosis to ensure free drainage
that allow this to be done percutaneously.                     urine despite anastomotic oedema to avoid ureteral
                                                               distension which can lead to necrosis of the ureter.
Extravesical implantation Lich-Gregoir technique, which        Routine use of a stent in extravesical ureteroneo-
is the standard technique in many units worldwide              cystostomy has a significantly lower urological compli-
requires a small extra vesical myotomy on the lateral          cation rate than those with nonstented anastomoses
surface of the bladder where the ureteroneocystostomy          from 10% to 1%. Largest series of five randomized,
is done followed by a tunnel created over the ureter by        controlled trials individually found stented anastomoses
approximating the two seromuscular flaps (22,23).              to have a lower complication rate and this was
This method which was originally described for the             confirmed by metanalysis of these trials (30). Use of a
correction of vesicoureteral reflux was introduced to          stent has shown to increase the chance of urinary tract
clinical transplantation by MacKinnon in 1968 (24). The        infection as high as 79% when compared to 54% in
method gained popularity due to the shorter length of          nonstented recipients (31). However, there are many
ureter and less dissection, lower incidence of urinary         large series showing that routine use of the stent is
leakage and stenosis although adequate randomized              more cost effective in the long-term. Stent is usually
studies are lacking (25). Subsequent transurethral             kept for 4-6 weeks prior to removal using a flexible
instrumentation or cannulation is also easy considering        cystoscopy. However, recent reports suggested that 2
the site of the neoureterocystostomy which is now              weeks are sufficient and the stent which has been left
redirected at posterolateral wall of the bladder.              tied in to the catheter can be removed together on the
                                                               8-10 days avoiding another hospital admission.
The two techniques have no difference apparent in early
or late complications in relation to obstruction, stenosis,
haematuria and urinary tract infections except urinary         Postoperative complications
leakage which is more common with the extravesical             The true incidence of urinary complications widely varies
technique (26). In addition, there does not appear to be       between institutions depending on the definitions used
                                                          UROLOGICAL CHALLENGES IN RENAL TRANSPLANTATION               5



to classify them. After excluding urinary tract infections     of patients with apparent narrowing of the ureter do
as a urological complication generally the true reported       not have mechanical obstruction (34). In cases in which
incidence of urological complications varies from              there appears to be any evidence of narrowing, and
2.5%-15% resulting in occasional graft loss (32).              therefore possible obstruction, an antegrade stent is
                                                               inserted (36). An improvement in renal function suggests
1. Ureteric obstruction                                        that obstruction had been present. Unfortunately, in the
                                                               majority of cases, chronic rejection has been found to
Ureteral obstruction is the most common urinary                be the underlying cause, with subsequent progressive
complication. It commonly presents during the early            decline in the remaining renal function over time. Long-
postoperative period due to blood clots, oedema and/or         term success has been reported with the treatment of
haematoma that exacerbate the narrowing in a relatively        ureteric strictures by percutaneous antegrade dilatation
tight submucosal tunnel, technical errors such as              using 6-8 mm angioplasty balloon catheter and placement
malrotation and extrinsic compression by the spermatic         of double J- stenting alone (37). This appears most
cord/ round ligament or due to perigraft fluid collection      effective in those presenting early within 3 months of
in the form of urinoma (Figure 2), haematoma or                transplantation, when 50% to 75% of strictures occur.
lymphocele. Late ureteric obstruction is also reported         Success rates in excess of 70% have been reported in this
due to chronic ischaemia.                                      group; in contrast to less than 30% with late presen-
                                                               tations (38). The late presenters require open surgery
                                                               whereby the ipsilateral native ureter or a tubularised
                                                               bladder segment is anastomosed to the obstructed
                                                               transplant collecting system.

                                                               2. Urinary leak
                                                               Urinary leak may result from faulty handling of donor
                                                               ureter, undue tension during anastomosis, ureter or renal
                                                               pelvis blowout due to obstruction, invasive wound
                                                               infection, distortion by pelvic haematoma or rarely due
                                                               to sluggish blood flow during an episode of rejection.
                                                               Clinical features such as oliguria, fever, pain and
                                                               swelling over the graft site, perineum, scrotum or labia,
                                                               cutaneous urinary drainage with elevated serum
Figure 2. Transplanted kidney complicated with a               creatinine can suggest a leak. These become apparent
urinoma.                                                       during the first month of transplant and can be readily
                                                               diagnosed by high creatinine content of the drained fluid.
                                                               Once suspected subsequent management is done
Clinical diagnosis is made in the presence of oliguria,
                                                               depending on the site and the degree of distruption.The
graft tenderness, urinary tract infection progressing to
                                                               three potential sites of leak in descending order of
sepsis and rising creatinine levels. When routine
                                                               frequency are at the ureter at the neoanastomosis, the
ultrasonography is performed, pelvicalyceal dilatation
                                                               bladder at the end of the anterior cystotomy or the
is detectable at some stage in as high as 57% of trans-
                                                               ureteral hiatus or renal pelvis. Diagnosis is aided by
plant recipients (33). In fact, at least some fullness of
the collecting system will be seen in virtually all patients   ultrasonography which will demonstrate a perigraft
with a stent in-situ if scanning is performed with a full      fluid collection where as gravity cystography will
bladder. Hence, a post void scan should be taken to            demonstrate a fistula (Figure 3). Also cystometrography
assess the collecting system true dilatation. Only a small     should be considered in patients in whom high voiding
percentage (10%) of those with dilatation will                 pressures may be contributing to a leakage at the
ultimately be found to be obstructed (33,34). Antegrade        ureterovesical anastomosis. However, an antegrade
pyelography is probably the preferred method for               pyleogram will be needed if cystogram is normal.
investigation of the patient with deteriorating renal          Nuclear renography scan will show evidence of isotope
function and dilatation of the pelvicalyceal system (35).      extravasation.
Isotope renography is not useful unless used serially to
monitor the progress. Combined Whitaker test which             Distal lesions from the ureterovesical junction are
is a pressure-flow study which measures pressure of            usually managed aggressively, whereas lesions in the
the renal pelvis as well as the intravesical pressure          more proximal ureter tend to be managed conservatively.
improve the diagnostic accuracy of antegrade                   An abscess or urinoma must be drained by either per-
pyelography, as is illustrated by the fact that up to 25%      cutaneous approach or by an open surgical approach.
6      N. SENEVIRATNE AND N. D. PERERA



At the same time combining a diverting nephrostomy            infections, and haematuria lead to the diagnosis in the
with antegrade ureteral stent leads to an 87% leak closure    majority of cases. The majority of calculi are less than
rate (39). Failing which retrograde stenting can be           1 cm in diameter, with staghorn calculi being an unusual
achieved with the availability of the flexible cystoscopy/    occurrence. As in the native urinary tract, the majority
ureteroscopy. However, larger urine leaks or drainages        of calculi can be treated with shock wave lithotripsy
that do not settle by 6 weeks following stenting needs        (ESWL), percutaneous nephrolithotomy or flexible
open surgical repair in the form of reimplantation,           ureteroscopy and lithotrity (42). Localization during
pyeloureterostomy or Boari flap repair. On the other          SWL can be a little more difficult than in the native
hand, vesical fistulas are generally controlled expectantly   kidney. Generally, a prone position is required although
by bladder decompression with an indwelling catheter          the close proximity of the kidney to the skin can create
for 2-6 weeks. Rarely substantial size vesical fistulas       problems in focusing the shock waves. Refractory cases
need early exploration and primary repair. Renal pelvic       which are rare, need open surgery. Urolithiasis related
wall necrosis is a rarity occurring due to vascular           to primary hyperoxalosis results in renal failure,
insufficiency due to inadvertent hilar dissection during      which must be treated by combined liver and renal
organ procurement. This will require urgent open              transplantation.
surgical restoration in the form of pyeloureterostomy
with the native ureter, a Boari flap or direct pyelo-         Kidneys have been transplanted knowingly containing
vesicostomy (40). It can be presumed that these early
                                                              a renal stone (43). Asymptomatic potential donor may
leaks reflected technical problems rather than extensive
                                                              be suitable for kidney donation if the stone is less than
ureteric necrosis.
                                                              1.5 cm in size, single stone and metabolic causes of
                                                              stone formation has been excluded in the recipient. The
                                                              stone has to be removed ex vivo prior to transplantation
                                                              by means of ureteroscopy or percutaneous surgery
                                                              (44,45).

                                                              4. Urinary retention
                                                              Postoperative urinary retention in renal transplant
                                                              recipients may cause problems in their management.
                                                              The more frequent acceptance of older males for
                                                              transplantation has resulted in an increasing number of
                                                              patients who are at risk of urinary retention as a result
                                                              of benign prostatic enlargement. Low urine outputs
                                                              while on dialysis may mask the development of bladder
                                                              outflow obstruction. Assessment is also difficult due
                                                              to reduced bladder volumes as a result of oliguria or
                                                              anuria. However, recommendation has been to avoid
                                                              prostatic surgery in patients who are approaching end-
                                                              stage renal failure or who have recently commenced
Figure 3. Cystogram showing evidence of urinary leak
at neoureterocystostomy of the transplanted kidney.           dialysis. In this situation there is a substantial risk of
                                                              urethral stricture and bladder neck contracture when
                                                              urine production is low in ESRD. It is preferable to
3. Urolithiasis                                               closely observe the patients at risk once the catheter
Urolithiasis is a relatively rare complication after renal    has been removed after transplantation. If any difficulties
transplantation. Risk factors include metabolic disease,      or problems are encountered, intermittent clean self
ureteric stenosis, the use of nonabsorbable suture            catheterization is immediately instituted. Patients
material, and prolonged stenting resulting in encru-          continue with this until a normal voiding pattern is re-
station. The incidence appears to be approximately 1%         established. When inadequate bladder emptying persists
(41). Higher rates have been reported, but they appear        or if the patient continues to suffer symptoms of
to be attributable to untreated hyperparathyroidism and       bladder outflow obstruction, a transurethral resection
the use of nonabsorbable sutures for the ureterovesical       of the prostate or bladder neck incision is performed 4
anastomosis or a metabolic cause. Clinical diagnosis          to 6 weeks later from the time after stent removal.
may be difficult because of denervation of the graft          Patients with atonic bladders or peripheral neuropathies
may not give rise to classical pain syndromes. Investi-       affecting detrusor function are also managed by early
gation of deteriorations in graft function, urinary tract     catheter removal with immediate institution of self
                                                            UROLOGICAL CHALLENGES IN RENAL TRANSPLANTATION                  7



catheterization. If and when residual volumes are                vasculogenic impotence include revascularization and
small this can be stopped, although it may need to be            implantation of penile prostheses (53). Vascularisation is
continued on a long-term basis.                                  performed in few centres and success rates are limited,
                                                                 probably because of fibrosis and other changes within
                                                                 the corporeal bodies as a result of chronic ischaemia
5. Erectile dysfunction
                                                                 that has already taken place by the time of surgery.
Sexual dysfunction is a common finding in end-stage              Penile prostheses while overall the most successful
renal disease, occurring in approximately 70% of either          treatment, can be associated with an increased risk of
sex of haemodialysis patients compared to 9% of the              infection as a result of immunosuppression (54).
general population. The prevalence of erectile dys-
function between dialysis and renal transplant recipients        6. Malignancy
varies from 21% and 43% (46). Co-existing neuro-
endocrine dysfunction including diabetes, hypertension,          Genitourinary cancers are the second most common
peripheral vascular disease and their drug treatments            tumours in transplant recipients with prostate cancer
together with psychological factors are the major                and renal cell carcinoma being the most common (55).
contributors to erectile dysfunction. Neuroendocrine             Unlike the more common skin malignancies, genito-
and psychological disturbances are frequently reversed           urinary tumours have a significant impact on both graft
by transplantation, with nearly 50% of those with erectile       and patient survival. During an average follow-up of
dysfunction before transplantation subsequently                  2.5 years, 25044 (3%) of 831804 transplant recipients
regaining potency (47). The sole reason being depression         developed cancer compared with an expected number
and disturbances of the hypothalamo-pituitary gonadal            of 21185 in respect to the general population (56).
axis which both substantially reduced after trans-               Younger than 35 years was considered as high risk for
plantation. However, elevations of serum prolactin and           genitourinary malignancy due to their long lifespan.
reduced testosterone can persist despite transplantation
in 25-57% of patients, although in these cases improve-          Renal tumours
ments in erectile function usually occur with hormonal
supplementation (48). Intracavernosal self-injection of          On the basis of the existing literature, it is very difficult
PGE1 is well accepted and tolerated by kidney transplant         to give a reasonable estimate of the prevalence of renal
patients with more than 90% response rates. It poses             tumours among chronic dialysis patients awaiting
no apparent risks to the transplanted kidney and could           transplantation (57). Acquired renal cystic disease
be a good modality to treat erectile dysfunction in kidney       (ARCD), renal adenoma, renal cell carcinoma (RCC) and
transplant recipients (49).                                      oncocytoma were found in 33%, 14%, 4.2% and 0.6%
                                                                 of cases respectively among over 800000 patients
After transplantation, vasculogenic factors appear               followed up beyond a decade (56,57). On multivariate
to be the most important in erectile dysfunction.                analysis, ARCD was positively associated with male
Mechanisms include renal failure associated with athero-         sex and longer dialysis duration and negatively
sclerosis and hypoxia, which may lead to structural              associated with peritoneal dialysis. On average 0.5%
changes in the contractile smooth muscle and collagen            pre transplant patients develop RCC signifying the
and elastin components of the erectile tissue. The               greater risk of malignant renal tumours over the general
resulting loss of elasticity may be a direct cause of            population. Transplantation is believed to be an effective
veno-occlusive dysfunction (50). Renal transplantation           and justifiable therapy for RCC patients based on data
may impair penile arterial blood supply. The blood               from North American and European Transplant
supply to the corporeal bodies is from the internal              Registries. Long-term follow-up revealed that only 10%
pudendal arteries, which are branches of the internal            subsequently developed metastatic disease and that there
iliac arteries. Arterial inflow from only one side may be        was a 5-year graft survival rate of 63% (58). Duration
adequate for an erection. However, this may not be the           of dialysis before transplantation was not a determinant
case if atherosclerosis or other effects of prolonged            of recurrence of RCC. Since tumour stage is an important
uraemia have restricted the circulation. Similarly, use          predictor of recurrence it would therefore seem
of the internal iliac artery at the time of retransplantation,   reasonable to consider that no waiting period would be
when the contralateral vessel was used or ligated at             necessary for patients who have low-stage (pTl-pT2),
the previous transplant operation, carries a risk of             incidentally discovered tumours. However, patients with
vasculogenic impotence (51). It is believed that, if             a higher stage (pT3 and above) or symptomatic
possible, these vessels should not be used in this               presentations should remain disease free for at least 2
situation. If use of the internal iliac artery may prove         years before consideration for transplantation (59,60).
necessary, the patient needs to be advised of the potential      Similar criteria can be applied to other patients with
risk to potency before surgery (52). Treatments of               non RCC.
8      N. SENEVIRATNE AND N. D. PERERA



ARCD is a progressive disease characterized by the           prostate to lead a more aggressive clinical course in
continuous replacement of the atrophic parenchyma            patients undergoing renal transplantation. Nevertheless,
by small cysts. Adenoma and carcinoma are seen in            this disease is potentially a significant issue in male
the kidneys of 5% to 19% of patients with ARCD (61).         recipients over the age of 50 years. The widespread
These tumours are often multifocal, with those reported      use of serum prostate specific antigen (PSA) testing
generally being small and asymptomatic. The distinction      has led to an increased diagnosis of this disease in men
between adenoma and carcinoma has been based on the          over 50 years old. However, the use of single value of
tumour diameter (less than 3 cm generally considered         PSA over free/total (f/t) -PSA quotient as a tool to
an adenoma and that 3 cm or greater to be carcinoma).        support the decision for or against a prostate biopsy, it
It is reasonable to screen potential transplant recipients   should be borne in mind that the cut-off criteria
with ultrasound if and when they have been on dialysis       determined for men with a normal kidney function
for 3 to 5 years, repeating this every 3 years and           cannot be applied to patients who suffer from kidney
continuing after transplantation. Nephrectomy should         failure. The f/t-PSA quotient of patients with terminal
be performed if suspicious lesions are detected. If an       renal failure is often shifted towards higher values. On
RCC is found, the contralateral kidney should also be        the other hand, there is no statistically significant
removed. Tumour size and stage would then determine          difference between the f/t-PSA quotients of kidney
the timing of subsequent transplantation.                    transplant recipients and patients with normal kidney
                                                             function, therefore the same diagnostic criteria apply
Transmission of malignancy can occur within an               in this case (67).
allograft. They may arise de novo or due to low grade
small tumour which proliferates during the immuno-           The treatment of patients with clinically localized disease
supressed period. To date there are very few (less than      remains controversial, with similar survival rates of 10
50) cases of RCC reported. These tumours do not appear       years being reported with close observation, radical
more aggressive than those arising in nonimmuno-             prostatectomy, and radiotherapy (68). Beyond that,
suppressed patients. Small tumours have been followed        possible survival advantages may be conferred by both
for several years before nephrectomy (60). During this       radiotherapy and radical surgery. Therefore, it would
period linear tumour growth of approximately 0.5 cm/
                                                             appear reasonable to offer transplantation to patients
year was observed, similar to that seen in nontrans-
                                                             with localized prostatic carcinoma, regardless of their
planted ESRD patients. Successful treatment by partial
                                                             treatment choice (if they are otherwise considered
nephrectomy has also been performed with continuation
                                                             suitable) (69). In addition, because clinical disease
of immunosuppression (62).
                                                             progression is predictable in this group after 10 years,
                                                             and highly unlikely within the first 2 to 3 years, there
Urothelial cancers                                           appears to be little rationale in deferring transplantation
Overall, there does not appear to be an increased risk       for the 2- to 5-year intervals, as suggested with other
of urothelial malignancy in renal transplant recipients.     malignancies. In contrast, patients with metastatic
However, it has been well documented that prolonged          disease have a much poorer outcome. These patients
consumption of compound analgesic agents is associated       are usually managed with androgen deprivation therapy.
with both endstage renal disease (analgesic nephropathy)     Despite an initial response in 70% to 80% of patients to
and a substantially increased risk of transitional cell      treatment, the mean survival duration in this group is
carcinoma (TCC) (63). Over the past few years, a few         approximately 24 to 36 months. Therefore, patients
cases of nephrogenic adenoma were reported. Although         with non-localized prostatic carcinoma represent a
regarded as a benign lesion, nephrogenic adenoma             poor risk group for transplantation despite apparent
may be difficult to distinguish from flat papillary          disease control by hormonal therapy at the time of
TCC endoscopically (64). Several reports have also           consideration.
documented TCC in association with nephrogenic
adenoma. It is therefore important to obtain biopsy
specimens, even with recurrent lesions (65). Defun-          Transplantation using compromised donor kidneys
ctionalisation of the bladder has also been identified as    Due to unavailability of renal donors readily diseased
a potential contributing factor.                             kidneys which have tumours/large cysts have been
                                                             successfully transplanted. After bench surgery to excise
Prostate cancer                                              small renal tumour less than 3 cm, have been used in
                                                             patients with numerous medical co-morbidities to
Currently there is an increased incidence of this cancer     increase the quality of life, despite the apparent contra-
in renal transplant recipients with a risk 2- to 5-fold      diction of an intuitive principle of organ transplantation
higher than that in the general population (66). It does     (70). Large cysts that occupy considerable volume of
not appear to carry a substantial risk of carcinoma of       the kidney might implicate complications after
                                                        UROLOGICAL CHALLENGES IN RENAL TRANSPLANTATION            9



transplantation due to its natural history. The renal        10. Kashi SH, Wynne KS, Sadek SA. An evaluation of
grafts with cyst of Bosniak I and II have been safely            vesical urodynamics before renal transplantation
transplanted with good long term results thus extending          and its effect on renal allograft function and
the criterion for the donor pool (71).                           survival. Transplantation 1994; 57: 1455.

In conclusion, presence of a urologist in the transplant     11. Kashi SH, Wynne KS, Sadex SA, et al. Post-trans-
team becomes an essential prerequisite, when it comes            plant bladder recovery: A prospective randomized
to perioperative correction of several non parenchymal           trial of two techniques of ureteric anastomosis.
diseases of the urinary tract, laparoscopic donor nephre-        Transplantation 1994; 57: 1523.
ctomy and executing a sound ureteric reimplantation          12. Serrano DP. Transplantation into long-term
technique which all eventually contribute for prolonged
                                                                 defunctionalized bladder. J Urol 1996; 156: 885-6.
graft survival. It is also necessary for a urologist to be
conversant with the skills to manage the wide range of       13. Erando C. Urodynamic evaluation and management
urological complications associated with renal trans-            prior to renal transplantation. Eur Urol 2000; 38:
plantation to be a useful member of the transplant team.         415-8.
                                                             14. Hatch DA et al. Kidney transplantation in children
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Authors

L. Niroshan Seneviratne, MS (Col), MRCS (Eng)
Senior Registrar in Urology and Transplant Surgery

Neville D. Perera, MS (Col), FRCS (Eng), FRCS (Edin), DUrol (Lond)
Consultant Urological Surgeon

Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.
12     A. M. ABEYGUNASEKERA



Sri Lanka Journal of Urology, 2009, 10, 12-17
Leading Article


Genitourinary tuberculosis

A. M. Abeygunasekera
Department of Urology, Colombo South General Hospital, Kalubowila, Sri Lanka.




Introduction                                                  minimises the default rates of TB therapy. Multi-drug
                                                              resistance is caused by poorly managed TB treatment
Although tuberculosis (TB) was known to have existed
                                                              and DOTS may help to effectively control this emerging
for more than 7000 years, the term genitourinary
                                                              menace.
tuberculosis (GUTB) was coined only in 1937. It is
credited to Wildbolz who showed that renal and
epididymal TB were local manifestations of the same           Historical background
blood-borne infection (1).
                                                              Tuberculosis has been known for many centuries. In
                                                              375 BC, Hippocrates described ‘pthisis’, a lingering
About 8 million new cases of TB occur each year and
                                                              disease with emaciation and diarrhoea (5). In 1761,
about two million die of the disease annually (2). Hence
                                                              Morgagni described a 15-year old boy with renal and
control of TB is included in the millennium development
                                                              retroperitoneal disease that was allegedly caused by TB.
goals to draw attention of the public as well as the
                                                              In 1882, Robert Koch isolated the tubercle bacillus. In
authorities to this worldwide scourge. Accordingly the
                                                              1883, Babes and Rosentein identified Mycobacterium
governments should take steps to halt and reverse the
                                                              in urine. Surgical treatment for GUTB was introduced
incidence of TB by 2015. The long-term goal of the Sri
                                                              in the latter part of nineteenth century. In 1870 Bryant
Lankan government and the National Programme for
                                                              performed the first nephrectomy for a pyelonephritic
Tuberculosis Control and Chest Diseases (NPTCCD)
                                                              kidney. Initial high mortality following nephrectomy
is to eliminate TB, defined as less than one case per
                                                              was reduced to about 10% around 1910. The occur-
million population by 2050. In Sri Lanka 7000 new TB
                                                              rences of fistulae from the residual ureteric stumps lead
cases were reported in 2008 with 392 fatalities (3).
                                                              to the first nephroureterectomy in 1895 by Howard
                                                              Kelly.
Though more than 90% of the cases and deaths due to
TB occur in the developing world the incidence is rising
                                                              Before the era of antimicrobials medical treatment of
in the developed world due to the emergence of HIV
                                                              TB consisted of a long term stay (about one year) in a
infection and increased number of transplants (4). This
                                                              sanitarium with strict bed rest with passive exercises,
has drawn attention of the rich countries for funding
                                                              controlled sunlight, well balanced diet and body massage
of research and preventive measures related to the TB
                                                              (6). The antimicrobials for TB were introduced in the
pandemic. The whole consignment of anti TB drugs
                                                              second half of the twentieth century. Introduction of
necessary for Sri Lanka is given as a grant by the Global
                                                              rifampicin in 1966 was a turning point in the history of
Drug Facility (GDF).
                                                              anti TB treatment.
GUTB is the second most common form of extra-
pulmonary TB in most countries. But according to the          Pathology
figures of the NPTCCD, the reported rate of GUTB is           Almost all infections due to Mycobacterium tuberculosis
very low in Sri Lanka. In 2007 there have been 1966           are acquired by inhalation of the organism. The
cases of extra-pulmonary TB reported in Sri Lanka.            probability that a person will become infected depends
But only 4 cases of GUTB were recorded by the                 on the duration of exposure to the index case, the size
NPTCCD. This may be due to deficiencies in reporting          of the bacillary inoculation inhaled, the infectivity of
and documentation. Properly instituted chemotherapy           the mycobacterial strain and the immunity of the host.
is the best way to break the transmission of TB.              The chance of a competent host developing active TB
Therefore the best way to prevent TB is to detect and         after M. tuberculosis infection is 5% to 10% over the
treat cases effectively. To achieve this, directly observed   person’s lifetime (7). Up to 50% of the active disease
treatment (DOTS) is practiced in Sri Lanka. This              occurs within 2 years of infection.
                                                                                 GENITOURINARY TUBERCULOSIS             13



Like other forms of TB, GUTB is also caused by the             stream in most patients (13). Direct spread from the
members of Mycobacterium tuberculosis complex. The             urinary tract is possible but rare. The transmission of
development of the disease and its progression depends         genital TB from male to female is very rare. Occasional
on the interaction between the pathogen and the immune         reports of pelvic tuberculosis in the sexual partner of
response of the host. Although the organism evokes             patients with epididymal TB suggest the possibility of
both a humoral and a cellular immune response, cellular        female to male sexual transmission (14). TB of the penis
response determines the outcome of an infection.               is extremely rare. Primary TB of the penis occurs after
                                                               coital contact with organisms already present in the
GUTB results from blood stream spread of M.                    female genital tract or by contamination from infected
tuberculosis from the lungs. This happens about 10-15          clothing (15). Blood stream spread also has been
years after the initial pulmonary inoculation. Therefore       reported.
GUTB is rare in children (8). GUTB is rare among
people under the age of twenty five, and these patients
                                                               Clinical features
are more likely to have a family history positive for TB
(9). Generally the bacillus infects one kidney and the         The symptoms of GUTB are non-specific. Hence a
disease progresses slowly. There is slow destruction           clinical diagnosis is almost impossible. Any symptom
of renal parenchyma with cavitation, abscess formation,        related to urinary tract can be due to GUTB! Tuber-
fibrosis and calcification. Fibrosis leads to calyceal         culous infection in the past as primary pulmonary TB
deformities, obstruction and tissue loss. Rarely, it           or extra-pulmonary TB gives an important clue. Storage
produces a diffuse glomerulonephritis with acute renal         symptoms not responding to antibacterial treatment
functional impairment. Generally the symptoms of renal         associated with haematuria, occurring from time to
involvement are minimal. If not identified and treated         time is a common presentation of GUTB.
the disease spreads down along the ureter into the
bladder. The ureteric involvement and fibrosis leads to        Tuberculous involvement of the epididymis presents
ureteric stenosis and stricture formation particularly at      as a solid mass in the scrotum. The commonest lump
the vesico-ureteric junction and pelvi-ureteric junction.      related to the epididymis in clinical practice is the epidi-
Once the bacilli enter the bladder the inflammatory            dymal cyst which is soft, fluctuant and transilluminant.
process starts and leads to storage (irritative), urinary      It can be differentiated from a solid mass of TB easily
symptoms (e.g. frequency, nocturia, urgency), lumbar           by clinical means. In most cases the testis can be felt
pain and haematuria. If it is still not treated, the bacilli   separately and is normal. If longstanding, tuberculous
ascends the contralateral ureter up to the other kidney.       epididymitis may rarely progress to sinus formation.

Epididymal tuberculosis is almost a separate entity and        Constitutional symptoms like night sweats, evening
the organisms reach the epididymis via the blood stream.       pyrexia and malaise are rare in GUTB. The commonest
Therefore most instances epididymal TB is an isolated          age group where GUTB is seen is 20-55 years. In this
finding without urinary tract involvement. Few cases           age group presence of vague, longstanding urinary
of epididymal TB have been reported where the infection        symptoms for which there is no obvious cause should
occurred by direct retrograde spread of the organism           raise the suspicion of GUTB. It is important to realise
or via lymphatics from the urinary tract. But these            that GUTB is not a disease of the very old, frail people
modes of spread are rare. Though epididymal TB is              who are cachectic and severely ill.
common, testicular involvement is rare. Most patients
with epididymal TB have a normal testis. Therefore             Persistent pyuria is characteristic of GUTB. But GUTB
even after the vasal involvement and blockage causing          is not the commonest cause of sterile pyuria. Partially
subfertility, sperms can be retrieved from the testis for      treated urinary tract infections with or without bladder
purpose of artificial insemination (10). Since the             outlet obstruction and urolithiasis are the common
obstruction is close to the epididymis, reconstruction         causes of sterile pyuria. However, once bladder outlet
is difficult and results are poor. In India about 2% of        obstruction leading to recurrent urine infections and
subfertile men have vasal obstruction due to TB (11).          urolithiasis are excluded, one has to think of GUTB if
                                                               the pyuria continues. At the same time it is important to
Tuberculous involvement of the prostate is rare in Sri         remember that up to 20% of patients with GUTB may
Lanka. Only one contemporary urological surgeon in             not have any leucocytes in the urine.
Sri Lanka has come across a single case where prostatic
chips after TURP became positive for TB (12). Spread           It is important to remember that GUTB is non-infective
of the organism to the prostate is also via the blood          if there is no concomitant lung infection.
14     A. M. ABEYGUNASEKERA



Investigations                                                   not a very common disease. This is true for laboratories
                                                                 both in the government and private sector but more so
Microbiology and laboratory diagnosis
                                                                 with the private sector labs and with newer and
A microbiologic diagnosis of TB is made by isolation             expensive techniques.
of the organism from urine or biopsy material on
conventional solid media. Detection of acid-fast bacilli
                                                                 Tuberculin test
from urine samples by Ziehl-Neelsen stain is not reliable
to make a definitive diagnosis due to the possible               The tuberculin test (Mantoux test) is done by intra-
presence of M. smegmatis which are acid-fast bacilli             dermal injection of a purified protein derivative of
too. However, it helps to screen suspected cases. At             tuberculin. A strongly positive (more than 20 mm) test
least three (some even suggest five) early morning               is very useful in the diagnosis of GUTB. If the Mantoux
samples (the whole urine sample voided first in the              test is over 15 mm, one has to pursue for TB relentlessly.
morning) should be sent for examination. For the acid-           However, a normal tuberculin test should not exclude a
fast bacilli to be positive at least 10,000 bacilli/ ml should   diagnosis of GUTB, especially epididymal TB. Mantoux
be present in urine. Since GUTB is a pauci-bacillary             test is negative in most patients with epididymal TB.
disease, false negatives with urine microscopy are
common.                                                          Radiology

Culture of M. tuberculosis from urine or biopsied                Plain X-ray KUB is useful in patients with calcifications.
tissues is the gold standard in diagnosis of GUTB. The           Any unusual pattern of calcification should raise the
traditional methods take 6 weeks to yield results                suspicion of GUTB. Calcification of the renal paren-
(Lowenstein-Jensen or Dubos media). However, there               chyma develops in about 25% of patients with renal
                                                                 tuberculosis. Calcification due to tuberculosis is ill-
are newer automated techniques which are capable of
                                                                 defined, diffuse and does not fit into any pattern (20).
giving the results within hours (BD ProbeTec ET
                                                                 Calcification does not mean inactive infection and need
System) (16). These are expensive and use specialised
                                                                 proper evaluation and treatment.
techniques (e.g. radiometry) to identify tiny colonies
which cannot be seen by the naked eye. Quinolones
                                                                 In spite of newer radiological investigations like
(e.g. ciprofloxacin) can destroy the M. tuberculosis and
                                                                 ultrasound, CT scan and MRI, IVU continue to be
should be avoided during the period when urine samples
                                                                 the key investigation in the diagnosis of GUTB.
are collected for diagnostic purposes.
                                                                 Approximately 90% of patients with urinary tract TB
                                                                 cause abnormalities in the IVU. Renal lesions may
Nucleic acid replication techniques such as polymerase
                                                                 appear as distortion of a calyx, as a calyx that is fibrosed
chain reaction (PCR) are used commonly to detect M               and completely occluded (lost calyx), as multiple
tuberculosis in urine. Few studies done specifically to          calyceal deformities or as severe calyceal or paren-
evaluate the success of PCR in detecting mycobacterial           chymal destruction and non-visualised kidneys. The
DNA in urine have shown satisfactory sensitivity and             IVU will demonstrate ureteric strictures when present.
specificity (17, 18). Though the reported sensitivity            The cystogram is important in defining the changes in
and specificity rates of around 60% are good enough              the bladder such as small capacity, irregular outline or
when compared with other tests to diagnose GUTB,                 vesicoureteric reflux.
clinicians who have to take decisions on individual
patients may not be happy with these rates.                      Ultrasonography may detect changes associated with
                                                                 parenchymal involvement (e.g. calyceal dilation, cavities)
Utilisation of serum interferon (IFN) assays provides            but its main role is in percutaneous nephro-stomy in
immunological evidence for tuberculosis exposure. This           obstructed kidneys due to ureteric stenosis. CT is
is useful in immunocompromised patients (e.g. end-stage          helpful in identifying small intrarenal lesions (scarring,
renal disease, post-transplant patients) where tuberculin        masses and cavities) and autonephrectomy. Retrograde
skin test is not useful (19). Positive IFN-gamma assay           uretero-pyelography is useful to delineate the site and
results (QuantiFERON TB Gold test and ELISPOT)                   length of a ureteric stricture. Ureteral cathetrisation can
may help the diagnosis of GUTB in such patients.                 be used to collect urine samples for culture from each
                                                                 kidney and the yield rates may be higher than ordinary
One drawback of laboratory investigations for the                voided samples.
diagnosis of GUTB is the difficulty for the laboratory
staff to get adequate experience necessary to gain
                                                                 Cystoscopy
expertise and for quality maintenance. This is due to
the small number of samples received by a single                 Cystoscopy will show extensive inflammatory changes
laboratory during a given period of time since GUTB is           in the bladder in the presence of tuberculous cystitis.
                                                                              GENITOURINARY TUBERCULOSIS           15



Late cases show the classical ‘golf hole’ ureteric orifice   ureteric stenosis and dilatation of the proximal urinary
due to scarring and contraction. However, bladder            tract require reconstructive surgery later. If steroids
biopsy is to be avoided in the presence of tuberculous       are used, it is important to remember the necessity to
cystitis (21). The possibility of spreading the organisms    adjust the doses in the presence of rifampicin which
to vertebrae via the venous plexus is given as the reason    induces enzymes that metabolise steroids.
for this. This may cause tuberculous meningitis and
spinal TB. This phenomenon has been described many           A serious problem at present is the occurrence of drug
decades ago and its relevance today is not very clear        resistance in patients with TB. Multi-drug resistance
due to paucity of data refuting or supporting it.            (MDR) TB is defined as resistance to rifampicin and
                                                             isoniazid with or without resistance to other drugs.
                                                             Such patients require second line drugs which are less
Biopsy and histopathology                                    effective and more toxic. MDR is a growing problem
Biopsy specimens or resected ureteric strictures sent        of serious concern and at present those who contract
for histopathology show caseating garnulomas with            MDRTB are destined to die of the disease. In 2007 Sri
Langhan’s giant cells in TB. This will confirm the           Lanka had 8 cases of MDRTB. Fortunately only one
diagnosis in cases where the microbiology has failed.        case of MDRTB was reported from Sri Lanka in 2009.
Recently several case reports have appeared where
patients from south Asian and middle eastern countries       Hepatotoxicity is a major concern with anti-TB drugs.
presenting with renal impairment and a clinical picture      All patients should be observed for occurrence of
of acute glomerulonephritis were found to have renal         jaundice. If jaundice occurs, expert help should be
TB on their renal biopsy specimens (22). Most of them        sought. It occurs in about 10-20% of patients and can
have responded well to anti TB drugs and the renal           be fatal.
functions returned to normal.
                                                             Special considerations apply to the treatment of TB in
                                                             patients with renal impairment. Rifampicin, isoniazid
Erythrocyte sedimentation rate                               and pyrazinamide can be given in normal dosage. These
Traditionally ESR is considered a useful test in helping     are eliminated in the bile or broken down to metabolites
the diagnosis of TB. In GUTB majority of patients will       that are not excreted by the kidney. Dose adjustment
have a ESR less than 50 mm. This is especially true in       (according to the GFR) is required in the use of etham-
epididymal TB.                                               butol. It is widely excreted by the kidneys. Ethambutol
                                                             causes optic neuritis which may be irreversible. Ence-
                                                             phalopathy is an uncommon complication of isoniazid
Treatment                                                    and can be prevented by pyridoxine 50 mg per day.
Pharmacological treatment
Since GUTB is a pauci-bacillary form of TB, a six-           Surgical treatment
months course of anti tuberculous drugs is adequate.
                                                             Although chemotherapy is the mainstay of treatment,
In Sri Lanka now the drugs are given under direct
                                                             about 50% of patients with GUTB will require some
supervision by health staff (DOTS) except in certain         form of surgical intervention at some stage of the
areas of the Northern province. Isoniazid (INAH),            disease. Half of them would require ablative surgery
rifampicin, ehambutol and pyrazinamide are given for         while the other half would require reconstructive
the initial two months (intensive phase). Isoniazid and      surgery. Ablative surgery may be necessary in the initial
rifampicin are given for the next 4 months (continuation     management of GUTB to control sepsis or to treat
phase). Now drugs are given in combination forms             abscesses. Nephrectomy is indicated if there is
and this has improved the compliance. In complicated         uncontrollable urinary tract sepsis, expanding calci-
cases (e.g. recurrence of TB, HIV infection, immuno-         fication and hypertension attributed to the diseased
suppression) longer courses (9-12 months) are recom-         kidney. Almost all these are non-functioning kidneys.
mended. Some believe drug regimens without
streptomycin have lead to more renal scarring in patients    Main forms of reconstructive surgery are ureteric
who complete the anti TB treatment (23). However,            reimplantation (after excision of stricture) and bladder
there is no substantial data to prove this.                  augmentation (for a small fibrotic bladder). Both
                                                             ablative and reconstructive surgical procedures are
Steroids (along with ureteric stenting) have been tried      recommended to be done after about 4 weeks of drug
in patients with ureteric stenosis to minimise late          treatment within the intensive phase. Early ureteric
scarring and stricture formation until the effects of        stenting or percutaneous nephrostomy may be indicated
chemotherapy becomes established (24, 25). But the           if the kidney is obstructed and patient has not yet
results have been disappointing. Almost all patients with    completed 4 weeks of treatment.
16     A. M. ABEYGUNASEKERA



The ureteric strictures are commonly situated in the          9.   Ferric BG, Rundle JS. Genitourinary tuberculosis
lower end at the uretero-vesical junction. It can occur            in patients under 25 years of age Urology 1985;
in the upper end or in the mid ureter less commonly.               25: 576-8.
Pelvi-ureteric junction obstruction can be treated with
                                                              10. Moon SY, Kim SH, Jee BC, et al. The outcome of
usual techniques of pyeloplasty (e.g. Anderson-Hynes
                                                                  sperm retrieval and intracytopasmic sperm
or Culp). Lower end strictures require reimplantation,
                                                                  injection in patients with obstructive azoospermia:
while the mid-ureteric strictures can be reconstructed
                                                                  impact of previous tuberculous epididymitis.
by direct end to end anastomosis if the stricture is short.
                                                                  Journal of Assisted Reproductive Genetics 1999;
Otherwise it may be necessary to raise a Boari flap.
                                                                  16: 431-5.
Endoscopic dilatation of strictures has very low success
rates and may jeopardise the kidney function. All TB          11. Kumar R. Reproductive tract tuberculosis and male
strictures require reconstructive surgery.                        infertility. Indian Journal of Urology 2008; 24: 23-6.
                                                              12. Samaraweera PGDS, Personal communication.
Follow up                                                     13. Sasidharan K, Natarajan K. Tuberculous prostatitis,
M. tuberculosis is an organism with very destructive              Sri Lanka Journal of Urology 2005; 6: 1-9.
capabilities. Its destructive nature is slow but long-        14. Wolf JS, McAninch JW. Tuberculous epididymo-
standing. Even after making the urine free of organisms,          orchitis: Diagnosis by needle aspiration. Journal
tissue fibrosis and scarring may progress. Hence these            of Urology 1991; 145: 836-8.
patients with GUTB should be followed up carefully to
identify the complications secondary to persisting tissue     15. Narayana AS, Kelly DG, Duff FA. Tuberculosis of
fibrosis.                                                         the penis. British Journal of Urology 1976; 48: 274.
                                                              16. Barber R. Evaluation of the BD ProbeTec ET
                                                                  system for the direct detection of Mycobacterium
References                                                        tuberculosis from clinical samples. British Journal
1.   Cek M, Lenk S, Naber KG, et al. EAU guidelines               of Biomedical Sciences 2008; 65: 7-12.
     for the management of genitourinary tuberculosis.        17. Magana-Arachchi D, Perera J, Gamage S,
     European Urology 2005; 48: 353-62.                           Chandrasekharan V. Low cost in-house PCR for
2.   Treatment of Tuberculosis: Guidelines for National           the routine diagnosis of extra-pulmonary
     Programmes, 3rd ed. WHO Geneva. 2003 (http://                tuberculosis. International Journal of Tuberculosis
     www.who.int/docstore/gtb/publicatins/ttgnp/pdf/              and Lung diseases 2008; 12: 275-80.
     2003.313.pdf).                                           18. Hemal AK, Gupta NP, Rajeev TP, et al. Polymerase
3.   Annual Report – 2007. National Programme for                 chain reaction in clinically suspected genitourinary
     Tuberculosis Control and Chest Diseases, Sri                 tuberculosis: Comparison with intravenous
     Lanka 2009.                                                  urography, bladder biopsy and urine acid fast
                                                                  bacilli culture. Urology 2000; 56: 570-4.
4.   Figueiredo A, Lucon AM, Falci R, et al. Epide-
     miology of urogenital tuberculosis worldwide.            19. Winthrop KL, Nyendak M, Calvert H, et al.
     International Journal of Urology 2008; 15: 827-32.           Interferon-gamma release assays for diagnosing
                                                                  Mycobacterium tuberculosis infection in renal
5.   Wise GJ, Marella VK. Genitourinary manifestations            dialysis patients Clinical Journal of American
     of tuberculosis. The Urologic Clinics of North               Society of Nephrology 2008; 3: 1357-63.
     America 2003; 30: 111-23.
                                                              20. Abeygunasekera AM, Fathihu AF, Perera C.
6.   Peacock AH. Renal tuberculosis. Chest 1939; 5;               Pictorial Tests in Uroradiology 1st ed. 2009; 44-5
     24-8.
                                                              21. Baker LRI. Genitourinary tuberculosis. In: Oxford
7.   Warren D, Johnson JR, Johnson CW, Lowe FC.                   Textbook of Medicine. editors Warrell DA, Cox
     Genitourinary tuberculosis. In: Walsh PC, Retik              TM, Firth JP, Benz EJ. 4th edition, Oxford
     AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s                  University Press. 3275-9.
     Urology 8th ed. WB Saunders 2002.
                                                              22. Sampathkumar K, Sooraj YS, Mahaldar AR, et al.
8.   Nerli RB, Kamat GV, Alur SB, Ashish K, Prabha V,             Granulomatous interstitial nephritis due to
     Amarkhed SS. Genitourinary tuberculosis in                   tuberculosis - a rare presentation. Saudi Journal
     paediatric urological practice. Journal of Paediatric        of Kidney Diseases and Transplantation 2009; 2:
     Urology 2008; 4: 299-303.                                    842-5.
                                                                          GENITOURINARY TUBERCULOSIS        17



23. Sreenivas V. Comparative study of surgical                study of 1117 cases over a period of 34 years.
    complications of genitourinary tuberculosis treated       British Journal of Urology 1984; 56: 449-55.
    with conventional and modern chemotherapy.
    Indian Journal of Urology 1987; 4: 20-2.              25. Claridge M. Ureteric obstruction in tuberculosis.
24. Gow G, Barbosa S. Genitourinary tuberculosis. A           British Journal of Urology 1970; 42: 688-92.




Author

Anuruddha M. Abeygunasekera, MS (Col), FRCS (Eng), FRCS (Edin)
Consultant Urological Surgeon

Department of Urology, Colombo South General Hospital, Kalubowila, Sri Lanka.
18     B. SATHESAN, A. P. I. PRABATH AND S. A. S. GOONEWARDENA



Sri Lanka Journal of Urology, 2009, 10, 18-21
Original Article


Retrocaval ureter: a venous anomaly causing ureteric obstruction

B. Sathesan, A. P. I. Prabath and S. A. S. Goonewardena
Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.



Abstract

Introduction The aim of this study is to report the experience in managing a rare entity, retrocaval ureter.

Patients and methods This is a retrospective study performed in a single urology unit of a tertiary referral center
over a period of 8 years since October 2001. The diagnosis of retrocaval ureter was confirmed by retrograde
ureteropyelogram. Symptomatic patients underwent open surgical pyelopyelostomy (ureteroureterostomy) after
the ureter had been transposed to its normal anatomic position. Post surgical relief of ureteric obstruction was
confirmed by 99mTc DTPA renogram.

Results There were 5 patients with retrocaval ureter. Mean age of the patients was 33 years (range 27-39 years).
Out of 5 patients 4 were males. All 5 patients were presented with right flank pain and 3 of them had haematuria
and a small mobile renal stone. All patients had type 1 right-sided retrocaval ureter. Associated anomalies were seen
in none of the patients. All patients were asymptomatic after the surgical correction. Post operative 99mTc DTPA
renograms were normal in all patients.

Conclusion Retrocaval ureter though rare can easily be diagnosed. Open surgical correction gives good results.




Retrocaval (circumcaval) ureter is an uncommon               tertiary referral centre over a period of 8 years since
congenital anomaly involving the venous system which         October 2001. The data were collected from the
results in the right proximal ureter coursing behind and     operation register and clinic files. The diagnosis was
at times becoming obstructed by the inferior vena cava       suspected with the finding of significant dilatation of
(IVC). The basic abnormality developmentally is the          the right pelvicalyceal system and proximal ureter to
abnormal persistence of the right subcardinal vein           the level of the transverse process of L3 vertebra with
(instead of the right supracardinal vein) forming the        the classical S shaped or “fish-hook” deformity at the
main portion of the IVC ventral to the ureter. Ureter        point of obstruction on intravenous urography (Figure 1).
then winds behind medial to the IVC instead of staying       This was confirmed by right retrograde uretero-
lateral to it. Hence the term retrocaval ureter is           pyelography (Figure 2). All patients were symptomatic
anatomically descriptive but misleading in regard to         and underwent open surgical correction. The dilated
development. The first case of retrocaval ureter repair      renal pelvis (upper ureter) was transected, following
was published in 1949 by Anderson and Hynes (1).             which the ureter was transposed to its normal anatomic
Herein we report 5 cases of retrocaval ureter treated        position. Before the pyelopyelostomy (ureterouretero-
successfully by surgical repair.                             stomy) retrocaval segment of ureter was examined for
                                                             its healthiness. The indwelling ureteral stent which was
                                                             inserted to splint the anastomosis was removed 6 weeks
Patients and methods                                         after the surgery. 99mTc DTPA renogram was performed
We carried out a retrospective study of patients with        3 or 4 months after the surgery to confirm the relief of
retrocaval ureter seen in a single urology unit of a         ureteric obstruction.
                                    RETROCAVAL URETER: A VENOUS ANOMALY CAUSING URETERIC OBSTRUCTION                             19




Figure 1. Intravenous urogram showing the classical                   Figure 2. Right retrograde ureteropyelogram showing
S shaped or "fish-hook" deformity in retrocaval ureter.               retrocaval ureter.



Results (Table 1)                                                     a small mobile renal stone. All patients had type 1 right-
There were 5 patients with retrocaval ureter. The mean                sided retrocaval ureter. Associated anomalies were seen
age of the patients was 33 years (range 27-39 years).                 in none of the patients. All patients were asymptomatic
Out of 5 patients 4 were males. All 5 patients presented              after the surgical correction. Post operative 99mTc DTPA
with right flank pain and 3 of them had haematuria and                renogram was normal in all patients.




            Table 1. Clinical, radiological and operative details of patients with retrocaval ureter
  Patient No    Age      Sex        Clinical Presentation      Diagnosis    Operation               Outcome

     1          33       Female     Right flank pain           IVU,         Pyelopyelostomy         Asymptomatic, 99mTc DTPA
                                    - 2 months                 RUP          (ureteroureterostomy)    renogram - non obstructed

     2          27       Male       Right flank pain and       IVU,         Pyelopyelostomy         Asymptomatic,99mTc DTPA
                                    haematuria -2.5 months     RUP          (ureteroureterostomy)   renogram - non obstructed

     3          32       Male       Right flank pain and       IVU,         Pyelopyelostomy         Asymptomatic, 99mTc DTPA
                                    haematuria -1.5 months     RUP          (ureteroureterostomy)   renogram - non obstructed

     4          31       Male       Right flank pain and       IVU,         Pyelopyelostomy         Asymptomatic,99mTc DTPA
                                    haematuria - 1.5 months    RUP          (ureteroureterostomy)   renogram - non obstructed

     5          39       Male       Right flank pain           IVU,         Pyelopyelostomy         Asymptomatic, 99mTc DTPA
                                    - 1 year                   RUP          (ureteroureterostomy)   renogram - non obstructed


IVU - intravenous urogram, RUP - retrograde ureteropyelogram
20     B. SATHESAN, A. P. I. PRABATH AND S. A. S. GOONEWARDENA



Discussion                                                 when compared with CT or retrograde uretero-pyelogram
                                                           (11). Nuclear diuretic renogram can categorize the
Retrocaval ureter is an uncommon congenital
                                                           anomaly as obstructed or nonobstructed. In our patients
anomaly. Abnormal embryologic development of the
                                                           the diagnosis was made by both intravenous urography
inferior vena cava due to the failure of atrophy of the
                                                           and retrograde ureteropyelography.
right subcardinal vein in the lumbar portion results in
retrocaval ureter. The first recorded case of retrocaval
                                                           Procedural intervention is indicated in the presence of
ureter was seen on autopsy and was described by
                                                           functionally significant obstruction leading to pain or other
Hochstetter in 1893 (2). The incidence at autopsy is
                                                           complications. The standard repair of retrocaval ureter is
about 1 in 1500 (3). Retrocaval ureter is almost always
                                                           open surgical pyelopyelostomy or ureteroureterostomy.
right sided; however, in cases with situs inversus or
                                                           Pure laparoscopic repair of the retrocaval ureter has been
duplication of the inferior vena cava, it may be seen
                                                           performed both transperitoneally and retroperitoneally
on the left side (4,5) .
                                                           (12,13). Pure robotic retrocaval ureter repair is feasible.
                                                           Apart from the ergonomic and technical benefits that the
The incidence of retrocaval ureter is higher in men
                                                           robotic approach gives to the surgeon, there does not
than in women 4:1 (6), and most patients do not present
                                                           appear to be any other advantage over the laparoscopy
with symptoms until the third or fourth decade of
                                                           (14). All of our patients were asymptomatic and
life (7). The symptoms depend on the degree of
                                                           obstruction free at 3 or 4 months after open surgical
ureteric obstruction or the presence of complications.
                                                           pyelopyelostomy (ureteroureterostomy).
Intermittent flank pain is often noted as the first
complaint. Occasionally, recurrent urinary tract
infection, haematuria, pyelonephritis or stone             References
formation is noted (8).
                                                           1.   Anderson JC, Hynes W. Retrocaval ureter: A case
                                                                diagnosed pre-operatively and treated successfully
Bateson and Atkinson classified retrocaval ureter into
                                                                by a plastic operation. Br J Urol 1949; 209-14.
two clinical types: [1] the more common type I has
hydronephrosis and typically obstructed demon-             2.   Hochstetter F. Beitrage zur Entwicklungsgeschichte
strating some degree of fishhook-shaped deformity               des Venensystems der Amniten: II. Reptilien (Lacerta,
of the ureter at the level of the obstruction, and [2]          Tropidonotus). Morphol Jahrb (Leipzig) 1892-1893;
type 11 has a less degree of obstruction or none at             19: 428-501.
all. Here the upper ureter is not kinked but passes
                                                           3.   Heslin JE, Mamonas C. Retrocaval ureter: Report of
behind the vena cava at a higher level, with the renal
pelvis and upper ureter lying almost horizontal before          four cases and review of literature. J Urol 1951;
encircling the vena cava in a smooth curve (9).                 65: 212.
                                                           4.   Wang LT, Lo HC, Yu DS, Sun GH, Wu CC, Fong
In our study all patients had right sided type 1                CJ. Ureteral obstruction caused by a duplicated
retrocaval ureter; the mean age of patient at presen-           anomaly of inferior vena cava. Int J Urol 2005; 12:
tation was 33 years; male to female ratio was 4:1; all          842-4.
patients had loin pain as presenting symptom.
                                                           5.   Gramegna V, Madaro A, Pellegrini F, et al. A rare
Associated anomalies with retrocaval ureter are                 case of retrocaval ureter associated with persistent
reported up to 21% and are mainly related to the                left venacava. Urol Int 2003; 70: 337-8.
cardiovascular and urogenital systems. The associated      6.   Xiaodong Z, Shukun H, Jichuan Z, et al. Diagnosis
anomalies include horseshoe kidney, contralateral               and treatment of retrocaval ureter. Eur Urol 1990;
renal hypoplasia or ectopia, Turner’s syndrome,                 18: 207.
Goldenhar syndrome, retroperitoneal fibrosis,
polycystic disease of the kidneys, congenital lack of      7.   Kenawi MM, Williams DI. Circumcaval ureter: A
the vas deferens and hypospadias. None of these                 report of four cases in children with a review of
anomalies were documented in our patients.                      literature and a new classification. Br J Urol 1976;
                                                                48: 183.
Retrocaval ureter has been previously diagnosed by         8.   Arana VA, Hodson JM, Kaiser TF. Retrocaval ureter.
intravenous urography and retrograde pyelography,
                                                                Am Fam Physician 1971; 4: 83.
but nowadays, CT scan is the best modality for
diagnosis (10). MRI can nicely demonstrate the             9.   Bateson EM, Atkinson D. Circumcaval ureter: A new
course of a retrocaval ureter and may be more detailed          classification. Clin Radiol 1969; 20: 173.
                               RETROCAVAL URETER: A VENOUS ANOMALY CAUSING URETERIC OBSTRUCTION             21



10. Kellman GM, Alpern MB, Sandler MA, Craig BM.             treatment of a retrocaval ureter. Eur Urol 1996;
    Computed tomography of vena caval anomalies              29: 115-8.
    with embryologic correlation. Radiographics 1988;   13. Ramalingam M, Selvarajan K. Laparoscopic
    8: 533.                                                 transperitoneal repair of retrocaval ureter: Report
11. Uthappa MC, Anthony D, Allen C. Case report:            of two cases. J Endourol 2003; 17: 85.
    Retrocaval ureter: MR appearances. Br J Radiol      14. Hemal AK, Rao R, Sharma S, Clement RGE. Pure
    2002; 75: 177-179.
                                                            robotic retrocaval ureter repair. Int Braz J Urol
12. Matsuda T, Yasumoto R, Tsujino T. Laparoscopic          2008; 34: 734-8.




Authors

Balasubramaniam Sathesan, MBBS (Jaffna), MS (Col)*

A. P. I. Prabath, MBBS (Ruhuna), MS (Col)*

*Senior Registrar in Urology

S. A. S. Goonewardena, MS (Col), FRCS (Eng), DUrol (Lond)
Consultant Urological Surgeon

Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.
22     C. DE SILVA, S. WIJEYAGUNAWARDANE, L. U. GIHAN AND A. M. ABEYGUNASEKERA



Sri Lanka Journal of Urology, 2009, 10, 22-23
Urological Oncology Audit


Characteristics of urological cancers – a prospective audit in a single unit

C. de Silva, S. Wijeyagunawardane, L. U. Gihan and A. M. Abeygunasekera
Department of Urology, Colombo South Teaching Hospital, Kalubowila, Sri Lanka.



Introduction                                                   mean age of clear cell carcinoma (n=6) was 58 years
                                                               and five were men. It is interesting to note that only 3
Malignancies are the fourth commonest cause of death
                                                               patients with renal tumours (n=8) had haematuria.
in Sri Lanka. In USA, prostatic cancer is the second-
most common cancer among men and urological
cancers constitute a large portion of all cancers (1).         Table 1. Distribution of urological malignancies
Though countrywide statistics are not available for Sri
Lanka, urological malignancies appear to be common               Organ        Number of         Male:      Average
in Sri Lanka too. According to the data collected at                           patients        Female        age
cancer units in government hospitals in Sri Lanka,                                                          years
prostate cancer is the eighth commonest cancer in men
in the year 2005 (2). Prostate and bladder cancer deaths         Kidney            8             6:2        53.4
rank 13th and 14th places of deaths due to cancer in
                                                                 Bladder          28           23:5         66.6
Sri Lanka. Crude annual cancer death rate has increased
by more than 50% over the last 20 years in Sri Lanka.            Prostate         25              -         71.4
Bladder cancer in Sri Lanka has been well studied and
                                                                 Testis            3              -         53.2
there are several publications (3,4). In the absence of a
true national cancer registry, data maintained at individual     Penis             2              -         62.0
units or at institutional level are useful to identify
epidemiological and demographic patterns. We
conducted a prospective audit of malignancies of the           All 28 newly diagnosed bladder cancers were transitional
genitourinary tract managed in a single urology unit at        cell carcinomas. Nine (32.1%) of them were muscle
the Colombo South Teaching Hospital.                           invasive. One of the 19 superficial bladder tumours were
                                                               poorly differentiated (G3). Haematuria was the
                                                               presenting symptom in 22 patients. The male to female
Method
                                                               ratio was 5:1. 88% of them were above 65 years old.
A cancer registry was maintained prospectively. Data
belonging to all newly diagnosed malignancies were             There were 25 newly diagnosed prostatic carcinomas
recorded. The data were updated as the patients’ follow        during the study period. 92% (23/25) of them were
up continued in the clinic. The data belonging to patients     more than 65 years old and 36% (9/25) were over the
from 1 January 2009 to 31 December 2009 were                   age of 75 years. The Gleason score was eight or more
analysed.                                                      in 39% of patients. It was between 5 and 7 in 44%.
                                                               Twenty patients had their serum PSA done. In 12 (60%)
Results                                                        of them the serum PSA was above 60 ng/ml.
Table 1 shows the number of malignancies in different
                                                               Two of the three testicular tumours were lymphomas
organs of the urinary tract. Out of the eight renal cancers
six were clear cell carcinomas. One was a squamous             (high grade Non-Hodgkin’s lymphoma and diffuse
cell carcinoma and the other was a nephroblastoma.             B-cell lymphoma). The other was a mixed germ cell
The squamous cell carcinoma was found in a woman               tumour with a predominant seminomatous component.
with no history of smoking. She did not have renal
stones which may have predisposed to a squamous                One penile cancer was a well differentiated squamous
cell carcinoma. There were two patients each belonging         cell carcinoma while the other was moderately
to Robson stage I and IV. The other two clear cell             differentiated. Both of them had been having a penile
carcinomas belonged to Robson II and IIIa stages. The          ulcer for more than 3 months.
                       CHARACTERISTICS OF UROLOGICAL CANCERS – A PROSPECTIVE AUDIT IN A SINGLE UNIT                 23



Discussion                                                  71.4 years. Fourteen patients were diagnosed from
                                                            prostatic chips after TURP. Since we have done 129
The characteristics of our renal cancers seem to be
                                                            TURPs during the study period the ratio of malignancy
similar to worldwide trends. 32.1% of the bladder
                                                            in prostatic chips after TURP is 11% – not very different
malignancies diagnosed by us were muscle invasive
                                                            from the standard figure of 10%.
tumours. A study done at the National Hospital of Sri
Lanka (NHSL) revealed a larger muscle-invasive group
                                                            As we do not have a national cancer registry it is useful
(48.4%) in a cohort of 301 patients (3). The difference
                                                            for individual units to maintain their records. Such data
may be related to the small number of this study. The
                                                            can be used as an adjunct to the data collected by the
male to female ratio in that study (6;1) is close to ours
                                                            National cancer control programme.
(5:1). Another study from the same hospital had a male
to female ratio of 9:1 (4). The Cancer control pro-
gramme figures give a male to female ratio of 4.5:1. All    References
bladder carcinomas were transitional cell carcinomas
                                                            1.   Jemal A, Siegel R, ward E, et al. Cancer statistics.
in our study. According to the cancer programme
                                                                 Ca - Cancer Journal for Clinicians 2009; 59: 225-49.
data 8.1% of bladder cancers were squamous cell
carcinomas and 4.5% were adenocarcinomas. 3.5%              2.   Cancer Incidence Data: Sri Lanka year 2001-2005.
were T1G3 tumours in our study compared to 5.3% at               National cancer control programme 2009.
NHSL (3).
                                                            3.   Goonewardena SAS, De Silva WAS, De Silva
                                                                 MVC. Bladder cancer in Sri Lanka: Experience
According to the western world statistics, 80% of                from a tertiary referral center. International Journal
prostatic cancers occur in the above 65 years age group.         of Urology 2004; 11: 969-72.
92% of our patients were above 65 years. This may be
                                                            4.   Perera ND. Characterisation of a bladder cancer
due to the differences associated with widespread PSA
                                                                 cohort in a urological unit. Ceylon Medical Journal
screening and consequent lead time bias. 36% of our
                                                                 2002; 47: 102.
patients were beyond the average life expectancy of
Sri Lankan men when the cancer was diagnosed. The           5.   Lokuhetty MDS, Wijesinghe HD, Abeysuriya DT,
average age of patients with prostatic cancer diagnosed          Samarasinghe UC, Perera ND. Transrectal
by PSA screening and trans rectal ultrasound guided              ultrasound guided prostate biopsies: A single centre
prostatic biopsies in Sri Lanka has been 71.3 years (5).         experience in Sri Lanka. The Ceylon Medical
In our patients with prostatic cancer, the average was           Journal 2009; 54: 6-10.




Authors

Chamini de Silva, MBBS*

Saranga Wijeyagunewardane, MBBS*

L. U. Gihan, MBBS*

*Senior House Officer in Urology

Anuruddha M. Abeygunasekera, MS (Col), FRCS (Eng), FRCS (Edin)
Consultant Urological Surgeon

Department of Urology, Colombo South Teaching Hospital, Kalubowila, Sri Lanka.
24     B. SATHESAN, A.P.I. PRABATH AND S.A.S. GOONEWARDENA



Sri Lanka Journal of Urology, 2009, 10, 24-27
Urological Oncology Audit



Urological malignancies: one-year audit from a tertiary referral centre

B. Sathesan, A. P. I. Prabath and S. A. S. Goonewardena
Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.


Abstract

Objective To study the clinicopathological characteristics of urological malignancies.

Patients and Method Newly diagnosed patients with urological malignancies in the year 2009 in a single urological
unit of a tertiary referral centre were included in this retrospective study.

Results During the study period there were 35 patients with carcinoma of the bladder; 17 patients with carcinoma
of the prostate; 9 patients with renal malignancy; 1 patient with synchronous transitional cell carcinoma of the
bladder and upper urinary tract; 1 patient with seminoma of the testis. Median age of the patients with primary
bladder carcinoma was 65 years (range 46-82 years). Majority of the patients with primary bladder cancer were
males (3.1:1) and had non-muscle invasive bladder cancer (72.7%). All patients with primary bladder cancer
except one had transitional cell carcinoma (97%). Median age of the patients with carcinoma of the prostate was
70 years (range 60-81 years). All patients with carcinoma of the prostate had advanced disease at presentation.
Median age of the patients with renal cell carcinoma (RCC) was 65 years (range 53-72 years). There is a 1.3:1
predominance of men over women. 85% of renal cell carcinomas were conventional renal cell carcinomas.

Conclusion Multicentre long-term studies are required to ascertain the actual clinicopathological characteristics of
urological malignancies.



Epidemiology of cancer depends on the population             Table 1. Site of urological malignancy, number
studied. The national cancer registry contains comp-               of patients and the sex distribution
rehensive cancer information for the whole population
of a country. Regrettably, we do not have a national              Site of          Number of      Male     Female
cancer registry in Sri Lanka. Herein we produce an               malignancy         patients
audit of urological malignancies from a single urological
unit in a tertiary referral centre.                            Urinary bladder           35         25       10
                                                               Prostate                  17         17        -
Patients and method                                            Kidney                    9          6        3
This study was performed in a single urological unit of        Upper urinary
a tertiary referral centre. Newly diagnosed patients with      tract and bladder         1          1         -
histopathologically confirmed urological malignancies
in the year 2009 were included in the study. The data          Testis                    1          1         -
were obtained retrospectively from the clinic notes and
operation register.                                         Out of 35 patients with bladder cancer 33 patients had
                                                            primary bladder cancer and 2 patients had secondary
Results                                                     bladder tumour from ovarian carcinoma. Median age
                                                            of the patients with primary bladder carcinoma was 65
During the one year period 63 patients with urological      years (range 46-82 years). Majority of the patients with
malignancy were diagnosed. Table 1 shows the site of        primary bladder cancer were males (3.1:1). Out of 33
malignancy, the number of patients diagnosed and the        patients with primary bladder carcinoma 24 patients
sex distribution.                                           (72.7%) had non-muscle invasive bladder carcinoma.
                                                                                       UROLOGICAL MALIGNANCIES       25



Pathological tumour stage and grade of non-muscle                Table 3. Clinical presentation of bladder cancer
invasive bladder tumour are shown in Table 2. All non-                       and number of patients
muscle invasive bladder tumours except two pT1 high
grade tumours had papillary configuration. All muscle             Presentation                        No. of patients
invasive bladder tumours were solid and high grade.               Haematuria (painless/painful)              31
All the patients with primary bladder carcinoma had
                                                                  LUTS and haematuria                          1
transitional cell carcinoma except the one who had
poorly differentiated carcinoma. In one patient                   LUTS                                         1
transitional cell carcinoma contained squamous and
                                                                  UTI (no haematuria)                          1
sarcomatoid components as well. Haematuria either
painless or painful was the commonest presentation of             Lower limb swelling                          1
bladder carcinoma (Table 3).

     Table 2. Pathological stage and grade of                   All patients with carcinoma of the prostate had
      non-muscle invasive bladder tumour                        adenocarcinoma – small acinar type. Median age of the
                                                                patients with carcinoma of the prostate was 70 years
 Pathological stage        Grade        No. of patients         (range 60-81 years). Majority of patients presented with
                                                                LUTS. Digital rectal examination (DRE) revealed
          pTa           Low Grade               9
                                                                clinically malignant prostate in 15 patients; equivocal
                         High Grade             1               prostate in 2 patients. One patient who had clinically
                                                                malignant prostate and serum PSA of <1 μg/L showed
          pT1           Low Grade               8               aggressive disease (Gleason sum score 5b+5b)
                         High Grade             6               (Table 4). All patients with carcinoma of the prostate
                                                                had advanced disease at presentation.


                       Table 4. Clinicopathological characteristics of prostatic carcinoma

    No.          Age             Presentation             DRE             Serum PSA                Gleason sum
                                                                            (ng/ml)                   score

     1           79                AUR                     M                     112                10 (5+5)
     2           70                LUTS                    M                   82.3                  7 (3+4)
     3           63                LUTS                    M                      38                10 (5+5)
     4           81                AUR                     M                  >100                   8 (5+3)
     5           62                LUTS                    M                   74.3                  7 (3+4)
     6           60                AUR                     M                     342                10 (5+5)
     7           68                LUTS                    M                     NA                  6 (3+3)
     8           74                LUTS                    M                     5.5                10 (5+5)
     9           74                LUTS                    E                     171                 6 (3+3)
     10          63                Hx                      M                     <1                 10 (5+5)
     11          65                AUR                     M                     103                 8 (3+5)
     12          65                LUTS                    M                     216                 8 (5+3)
     13          70                AUR                     M                   37.4                  8 (3+5)
     14          76                LUTS                    M                     NA                  7 (3+4)
     15          81                AUR                     M                      84                10 (5+5)
     16          72                LUTS                    M                     201                 9 (4+5)
     17          73                LUTS                    M                   6.28                  6 (3+3)

AUR – acute urinary retention, LUTS – lower urinary tract symptoms, Hx – haematuria, M – clinically malignant, E –
clinically equivocal, NA – not available
26       B. SATHESAN, A.P.I. PRABATH AND S.A.S. GOONEWARDENA



Out of 9 patients with renal malignancy 7 patients          Bladder tumour was the number one malignancy in the
had renal cell carcinoma (6 - clear cell, 1- unclassified   study which was performed in the same unit for a 24-
type), one patient had mucinous tubular and spindle         month period January 1994 to December 1995 (3). But,
cell carcinoma of kidney and another one had poorly         bladder tumours diagnosed for a year in this study were
differentiated malignancy or neuroendocrine tumour.         fairly less in number than the above study. An increase of
Patients with renal malignancy had a variety of clinical    urological surgeons in the country has probably
presentations (Table 5). Median age of the patients         contributed for this observation.
with RCC was 65 years (range 53-72 years). Among
the 7 RCC patients 4 were males (male:females =             Bladder cancer is generally a disease of the middle-aged
1.3:1). According to Robson’s staging 6 patients had        and elderly people, with the median ages at diagnosis for
stage 1 tumour, 1 patient had stage 11 tumour, 2 patients   urothelial carcinoma being 69 years in males and 71 years
had stage 1V tumour.                                        in females (4). It is more common in males with a male-
                                                            to-female ratio of 3.8:1 (5). More than 90% of bladder
       Table 5. Clinical presentation of renal              cancers are transitional cell carcinomas (6). At the initial
        malignancy and number of patients                   diagnosis of bladder cancer, 70% of cases are diagnosed
                                                            as non-muscle-invasive disease and 30% as muscle-
     Presentation                      No. of patients      invasive disease (7). All these findings were found in our
                                                            study as well. However, the largest bladder cancer study
     Abdominal pain                           1
                                                            which was performed in Sri Lanka by one of the authors
     Abdominal pain and lump                  2             revealed a sex ratio of male:female 6:1 and muscle invasive
     Haematuria                               2             disease on initial presentation in nearly half of the patients
                                                            (8). Further, in our study we found 18% of pT1 high
     Incidental                               2             grade tumours. This is also unduly high over the finding
     Pathological fracture                    1             of 5.3% of pT1 high grade tumours in the above largest
                                                            bladder cancer study. Differences in the study duration
     Fever and loss of appetite               1             could have resulted in these disparities. Tumour confi-
                                                            guration is an important prognostic variable. Papillary
                                                            tumours tend to be of a low grade, earlier stages and exhibit
The patient who had a testicular cancer was 45 years        less aggressive behavior than non papillary tumours (9,10).
old; presented with scrotal lump, bilateral sacral pain     In this study 91% of non-muscle invasive bladder cancers
and loss of weight. The tumour was a classic seminoma,      had papillary configuration and all muscle invasive bladder
stage 11 (AJCC staging system).                             cancers had solid configuration. The 8% of non-muscle
                                                            invasive bladder cancers that showed non papillary
Synchronous bladder and upper urinary tract tran-           configuration were pT1 high grade tumours. Haematuria
sitional cell carcinoma was found in a 68 year old          is the presenting symptom of urothelial malignancy in
male who had haematuria for 3 months.                       85% to 90% of cases but 10% never have haematuria
                                                            (11). 6% of primary bladder cancer patients never had
Discussion                                                  haematuria in this study.
In USA, excluding basal and squamous cell skin              Prostate cancer is rarely diagnosed in men younger than
cancers and in situ carcinoma except urinary bladder,       50 years, accounting for less than 0.1% of all patients.
carcinoma of the prostate is the number one cancer          Peak incidence occurs between the ages of 70 and 74
in males and constitute 25% of all cancers; cancers         years, with 85% diagnosed after the age of 65 years (12).
of urinary bladder and kidney and renal pelvis are the      In prostate cancer, there has been a substantial shift to
4th and 7th leading cancers in males and constitute         more favourable stage at presentation with newly
7% and 5% of all cancers; cancer of the kidney and          diagnosed disease. This clinical stage migration is largely
renal pelvis is the 8th leading cancer in females and       if not exclusively accounted for by PSA screening (13).
constitute 3% of all cancers; cancer of urinary bladder     Non palpable cancers (AJCC clinical stage T1c) now
has no place among the first ten leading cancers in         account for 75% of newly diagnosed disease (14). But
females (1). In Sri Lanka, carcinoma of the prostate        all of our patients were symptomatic, had clinically
is the 8th leading cancer in males; other urological        malignant or equivocal prostate and advanced disease
cancers have no place among the first ten leading           at presentation. Lack of awareness about the disease and
cancers both in males and females (2). In this study,       PSA based screening for carcinoma of the prostate resulted
carcinoma of the prostate is less common than               in this late presentation. In this study one patient who
carcinoma of the bladder in males. Non inclusion of         had clinically malignant prostate and serum PSA of
PSA based screening pT1c prostate carcinomas in             <1 μg/L showed aggressive disease (Gleason sum score
this study contributed for this observation.                5b+5b). In clinical decision making relying on serum PSA
                                                                                  UROLOGICAL MALIGNANCIES           27



alone without DRE can lead to a disaster by missing an           MVC. Bladder cancer in Sri Lanka: Experience
aggressive malignancy.                                           from a tertiary referral centre. International Journal
                                                                 of Urology 2004; 11: 969-72.
RCC shows a 1.5:1 predominance of men over women,            9. Hency NM, Proppe K, Prout GR, Griffin PP,
with peak incidence occurring between 60 and 70 years
                                                                 Shipley WU. Invasive bladder cancer: Tumour
of age (15). Renal cell carcinoma comprises different
                                                                 configuration, lymphatic invasion and survival. J
types with specific histopathological and genetic
                                                                 Urol 1980; 130: 895-7.
characteristics and 70%-80% are conventional RCC
(16). All these findings were found in our study as well.    10. Brawn PN. The origin of invasive carcinoma of
Due to the increased detection of tumours by imaging             the bladder. Cancer 1982; 50: 515-19.
techniques, such as ultrasound (US) and computerised         11. Hendry WF. Diagnosis and management of primary
tomography (CT), the number of incidentally diagnosed            bladder cancer: A British perspective. In: Raghavan
RCCs has increased. These tumours are more often                 D (ed). The Management of Bladder Cancer, 1st
smaller and of lower stage (17,18). In this study there          edn. Edward Arnold. London, 1988; 69-93.
were 2 incidentally found renal tumours (pT1a and
                                                             12. In: Ries LAG, Eisner MP, Kosary CL, et al ed. SEER
pT1b).
                                                                 Cancer Statistics Review, 1975-2001, Bethesda,
References                                                       Md: National Cancer Institute, 2004.
1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ.          13. Mettlin C, Murphy GP, Lee F, et al. Characteristics
    Cancer Statistics, 2009. CA Cancer J Clin 2009;              of prostate cancers detected in a multimodality
    59: 225-49.                                                  early detection program. The Investigators of the
                                                                 American Cancer Society – National Prostate
2. Jayanthi KGN, Somaratne L, Walpola N, et al.
                                                                 Cancer Detection Project. Cancer 1993; 72: 1701-8.
    Cancer Incidence Data: Sri Lanka Year 2001-2005.
    Cancer Registry 2009: 9.                                 14. Derweesh IH, Kupelian PA, Zippe C, et al.
                                                                 Continuing trends in pathological stage migration
3. Goonewardena SAS, De Silva WAS. Pattern of
                                                                 in radical prostatectomy specimens. Urol Oncol
    urological malignancy in Sri Lanka: Experience
    from a tertiary referral centre. Ceylon Medical              2004; 22: 300-6.
    Journal 1999; 44: 100-1.                                 15. Lindblad P. Epidemiology of renal cell carcinoma.
4. Lynch CF, Cohen MB. Urinary system. Cancer                    Scand J Surg 2004; 93(2): 88-96.
    1995; 75(Suppl): 316.                                    16. Campbell SC, Novick AC, Bukowski RM. Renal
5. Ferlay J, Autier P, Boniol M, Heanue M, Colombet              tumors. In: Wein AJ, Kavoussi LR, Novick AC, Partin
    M, Boyle P. Estimates of the cancer incidence and            AW, Peters CA (eds) Campbell-Walsh Urology 9th
    mortality in Europe in 2006. Ann Oncol 2007;                 edn. Saunders Elsevier, Philadelphia, 2007.
    18(3): 581-92.                                           17. Patard JJ, Rodriguez A, Rioux-Leclercq N, Guille
6. Messing EM. Urothelial tumors of the bladder. In:             F, Lobel B. Prognostic significance of the mode
    Wein AJ, Kavoussi LR, Novick AC, Partin AW,                  of detection in renal tumours. BJU Int 2002; 90(4):
    Peters CA (eds) Campbell-Walsh Urology 9th edn.              358-63.
    Saunders Elsevier, Philadelphia, 2007.                   18. Kato M, Suzuki T, Suzuki Y, Terasawa Y, Sasano
7. Vaidya A, Soloway MS, Hawke C, Tiguert R,                     H, Arai Y. Natural history of small renal cell
    Civantos F. De novo muscle invasive bladder cancer:          carcinoma: Evaluation of growth rate, histological
    Is there a change in trend? J Urol 2001; 165(1): 47-50       grade, cell proliferation and apoptosis. J Urol 2004;
8. Goonewardena SAS, De Silva WAS, De Silva                      172(3): 863-6.



Authors

B. Sathesan, MBBS (Jaffna), MS (Col)
Senior Registrar in Urology
A. P. I. Prabath, MBBS (Ruhuna), MS (Col)
Senior Registrar in Urology
S. A. S. Goonewardena, MS (Col), FRCS (Eng), DUrol (Lond)
Consultant Urological Surgeon
Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.
28     L. N. SENEVIRATNE, J. M. N. R. K. JAYASUNDARE AND N. D. PERERA



Sri Lanka Journal of Urology, 2009, 10, 28-30
Case Report


Virchow’s node – an unheard site of metastatic bladder cancer

L. N. Seneviratne, J. M. N. R. K. Jayasundare and N. D. Perera
Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.



Abstract
Metastatic carcinoma of the bladder presenting with
enlarged left supraclavicular lymphadenopathy is not
reported in literature published in English language. All
three cases presented with a Virchow’s node with
computer tomography confirming solid bladder tumour.
Histology proved muscle invasive high grade transitional             T
cell carcinoma (TCC) with one with neuroendocrine
differentiation and another with squamous metaplasia.
The article reviews diagnosis and management of three                    R
cases of metastatic bladder cancer presenting with left
supraclavicular lymph node deposits.


Introduction                                                Figure 1. CT Scan of the pelvis coronal section – large
Virchow’s node (or “signal” node) is an enlarged, hard,     muscle invasive tumour almost completely occupying the
left supraclavicular lymph node which contain               bladder but sparing the rectum (T – tumour, R – Rectum).
metastasis of a range of thoracic or abdominal visceral
malignancy. It was initially named after Rudolf Virchow
(1821-1902), the German pathologist. The presence           Case 2
of an enlarged Virchow’s node is also referred to as
Troisier's sign, named after Charles Emile Troisier, who    A 58-year old man, who was a non-smoker presented
also described this later.                                  with intermittent gross painless haematuria and a
                                                            Virchow’s node of a few weeks duration (Figure 2). X-ray
                                                            KUB revealed a large bladder calculus while com-
Case 1                                                      puterized tomography scan showed a large, well-
56-year old heavy smoker with a history of transurethral    enhanced, broad-based tumour causing thickening of
                                                            the left bladder wall along with intraureteric extension
resection of a bladder tumour (TURBT) for muscle
                                                            with unilateral hydronephrosis. TURBT and FNAC of
invasive (T2) tumour one year back who defaulted
                                                            the Virchow’s node confirmed high grade TCC with
further treatment, presented with with gross haematuria.
                                                            squamous metaplasia. He underwent percutaneous
Computerized tomography scan showed a large, well-
                                                            nephrostomy (PCN) to relieve the left obstructed kidney
enhanced, broad-based tumor causing thickening of the       as well as a palliative cystectomy since he was
left bladder wall and diffuse enlargement of the            exanguinating from the bladder.
pelvic and para aortic lymph nodes and bilateral inguinal
lymphadenopathy (Figure 1). Subsequently he underwent
palliative TURBT and a tru-cut biopsy of the Virchow’s      Case 3
node. Histology showed high grade muscle invasive           A 61-year old man, who underwent TURBT for high
transitional cell carcinoma (TCC). Pan-endoscopy of the     grade superficial bladder tumour, presented with a large
gastrointestinal tract (GIT) and brochoscopy were           Virchow's node after two months. Subsequent histology
normal. He was followed up with systemic chemo-             confirmed high grade TCC with neuroendocrine
therapy (M-VAC) treatment by the oncologist.                differentiation. It was characteristically composed of
                                    VIRCHOW’S NODE – AN UNHEARD SITE OF METASTATIC BLADDER CANCER                 29



sheets and nests of small round cells containing hyper-   any predilection towards lymphatic metastases as shown
chromatic nuclei. Immunostaining for neuroendocrine       in the present series of case studies.
markers were positive (Figure 3). He was referred to
the oncologist for systemic chemotherapy.                 The incidence of pelvic nodal metastases in patients
                                                          undergoing radical cystectomy varies from 15% to 25%
                                                          and is related to the depth of invasion and tumour. In a
                                                          large autopsy study (Smith et al) of 662 cancer of the
                                                          urinary bladder with lymph node involvement showed
                                                          a differential lymph node metastasis in obturator 74%,
                                                          external iliac 65%, hypogastric 17%, perivesical 16%,
                                                          common iliac 19%. In addition three other studies
                                                          showed that celiac (2/91), portal (2/91) and mesenteric
                                                          (4/91), mediastinal (23%) and tracheobronchial (7%)
                                                          nodal involvement. Yet the incidence of Virchow’s node
                                                          was not mentioned either in this study or other similar
                                                          studies.

                                                          High grade TCC has a poor oucome. Presence of
                                                          squamous metaplasia or neuroendocrine differentiation
                                                          makes tumour more aggressive resulting in poorer
Figure 2. Left supraclavicular lymph node enlargement.    prognosis (3,4).

                                                          Presence of Virchow’s node with muscle invasive
                                                          bladder tumour is considered as incurable metastatic
                                                          disease as the pathological retrograde tumour cell
                                                          deposition against the normal drainage of the node
                                                          (towards the thoracic duct) imply extensive tumour
                                                          occupation of the retro peritoneum.

                                                          In a multi-institutional review of 64 patients, a multi-
                                                          variate analysis has indicated that neither chemotherapy,
                                                          nor radiation, nor surgery has any impact on overall
                                                          survival. The poor prognosis of patients treated by radical
                                                          cystoprostatectomy alone reported by Sved et al.
                                                          supports the use of combination modality treatments
                                                          (3). Significant progress has been made in the systemic
Figure 3. Histology of a muscle invasive carcinoma of     chemotherapy with the 4-drug regimen consisting of
the bladder with neuroendocrine cells (H & E × 100).      methotrexate, vinblastine, adriamycin and cisplatin
                                                          (MVAC) which has been the standard treatment regimen
                                                          for approximately 10 years. Response rates have ranged
                                                          up to 60%. The benefits of MVAC appeared to have
Discussion                                                plateaued, and many patients with advanced disease
                                                          are not candidates for therapy as a result of preexisting
Troisier’s sign with Virchow’s node is an oncologically   cardiac and renal disease (because of contraindicated
ominous clinical entity. The majority of such nodes       use of adriamycin and cisplatin, respectively).
(64%) are due to primary malignancies of lung (22%
cases), breast (16.4% cases), cervix (11% cases)          This regimen has been challenged with newer drug
stomach (10%) and oesophagus (8.6% cases). In             combination which includes taxenes and gemcitabine
13.3% cases the primary site was unknown [1]. There       to the administration of cisplatin and etoposide (4). In
are no reported antemortum studies of bladder tumour      cases of contraindication for cisplatin, administration
deposits in the supraclavicular nodes.                    of cyclophosphamide, doxorubicin and etoposide is an
                                                          option (5).
Common sites of metastatic spread of bladder
carcinoma are regional lymph nodes (90%), liver (47%),    However, many of the patients have significant co-
lung (45%), bone (32%), peritoneum (19%), pleura          morbidity and are unfit for systemic chemotherapy by
(16%), kidney (14%), adrenal gland (14%), and the         the time Virchow’s node is apparent which leaves them
intestine (13%) [2]. Histological type has not shown      with terminal care.
30     L. N. SENEVIRATNE, J. M. N. R. K. JAYASUNDARE AND N. D. PERERA



References                                                     British Journal of Urology International 2004; 94:
                                                               12-7.
1.   Gupta N, Rajwanshi A, Srinivasan R, Nijhawan R.
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Authors

L. Niroshan Seneviratne, MS (Col), MRCS (Eng)*

J. M. N. R. K. Jayasundare, MS (Col)*

*Senior Registrar in Urology

Neville D. Perera, MS (Col), FRCS (Eng), FRCS (Edin), DUrol (Lond)
Consultant Urological Surgeon

Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka.
Sri LankaJoumalof Urology,2009, 10,31-33
CaseReport



Surgicalsite,renal fossaand vena caval recurrenceof renal cell carcinoma:
an unusualcaseoflate recurrence

L. N. Seneviratne, M. N. R. K. Jayasundare N. D. Perera
                 J.                       and
Department Urology,National Hospital of Sri Lanka,Colombo,Sri Lanka.
          of




Abstract                                                 casesof RCC recurring in the surgical site, renal
                                                         fossawith IVC involvementin combinationin a sinsle
A Sl-year old male who had undergonea radical
                                                         patient.
nephrectomy T2NoMo FuhrmangradeIII tumour
              for
5 yearsback developed  persistentloin pain. Clinically
he had a palpableright hypochondriac   mass.Imaging
                                                         Case
revealed tumour overthe previoussurgicalscar,renal
         a
fossawith inferior venacavaobstructionwith no other      A 51-yearold man who had undergone radical a
metastatic disease. underwentexcisionof the local
                   He                                    nephrectomy(T2NoMo grade III) 5 years back
recurrence,cavotomy,thrombectomywith caval               presented  with a right hypochondriacmass.Computer
resectionsince the tumour was adherentto the IVC.        tomography (Figure l) and MRI (Figure 2) scan
Histology confirmed it as a recurrenceof renal cell      identified a massattachedto the surgicalscar,in the
carcinomaand was followed by targetedtherapy.            renal fossa with invasion and near total occlusionof
                                                         the IVC. Bone scan and CT chest were negative.
Wereportanunusual    case latepresentation surgical
                          of              of             Excision of the recurrence,cavotomy and throm-
site and renal fossa recurrencewith invasion to the      bectomy with caval resection were successfully
inferior vena cava (IVC) in a patient who underwent      performed.Histology confirmedfumour as recurrence
radicalnephrectomy a renal cell carcinoma(RCC).
                     for                                 of renal cell carcinoma. Thereafter was followed up
                                                                                           he
A reviewofthe literature showedno previous published     with targetedtherapy.




        Figure l. CT scanof the abdomen.

                                                          Figure 2, Verticalreconstruction
                                                                                         film of MN scan.
A - Tumourrecurrence the surgicalsite
                    at
B - Renalfossatumour recurrence                          A - Tumour thrombusin the IVC
C - Tumour in the inferior vena cava                     B - Renalfossarecurrence
                                                                                tumour infiltratinethe IVC
32     L. N. SENEVIRATNE, J. M. N. R. K. JAYASUNDARE AND N. D. PERERA



Discussion                                                   pericardium or PTFE graft (8). Although technically
                                                             difficult, resection of IVC tumour and primary closure
Tumour recurrence of RCC reported varies from 10-37%
                                                             as in this case is an acceptable method of treatment.
where metastatic recurrence predominates with lung
(63%), bone (27%), brain (20%), liver (16%), retro-
                                                              Although many of the published reports support the
peritoneal lymph nodes (10%) far being the common
                                                             potential benefit associated with an aggressive surgical
sites(1). Local recurrence of RCC after radical
                                                             approach, the role of systemic therapy or radiation
nephrectomy remains an uncommon event. Published
                                                             therapy remains to be defined. So far, most authors
series report that between 2% and 5% of patients with
                                                             report that disease control with both treatment
RCC will develop a local recurrence after radical
                                                             modalities is far more less over surgery. Radiation
nephrectomy (2). However, majority of patients with
                                                             therapy may be of value for palliation of symptomatic
local recurrence also has systemic disease at diagnosis;
                                                             local recurrence for patients who are not surgical
only 10-17% of patients have true isolated local
                                                             candidates.
recurrences.
                                                             Prognosis of these patients with recurrence has an
Time to tumour recurrence generally occurs within the
                                                             inverse correlation between the number of risk factors
first 2 years with generally 83% affected (3). Though
                                                             which include time from diagnosis to start of systemic
late metastatic recurrence is reported even after 20
                                                             therapy <12 months, Karnofsky index <80%, serum
years, literature on late local recurrence is scarce (4).
                                                             corrected calcium >10 mg/dL, haemoglobin less than
The mean time of tumor recurrence usually is 17 months
                                                             the age/sex-specific lower limit of normal and an LDH
(range, 3-50 months).
                                                             more than 1.5× the upper limit of normal. Patients were
                                                             categorized into those with low risk (no risk factors),
Few pathological features have been proposed as risk
                                                             intermediate risk (1-2 risk factors present) and high
factors that predict an increased risk of local recurrence
                                                             risk (3-5 risk factors present) 2-year overall survival
of the disease. These include tumour size >5cm, T
                                                             rates were 88%, 51% and 11%, respectively (5).
stage >T3a, T3b, Robson stage III or more, histological
grade 3, 4 or node-positive disease in some but not
                                                             We emphasize the need for life long strict surveillance
all (5).
                                                             for all patients with RCC for early diagnosis of this
                                                             rare recurrence involving specially the IVC so that
Not all patients with locally recurrent disease will be
                                                             surgery becomes a viable option of treatment.
symptomatic at presentation. The presence of symp-
toms leading to the discovery of a recurrence varies
widely from 7% to 73%. The majority of the published         References
series shows that patients who died had a mean time to
                                                             1.   Eun Jin C. Renal cell carcinoma: Analysis of
recurrence of 16 months, compared with 79 months
                                                                  postoperative recurrence patterns. Radiology 2005;
for patients who survived. These findings reinforce
                                                                  234: 189.
the well-known heterogeneity of the characteristics of
RCC and its clinical behaviour (6).                          2.   Schrodter S et al. Outcome of surgical treatment
                                                                  of isolated local recurrence after radical
Since RCC has poor response to adjuvant treatments,               nephrectomy for renal cell carcinoma. Journal of
surgery is the best choice in a case of local recurrence          Urology 2002; 167: 1630-3.
or isolated metastatic recurrence in the absence of
                                                             3.   Nyree G, Martin EG, Aslam S. Imaging in metastatic
metastatic disease in other places. An aggressive surgical
                                                                  renal cell carcinoma. American Journal of
resection can provide up to 30% 5-year disease-free
                                                                  Radiology 2007; 189: 360-70.
survival. However, complete surgical resection with
negative surgical margins is crucial and en bloc resection   4.   Featherstone JM, Bass P, Cumming J, Smart CJ.
of adjacent organs should be done to achieve this goal.           Solitary, late metastatic recurrence of renal cell
Failing to do so will likely result in recurrent disease          carcinoma: Two extraordinary cases. International
and decreased survival. It is not surprising, then, that          Journal of Urology 13; 12: 1525-7.
most published series report complication rates ranging
                                                             5.   Eggener SE et al. Renal cell carcinoma recurrence
from 18% to 47% (7).
                                                                  after nephrectomy for localized disease: Predicting
                                                                  survival from time of recurrence. Journal of Clinical
Surgery for IVC recurrence is rarity. If encountered
                                                                  Oncology 2006 Jul 1; 24(19): 3101-6.
the options available are tumor thrombus removal and
primary cavotomy closure, IVC ligation and removal           6.   Master VA et al. Management of isolated renal
of tumour thrombus without vascular reconstruction                fossa recurrence following radical nephrectomy.
and IVC wall excision and placement of a bovine                   Journal of Urology 2005; 174: 473-7.
                    SURGICAL SITE, RENAL FOSSA AND VENA CAVAL RECURRENCE OF RENAL CELL CARCINOMA                33



7.   Bruno JJ et al. Renal cell carcinoma local            8.   Smaldone MC, Cannon GM, Hrebinko RL.
     recurrences: Impact of surgical treatment and              Resection of recurrent inferior vena cava tumor
     concomitant metastasis on survival. British Journal        after radical nephrectomy for renal cell carcinoma.
     of Urology International 2006; 97: 9338.                   Urology 2006; 67(5): 1084e4-1084e7.




Authors

L. Niroshan Seneviratne, MS (Col), MRCS (Eng)*

J. M. N. R. K. Jayasundare, MS (Col)*

*Senior Registrar in Urology

Neville D. Perera, MS (Col), FRCS (Eng), FRCS (Edin), DUrol (Lond)
Consultant Urological Surgeon

Department of Urology, National Hospital of Sri Lanka, Colombo, Sri Lanka
34      NEWS



Sri Lanka Journal of Urology, 2009, 10, 34
News


Sri Lanka Association of Urological Surgeons


Joint Academic Meeting of the Sri Lanka Association of Urological Surgeons (SLAUS) with the Section of Urology
of the Royal Society of Medicine (RSM), United Kingdom was held at the Cinnamon Lakeside Hotel, Colombo, Sri
Lanka on 27-28 November 2009. This landmark event was held to celebrate the 10th Anniversary of the SLAUS.
The meeting featured some outstanding lectures by several internationally and locally recognized experts in the
field of urology. The sessions were preceded by some excellent pre-congress workshops. The highlights of the
superb academic programme are listed below.
     • Pre-congress workshop on the management of Urinary Tract Injuries on 23 November 2009 at Skills Lab,
        University of Sri Jayawardenapura, Gangodawila, Nugegoda
        Faculty: Peter Tohompson, Ian Dickinson and Chris Parker
     • Masterclass in Paediatric Urology on 23 November 2009 at the Lady Ridgeway Hospital, Colombo
        Faculty: Supul Hennayake
     • Masterclass in Urolithiasis on 24 November 2009 at the Department of Surgery Auditorium, National Hospital
        of Sri Lanka, Colombo
        Faculty: Byron Walmsley and Graham Watson
     • Masterclass in Paediatric PCNL and Laparoscopy on 25 November 2009 at the Department of Surgery
        Auditorium, National Hospital of Sri Lanka, Colombo
        Faculty: Byron Walmsley and Graham Watson
     • Masterclass in Urogynaecology on 26 November 2009 at the Lanka Hospitals Auditorium, Colombo
        Faculty: Roland Morley, Roger Walker and Tom Rosenbaum

Inaugural ceremony was held on 26 November at 18:30 with the Presidential Address (SLAUS) delivered by
Serozsha A.S. Goonewardena on the 'History of Urology in Sri Lanka' and the Presidential Address (RSM) delivered
by Peter Thompson.

The SLAUS Lecture was given by Peter Thompson on 'Evolution and safety of prostate biopsy'

The UK Faculty comprised Ralph Beard, Aine Burns (Nephrologist), Ian Dickinson, Michael Dineen, Supul
Hennayake, David Jones, Roland Morley, Chris Parker (Secretary, RSM), Tom Rosenbaum, Nick Thomas
(Neurosurgeon), Peter Thompson (President, Urology Section of the RSM), Roger Walker, Byron Walmsley and
Graham Watson.

Ching Chong Ming of Singapore participated at the sessions delivering two lectures.
NEWS   35
36   NEWS




            SRI LANKA JOURNAL OF UROLOGY

            Co-Editors:      S. A. S. Goonewardena, MS FRCS
                             A. M. Abeygunasekera, MS FRCS

            Co-ordinator:    S. A. Dayananda, BA

            Editorial Office: C/o The College of Surgeons of Sri Lanka
                              6, Independence Avenue, Colombo 7.
                              Sri Lanka.
                              E-mail: collsurg@systec.lk
                              Tel/Fax: 2682290

				
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