Sentinel lymph node dissection during radical cystectomy for bladder adenocarcinoma following gastrocystoplasty

Abstract

Patients with spina bifida are at increased risk of developing malignancy in the native or augmented bladder and tend to present with more advanced disease. Surgical guidelines for oncologic resections in patients with augmented bladders are not well described. Furthermore, there is limited knowledge regarding the changes in lymphatic drainage after bladder reconstruction. Herein we describe the case of a 45-year-old male with spina bifida who underwent gastrocystoplasty and developed adenocarcinoma of the augmented bladder segment 33 years later. We describe his surgical management with radical cystectomy and the use of sentinel lymph node dissection.

1 Introduction

Patients with spina bifida typically develop neurogenic bladder and are at risk of multiple urologic complications, including recurrent urinary tract infections, chronic renal insufficiency, and end-stage renal disease . As such, effective bladder management is important to preserve overall health and renal function. Patients who fail medical management for bladder dysfunction proceed to surgical augmentation. Augmentation cystoplasty involves the use of a detubularized bowel segment to enlarge the bladder. Although augmentation cystoplasty can help protect the upper urinary tracts, there is an increased risk of long-term complications including metabolic imbalances, urolithiasis, bowel dysfunction, and bladder perforation. Furthermore, patients with spina bifida have an increased risk of malignancy in the native or augmented bladder. Importantly, spina bifida patients that develop such malignancies tend to present at a younger age, in an atypical fashion, and are usually diagnosed at an advanced stage, translating to poor survival outcomes. ^, Therapy, particularly surgical guidelines, for these patients is not well described. In addition, knowledge of the lymphatic drainage of the augmented bladder is currently limited and therefore the optimal dissection template is unknown.

The concept of sentinel lymph node (SLN) mapping involves identifying the first node or group of nodes into which a primary tumor drains. SLN biopsies have been successfully used in the evaluation of metastatic lymph nodes for several malignancies including breast cancer, melanoma, and penile cancer; with reports of decreased morbidity such as extremity edema and hospital stays. Herein we describe the case of a 45-year-old male with spina bifida who underwent gastrocystoplasty as a child and subsequently developed adenocarcinoma of the augmented bladder segment 33 years later. We describe his clinical course and, to our knowledge the first documented use of SLN dissection in augmented bladder oncologic resections.

2 Case presentation

A 45-year-old male presented to the emergency department with a five-month history of gross hematuria and two-month history of nausea, abdominal pain, and malaise. He had received four courses of oral antibiotics for presumed bacterial cystitis over the prior two months without improvement in symptoms. His past medical history was significant for lumbar myelomeningocele, hydrocephalus status post ventriculoperitoneal shunt with revisions, and neurogenic bladder status post gastrocystoplasty at age 10. His bladder management consisted of a home clean intermittent catheterization regimen. He did suffer from recurrent urinary tract infections, neurogenic bowel status post colostomy, chronic sacral decubitus ulcers, poorly controlled diabetes mellitus, bilateral below the knee amputations, chronic obstructive pulmonary disease, and nicotine dependence. He had normal vital signs with pyuria and hematuria on urinalysis. Computed tomography (CT) urogram of the abdomen and pelvis demonstrated diffuse bladder enlargement with an area of focal nodular enhancing mass along the right lateral bladder wall measuring 2.5 × 1.1 cm ( Fig. 1 ). There was no evidence of lymphadenopathy or metastatic disease.

The patient underwent outpatient cystoscopy, bladder biopsy, cystogram, retrograde urethrogram, and bilateral retrograde pyelograms. He was found to have a mass at the junction of the native bladder and augmented portion along the right anterolateral wall without evidence for ureteral, urethral, or vesical intestinal fistulas. Pathology was consistent with invasive adenocarcinoma. Tumor cells were positive for CK20, CK7, and CDX-2 with differential diagnosis including urachal adenocarcinoma, primary adenocarcinoma of the bladder, or gastric adenocarcinoma. Staging chest CT did not show evidence of metastasis. After extensive counseling emphasizing the presence of invasive adenocarcinoma and poor urinary quality of life, he was taken to the operating room for radical cystectomy with sentinel lymph node dissection and ileal conduit creation.

The procedure was started by performing a rigid cystoscopy in the lithotomy position. This redemonstrated the tumor on the right anterolateral bladder wall ( Fig. 2 a). A 3.7 F x 23 G x 350 mm needle was used to cystoscopically inject technicium Tc 99m tilmanocept (Cardinal Health, Dublin OH) into 3 peritumoral locations, one on the gastric augment side and two on the bladder side ( Fig. 2 b and c). A midline laparotomy was then performed and after extensive adhesiolysis, the pelvis was exposed with care taken to isolate and preserve the mesentery to the gastrocystoplasty. After bilateral ureteral dissection, a handheld Neoprobe gamma counter (Mammotome, Cincinnati OH) was used to inspect the abdomen and pelvis including the gastrocystoplasty mesentery. Counts of approximately 300 were noted on the right internal iliac and deep pararectal basin. Subsequently, a flexible cystoscope was replaced and a 75-cm BoNee needle was used to inject 3 cc of indocyanine green (ICG) into the bladder tumor. The handheld SPY camera (Stryker, Kalamazoo, MI) was used to visually confirm avidity of the right internal iliac/para-rectal lymph node chain ( Fig. 3 ). Removal of these lymph nodes was followed by an uncomplicated non-nerve sparing cystoprostatectomy and ileal conduit urinary diversion. The patient then had a primary suture para-colostomy hernia repair and abdominal closure.