Seminar article Malignancy associated with the use of intestinal segments in the urinary tract Amanda C. North, M.D., Yegappan Lakshmanan, M.D., F.A.A.P.* James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA Abstract Use of intestinal segments for urinary tract reconstruction has become widespread. In these patients, urologists are increasingly encountering malignancies that may be a direct result of this altered milieu. This review attempts to summarize the current literature on cancer in patients with intestinal segments in their urinary tracts. Although the exact etiology for this increased risk of malignancy is still unclear, several theories have been proposed. Many investigators now recommend annual screening in patients who have intestinal segments in contact with urine beginning 10 years after the initial surgery. © 2007 Elsevier Inc. All rights reserved. Keywords: Neoplasm; Enterocytoplasty; Urinary diversion Introduction Intestinal segments are commonly used in the urinary tract, either for augmentation, replacement, or diversion. Although the development of neoplasia after ureterosig- moidostomy is a well-known complication of this form of urinary diversion, more recently, tumors are being reported after other uses of intestinal segments in the urinary tract. These newer reports suggest that malignant transformation does not occur solely from the mixing of the urinary and fecal streams. This review will attempt to summarize the current English language literature on malignancy in pa- tients with intestinal segments as part of their urinary tracts with attention to risks, etiology, and screening. Because the risks with ureterosigmoidostomy have been well character- ized elsewhere, we will focus on the tumors occurring in enterocystoplasties, neobladders, conduits, and ileal ureters. Enterocystoplasty The use of bladder augmentation for contracted bladders first achieved popularity as a treatment for tuberculous blad- ders. In the last 25 years, this procedure has gained popu- larity in pediatric urology for neuropathic bladders. One study from 1999 estimated that more than 150 bladder augmentations were being performed on children in the United Kingdom each year [1]. The first case of cancer after enterocystoplasty was reported in 1971 [2]. Since then, there have been a number of cases reported. More than 20 of the cases were reported in patients with urogenital tuber- culosis. Others have occurred with known schistosomiasis infections. Because these entities may represent indepen- dent risk factors for malignancy, the exact risk of neoplasia, which can be directly attributed to the augmentation, is unclear. Currently, the most common indication for bladder aug- mentation is neuropathic bladder. Of the spinal cord injury population, there is an increased risk of squamous cell carcinoma when compared to the general population [3]. It is hypothesized that this risk may be related to chronic indwelling catheters [4]. In contrast, the tumor histology, in patients who have undergone bladder augmentation, shifts away from squamous cell carcinoma, and this may reflect the risk of cancer from the augmentation itself rather than being related to catheterization. Adenocarcinoma is the most frequently reported histology with 16 cases. There have been 12 cases of transitional cell carcinoma and 2 of squamous cell carcinoma. In the series of 260 patients with augmented neuropathic bladders followed for at least 10 years by Soergel et al. [5], all 3 patients who had a bladder tumor develop had transitional cell carcinoma, and all 3 died of their disease. Sarcoma, oat cell carcinoma, small cell carcinoma, and signet ring carcinoma have also been re- ported. * Corresponding author. Tel.: +1-410-955-2914; fax: +1-410-955-0833. E-mail address: ylaksh@jhmi.edu (Y. Lakshmanan). Urologic Oncology: Seminars and Original Investigations 25 (2007) 165–167 1078-1439/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.urolonc.2006.09.008