\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Sigmoid Colon Adenocarcinoma at the site of prior, now defunctionalized,
ureterosigmoidostomy for bladder exstrophy.}



\author[1]{Pavel Mazirka}%
\author[1]{Krista Terracina}%
\author[1]{Lindsey Goldstein}%
\author[1]{Thomas Read}%
\affil[1]{University of Florida}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Patients with a history of ureterosigmoidostomy are at an increased risk
of rectosigmoid adenocarcinoma. The cancer can occur many decades after
the diversion, even if there was conversion to ileal urinary conduit.
These patients may still be considered as high-risk individuals and
screened for colorectal cancer accordingly.%
\end{abstract}%



\sloppy


\textbf{Sigmoid Colon Adenocarcinoma at the site of prior, now
defunctionalized, ureterosigmoidostomy for bladder exstrophy.}

Mazirka PO\textsuperscript{1}, Terracina KP\textsuperscript{1},
Goldstein LE\textsuperscript{1}, Read TE\textsuperscript{1}

Department of Surgery, University of Florida College of Medicine,
Gainesville, FL, USA.

Correspondence to: Pavel Mazirka, MD. University of Florida Department
of Surgery. 1600 SW Archer Rd, Gainesville, FL 32610. Phone number:
516-203-6924.

Email: pavel.mazirka@surgery.ufl.edu\textbf{ORCID:~} 0000-0002-1111-3292

Krista Terracina, MD. Email: Krista.Terracina@surgery.ufl.edu

Lindsey Goldstein, MD. Email:
Lindsey.Goldstein@surgery.ufl.edu~\textbf{ORCID:~} 0000-0001-6796-040X

Thomas E Read, MD. Email:~Thomas.Read@surgery.ufl.edu ~\textbf{ORCID:~}
0000-0003-3760-3748

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy.

There are no conflicts of interest or funding to disclose.

\textbf{Abstract} : Patients with a history of ureterosigmoidostomy are
at an increased risk of rectosigmoid adenocarcinoma. The cancer can
occur many decades after the diversion, even if there was conversion to
ileal urinary conduit. These patients may still be considered as
high-risk individuals and screened for colorectal cancer accordingly.

\textbf{Key Clinical Message} : History of ureterosigmoidostomy
increases the risk of rectosigmoid adenocarcinoma decades after
diversion even after conversion to ileal urinary conduit and these
patients may be screened for colorectal cancer as high-risk individuals.

\textbf{Keywords} : Ureterosigmoidostomy, rectosigmoid adenocarcinoma,
case report

\textbf{Background}

There is a 100-fold increase in risk for colorectal adenocarcinoma in
patients who underwent urinary diversion by ureterocolic anastomosis,
usually by ureterosigmoidostomy for bladder exstrophy {[}1{]}. After
recognizing this association, surgeons converted many patients who had
previously undergone ureterosigmoidostomy as neonates to ileal loop
urinary diversion when they reached adulthood. It has been recommended
that patients who have an intact ureterosigmoidostomy undergo yearly
screening flexible sigmoidoscopy, as well as patients who had been
converted to another form of urinary diversion, but had the
ureterosigmoidostomy anastomosis left intact {[}2, 3{]}. Herein we
report a case of sigmoid adenocarcinoma developing in a patient with a
remote history of neonatal ureterosigmoidostomy and subsequent revision
to ileal loop urinary diversion, who was not undergoing enhanced
screening. We present the following case in accordance with the CARE
reporting checklist.

\textbf{Case Presentation}

A 72-year-old woman was referred for further evaluation of left lower
quadrant abdominal pain, blood per rectum and dark stools. Colonoscopy
had been attempted but could not be completed due to sigmoid tortuosity.
There was suggestion of a sigmoid mass, but this could not be confirmed
endoscopically and biopsies of the area in question revealed necrotic
tissue and atypical cells indeterminate for malignancy. The patient's
most recent colonoscopy was 7years prior.

She had a complicated medical history mostly related to her multiple
congenital anomalies. Her bladder exstrophy was addressed by
ureterosigmoidostomy diversion in the neonatal period that was
subsequently revised to ileal conduit at age 21. She had undergone
numerous prior abdominal and pelvic operations. Her other comorbidities
included right sided aortic arch, coronary artery disease, atrial
fibrillation, congestive heart failure, chronic kidney disease and
chronic vaginal prolapse. The patient had no personal or family history
of colon cancer or inflammatory bowel disease.

The initial step in our evaluation was another attempt to establish a
diagnosis with colonoscopy, which confirmed the presence of a partially
obstructing mass in the distal sigmoid {[}Fig 1{]}. Biopsies revealed
adenocarcinoma. Staging revealed no evidence of distant metastatic
disease. At operation, the tumor was found to be invading the
retroperitoneum, and remnant distal ureter stumps were found in the
region of the tumor, still anastomosed to the sigmoid {[}Fig 2{]}.
Anterior resection of the rectosigmoid with en bloc resection of the
retroperitoneum and the remaining ureters attached to the colon, and
construction of colorectal anastomosis was performed. Histologic
evaluation revealed pT3-4N0 adenocarcinoma with negative margins and
0/30 nodes involved with tumor. The patient had an uncomplicated
recovery.

\textbf{Discussion}

The association between urinary diversion with ureterosigmoidostomy and
subsequent development of rectosigmoid adenocarcinoma has been described
in the medical literature {[}4, 5{]}. Prevalence of ureterocolostomy in
the population is thought to be approximately 2 in 100,000 people, with
post diversion neoplasia occurring in 24\% of these patients at a mean
of 20 years follow up {[}3{]}.

Since the first case report by Hammer in 1929, the mechanism of this
increased risk of malignancy has remained elusive {[}6{]}. There are
varying theories regarding the etiology, including exposure of colon
mucosa to urine inciting hyperplasia, and alteration in bacterial flora
resulting in elevated nitrite compounds or elevated free oxygen species
{[}7, 8{]}. The tumor in our patient was near the site of original
anastomosis with the ureter stump still in place, suggesting that the
area was indeed exposed to urine during the 21 years that the
ureterosigmoidostomy was functional.

There is usually a latent period between creation of
ureterosigmoidostomy and cancer occurrence ranging from 6 to 55 years,
with a median of 21-33 years reported in small series {[}9{]}. Our
patient was 51 years removed from takedown of ureterosigmoidostomy and
conversion to ileal conduit and 72 years from the original
ureterosigmoidostomy as a neonate, which to our knowledge is the longest
latent period reported to date. Due to her history of
ureterosigmoidostomy, our patient should have been considered high-risk
for rectosigmoid cancer. As recommended by other authors, a reasonable
option for screening would be frequent flexible sigmoidoscopy and
screening the remainder of the colon based on standard guidelines
{[}2{]}. Although the number of patients with a history of prior
ureterosigmoidostomy is dwindling, clinicians should be aware of the
increased risk of rectosigmoid cancer in these patients and screen them
appropriately.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Stewart M. Urinary diversion and bowel cancer. Ann R Coll Surg Engl.
  1986 Mar;68(2):98-102. PMID: 3954318; PMCID: PMC2497821.
\item
  Woodhouse CR; British Society for Gastroenterology; Association of
  Coloproctology for Great Britain and Ireland. Guidelines for
  monitoring of patients with ureterosigmoidostomy. Gut. 2002 Oct;51
  Suppl 5(Suppl 5):V15-6. doi: 10.1136/gut.51.suppl\_5.v15. PMID:
  12221034; PMCID: PMC1867740.
\item
  Khan MN, Naqvi AH, Lee RE. Carcinoma of sigmoid colon following
  urinary diversion: a case report and review of literature. World J
  Surg Oncol. 2004 Jun 8;2:20. doi: 10.1186/1477-7819-2-20. PMID:
  15186498; PMCID: PMC425598.
\item
  Ragu R, Meurette G, Kim M, Le Normand L, Lehur PA. Carcinoma arising
  in enteric diversion or rectal neobladder for bladder exstrophy. Tech
  Coloproctol. 2016 Nov;20(11):745-752. doi: 10.1007/s10151-016-1519-2.
  Epub 2016 Sep 3. PMID: 27592221.
\item
  Azimuddin K, Khubchandani IT, Stasik JJ, Rosen L, Riether RD.
  Neoplasia after ureterosigmoidostomy. Dis Colon Rectum. 1999
  Dec;42(12):1632-8. doi: 10.1007/BF02236220. PMID: 10613486.
\item
  Hill MJ, Hudson MJ, Stewart M. The urinary bacterial flora in patients
  with three types of urinary tract diversion. J Med Microbiol. 1983
  May;16(2):221-6. doi: 10.1099/00222615-16-2-221. PMID: 6842572.
\item
  Chan CC, Tan A, Salman H. Colon cancer 15 years after
  ureterosigmoidostomy. J Clin Oncol. 2008 Apr 1;26(10):1755-7. doi:
  10.1200/JCO.2007.14.6126. PMID: 18375906.
\item
  Pettersson L, Tranberg J, Abrahamsson K, Pettersson S, Sillen U,
  Jonsson O. Half century of followup after ureterosigmoidostomy
  performed in early childhood. J Urol. 2013 May;189(5):1870-5. doi:
  10.1016/j.juro.2012.11.179. Epub 2012 Dec 5. PMID: 23220244.
\end{enumerate}

\textbf{Hosted file}

\verb`image1.emf`  available at \url{https://authorea.com/users/466223/articles/560579-sigmoid-colon-adenocarcinoma-at-the-site-of-prior-now-defunctionalized-ureterosigmoidostomy-for-bladder-exstrophy}

Figure 1: Ulcerated mass in the sigmoid colon.

\textbf{Hosted file}

\verb`image2.emf`  available at \url{https://authorea.com/users/466223/articles/560579-sigmoid-colon-adenocarcinoma-at-the-site-of-prior-now-defunctionalized-ureterosigmoidostomy-for-bladder-exstrophy}

Figure 2: Remnant ureteral stumps from prior ureterosigmoidostomy
(encircled with blue vessel loops) attached to sigmoid colon.

Conflict of Interests

All authors have completed the ICMJE uniform disclosure form. The
authors have no conflicts of interest to declare

Ethical Statement

All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or
national research committee(s) and with the Helsinki Declaration (as
revised in 2013).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/FIgure-1/FIgure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

