Journal of Visceral Surgery (2014) 151, 61—63
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Vesico-appendiceal fistula revealing pseudomyxoma peritonei M. Desantis ∗, J.-M. Bereder , D. Benchimol Service de Chirurgie Générale et Cancérologie Digestive, Archet 2, CHU de Nice, 151, route de Saint-Antoine-de-la-Ginestière, 06200 Nice, France Available online 23 January 2014
KEYWORDS Pseudomyxoma; Mucusuria; Appendiceal-vesical fistula; Hypothermic intraperitoneal chemotherapy; Cytoreductive surgery
Summary We report a case of grade III pseudomyxoma peritonei revealed by mucusuria and abdominal mass. These symptoms are unusual; the most frequent clinical presentation is acute appendicitis or progressively increasing abdominal diameter. © 2013 Elsevier Masson SAS. All rights reserved.
A 63-year-old man presented with dysuria and emission of mucus upon micturition of one month’s duration. The only other remarkable history was bilateral inguinal hernia repair (Lichtenstein technique) five years before. Clinical examination revealed right lower quadrant fullness, with a palpable mass. His laboratory findings were unremarkable; urinary culture was negative. Abdominal-pelvic CT scan confirmed the presence of a pelvic mass, containing liquid, in contact with the cecum and invading the bladder (Fig. 1A and B). Cystoscopy showed that the posterior wall of the bladder was bulging, erythematous, centered by a fistula, through which mucus was seen to exit. Colonoscopy was unremarkable.
∗
Corresponding author. E-mail addresses: [email protected], [email protected] (M. Desantis), [email protected] (J.-M. Bereder), [email protected] (D. Benchimol). 1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.11.002
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Figure 1. A. Abdominopelvic CT showing the pelvic mass containing liquid (L) adjacent to the cecum (C). B. Tumoral appendix presenting as intravesical tissular lesion (arrow). C. Coronal slice, tumoral appendix (arrow) with inflamed bladder wall (V).
The diagnosis of appendiceal pseudomyxoma complicated by bladder fistula was retained. The Sugarbaker pre-operative Peritoneal Cancer Index was 12 (Fig. 2A and B). The patient underwent initial surgery, including ileocecal resection, partial cystectomy, and electrovaporization of gelatinous nodules (Fig. 3). Hyperthermic intraperitoneal chemotherapy (HIPEC) using a perfusion of Mitomycin C 45 mg/m2 at 43 ◦ C over a period of 60 minutes was performed in addition to cytoreduction. The intestinal anastomosis and bladder repair were performed after HIPEC. The abdominal drains were removed on day 7; the bladder catheter was removed on day 9. Hospital stay was 11 days and postoperative recovery was unremarkable. The pathology results confirmed the diagnosis of Grade 3 appendiceal pseudomyxoma (PMP) (peritoneal mucinous carcinomatosis with signet-ring cells). No further treatment was proposed during the postoperative multidisciplinary gastrointestinal oncology meeting since cytoreduction was judged to be complete with all resection margins uninvolved, and all removed lymph nodes normal. Simple surveillance was prescribed. The patient was well 15 months postoperatively, without any remarkable findings. Initial presentation of pseudomyxoma by urinary symptomatology and in particular, an appendiculovesical fistula, is rare; 11 cases have been described in the literature [1]. On the other hand, the incidence of appendiculovesical fistula is higher in case of recurrent PMP or a past history of urological or pelvic surgery [2]. The diagnosis should be suggested when mucusuria is associated with an abdominal
Figure 2. A. Intra-operative view of the cecum (C) and appendicular pseudomyxoma (PMP). B. Intra-operative view of gelatinous masses (G) and hernia repair mesh (P).
Vesico-appendiceal fistula revealing pseudomyxoma peritonei
63 mass in the absence of intravesical or colonic lesions. The same symptomatology can be found in uracheal carcinoma but imaging should differentiate between the two. Treatment is the same as for pseudomyxoma, en bloc resection, debulking and HIPEC [3].
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Arisawa C, Takeuchi S, Wakui M. Appendiceal carcinoma invading the urinary bladder. Int J Urol 2001;8(4):196—8. [2] Smeenk RM, et al. Pseudomyxoma peritonei and the urinary tract: involvement and treatment related complications. J Surg Oncol 2006;93(1):20—3. [3] Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol 2006;7(1):69—76.
Figure 3. Open bladder (V), bladder catheter (SV), extrusion of mucus (arrow) through an appendiculovesical fistula. Tumoral appendix (A).
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL IMAGES
Vesico-appendiceal fistula revealing pseudomyxoma peritonei M. Desantis ∗, J.-M. Bereder , D. Benchimol Service de Chirurgie Générale et Cancérologie Digestive, Archet 2, CHU de Nice, 151, route de Saint-Antoine-de-la-Ginestière, 06200 Nice, France Available online 23 January 2014
KEYWORDS Pseudomyxoma; Mucusuria; Appendiceal-vesical fistula; Hypothermic intraperitoneal chemotherapy; Cytoreductive surgery
Summary We report a case of grade III pseudomyxoma peritonei revealed by mucusuria and abdominal mass. These symptoms are unusual; the most frequent clinical presentation is acute appendicitis or progressively increasing abdominal diameter. © 2013 Elsevier Masson SAS. All rights reserved.
A 63-year-old man presented with dysuria and emission of mucus upon micturition of one month’s duration. The only other remarkable history was bilateral inguinal hernia repair (Lichtenstein technique) five years before. Clinical examination revealed right lower quadrant fullness, with a palpable mass. His laboratory findings were unremarkable; urinary culture was negative. Abdominal-pelvic CT scan confirmed the presence of a pelvic mass, containing liquid, in contact with the cecum and invading the bladder (Fig. 1A and B). Cystoscopy showed that the posterior wall of the bladder was bulging, erythematous, centered by a fistula, through which mucus was seen to exit. Colonoscopy was unremarkable.
∗
Corresponding author. E-mail addresses: [email protected], [email protected] (M. Desantis), [email protected] (J.-M. Bereder), [email protected] (D. Benchimol). 1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.11.002
62
M. Desantis et al.
Figure 1. A. Abdominopelvic CT showing the pelvic mass containing liquid (L) adjacent to the cecum (C). B. Tumoral appendix presenting as intravesical tissular lesion (arrow). C. Coronal slice, tumoral appendix (arrow) with inflamed bladder wall (V).
The diagnosis of appendiceal pseudomyxoma complicated by bladder fistula was retained. The Sugarbaker pre-operative Peritoneal Cancer Index was 12 (Fig. 2A and B). The patient underwent initial surgery, including ileocecal resection, partial cystectomy, and electrovaporization of gelatinous nodules (Fig. 3). Hyperthermic intraperitoneal chemotherapy (HIPEC) using a perfusion of Mitomycin C 45 mg/m2 at 43 ◦ C over a period of 60 minutes was performed in addition to cytoreduction. The intestinal anastomosis and bladder repair were performed after HIPEC. The abdominal drains were removed on day 7; the bladder catheter was removed on day 9. Hospital stay was 11 days and postoperative recovery was unremarkable. The pathology results confirmed the diagnosis of Grade 3 appendiceal pseudomyxoma (PMP) (peritoneal mucinous carcinomatosis with signet-ring cells). No further treatment was proposed during the postoperative multidisciplinary gastrointestinal oncology meeting since cytoreduction was judged to be complete with all resection margins uninvolved, and all removed lymph nodes normal. Simple surveillance was prescribed. The patient was well 15 months postoperatively, without any remarkable findings. Initial presentation of pseudomyxoma by urinary symptomatology and in particular, an appendiculovesical fistula, is rare; 11 cases have been described in the literature [1]. On the other hand, the incidence of appendiculovesical fistula is higher in case of recurrent PMP or a past history of urological or pelvic surgery [2]. The diagnosis should be suggested when mucusuria is associated with an abdominal
Figure 2. A. Intra-operative view of the cecum (C) and appendicular pseudomyxoma (PMP). B. Intra-operative view of gelatinous masses (G) and hernia repair mesh (P).
Vesico-appendiceal fistula revealing pseudomyxoma peritonei
63 mass in the absence of intravesical or colonic lesions. The same symptomatology can be found in uracheal carcinoma but imaging should differentiate between the two. Treatment is the same as for pseudomyxoma, en bloc resection, debulking and HIPEC [3].
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Arisawa C, Takeuchi S, Wakui M. Appendiceal carcinoma invading the urinary bladder. Int J Urol 2001;8(4):196—8. [2] Smeenk RM, et al. Pseudomyxoma peritonei and the urinary tract: involvement and treatment related complications. J Surg Oncol 2006;93(1):20—3. [3] Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol 2006;7(1):69—76.
Figure 3. Open bladder (V), bladder catheter (SV), extrusion of mucus (arrow) through an appendiculovesical fistula. Tumoral appendix (A).
