72-Year-Old Woman with Urinary Hesitancy and Pelvic Pain

CASE SCENARIO We are pleased to introduce a new feature to Reviews in Urology: the “Case Scenario" section. In each issue, a brief case report will be presented, followed by multiple management options. After reviewing the case, readers will make their selection regarding case management by faxing, e-mailing, or voting online at www.medreviews.com. The distribution of responses will be summarized in the next issue of the journal, along with a discussion by one of our editors of the various management options and the editor’s choice as to the best of these. 72-Year-Old Woman with Urinary Hesitancy and Pelvic Pain Tracy Cannon, MD, Wendy Leng, MD, Michael B. Chancellor, MD Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA [Rev Urol. 2002;4(4):188–191] © 2002 MedReviews, LLC CASE REPORT 72-year-old woman presents with a 4-month history of voiding symptoms after a tension-free vaginal tape (TVT) sling operation. The patient had a 3-year history of progressively worsening stress urinary incontinence. She underwent a vaginal hysterectomy and Kelly plication 15 years ago. The TVT sling was reportedly performed without complication at an outside hospital. The operative report stated that the procedure was performed under general anesthesia. Post-operatively, she was in urinary retention and was initially managed with an indwelling urethral catheter for 1 week, followed by intermittent catheterization for 1 month. Her past medical history was significant for a mild stroke without significant neurological deficit. A Currently, she reports pain in the right side of her vagina that radiates to the right side of her pubic symphysis area and into the right side of her rectum. She has had four urinary tract infections since the sling operation. Other urological symptoms include urgency, frequency, nocturia (4 times per night), and inability to void sitting down. She had a normal urinalysis and culture. An initial history and physical examination were performed, with subsequent cystoscopy and video-urodynamic studies. Pelvic examination and cystoscopy revealed no foreign body in the bladder or urethra. There appeared to be an 80-degree angulation in the mid-urethra. Urodynamic study revealed an involuntary detrusor contraction at 200 mL with voiding pressure of 38 cm H2O and a maximum flow of 12 mL/sec. MANAGEMENT OPTIONS Select one: ❑ 1. -blocker ❑ 2. Oxybutynin ❑ 3. Urethral dilation/traction ❑ 4. Transvaginal urethrolysis ❑ 5. Pelvic floor biofeedback ❑ 6. Sacral nerve neuromodulation 188 VOL. 4 NO. 4 2002 REVIEWS IN UROLOGY ✁ Vote online at www.medreviews.com; fax your selection to MedReviews at (212) 971-4047, or send an e-mail message with your selection to dgern@medreviews.com. Selections will be tabulated and presented in the next issue of Reviews in Urology. Case Scenario Discussion of Last Issue’s Case Scenario IN THE LAST ISSUE, DRS. ARIE S. BELLDEGRUN, JEFF A. WIEDER, A 69-year-old male presented to his local urologist complaining of a painless mass in the upper left scrotum that progressively enlarged over 3 months. He was otherwise asymptomatic. Examination of the external genitalia revealed a 3-cm, non-tender, mobile, firm, nodular mass in the left spermatic cord several centimeters above the testicle. Overlying skin changes and inguinal hernia were absent. The rest of the physical examination (including testicles, scrotum, penis, and abdomen) was normal. Scrotal ultrasound revealed a 3-cm, solid, left spermatic cord mass THESE ❑ ❑ ❑ ❑ AND COLLEAGUES PRESENTED THIS CASE REPORT: separate from the left testicle and normal testicles bilaterally. Abdominal/pelvic computerized tomography (CT) showed a solid enhancing mass in the left spermatic cord (consistent with the ultrasound findings), but no evidence of metastasis or lymphadenopathy. Chest x-ray, urinalysis, blood count, liver function tests, electrolytes, and creatinine were normal. Left radical inguinal orchiectomy revealed both high and low grade liposarcoma with cancer at the lateral and proximal surgical margin. The patient has been referred to you for further evaluation. WERE THE MANAGEMENT OPTIONS OFFERED: ❑ 5. Retroperitoneal lymph node dissection (RPLND) ❑ 6. RPLND and wide excision of left groin (including 1. Surveillance 2. External beam radiation (XRT) to left groin 3. Wide excision of left groin (including excision of scar) 4. Wide excision of left groin (including excision of scar) and adjuvant XRT to left groin excision of scar) ❑ 7. RPLND and wide excision of left groin (including excision of scar) and adjuvant XRT AUTHOR’S DISCUSSION Soft tissue sarcoma is a general classification that includes liposarcoma, leiomyosarcoma, fibrosarcoma, rhabdomyosarcoma, and malignant fibrous histiocytoma. They can occur anywhere in the body. After treatment, both high- and low-grade sarcomas tend to recur locally. Distant metastases, which may occur through the lymphatics or bloodstream, have been reported in the lung, liver, bone, and lymph nodes. Spermatic cord sarcoma may metastasize to the pelvic or retroperitoneal nodes. The following discussion will be limited to nonmetastatic spermatic cord sarcoma. As with sarcomas in other locations, spermatic cord sarcoma has a high local recurrence rate (up to 50%) when resection is the only treatment.1 Even when surgical margins are negative, up to 27% of cases will recur locally despite initial “complete resection."2 Thus, local wide re-excision (including the scar from the initial resection) is often recommended. Two randomized prospective studies of extremity sarcoma showed that complete excision followed by adjuvant radiation results in significantly fewer local recurrences than surgery alone.3,4 However, adjuvant radi- ation does not influence disease-free3 or overall survival.4 After local treatment of soft tissue sarcoma, doxorubicinbased systemic chemotherapy may decrease recurrence (both local and distant) and improve overall survival (based on a meta-analysis of 1568 patients5 and a recent randomized trial6). Neither local radiation nor chemotherapy have been studied extensively in spermatic cord sarcoma because of the paucity of cases; however, the existing data suggest that local treatment of cord sarcoma should be similar to local treatment of primary sarcoma in other locations.1 In summary, local wide re-excision (including the scar from the initial resection) and adjuvant local radiation is recommended to reduce local recurrence. In nonmetastatic cord sarcoma, chemotherapy after local treatment is controversial, but seems to reduce recurrence and improve survival. The role of retroperitoneal lymph node dissection (RPLND) is controversial. In a report of 101 cases of spermatic cord sarcoma diagnosed from 1883–1964, Banowsky and Shultz reported that 17% had retroperitoneal metastasis as the only site of relapse.7 Therefore, they recommended RPLND. VOL. 4 NO. 4 2002 REVIEWS IN UROLOGY 189 Case Scenario continued Figure 1. Diagram of the skin incision for the excision of the previous scar (double solid line), inguinal canal, and remaining spermatic cord. The dotted line outlines the entire skin incision. The solid, single line shows the initial part of the incision used for high ligation of the spermatic cord. Figure 2. Gross pathology of tissue resected from the inguinal region. This view shows deep intra-abdominal surface. The solid white line outlines the inguinal canal. The course of the spermatic vessels (blue arrows) and the vas (yellow arrows) are shown as they enter the internal inguinal ring. After the specimen was excised, an incision was made into the inguinal canal (represented by the dotted green line). The flap of tissue created by this incision was flipped up (in the direction of the green arrow) to reveal the tumor (red arrow) in the distal inguinal canal. However, recent data (from 1956–1998) reveals that recurrence only in the retroperitoneal nodes occurs in 2% (1/46) of cases.1,2 This decline may be caused by more accurate staging with modern imaging and improved local therapy. Thus, current data suggests that prophylactic RPLND is probably unnecessary if the retroperitoneal nodes are normal on imaging studies.1 In the present case, the patient underwent wide local re-excision of the left scrotum, groin, inguinal region, and previous scar (Figure 1). The initial incision was made near the left anterior superior iliac spine. Early ligation of the cord was accomplished by entering the retroperitoneal space and ligating the vas deferens and spermatic vessels several centimeters proximal to the internal inguinal ring. The scrotum, anterior abdominal wall down to the pubic bone, and all components of the inguinal canal (except the ilioinguinal ligament) were excised. The defect in the abdominal wall was closed by suturing the conjoined tendon to the ilioinguinal ligament (similar to a hernia repair) and by reinforcing the closure with mesh. The scrotum was closed primarily. The gross pathology is shown in Figure 2. The pathology of the re-excision showed a 3-cm low-grade liposarcoma in the region of the external inguinal ring and negative margins (Figures 3 and 4). The patient recovered from surgery and underwent external beam radiation (XRT) to the left inguinal area. The best initial management option for this patient was #4 (wide excision of left groin including excision of scar and adjuvant XRT). This patient chose to undergo doxorubicin-based systemic chemotherapy after surgery and XRT because recent evidence 190 VOL. 4 NO. 4 2002 REVIEWS IN UROLOGY seemed to show that this combination improves survival. He completed his treatments a few months ago and is without recurrence. Figure 3. Microscopic pathology showing the high-grade component of the liposarcoma. Figure 4. Microscopic pathology showing the low-grade component of the liposarcoma. Case Scenario References 1. 2. 3. 4. Ballo MT, Zagars GK, Pisters PWT, et al. Spermatic cord sarcoma: outcome patterns of failure and management. J Urol. 2001;166:1306–1310. Catton C, Jewett M, O’Sullivan B, et al. Paratesticular sarcoma: failure patterns after definitive local treatment. J Urol. 1999;161:1844–1847. Pisters PW, Harrison LB, Leung DH, et al. Long terms results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol. 1996;14:859. Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the 5. 6. 7. extremity. J Clin Oncol. 1998;16:197–203. Sarcoma Meta-Analysis Collaboration. Adjuvant chemotherapy for localised resectable soft-tissue sarcoma of adults: meta-analysis of individual data. Lancet. 1997;350:1647–1654. Frustaci S, Gherlinzoni F, De Paoli A, et al. Adjuvant chemotherapy for adult soft tissue sarcoma of the extremities and girdles: results of the Italian randomized cooperative trial. J Clin Oncol. 2001;19:1238–1247. Banowsky LH, Shultz GN. Sarcoma of the spermatic cord and tunics: review of the literature, case report, and discussion of the role of retroperitoneal lymph node dissection. J Urol. 1970;103:628–631. VOL. 4 NO. 4 2002 REVIEWS IN UROLOGY 191