Confocal Laser Endomicroscopy and Chromoendoscopy - A New Option of Surveillance in Patients with Ureterosigmoidostomy or Rectosigmoid Pouch

Abstract

Purpose In patients with bladder exstrophy-epispadias-complex (BEEC) or in selected patients with bladder loss for other reasons, ureterosigmoidostomy (USIG) & rectosigmoid pouch (Mainz Pouch (MZP) II) has been used at our institution. This diversion carries a lifelong risk for secondary malignancies. Therefore annual colonoscopy is recommended. Identification of potentially malignant structures can be challenging, and biopsies are taken in doubt, with the risk of injuring the ureterocolic implantation site. Using confocal laser endomicroscopy (CLE) and chromoendoscopy, the uretero-intestinal anastomosis is better visualized compared to conventional colonoscopy, and target biopsies could be taken to exclude malignancy. In this study we analyzed the feasibility and accuracy using the new technique in these patients for the first time. Material and Methods Over the last 3 years endomicroscopy and chromoendoscopy was used in patients with USIG or MZP II for surveillance colonoscopy. A high resolution coloscop (Hi-Line, Pentax, Japan) was used to identify ureteral orifices or other lesions. Chromoendoscopy using 0.1% Methylene blue spray was used to recognize macroscopically abnormal mucosal areas. The CLE allows a high magnification (1000x) and in-vivo imaging of deeper parts of the mucosal layer - up to 250μm. Results Endomicroscopy was performed in 68 patients (BEEC n=48, traumatic incontinence/tumor n=20). A total of 156 lesions with average size of 0.9 cm were identified by chromoendoscopy and CLE, verified by histology (9 Adenoma, 25 inflammatory changes, 122 hyperplasia). Prediction accuracy with chromoendoscopy was 94%, and with CLE 98%. Conclusions The newly developed high-resolution chromoendoscopy and endomicroscopy was used for the first time for surveillance sigmoidoscopy in patients with USIG or MZPII. Chromoendoscopy allows targeting biopsies; CLE has the advantage of accurate prediction concerning the malignant potential of the lesion. Allowing a unique visualisation at detailed cellular architecture, unnecessary biopsies can be avoided, reducing the risk of injuries of the ureteral implantation site.