Urinary Bladder neoplasm

Dr Rikesh Jung Karkee

Assitant Professor
Urology Division
Surgery department
 Introduction
• 95% originates from transitional epithelium

• Remainder from connective tissue (Angioma, Fibroma, Myoma, Sarcoma) or

are etxra adrenal phaeocromocytoma

• Secondaries from neighbouring organs

Histological types

• Urothelial in origin- 90%

• Adenocarcinoma- 1-2% (from Urachal remanant or glandular metaplasia)

• Mixed

• Squamous- 5% ( Bilharzia is endemic)

Aetiology

• Cigarette smoking- 40%

• Occupational exposure to urothelial carcinogens

• Rehn 1895 Chemical cause, workers in aniline dye factory

 Carcinogenic compounds

• 2- napthylamine • O-toluidine

• 4- Aminobiphenyl • 4,4`-methylene bis

• Benzidine • Methylene dianiline

• Chlornaphazine • Benzidine-derived azo dyes

• 4-Chloro-o-toluidine
 Occupation

• Textile Workers • Painters

• Dye workers • Hair dressers

• Tyre rubber and cable workers • Lorry drivers drill press operators

• Petrol workers • Chemical workers

• Leather workers • Rodent exterminators and sewage

• Shoe manufacturers and cleaners workers

• Genetic polymorphisms for N-acetyletransferase(NAT 2), glutathione S-
trasferase MU1 , cytochrome P450(CYP2D6) increases the risk

• S. Haematobium endemic- Squamous cell

Staging of primary bladder cancer tumors (T)
T XPrimary tumor cannot be assessed
T 0 no evidence of primary tumor
Ta Noninvasive papillary tumor (confined to urothelium)
Tis CIS Carcinoma (high grade "flat tumor" confined to urothelium)
T1 Tumor invades lamina propria
T2 Tumor invades bladder muscle
T2a: Invades superficial bladder muscle
T2b: Invades deep bladder muscle
T3 Tumor invades perivesical fat
T3a: Microscopic perivesical fat invasion
T3b: Macroscopic perivesical fat invasion (and beyond bladder)
T4 Tumor invades prostate, uterus, vagina, pelvic wall or abdominal wall
T4a: Invades adjacent organs (uterus, ovaries, prostate)
T4b: Invades pelvic wall and/or abdominal wall
Staging of primary bladder cancer tumors (N,M)
Regional Lymph Nodes (N)*
NX Lymph nodes cannot be assessed
N0 No lymph node metastasis
N1 Single regional lymph node metastasis in the true pelvis (Hypogastric, Obturator,
External iliac, or Presacral lymph node).
N2 Multiple regional lymph node metastasis in the true pelvic (Hypogastric, Obturator,
External iliac, or Presacral lymph node metastasis).
N3 Lymph node metastasis to the common iliac lymph nodes.
Distant Metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
World Health Organization/ International Society of
Urologic Pathologists
• Urothelial papilloma

• Papillary urothelial neoplasm of low malignant potential (PUNLMP)

• Low grade papillary urothelial carcinoma

• High grade papillary urothelial carcinoma

Non muscle invasive(superficial)( pTa, pT1)
• pTa and pT1- 70%

• pTa - No invasion of lamina propria

• pT1- invasion of lamina propria

• Papillary tumours Grows in exophytic Fashion

• Common Sites- Trigone and Lateral walls

• May be single or multiple

• Pedunculated stalk with narrow base

solid with wider base- less well differentiated
Non muscle invasive(superficial)( pTa, pT1) contd..
• Mucosa may be oedematous or angry looking, dilated blood vessels

• Oedematous and velvety urothelium suggests “Field Change”- Carcinoma in situ

• After initial complete by TURT

-50–70% develop recurrent tumours that may be single or multiple
-15% will develop a recurrent tumour that invades the bladder muscle
Increased recurrence and progression

• High grade

• pT1 disease

• Concomitant CIS

• Multiple primary tumours

• Recurrent disease at the first check cystoscopy three months after diagnosis

Rationale for performing check cystoscopies

Muscle Invasive

• Muscle invasion is always solid

• Large with broad base, irregular, Ugly, sometimes ulcerated

• Metastasis through Lymphatic, blood- Lung, liver, bones are common and will
be the cause of death in 30-50%
In situ carcinoma
The histological appearance of irregularly arranged cells with large nuclei and
high mitotic index replacing the normally well ordered urothelium

1. Primary -Alone

2. Concomitant -association with new

3. Secondary -Previously had tumour

• Dysuria , supra-pubic pain and frequency (Malignant cystitis)

• In situ carcinoma with papillary tumours increases the chances of recurrence

and progression
Pure squamous cell carcinoma

• Solid and always associated with muscle invasive

• Bilharzia -endemic

• Chronic irritation caused by Stones -Metaplasia

Pure Adenocarcinma

• Accounts for 1–2%

• Urachal remanant- fundus of the bladder

• Primary - Glandular metaplasia

Clinical Features

• Painless haematuria, clot formation and urine retention

• Recurrent urinary tract infection

• Constant pain in the pelvis (Extra vesicle spread)

• Frequency and dysuria

• Pain in the loin or pyelonephritis -Ureteric obstruction and hydronephrosis

• Pain Suprapubic region, groin, Perineum, anus, thighs –Nerve involvement

Investigations

Urine

• Cytology—Malignant Cell

• New tests antigen based- Nuclear matrix protien (NMP22)or

minichromosome maintenance (MCM)
Investigations contd..
Blood-
• Hb%, Urea, Serum electrolyte

IVU, CT, magnetic resonance -

• Faint shadow Encrusted neoplasm of bladder

• Filling defect- most common finding

• Irregularity bladder wall

• Hydronephrosis
 Investigations contd..

USG

• If Kidney is non functioning

• Bladder tumour

• Clot

• Stone
Investigations contd..

Urethrocystoscopy

• Mainstay of diagnosis

• Rigid –GA

• Flexible-Local
Bimanual Examination

• Relaxed under GA- Before and after endoscopic surgical treatment

• Bladder should be emptied

• Rt index finger in the rectum in male and vagina in female, Four fingers of Lt
hand push down Ant abd wall in the suprapubic region
Findings

• Superficial fronded tumour—soft mobile thickening prior to resection

• Superficial tumours usually not felt after surgery

• Mass felt after surgery- T3

• Mass felt Fixed- T4a Prostate ,Vagina T4b lateral pelvic wall
Treatment

Non-Invasive tumours
Endoscopic surgery

• Resected in layers with resectoscope

• Further loops of tissues from base of the tumour is resected separately for
HPE –Lamina propria or muscle, then base is coagulated for haemostasis
• Small biopsies –From near and far from primary for unsuspected CIS

• Pale yellow, glistening fat –Perforated bladder, Stop the resection and place the
catheter procedure is completed after 2 wks

• Bimanual examination is done after resection

• Solid tumour should have enough tissue for histological staging and grading

• Debulking resection helpful prior radiotherapy

Following procedure

• Irrigating catheter for 48hours to prevent clot retention

• Single Dose Mitomycin C instilled 40mg in 60 ml fluid prior catheter removal

decreases recurrence in pTa and pT1 grade 1 and 2
Follow up

pTa

• Single Low or medium grade pTa Tumours resection alone with single

instillation of mitomycin-c with regular follow up with cystoscopies

• Multiple low or medium grade pTa resection alone or resection followed by 6

wks course of intravesical Mitomycin C, doxirubicin, or epirubicin

pT1

• Resection and repeat cystoscopy and re-resection of base after 6wks

• North American or Europian urologist pT1G3

-immediate cystectomy for multiple high grade accompanied by CIS-30% to

40% risk of progression to muscle invasive
-Or Intravesicle immunotherapy with BCG—Decreases risk of progression
Follow up

• Follow up with cystoscopies every 3 months for 1 year then 6 monthly for next
1 year

• 30% will not recur - after 2 years annual cystoscopies examination

Intravesical chemotherapy and Immunotherapy(BCG)

• Mitomycin C, Epirubicin, Doxirubicin

-by Urethral Catheter held for 1 Hour turned side to side each fifteen minutes
and patient is told to hold urine for 1hr

-Weekly for 6 wks

• Thiotepa –Low molecular weight cause blood dyscariasis

• BCG weekly for 6 wks followed by a gap period of 6 weeks where no BCG is given

• live attenuated strain of Mycobacterium bovis

• Maintenance therapy: 3 instillations once a week at 3- to 6-month intervals for 3

years following TUR

Side effects- Systemic BCGosis, Cystitis like symptoms,dysuria and urinary

frequency, Haematuria
Open surgery

• Open surgery for tumour should be avoided

• Entered bladder containing tumour is removed with diathermy needle and

base coagulated bladder closed

• Post-op radiotherapy
Musle Invasive tumours

• Primary surgical treatment

• Cisplatin, methotrexate, doxorubicin and vinblastine (M-VAC) or cisplatin plus

gemcitabine given before (neoadjuvant) radical cystectomy

• Improves survival by 5–7%

Radiotherapy

• External beam X ray therapy

• Radical radiotherapy 60Gy 4 to 6 wks –response rate 40 to 50 %

• Residual after radiotherapy –salvage cystectomy

• Complications-urinary frequency and diarrhoea

Local radiotherapy

• Small invasive lesion

• Open placement of a radio active tantalum wire (182Ta)

or Iridium wire or implantation of gold grains (198 Au)

Surgery

1. Partial Cystectomy

• Small Adeno carcinoma

2. Radical cystectomy and Pelvic Lymphadenectomy

• PT2 and PT3 with out secondaries

• CIS which has not responded to BCG

Radical cystectomy includes removal of the

• Urinary bladder

• Perivesical tissues

• Prostate, and seminal vesicles in men

• Uterus, tubes, ovaries, anterior vaginal wall, and urethra in women

• May or may not be accompanied by pelvic lymph node dissection.

Counselling

• Male- Impotence and absent ejaculation

• Female- Loss of ovarian and uterine function

• Urinary diversion –continent urinary diversion, orthotopic bladder

replacement

• Stoma care therapist

• Mortality with cystectomy <2%

• Late complication: urethral recurrence 5%-8%

Internal and External Urinary diversion

Indications
1. Temporary to relieve distal obstruction
2. Permanent

-Bladder removal

-Loss of neurological control

-Incurable fistula

-Irremovable obstruction
Methods

Temporary

1. Urinary catheter, eg… silicon catheter for three months

2. Suprapubic Catheter

3. Uretral bostruction can be relieved by placement Internal DJ ureteric stents

can be placed for 4- 5 months changed every 3 months

4. Nephrostomy tube
Permanent Urinary Diversion

1. External Diversion

Ileal conduit
2. Internal Urinary diversion

• Colon and Rectum

• Bladder Reconstruction- ileum, ileum and caecum or sigmoid colon

• Continent urinary diversion-invaginated loop of ileum supported by

three rows of staples (Kock pouch) or from the appendix, buried
in an anti-reflux manner in a submucosal tube

• Bladder substitution and augmentation

Complications after urinary diversion, bladder
substitution
Early complications Late complications
• Bleeding • Metabolic disorders

• Intestinal obstruction • Stomal stenosis

• Urinary extravasation • Pyelonephritis

• infection • calculi
Metabolic complications depends upon the bowel loop used

• In jejunal loop conduit hypochloraemic, hyperkalamic metabolic acidosis

• In ureterosigmoidestomy hyperchloremic acidosis with potassium depletion

due to diarrhea

• Fat malabsorption and steatorrhea, Vit A ,D deficiency, Vit B12 deficiency

• Mild acidosis over a long duration can cause osteomalacia bone pain and even
pathological fracture

• Stoma site infection , irritation

• Pyelonephritis due to ascending infection and ureteric reflux

• Calculi occurs in 8%of patient undergoing urinary diversion

• Risk of malignancy
Thank you