8. Tumors of the ureter and muscle invasive bladder cancer; Extracorporal shock wave lithotripsy

Question 1

Tumors of the ureter

Answer 1

Etiology is similar to bladder cancer. The most common location is in the lower part of the ureter.

Most common symptom is gross or microscopic hematuria.

Flank pain and acute colic pain (due to passing of blood clots) can also occur.

• Iron and aluminum processing
• Industrial painting - analine dyes
• Smoking
• Previous chronic infection
• Schistosoma haematobium
• Cyclophosphamide chemotherapy
- Phenacetin

A retrograde urography can show filling defects. Also check the urine for cytology.

To confirm the diagnosis do a biopsy with ureteroscopy.

Treatment: Radical nephron-ureterectomy (remove kidney and ureter)

Question 2

Muscle invasive bladder cancer

Answer 2

T2 and beyond
• T2: Invades detrusor muscle
• T3: Invades perivesical fat
• T4: Invades prostate, uterus, vagina, abdominal wall

Treatment: Radical cystectomy is the treatment of choice.
The bladder, seminal vesicle, prostate, adnexa (fallopian and ovaries), uterus and lymph nodes.

Alternatives: Radiotherapy
Neo-adjuvant chemo: prior to excision. MTX, vinblastine, cisplatin

Urinary diversion must be performed after cystectomy:
• Ileal conduit (stomy): Has the least complications, continuous flow into a bag.

• Continent pouch (valved stomy which is drained by patient)
• Ureterosigmoidostomy: Urine comes out of the anus
• Bladder reconstruction with bowels

NB: Due to reabsorption of urine, acidotic episodes can occur. Give oral alkalizing agents.

Neoadjuvant chemotherapy can also be done: Methotrexate, vinblastine, cisplastin

Question 3

Extracorporal shock wave lithotripsy

Answer 3

ESWL uses shock waves to break a kidney stone into small pieces that can more easily pass through the urinary tract.

The patient lies on a water-filled cushion and the surgeon uses US to precisely locate the stone. High-energy sound waves pass through the body without injuring it and breaks the stone into small pieces. The procedure takes 1 hour.

Used for stones that are between 4mm – 2cm in diameter that causes pain and obstruction.

Contraindicated in pregnancy, malignancy, bleeding disorder, abnormal kidney structure/function.