Bladder tumors - Surgery Flashcards
Risk factors of bladder tumors (B)
A)Smoking: Smoking has been reported as a major risk factor for bladder cancer. Smokers have four times the risk of bladder cancer than nonsmokers, as the carcinogens excreted by the kidneys. Urine containing carcinogens get in contact with bladder mucosa for potentially long time.
B) Industrial toxins e.g. beta-naphthylamines, and hair dyes
C)Bilharzial infestation: Bilharzial ova provoke an intense inflammatory reaction, and induce genetic mutations or promote the production of carcinogens.
Pathologic types of bladder tumors (A++)
- Transitional cell carcinoma (TCC) (95%): The commonest urothelial tumor.
- Squamous cell carcinoma (SCC) (4%):
Non-Bilharzial SCC cases are usually associated with chronic infection, vesical stones, or bladder diverticula.
Bilharzial SCC is predominantly found in regions where schistosomiasis is endemic, such as in the Middle East, Southeast Asia, and South America.
In Egypt, due to successful bilharzial control and presence of industrial pollutions, there is change of pathologic pattern, as SCC was highly predominant in the past, but nowadays SCC represents < 5 % of cases. - Adenocarcinoma (1%): It is classically associated with bladder exstrophy and a persistent urachus.
Stages of bladder tumors (A++)
Non-Muscle invasive tumors:
- Tis: Carcinoma in situ (flat)
- Ta: Noninvasive papillary carcinoma
- T1: Tumor invades into sub epithelial tissue
Muscle invasive tumors:
- T2: Tumor Invades muscle
- T3: tumor Invades perivesical fat
- T4: Tumor invades adjacent organs.
Clinical features of bladder tumor (B)
- Hematuria: Gross painless hematuria is present in over 80% of patients with bladder cancer.
- Irritative Voiding symptoms: Frequency, Urgency, Nocturia
- Necroturia: Passage of white or red pieces of necrotic tissue with urine specially occurred with squamous cell carcinoma.
Investigations used in bladder tumor (B)
A. Laboratory investigations:
Urinary cytology: a non-invasive method to detect malignant cells in urine but it has low sensitivity in low-grade tumors.
B. Imaging:
1. Ultrasonography: Shows mass inseparable from UB wall with internal
vascularity on color Doppler
2. CT:
Ct is the modality of choice in assessment of bladder carcinomas. Also, it is essential for staging of bladder tumors. Bladder tumors appear as either focal regions of thickening of the bladder wall, or as masses protruding into the bladder lumen or in advanced cases, extending into adjacent tissues.
3. MRI
MRI has been shown to allow more accurate staging of bladder carcinomas than CT because of its high soft-tissue contrast resolution, which allows clear differentiation between bladder wall layers. In addition, MR imaging has the advantage of involving no ionizing radiation.
C. Special investigations:
Cystoscopy is the primary modality for the diagnosis of bladder tumor, it permits biopsy and complete resection of small tumors
Treatment of bladder tumors (A++)
Treatment of Non-muscle invasive bladder cancer (Ta, T1, CIS):
- Complete Trans-Urethral Resection of the Bladder Tumor (TUR-BT)
- Intravesical instillation of BCG course: BCG is a live attenuated TB vaccine. When the vaccine instilled into the bladder, it attracts the immune cells, which then attack the malignant cells. It reduces the risk of recurrence and progression.
- Radical cystectomy is considered for recurrent high-risk cases.
Treatment of muscle invasive bladder cancer (≥T2):
- Operable cases: Neo-adjuvant (preoperative) chemotherapy and radical cystectomy and urinary diversion.
- Inoperable cases: pain management and palliative therapy.
Types of urinary Diversion after cystectomy
A. Non-Continent Diversions:
- Uretero- cutaneous diversion.
- Ileal conduit.
B. Continent Diversions: continence depends on:
- Anal sphincter: Ureterosigmoidostomy.
- Urethral sphincter: Orthotopic bladder substitution.
- Constructed valve: Continent reservoir with abdominal stoma for
Clean Intermittent self-Catheterization (CIC).
