Bladder tumors

Incidence. Pathological anatomy of tumors

• Bladder cancer is the most frequent cancer in the UT
• In Romania, it’s the 5th cancer as prevalence

• Primitive bladder tumors can be: epitheliasl, mesenchymal and mixed

• They can be benign or malign
Epithelial tumors can be:
1. Transitional carcinoma
2. Epidermoide
3. Adenocarcinoma undifferentiated

According to ISUP, malignant tumors can be: flat, papillary, invasive

Epithelial tumors
• Hyperplasia
- Flat hyperplasia
- Papillary hyperplasia

• Flat lesions with atypia

- Reactional atypia
- Atypical with unknown signification
- Dysplasia
- In situ carcinoma

• Papillary tumors
- Papilloma
- Reversed papilloma
- Papillary tumors with low potential of malignancy
- Papillary carcinoma with low grade anaplasia
- Papillary carcinoma with high grade anaplasia

• Infiltrative tumors
- Chorionic infiltration
- Muscle infiltration (detrusor)
Signs and symptoms
• Hematuria is the most common symptom of bladder cancer (85%)
- Pain free
Intermittent, so negative results in one or two urine testst doesn’t exclude the presenc of bladder cancer

• Pyuria is rarely present , but it indicates an infiltrative, ulcerated , necrotic tumors with associated suppuration

• Pollakiuria is not constant and is present more frequent in infiltrative tumors that lower the bladder capacity and flexibility, being
commonly associated with other bladder related symptoms . Intense night pollakiuria produces sleep deprivation , tumoral
impregnantion and anemia caused by bleeding.

• Dysuria can appear in bladder neck tumors and it can appear isolated or in combination with other signs. It can appear due to blood
clots or debris from papillary tumors that engage in the bladder neck during micturition. Bladder neck tumors or those that
obstruct the bladder necl can reproduce all of the obstructive symptoms of a prostate adenoma

• Pelvic pain suggests pelvic tumor infiltration or pelvic bones metastases. Pain appears in the pelvis, hypogastrium, rectum, penis
during micturition and spontaneously

• Tumoral cystitis is a late manifestation that results from detrusor muscle invasion, tummor suppuration, low bladder caapcity and
parieta neoplaic infiltration. It presents with hematuria and great pain

• Bone pain caused by metastasis

Local examination
• Inspection and palpation of the abdomen, especially examining the
bladder by hypogastrium palpation while performing a digital rectal
examination/ vaginal examination
• Examination done in gynecological position
• The bladder must be empty
• Revels best data when the patient is anesthesied and myorelaxed
Laboratory investigations
• Hematuria evidence, that can sometimes be associated with pyuria
that is the result of bacterial cystitis
• Renal failure in case of trigonal tumors that obstruct the ureters or in
local dvanced tumors with pelvic lymph nodes that compress the
ureters
• Anemia = the most common hematogenous finding in bone marrow
metastases
Exfoliative urinary cytology
We can obtain cells for analysis by:
1. Spontaneous eliminated urine, but NEVER from the 1st morning urine because night stagnant urine has
too many soaked cells
2. During cytoscopy
3. By bladder barbotage during cystoscopy or through a urethral catether
• Method based on direct highlighting of malignant exfoliated cells
• Fixation and coloration are based on Papaniolau technique or coloration with methylene blue
Urinary cytology can be used for:
1. Dx of UT cancer
2. Monitor patients after urothelial cancer treatment
3. Screening process for high risk population
4. Prognosis of biological potential of urothelial cancer
• Exfoliative urinary cytology sensitivity is proportional to the cell dysplasia grade
Tumoral markers
• Detected in urine samples and in a small part in the bladder mucosa
• BTA (bladder tumor antigen)
• BTA stat
• BTA track
• Immunocyt
• NMP22
Conclusion: Urinary exfoliative cytology is still the most frequently used
non-invasive test in bladder cancer diagnosis. Currently, there are no
markers or tests accurate enough to replace cytoscopy.
Imaging methods
• Bladder ultrasonography
- Can be performed abdominally, rectally, transrectally or transurethrally
- They appear as exofitic, echodense, intracavitary masses
- They are fixed on the bladder wall
- They do not change position when the patient moves
- Adjacent bladder wall looks normal

• Kidney-bladder simple Rx and IVU

- The main sign for bladder tumors is a lacunar image on the urographic cystogram
- Infiltrative tumors can modify the suppleness of the bladder wall that becomes rigid, inextensible, retracted
- Non functional kidneys are the result of solid, infiltrtive tumor invasion and obstruction of the ureters

• MRI and CT can differentiate infiltrative, organ confined tumors from infiltrative tumors that are no longer organ-confined . Both
appeciate lymph nodes with diameters bigger than 1cm (tumoral lymph nodes) and <1cm (reactive lymph nodes)

• Bone scintigraphy / radiography

• Pulmonary Rx
• Although modern imagistic methods have made progress, there is still no examination technique that can certainly differentiate
tumor stages
Endoscopic investigations
• Cytoscopy is performed under anesthesia in order to have relaxation,
comfort and to be able to fill the bladder enough
• We use different telescopes with different angulations to be able to
examine the complete surface of the urothelial field
• Flexible cytoscopes are less traumatic
• Cytoscopy completed or not by endoscopic resection allows
pelevation of randomised biopsies to detect microscopic neoplastic
lesions including in situ carcinoma
Bladder biopsy. Fluorescence
• The diagnosis of certainty is the histopathological exam of tissue prelevatd using
transurethral resection
• Only the miscroscopic exam of the tissue sample can provide neoplasm diagnosis
and staging of the disease

• Detection of bladder tumors using fluorescence

- Fluoescence can detect areas of microscopic dysplasia and their directed
biopsies followed by selective destruction of those areas
- Substances that are introduced in the bladder or IV are fixed on pathological
areas, allowing a selective fluorescence of these areas that can be highlighted
endoscopically using a xenon light
Differential diagnosis
• Proliferative urinary TB
• Bladder stones
• Benign prostate hyperplasia
• Hypertrophic cystitis
• Uretreocele
• Bladder clots
Natural evolution
• Natural evolution is defined by 2 factors:
1. Tumor relapse
2. Progression towards infiltration/metastases- this is the evolution
factor of the highest severity
Treatment of non-invasive bladder tumors

• TUR-B and cytostatic instillation in the first 6 hours +/- adjuvant treatment depending on the risk group of the tumor
- In its evolution towards infiltration, the G and T elements are most important

Transurethral resection and/or fulguration (TUR-B) is the choice method for superficial bladder tumors. (non-invasive tumors)
- It’s done after preoperatory preparation of the patient
- Radical procedure that allows the removal of the whole microscopically visible tumor and to obtain a sample for histological
examination, diagnosis and staging
- Allows the control of resection by getting biopsies from the resection areas and random biopsies from the mcroscopically-normal tissue
- Fulguration=simple coagulation of the urinary bladder tumor

Cystectomy is rarely done in non-invasive tumors of the bladder. It can be done in in situ cancer that is refractory to treatment

Adjuvant treatment- intravesical treatment

- After endoscopic resection of the primary tumor, there are 60-80% chances of relapse
- Most of relapses are new tumors
- We do it in multiple primary tumors/ multiple local relapses/ T3 tumors/T1 tumors/positive TUR-B after cytology

Instillation chemotherapy
Intravesical immunotherapy with BCG= 1st line treatment in patients with a superficial, aggressive, bladder tumors T1G3 and ICS
Patients follow-up after TUR in non-invasive
bladder tumos
• Cystoscopy
- 1st one must be made at 3 months in all cases
- In patients with low risk tumors with no relapse at 3 months, another cystoscopy is made at 9 months
later, every year for 5 years
- In case of relapse, the histology is identical to the initial one
- High risk patients : cystoscopy is made every 3 months in the first 2 years, then every 4 months in the
3rd year
- Total years of surveillance: 10-12 years

• Ultrasonography
• Cytology
• Urography
• Randomised biopsies of apparently normal mucosa
In situ carcinoma of the bladder
• Symptoms can be bladder irritative (pollakiuria, dysuria, burning sensation).
We frequently encounter secondary ICS and it can be diagnosed at the same
time as the bladder tumor
• Malignant cells can be detected in urine
• Endoscopically, it can be diffuse, solitary or associaed with dysplasia of the
bladder tumors
• ICS is a precursor of solid or papillary tumors of transitional cancer
• Untreated, it evolves in 54% of cases to infiltrative tumor
• Intravesical cytostatic work in 48% of cases
• BCG immunotherapy works in 93% of cases
Treatment of invasive bladder
tumors
• Radical cystectomy = gold standard treatment
- It’s the removal of the bladder, prostate, seminal vesicles and lymph nodes (men) and bladder, urethra,
uterus, cervix, fallopian tubes, ovaries, vagina and pelvic lymph nodes (women)
- Survival rates at 5 years decrease as the ,,T” grade is higher with a general rate of 50% of disese-free
patient for deep invasive tumor

• Partial cystectomy is the initial treatment but is not usually recommended

• Unique TUR-B- only for selected patients

• Radiotherapy

• Systemic chemotherapy if there are distant metastases. We try platinum salts