BLADDER CANCER

PRESENERS
TEOPISTA KADEFU
MASSALA S. BENJAMINI
NAIRO
SUPERVISOR
DR. AGGREY WILLIAM MD,
MMED (UROLOGY)
 TOPIC OUTLINE
• Introduction of BC
• Epidemiology
• Surgical anatomy
• Etiology
• Histological types
• Staging
• Clinical spectrum & common sites of metastasis
• Clinical features
• Diagnosis
• Management
• Complication
• Follow-up
 INTRODUCTION
• Urinary bladder cancer is an important urological malignancy, second to
prostate CA in incidence.
• It has been associated with environmental carcinogenic exposure, chronic
bladder irritation and genetic predisposition.
• More common in elderly
 EPIDEMIOLOGY
• Bladder cancer is the 11th mostly diagnosed cancer worldwide.
• Worldwide ASIR (per 100,000 persons/year) are 9.0 for men and 2.2 for
women
• In EU are 19.1 for men and 4.0 for women
• Disease of elderly mean age at dx is 70 years
• Common in males, with male: female of 3:1
• Common in whites than in African or Hispanic
 SURGICAL ANAOMY
• It is lined by transitional epithelium covering the connective tissue lamina
propria, which contains a rich plexus of vessels and lymphatics.
• •When the detrusor muscle hypertrophies, the inner layer, covered by
urothelium, stands out, resulting in the appearance of trabeculation.
• • Over the trigone is a thin layer of smooth muscle to which the epithelium
is closely adherent and which extends as a sheath around the lower ureters
and into the proximal urethra. •
• Around the male bladder neck is the smooth muscle internal sphincter
innervated by adrenergic fibres, which prevents retrograde ejaculation.
 SURGICAL AN….
 Fascial and ligamentous support of the bladder
• Posteriolateral bladder neck to join prostatic fascia
• Puboprostatic ligament
• Median and lateral umbilical ligaments
 Arterial supply
• Superior and inferior vesical arteries- anterior trunk of internal iliac artery
• Branches from uterine and vaginal arteries in women
Venous drainage
• Forms plexus (in male continuous with prostatic plexus) to drain in the internal iliac vein
 SURGICAL AN….
 Lymphatic drainage
• Drain into internal iliac vessel then to the obturator and external iliac chain
• Hypogastric nodes
 Nervous supply
• Parasympathetic S2 and S3
• Sympathetic T11&12 also from L1&L2
• Somatic innervation pudendal nerve
 ETIOLOGY
• Tobacco smoking 50%
• Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons, chlorinated
hydrocarbons 10% e.g. industrial plants which process paints, dyes, metal and petroleum
products
• Schistosoma hematobium infestation- (commonly in tropical areas)
• Chronic bladder irritation- catheter, bladder stones or paraplegia
• Drugs e.g. cyclophosphamide, phenacetin
• Chronic non specific cystitis- e.g. cystitis cystica and cystitis glandularis
• Congenital malformations e.g. extrophy of bladder and persistent urachus
• Chlorinated tap water
 ETIOLOGY CONT…
• Genetically predisposition – inactivation of tumor suppressor genes such as p53, p21,
p16 and retinoblastoma gene.
 Others
• Arsenic
• Low fluid intake
• HPV infections
• Hx of upper urinary tract cancers
• Bladder augmentation
• Radiation therapy
 HISTOLOGICAL TYPES
• Transitional cell carcinoma (TCC) 93%
-Common type in developed world ass/w industrial chemicals
• Squamous cell carcinoma (SCC)
- Ass/w schistosomiasis and chronic irritation
• Adernocarcinama
-Ass/w urachus, extrophy bladder and secondary tumor
• Small cell carcinoma
• Rhambdomyosarcoma
• Lymphoma
 STAGING
• TNM classification
• WHO histological classification for flat lesion
STAGING….
STAGING…
 CLINICAL SPECTRUM
&
COMMON METS SITES
 C. Spectrum
• Non muscle invasive bladder cancer (NMIBC)
• Muscle invasive bladder cancer (MIBC)
• Metastatic carcinomas
Common sites for metastasis
• Liver
• Lung
• Bones
• Adrenal glands &
• Intestine
 CLINICAL FEATURES
• Painless haematuria
• Pain – locally advanced or metastatic tumor eg flank pain, suprapubic
pain, hypogastric, rectal or perineal pain, abdominal pain, bone pain or
persistence headache
• Irritative voiding symptoms eg frequency, urgency or dysuria
• Obstructive voiding symptoms eg straining, intermittent stream, nocturia,
decrease force of stream and incomplete voiding
• General symptoms eg fatigue, weight loss, anorexia
 DIAGNOSIS
• Comprehensive patient history
• Physical exam
-a focused urological exam
• Bimanual examination under anaesthesia (EUA)
 DX…
Investigations
 Lab
• FBP HB
• Urinalysis RBC,WBC
• Urinary cytology
• Serum creatinine and BUN
• Liver enzymes
• Cystoscopy and TURBT –histology
 Imaging
To asses extravesical spread and pelvic lymph node
• Abdominopelvic uss
• Chest x-ray
• CT scan
• MRI
 MANAGEMENT
 Treatment depends on stage and histological type of cancer.
• endoscopic control,
• intravesical therapy,
• systemic chemotherapy,
• radiation therapy
• and radical procedures.
 MGX…
Endoscopic:
• Transurethral resection (TURBT) and surveillance
• Intravesical chemotherapy or immunotherapy if high grade tumour or frequent recurrence.
• Only for TCC, superficial cancer (Ta, T1)
• Surveillance (check cystoscopy) 3,6,9,12 months
Segmental resection:
• Single lesion and far from trigon
Total cystectomy and urine diversion.
• Muscle invasive tumour.
• Superficial, but failed conservative treatment.
• All Schistosomiasis related tumours.
 MGX…
Intravesical chemotherapy/immunotherpy:
• Carcinoma in-situ.
• Adjuvant treatment
• Thiotepa, Mitomycine, Doxorubicine, BCG.
Radiotherapy:
• Definitive treatment for muscle invasive, in patients unfit for cystectomy
• Adjuvant treatment.
• Palliation of pain and bleeding.
Chemotherapy:
• Poor response.
• Neoadjuvant treatment and adjuvant.
• Drugs- M-VAC (methotrexate, vinblastine, doxorubicine, and ciplatin) in combination.
 COMPLICATIONS OF B.CA
• Anemia
• Hydronephrosis
• Urinary incontinence
• Surgical complications
• Chemo-radiotherapy compliacatin
 FOLLOWUP
• Regular check cystoscopy.
• Urine cytology.
• Abdominal USS
• Chest x-ray
• Problems of urine diversions(Colonoscopy etc)
• CT Scan?
 REFERENCE
• EAU-Guideline on NMIBC-2019
• Schistosomiasis and urinary bladder cancer in North Western Tanzania a
retrospective review by Philipo L Chalya et el
• Bailey and Love – Short practice of Surgery 26th ED
• Smith’s General Urology 17th ED
• Up to date
 NK S
TH A