Urinary Tract Carcinoma: Diagnosis, Treatment, and Management

Posted on Apr 30, 2024 in Biology

UROTELIAL BLADDER TUMORS. CARCINOMA OF THE UPPER AND LOWER URINARY TRACT

INTRODUCTION

This document discusses tumors that originate in the urothelium, also known as the transitional epithelium, which lines the entire excretory tract. The lower excretory tract is most frequently affected by neoplasms, with tobacco being a major etiological factor. Bladder cancer is the second most frequent urological malignancy, more common in males between 60-70 years of age.

CARCINOMA OF THE LOWER URINARY TRACT OR BLADDER

Risk Factors for Urinary Tract Carcinomas

Smoking: The risk increases with greater consumption and exposure to secondhand smoke. Other risk factors include exposure to non-aromatic amines (e.g., 2-naphthylamine), artificial sweeteners (saccharin, cyclamate), cyclophosphamide, slow acetylators, and others.

Diagnosis

Clinical Presentation: Hematuria is the most frequent clinical symptom, present in 75% of patients. It can be macroscopic or microscopic. It is crucial to always rule out a urothelial tumor. Irritative symptoms (burning, pollakiuria, tenesmus) may occur alone or accompany hematuria. Unjustified cystitis-like symptoms without infection or stones should raise suspicion of bladder carcinoma due to its association with carcinoma in situ. Flank pain due to ureteral obstruction, pelvic pain, or lower limb edema may also be present.

Investigations:

  • Abdominal Ultrasound: Useful for differentiating upper urinary tract neoplasms.
  • Cytology: Performed in all cases, but only valuable if positive.
  • Cystoscopy: Performed if there is doubt after the above tests.
  • Intravenous Urography: Used to explore the upper excretory tract.
  • Ascending Pyelogram: If doubts persist about the upper urinary tract despite previous evidence. This is a more aggressive test and should only be conducted if doubt remains after intravenous urography.
Staging of Bladder Carcinoma

Stage According to Extension:

  • Superficial Tumor: Affects only the mucosa and submucosa layers, not infiltrating the muscle layer.
  • Infiltrating Tumor: Affects the muscle layer.

Grade of Differentiation: Grades I, II, III. A higher grade indicates a less differentiated tumor.

TREATMENT OF BLADDER CARCINOMA

Treatment of the Carcinoma Itself

A) Transurethral Resection (TUR): The resectoscope is introduced through the urethra, and the tumor is resected up to the muscular layer without perforating it. The pathology report will inform whether the tumor is superficial (treated with local TUR and QT) or infiltrating (treated with open surgery).

B) Partial Cystectomy: When the tumor is located in the dome of the bladder, only a portion of the bladder is removed.

C) Cystectomy: Performed when the tumor is located in other areas or is large in size. The entire bladder is resected.

D) When Cystectomy is Impossible: In cases of large infiltrating tumors, very old patients, etc., these patients often end up with kidney failure. Frequent checks are done with ultrasound to evaluate for hydronefrosis. Palliative treatments may be offered in these cases.

Palliative Treatment of Bladder Carcinoma

Chemotherapy (CT) and Radiotherapy (RT) may be used for palliation.

Treatment of Obstructive Uropathy

Unilateral or Bilateral Nephrostomy: A tube is inserted into the kidney to drain urine.

Ureterostomy: The ureters are divided, led to the skin, and a collection bag is placed.

Procedures to Perform After Cystectomy (Diversions)

Diversions are created using a segment of bowel (usually the small intestine). The bowel segment is sectioned while preserving its mesentery and vascularization. Posterior intestinal continuity is restored to form the reservoir.

Types of Diversions:

External (the reservoir is placed through the skin):

  • Non-continent (Cutaneous Ureterostomy): The bowel segment with active peristalsis is sectioned, and the intestinal fragment is connected to the ureter. This is then brought to the skin with an opening and a collection bag is placed. The pressure inside the bowel segment will cause urine to exit through the opening. The neobladder does not hold urine.
  • Continent: The bowel segment is detubularized, and an area is formed that will be brought to the skin, leaving a hole for catheterization. The patient self-catheterizes to extract urine through the hole 2 or 3 times a day.

Internal (the bowel reservoir is placed inside the body):

  • Orthotopic Non-continent: The two ends of the intestinal segment are closed, and it is placed in the bladder. An opening is created on the surface of the segment and joined to the urethra.
  • Orthotopic Continent: Similar to the external continent diversion, but the hole is connected to the urethra.
  • Heterotopic (Ureterosigmoidostomy) Non-continent: The two ureters are connected to the sigmoid colon. The patient urinates and defecates through the anus, with the anal sphincter controlling the flow of urine. There is a risk of urine and feces reflux, leading to pyelonephritis.
  • Heterotopic (Ureterosigmoidostomy) Continent: The sigmoid colon is divided at the antimesenteric border, forming a low-pressure reservoir. The two ureters are connected to this reservoir.
Guidelines After TURBT

Once the stage and grade of the tumor are known, the following actions are taken:

  • Superficial Tumor: Additional QT and local TURBT.
  • Infiltrating Tumor: Partial cystectomy if the tumor is in the dome or cystectomy with diversion. The decision depends on the patient’s life expectancy, age, and tumor extent. For patients with good prognosis and general health, an orthotopic detubularized diversion (continent, does not leak urine) is considered. For patients with poor prognosis or general health, an internal ureterosigmoidostomy detubularized diversion (to prevent pyelonephritis) or an external tubularized diversion (to avoid catheterization) is considered.

Carcinoma in Situ

After TURBT, the pathologist will determine the stage (superficial or invasive) and grade (I, II, III, IV). Carcinoma in situ is a high-grade superficial tumor located in the mucosa, with grade III (high-grade, poorly differentiated) cells, without affecting the submucosa. The most aggressive tumors are those that infiltrate the muscular layer.

Clinical Presentation: No hematuria, but may present with irritative voiding symptoms. Frequent urinary tract infections in women may be confused with cystitis.