8 bladder tumor


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8 bladder tumor

  1. 1. Bladder TumorMohamed Adel Atta
  2. 2. Classification• Epithelial: papilloma, carcinoma..• Mesenchymal: leiomyoma, sarcoma.
  3. 3. Epidemiology• Commonest cancer in males in Egypt.• Male:female ratio 3• Age of peak incidence 50-70, in Egypt 30-50
  4. 4. Bilharzial bladder carcinoma• Bilharziasis results in younger age,• Higher male:female ratio,• More squamous cell carcinoma,• Presents in advanced stage because bilh.cystitis masks symptoms of the tumor
  5. 5. Pathogenesis• Bilharziasis• Smoking• Aniline dyes• Balkan residency• Bladder extrophy (adenocarcinoma), allhave strong etiologic relationship tobladder carcinoma.
  6. 6. SpreadBladder carcinoma spreads equally by allroutes local, lymphatic and vascular.Bladder carcinoma spreads mainly locally inbilharzial bladder because of intensefibrosis that limits lymph and vascularspread.
  7. 7. StagingT0: Intraepithelial, Tis: Highgrade intraepithelialneoplasia (CIS).T1: Lamnia propria invasionT2: invasion of musclelayer:T2a: superficial musclelayerT2b: deep muscle layer.T3: invasion of perivesicalfatT3a: microscopicinvasionT3b: macroscopicinvasion.T4: invasion of pelvic wallor nearby organs.
  8. 8. Staging• Superficial bladder tumor (non muscleinvasive bladder carcinoma NMIBC ):Ta, T1, CIS• Invasive Bladder carcinoma (MIBC):T2-4
  9. 9. Natural History• Superficial bladder tumor: Ta&T1 and CIS,usually recur in other site of the bladder(70%),but rarely invades bladder wall (10%), solitary ormultiple with mobile fronds long stalk and narrowbase. CIS carcinoma in situ: high gradeintraepithelial carcinoma, appear as velvetyhyperemic areas.• Invasive deep tumor:T2-4 cauliflower, nodular orulcerative with necrotic surface.
  10. 10. Gross Types• Papillary: sea-weed appearance• Cauliflower mass with stunt fronds, somenecrotic.• Nodular• Ulcerative.
  11. 11. Invasive Cauliflower MultipleTumors
  12. 12. GROSS TYPES
  13. 13. Superficial Bladder Tumor
  14. 14. Clinical Presentations• Hematuria: Total painless hematuria (papillarytumors), may be terminal, intermittent orcontinuous bright red or with amorphous clots.• Necroturia: pathognomonic symptom especiallyin bilharzial bl. Ca.• Malignant cystitis: isolated CIS may present bysevere cystitis resisting Rx• Microhematuria• Complications: clot retention, anuria, hydro orpyonephrosis.
  15. 15. Diagnosis• Ultrasonography: echogenicintravesical mass• Plain&IVU: bladder filling defect• Pelvic and abdominal CT: confirmand stage bladder carcinoma
  16. 16. CT bladder tumors
  17. 17. Diagnosis• Urine cytology• Cystoscopy and biopsy: tumor andtumor bed for proper staging,bimanual examination underanathesia to asses the degree ofpelvic spread of the tumor• Metastatic workup X-ray chest andbone scan.
  18. 18. Urine cytologyCytology is the detection of cells in fluid,cells should be viable to take up the stainMalignant cells have ameboid movementdue to loss of intercellular attachments(nexi) and according can be seen in urinefrequently especially in CIS and grade 2carcinoma
  19. 19. Voided urine cytology high grade uroth ca: nuclearhyperchromatism and irregular nucl memb.
  20. 20. Voided urine cytology high grade uroth ca: nuclearhyperchromatism and irregular nucl memb.
  21. 21. Bladder wash cytology clump malignant cellsnuclear hyperchromatisia, vacuolated cytoplasm
  22. 22. Bladder wash cytology low grade car, thick nuclearmemb, hypochromatasia, homogenous cytoplasm
  23. 23. Voided urine cytology low gradecarcinoma
  24. 24. Transurethral Biopsy: The definitiveDiagnosis• 1- Tumor Tissue• 2- Tumor bed biopsy to properly stagemuscle infiltration• 3- Bimanual examination underanasthesia to asses clinically infiltration ofnearby organs and pelvic wall.
  25. 25. Histopathology• 1- Transitional cell carcinoma: the commonesttype• 2- Squamous cell carcinoma: develops on top ofsquamous metaplasia due to bilharziasis• 3- Verrucous Ca: subtype of sq. c. ca.,hyperkerratotic low grade squamous ca., locallymalignant with no vascular spread.• 4- Adenocarcinoma: bladder dome on top ofallantoic remnant, or bladder base on top cloacalremnants.
  26. 26. The papilloma is composed of a delicatefibrovascular core covered by normal urothelium
  27. 27. Low Grade urothelialcarcinomaThe low-gradepapillary urothelialcarcinoma groupincludes all formergrade 1 (WHO1973) cases andsome former grade2 cases (if avariation ofarchitectural andcytological featuresexist at highmagnification).
  28. 28. High grade UrothelialcarcinomaHigh grade urothelialcarcinoma showingatypical urothelialcells that vary in sizeand shape. Thenuclei are enlarged,with coarselygranular chromatin,hyperchromasia,abnormal nuclearcontours andprominent nucleoli
  29. 29. High grade UrothelialcarcinomaHigh grade urothelialcarcinoma showingatypical urothelialcells that vary in sizeand shape. Thenuclei are enlarged,with coarselygranular chromatin,hyperchromasia,abnormal nuclearcontours andprominent nucleoli
  30. 30. CISHigh gradeurothelialcarcinoma limittedto the urothelium.No invasion of theunderlyingbasement.. Lamniapropria underneathshowsangiogenesis
  31. 31. Lymphovascular invasion
  32. 32. Muscularis propria invasion
  33. 33. Squmous cell carcinoma
  34. 34. Bilharzial egg S Hemmatobiu
  35. 35. TreatmentSuperficial Bladder Tumor• 1- Transurethral resection (TURT):• 2- In multiple, big,T1, and recurrenttumors: Intravesical chemotherapy(thiotepa, mitomycin, adriamycin) or betterimmunotherapy (BCG Vaccine) is advisedto reduce tumor recurrence and avoidtumor progression 6 weekly instillationsfollowed by maintenance 3 weekly inst.every 6 months.
  36. 36. Treatment Superficial BladderTumor• 3- Followup Protocol: including US, urinecytology, cystoscopy and biopsy• 4- Radical cystectomy in high gradetumors resisting treatment and rapidlyrecurrent.
  37. 37. Treatment Of Invasive Tumors• Radical cystectomy is the gold standard excisionof bladder, lower ureters, as well as prostate,seminal vesicles in males and uterus uppervagina and ovaries in females together withpelvic lymph nodes.• Radical radiotherapy: less efficient• Bladder saving protocol using initialchemotherapy followed by radiotherapy inresponding tumors or salvage cystectomy innon-responding tumors.
  38. 38. Post-Cystectomy UrinaryReconstruction1- Orthotopic bladder substitutes2- Ectopic bladder substitutes:A- Cutaneous:a- Wet stoma: ileal conduitb- Continent stoma: cont.reservoirB- Anal:a- Ureterosigmoidostomy & its variantsb- Rectal bladder with left terminal colostomy
  39. 39. Post-Cystectomy UrinaryReconstructionAny part of GI tract can be used: ileum,colon or stomach.Detubularization and refashioning in theform of a sphere results in bigger (3 timesthe volume of the tubular intestine) andless intraluminal pressure (la Place law).
  40. 40. Effect of detubularization
  41. 41. Orthotopic Neobladder• Detubularized intestinal segmentfashioned in the form of sphere isanastomosed to the urethra and bothureters are anastomosed to thepouch with an antireflux mechanism.• Is the first option unless tumorinvades the proximal urethra.
  42. 42. Serous-lined W-shapeneobladder
  43. 43. Sigmoid neobladder
  44. 44. Ileal Conduit• Both ureters are anastomosed to 15cm ileal segment , one end is closedand the other end is anastomosed tothe skin.• Urine bag is applied to the stoma
  45. 45. Ileal Conduit
  46. 46. Ileal conduit
  47. 47. Continent Reservoir• Detubularized intestinal segment isfashioned in the form of sphere, bothureters are anastomosed to the pouchwith antireflux mechanism.• The pouch is anastomosed to theumblicus with continent mechanism toprevent urine leakage• Patient uses plastic catheter to evacuatethe pouch every 6-8 hours
  48. 48. Kock Reservoir
  49. 49. Indiana & Florida pouches
  50. 50. Ureterosigmoidostomy• First known continent diversion, bothureters are anastomosed to the sigmoidcolon with proper antireflux technique• Sequelae: electrolyte imbalancehyperchloremic hypokalemic acidosis,ascending infection, coloniccarcinogenesis.• New variants are introduced to avoid suchsequelae with better outcome.
  51. 51. Ureterosigmoidostomy
  52. 52. Ureterosigmoidostomy
  53. 53. UERETEROSIGMOIDOSTOMY1- Drawbacks: electrolyte imbalancehypokalemic hyperchloremicacidosis, repeated UTI, coloniccancer, inconvenient evacuation2- Less with the new modifications3- Not accepted in all centers
  54. 54. Detubularized IsolatedUreterosigmoidostomy (DIUS)
  55. 55. Detubularized IsolatedUreterosigmoidostomy (DIUS)