The commonest presenting symptom of a bladder tumour is haematuria, which may be repeated but frequently occurs on one occasion only. In males over the age of 40, about half the cases are due to neoplasm. It is therefore obvious that haematuria, however slight, should always be considered seriously. Thus the first essential in diagnosis is the proper investigation of all cases of haematuria. This phase is usually the responsibility of the general practitioner

Barnes, D.R.

English

AJOL - African Journals Online

118 S.A. MEDICAL JOURNAL 7 February 19591eirowsky, A. M., Scheiben, C. D. and Rose. D. K. (1952): J. Uro!., 67, 192.Moulder. M. K. and Meirowsky, A. M. (1956): Ibid., 75, 261.Nesbi,. R. M. (1947): Ibid., 57, 741.Pauon. J. F. and Schwar!z, H. G. (1953): Ibid., 70, 230.Rose, D. K. (1951): Ibid., 65, 1021.Seaman, J. A. (1950): Ibid., 63, 105.mi,h. G. G. (1952): Ibid.• 67, 903.Van Duzen, R. E. and Mus,ain, R. (1951): Ibid., 65, 1033.THE DIAG OSIS OF BLADDER TUMOURS*D. R. BARNES, ER.C.S.,Urologist, GrooJe Schuur Hospital, Observatory and Rondebosch and Mowbray Cottage Hospital, Cape TOWIIThe commonest presenting symptom of a bladder tumour ishaematuria, which may be repeated but frequently occurson one occasion only. In males over the age of 40, abouthalf the cases are due to neoplasm. It is therefore obviousthat haematuria, however slight, should always be con-sidered seriously. Thus the first essential in diagnosis is theproper investigation of all cases of haematuria. This phaseis usually the responsibility of the general practitioner.CLINICAL INVESTlGATIO SThese patients should have a full c1injcal examination, which,although usually negative, should not be neglected. AnLV. pyelogram is often helpful for it shows the state of theupper urinary tract and it may on occasion reveal a primarytumour of the renal pelvis or ureter, or the bladder tumourmay be seen as a filling defect in the cystogram. Cystoscopyusually facilitates location of the tumour and its macroscopiccharacters can be observed. The exact pathology of thegrowth is determined by biopsy. A careful bimanual pelvicexamination should be done under anaesthesia, for if thegrowth is palpable, it is almost certainly an infiltratingcarcinoma. All these steps are universally accepted andshould be carried out as a routine in every case.In recent years evidence has accumulated that the examina-tion of the urine for neoplastic cells, using the Papanicolaoustain, may be of value. Hazard et al. 5 found neoplasticcells in 70 %of cases with bladder tumours, and in cases withno tumour there were only 5·8 % false positives. Rowlandand Marshall'3 noted that a number of their cases withfalse positives later developed bladder tumours. Theyfound the test positive in 95 % of their cases. This test,therefore, should be used in the follow-up of cases withbladder tumours, particularly if neoplastic cells can bedetected before the growth can be seen cystoscopically.The test may also be used in cases of haematuria, when fullinvestigation is negative, for some of these cases may latermanifest a bladder tumour. It has also been suggested as ascreening test for workers in the dye industry, for it is moreacceptable to the workers than a cystoscopy.ASSESSMENTThe prognosis of bladder tumours depends almost entirelyon the histology of the tumour, and the depth to which it hasirtfiltrated through the bladder wall. ,Pugh12 has shown thatmost tumours of a low grade of malignancy are confined tothe mucosa and submucosa, while those that have infiltratedthe muscle layers are mostly of a high degree of malignancy.In view of the good results which are being obtained inthe treatment of bladder tumours by transurethral resectionand closed radon implants (Milner,lO Ernmett and Winter-• Paper presented at the Second Congress of the UrologicalAssociation of South Africa (M.A.S.A), Cape Town, July 1958.ringer,' Yates-Bell and HendricksU ), it has become imponantto assess the histology and the depth of penetration endo-scopically. Today there is little doubt that the best, andprobably the only, method by which this can be achieved, iby means of the resectoscope. This method was stronglyadvocated by Milner" in 1949, who found that his biopsyreports were remarkably accurate when compared with theoperative specimens. These findings have since been con-firmed by a number of workers.The great advantage of the resectoscope is that the baseof the tumour can be resected and, if muscle is included.histological assessment of muscle infiltration can be made.It can be argued that infiltration of muscle can be assessedby a bimanual pelvic examination. Marshall; found that33 % of growths which were not palpable on bimanualexamination showed infiltration of muscle in the operativespecimen. Thus, this method alone is too inaccurate.When examining a bladder which is the seat of a tumour,careful attention should be given to those parts not involvedby the tumour, for Masina8 has described areas of reddeningand oedema which may occur next to the growth or onoccasion remote from it; biopsy specimens of these areasshould be examined. One illustrative case has recently beenseen, where a patient had a solid carcinoma at the bladderneck and an area of oedema on the dome which on biopsyshowed carcinoma. This case probably illustrates the thesisof Roger Baker' that if the growth has gone through themuscle layer the lymphatics of a considerable area of thebladder are involved.One difficulty ir. the use of the resectoscope is the treat-ment of growths in the dome of the bladder in the male,partly due to the mechanical difficulty and partly becausethe size of these tumours is more difficult to assess. Beach'has suggested operating on these cases through a perinealurethrostomy in the prone position. An easy way out of thedifficulty is to obtain a biopsy specimen of the growth with arongeur and, if the growth is malignant, a partial cystectomycan be done.LESS MALIGNANT TUMOURSAll bladder tumours have a tendency to recur and theyshould therefore be examined periodically for many years.It may therefore be of value to consider the behaviour ofcertain of the less malignant papillary tumours.The typical villous papillomata with narrow pedicle,delicate fronds and benign histology do very well on cysto-scopic diathenny, even though they continue to producerecurrences for many years. However, Deming3 found that7· 8 % of his cases developed malignant tumours over aI5-year period.The group of sessile papillary tumours with stunted frondsare on the borderline between the benign and the malignant.In the past the response of these tumours to cystoscopic, Februarie 1959 S.A. TYDSKRIF VIR GENEESKU DE 119flllguration was used as a method of diagnosis. lrvine' hasspown, however, that when it becomes obvious that thetllmOur is not responding, it has usually infiltrated throughtpe bladder wall. He also found that when this group ofu.lmours was treated by cystoscopic fulguration, withoutbiopsy, 50% died of carcinoma within 5 years. These tumoursstlOuld be handled by transurethral resection, for they are(flen more adequately excised and a biopsy is obtained.Papillary tumours which are excised by open operationn1ay give rise to implants in the wound; these implants arealmost invariably malignant. However, in cases beingtreated endoscopically, growths may implant on the bladderneck, probably on areas which have been traumatized by theirlstruments. These implants are usually not malignant.DIAGNOSTIC DIFFlCUlTIESS a rule the diagnosis of bladder tumours is straightforward.ihere are, however, some clinical problems as well as somedifficulties in cystoscopic interpretation, which should beconsidered.On occasion cases of haematuria are fully investigated andnO abnormality found. Some of these cases may later showbladder tumours. The diagnosis may be missed because ofthe small size of the growth or its occurrence in a 'blind area'in the dome, particularly if there is an associated enlargementof the prostate. It is in this group of cases that the examina-lion of the urine for neoplastic cells with the PapanicolaouSlain may be of value.A patient with a bladder tumour may present with retentiondue to prostatism and no history of haematuria, and it isfor this reason that a cyStoscopy is done as a preliminary to aprostatectomy.An embarrassing source of error is an incorrect patholo-gical report. This difficulty appears to have been moreprevalent when small specimens were taken with smallbiopsy forceps. When reasonable amounts of tissue are takenwith the resectoscope, errors are uncommon.Inflammatory changes in the bladder, due to tuberculosis,diverticula, stones, indwelling catheters, vesico-intestinalfistula or bilharzia, may all simulate carcinoma on cystoscopy,but are usually distinguished by biopsy. Irradiation cystitis,particularly if the irradiation has been given for a bladderLUmour, may cause considerable difficulty, and here againthe diagnosis is made on biopsy examination.Carcinomas of adjacent organs may invade the bladder andpresent like primary bladder tumours. The commonest are.::arcinoma of the colon, the rectum, tbe uterus, the cervix andlhe prostate. In these cases the bulk of the tumour is feltoutside the bladder, on pelvic examination, and the biop yspecimen does not show the histological features of a bladdertumour.Cystitis cy tica and cy titis glandularis are not uncommonmetaplastic le ions, occurring in bladders which are theseat of chronic or recurrent infections. They are u uallyquite innocent, but recently e bit ll reported a case whichhowed typical cy titis cystica and glandularis on cy to copy,but the biopsy showed adenocarcinoma. One patient habeen een where typical cy titis cy tica and glandularis werefound on cystoscopy, but the biop y examination howedadenocarcinoma. This patient ultimately died of bladdercarcinoma with secondary deposits in her spine.The asses ment of ca es who have had a partial cy tectomyfor carcinoma may cau e difficulty, for a malignancy maybe present outside the bladder and a villou papilloma in thebladder. For example, an elderly lady had a partial cystec-tomy for carcinoma and 2 years later she had a typicalvillous papilloma of the bladder, which was fulgurated.She was found to' have an enlarged gland in the neck, whichshowed transitional-cell carcinoma on biopsy. She laterdied from meta tases.SUMMARYIn the diagnosis of bladder tumour the first essential i theinstitution of appropriate investigations in all cases ofhaematuria. These investigations are an intravenous pyelo-gram, a cystoscopy, a biopsy and a bimanual pelvic examina-tion under anaesthesia.The histology of the tumour and the depth to which it hasinvaded the bladder wall is assessed by removing the tumourand its base with the resectoscope and submitting the piecesto microscopic examination. Assessment by this method isremarkably accurate.In spite of all the diagnostic aids, there are still somepitfalls and difficulties, most of which can be solved by carefulclinical and cystoscopic examination, together with hi tolo-gical examination of biopsy material.REFERENCESI. Baker, R. (1955): J. ro!. (Baltimore), 73, 681.2. Beach. C. H. (1957): Ibid.. 77. 2 8.3. Deming, C. (1950): Ibid.. 63, 14.4. Emmen, J. L. and Winterringer, J. R. (1955): Ibid., 73. 502.5. Hazard. J. B., McCorrnack. L. J. and Belovich. D. (1957): Ibid., 78, 182.6. trvine, W. T. (1955): Brit. J. Uro!., 27, 224.7. Marshall, V. F. (1952): J. Uro!. (Baltimore), 68, 714.8. Masina, F. (1952): Brit. J. Uro!., 24, 344.9. Milner, w. A. (1949): J. Uro!. (Baltimore), 61, 917.10. Idem (1954): Brit. J. Uro!., 26. 375.11. Nesbit, R. M. (1956): J. Uro!. (Baltimore). 75. 443 .12. Pugh, R. C. B. (195 ): Postgrad. Med. J.. 34. 124.13. Rowland. S. I. and MarshaH. V. F. (1957): Surg. Gynec. Obstet.. 104. 41.14. Yates·Bell. J. G. and Hendricks, C. Q. (1957): Brit. J. Uro!., 29.97.PREVENTION OF THE COMPLICATIO S OF PROSTATECTOMYJ. D. JOUBERT, ER.C.S. (EDlN.), F.R.F.P.S., RA., Urologisi, Cape TownE110Ugh has been written and said about the aclual,:omplications after prostatectomy, and I propose rather toli,cuss the prevention of complications.Much post-operative trouble can be avoided by thorough're-operative examination, and here I want to stres the'[rporlance of looking at the patient as a whole. We must- nsider his weight, his chest, his cardiac re erve, his blood,. Paper presented at 2nd Congress of Urological Association11 South Africa (M.A.S.A.), Cape Town, July 1958.pressure, varico e veins, hi mental tate, hi bowel habits,glycosuria, haemorrhagic tendencie , etc.From the urological point of view, the following 3 pointare to be stressed: (a) Make a thorough rectal examination.(b) See the patient pas urine your elf if at all po ible.(c) Secure good IVP , excretion cy togram , and retrogradecy tograms whenever a catheter i in silu and whenever oneis in doubt abolll the pre ence or diverticuli, reflux, etc.There are 3 troublesome po t-operative complication

The diagnosis of bladder tumours

https://www.ajol.info/index.php/samj/article/download/173595/163029

The diagnosis of bladder tumours

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online