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REGUB Surgery - Bladder Cancer (i) (Intro (over 90% = TCC (10% have mixed…
REGUB Surgery - Bladder Cancer (i)
Intro
2nd most common urological malignancy
3% of all cancer deaths
average age: 8th decade, only 1% under 40
2.5:1 M:F ratio
over 90% = TCC
10% in situ
70% non-muscle invasive (superficial)
20% muscle invasive
70% papillary
3 grades - usually G1 or 2
G1: min/slight nuclear enlargement, normal/slightly distorted architecture, rare/absent mitotic figures
G2: displays great nuclear pleomorphism, coarsely clumped chromatin, some disruption of normal architecture
G3: P53 mutation
usually superficial i.e. confined to mucosa (Ta) or submucosa (lamina propria - T1)
T1G3 can be more aggressive, 40% get upstaged to muscle invasive
10% have mixed papillary + solid morphology, 10% solid
usually G3
50% muscle invasive @ presentation
10% in situ (CIS) , but most will progressive to muscle-invasive if untxed - CIS = most aggressive form of superficial CIS
1-7% = SCC
2% = adenocarc
1% = other (e.g. sarcomas)
dysuria = burning
nocturia: BPH, DM, sleep apnoea (?interrupted sleep or ANP secreted due to pressure on right heart)
anticoags cause haematuria
dipstick haematuria a/w false +ves
painless macro haematuria = bladder cancer until proven otherwise
ureteral cancer: rare, mets, stones, inflamm
urethral cancer: rare, diverticulum
US good for visually stones, hydronephrosis, renal parenchymal lesions (cystic or solid)
bilat hydronephrosis indicates problem @ level of bladder or lower
narrowest parts of ureter: UPJ, VUJ
when a stone is moving it causes pain
recurrence doesn't = progression
Risk factors
industrial carcinogens: aromatic amines, aniline dyes
pharmaceutical compounds: saccharin, phenacetin, insecticides
cigs: 2-5 fold increase (30-50% caused by smoking)
schisto - SCC
high dose cyclophosphamide
high risk occupations
textile workers
dye workers
tyre rubber workers
petrol workers
leather workers
shoe manufacturers
painters
hairdressers
lorry drivers
chemical workers
rodent exterminators
sewage workers
Clinical features
gross total painless haematuria = classical presentation (in 85%)
microscopic haematuria in 20%
irritative voiding symptoms in 25% - INDICATES CIS
clot retention in 17% (large clots can become wedged in urethra + cause acute urinary retention)
met disease
physical exam generally normal (unless mass palpable on rectal exam or fixation of pelvic structures)
hydronephrosis
Mets
invasion of surrounding structures: peri-vesical fat, contiguous organs, pelvic side wall
lymphatic: pelvic + pauaaortic nodes
vasc: lungs, bones, liver, brain
TCC investigations
urinary cytology
bimanual exam under anaesthesia
diagnostic cystoscopy
tumour bx +/- resection
upper tract imaging (CT-urogram, CT-IVP [IV pyelogram] - can see filling defects)