Histologically, a patient can have two kinds of carcinoma in his bladder: (1) A transitional cell carcinoma, which has a 75% chance of being papillary, and of such low-grade malignancy that it can be controlled with diathermy, although it may sometimes be as anaplastic and invasive as any squamous one. (2) A much more malignant squamous cell carcinoma.
In non-schistosomal areas, most tumours are transitional, papillary, and of low-grade malignancy, but in areas where Schistosoma haematobium is endemic, only about 5% are like this, 10% are anaplastic, and 85% are squamous. Of these, most are either sessile or ulcer-cancers, both of which grow rapidly, and penetrate early into the muscle of the bladder or into the paravesical tissues. They may also have obstructed a patient's ureters by the time you see him. Unlike the transitional tumours of the industrial world, they are not associated with tumours in the renal pelvis. Many patients are inoperable, and even if the primary can be removed by total cystectomy, recurrence is frequent, and there are few five year survivors.
The patient is usually between 35 and 60 and has a 2:1 chance of being male. He complains of: (1) haematuria, which is painless in early cases, (2) the passage of white sludge, or small pieces of white material (necrotic tumour), (3) increased frequency of micturition, as the result of irritability, infection, and a small bladder, (4) a suprapubic lump, and (5) retention of urine (5%), as the result of the tumour obstructing his urethra.
In areas where S. haematobium is not endemic, all patients with haematuria should be cystoscoped. This is impractical in endemic areas, because so many patients pass bloody urine. Macroscopic haematuria, due to S. haematobium alone, becomes less common as age advances, because of the fibrosis round the ova, so that by the time that a patient is 30, there is a 25% chance that, if he sees blood in his urine, it is caused by a bladder tumour, rather than merely by the worms laying their eggs. So, if you are in an endemic area, cystoscope everyone over the age of 30 who complains of blood in his urine (23.3, 23.4). Few cases of carcinoma of the bladder occur in anyone under 30.
There is little that you can do for aggressive schistosoma- associated carcinoma of the bladder, but do try to confirm the diagnosis. Patients need to know if they have a serious condition or not. Stage these tumours as described below. Most patients present in Stages Three or Four. The only useful treatment for squamous tumours in stages One and Two is total cystectomy; the recurrence rate after partial cystectomy is high, but even total cystectomy has few five year survivors. Radiotherapy is not effective for advanced cases, but is a possible alternative to surgery for Stages One and Two. No effective chemotherapy is known, except for those rare patients with high HCG (human chorionic gonadotrophin) levels and a positive pregnancy test. Ureteric transplantation gives symptomatic relief, but this is so short that the operation is seldom justified. All you can do is to palliate the patient (33.1). He is likely to die from renal failure, due to the obstuction of his ureters by the tumour.
Fig. 32-17 STAGING CARCINOMA OF THE BLADDER is done by examining a patient under anaesthesia combined with cystoscopy. Stage One, the tumour is not palpable. Stage Two, it is palpable, but is still mobile and not larger than expected from cystoscopy. Stage Three, it is mobile, but is larger than you would expect from cystoscopy. Stage Four, it is fixed. Stage Five (not shown) it is widespread. After Bailey and Love, ''Short Practice of Surgery', Fig. 1415. With kind permission.
CARCINOMA OF THE BLADDER SPECIAL TESTS. Measure the patient's haemoglobin, and his blood urea. Examine his urine microscopically, and if possible culture it.
X-RAYS. If Schistosoma haematobium is common; an IVU is unnecessary, because associated tumours of the pelvis of the kidney are rare. In areas where low-grade papillary transitional tumours predominate, do an IVU, because he may also have tumours of the pelvis of his kidney. An IVU will also show you the state of his upper urinary tract, dilatation of his ureters, and perhaps the tumour, as a filling defect in his bladder.
CYSTOSCOPY. If possible, cystoscope him under general anaesthesia and follow this with an EUA (examination under anaesthesia). A simple cystoscope will confirm the diagnosis, but will not allow you to take a biopsy. To do this you will need a biopsy attachment, which you can use under vision or blind in a man. In a woman with a large tumour which you can feel bimanually, you may be able to take a blind biopsy with some suitable straight instrument, such as the biopsy forceps normally used for the larynx. In advanced carcinoma, the urine is often so bloody, that it is difficult to see anything; if so you will have to rely on an EUA.
STAGING. Following cystoscopy, examine the patient bimanually under general anaesthesia, with his bladder empty and his muscles relaxed.
Stage One His tumour is sessile and not palpable. Refer him for possible cystodiathermy, or for partial cystectomy for a transitional tumour. Total cystectomy, for an aggressive squamous cell tumour, is only justified if he understands the situation fully, and the journey is not difficult. It will spare him much suffering, but is unlikely to cure him.
Stage Two It is palpable as a localized, but definite thickening, which is mobile. It is [lt]5 cm in diameter, and is not larger than you expect from cystoscopy. Refer him as above.
Stage Three It is mobile, [mt]5 cm in diameter, and is larger than you expect from cystoscopy. Cystectomy may be possible, but is unlikely to cure him. Consider referring him, but explain that there is little chance of a complete cure.
Stage Four It is fixed to the wall of his pelvis, or to his paravesical glands, or is infiltrating the vagina or rectum. Palliation only.
Stage Five There is widespread disease. Palliation only.
CAUTION ! (1) Try to confirm the diagnosis histologically, before advising radical surgery. Schistosomal granulomas (common in endemic areas) and tuberculosis, can simulate small tumours. (2) Avoid a suprapubic cystostomy, because it can cause a distressing, permanent urinary fistula if a malignant tumour is present.