Read online “Emergency conditions in urology” by Nikolay Aleksandrovich Nechiporenko – RuLit – Page 5

Causes of bladder cancer

The reasons for the development of this pathology are not fully known. There are a number of factors whose relationship with the disease has been proven:

Exogenous

This group includes:

• carcinogenic substances: a group of aromatic compounds (here at risk are workers in hazardous industries involved in the production of plastics, resins, paints, rubber, etc.);
• consumption of low-quality water, which is also a carcinogen (in case of violation of water purification, when the chlorine content in it exceeds permissible standards);
• tobacco smoking – the determining factors are the number of cigarettes smoked, duration of smoking, and the presence or absence of a cigarette filter;
• infectious diseases adversely affect the organ wall, causing chronic inflammation of the mucous membrane. For example, schistosomiasis (a tropical parasitic disease that affects residents of North Africa and Southeast Asia), human papillomavirus;
• radioactive exposure when used as a method of treating other cancers;
• a number of medications that have analgesic and antipyretic effects, such as analgin and paracetamol, can increase the likelihood of developing bladder cancer.

Endogenous

These include existing bladder dysfunctions - chronic cystitis, neurogenic bladder, bladder stones, prostate adenoma. All of them are, to one degree or another, accompanied by stagnation of urine, the metabolites of which adversely affect the wall of the organ.

Long-term use of catheters also contributes to malignant degeneration of the organ mucosa.

Classification of bladder lesions

There are several classifications. For ease of understanding by doctors around the world, a unified classification of oncological diseases has been adopted, which takes into account the primary tumor, the condition of local lymph nodes and the presence of metastatic lesions of internal organs. This classification is presented below in relation to RMP.

TNM classification (worldwide, for formulating a diagnosis)

• T - tumor: Tx - there is no way to evaluate the tumor,
• T0 – insufficient information about the tumor,
• Tis - carcinoma in situ;

G – designation of the degree of cell maturation

• Gx – it is impossible to assess differentiation;
• G1 – the tumor is highly differentiated;
• G2 – moderate differentiation;
• G3 - low differentiated;
• G4 – the tumor cannot be differentiated.

Distribution of bladder cancer by stages

• O, stage 1 – there is no damage to local lymph nodes and tumor spread to other distant organs, bladder cancer in the mucosa;
• Stage 2 – bladder cancer grows into the muscular layer of the organ, without metastases and tumor involvement of regional lymph nodes;
• 3 – the tumor reaches the outer layer of the affected organ and grows into the fatty tissue;
• 4 – in case of germination of a malignant tumor in local lymph nodes and metastasis to distant organs.

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What manifestations suggest bladder cancer?

RMP can proceed hidden for a long time. Patients affected by the disease and having problems with the functioning of the bladder often do not attach importance to the first signs. Let's take a closer look at them.

Hematuria

One of the most significant symptoms of bladder cancer is hematuria – the presence of blood and traces of it in the urine (90% of cases). Microhematuria (the presence of single red blood cells in the urine) is detected only when examining urine under a microscope; macrohematuria is indicated by blood staining of the urine, visible to the eye.

At the onset of the disease, hematuria occurs periodically and lasts several hours. As the affected area increases, it intensifies. There is a danger of continuous bleeding with the formation of clots and, as a result, bladder tamponade develops.

Dysuria – urination disorder

Patients are concerned about increased frequency of urination, the appearance of false urges, and even urinary incontinence.

Pain syndrome

Painful sensations appear when urinating. Pain above the womb, which, spreading along the nerve endings, radiates to the rectum, vagina, and perineum. Such pain may indirectly indicate a malignant lesion of the bladder in women.

The nature of the pain directly depends on the depth of tumor growth into the surrounding tissue. With bladder cancer in men, pain can spread to the scrotum, perineum, and also to the rectum. In later stages, pain occurs due to bone metastases.

Nonspecific signs

All malignant tumors are characterized by common symptoms that are caused by poisoning of the body with toxic waste products of the tumor. Manifestations are classic for cancer - weight loss, decreased performance against a background of weakness and increased fatigue.

Approaches to diagnosing bladder cancer

BC progresses quickly, so it is important to conduct a full examination when the first symptoms appear.

Instrumental diagnostic capabilities

Ultrasonography

It must be carried out in all patients with hematuria. Ultrasound sensors make it possible to determine the size of the tumor, location, structure, and whether the tumor has spread to neighboring organs. Bladder volumes are assessed. Disadvantage: insufficient visualization of small formations (less than 5 mm). There are several methods for doing this:

• abdominal sensor + full bladder (the most common and convenient method for patients);
• rectal (TRUS - transrectal ultrasound) and vaginal sensors: examination by inserting a sensor into the rectum (in men and women who are not sexually active) and vagina (in women);
• the study is carried out using a special device - it allows you to determine the depth of penetration of the pathological formation (the sensor is inserted through the external urethra) .

Urethrocystoscopy with biopsy

Mandatory method for diagnosing pathology. The cystoscope is inserted through the urethra, and local anesthesia is first performed. The mucous membrane of the urethra and bladder is examined: it becomes possible to identify pathological formations of the epithelium, clarify the location, size, number, and growth of the tumor. A biopsy allows you to make a correct diagnosis, determine the tactics of management and further treatment.

X-ray methods

Excretory urography and descending urography are informative in the growth of pathological tissues in the direction of the organ lumen. With their help, you can evaluate the capacity of the bladder, the condition of the urinary tract located above (patency of the ureters), the exact position and size of the formation.

The method of ascending cystography gives an idea of ​​the contours, capacity, condition of the walls of the bladder, and the presence of vesicoureteral reflux of urine. When performing cystography, it is possible to distinguish a malignant tumor: benign tumors give a filling defect (the study is carried out with contrast), but the contours of the organ from the inside remain unchanged.

CT scan

It is considered a more accurate examination method. With its help, you can evaluate local lymph nodes and the degree of their germination.

Dynamic nephroscintigraphy

Allows you to assess the condition of the kidney tissue during treatment.

In order to determine distant metastases, CT of the brain, ultrasound of the abdominal cavity, radioisotope study of the skeleton, CT/MRI of the abdominal cavity, CT of the chest are performed according to indications.

Laboratory diagnostics

To assess gross hematuria, a three-glass sample is used. The detection of blood in all three urine samples indicates a high probability of the presence of a malignant tumor in the bladder.

In all cases, a cytological examination of 24-hour urine sediment is performed (rarely, rinsing water after cystoscopy, a smear from a tumor on the mucosa).

Genetic markers

Due to the low sensitivity of urine cytology, methods for molecular diagnosis of the disease are currently being developed. Today there are several diagnostic tests, but none are included in urological examination standards.

Determination of bladder cancer marker in urine:

• BTA bladder tumor antigen;
• UBC is a bladder cancer antigen.

Treatment

TREATMENT. The main method is surgical. Surgical treatment. Types of operations: • For closed intraperitoneal injuries - laparotomy, revision of the abdominal organs (ruptures of parenchymal organs are sutured, then interventions are performed on the gastrointestinal tract). The bladder wound is sutured with a double-row suture. The abdominal cavity is drained. A permanent catheter is left in the bladder for 5–7 days • For closed extraperitoneal injuries, a median suprapubic approach is used. The peri-vesical urohematoma is emptied and loose bone fragments are removed. Bladder ruptures are sutured, preferably with a double-row catgut suture. An epicystostomy is applied. If necessary, the cellular spaces of the small pelvis are drained. Conservative treatment is indicated for bruises and incomplete ruptures of the bladder. In stationary conditions - complete rest, cold on the stomach. Hemostatic, anti-inflammatory, and painkillers are prescribed. In rare cases, a permanent urinary catheter is installed for 3–5 days or 3–4 single periodic catheterization is performed.

The prognosis depends on the severity of the injury and the timeliness of surgical treatment. For incomplete ruptures of the bladder - favorable.

ICD-10 • S37.2 Bladder injury

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Treatment tactics

Determined by the stage of the disease.

Surgery

Stage I cancer (T1N0M0), bladder papillomas, recurrent tumors (size of formations 2.5-3.0 cm) are an indication for TUR (transurethral resection - removal of a formation through the urethra).

Transvesical tumor removal using electrocoagulation or cryodestruction is used when it is impossible to perform a TUR (small size and gross irregularities in the shape of the bladder, stricture of the urethra, profuse hematuria).

To stop bleeding and for single papillomas, electric and laser coagulation is used.

Cystectomy (surgical removal of the affected bladder) is performed if there is no effect from other treatment methods (organ-preserving combination therapy). In men, not only the affected bladder is simultaneously removed, but also the area of ​​peritoneum covering it, adjacent tissue, prostate and regional lymph nodes are removed. When tumor tissue grows into the prostatic part of the urethra, a ureterectomy is performed (the areas affected by the malignant tumor are excised).

In women, the usual scope of cystectomy includes bilateral pelvic removal of lymph nodes, removal of the bladder with adjacent peritoneum and peri-vesical fat, removal of the reproductive organs, and partial excision of the anterior vaginal wall.

Chemotherapy

Due to the high incidence of new tumor growth after radical surgery (70-85% of cases), therapy must be combined. There are two types of chemotherapy: local (intravesical) and systemic.

For local chemotherapy, intravesical administration of Epirubicin, Doxorubicin, Gemcitabine, Mitomycin C is used according to the scheme.

For systemic use in bladder cancer, drugs such as Adriamycin, 5-fluorouracil, Methotrexate, Cisplatin, etc. are indicated.

Radiation therapy

Various methods of radiation treatment are used:

• remote;
• intracavitary;
• interstitial irradiation.

Treatment

Treatment measures are operational in nature. There are urgent and delayed surgical treatment. Urgent consists of revision of the urine reservoir and removal of the adenoma.

Hemostatics are medications used for bleeding of various types.

But delayed treatment involves clearing the bladder of blood through the urethra in parallel with antibiotic and hemostatic therapy. Replacement of lost blood is also used. If the bleeding has stopped, then there is time for a full examination and delayed intervention. Tamponade is a very dangerous condition and requires immediate treatment. At the first signs, consult a doctor.

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Measures to prevent bladder cancer

The prevailing majority of malignant tumors occur under the influence of carcinogenic compounds present in the air, soil and water. The share of infectious factors in the causes of malignant neoplasms accounts for up to 10%, the share of occupational hazards - up to 5%, ionizing radiation and ultraviolet - about 7%.

Healthy lifestyle

Preference should be given to natural products and homemade food. Vitamin C, B vitamins, as well as fat-soluble vitamins A and E not only have a beneficial effect on the body as a whole, but also have a suppressive effect on cancer cells. We should not forget about drinking enough liquid; it is with liquid that harmful substances are removed from the body. For an adult, at least 2 liters of fluid per day is considered the norm.

The carcinogenic impact of water and food increases significantly if industrial enterprises that are sources of arsenic compounds, asbestos dust and other chemical compounds are located nearby.

To give up smoking

The carcinogenic effect of nicotine and its combustion products has long been proven, so quitting smoking is mandatory for those who want to reduce the risk of bladder cancer, and other localizations too.

Mandatory treatment of diseases of the genitourinary system

Chronic inflammation is a precancerous condition. It is important to prevent conditions that contribute to stagnation of urine and the spread of pathogenic microorganisms.