On the detection and management of urinary bladder carcinoma

Abstract

Aims: To describe the diagnosis and clinical course of an unselected population-based cohort of patients with newly diagnosed transitional cell carcinoma of the urinary bladder. To assess if random bladder biopsies and the detection of concomitant carcinoma in situ have an impact on management and clinical outcome in bladder cancer patients. To study the functional outcome after cystectomy performed with a prostatic capsule and seminal sparing approach. To investigate possible effects on gastrointestinal functions caused by the intestinal reconstruction in patients with orthotopic ileal neobladder.

Patients and methods: This study prospectively included 78% (538 patients) of all newly detected bladder cancer patients in the Stockholm region 1995-1996. The patients were followed for at least five years. Choice of treatment, recurrence, progression and survival were studied. The same cohort was then analyzed in order to determine possible impact of random bladder biopsies on choice of treatment and cancer-specific survival. Twenty five male bladder cancer patients who underwent prostatic capsule and seminal sparing cystectomy were evaluated by a questionnaire concerning urinary-, bowel- and sexually related symptoms. Twenty eight patients who underwent radical cystectomy and orthotopic neobladder were compared with ten patients who underwent TURBT concerning possible effects on gastrointestinal functions, such as enterohepatic circulation of bile salt, gastric emptying and gastrointestinal hormone levels.

Results and conclusions: In this study none of the patients with PUNLMP (WHO 1999) progressed or died, confirming the low malignant potential. In the group of patients with TaG1-G2, only 2/187 patients (1%) died of bladder cancer. In contrast, patients with TaG3 or T1G2-G3, after five years of follow-up, had a cancer-specific death rate of 30%. Patients with TaG3 or T1G2-G3 in whom random bladder biopsies were performed were more likely to be treated with intravesical BCG compared to patients without random biopsies (58% vs. 23%, p=0.002). The Cox proportional-hazard ratio for death due to bladder cancer comparing TaG3 or T1G2-G3 patients without vs. with random biopsies was 2.5 (95% CI 1.1-5.6). For patients with muscle invasive bladder cancer the cancerspecific survival at five years was 31% and only 61% of the patients underwent a treatment with curative intention. However, our data indicates that in selected patients, prostatic capsule and seminal sparing cystectomy and orthotopic neobladder combines an appropriate oncological outcome with a satisfactory function of the lower urinary tract. When the distal ileum was removed from the gastrointestinal tract for orthotopic neobladder substitution, bile salt induced diarrhoea was found in 1/3 of the patients. Most of the patients that developed bile salt induced diarrhoea were relieved of their symptoms by cholestyramine.