Intestinal metaplasia of the bladder in 89 patients: a study with emphasis on long-term outcome

Classical bladder exstrophy in an adolescent: A case report on management, challenges and outcome

Classical bladder exstrophy is a congenital anomaly whose management and outcome has advanced over years. Management and outcome are better when management starts at the newborn period. This was the management of a neglected bladder exstrophy in a male presenting at 16 years of age. We report our challenges, management and outcome to highlight the rarity of this presentation, and the adaptation to the usual protocol of care. The patient presented at 16 years of age with classic bladder exstrophy. The bladder plate was contracted and had cystitis. The patient had a modification of complete primary repair of exstrophy (CPRE) with bilateral pelvic osteotomy stabilised with a 7-hole plate and 4 screws, then bladder neck reconstruction + bladder augmentation + cross-trigonal neocystoureterostomy in a 12-h procedure. He had surgical site infection, superficial wound breakdown and vesicocutaneous fistula that all healed with dressing and prolonged suprapubic cystostomy drainage. He achieved some degree of urinary continence and ability to void, though he still has stress incontinence and frequency at 6 months of follow-up. He has a micturition interval of 60-120 min, and is expected to improve. Presentation and repair of classic bladder exstrophy in the adolescent is very rare in the literature and therefore no known standard of care. This report adds to the body of knowledge. Again, this experience lends credence to the proponents of CPRE in reducing the number of procedures required to treat exstrophy.

Precursors of urinary bladder cancer: molecular alterations and biomarkers

Clinical surveillance and follow-up of patients diagnosed with or at risk for urinary bladder cancers represent long-term, invasive, and costly processes for which supplemental biomarker information could help provide objective, personalized risk assessment. In particular, there are several precursors and possible precursors to urinary bladder cancer for which clinical behavior is heterogenous and interobserver variability in histopathologic diagnosis make it difficult to standardize management. This review seeks to highlight these precursor lesions from a diagnostic perspective (including flat urothelial lesions, papillary urothelial lesions, squamous lesions, and glandular lesions) and qualify known multiomic biomarkers that may help explain their behavior, predict patient risk, and acknowledge the nuance inherent to the question of whether these lesions are "benign" or "preneoplastic."

Analysis of Intestinal Metaplasia Without Dysplasia in the Urinary Bladder Reveal Only Rare Mutations Associated With Colorectal Adenocarcinoma

Intestinal metaplasia (IM) is a rare finding in urinary bladder specimens. It is unclear whether IM without dysplasia is a precursor of malignancy in the urinary system. We retrospectively selected 9 cases of IM of bladder (1 case harboring high-grade dysplasia), and performed mutation analysis for genes frequently mutated in colon cancer including BRAF, APC, KRAS, MET, NRAS, PIK3CA, CTNNB1, FBXW7, and TP53 using validated clinical tests. Control groups included 7 colonic tubular adenomas, 10 high-grade papillary urothelial carcinomas. One IM case revealed an APC mutation and another showed an NRAS mutation. Among the tubular adenomas cases, 6 of 7 (85.7%) harbored KRAS mutations and 3 of 7 (42%) APC mutations. Among urothelial carcinomas cases, 1 revealed a KRAS mutation, 2 had PIK3CA mutations, and all cases were negative for APC mutations. Clinical follow-up for the IM patients was available with a median follow-up of 70 months. One patient-without any mutation in the genes investigated-developed invasive bladder adenocarcinoma with intestinal differentiation with metastasis to the liver and lung. Neither of the 2 patients harboring mutations developed any malignancy. In conclusion, a minority of cases with IM without dysplasia bear mutations in the genes commonly associated with colonic adenocarcinoma, suggesting a premalignant potential for such lesions possibly following the classic multistep chromosomal instability pathway of carcinogenesis. A larger cohort of patients with longer follow-up is needed to better establish whether close follow-up is warranted for mutation-harboring IM of the bladder.

Understanding an unusual urothelial disorder: cystitis cystica et glandularis

Objectives:

To study the presentation and natural course of cystitis cystica et glandularis.

Methods:

A retrospective analysis of patients with histopathologically confirmed cystitis cystica et glandularis from March 2016 to March 2018 who at least completed their 2 years’ follow-up was performed. Perioperative details along with the last available follow-up were included in the analysis.

Results:

A total of 10 patients were included. The mean age (± standard deviation) was 33.4 (±14.0) years and nine (90%) were men. The most common presentation was storage and voiding lower urinary tract symptoms (80%) along with haematuria (40%) and dysuria (20%). Four patients had the presence of hydronephrosis in preoperative imaging, of which three patients had bilateral mild hydroureteronephrosis. All the patients underwent transurethral resection of the bladder tumour as all were diagnosed with urinary bladder mass on preoperative imaging. All the patients had a trigonal lesion with a bullous appearance partially obstructing the bladder neck. Six patients underwent double J stenting in the perioperative period. The mean (± standard deviation) follow-up duration was 32.8 (±7.5) months. Patients were kept on regular surveillance with imaging and cystoscopy as indicated. Eight patients (80%) developed recurrence in the follow-up period. The mean number of recurrences was 1.5 (±1.1). One of the patients had to undergo augmentation ileocystoplasty with bilateral ureteric reimplantation because of the recurrent lesion with small contracted bladder, while another patient underwent cystectomy with urinary diversion owing to recurrence and refractory lower urinary tract symptoms. Besides, there was no evidence of malignancy after this entity in any of the patients.

Conclusion:

Cystitis cystica et glandularis is a rare clinic pathological entity which often mimics bladder tumour. Cystitis cystica et glandularis is common in men and often presents with lower urinary tract symptoms. Transurethral resection forms the mainstay of treatment. However, it is often associated with upper tract hydronephrosis. Its controversial premalignant nature compounded with recurrence and risk of upper tract deterioration warrants close surveillance.

Level of evidence:

4

The Genitourinary Pathology Society Update on Classification and Grading of Flat and Papillary Urothelial Neoplasia With New Reporting Recommendations and Approach to Lesions With Mixed and Early Patterns of Neoplasia

The Genitourinary Pathology Society (GUPS) undertook a critical review of the recent advances in bladder neoplasia with a focus on issues relevant to the practicing surgical pathologist for the understanding and effective reporting of bladder cancer, emphasizing particularly on the newly accumulated evidence post-2016 World Health Organization (WHO) classification. The work is presented in 2 manuscripts. Here, in the first, we revisit the nomenclature and classification system used for grading flat and papillary urothelial lesions centering on clinical relevance, and on dilemmas related to application in routine reporting. As patients of noninvasive bladder cancer frequently undergo cystoscopy and biopsy in their typically prolonged clinical course and for surveillance of disease, we discuss morphologies presented in these scenarios which may not have readily applicable diagnostic terms in the WHO classification. The topic of inverted patterns in urothelial neoplasia, particularly when prominent or exclusive, and beyond inverted papilloma has not been addressed formally in the WHO classification. Herein we provide a through review and suggest guidelines for when and how to report such lesions. In promulgating these GUPS recommendations, we aim to provide clarity on the clinical application of these not so uncommon diagnostically challenging situations encountered in routine practice, while also importantly advocating consistent terminology which would inform future work.

Intestinal metaplasia of the urinary tract harbors potentially oncogenic genetic variants

In the urinary tract, there is an uncertain relationship between intestinal metaplasia (IM), primary adenocarcinoma, and urothelial carcinoma. Although IM is usually found adjacent to concurrent urothelial carcinoma or adenocarcinoma, small retrospective series have shown that most bladder biopsies with only IM do not subsequently develop cancer. However, IM with dysplasia does seem to be associated with a higher risk of concurrent malignancy or progressing to cancer. Since the molecular landscape of these lesions has remained largely unexplored, there are significant uncertainties about the oncogenic potential of IM in the bladder and urethra. This study investigated the presence of potentially oncogenic genetic variants in cases of IM with and without dysplasia. Twenty-three (23) cases of IM (3 urethra, 20 bladder) were sequenced using a solid tumor next-generation sequencing panel. Of these, five contained IM with high-grade dysplasia (including a case with paired IM-adenocarcinoma and another with paired IM-urothelial carcinoma) and 18 lacked dysplasia. Oncogenic genetic variants were found in all cases of IM with high-grade dysplasia and in five non-dysplastic IM cases, including mutations and copy number variants commonly seen in primary adenocarcinoma of the bladder and urothelial carcinoma. This study demonstrates that IM can harbor potentially oncogenic genetic variants, suggesting that it might represent a cancer precursor or a marker of increased cancer risk in a subset of cases.

Tumour-like lesions of the urinary bladder

There are a number of benign epithelial proliferations in the bladder that may be difficult to distinguish from carcinomas, including urothelial carcinoma and its variants, squamous cell carcinoma and adenocarcinoma. If misdiagnosed, there is the potential for over treatment, with its attendant risk of complications, as well as errors relating to prognostic assessment. In the case of the misdiagnosis of high grade proliferative lesions that mimic invasive carcinoma, unnecessary radical surgery, chemotherapy and radiotherapy may result. Similarly, the misdiagnosis of lesions that have the appearance of low grade carcinoma can prompt a lifetime of radiological investigation and cystoscopies. In this review, we discuss a variety of entities that may be diagnostically challenging and emphasise the importance of identifying key morphological features that have diagnostic utility. We also highlight the importance of relevant clinical information and the clinical settings in which these lesions may occur. In this review we have divided the lesions on the basis of morphology in order to facilitate discussion relating to the differential diagnosis. The architectural patterns we discuss include papillary lesions (polypoid/papillary cystitis and papillary urothelial hyperplasia), pseudocarcinomatous proliferations (pseudocarcinomatous urothelial hyperplasia, florid proliferation of von Brunn nests and fibroepithelial polyps), glandular lesions (intestinal metaplasia and müllerianosis) and lesions with several different patterns (prostatic type urethral polyps and nephrogenic adenoma or metaplasia).

Urethral caruncle with intestinal metaplasia: A case report and literature review

A 66-year-old female presented with a urethral caruncle. Histological features of incomplete intestinal metaplasia were reported. Only five previous cases of intestinal metaplasia in urethral caruncles have been reported. The mechanism of this tissue transformation remains unclear but theorised aetiologies include embryological and infective causes. Intestinal metaplasia carries a malignant potential in other organs, most notably the bladder. Therefore we recommend urethral caruncles be completely excised with prolonged follow up for atypical variants.

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The urethral carcuncle is historically considered a rare benign lesion.

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Intestinal metaplasia and dysplasia has been reported in urethral caruncles.

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Theorised etiologies include oestrogen deficiency, embryological remnant and infection.

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Urethral caruncles should be completely resected, with extended follow up for atypical variants.

Development and validation of a predictive nomogram for the risk of recurrence in patients with cystitis glandularis

Background

Most patients with cystitis glandularis (CG) suffer from recurrence after primary treatment. Therefore, we performed this multicenter study to clarify the recurrent risk factors and constructed a predictive nomogram for the risk of recurrence. Also, we try to investigate the correlation between CG and bladder cancer.

Methods

Consecutive patients with pathologically confirmed CG were divided into training and validation sets. Clinicopathological characters were collected from electronic medical records. Uni- and multivariate logistic regression analyses were used to identify independent risk factors of CG recurrence in the training set. The predictive nomogram was developed by incorporating these independent factors and histological subtype. The performance of the nomogram was assessed and validated with respects to its calibration, discrimination, and clinical usefulness. The risk of developing subsequent bladder cancer was analyzed from the follow-up data.

Results

Ultimately, 278 eligible patients were included and were allocated to a training set (n=190) and a validation set (n=88). Of them, 165 (59.35%) patients experienced CG recurrence, and none showed evidence of subsequent bladder carcinoma during a median (IQR) follow-up time of 27 months (14–57 months). Results of multivariate analysis showed that urinary infections, long-term indwelling catheter usage, urinary calculus, squamous metaplasia, and atypical hyperplasia were independent risk factors of CG recurrence. The C-index (95% CI) of the nomogram was 0.76 (0.69–0.83) in the training set and 0.72 (0.61–0.83) in the validation set. A decision curve analysis (DCA) demonstrated that this predictive nomogram was clinically useful.

Conclusions

We developed and validated a nomogram to predict the individualized risk of CG recurrence. Also, we demonstrated that neither intestinal nor typical CG increased the consequent risk of bladder cancer during the follow-up period.

Villous Adenoma Arising in the Native Bladder Mucosa and the Upper Urinary Tract With Coexisting Neuroendocrine Carcinoma Following Augmentation Cystoplasty

Villous adenomas arising in the bladder following augmentation cystoplasty procedures are exceedingly rare. Even rarer is their occurrence in the native bladder mucosa and the upper urinary tract. In this article, we present a unique case of multifocal recurrent villous adenoma involving native bladder mucosa of an augmented bladder, bilateral ureters, and renal pelvis, with coexistent foci of adenocarcinoma and neuroendocrine carcinoma, in a patient with history of augmentation colocystoplasty. We additionally discuss the pathogenesis of development of carcinoma in the setting of augmentation cystoplasty.

'No visible lesions?'-an unusual case of Intestinal metaplasia of the bladder

Intestinal metaplasia (IM) of the bladder is an extremely rare benign condition. The clinical features are similar to other bladder tumours. Its pathogenesis is unclear and its role as a precursor of adenocarcinoma has long been debated. Transurethral resection is the main form of treatment for IM. We report the case of a 49-year-old gentleman who presented with visible haematuria. He was submitted to multiple cystoscopies which showed no macroscopic irregularities. Radiological (CT urogram and multiparametric MRI) imaging revealed abnormalities within the bladder neck, suspicious of a neoplastic lesion. Following transurethral resection of his trigonal area, pathology demonstrated IM occurring on a background of cystitis glandularis. This case highlights the unusual difficulty in macroscopically diagnosing IM of the bladder compared to other neoplasms of the bladder. Therefore, in patients with persistent visible haematuria there should be a low threshold to perform biopsies.