Clinicopathologic characterization of intradiverticular carcinoma of urinary bladder - a study of 22 cases from a single cancer center

Clinical Presentation, Tumor Characteristics, and Management of Intradiverticular Transitional Cell Carcinoma of the Urinary Bladder: A Systematic Review

Intradiverticular transitional cell carcinoma (TCC) of the bladder poses unique challenges due to its presentation within the bladder diverticula. This review synthesizes current knowledge on the diagnosis and management of this condition, emphasizing the need for early detection to optimize patient outcomes. The literature underscores the importance of tailored treatment strategies, ranging from radical surgeries to adjuvant chemotherapy, to combat the aggressive nature of intradiverticular TCC. Additionally, stringent post-treatment surveillance protocols are vital in addressing high recurrence rates. Future research directions include biomarker identification, comparative efficacy studies of treatment modalities, and the exploration of innovative therapeutic approaches such as immunotherapy. Longitudinal studies analyzing patient outcomes will provide valuable insights into survival rates and quality of life post-treatment, informing future clinical guidelines. This comprehensive review aims to enhance understanding and management strategies for intradiverticular TCC, paving the way for improved patient care and outcomes in this challenging form of bladder cancer.

[New WHO classification 2022: urinary bladder cancer]

The new World Health Organization (WHO) classification of urogenital tumors is still primarily based on anatomic location, but is also a hierarchical taxonomic classification without separate chapters for tumors of the upper urinary tract and the urethra. It clarifies aspects regarding grading and noninvasive entities. It consolidates the use of the Paris system for urinary cytology as well as various subtypes/special types of neoplasms, and incorporates general concepts of the 5th edition of the WHO blue book. In addition to mesenchymal tumors, well-differentiated neuroendocrine tumors and neuroendocrine carcinomas are addressed in separate chapters. Papillary non-invasive low- and high-grade carcinomas and carcinoma in situ remain, while dysplasia and urothelial proliferation of unknown malignant potential (UPUMP) are no longer treated as separate entities. Former variants of urothelial carcinoma are now called subtypes and aberrant differentiation and special types are more precisely defined.

Urothelial carcinoma in a urinary bladder diverticulum: A case report and review of the literature

Bladder diverticula are defined as an outpouching of the mucosa into the muscle layer of the bladder wall. There is a well-known link between urinary bladder diverticula and tumors arising within the diverticula. They are rare with an incidence rate of 0.8%-10%. We report an intradiverticular urothelial carcinoma in a 72-year-old man with a known history of multiple episodes of acute urinary retention and urinary tract infections, followed by transurethral resection of the benign prostatic hyperplasia.

Diagnosis and management of intradiverticular bladder tumours: A pooled analysis of 498 cases

OBJECTIVE

Intradiverticular bladder tumors (IDBT) are uncommon clinical entities. We reviewed the literature for clinical presentation, diagnosis and therapeutic options to establish recommendations for diagnostic and therapeutic management.

METHODS

Bibliographic research was performed using PubMed from database inception until October 15, 2022. A pooled analysis was performed of 498 patients with IDBT presented in the literature. The evaluation included patient sex, age, diagnostic methods, symptoms, localization of the tumor, tumor staging, tumor histopathology, treatment, and the presence of recurrence. To express results, descriptive statistics were used appropriately.

RESULTS

The mean age at diagnosis was 64.81 years (range 49 days to 84 years). The ratio between men and women was ≈ 24:1, suggesting a male predominance (85% male, 3.6% female). The most common presenting symptom was gross hematuria (60.88%). Most of the patients had cystoscopy (56.85%) and intravenous or computed tomography urography (52.01%). Regarding tumor staging, most of the patients were diagnosed with pT1 tumors. For the histopathology of IDBT, 87.95% of the specimens were transitional cell carcinomas and in 10.84% there were concomitant CIS. Regarding the treatment, radical cystectomy was chosen in 34.34%, partial cystectomy in 26.66%, diverticulectomy in 15.95% and transurethral resection of bladder tumour (TURBT) in 16.36% of the patients.

CONCLUSIONS

Most common diagnostic tool for IDBT seems to be cystoscopy followed by computerized tomography urogram. Due to the absence of muscle layer in the diverticulum and the highgrade histology of most of them at diagnosis, cystectomy is the first therapeutic choice. However, for patients that are not considered appropriate candidates or for those presenting with lowgrade and low volume tumors, TURBT is a good option.

Prognostic Utility of MRI Features in Intradiverticular Bladder Tumor

BACKGROUND

Intradiverticular bladder tumors (IDBT) are rare but clinically important, as they are difficult to assess endoscopically due to limited anatomic access and risk of perforation. MRI may be helpful in assessing IDBT and providing relevant staging and prognostic information.

PURPOSE

To assess MRI findings of IDBT and their relationship with overall survival.

METHODS

This retrospective study included 31 consecutive patients with IDBT undergoing MRI from 2008 to 2018 identified through electronic medical records and PACS database search. Two radiologists independently assessed the following MRI features: size (>3 vs ≤3 cm), diverticular neck involvement, Vesical Imaging-Reporting and Data System (VI-RADS) score (>3 vs ≤3), perivesical fat infiltration, additional tumors and suspicious pelvic lymph nodes. Overall survival was estimated using Kaplan-Meier analysis; and the relationship with clinicopathological and MRI features was determined using the Cox proportional-hazards regression model. Inter-reader agreement was assessed using intraclass correlation coefficients (ICC) and Cohen's kappa (K).

RESULTS

Median follow-up was 1044 days (interquartile range, 474-1952 days). Twenty-six (83.9%) patients underwent surgical treatment with or without neoadjuvant chemotherapy. On MRI, greater tumor size (>3 cm), diverticular neck involvement, perivesical extension, and suspicious lymph nodes were associated with lower overall survival (HR = 3.6-8.1 and 4.3-6.3 for the 2 radiologists, p ≤ 0.03). Other clinicopathological or MRI findings were not associated with survival (p = 0.27-0.65). Inter-reader agreement was excellent for tumor size (ICC = 0.991; 95% CI 0.982-0.996), fair for VI-RADS (K = 0.52, 95% CI, 0.22-0.82), and moderate for others (K = 0.61-0.79).

CONCLUSION

In patients with IDBT, several MRI features were significantly associated with overall survival. Utilizing all available clinicopathological and imaging information may improve estimation of prognosis.

Robot-Assisted Laparoscopic Bladder Diverticulectomy: Adaptation of Techniques for a Variety of Clinical Presentations

OBJECTIVE

To report our experience in robot-assisted laparoscopic bladder diverticulectomy (RALBD) with a focus on technical modifications aimed at accommodating for differences in anatomy and pathologies.

MATERIALS AND METHODS

A prospective database was maintained for 20 patients who had RALBD at our institution. Clinicopathological and follow-up details including concomitant procedure performed were reviewed for each case. Two patients had intra-diverticular urothelial carcinoma refractory to endoscopic and intravesical management. The dissection of the diverticular neck was performed utilising one of the 3 approaches: extravesical (8 of 20 patients), transvesical (11), and trans-diverticular (1). Pre and postoperative postvoid residual and International Prostate Symptom Score were compared using paired-sample t test. In addition, 6 patients underwent open bladder diverticulectomy during the period and their perioperative parameters were compared with the RALBD group.

RESULTS

The median age was 66 and the average BMI was 27.2. Thirteen patients underwent major concomitant urologic procedures. Mean operative duration was 184 minutes with average length of hospital stay at 2.1 days. One Clavien 3 complication was encountered. There were significant improvements in pre & postoperative postvoid residual (425-49 ml, P = .000) and International Prostate Symptom Score (19-6, P = .033). When compared to open bladder diverticulectomy, RALBD is associated with reductions in blood loss (100 ml vs 283 ml, P = 0.003).

CONCLUSION

Despite the wide variability in clinical presentations, RALBD is associated with minimal surgical morbidity and good perioperative outcomes. It can be safely performed in conjunction with other major urologic procedures in the pelvis.

Management of Intradiverticular Bladder Tumours: A Systematic Review

The aim of this systematic review was to present available data on diagnostic and therapeutic options in intradiverticular bladder tumour cases. A literature search within the Medline database was conducted in March 2019 with combinations of the following search terms: bladder cancer, bladder tumour, bladder diverticulum, diverticulum, intradiverticular. Seventeen relevant articles were identified. Diagnostic and therapeutic options for intradiverticular bladder tumour follow the general management of bladder cancer patients. The most important differences include a higher rate of non-urothelial histology, higher rate of invasive cancers (stage T1 and higher), no stage T2 disease due to lack of a muscularis propria layer and potential role of partial cystectomy or diverticulectomy in the treatment. Among cystectomized patients, the survival is comparable to general bladder cancer patients after cystectomy. Data on accuracy of imaging and endoscopy in diagnosing intradiverticular bladder tumour are poor. There is no study comparing different treatment modalities in intradiverticular bladder tumour patients. Limitations of this review include low number and low evidence level of available studies, as well as low number and heterogeneity of enrolled subjects. Available literature data cannot be the basis for clinical recommendations in intradiverticular bladder tumour cases. While bladder cancer is the most common urinary tract malignancy and at least 1% of cases are intradiverticular, further research in this field is justified.

Challenges in Pathologic Staging of Bladder Cancer: Proposals for Fresh Approaches of Assessing Pathologic Stage in Light of Recent Studies and Observations Pertaining to Bladder Histoanatomic Variances

The paradigm of pathologic stage (pT) categorization in bladder cancer remains the depth of invasion into the different histologic layers of the bladder wall. However, the approaches to assigning pT stage category toward an enhanced outcome stratification have been marked by challenges and innovations, due in part to our growing appreciation of the surprisingly perplexing bladder histoanatomy. Upstaging of pT1 tumors after radical cystectomy is substantial and underscores the potential value of pT1 substaging in transurethral resection (TUR) specimens. The 2017 American Joint Committee on Cancer tumor-node-metastasis system recommends pT1 substaging but recognizes the need to optimize the approach. Over the years, the cut-off for microinvasion has been significantly lowered to 0.5 mm and is now a promising scheme for pT1 (micrometric) substaging. Unlike the micrometric approach, histoanatomic substaging using muscularis mucosae (MM) and vascular plexus as landmarks is less feasible in TUR specimens and inconsistent in stratifying the outcome of pT1 tumors. The lamina propria possesses inherent variations in depth, MM, and vascular plexus dispositions that should be factored in future pT1 substaging proposals. Histoanatomic variations among the bladder regions also occur, and studies suggest that trigone and bladder neck cancers may have more adverse outcomes. The muscularis propria (MP), besides being the essential histologic landmark for assigning pT2 stage category, is also considered a surrogate for the adequacy of TUR, furthering the importance of identifying its presence in TUR specimens. MP, however, may be mimicked by hyperplastic or isolated MP-like MM muscle bundles in the lamina propria with overstaging implications, and caution should be exercised in distinguishing these 2 muscle types morphologically and immunohistochemically. Presence of additional superficial MP unique from the detrusor muscle proper may also complicate staging at the trigone and ureter insertion sites. With regard to the depth of MP invasion, large and multicenter studies have reaffirmed the prognostic significance of pT2a/b subcategories. It is revealed that there are at least 3 ways used to demarcate the irregular MP to perivesical soft tissue junction, and use of a common criterion indicates improvement in pT2b/pT3a staging reproducibility. Although studies have shown significantly poorer outcome in pT3b compared with pT3a tumors, this designation has a substantial reliance on the prosector's gross assessment of perivesical soft tissue invasion which if performed incorrectly may lead to staging inaccuracy of pT3 tumors. The 8th edition of the American Joint Committee on Cancer has updated the staging schema for bladder cancers with concomitant prostatic stromal invasion and cancers within bladder diverticula. Because of 2 possible pT designations, prostatic stromal invasion in TUR specimens should not be automatically staged as either pT4a or pT2 (urethral). Recent data support that bladder cancer invading into the seminal vesicle has comparable outcome to pT4b tumors. Interestingly, several studies in pT4a tumors, which are staged based on sex-specific organs, have shown poorer outcome in females than males after radical cystectomy, and while there are possibly several reasons, they may also include anatomic factors. Despite the progress has been made, work remains to be done to inform future bladder cancer pT category definitions and their reproducibility in application and prognostication.

Diverticulectomy in the Management of Intradiverticular Bladder Tumors: A Twelve-Year Experience at a Single Institution

Purpose. In this retrospective case review we analyze the outcomes of patients treated for intradiverticular bladder tumors (IDT). Materials and Methods. A retrospective case review was done between January 2002 and May 2014 in Hotel-Dieu de France hospital. The series included 17 patients diagnosed with IDT, all males with a mean age of 49.8 years. Results. One patient was treated with tumor resection and adjuvant BCG instillation with no recurrence on follow-up cystoscopies and urine cytologies. 64% of patients were treated by diverticulectomy. Mean follow-up time was 38.7 months. At the end of the follow-up, 81% were disease-free. One patient had a radical cystectomy 6 months after diverticulectomy for recurrent high grade tumor; another one had a nodal metastasis 10 months after diverticulectomy and was managed with chemotherapy. 29% of patients were treated with radical cystectomy. Mean follow-up time was 28.4 months. No recurrence was documented on annual CT scans. Conclusions. Our data support a conservative approach for tumors confined to the bladder diverticulum, even in high grade or in the presence of CIS provided complete removal is feasible and close follow-up is ensured.