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Related theory

Abnormalities of the lower urinary tract

Abnormalities of the lower urinary tract can be identified and in some cases biopsied/treated through flexible cystoscopy. These include:
  • bladder cancer
  • urinary tract infection
  • interstitial cystitis/painful bladder syndrome
  • bladder neck/urethral stricture
  • prostatic enlargement/occlusion
  • bladder stone.
Urinary stents can also be removed using a flexible cystoscope.

Bladder cancer

Most bladder cancers are transitional cell carcinomas (TCC). A minority of bladder tumours are squamous cell carcinomas (SCC). They are broadly categorized into non‐muscle invasive (superficial), muscle invasive and metastatic, depending on the extent to which the cancer is invading into the bladder wall (NICE [111]). Superficial tumours are largely confined to the bladder lining and superficial layers and do not penetrate the muscle layer of the bladder. Deep tumours penetrate the muscular wall of the bladder, and metastatic tumours are present beyond the primary organ (BAUS [18]).
Cancers are graded by their microscopic appearance. The cells of superficial cancers are similar in appearance to normal bladder cells and the tumours are generally slow growing (low grade). High‐grade cancers often behave aggressively. Other factors of prognostic importance are: the number of tumours present, the size of the tumours, and their physical characteristics (EAU [45]).
The biopsy information will enable the staging and grading of the bladder cancer. The grade (Box 20.2) is in accordance with the cells’ appearance and rate of growth. The TNM classification of malignant tumours (Table 20.6) describes the stage of a solid tumour according to its tissue involvement. T is the size of the original tumour, N is the nearby lymph nodes and M is the presence of distant metastasis (Brierley et al. [15]).
Table 20.6  TNM classification of bladder cancer
StageDescription
T – primary tumour
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Ta Non‐invasive papillary carcinoma
Tis Carcinoma in situ: ‘flat tumour’
T1 Tumour invades subepithelial connective tissue
T2 Tumour invades muscle
  T2a Tumour invades superficial muscle (inner half)
  T2b Tumour invades deep muscle (outer half)
T3 Tumour invades perivesical tissue
  T3a Microscopically
  T3b Macroscopically (extravesical mass)
T4 Tumour invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall
  T4a Tumour invades prostate, uterus or vagina
  T4b Tumour invades pelvic wall or abdominal wall
N – lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node in the true pelvis (hypogastric, obturator, external iliac, or presacral)
N2 Metastasis in multiple lymph nodes in the true pelvis (hypogastric, obturator, external iliac, or presacral)
N3 Metastasis in common iliac lymph node(s)
M – distant metastasis
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Source: Brierley et al. ([15]). Reproduced with permission of John Wiley & Sons.
Box 20.2
WHO grading of bladder cancers

Grading of non‐muscle‐invasive bladder urothelial cancer

  • Papillary urothelial neoplasm of low malignant potential (PUNLMP)
  • Low‐grade (LG) papillary urothelial carcinoma
  • High‐grade (HG) papillary urothelial carcinoma

Histological classification for flat lesions

  • Hyperplasia (flat lesion without atypia or papillary aspects)
  • Reactive atypia (flat lesion with atypia)
  • Atypia of unknown significance
  • Urothelial dysplasia
  • Urothelial CIS is always high‐grade
Source: Adapted from Eble et al. ([41]). CIS, carcinoma in situ.
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