LASER TURBT: THULIUM LASER FOR TURBT

A 45 year old patient presented to us with hematuria,dysuria and left flank pain.On investigations we found that he had a 3 cm lesion over the left vesicoureteric junction with left hydro-ureteronephrosis.

We took him up for LASER TURBT.The tumor was covering the orifice. We used 70 W setting and did the complete resection of the tumor.The ureteric orifice could be detected after the completion of the TURBT. We did the stenting for the left side and sent the specimen for histopathological analysis.

The bladder is a hollow organ in the lower abdomen. It stores urine, the urine produced by the kidneys. Urine passes from each kidney into the bladder through a long cylindrical tube called a ureter. Urine leaves the bladder through another tube, the urethra. 

Understanding bladder cancer 

The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is 

called transitional cell carcinoma.  Cancer that is only in cells in the lining of the bladder is called superficial bladder cancer. Cancer that begins as a superficial tumors may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina (in women) or the prostate gland (in men). It also may invade the wall of the abdomen. When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver, or bones.Some of the lymph node spread like para-aortic lymph nodes or nodes at the aortic bifurcation may denote the metastatic disease precluding surgery and indicating the need of chemotherapy rather than a curative option. When cancer spreads from its original place to another part of the body, the disease is metastatic bladder cancer. Less than 10% of the carcinomas are squamous cell carcinoma or adenocarcinoma. In underdeveloped nations, SCC is associated with bladder infection by Schistosoma haematobium(In india, this infection is found at the coastal belt of Maharashtra region) . Adenocarcinomas account for less than 2% of primary bladder tumors. These tumors are observed most commonly in exstrophic bladders and respond poorly to radiation and chemotherapy. Radical cystectomy is the treatment of choice. Small cell carcinomas are extremely aggressive tumors associated with a poor prognosis and are thought to arise from neuroendocrine stem cells. 

Pathophysiology:

The World Health Organization classifies bladder cancers as low grade (grade 1 and 2) or high grade (grade 3). Tumors are also classified by growth patterns: papillary (70%), sessile or mixed (20%), and nodular (10%). Carcinoma in situ (CIS) is a flat, noninvasive, high-grade urothelial carcinoma. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of CIS. Upon presentation, 55-60% of patients have low-grade superficial disease, which is usually treated conservatively with transurethral resection and periodic cystoscopy. Forty to forty-five percent of patients have high-grade disease, of which 50% is muscle invasive and is typically treated with radical cystectomy. 

Bladder cancer: Who's at risk? 

No one knows the exact causes of bladder cancer. However, it is clear that this disease is not contagious. People who get bladder cancer are more likely than other people to have certain risk factors. Still, most people with known risk factors do not get bladder cancer, and many who do get this disease have none of these factors( so a clear cut cause and effect relationship may not be obtained in all cases). Doctors always find themselves in dilemma when a patient asks why he got the disease and ends up in answering a multi factorial cause for the cancer. Studies have found the following risk factors for bladder cancer: 1. Age. The chance of getting bladder cancer goes up as people get older. People under 40 rarely get this disease. 2. Sex: Men are likelier to get the disease than the females(3-4:1) 3. Tobacco. The use of tobacco is a major risk factor. Cigarette smokers are two to three times more likely than nonsmokers to get bladder cancer. Pipe and cigar smokers are also at increased risk.  4. Occupation. Some workers have a higher risk of getting bladder cancer because of carcinogens in the workplace. Workers in the rubber, chemical, and leather industries are at risk. So are hairdressers, machinists, metal workers, printers, painters, textile workers, and truck drivers. 5. Infections. Being infected with certain parasites(like scistosomiasis) increases the risk of bladder cancer. 6. Treatment with cyclophosphamide or arsenic. These drugs are used to treat cancer and some other conditions. They raise the risk of bladder cancer. 7. Race. Whites get bladder cancer twice as often as African Americans and Hispanics. The lowest rates are among Asians. 8. Family history. People with family members who have bladder cancer are more likely to get the disease. Certain genes have been identified as the cause for the development or progress of the disease. Symptoms of bladder cancer 

Common symptoms of bladder cancer include: 

• Blood in the urine (making the urine slightly rusty to deep red), • Pain during urination • Frequency, or urgency. • Dysuria- especially if Carcinoma in Situ has been the cause • Weak stream: especially if bladder neck region is affected as in our second case. • Flank pain: In case of bladder tumor blocking one of the orifices the kidney can get swelled up(Hydro-ureteronephrosis) and the patient can have the flank pain because of that reason. These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones, also can cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. 

Diagnosis of bladder cancer 

• Physical exam -- The doctor feels the abdomen and pelvis for tumors. The physical exam may include a rectal or vaginal exam; this is useful in advanced disease spreading to the pelvic wall precluding probably a complete resection(so called R0 resection). 

• Urine tests -- The laboratory checks the urine for blood, cytology.

• Intravenous pyelogram/ CT UROGRAPHY: The radiologist injects the dye(radio-contrast one) to delineate the kidneys and bladder region mainly for assessing the upper tracts. As the bladder cancer has a tendency for a field change (it may affect many regions of the genitourinary tract simultaneously or metachronously) the imaging can detect such changes. The CT urography/MRI is now-a-days more and more resorted to for its reliability in staging the local disease.It also vaguely indicates the lymphnode status  

• Cystoscopy – An endoscope is inserted into the bladder through the urethra to examine the lining of the bladder. The patient may need anesthesia for this procedure as the same sitting can be utilized for diagnosis/biopsy/complete resection of a superficial tumor. 

Staging 

The following is the TNM staging system for bladder cancer: • CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium • Ta - Papillary tumor confined to the epithelium • T1 - Tumor invasion into the lamina propria • T2 - Tumor invasion into the muscularis propria • T3 - Tumor involvement of the perivesical fat • T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall • N+ - Lymph node metastasis • M+ - Metastasis More than 70% of all newly diagnosed bladder cancers are non–muscle invasive, approximately 50-70% are Ta, 20-30% are T1, and 10% are CIS. Approximately 5% of patients present with metastatic disease, which commonly involves the lymph nodes, lung, liver, bone, and central nervous system. Approximately 25% of affected patients have muscle-invasive disease at diagnosis.  

Treatment • Ta, T1, and CIS Endoscopic treatment

  Transurethral resection of bladder tumor (TURBT) is the first-line treatment to diagnose, to stage, and to treat visible tumors. 

 Patients with bulky, high-grade, or multifocal tumors should undergo a second procedure to ensure complete resection and accurate staging. Approximately 50% of stage T1 tumors are upgraded to muscle-invasive disease.This procedure is called as Relook TURBT and is usually undertaken after a period of 4 weeks to restage the disease 

 Because bladder cancer is a polyclonal field change defect, continued surveillance is mandatory with IVP/CT Urography for upper tract affections.