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Rapid development of carcinoma in diverticulum of the bladder
RAPID
DEVELOPMENT
DIVERTICULUM A Pitfall JOHN
STEPHEN PATRICK
OF THE
in Conservative
R. PICONI,
OF CARCINOMA
IN
BLADDER
Management
M.D.
C. HENRY, C. WALSH,
From the Department San Diego, California
M.D. M.D.* of Urology,
U.S. Naval Hospital,
ABSTRACT-The poor prognosis associated with carcinoma in diverticula of the bladder is well documented. This case report demonstrates the rapid development of carcinoma in a diverticulum of the bladder within a four-month--period of observation, and suggests that early surgical excision is indicated.
The reported incidence of carcinoma developing in diverticula of the bladder ranges from 4 to 7 per cent. 1*2 Because these tumors are predominantly high grade and penetrate the thin wall of the diverticula, early survival rates are poor. Of 19 patients treated at the Mayo Clinic, 16 died within two years.l Despite this poor outlook, early surgical excision is not frequently undertaken in patients with diverticula of the bladder. The following case report, in which malignant transformation occurred within a four-month period, emphasizes the difficulty and hazards of conservative management. Case Report A fifty-two-year-old white man was admitted in May, 1972, with a history of recurrent episodes of cystitis and bladder calculi. He had a past history of obstructive symptoms of the lower urinary tract as a child and young adult, presumably due to tight phimosis, which were relieved by circumcision at the age of eighteen. Eight years prior to admission pyelonephritis developed on the left side during passage of “Present address: Department of Internal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235.
676
a ureteral calculus. Thereafter frequent attacks of cystitis occurred which were treated with oral antibiotics. Urologic consultation was obtained when symptoms persisted despite therapy. Physical examination was unremarkable. The urine was alkaline, contained many white cells and bacteria, and culture was positive for pseudomonas. An intravenous pyelogram showed mild blunting of the intrarenal collecting systems bilaterally. There was a large, smooth-walled diverticulum of the bladder which displaced the left distal ureter medially (Fig. 1A). Postvoid residual urine was 150 cc. At cystoscopy the diverticulum was seen at the lateral edge of the left hemitrigone, and a Brown-Burger cystoscope easily passed into it permitting complete visualization of normal mucosa. The urethra was unobstructed by stricture or prostatic hypertrophy. Although diverticulectomy was advised, the patient refused and was managed conservatively. Four months later recurrent infections despite antibiotic therapy prompted repeat urologic evaluation. The intravenous pyelogram now showed an irregular filling defect in the superior portion of the diverticulum (Fig. 1B). Cystoscopy confirmed an elevated broad-based lesion in the diverticulum. A left hemicystectomy, distal ureterectomy, pelvic lymphadenectomy, and a left-to-right transureteroureterostomy
UROLOGY
/
DECEMBER
1973
/
VOLUME
II, NUMBER 6
diverticulum FIGURE 1. (A) Large, smooth-walled filling defect in superior portion of diverticulum.
was performed. The tumor was a Grade I squamous-cell carcinoma with invasion of perivesical fat. There were no positive lymph nodes. Comment A common approach to the uncomplicated diverticulum of the bladder in men is relief of outflow obstruction. Complications such as infection or stone formation are often treated with antibiotics or resection of the neck of the diverticulum. Kelalis and McLean,’ however, demonstrated that despite transurethral resection of the prostate or resection of the neck of the diverticulum, malignant transformation occurred in 7 of 19 patients. They recommended prophylactic excision of all diverticula of the bladder in patients under seventy years of age. However, many patients are still managed conservatively, relying upon periodic examinations to detect the development of tumor.
UROLOGY
I DECEMBER 1973 / VOLUME II, NUMBER 6
of bladder;
(B) intravenous
pyelogram
showing
irregular
Summary The development of invasive squamous-cell carcinoma in a diverticulum of the bladder within a four-month period of observation has been reported. This case indicates that cystoscopy at frequent intervals may be necessary to detect malignant transformation before invasion occurs. Because this is impractical, surgical excision of diverticula of the bladder in the healthy patient appears warranted. Urology Department U.S. Naval Hospital San Diego, California 92134 (DR. PICONI) References 1. KELALIS, P. P., and MCLEAN, P.: The treatment of diverticulum of the bladder, J. Urol. 98: 349 (1967). 2. KNAPPENBERGER, S. T., USON, A. C., and MEYER, M. M.: Primary neoplasms occurring in vesicle diverticula: a report of 18 cases, ibid. 83: 153 (1960).
677
DEVELOPMENT
DIVERTICULUM A Pitfall JOHN
STEPHEN PATRICK
OF THE
in Conservative
R. PICONI,
OF CARCINOMA
IN
BLADDER
Management
M.D.
C. HENRY, C. WALSH,
From the Department San Diego, California
M.D. M.D.* of Urology,
U.S. Naval Hospital,
ABSTRACT-The poor prognosis associated with carcinoma in diverticula of the bladder is well documented. This case report demonstrates the rapid development of carcinoma in a diverticulum of the bladder within a four-month--period of observation, and suggests that early surgical excision is indicated.
The reported incidence of carcinoma developing in diverticula of the bladder ranges from 4 to 7 per cent. 1*2 Because these tumors are predominantly high grade and penetrate the thin wall of the diverticula, early survival rates are poor. Of 19 patients treated at the Mayo Clinic, 16 died within two years.l Despite this poor outlook, early surgical excision is not frequently undertaken in patients with diverticula of the bladder. The following case report, in which malignant transformation occurred within a four-month period, emphasizes the difficulty and hazards of conservative management. Case Report A fifty-two-year-old white man was admitted in May, 1972, with a history of recurrent episodes of cystitis and bladder calculi. He had a past history of obstructive symptoms of the lower urinary tract as a child and young adult, presumably due to tight phimosis, which were relieved by circumcision at the age of eighteen. Eight years prior to admission pyelonephritis developed on the left side during passage of “Present address: Department of Internal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235.
676
a ureteral calculus. Thereafter frequent attacks of cystitis occurred which were treated with oral antibiotics. Urologic consultation was obtained when symptoms persisted despite therapy. Physical examination was unremarkable. The urine was alkaline, contained many white cells and bacteria, and culture was positive for pseudomonas. An intravenous pyelogram showed mild blunting of the intrarenal collecting systems bilaterally. There was a large, smooth-walled diverticulum of the bladder which displaced the left distal ureter medially (Fig. 1A). Postvoid residual urine was 150 cc. At cystoscopy the diverticulum was seen at the lateral edge of the left hemitrigone, and a Brown-Burger cystoscope easily passed into it permitting complete visualization of normal mucosa. The urethra was unobstructed by stricture or prostatic hypertrophy. Although diverticulectomy was advised, the patient refused and was managed conservatively. Four months later recurrent infections despite antibiotic therapy prompted repeat urologic evaluation. The intravenous pyelogram now showed an irregular filling defect in the superior portion of the diverticulum (Fig. 1B). Cystoscopy confirmed an elevated broad-based lesion in the diverticulum. A left hemicystectomy, distal ureterectomy, pelvic lymphadenectomy, and a left-to-right transureteroureterostomy
UROLOGY
/
DECEMBER
1973
/
VOLUME
II, NUMBER 6
diverticulum FIGURE 1. (A) Large, smooth-walled filling defect in superior portion of diverticulum.
was performed. The tumor was a Grade I squamous-cell carcinoma with invasion of perivesical fat. There were no positive lymph nodes. Comment A common approach to the uncomplicated diverticulum of the bladder in men is relief of outflow obstruction. Complications such as infection or stone formation are often treated with antibiotics or resection of the neck of the diverticulum. Kelalis and McLean,’ however, demonstrated that despite transurethral resection of the prostate or resection of the neck of the diverticulum, malignant transformation occurred in 7 of 19 patients. They recommended prophylactic excision of all diverticula of the bladder in patients under seventy years of age. However, many patients are still managed conservatively, relying upon periodic examinations to detect the development of tumor.
UROLOGY
I DECEMBER 1973 / VOLUME II, NUMBER 6
of bladder;
(B) intravenous
pyelogram
showing
irregular
Summary The development of invasive squamous-cell carcinoma in a diverticulum of the bladder within a four-month period of observation has been reported. This case indicates that cystoscopy at frequent intervals may be necessary to detect malignant transformation before invasion occurs. Because this is impractical, surgical excision of diverticula of the bladder in the healthy patient appears warranted. Urology Department U.S. Naval Hospital San Diego, California 92134 (DR. PICONI) References 1. KELALIS, P. P., and MCLEAN, P.: The treatment of diverticulum of the bladder, J. Urol. 98: 349 (1967). 2. KNAPPENBERGER, S. T., USON, A. C., and MEYER, M. M.: Primary neoplasms occurring in vesicle diverticula: a report of 18 cases, ibid. 83: 153 (1960).
677