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  IN THIS Article
 ::  Introduction
 ::  Material and methods
 ::  Observations
 ::  Discussion
 ::  Acknowledgement
 ::  References

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Year : 1983  |  Volume : 29  |  Issue : 1  |  Page : 10-4

Usefulness of urinary bladder biopsies--study of 98 cases.







How to cite this article:
Ranadive N U, Deodhar K P, Bapat S D. Usefulness of urinary bladder biopsies--study of 98 cases. J Postgrad Med 1983;29:10


How to cite this URL:
Ranadive N U, Deodhar K P, Bapat S D. Usefulness of urinary bladder biopsies--study of 98 cases. J Postgrad Med [serial online] 1983 [cited 2019 Nov 14];29:10. Available from: http://www.jpgmonline.com/text.asp?1983/29/1/10/5561




  ::   Introduction Top

It was observed, over a period that there was a discrepancy between cytoscopic observations and histological findings, particularly in non-neoplastic diseases. Since the final diagnosis and treatment depends upon histological confirmation, it was considered worthwhile to review and assess the usefulness of bladder biopsy in urological diseases by comparing the clinical diagnosis and histological observations.

  ::   Material and methods Top

Ninetyeight urinary bladder biopsies were done from January 1978 till October 1981. The biopsy was taken either by a resectoscope or a cold punch. The patients were followed up in urology O.P.D. and cystoscopy was repeated whenever required.

  ::   Observations Top

The age and sex distribution is shown in [Fig. 1]. Fifty-one patients presented with haematuria; 35 had frequency of micturition, 26 had dysuria and 7 had retention of urine. Two cases had loss of weight and appetite; of these, one had haematuria in addition. One case had a lump in the hypogastrium. According to clinical and cystoscopic findings, the cases were divided in five groups [Table - 1]. In the neoplasia group, cystoscopy showed single or multiple, sessile or papillary growths or polypoidal thickening of mucosa. In tuberculosis group, the patients had radiological evidence of pulmonary kochs together with tubercles (single or multiple) or ulcers on the mucosa, revealed cytoscopically. In the inflammation group, there was bullous oedema and redness or congestion of the mucosa. In groups 4 and 5, there were five cases each. In group 5, all patients had haematuria but cystoscopy did not show any specific lesion.
Comparison between cystoscopy and histopathology is shown in [Table - 2]. Out of 53 cases of bladder growths on cystoscopy, histology was confirmatory in 38 cases. In one out of five cases of cancer cervix the histology showed infiltration in the bladder. In this group, two cases showed dysplasia, one of which on repeat biopsy revealed transitional cell carcinoma. Three cases in this group showed metaplasia, two of squamous type and the third showed cystitis cystica. Cystitis cystica was present in a girl of 8 years, which was associated with vesical calculus. Dysplastic and metaplastic lesions were considered compatible [Table - 4] to the clinical diagnosis due to their precancerous nature.[3], [4] Six biopsies showed chronic cystitis and two showed eosinophilic cystitis. On follow up, the possibility of neoplasia was ruled out in these cases.
Thus in 8 cases new diagnosis was made [Table - 4].
In tuberculosis group, only two out of 17 cases showed confirmatory histology. 9 cases showed chronic cystitis on histology; in 3 of these cases, renal tuberculosis was confirmed subsequently. In two, the nephrectomies done for non-functioning kidneys revealed evidence of ulcerocavernous tuberculosis and in the third the urine culture for A.F.B. was positive. In this group, two patients showed transitional cell carcinoma on histology. Both these patients had radiological evidence of apical Koch's and very high frequency of micturition, but no haematuria. One case, where cystoscopy revealed multiple tubercles almost all over the mucosa, showed follicular cystitis on histology.
In group 3, in nine out of thirteen cases the histology was confirmatory. Two biopsies showed squamous metaplasia in this group, one of which was associated with vesical calculus [Table - 3].
In the miscellaneous group, one case of bladder neck obstruction and post-transplant fistula showed chronic cystitis on histology. Since chronic infection is associated with these conditions, these were considered to be compatible [Table - 4]. Another case of bladder neck obstruction and one single case of neurogenic bladder showed squamous metaplasia.
In group 5, two biopsis showed neoplasia and two showed metaplasia (Squamous-1; Cystitis glandularis-l).
Out of 43 cases of histologically confirmed neoplasia, 38 were transitional cell carcinomas and 3 were squamous cell carcinomas [Table - 3]. One case of primary lymphoma of urinary bladder presented with the lump in the hypogastrium. Five out of seven cases of squamous metaplasia were in females, the vesical trigone being involved in four of them.

  ::   Discussion Top

Diseases of urinary bladder were common in males at the age 40-60 years, and in females between 20 and 40, years. Haematuria, frequency, dysuria were the common symptoms for neoplastic as well as non-neoplastic diseases. A single case of primary lymphoma of bladder presented with the lump in the hypogastrium, thus the palpable bladder indicates worst type of malignancy. On cystoscopy, in 2 out of 58 cases dysplasia was mistaken for malignancy. A single case of dysplasia which was subsequently diagnosed as neoplasia could be due to the sampling error, as dysplasia is known to occur in the vicinity of malignant urothelium.[1] Histology showed metaplasia in 3 cases where neoplasia was suspected on cystoscopy. Totally out of 98 cases, 9 cases showed metaplasia on histology. Five cases of squamous metaplasia were in females, the vesical trigone being involved in four. The commonness of squamous metaplasia in females is attributed to the hormonal influence on the vesical mucosa especially at the trigone.[6] One case of neurogenic bladder also showed squamous metaplasia. Prolonged use of indwelling catheter in neurogenic bladders can lead to squamous metaplasia as well as squamous cell carcinomas.[2] Both metaplastic and neoplastic diseases were associated with vesical calculus [Table - 3]. It is well established that bladder calculus can lead to squamous or glandular metaplasia which can develop subsequently to squamous cell carcinoma or adenocarcinoma respectively. Its presence in a single case of transitional cell carcinoma indicates that it may promote dysplastic change in the urothelium which can develop further into transitional cell carcinoma probably under the influence of the same or in association with other promoting carcinogenic agent. Dysplastic and metaplastic lesions are precancerous and there is a long latent period for carcinogenesis. A long term follow up is, therefore, necessary in these cases. Chronic cystitis, (6/58) and eosinophilic cystitis (2/58) were mistaken for malignancy probably due to the presence of accompanying oedema and congestion of the bladder wall. Eosinophilic cystitis simulating malignancy both clinically and cystoscopically has been reported.[5]
Diagnosis of renal tuberculosis is rather difficult, as the patients manifest clinically late, only after the extensive damage of renal parenchyma. Bladder biopsy is one of the means of diagnosis. In the present series, the histology was confirmatory in two out of 17 suspected cases. But, in 3 cases renal tuberculosis was confirmed subsequently. The failure to detect tuberculosis on histology inspite of cystoscopic evidence of tubercles could be due to the sampling error. Thus, the bladder biopsy may have a limited value in the diagnosis of renal tuberculosis. Yet once confirmed, the treatment could be started. immediately as against urine culture for AFB where nearly six weeks are required for the diagnosis. In two suspected cases of tuberculosis, malignancy mimiced tuberculosis. Follicular cystitis, a variety of chronic cystitis characterised by the presence of reactive follicles in submucosa, was also mistaken for tuberculosis on cystoscopy. In four patients presenting only with haematuria and in whom cystoscopy was non-contributory, histology showed transitional cell carcinoma in two and cystitis glandularis and squamous metaplasia in one each. Thus, the patients with haematuria and normal cystoscopic findings should be biopsied and followed up clinically.
The biopsy was unhelpful in 21 cases (21.4%); of these, 57.7% (12/21) were from the tuberculous group. In neoplasia group, 6 out of 58 cases were unhelpful. Three of these showed normal mucosa, which could be due to the sampling error. The remaining were either inadequate or necrotic biopsies which could be due to the technical error.

  ::   Acknowledgement Top

The authors thank Dr. B. R. Kalke, Dean, L.T.M.G. Hospital and L.T.M. Medical College for permission to publish this material. We also thank Dr. Sanghvi, Tutor in the Department of Urology, for his kind co-operation.

  ::   References Top

1.Cooper, P. M., Waisman, J., Johnston, W. H. and Skinner, D. G.: Severe atypia of transitional epithelium and carcinoma of urinary bladder, Cancer, 31: 1055-1060, 1973,  Back to cited text no. 1    
2.Kaufman, J. M., Fam, B. K., Jacobs, S. C., Gabilondo, F., Yalla, S., Kane, J. P. and Rossier, A. B.: Bladder cancer and squamous metaplasia in spinal cord injury patients, J. Urol., 118: 967-971, 1977.  Back to cited text no. 2    
3.Koss, L. G.: Tumours of urinary bladder, In, "Atlas of Tumour Pathology" Fasicle 11, Second series. Armed Forces Institution of Pathology, Washington, D.C., 1975, pp. 62-69.  Back to cited text no. 3    
4.Koss, L. G.: Tumours of urinary bladder. In, "Atlas of Tumour Pathology". Fasicle 11, Second Series, Armed Forces Institute of Pathology, Washington, D.C., 1975, pp. 103-104.  Back to cited text no. 4    
5.Pugh, R. C. B.: Histopathology. In, "Scientific Foundations of Urology". Vol. II, Editors: Williams, D. I., and Chishlom, G. D. First Edition, William Helnemann Medical Books Ltd., London, 1976, pp. 296-297.  Back to cited text no. 5    
6.Tyler, D. E.: Stratified squamous epithelium in the vesical trigone and urethra; findings correlated with the menstrual cycle and age, Amer. J. Anat., 111: 319-335, 1962.  Back to cited text no. 6    

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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