S. Adeebul Hassan Rizvi ( Department of Urology, Dow Medical College and Civil Hospital, Karachi. )
S. Anwar Naqvi ( Department of Urology, Dow Medical College and Civil Hospital, Karachi. )
A retrospective review of 250 cases of carcinoma of the urinary bladder is presented. The peak age group was 40-60 years and male/female ratio was 14:1. One hundred and sixty seven (89.8%) patients had transitional cell carcinoma and in 42% the lateral wall was the site of tumour. Papillary tumours were seen in 218 (87.2%) cases. Radiotherapy and surgery combined was the most frequent mode of treatment (119 cases: 47.6%). The 5 years survival rate was 17% (JPMA 31:102, 1981).
Carcinoma of the urinary bladder remains a problem of considerable importance and its management still poses a challenge in a developing country like Pakistan. Some times the disease is too far advanced when discovered, rendering radical treatment impossible, or radical treatment may be refused by the patient.
Patients and Methods
Two hundred and fifty patients with carcinoma of bladder were admitted to the Urology unit between 1974 and 1979. Carcinoma bladder accounted for 9.8% of the 2553 admissions during this period.
Clinical history and physical findings were recorded. Investigations included haemoglobin, total and differential leucocyte count, blood urea, serum electrolytes, excretory urogram, urinalysis and cystoscopy. Biopsy was done in 186 cases whereas endoscopy alone was the basis of diagnosis in 64 cases.
The patients had surgery, radiotherapy and chemotherapy either alone or in combination. Thirty six patients refused treatment.
Geographical variations have been observed in malignant lesions of the urinary bladder.
The average age in this series is 53.2 years with peak age group between 40-60 years which is moderately lower when compared with the series from Western countries. Payne (1959) gave an average age incidence of 63.5 years with only 12% cases under the age of 50 years. Whitmore and Marshall (1962) found the average age in his series to be 58 years. Miller, Mitchell and Brown (1969) reported the maximum incidence in the seventh decade.
Squamous cell carcinoma associated with bilharzial bladder, however, had a lower average age of 46.3 years (El Bouklany et al., 1972).
The male to female ratio of 14:1 is not usual in other series. Morrison and Cole (1976) found male preponderance in bladder cancer in all nations where studies were undertaken. In the United States the male/female ratio is 2:1 (Gittes, 1979). Payne (1959) records a male preponderance of 4.1:1 and Dodge (1962) found it to be 10:1. Failure of the females to submit to urological examination in this Country may account for this finding.
Only 46 percent of the patients presented within 6 months of onset of symptoms. The majority, over 54%, presented 6 months to 2 years after the symptoms occurred. Massey and associates (1965) found that 60% of the patients consulted physicians within 3 months of onset of symptoms. The unusual delay in presentation appears to be, in part, responsible for the poor survival rate.
This study failed to include the role of exogenous carcinogens including smoking in the etiology of bladder cancer. Future studies should enquire into this aspect of bladder carcinogenesis. Another lacunae in this review is the paucity of accurate staging of the disease. This was partly due to a large number of endoscopies being done under local anaesthesia. General anaesthesia in any country has the connotation of a major procedure and is often avoided by our patients.
Haematuria was the commonest presenting symptoms (66%). This compares favourably with the studies of others where the incidence of haematuria has varied from 66.85% (Ash, 1940; Flocks, 1951; Massey et al., 1965)
Transitional cells carcinoma is the commonest type of tumour (89 8%) which is again similar to other studies. Miller, Mitchell and Brown (1969) found transitional ceil as the commonest malignancy of bladder averaging 90-95%. Payne (1959*) records 962 cases of bladder tumours of which 92.5% were transitional cell carcinoma.
Delay in diagnosis and patient resistance to radical surgery are two important impediments in the treatment of carcinoma of bladder in this study. Barnes et al (1967) had 63% 5 years survival in stage A, 40% in stage B and 5% in stage C on endoscopic resection. Marshall et al (1956) showed 63% survival in stage A and 22% in stage C employing partial cystectomy. Riches (1960) had 42% survival in stage A, 9% in stage B2 and only 4% in stage C performing simple cystectomy. Radical cystectomy combined with radiotherapy in a series by Whitmore et al (1977) had 56% survival in stages OAB1 and only 14% in stage D1 D2. By comparision the 5 years survival rate in this series is 17%. However, the selection employed in the series of others and the inherent limitation in diagnosis and treatment, as mentioned earlier, could explain the difference.
1. Asb, J.E. (1940) Epithelial tumour of bladder. J. Urol., 44:135.
2. Barnes, R.W., Bergman, R.T., Hadley, H.L. and Love, D. (1967) Control of bladder tumours by endoscopic surgery. J. Urol., 97:864.
3. Dodge, O.G. (1962) Tumours of the bladder in Uganda Africans. Acta. Un. Int. Cancer, 18:548.
4. El Boulkany, M.N., Ghoneim, M.A. and Mansour, M.A. (1972) Carcinoma of the bilharzial bladder in Egypt. Br. J. Urol., 44:561.
5. Flocks, R.H. (1951) Treatment of patients with carcinoma of the bladder. JAMA., 145:295.
6. Gittes, R.F. Tumors of the bladder, in Campbell\'s urology, v. 2. 4th ed. Philadelphia, Saunders, 1979, pp. 1033-70.
7. Marshall, V.F., Holden, J. and Ma, K.T. (1956) Survival of patients with bladder carcinoma treated by simple segmental resection; One hundred twenty three consecutive cases five years later. Cancer, 9:568.
8. Massey, B.D., Nation, E.F., Gallup, C.A. and Hendriks, E.D. (1965) Carcinoma of the bladder: 20-year experience in private practice. J. Urol., 93:212.
9. Miller, A., Mitchell, J.P. and Brown, N.J. (1969) The Bristol Bladder Tumour Registry. Br. J. Urol., 41 Suppl:l.
10. Morrison, A.S. and Cole, P. (1976) Epidemiology bladder cancer. Urol. Clin. North Am., 3:13.
11. Payne, P. In "tumours of the bladder", edited by Wallace, Edinburgh, Livingstone, 1959, pp. 285-305.
12. Riches, E. (1960) Choice of treatment in carcinoma of the bladder. J. Urol., 84:472.
13. Whitmore, W.F. Jr., Batata, M.A., Ghoneim, M. A., Grabstald, H. and Unal, A. (1977) Radical cystectomy with or without prior irradiation in the treatment of bladder cancer. J.Urol., 118:184.
14. Whitmore, W.F. Jr. and Marshall, V.F. (1962) Radical total cystectomy for cancer of the bladder; 230 consecutive cases five years later. J. Urol., 87:853.