Clinico-pathological characteristics and outcome of upper urinary tract urothelial carcinoma presenting to a tertiary care urology unit in Sri Lanka

Introduction: Upper urinary tract urothelial cancers account for 5% of urothelial tumours. In the West, the majority affect the pelvicalyceal system, with pyelocalyceal to ureteric ratio of 3:1. This study aims to describe the clinico-pathological features and outcome of upper urinary tract urothelial cancer treated surgically in a tertiary care unit in Sri Lanka. Methods: A retrospective analysis of all patients who underwent nephroureterectomy for upper urinary tract urothelial cancer at the Urology Unit at National Hospital of Sri Lanka between January1997 and December 2016 was carried out. Results: There were 43 patients. Male: female=1.87. Median age was 65 years (range:42-83). Macroscopic haematuria was the commonest presentation (n=29; 67.4%). Median duration of symptoms was 3 months (range 0.5-6). In the majority (n=20;46.5%) the tumour was confined to the ureter. Thirty-three (75.6%) were papillary tumours. Twenty-one had non-muscle invasive tumours (pTa: n=6(14%), pT1: n=15(34.9%) and others had invasive cancers (pT2: n=11(25.6%), pT3: n=7(16.3%) and pT4: n=4(9.3%)). Majority were low grade tumours (n=23;53.5%). Twelve (27.9%) had preceding urothelial bladder cancer. Nineteen (44.2%) were lost to follow up after surgery. Median follow up duration of the rest was 40 months (range:4-224months). Of them, 9(20.9%) developed metachronous bladder tumours. Nine had recurrence free survival of ≥5years and 15 had overall survival of ≥5 years. Of them, 4 patients survived ≥10 years. Older age (p=0.015) and presence of necrosis(p=0.05) were the only clinico-pathological parameters predictive of tumour recurrence. Conclusions: A relatively higher number females and high number of ureteric tumours were noted compared to similar studies from Asia.

Primary Signet-Ring Cell Adenocarcinoma of the Urinary Bladder Treated with Partial Cystectomy: A Case Report and Review of the Literature.

Primary signet-ring cell carcinoma is a variant of adenocarcinoma which is extremely rare, associated with poor prognosis and generally found to be resistant to chemotherapy and radiotherapy. We report a case of primary signet-ring cell carcinoma of the bladder which was successfully treated with partial cystectomy. A 71-year-old female with a history of type 2 diabetes, hypertension, and ischaemic heart disease presented with painless haematuria for 2 months' duration. The abdominal ultrasonography showed a localised polypoidal vesical growth arising from the bladder dome. Cystoscopy revealed an exophytic solid tumour in the anterior fundal wall. A deep transurethral resection of bladder tumour was done and histology revealed an adenocarcinoma composed of mucinous and signet-ring cell components. Later, considering the patient's age and the poor general condition, a partial cystectomy was done. Follow-up cystoscopy and ultrasonography were done at 12 months and there was no evidence of tumour recurrence and the patient is currently symptom-free. Partial cystectomy may be considered in patients with localised tumour without evidence of metastasis and poor general condition. Regular cystoscopies and ultrasound imaging are necessary for follow-up and early identification of recurrences.

High pressure chronic retention: a life-threatening clinical entity.

OBJECTIVES: To report our experience with high pressure chronic retention (HPCR), a clinical syndrome with potentially disastrous consequences. DESIGN: A prospective hospital based descriptive study. Setting A urology unit at the National Hospital of Sri Lanka, Colombo. Patients Forty seven consecutive new patients with HPCR evaluated during a 2-year period. RESULTS: Of the 47 (39 male) patients, 15 (32%) were below 50 years of age. Nocturnal enuresis was encountered in 32 (68%) patients, and a tense, non-tender distended bladder found in all 47 patients. Hypertension was recorded in 25.5% of the patients. Bilateral hydroureteronephrosis was detected on ultrasonography in nearly 80% of the patients, and renal impairment was found in 20 (42.5%). The mean retained volume was 968 mL. Seven (15%) patients developed post-obstructive diuresis. Eight women (mean age 47.5 years, range 30-70 years) had HPCR. Four had no obvious cause. Six (75%) had adult onset nocturnal enuresis. Renal impairment was found in four (50%) patients. Post-obstructive diuresis was recorded in two women. CONCLUSIONS: HPCR, a clinical entity known to affect the elderly in the West, was found to affect a relatively young patient group in Sri Lanka. The symptom of adult-onset nocturnal enuresis should alert the clinician to the possibility of HPCR. Renal failure is common at initial presentation. Urethral catheterization could lead to life-endangering diuresis. We describe eight women with this entity, hitherto unreported in the medical literature.

Bladder cancer in Sri Lanka: experience from a tertiary referral center.

BACKGROUND: Bladder cancer is one of the most common malignancies occurring worldwide. No published data exists on bladder cancer in Sri Lanka. The objective of the study was to determine the clinicopathological characteristics of histologically confirmed transitional cell carcinoma (TCC) of the bladder in Sri Lanka. METHODS: Three hundred and one patients were diagnosed with primary bladder cancer during a 7.5-year period from 1993 to 2000. Two hundred and eighty-one patients (239 men and 42 women; mean age, 66 years; range, 26-88) with TCC of the bladder were evaluated with regard to clinical presentation, cystoscopic findings and histopathological data. RESULTS: Transitional cell carcinoma accounted for 93.4% of primary bladder cancer. There was a male predominance with a sex ratio of 6:1. The majority of patients (63.7%) were in the 7th and 8th decades of life. Painless hematuria was the most common presenting symptom (52.7%), followed by painful hematuria (39.2%). The median duration of hematuria for all TCC patients, as well as for muscle-invasive TCC patients, was 3 months. Papillary configuration at cystoscopy, was found in 89.7% of non-invasive urothelial tumors. In contrast, 77.8% of invasive TCC patients had a solid/mixed tumor configuration. One hundred and forty-five patients (51.6% of TCC) had non-invasive urothelial tumor and 136 patients (48.4%) had muscle-invasive disease. In the non-invasive urothelial tumor category, 61 patients (42.0%) had pTa tumors and 84 patients (58.0%) had pT1 tumors. Of newly diagnosed TCC cases, 5.3% were found to be T1G3 urothelial carcinomas. Fifty-six patients (38.6%) with non-invasive urothelial tumor had a tumor greater than 5 cm in size. CONCLUSIONS: More than 90% of primary bladder tumors in Sri Lanka are TCC, with nearly half the patients having muscle-invasive diseases on initial presentation. Even in non-invasive urothelial tumors, the majority (58.0%) have lamina propria invasion.