European Journal of Cardiovascular Medicine

Diseases of the urinary bladder both non-neoplastic and neoplastic are quite common. The most common non-neoplastic lesion encountered is cystitis. [1]

Urinary bladder neoplasm is responsible for significant morbidity and mortality. Urothelial carcinoma is the commonest type accounting for 90% of all primary tumors of the bladder. [2]

It is the 9th most common cancer worldwide. [3]

Bladder neoplasm account for 6% and 2% of the cancer incidence in men and women respectively. [4]

Urinary bladder cancer is a complex and heterogeneous disease with a broad spectrum of histologic findings and potentially lethal behavior. Despite advances in surgical techniques, as well as intravesical and systemic therapies, upto 30% of patients with non-muscle invasive urothelial carcinoma and 50% of patients with muscle invasive carcinoma experience disease progression, recurrence and eventual death. [5]

Cystoscopy is the primary diagnostic tool for patients who are suspected of having bladder tumors which allows a direct visualisation of the bladder mucosa and biopsies of the suspected lesions. [6]

External risk factors are smoking, occupational carcinogens, artificial sweeteners, Schistosoma hematobium infection in endemic areas. [7]

This study is aimed to study the different spectrum of urinary bladder lesions in tertiary level hospital.

Aims and Objectives:

1. To assess various types of urinary bladder lesions with regard to frequency, age and sex distribution.
2. To describe the histopathological features of various lesions in the urinary bladder biopsies.
3. To categorize the neoplastic lesions according to W.H.O (2022)/ISUP classification of urinary bladder tumors.

This is a one year retrospective study from January 2023 to December 2023. The study was carried out in the Department of Pathology, Grant Government Medical College, Mumbai. Clinical and cystoscopic findings with the clinical diagnoses of all cases of urinary bladder lesion sent to the laboratory were noted. The material for the study comprised of biopsy from Transurethral Resection of Bladder Tumor (TURBT)/ Bladder biopsy.

Inclusion Criteria: All the TURBT biopsies received in the Department of Pathology, Grant Government Medical College, Mumbai.

Exclusion Criteria: Autolysed specimen, inadequate biopsies and those with no adequate information were excluded from the study.

Postoperative histopathology specimens were fixed in 10% formalin. The specimens were subjected to standard paraffin embedding and hematoxylin and eosin staining. The specimen was examined in its entirety and the detailed histomorphological examination was done. In each specimen revealing neoplastic pathology, at least 20 fields were examined and grading was done. Then, bladder tumors were studied according to WHO/ISUP (2022) classification. Data was analyzed using Statistical Package for the Social Sciences (SPSS) 21

Total 34 cases were examined for various urinary bladder pathologies by doing histopathological examination.

Among the non-neoplastic lesions, there were 2 cases of acute on chronic cystitis (image 1) and 1 case of cystitis glandularis (image 2).

Among neoplastic lesions, 1 case of urothelial papilloma with inflammation (image 3), 4 cases of papillary urothelial neoplasm of low malignant potential (image 4), 21 cases were of infiltrating urothelial carcinoma, out of which 18 cases were of high grade (image 5) and 3 cases were of low-grade malignancy. Out of 18 high grade cases, 2 cases showed muscle involvement (image 6).

One case showed squamous differentiation (image 7).

There were 4 cases of low grade, non-invasive urothelial carcinoma.

In the present study of total 34 patients – Age of the patients ranged from 20 year to 80 years with highest number of cases in the 6th decade, given in the table 1.

Out of 34 patients, 26 were male and 8 were female with M: F ratio of 3.2:1, given in the table 2.

Table 1: Age wise distribution of various urinary bladder lesions

Table 2: Sex distribution of urinary bladder lesions

Presenting symptoms of urinary bladder neoplasms were painless hematuria (90.4%) followed by increased frequency of micturition (32.8%), burning micturition (32%), dysuria (9.6%) and abdominal pain (5.9%) which is given in the table 3.

Table 3: Distribution of the lesions according to clinical features

Table 4: Distribution of Non-Neoplastic Lesions

Table 5: Distribution of Neoplastic Lesions

MICROSCOPIC IMAGES:

Image 1: Acute on chronic cystitis (H & E, 20x)

Image 2: Cystitis Glandularis

Image 3: Urothelial papilloma

Image 4: Urothelial carcinoma with low malignant potential

Image 6: High grade urothelial carcinoma, muscularis propria involved

Image 7: Invasive urothelial carcinoma with squamous differentiation.

The present study is undertaken mainly to highlight the importance of histopathological examination in the diagnosis of bladder lesions. In recent days, the diagnosis and monitoring of bladder lesions are made by combination of cystoscopy, histopathology and urine cytology. [8]

All these diagnostic methods have their own limitations and cannot diagnose the presence of bladder tumours at every point of time. [9]

Total 34 cases were studied, in which the peak age incidence was in the 6^th decade followed by 7th decade. Commonest age group affected by neoplastic lesion was 61-70 years that was reported by Rajesh et al [10], Gupta et al [12], Goyal et al [13], Vaidya et al [11] and Matalka et al [14].

In this study, 26 were male and 8 were female (M: F = 3.2:1).

Rajesh et al, Anupama et al and Vaidya et al had similar study in which M: F ratio was 1.5:1, 3:1 and 4.5:1 respectively. [10,11]

In present study, presenting symptoms were painless hematuria (90.4%) followed by increased frequency of micturition (32.8%), burning micturition (32%), dysuria (9.6%) and abdominal pain (5.9%). Agarwal et al [15] reported that commonest clinical presentation was hematuria followed by abdominal pain (54%), increase frequency (46%), dysuria (40%), urgency (38%) and incomplete voiding (22%). Gupta et al [12] had found that commonest clinical presentation was hematuria.

In present study, among the non-neoplastic lesions, there were 3 cases of acute on chronic cystitis (75%) and one case of cystitis glandularis (25%).

Urothelial carcinoma was the most common malignant lesion (93.10%) in our study which correlated with the study of Goyal et al [13] (96.87%) and Sharma et al [16] (91.9%) and Jhaveri et al [17] (89%). Most common lesion was invasive papillary urothelial carcinoma (21 cases) comprising of 18 (85.71%) cases of high grade and 3 (14.28%) cases of low-grade malignancy.

In our study, 6 non-invasive urothelial lesions include non-invasive papillary urothelial carcinoma (4 cases), Papillary urothelial neoplasm of low malignant potential (PUNLM) (4 cases) and urothelial papilloma (1 case).

Pathologic grade and muscle invasion in urothelial carcinoma are the most important prognostic factors. Blaveri et al evaluated the association between genomic instability and muscle invasive tumors, and found that muscle invasive tumors are associated with worse outcome[18]. In present study, detrusor muscle layer was absent in 4 cystoscopic biopsies. This can lead to incorrect staging and grading of tumor. Hence, including muscle layer in the cystoscopic biopsy specimens is very important. Of the remaining 30 cases that included muscle layer, muscle invasion was seen in 1 case (33.34%) of low grade and 1 case (33.34%) of high grade urothelial carcinoma which nearly correlated with Jhaveri et al [17]. It is important to include smooth muscle in biopsy to prevent under staging of tumors.

The present study is undertaken mainly to highlight the importance of histopathological examination in the diagnosis of bladder lesions. In recent days, the diagnosis and monitoring of bladder lesions are made by combination of cystoscopy, histopathology and urine cytology. [8]

All these diagnostic methods have their own limitations and cannot diagnose the presence of bladder tumours at every point of time. [9]

Total 34 cases were studied, in which the peak age incidence was in the 6^th decade followed by 7th decade. Commonest age group affected by neoplastic lesion was 61-70 years that was reported by Rajesh et al [10], Gupta et al [12], Goyal et al [13], Vaidya et al [11] and Matalka et al [14].

In this study, 26 were male and 8 were female (M: F = 3.2:1).

Rajesh et al, Anupama et al and Vaidya et al had similar study in which M: F ratio was 1.5:1, 3:1 and 4.5:1 respectively. [10,11]

In present study, presenting symptoms were painless hematuria (90.4%) followed by increased frequency of micturition (32.8%), burning micturition (32%), dysuria (9.6%) and abdominal pain (5.9%). Agarwal et al [15] reported that commonest clinical presentation was hematuria followed by abdominal pain (54%), increase frequency (46%), dysuria (40%), urgency (38%) and incomplete voiding (22%). Gupta et al [12] had found that commonest clinical presentation was hematuria.

In present study, among the non-neoplastic lesions, there were 3 cases of acute on chronic cystitis (75%) and one case of cystitis glandularis (25%).

Urothelial carcinoma was the most common malignant lesion (93.10%) in our study which correlated with the study of Goyal et al [13] (96.87%) and Sharma et al [16] (91.9%) and Jhaveri et al [17] (89%). Most common lesion was invasive papillary urothelial carcinoma (21 cases) comprising of 18 (85.71%) cases of high grade and 3 (14.28%) cases of low-grade malignancy.

In our study, 6 non-invasive urothelial lesions include non-invasive papillary urothelial carcinoma (4 cases), Papillary urothelial neoplasm of low malignant potential (PUNLM) (4 cases) and urothelial papilloma (1 case).

Pathologic grade and muscle invasion in urothelial carcinoma are the most important prognostic factors. Blaveri et al evaluated the association between genomic instability and muscle invasive tumors, and found that muscle invasive tumors are associated with worse outcome[18]. In present study, detrusor muscle layer was absent in 4 cystoscopic biopsies. This can lead to incorrect staging and grading of tumor. Hence, including muscle layer in the cystoscopic biopsy specimens is very important. Of the remaining 30 cases that included muscle layer, muscle invasion was seen in 1 case (33.34%) of low grade and 1 case (33.34%) of high grade urothelial carcinoma which nearly correlated with Jhaveri et al [17]. It is important to include smooth muscle in biopsy to prevent under staging of tumors.

1. Kumar V, Abbas AK, Fausto N. The lower urinary tract and male genital system: Robbins and Cotran pathologic basis of diseases.8th Ed , Saunders, Philadelphia, USA ; 2016 .1026- 36.
2. Rosai J. Rosai and Ackerman’s surgical pathology. 11^th Edinburgh: Mosby; 2017.
3. Aparana C, Reddy T, Padmavati C, Vanapalli J, Mounika T. Histological spectrum of urothelial lesion experience of a single tertiary care institute. Int J Contemp Med Res. 2016;3(6):1731–3.
4. Raghuveer CV, Hingle S. Profile of lesions in cystoscopic bladder biopsies: a histopathological study. J Clin Diagn Res: JCDR. 2013;7(8):1609–12.
5. Gray H. The anatomy of Human body. Philadelphia: Lea & Febiger; 1918
6. Grignon DJ. Urologic Surgical Pathology. St Loius: Mosby. Neoplasm of the urinary bladder, 1997;215-305.
7. Epstein JI. The lower urinary tract and male genital system. In: Kumar V, Abbas AK, Fausto N, editors. Robbins and Cotran Pathologic Basis of Disease. Philadelphia: Saunders; 2004. P. 1023-58.
8. Muhammed M, Javed IK,Altaf H et al. Urinary bladder tumours in southern Pakistan: A histopathological perspective, MJC.2014;5(3): 167-173
9. Reuter VE. The pathology of bladder cancer. Urology. 2006; 67(3Suppl 1): 11-8.
10. Laishram RS, Kipgen P, Laishram S, Khuraijam S, Sharma DC. Urothelial tumors of the urinary bladder in Manipur: a histopathological perspective. Asian Pacific J Cancer Prev. 2012;13 (6):2477–9.
11. Vaidya S, Lakhey M, Sabira KC, Hirachand S. Urothelial tumours of the urinary bladder: a histopathological study of cystoscopic biopsies. Nepal Med Coll J. 2013;52 (191):475–8.
12. Gupta AP, Gupta A, Kumbhalkar DT. Histomorphologic study of cystoscopic urinary bladder biopsies: a gold standard. Indian J Pathol Oncol . 2019;6(2):174–81.
13. Goyal VK, Vyas SP, Kothari DC. Spectrum of lesions in urinary bladder biopsies: histopathological study. Int J Dent Med Res.2015;1(6):42–6.
14. Matalka I, Bani-Hani K, Shotar A, Hani OB, Bani-Hani I. Transitional cell carcinoma of the urinary bladder: a clinicopathological study. Singapore Med J. 2008;49(10):790–4.
15. Agarwal S, Dutta S, Awasthi S, Kumar A, Arora D. Histopathological Spectrum of Urinary Bladder Biopsies; 2019.
16. Sharma S, Nath P, Srivastava AN, Singh KM. Tumours of the male urogenital tract: A clinicopathologic study. J Indian Med Assoc. 1994;92(11):357–60.
17. Jhaveri PN, Makwana SV, Oza KK, Shah CK. A histopathological study of urinary bladder neoplasms. Indian J Pathol Oncol. 2021;8(1):59–63.
18. Blaveri E, Brewer JL, Roydasgupta R, Fridlyand J, DeVries S, Koppie T, et al. Bladder cancer stage and outcome by array-based comparative genomic hybridization. Clin Cancer Res. 2005;11(19 Pt 1):7012–22. doi:10.1158/1078-0432.CCR-05-0177.