Carcinoma of the urinary bladder is one of the common malignant tumors. Men are affected twice as often as women. The main symptom is hematuria as microhematuria or painless macrohematuria. Pain does not occur until a tumor-related urinary obstruction develops in the upper urinary tract. In addition to X-ray, ultrasound, CT and MRI, ureterorenoscopy has also established itself as an important diagnostic procedure.
Urothelial carcinoma, also called transitional cell carcinoma or transitional cell carcinoma, refers to malignant tumors of the urothelium lining the urinary tract [3,4]. Accordingly, tumor localization may be in the renal pelvis, ureters, urinary bladder and urethra. Approximately 90% of malignancies are located in the urinary bladder, and 8% of all renal carcinomas are transitional cell carcinomas. More than 60% of patients with urothelial carcinoma of the kidney develop a second tumor of the urinary bladder during the course of the disease. With primary involvement of the urinary bladder, subsequent tumor in the upper urinary tract is found in 3% to 13% of patients.
Depending on the degree of dedifferentiation, papillary to solid growth of the mass is found. Men are affected twice as often as women, and the peak age is between the ages of 60 and 70. The European Community counts about 104,000 new cases a year with over 36,000 deaths. Overview 1 lists the disposing risk factors. Frequently, macrohematuria occurs as a leading symptom in two-thirds of cases. Flank pain is present in about one-third of patients but is relatively nonspecific as a sole symptom, as are loss of appetite, weight loss, and decreased performance in late-stage tumors. Metastasis is primarily lymphogenic in early stages, and later hematogenous to the liver, lungs, and skeletal system. Urothelial carcinomas without and with alteration of the urinary bladder were also found in the prostate [1].
Surgery and cisplatin-based chemotherapy are the current standard of drug therapy, with the vinca alkaloid vinflunine also used in tumor recurrence. Organ-preserving surgical therapies are possible for tumor size up to 1 cm and are sought in patients with impaired renal function or single kidney. The basic prerequisite for organ-preserving measures is stringent follow-up care.
X-ray examinations are no longer so important today, and the advantage of retrograde ureteropyelography in side-separated tumor imaging even in patients with contrast allergy is limited by its lower sensitivity of 75 to 80% [4]. In addition, unilateral presentation does not take into account the fact that urothelial carcinomas may be multicentric.
Sonography can detect the tumorous changes in the renal pelvis and urinary bladder and solidly differentiate them from cystic changes [2]. If renal congestion is due to a stenosing space-occupying process of the ureter, it will also be well documented sonographically. General disadvantages of the method are the limited field of view, reduced image quality in obesity and meteorism, and examiner dependence. The assessability of the middle ureteral segments is usually reduced [5].
Computed tomography is the imaging method of choice for the diagnosis of urothelial carcinoma of the upper urinary tract. Sensitivity ranges from 67 to 100% with a specificity of 93 to 99%. The extent of the tumor can be detected very well, including existing metastases [4]. The differential diagnosis against renal cell carcinoma offers several criteria in CT [2], to be read in review 2.
Magnetic reson ance imaging is also a valuable tool of imaging diagnosis of the urinary tract especially in the patients who have intolerance to X-ray contrast agents [4].
Ureterorenoscopy has been established as an invasive diagnostic procedure, which also offers the advantage of tissue clarification from the tumor formation [4].
Case studies
In case report 1 (Figs. 1A to 1C), extensive urothelial carcinoma of the left ureter in a 56-year-old patient resulted in massive urinary retention with significant dilatation of the renal caval system. In addition to macrohematuria, increasing left flank pain was prominent.
Case 2 shows a solid right ureteral tumor with consecutive congestion of the proximal ureteral portions in a 61-year-old woman with recurrent hematuria. She had been referred for CT diagnosis to clarify intermittent stream pain (Figs. 2A and 2B) . Surgical therapy confirmed urothelial carcinoma.
Case report 3 demonstrates extensive urothelial carcinoma of the left renal pelvis with extension into the upper ureter in a 58-year-old female patient (Figs. 3A to 3C), surgically confirmed histologically. The renal pelvis was subtotally filled by the tumor, and the outgoing renal vein was already markedly compressed.
Take-Home Messages
- Urothelial carcinomas can occur in the renal cavity system, ureters, urinary bladder and urethra. The main site of localization is the urinary bladder.
- Men are affected twice as often as women, and the peak age is between the ages of 60 and 70.
- Leading symptom is macrohematuria in two-thirds of cases.
- Metastasis is primarily lymphogenic in early stages, and later hematogenous to the liver, lungs, and skeletal system.
- Computed tomography is the imaging modality of choice for the diagnosis of urothelial carcinoma of the upper urinary tract.
- Chemotherapy and surgical treatment comprise the spectrum of therapy; organ-preserving treatment is also possible for tumors up to 1 cm in size.
Literature:
- Dhom G, Mohr G: Urothelial carcinoma in the prostate. Urologist [A] 1977; 16(2): 70-72.
- Galanski M, Hüper K, Weidemann J: Tumors of the kidneys and upper urinary tract. Radiology up2date 2011: 3: 203-225.
- Wikipedia, https://de.wikipedia.org/wiki/Urothelkarzinom,(last accessed 01.06.2023).
- UK Köln, https://urologie.uk-koeln.de/erkrankungen-therapien/urothelkarzinom,(last accessed 01.06.2023)
- Nolte-Ernsting C: Status of radiological imaging in the diagnosis of renal and upper urinary tract diseases in adults. Radiology up2date. 2004; 2: 151-176.
HAUSARZT PRAXIS 2023, 18(7): 20-22
