Original ArticleIntradiverticular bladder cancer: CT imaging features and their association with clinical outcomes☆
Introduction
Bladder diverticula are defined as outpouchings of the urothelial lining through the muscularis layer of the bladder wall. They may result from congenital weakness of the bladder wall at the level of the ureterovesical junction (e.g., Hutch’s diverticulum) or may be acquired as a result of increased intravesical pressure, typically in the context of lower urinary tract obstruction.
Bladder diverticula may sometimes harbor tumors, classically thought to be secondary to urinary stasis with chronic infection and inflammation leading to metaplasia and subsequent tumor formation. However, the transitional cell lining of a diverticulum is identical to that which covers the entire urinary drainage system, and therefore carcinogenic alteration related to exposure of urinary agents can similarly affect the lining of the diverticulum, predisposing to cancer formation. Although diverticular tumors account for only about 1.5% of all bladder cancers [1], they pose distinct challenges for diagnosis and management and warrant special attention. First, although direct visualization of the bladder lumen through cystoscopy has been demonstrated to be an adequate first-line method for the diagnosis of bladder neoplasms, cystoscopic visualization of diverticular tumors may be difficult, particularly if the diverticula have narrow orifices or are otherwise difficult to access. Furthermore, diverticula are characterized by absent or thin muscularis propria layer, which increases the risk of perforation during biopsy or transurethral resection (TUR) and also theoretically facilitates extravesical tumor spread [2]. Attempts to avoid perforation and tumor cell dissemination during biopsy often lead to understaging on TUR.
The role of imaging for the evaluation of intradiverticular tumors is not well known since prior studies have been limited to case reports and small case series [3], [4], [5], [6], [7], [8], [9], [10], [11]. Therefore, the purpose of this study was to describe the computed tomographic (CT) features of intradiverticular bladder cancer and evaluate if the imaging features can predict clinical outcome.
Section snippets
Patients
This retrospective study was compliant with the Health Insurance Portability and Accountability Act. The institutional review board issued a waiver of informed consent. The inclusion criteria for the study were: (a) cystoscopy-guided biopsy or resection of intradiverticular bladder tumor performed between 2001 and 2010 at our institution, (b) CT imaging performed before treatment, (c) CT imaging study available in DICOM format through our institution’s picture archiving and communications
Clinical and pathological evaluation
Clinical staging confirmed a total of 37 intradiverticular bladder cancers in 34 patients. Tumor histologies were obtained by transurethral biopsy in all cases and consisted of transitional cell carcinoma in 26 patients, mixed transitional and squamous cell carcinoma in 3, neuroendocrine carcinoma in 2, squamous cell carcinoma in 1, adenocarcinoma in 1, and sarcomatoid carcinoma in 1 patient (Table 1). Eighteen (53%) patients underwent partial/radical cystectomy. In 8 of these 18 patients
Discussion
In this study, we identified two CT features—namely, tumor width and the length of contact between the tumor and the diverticular wall—that were associated with survival and could serve as prognostic indicators in patients with intradiverticular bladder tumors. This information is clinically relevant, as the pathology stage from the transurethral resection specimen, which is typically considered to guide treatment decisions in these patients, provided limited prognostic information in our study
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Cited by (14)
Urothelial carcinoma in a urinary bladder diverticulum: A case report and review of the literature
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2022, Annals of Medicine and SurgeryCitation Excerpt :Cystoscopy allows for direct visualization of the bladder cavity and is considered an acceptable initial examination in detecting bladder tumors and bladder diverticula. Nevertheless, cystoscopy often fails to identify the tumor mass in the diverticulum, particularly when obstructed by a tight orifice, making the diverticulum difficult to access [23–25]. In general, the first imaging study performed on patients with hematuria is ultrasound (US) [24].
Prognostic Utility of MRI Features in Intradiverticular Bladder Tumor
2022, Academic RadiologyCitation Excerpt :These MRI findings are generally indicative of greater local extent of the IDBT and thus their relationship with survival can be intuitively understood as well as in agreement with the literature (7,30). The relationship between larger size on MRI and survival is in agreement with a previous study by Di Paolo et al (8) in which the size of the IDBT on CT was also associated with poorer survival. However, in their study, involvement of the diverticular neck was not associated with survival.
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
2020, Diagnostic and Interventional ImagingCitation Excerpt :They are relatively common, particularly in older male patients with chronic bladder outlet obstruction from prostatic enlargement. Urinary stasis in bladder diverticula may be a risk factor for the development of infection and inflammation [27]. In patients that have intractable lower urinary tract irritative voiding symptoms or develop associated intra-diverticular tumor, treatment may include diverticulectomy [28].
Urothelial Carcinoma in Bladder Diverticula: A Multicenter Analysis of Characteristics and Clinical Outcomes
2020, European Urology FocusCitation Excerpt :However, clinical staging of BC comprises cross-sectional imaging, usually by contrast-enhanced computed tomography (CT). One study has evaluated whether CT features of UCBD can predict clinical outcome [22]. The authors found that in UCBD, tumor diameter and the length of contact between the tumor and the diverticular wall were associated with survival.
Imaging in Urology
2018, Imaging in Urology
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Conflict of interest statement: All authors state that no conflict of interest exists.
- 1
Contributed equally to this manuscript.