A STUDY OF CYSTOSCOPIC BIOPSIES IN

Fifty cystoscopic biopsies submitted for histopathological evaluation in Nidaan Clinic of Kathmandu over a period of one year were analysed to ascertain the type of bladder diseases in Kathmandu valley. Maximum number of cases were of chronic nonspecific inflammation of urinary bladder followed by transitional cell carcinoma, tubercular cystitis, dysplasia and leiomyoma. Majority of the cases were in the age group of 31–60 years and majority were men.


INTRODUCTION
Diseases of the bladder, particularly inflammation (cystitis), constitute an important source of clinical signs and symptoms.Usually, these disorders are more disabling than lethal.Cystitis is particularly common in young women of reproductive age and in older age groups of both sexes.
The urothelium is subject to hyperplasia, dysplasia and metaplasia under a variety of circumstances including infections, nonspecific inflammation as may be caused by calculi, exposure to radiation, and a wide variety of excretory products of metabolized drug.Whether these mucosal changes after the age of 30, the incidence rates increases with age, in log-linear fashion, in both sexes 1 .
Cystoscopic biopsies have been extensively studied for various diseases of bladder.However such study has not been conducted so far in Kathmandu.In view of this, cystoscopic biopsies study was done to ascertain the type of bladder diseases in Kathmandu Valley.

MATERIAL AND METHODS
The material consisted of 50 cystoscopic biopsies submitted for histopathological evaluation in the private clinic of Kathmandu over a period of one year from Sept. 1999 to Aug. 2000.The pathological observations made in these cases were analyzed.

OBSERVATIONS
In our study urinary bladder lesions were 1.7 times more common in men than in women as shown in Table I.
Observations are based upon total number of cases given in Table II.Maximum number of cystoscopic biopsies were of chronic nonspecific inflammation followed by transitional cell carcinoma bladder, tubercular cystitis, dysplasia and leiomyoma urinary bladder.
On analysing the various lesions, maximum number of cases were in the age group of 31 -70 years.Inflammatory diseases were more common between 21-50 years of age.In cases of bladder carcinoma age of the patient ranged from 41-60 years, as shown in Table III.

DISCUSSION
Maximum number of cases (44%) in the present study were of chronic nonspecific cystitis.Chronic cystitis usually results from repeated attacks of acute cystitis.It varies greatly in severity.There may be only a mild exudate predominantly of lymphocytes and macrophages in the subepithelial tissues, or the inflammation may involve the whole thickness of the bladder wall, with an extensive exudate of lymphocytes, macrophages, and plasma cells.
In the present study, tubercular cystitis was found in 14% cases.Tuberculosis remains the most frequent cause of granulomatous inflammation of the bladder in many parts of the world.In Kathmandu valley, incidence of tuberculosis involving the urinary bladder is not known as no such study has been conducted to the best of our knowledge.It invariably develops from secondary foci, most often located in kidney 2 .Most bladder lesions are found in the region of the trigone, especially around the ureteral orifices.The usual tuberculous granulomata appear in the submucosa which are usually few but may become confluent, with caseous necrosis.In males, there may be secondary involvement of the prostate, whereas in females the disease may be complicated by vasico -vaginal fistula 3 .Intravesical administration of Bacillus Calmette -Guerin (BCG), as used for the treatment of superficial carcinoma of the bladder, can result in granulomatous inflammation of this organ, which may be detected microscopically or on cytologic examination of bladder wash specimens 4,5 .The change can extend to the prostate and sometimes even to the lungs .
A great variety of benign mesenchymal tumours may arise in the bladder.Collectively, they are rare.They account to less than 1% of tumours of the urinary tract.The most common is leiomyoma.In the present study the incidence of leiomyoma was (2%).They tend to grow as isolated, intramural, encapsulated, oval -to -spherical masses, varying in diameter upto several centimeters.Occasionally, they assume submucosal pedunculated position.
They have the histologic features of their counterparts else where.
Dysplastic changes in the bladder epithelium, are often seen in the urothelium in close anatomical relationship to a primary bladder tumour.In this study incidence of dysplasia was (10%).Recent studies have shown that dysplastic changes elsewhere in the bladder, especially those at some distance from the primary lesion, are of grave prognostic importance whether detected on histological examination of a cystectomy specimen,

Fig. 2. Microphotograph showing papillary carcinoma of urinary bladder (H&E, 5X)
or by random biopsy of the apparently unaffected epithelium. 6,7,8ithelial tumours of the urinary bladder develop most commonly in subjects 40 -70 years old and do so in men about three times as frequently as in women. 9In our study most of the patients were between 31 -60yrs of age and tumours were more commen in men.According to various studies conducted in Kathmandu the common malignancies are carcinoma stomach, lung cancer, breast cancer, carcinoma cervix and skin cancer.
In our study the incidence of urinary bladder cancer was 28%, it was high probably because the number of urologist in Nepal is restricted and all the cases analysed in our study were referred by them because of which concentration of the cancer cases might be high.Only seldom does bladder carcinoma arise in adolescent. 10The study of age -adjusted death rates for bladder carcinoma in various countries shows a high rate for males in South Africa and a low one in Japan and Sweden, whereas the corresponding mortality rates for Denmark, the USA, the U.K. and Australia are more or less comparable. 9The great majority (90%) of bladder cancers are transitional cell carcinoma, which includes grade I to III and carcinoma in situ.
Transitional cell carcinoma of the bladder is less common in young individuals and it has been suggested that the prognosis in younger people is better than in the older patients. 11,12In a study of 388 tumours of the male urogenital tract by Sharma et.al, Urinary bladder cancers comprised 29.52% of all the malignancies of male urogenital tract or 4.19% of all malignant growths in males. 13The average age of patients was 53.9 years.Transitional carcinoma was the commonest type of tumour (91.9%).Stokes and Kelly 14 reported 23 cases of bladder cancer in patients under the age of 40 years and found that most were well differentiated and showed little evidence of invasion.Nevertheless, it is essential that the histological and clinical criteria used in planning treatment should be the same in younger patients as in those who are older. 15l transitional cell cancers, whatever their grade, have a tendency to recur following excision, and usually the recurrence exhibits greater anaplasia.In many instances, the recurrence is seen at a different site, and the question of a new primary tumour must be entertained.Overall, about 60% of grade I papillary carcinomas recur, in contrast to 80% to 90% of grade III lesions.In our study not a single case has been encountered with a recurrence of TCC after surgery till date.

CONCLUSION
Cystoscopic biopsies are a recognised procedure for early diagnosis of urinary bladder diseases when clinical and radiological findings are inconclusive.Analysis of cystoscopic biopsies was done to ascertain the type of urinary bladder lesions in Kathmandu valley.