Placenta percreta with bladder invasion as a cause of life threatening hemorrhage

PURPOSE: Abnormal placental penetration through the myometrium with bladder invasion is a rare obstetric complication with potential for massive blood loss. Urologists are usually consulted after a life threatening emergency has already arisen. Their familiarity with this condition is crucial for effective management. We describe 2 cases of placenta percreta with bladder invasion to highlight the catastrophic nature of this clinical entity, and review the literature on current diagnostic and management strategies. MATERIALS AND METHODS: Between 1986 and 1998, 250 cases of adherent placenta (0.9%) were identified in 25,254 births at our institution, including 2 (0.008%) of placenta percreta with bladder invasion. We treated these 2 multiparous women who were 33 and 30 years old, respectively. Each had undergone 2 previous cesarean sections. RESULTS: Presenting symptoms were severe hematuria in 1 patient and prepartum hemorrhage with shock in the other. Ultrasound showed complete placenta previa in each with evidence of bladder invasion in 1 patient. Hysterectomy, bladder wall resection and repair, and bilateral internal iliac artery ligation were required to control massive intraoperative hemorrhage. The patients received 22 and 15 units of packed red blood cells, respectively. Fetal death occurred in each case. Convalescence was complicated by disseminated intravascular coagulation in patient 1 but subsequent recovery was uneventful. CONCLUSIONS: A high index of suspicion for placenta percreta with bladder invasion is required when evaluating pregnant women with a history of cesarean delivery and placenta previa who present with hematuria and lower urinary tract symptoms. Ultrasonography and magnetic resonance imaging may assist in establishing the diagnosis preoperatively. With proper planning and a multidisciplinary approach fetal and maternal morbidity and mortality may be decreased.     

Urothelial carcinoma of the bladder with trophoblastic differentiation: A case report

We report a case of a urothelial carcinoma with trophoblastic differentiation of the bladder that occured in a 23-year-old man. The patient presented with hematuria. Multiple papillary masses were resected transurethrally. Histopathologically, grade III urothelial cell carcinoma contained giant cells that were positive for human chorionic gonadotrophin (HCG), placental alkalen phosphatase, and human placental lactogen. HCG secreting tumors are reported to be highly aggressive. The patient is alive and well without evidence of recurrent disease or metastasis at 10 months from transurethral resection. To our knowledge, this case is the youngest patient in the literature so far.     

Placenta percreta invading the urinary bladder

The placenta, normally confined to the decidual lining of the uterine cavity, can in some circumstances invade the muscular wall of the uterus, a condition known as placenta accreta. Less common is placenta increta, in which placental cotyledons become intertwined with the muscular stroma of the uterus. Placenta percreta, in which the trophoblastic tissues penetrate the serosa of the uterus and may extend directly to adjacent structures, is even more rare and is potentially life-threatening. There have been only 10 reports of direct invasion of placenta percreta into the urinary bladder. We review these cases and report 3 recent patients, one of whom was diagnosed pre-operatively by ultrasonography.     

Adenocarcinoma of the urinary bladder with a bladder stone: report of a case

A case of primary adenocarcinoma of the bladder is reported. The patient was a 83-year-old man admitted to our hospital in February, 1988 with the complaint of gross hematuria that had lasted for about 1 month. Cystoscopic examination showed a solid tumor in the lateral wall of the bladder with a bladder stone. Papillary adenocarcinoma was found in the biopsy specimen from the bladder tumor. The gastrointestinal, respiratory and genitourinary tracts were examined but no other tumor lesions could be found. Therefore, primary adenocarcinoma of the bladder with a bladder stone was suspected. Transurethral resection of the bladder tumor and cystolithotripsy were performed; histological study showed that the tumor was limited to submucosa, that is to pTlb. The literature is reviewed.     

Localized amyloidosis of the urinary bladder.

Localized amyloidosis of the urinary bladder is a rare condition. Five patients, 1 with localized secondary amyloidosis, are described. The symptoms, macroscopic hematuria and tumor-like appearance in cystoscopy, may mimic bladder cancer. Diagnosis is based on histopathological examinations with Congo red staining. In most instances, the treatment of choice is transurethral resection and electrocoagulation. Because of the risk of recurrences, a close follow-up is recommended.     

膀胱平滑肌瘤的诊断和治疗

目的 探讨膀胱平滑肌瘤的病因、诊治方法和预后。方法 回顾性分析1984年至2005年收治6例膀胱平滑肌瘤患者资料。患者男1例，女5例，平均年龄36岁。临床表现为排尿障碍4例、血尿1例、膀胱刺激症状1例。病程1～16个月。除1例血尿患者外，其余5例均非首诊。6例B超检查，首次发现病变3例。5例行CT检查，均发现肿块且有不同程度强化。6例膀胱镜检，发现肿瘤2例，提示占位病变3例。肿瘤直径1．5-5．0cm。6例均采用手术治疗。结果 6例患者术后排尿通畅，血尿消失，排尿刺激症状明显缓解。1例术后出现伤口漏尿，经保守治疗治愈，余未发生其他并发症。6例随访9个月～8年，未见肿瘤复发或转移。结论 膀胱平滑肌瘤是一种少见的良性肿瘤，临床症状不典型，排尿障碍和血尿是最常见的表现，诊断主要依靠B超、CT和膀胱镜检查，初诊时误诊率较高。外科手术治疗预后良好。     

Management of metastatic malignant melanoma of the bladder

Recombinant interleukin-2 (IL-2) has demonstrated antitumor activity and durable clinical responses in patients with metastatic melanoma. Careful screening and selection of appropriate patients has improved the safety profile of IL-2 administration. Gross hematuria would ordinarily preclude the safe delivery of IL-2. We report a case of metastatic melanoma to the bladder presenting with hematuria. A complete resection was performed and subsequently allowed the administration of high-dose, bolus IL-2. The combination of resection and IL-2 therapy resulted in a partial response maintained for more than 18 months. Symptomatic bladder melanoma should be aggressively treated to allow for systemic immunotherapy, which can provide durable responses.     

Therapeutic options for intractable hematuria in advanced bladder cancer

Intractable hematuria is a common and severe complication in patients with inoperable bladder carcinoma. The aim was to provide an overview of therapeutic options for such cases, and analyze their effectiveness and risk profile, so a systematic literature search of peer‐reviewed papers published up to September 2012 was carried out. Various options are available to treat hematuria in patients with inoperable bladder cancer; these include orally administered epsilon‐aminocaproic acid, intravesical formalin, alum or prostaglandin irrigation, hydrostatic pressure, urinary diversion, radiotherapy, embolization and intraarterial mitoxantrone perfusion. These treatment options are associated with different prospects of success, risks and side‐effects. Well‐designed and large studies comparing options are completely lacking. Despite various treatment options, management of intractable hematuria in patients with inoperable bladder cancer remains a challenge, and most of the reported methods should be seen as experimental. Interventional radiology and alum instillation seem to be suitable alternative options for patients who, after critical consideration, cannot be treated by irrigation, transurethral resection or palliative cystectomy.     

Laparoscopic partial cystectomy with endo-GIA stapling device in bladder diverticular carcinoma

BACKGROUND AND PURPOSE: The incidence of bladder diverticular carcinoma is low, ranging from 0.8% to 10%. Traditionally, treatment consisted of open surgical excision or transurethral resection. More recently, laparoscopic surgery has become widely accepted. We report here a case of bladder diverticular carcinoma treated with laparoscopic partial cystectomy. CASE REPORT: A 56-year-old man presented with gross hematuria and was found to have transitional-cell carcinoma in a bladder diverticulum. We performed transurethral resection of the tumors and laparoscopic partial cystectomy. A 45-mm Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT) was used for direct resection of the diverticular tissue, and the specimen was removed en bloc. Suture of the seromuscular layer was performed with the intracorporeal knotting technique. Lymph-node dissection also was performed. At 3-month follow-up, it was noted that there was tumor recurrence that was not at the original diverticular site, and transurethral resection was carried out. After 1 year, cystoscopy and CT scans showed neither recurrence nor metastasis. No encrustation or erosion was induced by the staples. CONCLUSION: Laparoscopic partial cystectomy can be an alternative treatment for bladder diverticular carcinoma.     

A case of bladder transitional cell carcinoma with sigmoidovesical fistula due to diverticulitis

We present a case of bladder transitional cell carcinoma with sigmoidovesical fistula due to diverticulitis. The patient was a 65-year-old male who had been suffering from recurrent abdominal pain with high fever for the past 6 months. He noticed pneumaturia and cloudy urine several times. He visited a doctor complaining of macroscopic hematuria and high fever, and was treated under the diagnosis of acute prostatitis. In our University Hospital cystoscopy showed a papillary bladder tumor. Pathological study of the tumor revealed transitional cell carcinoma, grade II, noninvasive type. Multiple diverticulosis of sigmoid colon was identified with barium enema examination. We performed transurethral resection of the bladder tumor. Three weeks later, the sigmoidovesical fistula was treated by primary resection of the sigmoid colon and wedge resection of the bladder including fistula.     

Transurethral resection of a bladder tumor in pregnancy: A report of 2 cases

Carcinoma of the urinary bladder presenting during pregnancy is rare. We report two such cases presenting with gross hematuria, both of which were managed by transurethral electroresection of the tumor; there was no adverse effect on the pregnancies. Transurethral resection thus appears to be the procedure of choice in the management of this condition, and carries minimal morbidity even when performed during pregnancy. EDITORIAL COMMENT: As these authors point out, bladder tumors are rare in pregnancy and frequently present as gross hematuria that is mistaken for vaginal bleeding due to the pregnancy. Ultrasound is very helpful in distinguishing the causes of bleeding, and will show the bladder filled with clots and frequently the tumor as well. Standard transurethral resection is effective when performed during pregnancy, bearing in mind the need to heed to the anesthetic risks inherent in any operative procedure during pregnancy.     

A case of mucinous cystadenocarcinoma of the appendix penetrating the urinary bladder

The patient, an 81-year-old woman, had the chief complaint of macroscopic hematuria. Cystoscopy revealed a bladder tumor, which was determined by biopsy to be mucin-producing adenocarcinoma. Appendiceal carcinoma that invaded the bladder were diagnosed preoperatively by air-contract barium enema and magnetic resonance. She was treated with partial cystectomy and resection of the cecum. Sixteen cases of appendiceal carcinoma with invasion into the bladder have been reported in Japan.     

Primary localized amyloidosis of urinary bladder

Primary localized amyloidosis of the bladder is rare. Two new cases are presented, and 44 cases from the literature are reviewed. The disease tends to occur in a younger age group in men than in women. It presents most frequently with gross painless hematuria, and usually appears at cystoscopy as a tumefied, yellowish, and occasionally ulcerated lesion. The amyloid deposits usually involve suburothelial connective tissue, suburothelial vessels, and less markedly the vesical muscularis. The treatment varies from transurethral resection to total cystectomy with urinary diversion. Transurethral resection appears to be the treatment of choice, if feasible. Close follow-up of the patient is necessary because of the frequency of multiple recurrences, which may require an ablative procedure.     

膀胱平滑肌瘤15例临床分析

目的探讨膀胱平滑肌瘤的临床表现、诊治方法和预后。方法回顾性分析1997年1月～2008年5月收治的15例膀胱平滑肌瘤患者的资料。其中男4例,女11例,年龄28~65岁,平均35岁。临床表现为排尿梗阻6例,排尿刺激症状5例,肉眼血尿3例,无任何临床症状体检时发现1例。病程1个月～3年,平均11．5个月。15例B超检查发现膀胱内占位病变,CT检查发现肿物均有不同程度强化,IVU检查12例发现膀胱充盈缺损,膀胱镜检查11例提示黏膜下占位。15例术前病理活检2例报告为平滑肌瘤。15例分别采用肿瘤剜除、膀胱部分切除和经尿道膀胱肿瘤电切术治疗。13例行术中冰冻切片检查,报告为平滑肌瘤。结果15例患者术后排尿通畅,排尿刺激症状明显缓解,血尿消失。未发生手术并发症。术后随访6个月～5年,平均3年,未见肿瘤复发或转移。结论影像学结合膀胱镜检查是诊断膀胱平滑肌瘤的主要手段,外科手术治疗预后良好。     

A case of micropapillary bladder carcinoma

A case of urothelial carcinoma containing micropapillary variant in the urinary bladder is reported. The micropapillary bladder carcinoma isa rare variant of urothelial carcinoma and has an aggressive clinical course. A 45-year-old man complained of hematuria in October, 2009. He visited a hospital and was diagnosed with a bladder tumor. Transurethral resection of the bladder tumor was performed at the hospital. The transurethral resection demonstrated poorly differentiated adenocarcinoma invading the bladder muscle layer. Then he consulted our hospital. Our pathologist diagnosed the case as micropapillary variant of urothelial carcinoma in the urinary bladder. Accordingly, radical cystectomy and pelvic lymph nodes dissection were performed. After the operation, he received three courses of gemcitabine and cisplatin as adjuvant chemotherapy. The patient remains free of tumor recurrence and metastasis for 28 months after the cystectomy.     

Inverted papilloma of the bladder with mild atypia

A case of inverted papilloma of the bladder with mild atypia in a 31-year-old male is reported. The patient was admitted complaining of macroscopic hematuria. An excretory urogram revealed a small filling defect in the center of the bladder. A 15 x 11 mm. exophytic lesion was noted at the center of the trigone by cystoscopy and ultrasonography. The patient underwent transurethral resection of the bladder tumor and selected-site mucosal biopsies. The result of a histopathological examination of the tumor was an inverted configuration with nuclear atypia, corresponding to transitional cell carcinoma, grade 1. No histopathological abnormalities in the normal-appearing bladder mucosa were observed. The patient has been subsequently followed up for 43 months and there was no evidence of recurrence.     

Adenocarcinoma of bladder

Twenty-five patients with pure primary adenocarcinoma of the bladder were treated in a fifteen-year period. Practically all patients presented with some combination of gross hematuria, irritative lower urinary tract symptoms, or obstruction. Almost half the lesions were at the dome of the bladder. Most of the lesions were high grade and invasive. Transurethral resection is, at best, only diagnostic and palliative, and radiotherapy has been of little value. Radical cystectomy seems to produce five-year survival almost twice that of segmental resection. However, solitary lesions at the dome of the bladder, which usually represent neoplasia in a urachal remnant, seem to behave somewhat differently from lesions elsewhere in the bladder. Indeed, five-year survival of patients with lesions at the dome of the bladder who underwent segmental resection approximated that of those with similar lesions who underwent total cystectomy.     

Pheochromocytoma of the urinary bladder presenting only with macroscopic hematuria

Pheochromocytoma of the bladder is an unusual tumor that typically presents with hypertensive crises related to micturition. We describe a case of bladder pheochromocytoma in a 42-year-old female in which macroscopic hematuria was the only alarming symptom. The diagnostic and operative issues of this type of tumor are discussed, along with the challenging treatment option of transurethral resection. Diagnosis, treatment and follow-up trends of this rare tumor are reviewed.     

Unusual cause of early preeclampsia: bladder paraganglioma

Ten to twenty percent of paragangliomas occur at extra-adrenal locations and less than 1% are at the urinary bladder. The most common presenting symptom of bladder paraganglioma is hypertensive attacks precipitated by micturition and hematuria. Paraganglioma of the urinary bladder occurring at pregnancy is extremely rare. We present a case of bladder paraganglioma as an unusual cause of early preeclampsia. After termination of the pregnancy, surgical resection was performed and the histopathologic diagnosis of paraganglioma confirmed. At 24 months of follow-up the patient felt well and was normotensive without any foci of paraganglioma. Although rare, paraganglioma must be considered in the differential diagnosis of early preeclampsia.     

Primary amyloidosis of the bladder: a case report

A case of primary amyloidosis of the bladder, which developed 4 years after primary treatment, is described. The patient is a 55-year-old male, who consulted our clinic with a complaint of asymptomatic gross hematuria on October 1, 1983. Cystoscopic examination showed a tumorous lesion involving right lateral wall of the bladder, which was resected transurethrally. No malignancy was found by histopathological examination. About 4 years later, he consulted our clinic again with a complaint of asymptomatic gross hematuria. There was a tumorous lesion involving left lateral wall of the bladder on cystoscopy. Transurethral resection of bladder tumor was performed under a diagnosis of bladder tumor. Histological examination revealed amyloidosis of the bladder, AL-type amyloid. Re-examination of the specimens resected 4 years ago showed the same findings. Biopsies from the tongue, skin and rectum disclosed no amyloid deposition. During these 19 months, he had no recurrence. This case was thought to be the first one of primary amyloidosis of the bladder showing new recurrence reported in Japanese literature.