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LETTER TO EDITOR
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 121-122

Giant vesical calculus with coexisting bladder carcinoma and diverticulum


Department of Radiology, Malabar Medical College, Kozhikode, Kerala, India

Date of Web Publication26-Dec-2018

Correspondence Address:
Dr. Reddy Ravikanth
Department of Radiology, Malabar Medical College, Kozhikode - 673 315, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_14_18

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How to cite this article:
Ravikanth R. Giant vesical calculus with coexisting bladder carcinoma and diverticulum. BLDE Univ J Health Sci 2018;3:121-2

How to cite this URL:
Ravikanth R. Giant vesical calculus with coexisting bladder carcinoma and diverticulum. BLDE Univ J Health Sci [serial online] 2018 [cited 2019 Mar 22];3:121-2. Available from: http://www.bldeujournalhs.in/text.asp?2018/3/2/121/248546



Sir,

An 85-year-old male presented with dribbling of urine for 1 year associated with burning micturition, hematuria, dysuria, and hesitancy. The general physical examination was unremarkable, and abdominal examination did not reveal any tenderness or a palpable bladder. His urine analysis showed 50–100 pus cells and 25–30 red cells per high-power field. Urine culture yielded no significant growth. Uroflowmetry had a bell-shaped curve with a maximum flow rate of 20 mL/s for a voided urine volume of 164 mL. Ultrasonography suggested the presence of a large vesical calculus, a bladder diverticulum, prostatomegaly, and multiple lobulated lesions arising from the wall of the urinary bladder. The findings were confirmed on computed tomography scan which revealed a giant vesical calculus measuring 4.7 cm × 3.6 cm [Figure 1]a and [Figure 1]b and a large diverticulum in the right lateral wall of the bladder measuring 5.6 cm × 4.0 cm with no evidence of tumor within the diverticulum [Figure 2]. A lobulated, nonpedunculated lesion arising from the left lateral wall was noted showing foci of calcifications [Figure 2]. The mass lesion was not invading trigone and ureterovesicular junction with no evidence of hydroureter and hydronephrosis. There was no evidence of lymphadenopathy. Prostate was normal. Other abdominal and pelvic organs were normal. The radiological diagnosis was given as malignant urinary bladder neoplasm. Histopathology revealed a nonkeratinizing squamous cell carcinoma with invasion of lamina propria and muscularis propria and absent lymphovascular invasion compatible with a pathological tumor stage of pT2. Radical cystectomy with an ileal conduit was done. At the 6-month follow-up, the patient is doing well. Patients with giant vesical calculus usually present with recurrent urinary tract infection, azotemia, and retention of urine. Chronic infection and inflammation, secondary to urinary stasis, were responsible for this condition. Nonurothelial bladder cancers are less common, comprising approximately 5% of all bladder cancers.[1] Squamous cell carcinoma of the bladder is a rare cause of bladder cancer, accounting for 2.7% of bladder cancers in the developed world.[2] In areas where schistosomiasis is endemic, it is the most common cause of bladder cancer which accounts for around 59% of bladder cancers.[3] The association between chronic bladder irritation and squamous cell carcinoma has been postulated by many researchers. Chronic bladder irritation includes chronic or recurrent urinary tract infection, chronic indwelling urinary catheter, bladder calculi, foreign bodies, intravesical bacillus Calmette–Guerin, and prolonged exposure to cyclophosphamide. Long-standing bladder stones have been implicated as a cause of squamous cell bladder cancer through chronic mucosal injury with resulting inflammation and disruption of the protective glycosaminoglycan layer. Bladder diverticulum is herniation of the bladder mucosa through detrusor muscle. The incidence of bladder diverticulum is approximately 1.7% in children and 6% in adults.[4] Dysplasia, leukoplakia, and squamous metaplasia develop in approximately 80% of diverticulum. Diverticular neoplasms have a worse prognosis than regular bladder neoplasms secondary to early invasion. Since the bladder diverticula have minimal, if any, muscular wall, neoplasms rapidly progress from T1 to T3. Some authors have suggested that for intradiverticular neoplasms stage pT2 should be omitted and stage pT3 should follow pT1.[5] Surgery is the mainstay of treatment of squamous cell carcinoma of the bladder; however, there is an associated high recurrence and poor prognosis following surgery. Radical cystectomy remains the mainstay of therapy in select patients with resectable disease. Chemotherapy and radiation therapy can be considered in patients who are not surgical candidates or patients with metastasis. When metastatic disease is not evident, the treatment with the standard protocol of cystectomy and radiation therapy should achieve the same results as for the transitional cell tumor.
Figure 1: Computed tomography images in supine (a) and prone (b) positions demonstrating the dependent position of a giant vesical calculus with lamellated appearance

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Figure 2: Computed tomography image demonstrating a large diverticulum in the right lateral wall of the bladder with no evidence of tumor within it (white arrows) and a lobulated lesion arising from the left lateral wall of the urinary bladder (black arrows) in a biopsy-proven case of nonkeratinizing squamous cell carcinoma of the bladder

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tavora F, Epstein JI. Bladder cancer, pathological classification and staging. BJU Int 2008;102:1216-20.  Back to cited text no. 1
    
2.
Abol-Enein H, Kava BR, Carmack AJ. Nonurothelial cancer of the bladder. Urology 2007;69:93-104.  Back to cited text no. 2
    
3.
Felix AS, Soliman AS, Khaled H, Zaghloul MS, Banerjee M, El-Baradie M, et al. The changing patterns of bladder cancer in Egypt over the past 26 years. Cancer Causes Control 2008;19:421-9.  Back to cited text no. 3
    
4.
Tamas EF, Stephenson AJ, Campbell SC, Montague DK, Trusty DC, Hansel DE, et al. Histopathologic features and clinical outcomes in 71 cases of bladder diverticula. Arch Pathol Lab Med 2009;133:791-6.  Back to cited text no. 4
    
5.
Golijanin D, Yossepowitch O, Beck SD, Sogani P, Dalbagni G. Carcinoma in a bladder diverticulum: Presentation and treatment outcome. J Urol 2003;170:1761-4.  Back to cited text no. 5
    


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