Archivio Italiano di Urologia e Andrologia 2018; 90, 18 ORIGINAL PAPER Pathology outcomes in patients with transurethral bladder tumour resection in a Turkish population: A retrospective analysis Salih Budak 1, Cem Yücel 1, Mehmet Zeynel Keskin 1, Mehmet Yoldas 1, Erdem Kısa 1, Ertan Can 1, Ulku Kucuk 2, Zafer Kozacıoğlu 1 1 Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey; 2 Tepecik Training and Research Hospital, Pathology Department, Izmir, Turkey. Objectives: Transurethral bladder tumour resection (TURBT) is the common surgical method used in the diagnosis, staging and treatment of patients with bladder tumour. Most of the rare tumours other than the urothelial carcinomas of the bladder are in advanced stage on diagnosis and necessitate aggressive treatment. In our study, we aimed to the histologic types of bladder cancer and to determine the regional incidence of rare bladder cancer types in our region. Materials and methods: We retrospectively evaluated 815 patients who underwent TURBT surgery between January 2010 and March 2016 in our clinic with a diagnosis of bladder cancer and at least 1 year follow-up. Patients with tumour histopathological examination including histological tumour type, grade and were reported. Thirty-nine patients with an unclear pathology report (neighboring organ invasion, cautery artifact, etc) and 17 patients whose data could not be accessed were excluded from the study. The patients who had received chemotherapy or radiotherapy due to any type of malignancy (23) were also excluded from the study. Results: The outcomes of 736 patients operated in our clinics due to bladder tumour were evaluated. The mean age was 65.2 ± 8.4; 135 were female and 601 were male. Among them 711 patients with urothelial carcinoma were reported (94.2%). According to TNM classification, stage Ta was observed in 270 patients (37.9%), stage T1 in 297 (41.7%), and stage T2 in 144 (20.3%). Non-urothelial cancers were reported in 25 cases (3.3%). Conclusion: The incidence of bladder carcinoma varies between regions. The results of our study are similar to those of the western countries. Increased smoking and exposure to environmental carcinogenetic agents may lead to altered inci- dences and histological types of bladder tumours. Revision of regional tumour records may be useful to develop and evaluate future treatment strategies. KEY WORDS: Bladder cancer; Transurethral resection; Pathology; Squamous cell; Adenocarcinoma. Submitted 14 July 2017; Accepted 19 July 2017 Summary No conflict of interest declared. sis (2, 3). Transurethral bladder tumour resection (TURBT) is the basic surgical method used in the diagnosis, staging and treatment of bladder cancer (4). Prognosis of urinary bladder tumors is directly connected to histological type and stage of the tumour (5). Urothelial carcinomas (UC) constitute 90-95% of bladder cancers (4). The second most common subtype is the squamous cell carcinoma (SCC) that has an incidence of less than 5% in western countries (6). Adenocarcinomas constitute less than 2% of all bladder cancers (7). Most of these rare histologic sub- types are in advanced stage when they are diagnosed and they require more aggressive treatment options (8). In our study, we aimed to the histologic types of bladder cancer and to determine the regional incidence of rare bladder cancer types in our region. MATERIALS AND METHODS We retrospectively evaluated 815 patients who underwent TURBT surgery between January 2010 and March 2016 in our clinic with at least 1 year follow-up. All operations were performed under spinal or general anesthesia. TURBT was performed with bipolar energy system using saline irrigation. All obtained materials were placed in containers with 10% formaldehyde and sent to the pathol- ogy laboratory. The materials were buried in paraffin blocks after tissue follow-up procedures. Sections with 5 micron thickness were prepared from paraffin blocks and stained with hematoxylon-eosin. The cases in which tumours were determined in the histopathological exami- nation were reported by specifying tumour histological subtype, grade and pathological tumour stage. Second transurethral resection was performed in cases which had recurrence from clinical and radiologic follow-up, and the highest tumour stage and grade was recorded. Thirty-nine cases with unclear pathology (adjacent organ invasion, cautery artifact etc.), 17 cases the data of which could not be accessed, and 23 cases with chemotherapy/radiothera- py due to any malignancy were excluded from the study. RESULTS One hundred and eighty five of the 736 patients (25.1%) included in the study were diagnosed as primary bladder DOI: 10.4081/aiua.2018.1.8 INTRODUCTION Bladder cancer is the second most common tumour of the genitourinary system (1). Global cancer burden continues to increase due to increased age of population, smoking, western diet and exposure to environmental carcinogene- Budak_Stesura Seveso 27/03/18 09:15 Pagina 8 9Archivio Italiano di Urologia e Andrologia 2018; 90, 1 Pathology outcomes in bladder tumor resection cancer and 551 (74.9%) as recurrent after surgery due to bladder tumour. One hundred and thirty five of the patients were female, 601 were male and the mean age was 65.2 ± 8.4. It was determined that incidence of blad- der carcinoma is 4.5 times more common in males than females. According to our results of pathological examination, UC was reported at a rate of (94.2%). According to TNM classification, it was determined that 270 patients were in Ta stage (38%), 297 patients were in T1 stage (41.8%), and 144 patients were in T2 stage (20.3%) (Table 1). Twenty five (3.3%) cases were reported as non-urothelial carcinoma. In the pathological evaluation result of these tumours, it was seen that 10 cases were squamous cell carcinoma (1.3%), 9 cases were adenocarcinomas (1.2%), 1 case was neuroendocrine (0.1%), 1 case was small cell carcinoma (0.1%), 2 cases were sarcomatoid carcinoma (0.3%), and 2 cases were bladder leiomyoma (0.3%) (Table 2).. DISCUSSION Currently, the most important prognostic factors in blad- der tumours are the pathological stage and the grade of tumour as determined by histopathological examination (5). Presence of muscle invasion in bladder carcinomas is very important in terms of foreseeing the prognosis and determining the treatment approach. In the study conducted by Horstmann et al., in which 1269 bladder tumours were evaluated, incidence of mus- cle invasion was reported to be 35.8% (9). In our study, incidence of muscle invasion was deter- mined as 21.9% (161). In western countries, primary SCC of bladder is 1.2- 4.5% of all bladder tumours and it is often seen in the seventh decade (10, 11). Radical cystectomy is still the most suitable treatment for bladder SCC. The 5-year sur- vival rate after cystectomy was reported to be 50% and mean period of survival was 5.4 years (12). Almost all squamous cell cancers are already advanced and muscle infiltrative at the time of diagnosis (13). In our study we determined the incidence of SCC as 1.3%. Adenocarcinomas constitute less than 2% of all bladder cancers (14). Adenocarcinoma diagnosis may be consid- ered as originating primarily from the bladder after excluding metastasis or invasion from neighboring organs. Due to poor prognosis, standard treatment for adenocarcinomas is radical cystectomy and dissection of the pelvic lymph nodes (15). Therefore, early diagnosis is important. In our study we determined the incidence of adenocarcinoma as 1.2%. The benign tumours that are seen in the bladder are myoma, leiomyoma, rhabdomyoma, fibroma, angioma, osteoma and myxoma. The most common benign mes- enchymal bladder tumour is leiomyoma (16).The avail- able evidence about most of these rare tumours originate from small retrospective case series (17). In our study, 2 (0.3%) cases of bladder leiomyoma were detected. CONCLUSIONS There are differences in incidence of bladder carcinoma between regions. The results of our study are similar to those of the western countries. The diagnosis of non- urothelial cancers is usually made in the advanced stage and the most applied treatment is radical surgery. Increased smoking and exposure to environmental car- cinogenesis may lead to a change in the frequency of his- tological type of bladder tumours. It may be useful to update regional tumour records to develop and evaluate future treatment strategies. REFERENCES 1. Grossfeld GD, Carroll PR. Evaluation of asymptomatic micro- scopic hematuria. Urol Clin North Am. 1998; 25:661-76. 2. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin. 2011; 61:69-90. 3. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012; 62:10-29. 4. Richterstetter M, Wullich B, Amann K, et al. The value of extend- ed transurethral resection of bladder tumour (TURBT) in the treat- ment of bladder cancer. BJU Int. 2012; 110:76-79. 5. Arslan B, Bozkurt IH, Yonguc T, et al. Clinical features and out- comes of nontransitional cell carcinomas of the urinary bladder: analysis of 125 cases. Urol Ann 2015;7:177-82. 6. Shokeir AA. Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment. BJU international. 2004; 93:216-20. 7. Dahm P, Gschwend JE. Malignant non-urothelial neoplasms of the urinary bladder: a review. Eur Urol. 2003: 44:672-81. 8. Manunta A, Vincendeau S, Kırıkakou G, et al. Non-transitional cell bladder carcinomas. BJU Int. 2005; 95:497-502. 9. Horstmann M, Witthuhn R, Falk M, Stenzl A. Gender-specific dif- Table 1. Clinical stages of UC cases with TNM classification. Stage and grade Number of patients (% ) TAG1 167 (23.5%) TAG2 87 (12.2%) TAG3 16 (2.3%) T1G1 92 (12.9%) T1G2 79 (11.1%) T1G3 126 (17.7%) T2 144 (20.3%) Total 711 (100%) Table 2. Distribution of TURBT pathologic diagnosis (n = 736). Histopathological diagnosis Number of patients (% ) Urothelial carcinomas 711 (94.2) Squamous cell carcinoma 10 (1.3%) Adenocarcinoma 9 (1.2%) Neuroendocrine 1 (0.1%) Leiomyoma 2 (0.3%) Small cell carcinoma 1 (0.1%) Sarcomatoid carcinoma 2 (0.3%) Total 736 (100%) Budak_Stesura Seveso 27/03/18 09:15 Pagina 9 Archivio Italiano di Urologia e Andrologia 2018; 90, 1 S. Budak, C. Yücel, Mehmet Z. Keskin, M. Yoldas, E. Kısa, E. Can, U. Kucuk, Z. Kozacıoğlu 10 ferences in bladder cancer: a retrospective analysis. Gen Med. 2008; 5:385-94. 10. Lopez JI, Angulo CJ, Flores CN, Toledo JD. Squamous cell car- cinoma of the urinary bladder. Clinico-pathologic study of 7 cases. Arch Esp Urol. 1994; 47:756-60. 11. Serretta V, Pomara G, Piazzo F, Gange E. Pure squamous cell carcinoma of the bladder in western countries. Eur Urol. 2000; 37:85-9. 12. Ghoneim MA, El Mekresh MH, El Baz MA, et al. Radical cys- tectomy for carcinoma of the bladder: Critical evaluation of the results in 1026 cases. J Urol. 1997; 158:393-9. 13. El-Sayed MI, Abdel-Rahim AM. Survival Analysis in Patients with Non-metastatic Squamous Cell Carcinoma of the Urinary Bladder. Middle East J Cancer. 2011; 2: 59. 14. Dahm P, Gschwend JE. Malignant non-urothelial neoplasms of the urinary bladder: a review. Eur Urol. 2003; 44:672-81. 15. Wilson TG, Pritchett TR, Lieskovsky G, et al. Primary adeno- carcinoma of bladder. Urology. 1991; 38:223-6. 16. Goktug GH, Ozturk U, Sener NC, et al. Transurethral resection of a bladder leiomyoma: A case report. Can Urol Ass J. 2014; 8:111. 17. Park JW, Jeong BC, Seo SI, et al. Leiomyoma of the urinary blad- der: A series of nine cases and review of the literature. Urology. 2010; 76:1425-9. Correspondence Salih Budak, MD (Corresponding Author) salihbudak1977@gmail.com Tepecik Training and Research Hospital, Urology Clinic 206/26 sok. no:16 D:24 yıldız mah. Buca/Izmir, Turkey Cem Yücel, MD meclecuy@hotmail.com Mehmet Zeynel Keskin, MD zeynel_akd@hotmail.com Mehmet Yoldas, MD yoldas_2297@hotmail.com Erdem Kısa, MD drerdemkisa@hotmail.com Ertan Can, MD drertancan@yahoo.com Ulku Kucuk, MD Associate Professor kucukulku@hotmail.com Zafer Kozacıoğlu, MD Associate Professor zaferkozacioglu@gmail.com Tepecik Training and Research Hospital, Urology Clinic Tepecik EAH, Üroloji Kliniği, Yenişehir, Izmir, Turkey Budak_Stesura Seveso 27/03/18 09:15 Pagina 10