How are cystoscopic biopsy specimens obtained during the workup for bladder cancer?

Updated: Aug 03, 2019
  • Author: Gary David Steinberg, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Answer

During cystoscopy, the urologist generally obtains multiple bladder biopsy specimens from various locations in the bladder to help establish the diagnosis and to determine the extent of the tumor. A process known as bladder mapping is used for this purpose. In general, biopsy specimens are taken from the left lateral wall, right lateral wall, base, dome, and trigone of the bladder, as well as from the prostatic urethra.

Adequate tissue should be obtained to allow the pathologist to determine the depth of penetration of the tumor. Usually, a cold-cup biopsy forceps is used to avoid cautery artifact to the specimen. Biopsy specimens, which are submitted in separate containers, are obtained from different areas using a punch biopsy forceps. The pathologist provides a report for each location from where a specimen was taken.

In order to detect invasion into the lamina propria or muscle, the biopsies should be deep, and the pathologist should record the presence or absence of these areas. Carcinoma in situ (CIS) may not be visible, and a map of the areas where biopsy samples were obtained is helpful for subsequent follow-up examinations. [7]

At the time of this procedure, the bladder can be lavaged with saline and the specimen can be sent for cytology. The specimen should be labeled as a bladder washing or lavage to assist the pathologist in evaluation, as specimens from washings tend to have larger clumps of cells than simple voided urine.

When visible, CIS may have a characteristic red, velvety appearance that resembles an area of inflammation. Obtain biopsy specimens from any areas of suspicious erythema that are not included in these biopsies, and label them as an additional site.

Following tissue acquisition, the biopsy sites can be cauterized for hemostasis. Avoid damaging the ureteral orifice or intramural tunnel of the ureter. If potential damage to the ureteral orifice is unavoidable because of the location of suspicious lesions, a ureteral stent may be placed.

The role of random bladder biopsies is controversial. The minimal benefit of identifying unsuspected CIS must be weighed against the risk of increasing tumor implantation plus the risk of additional bleeding or bladder perforation. However, CIS is often not visible and may be underdetected without biopsies of normal-appearing bladder urothelium.

Retrograde pyelography is generally discouraged during bladder biopsies to avoid reflux of malignant cells, but the study may be performed if the patient has contrast allergies or other issues that prevent other imaging modalities for evaluation of the upper urinary tract. Ureteral washes for cytologic analysis may also be performed. These should be obtained with saline (not water) and should be collected prior to the instillation of any contrast material, which has been shown to negatively affect cytology results.

Transitional cell tumors are typically papillary or sessile, and CIS may appear as an erythematous, velvety lesion. Unless the lesion is in a bladder diverticulum (pseudodiverticulum), attempt to resect the primary tumor completely.

A bladder diverticulum lacks a surrounding muscle layer, and a deep biopsy of a lesion within a diverticulum risks perforating the bladder and extravesical extravasation of cancer cells.

Because no muscle layer surrounds the bladder diverticulum, the next step in the progression of a superficial tumor is extravesical spread, requiring more aggressive surgical therapy (eg, partial cystectomy, open diverticulectomy) rather than a simple resection followed by surveillance.


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