Endoscopic urinary bladder biopsy (synonym: cystoscopic biopsy) is a diagnostic procedure in urology and oncology used to diagnose tumors of the urinary bladder. To perform the examination, a flexible or rigid cystoscope is used, which is inserted into the urethra under visual control. Irrigation of the urethra must be performed regularly to improve visibility. Endoscopic urinary bladder biopsy is of particular importance in the detection of carcinoma of the urinary bladder, which occurs relatively frequently in Germany. The use of endoscopic urinary bladder biopsy is therefore of great importance, since early detection of the tumor significantly improves the chance of cure. Overall, more than 70% of patients have non-invasive involvement of the urothelium (tissue in urinary organs that is characterized by a special resistance to urine) or the underlying connective tissue lamina propria (superficial layer of tissue) when urinary bladder cancer is detected. However, the prognosis for life expectancy in the presence of a tumor depends not only on the time of diagnosis, but also on the type of tumor. If we consider low-grade papillary (growth form) tumors with a recurrence risk (recurrence of the tumor) of approximately 50% in the first two years, this form of carcinoma can be treated relatively well by local therapy. In contrast, tumors can also occur in the urinary bladder, which are far more aggressive and are associated with a poorer prognosis even when detected early by biopsy.As a therapeutic measure, local therapy is now usually not the main focus, and instead surgical therapeutic measures such as cystectomy (surgical removal of the urinary bladder) and bladder replacement are performed. Early therapy as a result of early detection increases the overall chance of organ-preserving therapy, so it is important to identify this aggressive tumor entity (tumor type or cancer characteristic) early. Precise tumor identification including determination of the malignancy of the tumor can only be achieved by endoscopic urinary bladder biopsy, so this is currently the gold standard (first choice procedure) in urinary bladder tumor diagnosis. The biopsy itself is defined by the removal of tissue for further examination. Microscopically and possibly also histochemically (immunologically), it can now be determined whether the tissue sample is a pathologically altered tissue and, should a pathological process be present, whether it is benign or malignant (benign or malignant). The presence of bladder carcinoma presents on cystoscopy as typically isolated, raised, and reddened bladder mucosal areas.
Indications (areas of application)
- Urinary bladder carcinoma – to assess the entity of a tumor, the use of urinary bladder biopsy is of important significance. Furthermore, the staging of the carcinoma is crucial for the selection of therapeutic measures.
Contraindications
There are no known contraindications to performing endoscopic urinary bladder biopsy.
Before surgery
- Anesthesia – before endoscopic urinary bladder biopsy, administration of narcotic is done. The biopsy is performed under general anesthesia. Thus, the ability to be anesthetized is a prerequisite for the procedure.
The surgical procedure
The procedure
- After anesthesia has been induced, the patient is placed in the thoracic-abdominal position. After connecting the various irrigation units to improve visibility, the endoscope can now be inserted into the urethra after cleaning the urethral outlet.
- After reaching the bladder, endoscopy is used to check which area is suitable for biopsy.
- Once this is done, the biopsy forceps can be inserted into the working channel of the endoscope. Subsequently, the forceps is opened and the selected mucosal area can be removed after grasping by closing the biopsy forceps. When removing the tissue must be a jerky movement of the forceps to remove.
- Once the tissue has been removed, it is pulled through the working channel of the endoscope and, after being transferred to a special transport medium, is left for the pathologist to examine.
- To avoid possible complications, it is necessary to endoscopically assess the tissue area from which the material to be examined was taken.
Additional procedures for the evaluation of carcinoma of the urinary bladder.
- Urine cytology examination (synonym: urine cytology) – to increase the sensitivity (percentage of diseased patients in whom the disease is detected by the use of the test, ie, a positive test result occurs), it is necessary to add additional diagnostic procedures to the endoscopic biopsy of the urinary bladder. Of particular importance is urine cytology examination (cell examination from urine) of urine excreted spontaneously or obtained by bladder irrigation. The primary goal of this examination method is to search for malignant (malignant) altered cells. A positive urine cytology result indicates the presence of a tumor, which can be localized either within the urinary bladder or in the upper urinary tract (ureters/pelvicocaliceal system). However, it should be noted that low-grade tumors or isolated cells are associated with a negative finding, as the presence of a “low-grade” tumor (low malignancy) cannot be excluded with certainty. Furthermore, ancillary findings can influence the interpretation of cytological findings, as degenerative changes, urinary tract infections and foreign bodies can feign a positive finding.
- Sonography – The influence of sonography in the evaluation of the urinary bladder is now used almost by default. Ultrasonography allows for the assessment of both renal tissue space and renal pelvic caliceal system masses. Moreover, possible metastases (daughter tumors) can be detected by sonography.
After surgery
- After surgery, the patient receives a mild analgesic (pain reliever) and an antibiotic if necessary.
- The patient should take enough liquid (2-2,5 l)in the next days, so that possible germs as well as blood can be excreted better. Furthermore, in the first 24 hours should not be lifted heavy and strenuous activities should be avoided.
- The doctor should be consulted if after 3 days there is still blood in the urine. Other symptoms that prompt a visit to the doctor are burning pain during urination beyond the second day, cloudy or foul-smelling urine, appearance of large coagual (blood clots) in the urine, flank pain (pain in the right or left flank of the body) and fever.
Possible complications
- Bleeding – the removal of tissue from the urinary bladder is usually accompanied by mild bleeding. However, in exceptional cases, massive bleeding may occur because the surrounding tissue is highly perfused. However, because urinary bladder cancer often occurs primarily in the elderly and less stable in health, significant blood loss can be accompanied by significant symptoms.
- Perforation of the bladder wall – in addition to bleeding, injury to the bladder wall may occur from the biopsy or from the endoscope itself. Perforation of the bladder wall is a massive and potentially life-threatening complication.