Ursachenzusammenhang zwischen langjähriger Querschnittlähmung und malignen Harnblasentumoren

[Oncological relevance of neuro-urological diseases]

Apart from a few exceptions, there is currently little scientific evidence on the oncological relevance of neuro-urological diseases. Most research has been conducted into the association between long-term spinal cord injury with its consequences for the lower urinary tract and the occurrence of bladder cancer. These cancers differ in many ways from bladder cancers in patients without spinal cord injury: patients are 20 years younger on average, tumours are very often already muscle-invasive and poorly differentiated with a high proportion of squamous cell carcinomas, and the prognosis is poor. These characteristics also occur in spinal cord injury patients without permanent catheter drainage of the urinary bladder. Although the pathophysiological association has not been clarified in detail, the presence of a neurogenic bladder appears to be the decisive link between spinal cord injury and the occurrence of bladder cancer. Pathological pressure conditions in the urinary bladder and frequent urinary tract infections or asymptomatic bacteriuria resulting from neurogenic lower urinary tract dysfunction could be the decisive pathophysiological factors. In this respect, urinary bladder cancer in persons with a chronic spinal cord injury represents a model tumour after denervation. The clinically important question of screening requires future interdisciplinary research approaches.

[When must the suspicion of an occupational disease or urological sequelae of an occupational accident be reported? : Legal background, medical obligations and course of the procedure]

Physicians are obliged to report the suspected presence of an occupational disease to the German Social Accident Insurance Institutions or to the state authority responsible for occupational health and safety. In the field of urology, tumors of the urinary tract are the most common, followed by the less common renal cell cancer and mesothelioma of the tunica vaginalis testis; however, for such a suspicion to arise at all, sufficient knowledge of urological occupational diseases must be present and the occupational or work history over the entire training and working life since the beginning of employment must be collected. In daily life the notification often fails at this point. In addition to the legal foundation and the principal course of the procedure, this article explains how a relevant comprehensive medical history by means of questionnaires can contribute to the fact that neither too many or all tumor diseases are unreflectedly reported, nor that occupational diseases are overlooked due to the lack of a medical history or detailed knowledge (or fear of this). Urological sequelae of accidents are often not adequately appreciated in the primary process or may take a long time to develop. In this case reporting the aggravation of the consequences of the accident is essential.

[Urinary Bladder Cancer as a Long-term Sequela of Spinal Cord Injury - Relevance to Practice]

Urinary bladder cancer is the second most common tumour disease after lung cancer leading to death in people with a spinal cord injury. This paper provides a comprehensive overview of the differences relevant to urologists between urinary bladder tumours in this population compared with urinary bladder tumours in the general population.People with a spinal cord injury are 1 to 2 decades younger on average at the time of tumour diagnosis than patients without a spinal cord injury. Histopathologic findings at the initial diagnosis of urinary bladder cancer in people with a spinal cord injury are much less favourable than for urinary bladder cancers in the general population. Muscle-invasive tumours and tumours with poor differentiation are much more common, and the proportion of squamous cell carcinomas is significantly higher. The incidence rises after more than 10 years of paralysis. Urinary bladder cancer mortality is significantly elevated and increases with the duration of paralysis. In diagnostic procedures and, in particular, in radical cystectomy, clinically important features have to be considered. For example, urodynamic examinations or cystoscopy may trigger autonomic dysreflexia with hypertensive crises and the risk of life-threatening bradycardia.In the case of radical cystectomy, frequent adhesions and callosities of the urinary bladder, among other things, must be taken into account intraoperatively. Severe paralysis, prolonged intestinal atony and other conditions are frequently observed after the surgical procedure due to neurogenic bowel dysfunction. Correct positioning of the patient immediately after surgery to avoid decubitus and to support breathing, as well as bowel management specific to spinal cord injury, must be strictly observed.Other special features of paraplegic patients with urinary bladder cancer that should also be considered in clinical practice, as well as considerations for screening for urinary bladder tumors, are presented in the article.

[Occupational cancers in urology]

Cancers can be triggered by occupational causes. In the field of urology, bladder cancer is by far the most frequent occupationally induced tumor disease. Causes are particularly carcinogenic aromatic amines and carcinogenic polycyclic aromatic hydrocarbons. The frequency of this disease has shifted over the last decades from the classical hazard in the chemical industry to the users. Among a variety of hazardous occupations, hairdressers and painters are the best known. Rarely, renal cell carcinoma can be triggered by high trichloroethylene exposure and mesothelioma of the tunica vaginalis testis by asbestos. If a disease that can be caused by occupational activities has been confirmed (e.g. urinary bladder cancer), the risk factors must be recorded by a complete occupational history from the first employment on in order to be able to report a suspected occupational disease. In addition, spinal cord injury due to occupational and commuting accidents can lead to urinary bladder cancer over the long term.

[Urinary bladder cancer as a late sequela of spinal cord injury : Decision-making aids for assessment of this causal association]

BACKGROUND

There is to date no convincing literature that has assessed the association between traumatic spinal cord injury (SCI) and the later development of urinary bladder cancer. The aim of this work is to present medical experts as well as the national accident insurance and the social courts decision-making aids based on the latest medical scientific knowledge, for assessment of this causal association.

MATERIALS AND METHODS

A study conducted between April 1998 and March 2017 in the BG Trauma Hospital Hamburg forms the basis for the decision-making aids. Urinary bladder cancer was diagnosed in 32 out of 6432 treated outpatient and inpatient SCI patients. Furthermore, relevant published literature was taken into consideration for the decision-making aids.

RESULTS

It was found that urinary bladder cancer in SCI patients occurs at a considerably younger age as compared to the general population, more frequently shows muscle invasive carcinoma with a higher grade at first diagnosis and a higher proportion of the more aggressive squamous cell carcinoma than that of the general population. Correspondingly, the survival time is extremely unfavorable. For medical experts a matrix was compiled where the various influencing factors, either for or against the recognition of an association between SCI and urinary bladder cancer, were weighted according to their relevance.

CONCLUSION

The results showed that urinary bladder cancer in SCI patients differs considerably from that of able-bodied patients. These differences drastically shorten the survival time. A study on patients with spina bifida, i.e., a congenital spinal cord disorder, corroborates these observations. They indicate histopathological differences that have so far been intangible.