Vesical Neoformations in Glandular Cystic Cystitis
58-year-old male diagnosed with sigmoid colon diverticulosis. In the past (2000&2008) he underwent trans urethral resections of bladder lesions which were diagnosed to be glandular cystitis cystica. Follow up cystoscopy performed lately revealed two new strawberry like lesions close to the bladder neck. Urine cytology was negative for malignant cells, pelvic ultrasound demonstrated a thickened bladder. The patient was offered another resection surgery.
1. Is surgery deemed necessary?
2. If not so, could you recommend an alternative drug therapy?
3. What is the risk of recurrence of this condition in the future?
58 years old
Diagnosis: Vesical Neoformations in Glandular Cystic Cystitis
Past Medical History:
58 year-old patient, ex-smoker of 8 years suffering from sigmoid colon diverticulosis and HBsAg positive. Approximately 20 years ago, he underwent fruitless cystoscopy to remove a ureteral stone which was subsequently expelled spontaneously. In 2000 a new cystoscopy was performed and a biopsy taken. The histology report confirmed a diagnosis of glandular cystic cystitis. No specific follow-on tests were run since then.
On 05.2009, the patient had endoscopic resection of a mamelons-shaped mucosal area located in the bladder trigone region following an ultrasound report of vegetating neoformations in a patient known for glandular cystitis (first diagnosed in 2000) and essential thrombocytosis. Histology performed after the procedure was conducive to a diagnosis of glandular cystic cystitis. Recently during a follow-up endoscopy, evidence of 2 cystic strawberry-like neoformations on the vesical neck. Further evidence of some mucosal cysts scattered on all bladder quadrants which should be examined under anesthesia. The ultrasound performed on 06/2009 shows “moderately distended bladder with finely thickened walls. No lesion protruding into the lumen. Prostate with increased dimensions (volume 31 cc) on supra-pubic examination and with a somewhat dishomogeneous echostructure”. Search for tumor cells in urine was negative. In view of the information above, repeat resection surgery was advised as was the case in 2008.
Cystitis cystica is a rare benign hyperplastic condition of the urinary bladder. It is associated with chronic urothelial irritation. It usually occurs in the elderly or occasionally in children. In its minor form, it has the same clinical features as cystitis, but its major form may be mistaken for bladder tumor on endoscopy.
On cystoscopy, cystitis cystica nodules are usually found located on the trigone and bladder neck region. Cystoscopic biopsy is mandatory, as the diagnosis is histological. It appears histologically as submucosal nests of columnar epithelial cells surrounding a central liquefied region of columnar degeneration. Cystitis cystica glandularis is essentially cystitis cystica that has undergone metaplasia to form glandular tissue. It differs from cystitis cystica only in the nature of the epithelia. Cystitis cystica can be considered a premalignant disease of the urinary bladder. It is perceived that these glands undergo dysplasia and can progress to adenocarcinoma of the bladder. In the absence of obvious lesion, treatment is usually medical, based on the eradication of the irritative factors. Surgery is required in case of complications of the disease like recurrent haematuria or features associated with bladder outlet obstruction secondary to the pseudoneoplastic growth. However, as cystitis cystica can predispose to bladder malignancy and that its clinical course is unclear.
I do recommend this patient will undergo the planned surgery and will require long-term surveillance in the form of cystoscopic examinations.