Squamous Cell Carcinoma of the bladder as a cause of spontaneous bladder rupture : a case report

doi:10.21203/rs.3.rs-5023972/v1

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Case Report

Squamous Cell Carcinoma of the bladder as a cause of spontaneous bladder rupture : a case report

https://doi.org/10.21203/rs.3.rs-5023972/v1

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Background: Spontaneous bladder rupture is a rare condition typically presenting with abdominal pain and peritonitis. Although bladder malignancies seldom cause spontaneous perforation, when they do, the condition carries a high mortality rate due to delayed diagnosis and poor prognosis.

Case presentation: A 69-year-old woman with a history of subtotal hysterectomy presented with acute abdominal pain and recurrent haematuria. Imaging showed a bladder rupture. Extensive bladder necrosis and multiple perforations were found during surgery, necessitating cystectomy. Histopathology confirmed infiltrating keratinising squamous cell carcinoma (SCC). Her condition deteriorated postoperatively, and she died four months later.

Conclusions: This case highlights the diagnostic and therapeutic challenges of spontaneous bladder rupture in SCC, the aggressive nature of the malignancies causing spontaneous bladder rupture, and the need for high clinical suspicion and timely intervention.

Bladder

Spontaneous rupture

Squamous cell carcinoma

Radical cystectomy

case report

Spontaneous bladder rupture, a rare condition also known as non-traumatic bladder rupture, presents both diagnostic and therapeutic challenges. The diagnostic difficulty arises from its often atypical symptoms. [1] A rare cause of spontaneous urinary bladder rupture is malignancy, often presenting as advanced disease with a poor prognosis, with a challenging diagnosis that typically involves imaging techniques such as computed tomography (CT) scans and cystography, which help identify free air in the abdominal cavity, bladder masses, and the extent of the rupture. [2]

Here, we present an exceptionally rare case of spontaneous bladder rupture secondary to bladder squamous cell carcinoma. Squamous cell carcinoma (SCC) of the bladder, is aggressive and uncommon malignancy resistant to chemotherapy, further complicates this scenario.

Patient information

A 69-year-old woman with a history of subtotal hysterectomy for uterine fibroids 20 years ago presented to the emergency department with recent deterioration in her general condition, acute abdominal pain, and recurrent hematuria over several months.

Clinical findings

Initial assessment revealed signs of an acute surgical abdomen and a distended bladder requiring catheterization. The 500cc of collected urine was hematuric with blood clots.

Timeline of current episode

The patient presented with a decline in general health, characterized by unquantified weight loss and recurrent episodes of hematuria over the past few months. The consultation was sought following the onset of an infectious state, accompanied by an absence of urination.

Diagnostic assessment

Abdominal-pelvic CT and cysto-scan showed a subperitoneal bladder rupture with a massive collection extending to the flanks and communicating with the peritoneal cavity (Figs. 1 and 2). Laboratory tests indicated a CRP of 267 mg/dL, creatinine of 35 mg/dL, and anemia with a hemoglobin level of 8 g/dL.

Therapeutic interventions

After stabilization with the transfusion of 2 units of packed red blood cells and dual antibiotic therapy, the decision for surgery was made after discussion with the family and the patient.

A midline laparotomy revealed urinary peritonitis and intestinal adhesions. With difficulty accessing the bladder cavity, the anterior and posterior walls were found to be completely necrotic with a tumoral appearance and multiple perforations. Due to the extensive necrosis and the complexity of the dissection, bladder repair was deemed infeasible. Therefore, a cystectomy was performed with urinary diversion via a cutaneous ureterostomy, as a trans-intestinal shunt would be risky due to secondary adhesions and urine peritonitis (Fig. 3).

Follow-up and Outcomes

The postoperative period was complicated by a delay in the resumption of bowel movements and the onset of deep vein thrombosis, which required curative anticoagulation with low molecular weight heparin. However, renal function returned to normal following the urinary diversion.

Histopathological examination revealed features consistent with infiltrating keratinizing squamous cell carcinoma, stage pT2, with vascular emboli and perineural invasion. Immunohistochemical analysis with an anti-GATA3 antibody confirmed the absence of a urothelial component (Fig. 4). Unfortunately, the patient's condition deteriorated rapidly with the appearance of pulmonary metastases, and she died 4 months after surgery due to massive pulmonary embolism.

Bladder rupture is a potentially life-threatening event that is typically associated with blunt or penetrating trauma, and instrumentation including catheterization. It can also occur from previous bladder surgery, such as cystoscopy or bladder resection [3].. The distinction between routine bladder rupture and spontaneous bladder rupture can be vague, but spontaneous bladder rupture is generally distinguished by its etiology, occurring without trauma, surgery, or instrumentation. Numerous factors can contribute to spontaneous bladder rupture, including a reduction in bladder wall integrity (such as through pelvic radiation), neurogenic mechanisms that impair awareness of bladder filling and the need to void, as well as conditions that lead to increased intraperitoneal pressure, such as normal vaginal delivery, alcohol poisoning, or pelvic radiotherapy. [4] [5] [6] [7] While bladder carcinoma can reduce the integrity of the muscle wall, spontaneous bladder rupture secondary to this is extremely infrequent and often indicates delayed presentation and diagnosis, with advanced disease and a poor prognosis. Cases with bladder rupture through areas of squamous cell carcinoma, sarcomatoid carcinoma and transitional cell carcinoma have been reported. The mortality rate associated with spontaneous bladder rupture is estimated to be between 47% and 80%, depending on the clinician's awareness of the condition. [2] [8]

Spontaneous bladder rupture typically presents with abdominal pain and symptoms of peritonitis. Bladder cancer often presents with painless macroscopic hematuria and urinary symptoms. The presence of these symptoms is important for predicting bladder perforation causing acute peritonitis[9]. .In our case, the patient's presentation included recurrent hematuria, highlighting its importance in predicting bladder perforation when associated whit acute peritonitis. Despite the known diagnostic challenges of spontaneous bladder rupture, our initial suspicion was confirmed through abdominal-pelvic CT and cysto-scan. The preferred investigation for suspected bladder injury in trauma is a cystogram. Spontaneous bladder rupture is difficult to diagnose, with most cases being identified during surgery. The low pre-surgical diagnosis rate is attributed to nonspecific clinical signs and a low index of suspicion, such as Reddy et al., where only 36% of cases were identified pre-surgery.[9].

Bladder cancer predominantly comprises urothelial cell carcinomas (UCCs), accounting for about 90% of cases, while squamous cell carcinomas (SCCs constitute around 5%. However, SCCs had a higher proportion in bladder rupture cases due to their aggressive nature and rapid invasion of the bladder wall. Factors such as delayed presentation and reduced access to healthcare in certain regions may also contribute, our patient with bladder rupture was diagnosed with SCC, reflecting the higher incidence of SCC in bladder rupture cases due to its aggressive nature. [10]

Our patient succumbed to her condition within four months post-surgery, highlighting the high mortality associated with bladder cancer-related perforations. This aligns with findings by Johnson, Da Huang, et al. [11], where 30% of patients died during admission and another 17% died within six months due to cancer or complications. This indicates a significantly higher mortality rate compared to non-cancerous spontaneous bladder ruptures, which had a mortality rate of 15%. The aggressive nature of SCCs likely contributes to this increased mortality.

The aggressive nature of bladder SCC necessitates prompt surgical intervention, systemic therapy, and palliative care considerations. Emergency cystectomy, as performed in our patient, is critical in managing these complex cases and potentially improving outcomes. [11] [10]

Spontaneous bladder perforation in bladder cancer patients is a rare and often overlooked cause of acute abdomen, with nonspecific symptoms and high mortality. Our case reinforces the need for heightened clinical suspicion, especially with preceding hematuria and urinary symptoms. The aggressive nature of bladder SCC necessitates prompt surgical intervention, systemic therapy, and palliative care considerations. Emergency cystectomy, as performed in our patient, is critical in managing these complex cases and potentially improving outcomes.

Spontaneous intraperitoneal bladder rupture associated with squamous cell carcinoma is rare, but carries a high mortality rate due to delayed diagnosis and the poor prognosis associated with bladder cancer. Our patient’s presentation and outcomes underscore its aggressive nature, the diagnostic challenges, and the critical need for timely and appropriate intervention to manage this rare but severe condition.

Ethical approval and consent to participate: Ethical approval is not required by our institution. Our case report is exempt from ethical approval as it involves a retrospective and observational analysis, maintains strict patient anonymity and confidentiality, adheres to ethical guidelines, aligns with our institution's policy, and has been conducted with the full and informed consent of the patient involved, which does not mandate approval for such studies.

Consent for publication: Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Funding: No funding from an external source supported the publication of this case report.

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Johnson Da Huang, Emily Ximin Shao, Chui Ming Tham, Eric Chung, Handoo Rhee. Bladder malignancy as a cause of spontaneous bladder rupture:A systematic review. BJIU COMPASS Volume5, Issue1. January 2024. Pages 12-16. https://doi.org/10.1002/bco2.281

No competing interests reported.

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You are reading this latest preprint version

Squamous Cell Carcinoma of the bladder as a cause of spontaneous bladder rupture : a case report

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Abstract

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Background

Case presentation

Discussion

Conclusion

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