Intermittent self-catheterization and the risk of squamous cell cancer of the bladder: An emerging clinical entity?

Abstract

There are only 7 cases reported in the literature of squamous cell cancer of the bladder in patients performing intermittent selfcatheterization (ISC). We report on an eighth case, and the first case described in a patient with a Mitrofanoff continent appendicovesicostomy. A description of the case and review of the literature are presented. Risk factors for squamous cell cancer include recurrent urinary tract infections, keratinising squamous metaplasia (leukoplakia) and local mucosal trauma from intermittent selfcatheterization. There is no recognized or validated monitoring program for patients performing ISC who may also have these risk factors. Reasonable protocols may include regular urinary cytology and cystoscopy with random or targeted bladder biopsies. Squamous cell cancer may present late in this cohort of patients and is associated with a dismal prognosis. Can Urol Assoc J 2009;3(5):E51-E54 IntroductionSquamous cell cancer (SCC) of the bladder usually occurs secondary to bilharzia in the Middle East, Southeast Asia and South America, where schistosomiasis is endemic and accounts for 59% to 75% of cases. However, in western regions, SCC of the bladder usually constitutes only 1.2% to 4.5% of all bladder cancers, and these cases are usually secondary to prolonged indwelling catheters, especially in spinal cord-injured patients. This association with SCC has been documented for the last 30 years, 1 and a 10% incidence of bladder SCC in patients with an indwelling catheter for ≥10 years has been recognized. 2 SCC of the bladder may also occur secondary to other chronic irritants, such as bacterial infections, foreign bodies (catheters, bladder calculi) and chronic bladder outlet obstruction. More rarely, there are reports of SCC of the bladder following intravesical Bacillus Calmette-Guéri (BCG), 3 systemic cyclophosphamide therapy, 4 and suprapubic catheters. 5 Lapides and colleagues introduced the concept of clean intermittent self-catheterization (ISC) in 1972 as a means of avoiding long-term catheterization or surgery. 6 It was associated with low intravesical pressures, urinary bacterial wall translocation and thus infection, in a variety of neurogenic and non-neurogenic bladder disorders. This technique has been successful in a large number of adults and children on follow-up of more than 20 years. 7,8 Indeed, it is reported that clean ISC is more suitable than indwelling catheterization in patients who require long-term bladder drainage as a means of minimizing the histological changes that occur in the bladder mucosa that may predispose and lead to malignant transformation. 9,10 There are 7 reported cases in the published literature of SCC of the bladder due to a variety of reasons in patients using clean ISC (Table 1). [11][12][13][14] There may be a synergistic association of leukoplakia, persistent bacteriuria, direct catheter trauma and keratinizing squamous metaplasia with progression to SCC in these cases. Squamous metaplasia, which initially may be adaptive and protective, may also...

Risk factors for development of primary bladder squamous cell carcinoma

“…The mechanism by which SCC develops in the CISC bladder has been proposed as a combination of keratinising squamous metaplasia (a premalignant condition), persistent (and often asymptomatic) bacteriuria and direct epithelial trauma. 2 This theory would therefore support the use of antimicrobial catheters to reduce bacteriuria in the hope of decreasing the synergistic effect of these factors. Notably, it would appear that the risk of SCC is elevated with the use of CISC in the presence of another risk factor for primary SCC (such as smoking), suggesting some underlying synergistic mechanism.…”

“…2 However, the literature relating to this association is relatively scarce. The findings of our series suggest that it is not merely the presence of a neuropathic bladder or recurrent UTI alone that may contribute to the development of primary SCC but that the chronic use of CISC also has an important role.…”

“…Although it was previously thought to minimise histological changes in the bladder compared with IDC use, 17 it has subsequently been hypothesised that CISC promotes progression to SCC through a combination of direct catheter trauma, persistent bacteriuria and keratinising squamous metaplasia. 2 Finally, another frequent hypothesis is that longstanding bladder stones have a role in the development of primary bladder SCC. 18 As with the mechanisms described above, the chronic mucosal injury and inflammation may facilitate progression to SCC.…”

“…1 While the predominant risk factor in the Middle East, Southeast Asia and South America is chronic infection with schistosomiasis, risk factors in Western countries are those associated with repeated urothelial injury and the induction of keratinising squamous metaplasia such as recurrent urinary tract infection (UTI), radiation exposure, smoking, spinal cord injury (SCI) with neurogenic bladder and the presence of foreign bodies (eg catheters or bladder stones). 2 Although risk factors and the role of bladder management in the development of SCC has been studied in the SCI population, less information is available regarding the relationship of bladder management and SCC in the general population. We present an analysis of the largest series of cases of primary SCC to date with the aim of identifying salient risk factors.…”

Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population

“…Regular cystocopy and bladder biopsy are also recommended to screen for malignancy in long-term indwelling catheter users. 16 If a recurrent UTI develops, the patient needs renal and bladder ultrasound tests and blood work (or have results reviewed from previous tests) to identify significant changes in the structure and function of the urinary tract. Hydration, catheterization technique and hygiene should have already been discussed with the patient; if this is not the case, it is a priority to refer the patient to a home care or a continence clinic to receive this information.…”