Tumor (cancer) of the bladder: symptoms, treatment and causes

Bladder cancer is a disease in which a malignant tumor forms in the mucous membrane or wall of the bladder. The first symptoms of such a formation: blood in the urine, pain above the pubis. In men, the disease occurs several times more often than women, which is associated with diseases of the prostate gland, leading to stagnation of urine. Symptoms may be absent for a long time, which leads to late diagnosis and difficult treatment.

Cancer treatment using advanced methods is carried out at the Yusupov Hospital. One of the leading areas of the clinic is oncourology, specializing in the treatment and diagnosis of malignant tumors of the genitourinary system.

How does bladder cancer develop?

The bladder works like a reservoir that can shrink and expand, holding about 500 milliliters.

From the kidneys, fluid with water-soluble substances waste from the body enters it, is collected in an amount of approximately 250 ml, after which the body receives a signal about the need to urinate.

At the bottom of the bladder there is a special muscle - the sphincter, which opens at the command of the brain and releases the contents into the urethra.

The organ wall has 4 layers:

• internal mucous membrane, protecting deep-lying tissues from substances contained in urine, lying on the second -
• submucosal;
• muscular, due to which the bladder contracts and releases fluid;
• and the adventitia, consisting of loose connective tissue.

Cancer begins with a single cell that is different from normal, altered by exposure to various chemicals, genetics, disease, random failure, and other factors. It grows, multiplies and creates a tumor that gradually grows into the layers of the bladder, extends beyond its boundaries and damages surrounding tissues.

Unlike normal, healthy cells, cancer cells are able to move throughout the body. They enter the bloodstream or lymphatic system. The lymphatic system complements the cardiovascular system. The lymph circulating in it - the intercellular fluid - washes all the cells of the body and delivers the necessary substances to them, taking waste from them. In the lymph nodes, which act as “filters,” dangerous substances are neutralized and removed from the body. , with their help they are transferred to other areas of the body, fixed there and form a new focus of oncology - metastasis.

Reconstructive surgery after radical cystectomy

After removal of the bladder, it is necessary to create a new reservoir for the accumulation and removal of urine (diversion). For this purpose, reconstructive surgery is performed. There are several options for bladder reconstruction4:

• External urinary diversion (ureterocutaneostomy). The operation involves removing the ureters to the anterior abdominal wall with the formation of a stoma (an artificial opening between the organ cavity and the external environment). When choosing reconstructive surgery with the formation of a stoma, it is necessary to constantly wear a special bag on the anterior abdominal wall for collecting urine (urinal bag). Urine flows slowly, uncontrollably into the pouch, which the patient empties as it becomes full4.
• Diversion of urine into an isolated area of ​​the intestine with the formation of a stoma. The most commonly used site for bladder replacement is the terminal ileum (a section of the small intestine). The ureters are connected to an isolated section of the intestine, which is brought to the anterior abdominal wall.
• Formation of a new reservoir for urine accumulation from a section of the intestine. To do this, the surgeon creates a new bladder from a piece of intestine, which is sutured to the urethra. This method allows the patient to urinate independently.

Reconstructive surgery with the formation of a new bladder from small intestinal loops

Evgeniy Valerievich explained what contraindications there are for performing reconstructive surgery.

– Reconstructive surgery is not indicated for everyone: we do not recommend this intervention for patients over 65 years of age due to the high risk of complications. Provided that the candidate is healthy (does not have diabetes, vascular diseases, etc.), we can perform the operation on a patient 65-70 years old. We also take into account the patient’s mental status: after reconstructive surgery, 6 months of regular training are required, and you need to wake up to an alarm clock at night. We must be sure that the patient can cope with the load.

Types of Bladder Cancer

Doctors distinguish three types of oncology of this organ:

• Urothelial
  or transitional cell carcinoma, also known as
  urothelial carcinoma
  : the most common type of dangerous tumors that develop in special cells of the inner layer of the bladder and urinary tract - those that are able to change shape without being damaged when the tissue is stretched.
• Squamous cell carcinoma
  : Begins in thin, flat cells that appear in a blister after long-term infection or irritation. It accounts for about 1-2% of all cases of dangerous organ formations.
• Adenocarcinoma
  : occurs in glandular cells - those found in the mucus-producing organs of the human body. They form in the bladder after prolonged irritation and inflammation.
• Small cell carcinoma
  : quite rare - less than 1% of cases. Such formations develop in neuroendocrine cells that produce hormones - substances created by glands that tell organs and tissues how to act: work or rest, secrete something or absorb something.
• Sarcoma:
  This is a rare type of cancer that starts in the muscle cells of the bladder.

In addition, carcinomas are classified according to their growth pattern:

• Papillary:
  They appear as finger-like projections that develop from the inner surface of the bladder towards its hollow center. They often do not penetrate into the deeper layers of the organ, slowly increase in size and respond well to treatment.
• Flat:
  do not grow towards the hollow part at all. If such a formation is located only in the inner layer of cells, it is called non-invasive squamous carcinoma in situ, and when it grows into the deeper layers of the bladder, it is called invasive urothelial or transitional cell carcinoma.

Disease prognosis

The survival prognosis depends on the stage at which the tumor is diagnosed and how timely and complete the treatment is. If a single epithelial lesion is detected and TUR is performed in conjunction with chemotherapy or immunotherapy, the chances of recovery are about 91%. In the second stage, without cancer spreading to other organs, timely transurethral resection and chemotherapy (less commonly, radiation) allow hope for recovery without relapse in 73-75% of patients. In the third stage and the process spreads to nearby organs, even after removal of the bladder and chemotherapy, there is a possibility of relapse; five-year survival is observed in 50% of patients. At the fourth stage, the process is considered inoperable, palliative methods are used, five-year survival rate is less than 7%.

Causes of bladder cancer

Today, doctors do not know the exact reasons for the development of oncology - they only know about the so-called risk factors that can cause its occurrence.

Smoking

Addicts to the bad habit are at least 3 times more likely to get sick compared to those who do not use nicotine-containing products. Smoking is considered to be the cause of approximately half of all cases of this type of cancer in men and women. The relationship here is obvious: harmful substances contained in tobacco smoke accumulate in the urine and damage the mucous membrane of the bladder, which leads to the formation of dangerous tumors.

Arsenic

Several studies have shown that consuming large amounts of arsenic in drinking water is associated with an increased likelihood of receiving this diagnosis.

Treatment

Some drugs, such as the chemotherapy drug cyclophosphamide, as well as radiation therapy, increase the likelihood of developing cancer.

Nutritional supplements

Supplements containing aristolochic acid used for arthritis, gout, inflammation and as a means for weight loss are considered carcinogenic, that is, capable of leading to the appearance of altered cells.

Chemical substances

Research suggests that occupational exposure is responsible for 18% of bladder cancer cases. This is explained simply: first, the chemical enters the bloodstream, then into our “filter” - the kidneys, and from them into the bladder. The production of rubber, paints, leather and paints and varnishes is considered harmful, and artists, hairdressers, machinists and truck drivers have an increased risk of developing cancer.

Dehydration

Scientists believe that the disease is more common in people who do not drink enough water - they rarely empty the bladder, which is why harmful substances remain in it for a long time.

Genetics

A person’s chance of becoming a patient of an oncologist is higher than the average if his blood relatives have already had this type of cancer or Lynch syndrome, which increases the likelihood of developing dangerous tumors before the age of 50. Changes in the RB1 and PTEN genes also increase such risks.

Diseases

Chronic urinary tract infections, kidney and bladder stones, long-term catheters, and schistosomiasis, an infection caused by a parasitic worm, can also lead to life-threatening tumors.

Age

The average age of patients is 73 years, and 9 out of 10 holders of this diagnosis are over 55 years old.

Floor

The disease occurs in men 3-4 times more often than in women.

Quite rare congenital bladder defects

also increase the likelihood of developing cancer.

Cancer of the bladder or other urinary tract tissue

Those who have had similar tumors in the past, even completely removed ones, are at particular risk.

What kind of observation is required after treatment?

After treatment, recurrence of the tumor (relapse) may occur, the probability of which in superficial forms reaches 70%. A new tumor may appear in the same place as the primary one, and often relapses occur in another area of ​​the bladder mucosa. Therefore, patients undergoing treatment for bladder cancer need to be examined every 3-6 months. One of the most important components of the examination is cystoscopy and urine cytology. The examination also includes an examination, blood and urine tests, and an ultrasound or computed tomography may be prescribed.

Symptoms and signs of bladder cancer

This type of cancer is often detected at an early stage, as it leads to noticeable symptoms that make a person wary and consult a doctor.

Blood in urine

, or hematuria: This may be enough to make the urine orange, pink, or dark red. The color does not always change - sometimes problems with the bubble are discovered only during analysis. Usually, in the initial stages of cancer, even with bleeding, a person does not feel pain or discomfort.

Another important symptom is a change in urination

: the need for more frequent, urgent or nightly visits to the toilet, pain or burning, delayed urine flow and a weak stream.

After tumor cells spread throughout the body and grow in other parts of the body, other signs appear:

• loss of appetite;
• weight loss due to lack of desire to eat normally and spending a lot of energy fighting cancer;
• lower back pain on one side;
• constant fatigue and weakness;
• swelling of the legs as a result of impaired fluid outflow and damage to the lymph nodes - our “filters” that retain and neutralize harmful substances;
• bone pain or fractures due to the development of metastases in them - additional tumors.

Chemotherapy

Chemotherapy is the use of drugs that kill cancer cells. For bladder cancer, several different ways of administering chemotherapy are used - intravesical chemotherapy, when the medicine is injected directly into the bladder, and systemic chemotherapy, when chemotherapy is administered intravenously:

• Intravesical chemotherapy targets cancer cells in the bladder and is used for superficial tumors to prevent tumor recurrence. When chemotherapy is injected into the bladder, side effects are usually minor. For several days after treatment, you may experience blood in your urine and more frequent and painful urination. These symptoms usually disappear after treatment.
• Systemic chemotherapy kills cancer cells throughout the body, not just the bladder, and is used for invasive or metastatic cancer. Chemotherapy is usually given in cycles. Each cycle has a treatment period and a rest period. Side effects depend on the chemotherapy drug and its individual tolerance.

Diagnosis of bladder cancer

Every cancer patient needs to undergo a full course of diagnostics, as this will allow the doctor not only to detect cancer, but also to select the correct treatment.

When choosing a clinic, it is advisable to pay attention to the possibility of receiving all the required procedures there. The optimal medical institution is one where you can not only be examined, but also carry out all the necessary treatment. This will save you from the need to redo studies with questionable results that do not suit your doctor, carry a pile of documentation with you and waste time traveling to distant ends of geography to see different doctors. Onko has all the modern equipment and highly qualified specialists who fully guide the patient and carry out any interventions.

Diagnosis begins with a survey about symptoms, the presence of other diseases or relatives with cancer, and continues with a series of studies.

Urine tests:

• Cytology
  : examining a sample for the presence of cancer cells.
• Culture
  : testing a sample for bacteria to rule out infection.
• Tests
  for
  tumor markers
  - substances secreted by the tumor.

Pyelography

- injection of a dye into the bladder or vein, which makes the contours of its tissues and related organs clear, and tumors visible on an x-ray.

– computer, or MRI – magnetic resonance imaging: obtaining a clear image of a certain area of ​​the body, which clearly shows the shape, size and location of oncology.

Ultrasound

– ultrasound is used to determine the size of the tumor and assess its spread to nearby tissues or organs.

Cystoscopy

– examining the inside of the urethra and bladder using a narrow tube containing a camera and a light source.

Biopsy

– collection of tissues for study in the laboratory. It is performed during cystoscopy or as a separate procedure using a thin needle under ultrasound or CT control.

Modern approach to cystectomy

In modern surgery, open cystectomy (through an incision in the abdominal cavity) is gradually fading into the background. Minimally invasive methods are becoming widespread: laparoscopic and robot-assisted cystectomy, which are performed through small punctures in the abdominal cavity. Minimally invasive methods can reduce the number of complications, blood loss and the risk of infection. The advantages also include: less intense pain, the absence of a rough postoperative scar and a short period of rehabilitation for the patient after surgery.

Among the minimally invasive methods, the high-tech robotic method should be highlighted. Additional benefits of da Vinci robotic cystectomy include5:

• No trembling of the surgeon’s hands during manipulations;
• Providing clear three-dimensional visualization of the surgical field, which allows for a clear view of the operated organ, neighboring structures and eliminates the risk of missing affected areas;
• Reducing the risk of bleeding due to effective hemostasis;
• The tools have 7 degrees of freedom of movement with the ability to rotate 90 degrees, which provides better access to hard-to-reach areas;
• The ability to operate on patients with severe obesity - in the deep pelvic areas in such patients, visualization is higher than with laparoscopy and open surgery.

Treatment of bladder cancer with robot-assisted method

– The robotic method is more convenient for cystectomy in general; it provides comfortable work in narrow spaces, such as the small pelvis. The robot helps to effectively perform orthotopic bladder surgery (creation of a new bladder): it should be noted the quality and convenience of applying an intracorporeal suture and tightness. This technology is also low-traumatic for the patient and ensures quick recovery. In obese patients, it makes it easier to cope with weight and provides better visualization, says Evgeniy Valerievich.

Stages of bladder cancer

Determining the stage of the disease is necessary for the doctor to assess the patient’s prognosis and select the correct treatment regimen.

In total, experts distinguish 5 stages:

0.

Tumor cells are on the outer surface of the inner lining of the bladder - this is carcinoma, which grows towards the hollow part of the organ, or simply has not yet managed to go beyond 1 layer.

I:

Cancer develops in the first two layers of the inner lining of the bladder, but does not damage the muscle wall.

II:

Oncology penetrated the muscle wall, but did not go beyond the organ and did not grow into the surrounding fatty layer.

III:

the formation has damaged the tissue surrounding the bladder, prostate gland, uterus, vagina or lymph nodes.

IV:

The cancer has spread to parts of the body far from the bladder—bones, lungs, liver, abdomen, distant lymph nodes, or nearby organs.

How effective are modern treatment methods, what is the prognosis?

On average, 77% of patients survive within 5 years, 70% within 10 years, and 65% within 15 years. Five-year survival rate for malignant bladder tumors depends on the stage:

• Stage 0–98%.
• Stage I—88%.
• Stage II—63%.
• Stage III—46%.
• Stage IV—15%.

Clinical studies are currently being conducted, doctors are looking for more effective ways to combat the disease, which means there is hope that these indicators will improve in the near future.

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Bladder cancer treatment

The treatment regimen is selected for each patient individually, based on prognosis, advanced stage of cancer, general health and age of the person.

There are several treatment options for this type of cancer:

Surgery

– used at all stages of the disease:

• Transurethral resection
  , TUR: the method is used at stages 0 and 1. The operation is performed without incisions - a specialist inserts instruments through the urethra that remove or burn out small tumors and altered cells.
• Cystectomy
  : removal of the entire bladder or part of its tissue is performed if the size of the formation does not allow for a TURBT, or it has damaged more than two layers of the organ.
• Reconstructive surgery
  - reconstruction of the bladder and ureters is performed after cystectomy to maintain normal urination.

Chemotherapy

– poisonous drugs that kill cancer cells. Neoadjuvant chemotherapy is prescribed before surgery to reduce the size of the tumor, and adjuvant chemotherapy fights the remaining tumor particles after surgery. It is also used as palliative treatment at the last stage of the disease - in this case, it does not completely eliminate cancer, but it alleviates symptoms and improves the patient’s quality of life.

Immunotherapy

– strengthening and directing a person’s own immunity to fight cancer.

Its most common form is the bacterium Bacillus Calmette-Guerin

,
BCG
. It is inserted into the bladder through a catheter and attracts and activates the immune system, helping it destroy cancer cells.

Side effects of BCG are similar to flu symptoms - they include fever and fatigue, and sometimes a burning sensation in the bladder.

Another option for biological therapy is the protein interferon

, which our body produces to fight infection. Its synthetic, that is, artificially created version, is also capable of fighting this type of dangerous formations, and can be prescribed in combination with BCG.

The third drug is atezolizumab

(Tecentriq), injections of which are safe and effective if the cancer continues to develop:

• during or after platinum-containing chemotherapy;
• within 12 months after neoadjuvant - given before surgery, or neoadjuvant - given after surgery, platinum-containing chemotherapy.

Radiation therapy:

destruction of tumor cells of the muscle wall of the bladder using radiation. It is also used in combination with chemotherapy, and is suitable for people who cannot undergo surgery.

An approximate treatment regimen depending on the stage of cancer is as follows:

On 0 and 1: May include tumor removal, chemotherapy or immunotherapy.

There are 2 and 3 more options:

• removal of part of the bladder plus chemotherapy or
• organ completely and creating a new path for urine removal from the body;
• chemotherapy, radiation therapy or immunotherapy: to reduce tumors before surgery, destroy remaining cancer cells after surgery, treat cancer if surgery is not possible, or prevent its recurrence.

At stage 4:

• only chemotherapy to relieve symptoms and prolong life;
• radical cystectomy - removal of the bladder, as well as nearby lymph nodes;
• chemotherapy, radiation therapy, and immunotherapy after surgery to kill tumor cells, relieve symptoms, and prolong life;
• use of drugs under clinical trial programs - testing of new substances and treatment regimens.

Urological oncology department of the oncology center Lapino 2

Immunotherapy (BCG therapy)

For superficial bladder cancer, a treatment called immunotherapy is given. The essence of the treatment is to administer a solution of a specially created BCG vaccine into the bladder. BCG was originally developed as a vaccine against tuberculosis, but later activity was detected against bladder tumors.

The weakened bacteria included in the vaccine stimulate the body's own immune system, which destroys tumor cells. The use of the BCG vaccine reduces the likelihood of tumor recurrence by half.

Living with bladder cancer - how to reduce symptoms and side effects of treatment?

Cancer and its treatment do not have the best impact on well-being, which creates a vicious circle - if a person’s general health leaves much to be desired, the doctor will not prescribe the necessary therapy, and the tumor will continue to develop.

Anyone who wants to overcome the disease can relieve symptoms and help their body.

Proper nutrition.

Cancer is often draining and fatigued, and chemotherapy or radiation treatments can cause loss of appetite, depriving patients of much-needed energy. A healthy diet with whole grains, fruits, vegetables, protein, and a minimum of sugar and unsaturated fats will help maintain strength. Saturated fats are found in large quantities in palm and coconut oil, pork and beef, and dairy products. . It is advisable to eat in small portions, but often, and if nausea or vomiting occurs, you should consult a doctor who will prescribe medications that reduce unpleasant symptoms.

Exercise stress.

Our body is created by nature for movement, the absence of which leads to disruption of the functioning of important organs and systems. Regular walks and swimming do not provide much stress, but they help reduce fatigue and improve your mood. Light exercise is beneficial for most cancer patients, but it is best to consult your doctor before starting.

Painkillers.

Pain management is an important part of cancer treatment for many people. It does not need to be tolerated, since it leads to a noticeable deterioration in both physical and moral condition. Tell your doctor as much as possible about your feelings, who will select the right medications and regimen for taking them.

How to avoid getting bladder cancer?

Unfortunately, there is not a single method that guarantees protection against cancer. All that doctors can advise today is to follow simple measures, such as:

• quitting smoking, including passive smoking, since smoke contains carcinogens that can lead to the formation of tumors in almost any vital organ;
• drinking plenty of fluids, thanks to which urine is excreted faster, and the harmful contents of the bladder do not linger in it for a long time;
• caution with toxic chemicals that cause cancer;
• a varied diet with plenty of fruits and vegetables in the diet: it is thanks to the right food that the digestive and excretory systems of our body work without failures, which reduces the likelihood of oncology.

The International Statistical Classification of Diseases and Related Health Problems (ICD) is a normative document that ensures the unity and comparability of materials on public health, the epidemiological situation and the activities of health care institutions both within the country and between countries. Statistical classification of diseases has become one of the mandatory sections of clinical guidelines and should contribute to the unification of the activities of scientific schools that defend various directions in the formation of clinical classifications of diseases. This is necessary to further strengthen the links between population health statistics, health statistics and clinical practice, which was especially the focus of the efforts of specialists in the preparation of the tenth revision of the International Classification of Diseases (ICD-10), the transition to which took place on 01/01/1999 in accordance with By Order of the Ministry of Health of Russia No. 3 of January 12, 1998 [1].

However, the problem of comparing clinical diagnoses in medical documentation and diagnoses given in the international classification of diseases still remains unresolved. The latest revision of ICD-10 continued the trend towards significant modernization of statistical diagnoses, but the main problem was not solved. As a result, some diagnoses may fall within the range of unspecified conditions or conditions that are not sufficiently differentiated, and not in the headings or subheadings of the corresponding sections of the classification [1].

In clinical practice, ICD-10 and ICD-O are used to code urological cancer diseases. In ICD-10, oncological urological diseases are located in six blocks of class II “Neoplasms”, which separately describe malignant neoplasms of the male genital organs, malignant neoplasms of the urinary tract, malignant neoplasms of ill-defined, secondary and unspecified localizations, neoplasms in situ, benign neoplasms, neoplasms of unspecified and unknown nature (Table 1).

Table 1. Coded classification of urological cancer diseases ICD-10

Table 2. Coded classification reflecting the localization of renal parenchymal neoplasms

Compared to ICD-9, the coded structure of oncological diseases of ICD-10 has remained virtually unchanged, therefore all the shortcomings of ICD-9 are also present in ICD-10. However, unlike ICD-9, in ICD-10 it becomes possible to code a morphological diagnosis by combining the histological codes of the ICD-O with the topographic codes of the ICD-10. So, for example, transitional cell cancer of the lateral wall of the bladder of II degree of differentiation, according to the rules of ICD-10, can be coded as C67.2, M8120.3/2, where C67.2 indicates cancer of the lateral wall of the bladder, M indicates the beginning morphological diagnosis, 8120 is a transitional cell tumor code, 3 reflects the presence of a malignant neoplasm, 2 indicates the degree of differentiation of bladder cancer. In this example, it is important to pay attention to the duplication of encodings about the malignant nature of the tumor by two classifications, which significantly complicates the processing and analysis of statistical information on oncology.

Isolated use of ICD-O in clinical practice is widespread only in specialized oncology institutions. ICD-O has only one topographic code for a specific tumor location, based on the ICD-10 section for malignant neoplasms. To encode the histological characteristics of the tumor, a separate morphological code is provided, including the histological type, degree of malignancy and differentiation of the neoplasm. For example, the diagnosis “Carcinoma of the upper segment of the right kidney T3bNxM0” (clear cell carcinoma, differentiation grade II) will be coded as C64.9, M8310.3/2, where C64.9 indicates the topography of the process (kidney), M indicates the beginning of the morphological diagnosis , 8310 code for clear cell carcinoma, 3 reflects the malignancy of the neoplasm, 2 indicates the degree of differentiation of kidney cancer.

Summarizing all of the above, it is advisable to highlight the main differences between ICD-10 and ICD-O. ICD-10 includes mainly a coded topographic classification of tumors, while ICD-O is primarily a morphological classification and reflects the histological variants of the structure of neoplasms. However, it is important to note that none of these coded classifications fully meets the modern requirements of the diagnostic and treatment process. The main disadvantages of these classifications are:

1. lack of information about the most important topographical features of the location of tumors;
2. lack of information about the stage of the oncological process in accordance with the accepted TNM classification (local spread of the tumor, presence and localization of metastases);
3. duplication of coded information about the malignant nature of the tumor in ICD-10 and ICD-O;
4. the need for simultaneous use of several classifications.

Based on the above, we have developed principles for creating a unified coded clinical and statistical classification of urological diseases [2, 3]. The section of this classification devoted to urological oncological diseases, in our opinion, eliminates most of the existing shortcomings and contradictions of previous classifications and will improve the reliability of statistical information on urological oncology, especially when used in computer information systems. Coding a clinical diagnosis in the electronic medical history S allows you to generate statistical reports from institutions and summarize statistical information at various levels: locality, region, Russian Federation. In fact, the widespread use of the proposed system will allow, at minimal cost, to “automatically” create appropriate cancer registries for the needs of organizing, planning and economically supporting urological oncology care.

Figure 1. Formation of the diagnosis “Cancer of the upper segment of the right kidney T1aN,M0” (clinical code C64.0.0.2.0.0.2.1)

Figure 2. Formation of the diagnosis “Multiple cancer of the upper (4 cm) and lower (3 cm) segments of the right kidney T, ,NxMn” (clinical code C64.0.0.2.0.1.0.1)

MATERIALS AND METHODS

The system for coding additional information about urological cancer diseases in such a classification is presented in the form of a tree, where each subnode clarifies the semantic load of the previous node. When forming a subnode, a number from zero to nine is added to the main code through a dot. This classification does not in any way affect the basic structure of ICD-10, and its electronic version provides for separate display of both the statistical code taken from ICD-10 and the clinical code. Let us analyze the structure of the proposed classification using the example of kidney tumors.

Initially, it seems appropriate to divide all kidney tumors into right-sided and left-sided. Next, the tumors of each kidney must be divided into tumors of the upper, middle and lower segments. It is important to identify kidney damage that extends beyond one or more kidney segments as a separate nosological unit (Table 2).

We propose to supplement the subheadings that include malignant kidney tumors with the modern TNM classification of 2002. The structure of such a classification using the example of a malignant neoplasm of the upper segment of the right kidney is presented in Figure 1.

In the presence of multiple malignant kidney tumors, according to the TNM classification rules, it is necessary to register only formations with a maximum category of “T”. In such clinical cases, coding of diagnoses should be done in several stages. At the first stage, it is necessary to determine the topographic localization of the tumor formation with the maximum category “T”. At the second stage, within the selected kidney segment, it is necessary to select the “Tm” category, indicating the multiplicity of the tumor process. The third stage involves coding the corresponding category “N” and “M” (Figure 2).

With a bilateral tumor process, coding is reduced to setting two codes that characterize separately the processes in the right and left kidney.

Coding of the morphological part of oncourological diagnoses. As noted above, currently, histological ICD-O codes are used to encode the morphological part of oncological diagnoses. The main disadvantage of the combined use of ICD-10 and ICD-O is the duplication of information about the nature of the neoplasm (malignant, benign, etc.) by these two classifications. To eliminate this discrepancy, we consider it necessary to change the rules for setting the morphological code. The latter should reflect only the type of tumor and the degree of its malignancy. So, for example, granular cell carcinoma of the middle segment of the right kidney T1aN0M0, II degree of differentiation, according to the rules of ICD-10, is coded as C64, M8320.3/2, where C64 indicates kidney cancer, M indicates the beginning of the morphological diagnosis, 8320 is the code granular cell carcinoma, 3 reflects the presence of a malignant neoplasm, 2 indicates the degree of differentiation of kidney cancer. In this example, the number “3” of the morphological code duplicates information about the malignancy of the tumor, which is already contained in the topographic code C64. According to the proposed classification, the above-described clinical case should be coded as C64.0.1.2.0.0.0.1, M8320.2 (the number “3” is not set).

RESULTS

Let us analyze the above-described classification of malignant kidney tumors in comparison with ICD-10 using several specific examples.

Clinical case No. 1. During the examination, the patient was diagnosed with a tumor formation in the middle segment of the right kidney up to 3 cm, within the kidney capsule. There are no foci of regional or distant metastasis.

Treatment: resection of the right kidney.

Final diagnosis: “Cancer of the middle segment of the right kidney T1aN0M0 (clear cell carcinoma, stage II differentiation).”

In ICD-10 this diagnosis is coded as C64.

In accordance with the proposed classification in the medical history, this diagnosis should be coded as C64.0.1.2.0.0.0.1, M8310.2.

Clinical case No. 2. The patient was found to have isolated tumor formations of the upper (8 cm), middle (5 cm) and lower (5 cm) segments of the right kidney, within its capsule. There are no foci of regional or distant metastasis.

Treatment: radical nephrectomy on the right, adrenalectomy on the right.

The final diagnosis: “Multiple cancer of the upper, middle and lower segments of the right kidney T3a(m)N0M0 (clear cell carcinoma, grade I differentiation).”

In ICD-10, this diagnosis is coded with one statistical code C64.

In accordance with the proposed classification in the medical history, this diagnosis should be coded as C64.0.0.4.0.1.1.1, M8310.1.

Clinical case No. 3. The patient has a tumor formation in the middle segment of the right kidney up to 3 cm, within the kidney capsule, as well as a tumor formation in the middle segment of the left kidney up to 9 cm, also within the kidney capsule. There are no foci of regional or distant metastasis.

Treatment: Stage I resection of the right kidney; Stage II left radical nephrectomy.

Final diagnosis: “Cancer of the middle segment of the right kidney T1aN0M0 (granular cell carcinoma, II degree of differentiation). Cancer of the middle segment of the left kidney T2N0M0 (granular cell carcinoma, II degree of differentiation).”

In ICD-10, this entire clinical case is coded with one code C64.

In accordance with the proposed classification, this diagnosis has two separate clinical codes: C64.0.1.0.0.1.1, M8320.2 and C64.1.1.3.0.1.1, M8320.2. To avoid duplication of information, in the electronic medical history the possibility of such an error is eliminated by reference to a single medical history number (passport data, etc.).

Clinical case No. 4. During the examination, the patient was diagnosed with a tumor formation in the upper and middle segments of the right kidney up to 10 cm, extending beyond the kidney capsule to the right adrenal gland and perinephric tissue, within Gerota’s fascia. There are no foci of regional or distant metastasis.

Treatment: radical nephrectomy on the right, adrenalectomy on the right.

The final diagnosis: “Cancer of the upper and middle segments of the right kidney T3bN0M0 (clear cell carcinoma, grade III differentiation).”

In ICD-10 this diagnosis is coded as C64.

In accordance with the proposed classification in the medical history, this diagnosis should be coded as C64.0.4.4.1.0.3.1, M8310.3.

It is important to pay attention to the fact that in all the presented clinical cases, the tumors are at different stages of the pathological process and do not always have the same histological structure. This, in turn, is a determining factor in choosing treatment tactics and determining the prognosis of the disease. It is significant that in ICD-10 all these examples are coded with one common statistical code C64, which provides information only about the organ affiliation of a malignant neoplasm in the kidney.

The proposed classification allows us to provide detailed clinical and statistical coding of all variants of malignant kidney tumors. All this is necessary, first of all, to standardize diagnostic and treatment approaches in oncourology: each clinical code must correspond to a specific list of diagnostic and therapeutic measures.

DISCUSSION

Modern development of healthcare, including oncourology, requires a significant improvement in the reliability and completeness of the collected statistical information on diseases, with the aim of its further analysis in the interests of planning, organizing and economic support of medical (including high-tech) care. Such work is impossible outside of modern information computer technologies, for which the proposed unified coded classification is intended [2]. It is based on the integration of statistical (ICD-10, ICD-O), clinical (TNM) and morphological classifications widely used in practice, without violating the ability to collect information on each of them separately (involving elements of a complex digital code in the analysis).

In order for the classification to be understandable to all doctors involved in the diagnostic and treatment process, taking into account only the organ affiliation and histological structure of malignant tumors is insufficient. In modern classification, an objective and informative base of clinical and morphological data on the anatomical distribution of the tumor must be used. In addition, information is needed about the condition of regional lymph nodes, the presence or absence of distant metastases. All this affects treatment tactics and prognosis of the disease. The above requirements are met by the TNM classification of malignant tumors, in the emergence of which the International Union Against Cancer plays a major role. Therefore, integration of the TNM system into a single coded classification is an important step in standardizing the diagnosis and treatment of urological cancer diseases.

The use of a unified clinical and statistical classification will contribute to the process of standardization of medical care, including in the interests of insurance medicine.

In our case, the division of kidney tumors into right-sided and left-sided makes it possible, unlike ICD-10, to provide coding of a bilateral tumor process due to double coding, which takes into account separately the condition of both the right and left kidneys. The segmental division of the localization of renal tumors, as well as the size of the tumors, undoubtedly influence the determination of the scope of surgical treatment. Thus, when the tumor is localized in the upper segment of the kidney, as well as with subtotal kidney damage, it is scientifically justified to perform ipsilateral adrenalectomy [4].

In addition, taking into account the topographical features of the location of the tumor within the kidney also determines the choice of optimal surgical access, which would enable the operator to quickly access the vascular pedicle of the kidney and remove it en bloc along with the perinephric tissue. The use of unilateral or bilateral subcostal transperitoneal incisions (Chevron approach) provides better exposure of the upper abdominal cavity. Therefore, this approach is especially convenient for large tumors of the upper segments of the kidneys. The thoracoabdominal approach provides an excellent view of the upper segment of the kidney, the adrenal gland, and the hepatic portion of the inferior pudendal vein, which is why many urologists use it to perform thrombectomy [5].

The concept of a “unified classification” also reflects the need for its widespread implementation at all levels of medical care (from primary care to health care management), which, in addition to clinical application, will ensure the receipt of statistical data in a single format with maximum reliability.

And finally, anticipating comments about the complexity of using the proposed classification in real clinical practice, we consider it necessary to emphasize that this system is being developed primarily for use in computer medical documents, databases and information analytical systems. In this case, it is assumed that the primary user will select a diagnosis from an electronic dictionary in the usual descriptive form, while digital diagnosis codes may be completely hidden from him. The diagnosis will be made at the level of medical institutions, and the information will be summarized and analyzed both in the medical institution itself and at the level of higher health authorities. In fact, from this primary clinical and statistical material, at minimal cost, personalized cancer registries will be formed not only for individual nosologies, but also according to more detailed criteria: stage, presence of metastases, histological form, etc.

CONCLUSION

The introduction and widespread use of a unified clinical and statistical classification of oncological diseases will allow:

1. facilitate the collection and improve the analysis of statistical material on urological oncology by increasing the reliability of information and reducing the number of errors due to inconsistency of clinical diagnoses with ICD-10 diagnoses;
2. significantly increase the flexibility of information requests and the detail of the responses received;
3. create personalized oncological urological cancer registries;
4. create conditions for standardization of diagnosis and selection of a specific method of treatment for urological cancer diseases;
5. improve the economic and statistical analysis of the provision of medical care to patients with urological cancer in the interests of the healthcare system and health insurance;
6. optimize costs for diagnosis and treatment of urological cancer patients.

LITERATURE

1. On the use of the international statistical classification of diseases and health-related problems, tenth revision: Instruction dated May 25, 1998 No. 2000/52-98//MZRF.1998.
2. Sivkov A.V., Kakorina E.P., Keshishev N.G. “Unified clinical and statistical classification of urological diagnoses” // Materials of the XI Congress of Urologists of Russia. M. 2007. pp. 598-599.
3. Apolikhin O.I., Dzeranov N.K., Sivkov A.V., Kakorina E.P., Keshishev N.G. “Unified clinical and statistical classification of urolithiasis” // Urology. No. 6. 2008. P.3-6.
4. Sagalowsky AI, Kadasky KT, Ewalt DM et al. Factors influencing adrenal metastasis in renal carcinoma // J. Urol. 1994. Vol. 151. P. 1181-1182.
5. Clinical oncourology / B.V. Bukharkin, M.I. Davydov, O.B. Koryakin et al. Reply. ed. B.P. Matveev. M. Medicine. 2003. pp. 49-50.

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