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    Bladder resection

    Background

    Partial or radical cystectomies may be undertaken for the resection of malignant tumours; most commonly urothelial carcinomas and sometimes some non-urothelial malignancies including squamous cell carcinomas, adenocarcinomas and sarcomas are found. Surgery may also be necessary for the resection of bladder diverticula, ulcerative interstitial cystitis, colovesical fistula, vesicovaginal fistula and localized endometriosis of the bladder.1-4

    See the genitourinary small biopsy protocol for TURBT and other small bladder specimens.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    Record details of any previous biopsies including diagnosis and site(s) taken to guide sampling in the absence of a macroscopically identifiable tumour.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify anatomical features of the specimen. Refer to the diagram provided.

    Confirm which anatomical surfaces and structures are included:

    • Anterior
    • Posterior
    • Left lateral
    • Right lateral

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen.

    Describe the following features of the specimen:1,2,4

    Procedure

    ​Record as stated by the clinician.

    • Radical cystectomy
    • Partial cystectomy
    • Urethrectomy resection
    • Other tissue/organs present, describe
    • Separate ureteric margins received (specify pot lab numbers)

    Anatomical features included (more than one may apply) and dimensions (mm)

    Describe and measure the anatomical components present.

    Measure in three dimensions unless otherwise specified. Refer to relevant specimen protocol also where applicable.

    • Bladder, superior-inferior x transverse x anterior-posterior
    • Ureter, length(s)
      • Right
      • Left
    • Urethra, length
    • Kidney
    • Other, describe

    Male

    • Prostate
    • Seminal vesicles, maximum dimension of each

    Female

    • Vagina
    • Uterus
    • Cervix
    • Ovary(ies)
      • Right
      • Left
    • Fallopian tube(s)
      • Right
      • Left

    Specimen integrity

    • Intact
    • Opened or disrupted, describe

    Dissection

    Two methods are possible.
    1. The specimen normally comes with a urinary catheter in-situ. Remove any urine via the catheter and inflate the bladder with 150-250ml of formalin using a syringe. The syringe is then left plugging the catheter outlet and the specimen is transferred to a bucket of formalin and allowed to fix overnight before opening the bladder (as described in method 2).
    2. Paint the relevant surgical margins with ink (usually perivesical fat resection margin deep to the tumour) and record the colours applied. Open the bladder along the anterior surface, with an incision that avoids the tumour, from the trigone through the urethra, then to the dome. If uterus is included, a posterior incision through to the endometrial cavity may be appropriate to improve fixation. Allow to fix overnight. The specimen may require longer fixation in larger quantity of formalin.

    Internal Inspection

    Describe the internal appearance including the following items:1,2,4

    Mucosal surface

    Tumour
    • Absent

    If a tumour resection specimen, search for site of previous positive biopsies and sample that area. Otherwise, contact the clinician for more information.

    • Present

    Multifocal

    • No
    • Yes
    • Number; if more than one tumour, designate and describe each tumour separately

    Tumour site

    • Trigone
    • Right lateral wall
    • Left lateral wall
    • Anterior wall
    • Posterior wall
    • Ureteric orifice
      • Left
      • Right
    • Dome
    • Other, describe

    Tumour size(mm)

    • Maximum dimension
    • Other dimension

    Tumour appearance

    • Polypoid
    • Fungating
    • Papillary
    • Ulcerated
    • Solid and indurated
    • Scarring/fibrosis

    Macroscopic evidence of invasion

    • Absent
    • Present
    Specify site(s)
    • Bladder wall
    • Perivesical tissue
    • Ureter(s)
      • Uninvolved
      • Involved
    • Tumour obstructing ureter
      • Right
      • Left
    • Urethra
      • Uninvolved
      • Involved

    Macroscopic evidence of adjacent organ involvement

    • Absent
    • Present (specify all that apply)
      • Prostate
      • Seminal vesicles
      • Rectum
      • Uterus/cervix
      • Ovary(ies), specify laterality
      • Fallopian tube(s), specify laterality
      • Vagina
      • Other, describe

    Macroscopic evidence of margin involvement

    • Absent
    • Present (specify all that apply)
      • Perivesical fat
      • Peritoneal surface
      • Ureteric
      • Urethral

    Macroscopic evidence of peritoneal surface involvement

    • Absent
    • Present

    Uninvolved bladder appearance

    • Normal
    • Erythematous
    • Ulcerated
    • Other, specify

    Non-tumour specimens

    • Mucosa, describe
    • Lesions present
    • Diverticula
      • Size (mm)
      • Location
    • Ulcer
    • Abscess
    • Stricture
    • Polyp

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each specimen container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of grossly identified lymph nodes submitted
    • Maximum diameter of each (mm)

    Palpate adipose tissue for lymph nodes. They are not commonly present but more likely in female specimens.


    Processing

    Serially section the bladder transversely from the bladder neck to the fundus at 5mm intervals. Lay out the slices, number sequentially and photograph the dissected specimen to provide a block allocation key.

    Dissect the specimen further and submit sections for processing according to the diagram provided.

    Note photographs taken, diagrams recorded and markings used for identification.

    Prostate and seminal vesicles

    The prostate is sampled to exclude co-existent prostate and microscopic invasion by urothelial carcinoma. A shave of the prostatic apical margin (urethral margin) and longitudinal sections from the bladder neck/prostate base are taken to exclude involvement by invasive or in situ carcinoma. There is no consensus on the number of blocks to be taken from the prostate. Paint the prostate with ink and serially section the remaining tissue according to the protocol for prostate adenocarcinoma. If normal, submit four representative sections from each lobe. Total or partial embedding should be performed according your institution’s procedures. Store both the serially sectioned bladder and prostate slices so that they can be easily reconstructed at a later date.

    Posterior wall tumours

    If invasion into a gynaecological organ is suspected, transverse incisions should be made through the tumour in the posterior wall into the underlying organ to confirm involvement.

    Longitudinal sections from the vaginal resection margin should be taken if the tumour is in close proximity.

    Representative blocks from accompanying organs should be taken according to the relevant gynaecological non-neoplastic protocol.

    Submit representative sections, at least three sections or one per 10mm of tumour, demonstrating:

    • Maximum depth of invasion
    • Relationship with closest resection margin and peritoneal surface
    • Interface with uninvolved bladder tissue
    • Ureteric shave margins (if not received separately)
    • Relationship of tumour with adjoining tissues
    • Urethral margin

    Male specimens

    • Sections from prostate and seminal vesicles (as described above).

    Female specimens

    • Representative section(s) from the vaginal wall segment and any other gynaecological tissues included.

    Submit representative sections of:

    • Uninvolved bladder
    • Ureteric orifices
    • Lateral, anterior and posterior walls
    • Dome
    • Trigone
    • Other lesions

    Submit all lymph nodes.

    Record details of each cassette.

    An illustrated block key similar to the one provided may be useful.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A
    Left ureteric margin
     
    B
    Right ureteric margin
     
    C-G
    Tumour sections including tumour to closest perivesical margin
     
    H
    Tumour to closest peritoneal surface
     
    I
    Tumour interface with uninvolved bladder
     
    J
    Tumour closest to/representative of vagina (female)/section including bladder neck/base prostate  (male)
     
    K
    Apical shave of prostate (distal urothelial margin)
     
    L+
    Sections from quadrants of uninvolved bladder, representative sections of prostate/ uterus/ovaries/fallopian tubes.
     
    O+
    Lymph nodes
     
     

    Acknowledgements

    A/Prof Hemamali Samaratunga for her contribution in reviewing and editing this protocol.


    References

    1. O’Rourke D, Turner G and Allen D. Tissue Pathways for Urological Pathology, The Royal College of Pathologists, London, 2010.
    2. Samaratunga H, Clouston D, Delahunt B, Delprado W, Grimes D, Kench J, Perry-Keene J and Yaxley J. Urinary bladder carcinoma structured reporting protocol. Radical cystectomy, partial cystectomy, cystoprostatectomy, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012.
    3. Keoghane SR, Gubbay N and Kinder RB. Severe unremitting cystitis progressing to cystectomy. Int Urol Nephrol 1998;30(2):133-136.
    4. Shanks JH, Chandra A, McWilliam L and Varma M. Dataset for tumours of the urinary collecting system (renal pelvis, ureter, bladder and urethra), The Royal College of Pathologists, London, 2013.

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      25-Mar-2019
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