Urinary bladder cancer as a late sequela of traumatic spinal cord injury

Abstract

Background: Traumatic spinal cord injury (SCI) is also a combat-related injury that is increasing in modern warfare. The aim of this work is to inform medical experts regarding the different course of bladder cancer in able-bodied patients compared with SCI patients based on the latest medical scientific knowledge, and to present decision-making aids for the assessment of bladder cancer as a late sequela of traumatic SCI.

Methods: A study conducted between January 1998 and December 2019 in the BG Trauma Hospital Hamburg formed the basis for the decision-making aids. Urinary bladder cancer was diagnosed in 40 out of 7396 treated outpatient and inpatient SCI patients. General patient information, latency period, age at initial diagnosis, type of bladder management and survival of SCI patients with bladder cancer were collected and analysed. T category, grading and tumour entity in these patients were compared with those in the general population. Relevant bladder cancer risk factors in SCI patients were analysed. Furthermore, relevant published literature was taken into consideration.

Results: Initial diagnosis of urinary bladder cancer in SCI patients occurs at a mean age of 56.4 years (SD ± 10.7 years), i.e., approximately 20 years earlier as compared with the general population. These bladder cancers are significantly more frequently muscle invasive (i.e., T category ≥ T2) and present a higher grade at initial diagnosis. Furthermore, SCI patients show a significantly higher proportion of the more aggressive squamous cell carcinoma than that of the general population in areas not endemic for the tropical disease schistosomiasis. Consequently, the survival time is extremely unfavourable. A very important finding, for practical reasons is that, in the Hamburg study as well as in the literature, urinary bladder cancer is more frequently observed after 10 years or more of SCI. Based on these findings, a matrix was compiled where the various influencing factors, either for or against the recognition of an association between SCI and urinary bladder cancer, were weighted according to their relevance.

Conclusions: The results showed that urinary bladder cancer in SCI patients differs considerably from that in able-bodied patients. The presented algorithm is an important aid in everyday clinical practice for assessing the correlation between SCI and bladder cancer.

Keywords: Battlefield injury; Medical assessment; Neurogenic bladder; Squamous cell carcinoma; Survival time; Transitional cell carcinoma; Traumatic spinal cord injury.

Fig. 1

Age and gender of 40 spinal cord injury patients at initial bladder cancer diagnosis. Blue. Male; Red. Female

Fig. 2

Comparison of cumulative percentage of bladder cancer in spinal cord injury patients and bladder cancer incidence rates in the general population in Germany. a Cumulative percentage of bladder cancer in spinal cord injury patients (Hamburg data 1998–2019). b Bladder cancer incidence rates in the general population in Germany (Robert Koch Institute data 1999–2016)

Fig. 3

Level of spinal cord injury. Blue. Upper motor neuron lesions (UMNL); Red. Lower motor neuron lesions (LMNL). Please note that the split blue and red bar for L1 indicates one UMNL case and three LMNL cases

Fig. 4

Histopathological findings for T categories and grading. Spinal cord injury patients (Hamburg data 1998–2019) vs. the general population in Germany (Robert Koch Institute data 1999–2016). T category. P < 0.0001; Grading. P < 0.0002

Fig. 5

Latency between onset of spinal cord injury and initial bladder cancer diagnosis. Blue. Transitional cell carcinoma; Red. Squamous cell carcinoma