KANKERBULI

KANKER BULI
dr. Ahmad Zulfan Hendri, Sp.U

KANKER BULI
dr. Ahmad Zulfan Hendri, Sp.U
Staf Urologi
Departemen Bedah
RSUP Dr. Sardjito
Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan
Universitas Gadjah Mada
Illustrator
Ali Ariyono
Kata Pengantar
Daftar Isi
Anatomi Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Kanker Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Epidemiologi Kanker Buli pada Laki-laki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Insidensi Kanker Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Faktor Resiko Kanker Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Tipe Patologi Kanker Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Diagnosis Kanker Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Kanker Buli Urotelial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Tanda dan Gejala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Pola-pola Morfologi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Staging T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Staging Node . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Stratifikasi Resiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Investigasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Evaluasi Awal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Manajemen NMIBC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Manajemen MIBC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Kanker Buli dengan Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Squamous Cell Carcinoma of the Urinary Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Epidemiologi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Etiologi dan Faktor Resiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Tanda dan Gejala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Investigasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Patologi dan Faktor Prognostik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Manajemen SCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Adenokarsinoma Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Epidemiologi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Insidensi Kejadian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Tipe Adenokarsinoma Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Tanda dan Gejala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Investigasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Perbandingan Clear Cell Ca, non-Urachal, Urachal, Sekunder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Sistem Staging Sheldon untuk Urachal Karsinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Manajemen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Small Cell Ca Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Mindmap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Investigasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Manajemen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Sarkoma Buli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Ikhtisar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Faktor Resiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Tanda dan Gejala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Investigasi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Marker dan MSKCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Manajemen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Malignant Melanoma of the Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Anatomi Buli
ureter
superior
urachus
apex
inferolateral
inferoposterior batas anterior
trunkus
uretra
ureter
peritoneum
corpus vesica
m. detrusor vesica
ostium ureteris
trigonum vesica
ostium uretra internum
prostat
uretra
1
Kanker Buli
Epidemiologi Kanker Buli pada Laki-laki
kanker paru
kanker prostat
1
2 kanker buli
7
Es masi Insidensi Kanker pada Laki-Laki tahun 2012
Epidemiologi Kanker di Dunia 1,400,000
laki-laki laki-laki & perempuan 1,200,000
1. Paru 1. Payudara 1,000,000
2. Prostat 2. Prostat
800,000
.. ..
.. .. 600,000
7. Buli .. 400,000
(9/100,000 orang) 11. Buli 200,000
0
Paru Prostat Colorektal Stomach Ha Buli
Jumlah Kasus
sumber: Antoni et al., 2017

2
Insidensi Kanker Buli
Insidensi di Dunia
spanyol
36.7/100,000
3Denmark
Denmark
27.4/100,000
Spanyol
2 Itali
Itali
33.2/100,000
Insidensi di Asia
1 Turki
26.1/100,000
2 Israel
25.1/100,000
3 Jepang
9.6/100,000
sumber: Antoni et al., 2017

3
Faktor Resiko Kanker Buli
paparan tempat kerja

merokok - bahan warna, cat
- karet
50% - 65% kasus pada ♂ - tekstil, kulit
20% - 30% kasus pada ♀
20% - 25% dari semua kasus
♂♀
laki-laki > perempuan
Cl
As
konsumsi air ber klorin
dan arsenik
As
Cl
- chlornaphazine
- cyclophosphamide
b a t
O
radioterapi
- isk kronis
riwayat keluarga - schistosomiasis
dan genetik
sumber :(Babjuk et al., 2018; Umbas et al., 2014; Witjes et al., 2018)
4
Papillary Tumor papiloma
Urothelial/
urothelium
Transi onal Cell Ca
(≥ 90%) urothelium
Flat Tumor/Cis
Carcinoma in situ
Squamous Cell Ca
horn pearl
Keganasan Buli
Epithelial
Adenocarcinoma
(90%)
Small Cell Ca
Non-Urothelial
(< 5%) Sarcoma
Rhabdomyosarcoma Leiomyosarcoma
Lymphoma
Non-Epithelial
zellballen pattern
Paraganglioma
of paraganglioma
Melanoma
sumber: (Carroll and Nodit, 2013; Dahm and Gschwend, 2003)
5
Diagnosis Kanker Buli
hematuria tapi
tidak nyeri
LUTS “Storage/irritative”
- Urgensi
- Frekuensi
- Inkontinensia
- Nokturia
- Dysuria
Sistoskopi + Biopsi
- sistoskopi menilai ukuran, jumlah, bentuk dan lokasi
kanker buli
Sitologi urin, histopatologi

- sitologi urin mencari adanya sel kanker di urin
- hispatologi menilai derajat dan karakteristik kanker buli
Ct scan/ CT-PET dan MRI dengan kontras digunakan

apabila ditemukan MIBC pada hasil TUR-BT dan untuk
menilai perluasan tumor dan mengeksklusi adanya
metastasis
sumber: (Babjuk et al., 2018; Fosså et al., 1991; Umbas et al., 2014; Witjes et al., 2018)
6
Kanker Buli Urotelial
Non-invasive
Papillary Tumor
Invasive
Urothelial/
Keganasan Buli Transi onal Cell Ca
(= 90%)
Non-invasive
Flat Tumor/Cis
Invasive
Signs and Symptoms

Painless gross haematuria
Irritative LUTS
- dysuria
- freq increased
- urgency
- incontinence
- Nyeri di pelvis/nyeri tulang; edema tungkai bawah,

nyeri pinggang penyakit lanjut/ advanced
disease
- Massa terpalpasi saat pemeriksaan fisik (jarang
pada kanker superfisial)
sumber: (Babjuk et al., 2018; Epstein and Lotan, 2015; Umbas et al., 2014; Witjes et al., 2018)
7
Pola-Pola Morfologi
1. Carsinoma In Situ (Cis)
Carcinoma in situ
urotelium
lamina propria
otot detrusor
2. Papiloma
papiloma
urotelium
lamina propria
otot detrusor
sumber: (Epstein and Lotan, 2015)

8
3. Flat Invasive Carcinoma
urotelium
lamina propria
otot detrusor
4. Invasive Papillary Carcinoma
urotelium
lamina propria
otot detrusor
sumber: (Epstein and Lotan, 2015)

9
Staging T
Tx Tumor primer tidak dapat di nilai
T0 Tumor tidak ditemukan
lemak peri-vesika Ta Tumor non-invasif
T3a
T1 T2a T2b TisCarcinoma in situ = “flat tumor”
T3b
T1 Tumor menginvasi jaringan ikat subepitel
vesica urinaria
T2 Tumor menginvasi otot
Ta T4b
T2a invasi ke otot bagian superfisial/ setengah
Tis T4a
muskulus profunda dalam
muskulus superfisialis rectum T2b invasi ke otot bagian dalam/ setengah luar
jaringan ikat
T3 Tumor menginvasi jaringan peri-vesika
T3a secara mikroskopis
T3b secara makroskopis (massa diluar vesika)
prostat T4 Tumor menginvasi:
T4a menginvasi stroma prostat, vesika seminalis,
uterus/ vagina
T4b menginvasi dinding pelvis/abdomen
uretra
Non-Muscle Invasive
Zzz
Bladder Cancer (NMIBC)
Ta T1
mukosa Tis
Lamina propria
muskulus
Muscle Invasive Bladder Cancer (MIBC)

mukosa T2a
lamina propria
muskulus
T2b T3a T3b
superfisial
profunda
jaringan lemak
T4a
T4b
dinding abdomen prostat/ uterus/ vagina

atau
dinding pelvis
sumber: (Babjuk et al., 2018; Moch et al., 2016; Umbas et al., 2014; van Rhijn et al., 2012;
Witjes et al., 2018
10
Staging Node
jantung invasi tumor
limfanodi
iliaka eksterna
obturator
iliaka interna
iliaka komunis
paru-paru paru-paru
ren/ginjal ren/ginjal
true pelvis
N – Regional lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node in the true pelvis (hypogastric, obturator, external iliac,
or presacral)
N2 Metastasis in multiple regional lymph nodes in the true pelvis (hypogastric, obturator,
external iliac, or presacral)
N3 Metastasis in common iliac lymph node(s)
M - Distant metastasis
M0 No distant metastasis
M1a Non-regional lymph nodes
M1b Other distant metastases
sumber: (Babjuk et al., 2018; Moch et al., 2016; Umbas et al., 2014; van Rhijn et al., 2012;
Witjes et al., 2018
11
Stratifikasi Resiko
papiloma
Ta, tunggal
Tunggal, Ta, Cis (-), Diameter
Low Risk
< 3cm < 3cm
urothelium
Other than Low and High

Intermediate
Risk
Stra fikasi resiko NIMBC
CIS; T1; HG
> 3cm > 3cm

Tumor Ta Low Grade
mul ple, diameter > 3 cm papiloma, Ta, multiple
High Risk
Highest risk: T1,G3/HG+ CIS;

T1,G3/HG berbanyak/besar;
T1,G3/HG+Cis di uretra
prostat; invasi vasa limfa k
T1
mukosa Cis
Lamina propria
muskulus
sumber: (Fernandez-Gomez et al., 2009; Palou et al., 2012;
Witjes et al., 2018)
12
Investigasi
Sitoskopi (Gold Standard) + Biopsi/reseksi
(+) Narrow Band Imaging (NBI) dan Fluorescence
Cystoscopy (FC)
meningkatkan sensitivitas terhadap lesi Cis dan papilar
(+) bila kanker di leher buli lakukan biopsi urethra prostat
Sistoskopi menilai ukuran, jumlah, bentuk dan lokasi
kanker buli
Sitologi Urin + Histopatologi Lesi + Marker Urin

- sitologi urin memiliki sensitivitas tinggi (84%) pada
tumor G3 dan High Grade (HG), namun pada G1 dan
Low Grade (LG) sensivitas hanya 16%. untuk Cis
sensitivtas berkisar 28-100%
USG
- menilai adanya massa renal, hidronefrosis, massa
intravesika, obstruksi pada traktus urinarius bagian atas,
- tidak dapat mengeksklusi karsinoma urothelial traktus
urinarius
- tidak dapat menggantikan peran Ct-scan
Ct scan/ CT-PET dan MRI dengan kontras

- digunakan apabila ditemukan MIBC pada hasil TUR-BT
dan untuk menilai perluasan tumor, keterlibatan LN dan
adanya metastasis
- untuk staging lokal Ct-scan/MRI tidak dapat
membedakan T2-T3a,
- lebih sensitif dan akurat pada T3b dan seterusnya
sumber: (Babjuk et al., 2018; Goessl et al., 1997; Hilton and Jones, 2014; Mungan et al., 2005;
Têtu, 2009; Umbas et al., 2014; Witjes et al., 2018; Yafi et al., 2015)
13
Evaluasi Awal
Reseksi dalam Fraksi-
fraksi
tumor besar
TransUrethral Resec on (diameter>1cm)
of
Bladder Tumor (TUR-BT)
+ Reseksi En-Bloc
Px pelvis tumor kecil
(diameter<1cm)
papiloma papiloma
urothelium urothelium
lamina propria lamina propria
otot detrusor otot detrusor
reseksi fraksi-fraksi reseksi En-Bloc
PDD (-) PDD (+) TUR-BT + Photodynamic Diagnosis (PDD)/NBI(Narrow

Band Imaging)
- meningkatkan sensitivitas dan visualisasi terhadap
tumor seperti Cis
NBI (-) NBI (+)
Reseksi ke-2
- dilakukan 2-6 minggu setelah reseksi pertama
- meningkatkan recurrence-free survival, meningkatkan
luaran setelah
terapi BCG, dan menjadi acuan prognosis
Indikasi reseksi ke-2:

- reseksi pertama tidak tuntas/ diragukan ketuntasannya
- spesimen reseksi pertama tidak sampai otot, kecuali
pada tumor
TaLG/G1 dan Cis primer
sumber: (Babjuk et al., 2018; Baltacı et al., 2015; Bishr et al., 2014; Chou et al., 2017; Dalbagni et al.,
2009; Divrik et al., 2006; Gontero et al., 2016; Grimm et al., 2003; Hurle et al., 2016; Kramer et al.,
2017, 2015; Nabi et al., 2004; Richterste er et al., 2012; Witjes et al., 2018)
14
Manajemen NMIBC
1.
Smoking Cessation TransUrethral Resection of Bladder Tumor (TUR-BT)
TUR-BT dapat mengangkat tumor TaT1
& dengan tuntas namun, resiko rekuren

tinggi
2.
Intravesical Chemotherapy post TUR-BT (Mitomycin C/Epirarubicin/Pirarubicin/
doxorubicin)
Instalasi tunggal langsung:
- menghancurkan sel tumor yang bersikulasi post TURB, dan efek ablasi
pada tempat reseksi dan tumor yang tidak terlihat
- penambahan instalasi tunggal langsung dapat menurunkan resiko
rekurensi 5 tahun
sebanyak 14% hanya pada pasien dengan riwayat rekurensi ≤ 1 kali per
tahun dan skor rekurensi EORTC <5
- diberikan dalam 24 jam setelah TUR-BT, kemanjuran maksimal bila
diberikan dalam 2 jam setelah TUR-BT
- pasien resiko rendah instalasi tunggal langsung menurunkan resiko rekurensi dan sebagai
standar
- instalasi kemoterapi berulang diberikan pada pasien dengan resiko menengah dan tinggi
- saat pemberian intravesical chemotherapy, berikan obat di PH optimal, durasi pemberian
(maksimal 1 jam), menjaga konsentrasi obat dengan mengurangi konsumsi cairan sebelum
dan selama instalasi
Intravesical Immunotherapy (BCG)

- TUR-BT+BCG > TUR-BT+Chemotherapy dalam mencegah rekurensi
- Efek samping pada TUR-BT+BCG lebih besar daripada TUR-
BT+Chemotherapy
- terdapat penurunan resiko rekuren 32% pada BCG rumatan dibanding
MMC,
akan tetapi, meningkatkan resiko 28% bila tidak diberikan BCG rumatan
- BCG rumatan menghambat dan menurunkan progresi tumor
- 3 tahun BCG rumatan lebih efektif dalam mencegah rekurensi pada
pasien resiko
KI absolut instalasi BCG:

- 2 minggu pertama setelah TUR-BT
- pasien dengan hematuria yang terlihat
- setelah trauma kateter
- pasien dengan ISK simptomatik
sumber: (Abern et al., 2013; Au et al., 2001; Böhle and Bock, 2004; Brausi et al., 2002; Crivelli et al.,
2014; Grotenhuis et al., 2015; Han and Pan, 2006; Oosterlinck et al., 1993; Perlis et al., 2013; Rink et al.,
2012; Shelley et al., 2004, 2001; Soloway and Masters, 1980; Sylvester et al., 2016, 2004, 2002)
15
3.
Stratifikasi pasien
Surveillance/difulgu
Follow-up sistoskopi
Sistoskopi pada rasi
bulan ke 3, bila
nega f ulangi di
Per mbangkan
Tumor resiko bulan ke 12, lalu Rekurensi tumor TUR-BT + biopsy
usia,komorbid, dan
rendah per tahun selama 5 papilar kecil mukosa abnormal,
pilihan pasien
(primer, tunggal, tahun biopsi acak dan
TaLG/G1, < 3cm) atau urethra
prostat bila ada
Bila curiga/posi f indikasi,
tumor saat follow-
up
TUR-BT + biopsy NMIBC kembali ke

mukosa abnormal, manajemen awal
Rekurensi tumor
biopsi acak dan
non papilar atau Hasil PA
atau urethra
besar
prostat bila ada MIBC, manajemen
indikasi, sesuai terapi MIBC
Tumor primer/rekuren tanpa riwayat chemotherapy:

intravesical BCG selama 1 tahun (per 6mgg dan per 3 mgg
pada bulan ke 3,6 dan 12) atau intravesical chemotherapy TUR-BT + biopsy mukosa
hingga 1 tahun Curiga/posi f tumor abnormal, biopsi acak dan
Tumor rekuren dengan riwayat chemotherapy: saat follow-up atau urethra prostat bila
ada indikasi,
intravesical BCG selama 1 tahun (per 6mgg dan per 3 mgg
Tumor resiko menengah
pada bulan ke 3,6 dan 12) , pada rekurensi terlambat(late)
tumor kecil TaLG/G1 per mbangkan pengulangan Cek traktus superior
chemotherapy Sitologi posi f tanpa biopsi acak, biopsi urethra
terlihat adanya tumor prostat, bila ada gunakan
PDD
Sistoskopi pada bulan ke 3, bulan ke 12, lalu per tahun
selama 5 tahun
sumber: (Babjuk et al., 2018)

16
Sangat nggi
Urethra prostat, Jelaskan resiko dan
mul ple T1G3/HG, per mbangkan radical
T1G3/HG > 3 cm, LVI cystectomy
atau beberapa varian
Urothelial Carcinoma
Tumor resiko nggi
Intravesical BCG selama 1 sampai
3 tahun
T1 atau Tis atau Sistoskopi dan sitologi pada bulan Cek ulang traktus
G3/HG ke 3 Jika s ologi posi f superior
atau mul ple dan Jika nega ve, ulangi sistoskopi tanpa terlihat adanya biopsi acak, biopsi
rekuren dan > 3 cm dan sitologi per 3 bulan selama 2 tumor prostat, bila ada,
TaG1-2/LG) tahun, lalu per 6 bulan sampai 5 gunakan PDD
tahun dan setelahnya per tahun,
CT-IVU atau IVU per tahun
NMIBC kembali ke
manajemen awal
Hasil PA
MIBC, manajemen
sesuai terapi MIBC
sumber: (Babjuk et al., 2018)

17
gagal terapi BCG:
Gagal Terapi E Dintravesika - tumor refrakter BCG
A IL - rekuren high grade setelah terapi BCG

- rekurensi non-high grade setelah terapi
F gagal intravesical
BCG pada tumor primer resiko menengah
BCG
(Babjuk et al., 2018)
Radical Cystectomy
E D
CG I L
rap
iB
F A
Te
gagal intravesical
chemotherapy
tidak terdapat
E D BCG
I L
F A NMIBC,
resiko tinggi kandidat RC:
- tumor besar/multipel (> 3cm) T1, G3 (HG)
nilai ulang tumor, - T1,G3, terdapat Cis di kandung kemih dan
re-staging urethra prostat
- T1 G3 rekuren
- varian mikropapilar dan karsinoma urothelial
(Umbas et al., 2014)
intravesical
chemotherapy ulang
NMIBC,
resiko rendah/menengah
instalasi 1x per minggu selama 8 minggu,
selanjutnya 1x per bulan, hingga maksimal 1 tahun
sumber: (Umbas et al., 2014)

18
Manajemen MIBC
Radical cystectomy sexual-preserving technique
-RC merupakan standar terapi pada pasien MIBC T2-T4a, N0-
Nx, M0, resiko tinggi, rekuren NMIBC, Tis resisten BCG, T1G3,
gagal terkontrol dengan TUR-BT
- Penundaan RC tidak lebih dari 3 bulan setelah diagnosis
- RC pada laki-laki: vesika urinaria, ureter distal, prostat
vesika seminalis, regional LN (lymph node)
- RC pada perempuan: vesika urinaria, uterus, cervix, dinding
vagina anterior, distal urethra, regional LN
- standar lymphadenectomy pada keganasan buli sampai
dengan bifurcasio iliaka communis, termasuk nodus iliaka
interna,
Neo-Adjuvant Chemotherapy
(cisplatin-based combination)
- methotrexate, vinblastine, adriamycin ( or epirubicin) cisplatin
(MVA(E)C) 3-4 siklus
- alternatif: gemcitabine/cisplatin 4 siklus
- pada pasien T2-T4a, cN0M0, meningkatkan kesintasan umum
dalam 5 tahun sebanyak 8%
Radioterapi pre-operatif
- menurunkan kematian akibat penyebab spesifik dan secara
keseluruhan pada T1-T3
- pada MIBC yang dapat dioperasi, dengan dosis 45-50 Gy dalam
fraksi of 1.8-2 Gy, dapat menurunkan staging tumor setelah
4-6 mgg
- meningkatkan progression-free survival
Adjuvant chemotherapy (cisplatin-based)

- diberikan pada pT3/4 dan/atau pN+, dan belum diberikan
Neoadjuvant Chemotherapy
- berdasarkan hasil penelitian, dapat menghambat rekurensi dan
meningkatkan kesintasan umum
Robot-Assisted RC (RARC)
- operasi RARC lelbih lama 1-1.5 jam dibanding Open RC
- biaya operasi RARC > Open RC
- jumlah transfusi dan kehilangan
darah saat operasi lebih sedikit
- waktu rawat inap lebih singkat 1-1.5 hari
dibanding Open RC
sumber: (Abol-Enein et al., 2004; Advanced Bladder Cancer (ABC) Meta-analysis Collabora on, 2005;
Advanced Bladder Cancer Meta-analysis Collabora on, 2003; Bayoumi et al., 2014; Bruins et al., 2016;
Chang et al., 2003; Dorin et al., 2011; Gore et al., 2009; Leissner et al., 2004; Spiess et al., 2017; Stein,
2007; Stein et al., 2001; Stenzl et al., 2005; Umbas et al., 2014; Witjes et al., 2018; Zlo a, 2012)
19
Multimodal therapy : TURB+ Chemotherapy+ Radiation
(bladder preserving technique)
- Pada pasien yang tidak dapat atau tidak ingin dilakukan RC

- Pada pasien terseleksi dengan baik, overall survival (OS) dan cancer
spesific survival (CSS) antara RC dan multimodal therapy tidak berbeda
signifikan
- Pendekatan bladder-preserving sebagian berdasarkan lokasi lesi,
kedalaman invasi, ukuran tumor, status urotelium yang tidak terkena, dan
status pasien (seperti kapasitas kandung, fungsi kandung, komorbiditas)
- Bladder-preservation merupakan suatu alternatif selain cystectomy
pada pasien dengan tumor tunggal kecil (T2 dan tidak terdapat Cis),
tidak melibatkan nodus, bukan Cis, bukan hidronefrosis terkait tumor,
dan fungsi ginjal yang masih bagus sebelum diterapi
- Pasien yang dapat di RC namun memiliki hidronefrosis tidak dapat
dilakukan prosedur bladder-preserving. TUR-BT maksimal bersamaan
dengan chemoradiotherapy sebaiknya diberikan sebagai terapi utama,
dengan hanya RT atau TUR-BT pada pasien tertentu.
Organ-preserving technique
- mempertahankan organ genital dan atau pelvis pada laki-laki dan perempuan
- pada laki-laki, terdapat 4 tipe yaitu: prostate-, capsule-, seminal-, nerve- sparing technique
- pada perempuan, mempertahankan organ pelvis termasuk uterus, tuba fallopi, ovari, dinding
vagina anterior
- keuntungan yang mungkin didapatkan yaitu, mempertahankan fungsi seksual, mengurangi
inkontinensia urin
dengan orthotopic neobladder urinary diversion, mengurangi resiko fistula post operasi, dan
prolapsus organ pelvis
- kriteria seleksi pasien:
Laki-laki Perempuan
cT2 atau kurang (less) Usia 55 tahuan atau lebih muda
Usia Performance status
Performance Status Status pre-menopause
Biopsi urethra prostat dan atau kandung nega ve Fungsi seksual pre-opera f
PSA < 4, normal DRE, TRUS normal dan atau PSA free Keterampilan manual katerisasi
to toal ra o > 15%
Tidak terdapat kanker prostat pada pemeriksaan ru n Tidak ada Cis
prostat berdasarkan biopsi TRUS
Fungsi seksual pre-opera f Tidak ada tumor pada leher kandung atau trigonum
Pre-opera ve con nence cT2 atau kurang
- kriteria seleksi pasien mencakup tidak terdapat penyakit multifokal (seperti Cis), penyakit
terlokalisir, tidak terdapat keganasan pada trigonum atau leher kandung, prostat dan uretra
prostat.
- luaran onkologi dan luaran kontinensia antara organ-preserving techniques (prostate-,
capsule-, seminal-, nerve- sparing technique dengan RC tidak berbeda bermakna
sumber: –(Avulova and Chang, 2018; Hong et al., 2017; Ploussard et al., 2014; Umbas et al., 2014;
Witjes et al., 2018)
20
Pada cT2, dengan pasien
Manajemen MIBC sangat selek f (tumor
diberikan pada pT3/4
dan/atau pN+,
tunggal, dak ada Cis) margin/batas +, HG dan
Par al Cystectomy + bila belum diberikan
Neoadjvant Chemotherapy Neoadjuvant
( Cyspla n based) Chemotherapy
diberikan pada pT3/4

RC+Neo-Adjuvant dan/atau pN+, dan bila
Chemotherapy (Cispla n- belum diberikan
based combina on) Neoadjuvant
Chemotherapy
Bila dak ada tumor,

Nilai ulang tumor 2-3 bulan observasi/selesaikan terapi
cT2,T3,t4a,
TUR-BT maksimal diiku setelah terapi dosis penuh
cN0M0 Bladder preserva on + atau 3 minggu setelah 40-
radiochemotherapy secara 45 Gy
bersamaan
Bila ada tumor,
per mbangkan cystectomy
Bila dak ada tumor,

obesrvasi
Kandidat non-cystectomy:
- Chemoradiotherapy
Nlai ulang tumor 2-3 bulan Bila ada tumor:
bersamaan
setelah terapi - Chemotherapy
- Hanya radiotherapy
- Hanya TUR-BT - Chemoradiotherapy
bersamaan (jika dak ada
RT sebelumnya)
Staging Terapi Utama -TUR-BT palia f
- Terapi supor f
sumber: (Spiess et al., 2017) Terapi Adjuvan

21
cT4b
Staging
N0 cN1-3,
Berdasarkan hasil per mbangkan
biopsi/CT-Scan/MRI biopsi nodus
Nodus posi f
dengan biopsi, CT-
Scan/MRI
Chemoradiotherapy Chemotherapy atau

Chemotherapy Chemoradiotherapy
bersamaan
bersamaan
Terapi Utama
Setelah 2–3 siklus, Evaluasi dengan
Nilai ulang tumor 3
Nilai ulang dengan cystoscopy, minggu setelah cystoscopy, EAU,
EUA, TURBT, terapi 40-45 Gy atau TUR-BT, dan foto
2-3 bulan setelah abdomen/pelvis
dan foto
terapi dosis penuh
abdomen/pelvis
Tidak ada tumor,
per mbangkan: Terdapat tumor: Tidak ada
Ada tumor
tumor
- Consolida on - Sistemic
chemotherapy chemotherapy
- Chemoradiotherapy jika - Chemoradiotherapy
dak RT sebelumnya jika dak RT Terapi sesuai
Tambahkan
sebelumnya algoritma
- Selesaikan RT defini f RT atau
rekuren/persi
-cystectomy cystectomy
-cystectomy stent
Terapi Adjuvan
sumber: (Spiess et al., 2017)

22
RC Urinary Diversion
- 2 aspek preparasi usus:
1. secara mekanis untuk membersihkan feces
2. antibiotik untuk menurunkan jumlah bakteri (konsentrasi bakteri berkisar 10 - 105 organisme
per gram isi feces di jejunum, 105-107 di ileum distal,106-108 di colon ascending dan 1010-1012 di
colon descending).
- bagian yang paling sering digunakan adalah ileum, colon dan rectum. jejunum dan gaster
lebih jarang digunakan
Jejunum
usus halus
- percabangan arcade dan arteri ileales lebih banyak dibanding
jejunum yang cenderung tunggal
2/5 - secara eksperimental 15 cm usus halus masih hidup dengan hanya
dialiri 1 vasa darah, namun, dalam prakteknya sebaiknya panjang
3/5 usus sebaiknya tidak melebihi 8 cm untuk 1 vasa darah
- pada pasien post radiasi,penggunaan 2 inci terakhir ileum terminal
dan sepanjang 5 kaki dari awal usus halus atau 6 khaki dari
ligamentum treitz sebaiknya dihindari pada rekonstruksi apapun
ileum
jejunum ileum
Ureterocolonic Diversion
- teknik yang sudah obsolet karena insidensi ISK tinggi dan pada jangka panjang dapat
meningkatkan resiko kanker kolon
- 3 titik lemah pada colon yang proses penyembuhannya lebih lambat:
- titik kritis sudect, area pertemuan diantara arteri sigmoid dan hemoroidalis superior
- titik tengah antara arteri colica dextra dan media
- titik tengah antara arteri colica media dan sinistra
Ileal Conduit
- standar diversi urin post RC
+ rata-rata klinis adekuat,

cost-effective,
dapat diandalkan s Realible
- komplikasi renal karena infeksi

beban psikososial post ileal conduit
ileal conduit anastomosis bocor, terutama saat terapi sinar
Ureterocutaneostomy
- tipe paling sederhana
- lama operasi, tingkat komplikasi, waktu rawat intensif dan inap paling
rendah dibanding ileal conduit
- ISK ascending lebih sering terjadi pada ureterocutaneostomy
skin
dibanding ileal conduit
ureteral diversion
sumber: (Ahlering et al., 1989; Colombo and Naspro, 2010; Dahl, 2016)
23
Continent cutaneous urinary diversion
- kantung dapat diambil dari ileum (paling sering),gaster, ileocaecal,
dan sigma
- dilakukan pada pasien yang mampu melakukan kateter sendiri
- 4 teknik operasi: dengan colon dextra, appendix sebagai pipa
saluran; pada kantung colon dextra menggunakan ileum terminal
yang saling tumpang tindih dan/atau lancip dan katup ileocaecal;
stoma intussuscepted nipple valve atau katup flap;membuat kontruksi katup
hidrolik seperti pada Benchekroun nipple.
- retensi urin jarang terjadi namun merupakan kondisi emergency
continent cutaneous reservoir
reservoir detubularisasi ileal
+ sistem urinari non-refluks
reservir tanpa alat
tempat tampung urin
volume urin tampung
stoma
- teknik operasi kompleks
durasi operasi lama
-sekitar 150 mL (ileum)
-sekitar 300 mL (colon
resiko operasi ulangan dextra)
Kock pouch
tekanan rendah
+ durasi operasi = ileal conduit
teknik operasi sederhana dikeluarkan dengan kateter oleh pasien
tidak perlu operasi ulangan
Stoma
Indiana pouch
Orthotopic neobladder
- pada beberapa center telah menjadi pilihan urinary diversion, paling
sering menggunakan ileum terminal
- tidak direkomendasikan pada stadium N2 dan 3
3 prinsip dasar konstruksi orthoropic neobladder urinary diversion:
- pasien memiliki urethra yang sehat (terbebas dari kanker) dan
fungsi sfingter eksterna yang adekuat
new bladder - segmen usus harus di detubularisasi dan dibentuk menjadi bulat
- kandung kemih buatan mampu menampung urin minimal 300 mL -
500 mL
orthotopic neobladder
- pengosongan resevior diperlukan “ngeden”, peristaltik usus dan
relaksasi sfingter
- morbiditas ditemukan hingga 22% pasien, komplikasi jangka
panjang:
B12
20-30% 8-10%
nokturnal diurnal
Inkontinensia urin Gangguan metabolik Stenosis Ureterointestinal Defisiensi Vitamin B12
sumber: (Ahlering et al., 1989; DeCastro et al., 2016; Moon et al., 2013; Skinner and Daneshmand,
2016)
24
Kanker Buli dengan Metastasis
prognosis metastasis hanya pada LN lebih baik daripada metastasis jauh(ke paru, hati)
first line chemotherapy Tx metastasis ke tulang
cisplatin-based combination:
1
st - methotrexate - prevalensi 30-40% pada
pasien penyakit lanjut/
- vinblastin metastasis
- adriamycin - zoledronic acid (ZA) atau
- cisplatin (MVAC)
atau b a t Denosumab
Gemcitabine/Cisplatin O
2
nd
second line chemotherapy
- Vinflunine
ZA
KI
- PS > 1
- GFR < 60 mL/min
- grade > 2 audiometric loss
- peripheral neuropathy, and
- New York Heart Association (NYHA) class III heart failure
Cisplatin
- Immunotherapy pada pasien yg KI cisplatin antibodi menyerang

programmed cell death-1 (PD-1).
- ligan PD-L1, atau cytotoxic T-lymphocyte-associated protein- 4 (CTLA-4)-
b a t pathway
O - first line: pembrolizumab (kesintasan umum meningkat)
- 2nd line: Atezolizumab
• Bone scan bila secara klinis Hanya Nodus Per mbangkan biopsi nodus
mencurigkan atau terdapat gejala
metastasis ke
Metastasis • Chest CT
• per mbangkan CNS imaging
• Es masi GFR sebagai Lanjut algoritma penyakit
per mbangan cispla n Metastasis menyeluruh
rekuren/menetap
sumber: (Spiess et al., 2017)

25
DAFTAR PUSTAKA
Abern, M.R., Owusu, R.A., Anderson, M.R., Rampersaud, E.N., Inman, B.A., 2013. Perioperative
intravesical chemotherapy in non-muscle-invasive bladder cancer: a systematic review and
meta-analysis. J. Natl. Compr. Cancer Netw. JNCCN 11, 477–484.
Abol-Enein, H., El-Baz, M., Abd El-Hameed, M.A., Abdel-Latif, M., Ghoneim, M.A., 2004. Lymph node
involvement in patients with bladder cancer treated with radical cystectomy: a patho-
anatomical study--a single center experience. J. Urol. 172, 1818–1821.
Advanced Bladder Cancer (ABC) Meta-analysis Collaboration, 2005. Neoadjuvant chemotherapy in
invasive bladder cancer: update of a systematic review and meta-analysis of individual patient
data advanced bladder cancer (ABC) meta-analysis collaboration. Eur. Urol. 48, 202–205;
discussion 205-206. https://doi.org/10.1016/j.eururo.2005.04.006
Advanced Bladder Cancer Meta-analysis Collaboration, 2003. Neoadjuvant chemotherapy in invasive
bladder cancer: a systematic review and meta-analysis. Lancet Lond. Engl. 361, 1927–1934.
Ahlering, T.E., Weinberg, A.C., Razor, B., 1989. A Comparative Study of the Ileal Conduit, Kock Pouch
and Modified Indiana Pouch. J. Urol. 142, 1193–1196. https://doi.org/10.1016/S0022-
5347(17)39026-2
Antoni, S., Ferlay, J., Soerjomataram, I., Znaor, A., Jemal, A., Bray, F., 2017. Bladder Cancer Incidence
and Mortality: A Global Overview and Recent Trends. Eur. Urol. 71, 96–108.
https://doi.org/10.1016/j.eururo.2016.06.010
Au, J.L., Badalament, R.A., Wientjes, M.G., Young, D.C., Warner, J.A., Venema, P.L., Pollifrone, D.L.,
Harbrecht, J.D., Chin, J.L., Lerner, S.P., Miles, B.J., International Mitomycin C Consortium,
2001. Methods to improve efficacy of intravesical mitomycin C: results of a randomized phase
III trial. J. Natl. Cancer Inst. 93, 597–604.
Avulova, S., Chang, S.S., 2018. Role and Indications of Organ-Sparing “Radical” Cystectomy. Urol. Clin.
North Am. 45, 199–214. https://doi.org/10.1016/j.ucl.2017.12.005
Babjuk, M., Burger, M., Comperat, E., Gontero, P., Mostafid, A.H., Palou, J., van Rhijin, B.W.G., Roupret,
M., Shariat, S.F., Sylvester, R., Zigeuner, R., Capoun, O., Cohen, D., Hernandez, V., V. Soukup,
2018. EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Cis), in: European
Association of Urology Guidelined Compilations. EAU Guidelines Office, Arnhem, The
Netherlands.
Baltacı, S., Bozlu, M., Yıldırım, A., Gökçe, M.İ., Tinay, İ., Aslan, G., Can, C., Türkeri, L., Kuyumcuoğlu, U.,
Mungan, A., 2015. Significance of the interval between first and second transurethral
resection on recurrence and progression rates in patients with high-risk non-muscle-invasive
bladder cancer treated with maintenance intravesical Bacillus Calmette-Guérin. BJU Int. 116,
721–726. https://doi.org/10.1111/bju.13102
Bayoumi, Y., Heikal, T., Darweish, H., 2014. Survival benefit of adjuvant radiotherapy in stage III and
IV bladder cancer: results of 170 patients. Cancer Manag. Res. 6, 459–465.
https://doi.org/10.2147/CMAR.S69055
Bishr, M., Lattouf, J.-B., Latour, M., Saad, F., 2014. Tumour stage on re-staging transurethral resection
predicts recurrence and progression-free survival of patients with high-risk non-muscle
invasive bladder cancer. Can. Urol. Assoc. J. 8, E306–E310. https://doi.org/10.5489/cuaj.1514
Böhle, A., Bock, P.R., 2004. Intravesical bacille Calmette-Guérin versus mitomycin C in superficial
bladder cancer: formal meta-analysis of comparative studies on tumor progression. Urology
63, 682–686; discussion 686-687. https://doi.org/10.1016/j.urology.2003.11.049
Brausi, M., Collette, L., Kurth, K., van der Meijden, A.P., Oosterlinck, W., Witjes, J.A., Newling, D.,
Bouffioux, C., Sylvester, R.J., EORTC Genito-Urinary Tract Cancer Collaborative Group, 2002.
Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1
transitional cell carcinoma of the bladder: a combined analysis of seven EORTC studies. Eur.
Urol. 41, 523–531.
26
Bruins, H.M., Aben, K.K.H., Arends, T.J., van der Heijden, A.G., Witjes, A.J., 2016. The effect of the time
interval between diagnosis of muscle-invasive bladder cancer and radical cystectomy on
staging and survival: A Netherlands Cancer Registry analysis. Urol. Oncol. 34, 166.e1–6.
https://doi.org/10.1016/j.urolonc.2015.11.006
Carroll, S.J., Nodit, L., 2013. Spindle Cell Rhabdomyosarcoma: A Brief Diagnostic Review and
Differential Diagnosis. Arch. Pathol. Lab. Med. 137, 1155–1158.
https://doi.org/10.5858/arpa.2012-0465-RS
Chang, S.S., Hassan, J.M., Cookson, M.S., Wells, N., Smith, J.A., 2003. Delaying radical cystectomy for
muscle invasive bladder cancer results in worse pathological stage. J. Urol. 170, 1085–1087.
https://doi.org/10.1097/01.ju.0000086828.26001.ca
Chou, R., Selph, S., Buckley, D.I., Fu, R., Griffin, J.C., Grusing, S., Gore, J.L., 2017. Comparative
Effectiveness of Fluorescent Versus White Light Cystoscopy for Initial Diagnosis or Surveillance
of Bladder Cancer on Clinical Outcomes: Systematic Review and Meta-Analysis. J. Urol. 197,
548–558. https://doi.org/10.1016/j.juro.2016.10.061
Colombo, R., Naspro, R., 2010. Ileal Conduit as the Standard for Urinary Diversion After Radical
Cystectomy for Bladder Cancer. Eur. Urol. Suppl. 9, 736–744.
https://doi.org/10.1016/j.eursup.2010.09.001
Crivelli, J.J., Xylinas, E., Kluth, L.A., Rieken, M., Rink, M., Shariat, S.F., 2014. Effect of smoking on
outcomes of urothelial carcinoma: a systematic review of the literature. Eur. Urol. 65, 742–
754. https://doi.org/10.1016/j.eururo.2013.06.010
Dahl, D.M., 2016. Use of Intestinal Segments in Urinary Diversion, in: Campbell-Walsh Urology.
Elsevier, Inc., Philadelphia, p. 2281.
Dahm, P., Gschwend, J.E., 2003. Malignant Non-Urothelial Neoplasms of the Urinary Bladder: A
Review. Eur. Urol. 44, 672–681. https://doi.org/10.1016/S0302-2838(03)00416-0
Dalbagni, G., Vora, K., Kaag, M., Cronin, A., Bochner, B., Donat, S.M., Herr, H.W., 2009. Clinical outcome
in a contemporary series of restaged patients with clinical T1 bladder cancer. Eur. Urol. 56,
903–910. https://doi.org/10.1016/j.eururo.2009.07.005
DeCastro, G.., McKiernan, J.M., Benson, M.C., 2016. Cutaneous Continent Urinary Diversion, in:
Campbell-Walsh Urology. Elsevier, Inc., Philadelphia, pp. 2216–2223.
Divrik, R.T., Yildirim, U., Zorlu, F., Ozen, H., 2006. The effect of repeat transurethral resection on
recurrence and progression rates in patients with T1 tumors of the bladder who received
intravesical mitomycin: a prospective, randomized clinical trial. J. Urol. 175, 1641–1644.
https://doi.org/10.1016/S0022-5347(05)01002-5
Dorin, R.P., Daneshmand, S., Eisenberg, M.S., Chandrasoma, S., Cai, J., Miranda, G., Nichols, P.W.,
Skinner, D.G., Skinner, E.C., 2011. Lymph Node Dissection Technique Is More Important Than
Lymph Node Count in Identifying Nodal Metastases in Radical Cystectomy Patients: A
Comparative Mapping Study. Eur. Urol. 60, 946–952.
Epstein, J.., Lotan, T.L., 2015. The Lower Urinary Tract and Male Genital System, in: Robbins & Cotran
Pathologic Basic of Disease. Elsevier Saunders, Philadelphia, pp. 964–966.
Fernandez-Gomez, J., Madero, R., Solsona, E., Unda, M., Martinez-Piñeiro, L., Gonzalez, M., Portillo,
J., Ojea, A., Pertusa, C., Rodriguez-Molina, J., Camacho, J.E., Rabadan, M., Astobieta, A.,
Montesinos, M., Isorna, S., Muntañola, P., Gimeno, A., Blas, M., Martinez-Piñeiro, J.A., 2009.
Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated
with bacillus Calmette-Guerin: the CUETO scoring model. J. Urol. 182, 2195–2203.
https://doi.org/10.1016/j.juro.2009.07.016
Fosså, S.D., Ous, S., Berner, A., 1991. Clinical significance of the “palpable mass” in patients with
muscle-infiltrating bladder cancer undergoing cystectomy after pre-operative radiotherapy.
Br. J. Urol. 67, 54–60.
Goessl, C., Knispel, H.H., Miller, K., Klän, R., 1997. Is routine excretory urography necessary at first
diagnosis of bladder cancer? J. Urol. 157, 480–481.
27
Gontero, P., Sylvester, R., Pisano, F., Joniau, S., Oderda, M., Serretta, V., Larré, S., Di Stasi, S., Van Rhijn,
B., Witjes, A.J., Grotenhuis, A.J., Colombo, R., Briganti, A., Babjuk, M., Soukup, V., Malmström,
P.-U., Irani, J., Malats, N., Baniel, J., Mano, R., Cai, T., Cha, E.K., Ardelt, P., Vakarakis, J.,
Bartoletti, R., Dalbagni, G., Shariat, S.F., Xylinas, E., Karnes, R.J., Palou, J., 2016. The impact of
re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with
T1 high-grade/Grade 3 bladder cancer treated with bacille Calmette-Guérin. BJU Int. 118, 44–
52. https://doi.org/10.1111/bju.13354
Gore, J.L., Lai, J., Setodji, C.M., Litwin, M.S., Saigal, C.S., 2009. MORTALITY INCREASES WHEN RADICAL
CYSTECTOMY IS DELAYED MORE THAN 12 WEEKS: RESULTS FROM A SEER-MEDICARE
ANALYSIS. Cancer 115, 988–996. https://doi.org/10.1002/cncr.24052
Grimm, M.-O., Steinhoff, C., Simon, X., Spiegelhalder, P., Ackermann, R., Vogeli, T.A., 2003. Effect of
routine repeat transurethral resection for superficial bladder cancer: a long-term
observational study. J. Urol. 170, 433–437.
https://doi.org/10.1097/01.ju.0000070437.14275.e0
Grotenhuis, A.J., Ebben, C.W., Aben, K.K., Witjes, J.A., Vrieling, A., Vermeulen, S.H., Kiemeney, L.A.,
2015. The effect of smoking and timing of smoking cessation on clinical outcome in non-
muscle-invasive bladder cancer. Urol. Oncol. 33, 65.e9–17.
Han, R.F., Pan, J.G., 2006. Can intravesical bacillus Calmette-Guérin reduce recurrence in patients with
superficial bladder cancer? A meta-analysis of randomized trials. Urology 67, 1216–1223.
https://doi.org/10.1016/j.urology.2005.12.014
Hilton, S., Jones, L.P., 2014. Recent advances in imaging cancer of the kidney and urinary tract. Surg.
Oncol. Clin. N. Am. 23, 863–910. https://doi.org/10.1016/j.soc.2014.06.001
Hong, J.-H., Lin, Y.-H., Lu, Y.-C., Chiang, Y., Tai, H.-C., Huang, K.-H., Cheng, C.-H., Pu, Y.-S., 2017.
Comparative analysis between radical cystectomy and trimodality therapy for clinical stage II
bladder cancer – Experience from a tertiary referral center. Urol. Sci.
https://doi.org/10.1016/j.urols.2017.07.005
Hurle, R., Lazzeri, M., Colombo, P., Buffi, N., Morenghi, E., Peschechera, R., Castaldo, L., Pasini, L.,
Casale, P., Seveso, M., Zandegiacomo, S., Taverna, G., Benetti, A., Lughezzani, G., Fiorini, G.,
Guazzoni, G., 2016. “En Bloc” Resection of Nonmuscle Invasive Bladder Cancer: A Prospective
Single-center Study. Urology 90, 126–130. https://doi.org/10.1016/j.urology.2016.01.004
Kramer, M.W., Altieri, V., Hurle, R., Lusuardi, L., Merseburger, A.S., Rassweiler, J., Struck, J.P.,
Herrmann, T.R.W., 2017. Current Evidence of Transurethral En-bloc Resection of Nonmuscle
Invasive Bladder Cancer. Eur. Urol. Focus. https://doi.org/10.1016/j.euf.2016.12.004
Kramer, M.W., Rassweiler, J.J., Klein, J., Martov, A., Baykov, N., Lusuardi, L., Janetschek, G., Hurle, R.,
Wolters, M., Abbas, M., von Klot, C.A., Leitenberger, A., Riedl, M., Nagele, U., Merseburger,
A.S., Kuczyk, M.A., Babjuk, M., Herrmann, T.R.W., 2015. En bloc resection of urothelium
carcinoma of the bladder (EBRUC): a European multicenter study to compare safety, efficacy,
and outcome of laser and electrical en bloc transurethral resection of bladder tumor. World
J. Urol. 33, 1937–1943. https://doi.org/10.1007/s00345-015-1568-6
Leissner, J., Ghoneim, M.A., Abol-Enein, H., Thüroff, J.W., Franzaring, L., Fisch, M., Schulze, H.,
Managadze, G., Allhoff, E.P., el-Baz, M.A., Kastendieck, H., Buhtz, P., Kropf, S., Hohenfellner,
R., Wolf, H.K., 2004. Extended radical lymphadenectomy in patients with urothelial bladder
cancer: results of a prospective multicenter study. J. Urol. 171, 139–144.
https://doi.org/10.1097/01.ju.0000102302.26806.fb
Moch, H., Cubilla, A.L., Humphrey, P.A., Reuter, V.E., Ulbright, T.M., 2016. The 2016 WHO Classification
of Tumours of the Urinary System and Male Genital Organs-Part A: Renal, Penile, and
Testicular Tumours. Eur. Urol. 70, 93–105. https://doi.org/10.1016/j.eururo.2016.02.029
Moon, A., Vasdev, N., Thorpe, A.C., 2013. Continent Urinary Diversion. Indian J. Urol. IJU J. Urol. Soc.
India 29, 303–309. https://doi.org/10.4103/0970-1591.120111
28
Mungan, M.U., Canda, A.E., Tuzel, E., Yorukoglu, K., Kirkali, Z., 2005. Risk factors for mucosal prostatic
urethral involvement in superficial transitional cell carcinoma of the bladder. Eur. Urol. 48,
760–763. https://doi.org/10.1016/j.eururo.2005.05.021
Nabi, G., Greene, D., O’Donnell, M.O., Donnel, M.O., 2004. Suspicious urinary cytology with negative
evaluation for malignancy in the diagnostic investigation of haematuria: how to follow up? J.
Clin. Pathol. 57, 365–368.
Oosterlinck, W., Kurth, K.H., Schröder, F., Bultinck, J., Hammond, B., Sylvester, R., 1993. A prospective
European Organization for Research and Treatment of Cancer Genitourinary Group
randomized trial comparing transurethral resection followed by a single intravesical
instillation of epirubicin or water in single stage Ta, T1 papillary carcinoma of the bladder. J.
Urol. 149, 749–752.
Palou, J., Sylvester, R.J., Faba, O.R., Parada, R., Peña, J.A., Algaba, F., Villavicencio, H., 2012. Female
gender and carcinoma in situ in the prostatic urethra are prognostic factors for recurrence,
progression, and disease-specific mortality in T1G3 bladder cancer patients treated with
bacillus Calmette-Guérin. Eur. Urol. 62, 118–125.
Perlis, N., Zlotta, A.R., Beyene, J., Finelli, A., Fleshner, N.E., Kulkarni, G.S., 2013. Immediate post-
transurethral resection of bladder tumor intravesical chemotherapy prevents non-muscle-
invasive bladder cancer recurrences: an updated meta-analysis on 2548 patients and quality-
of-evidence review. Eur. Urol. 64, 421–430. https://doi.org/10.1016/j.eururo.2013.06.009
Ploussard, G., Daneshmand, S., Efstathiou, J.A., Herr, H.W., James, N.D., Rödel, C.M., Shariat, S.F.,
Shipley, W.U., Sternberg, C.N., Thalmann, G.N., Kassouf, W., 2014. Critical analysis of bladder
sparing with trimodal therapy in muscle-invasive bladder cancer: a systematic review. Eur.
Urol. 66, 120–137. https://doi.org/10.1016/j.eururo.2014.02.038
Richterstetter, M., Wullich, B., Amann, K., Haeberle, L., Engehausen, D.G., Goebell, P.J., Krause, F.S.,
2012. The value of extended transurethral resection of bladder tumour (TURBT) in the
treatment of bladder cancer. BJU Int. 110, E76-79. https://doi.org/10.1111/j.1464-
410X.2011.10904.x
Rink, M., Xylinas, E., Babjuk, M., Hansen, J., Pycha, A., Comploj, E., Lotan, Y., Sun, M., Karakiewicz, P.I.,
Abdennabi, J., Fajkovic, H., Loidl, W., Chun, F.K., Fisch, M., Scherr, D.S., Shariat, S.F., 2012.
Impact of smoking on outcomes of patients with a history of recurrent nonmuscle invasive
bladder cancer. J. Urol. 188, 2120–2127. https://doi.org/10.1016/j.juro.2012.08.029
Shelley, M.D., Kynaston, H., Court, J., Wilt, T.J., Coles, B., Burgon, K., Mason, M.D., 2001. A systematic
review of intravesical bacillus Calmette-Guérin plus transurethral resection vs transurethral
resection alone in Ta and T1 bladder cancer. BJU Int. 88, 209–216.
Shelley, M.D., Wilt, T.J., Court, J., Coles, B., Kynaston, H., Mason, M.D., 2004. Intravesical bacillus
Calmette-Guérin is superior to mitomycin C in reducing tumour recurrence in high-risk
superficial bladder cancer: a meta-analysis of randomized trials. BJU Int. 93, 485–490.
Skinner, E.C., Daneshmand, S., 2016. Orthotopic Urinary Diversion, in: Campbell-Walsh Urology.
Elsevier, Inc., Philadelphia, pp. 2244–2252.
Soloway, M.S., Masters, S., 1980. Urothelial susceptibility to tumor cell implantation: influence of
cauterization. Cancer 46, 1158–1163.
Spiess, P.E., Agarwal, N., Bangs, R., Boorjian, S.A., Buyyounouski, M.K., Clark, P.E., Downs, T.M.,
Efstathiou, J.A., Flaig, T.W., Friedlander, T., Greenberg, R.E., Guru, K.A., Hahn, N., Herr, H.W.,
Hoimes, C., Inman, B.A., Jimbo, M., Kader, A.K., Lele, S.M., Meeks, J.J., Michalski, J.,
Montgomery, J.S., Pagliaro, L.C., Pal, S.K., Patterson, A., Plimack, E.R., Pohar, K.S., Porter, M.P.,
Preston, M.A., Sexton, W.J., Siefker-Radtke, A.O., Sonpavde, G., Tward, J., Wile, G., Dwyer,
M.A., Gurski, L.A., 2017. Bladder Cancer, Version 5.2017, NCCN Clinical Practice Guidelines in
Oncology. J. Natl. Compr. Canc. Netw. 15, 1240–1267.
https://doi.org/10.6004/jnccn.2017.0156
29
Stein, J.P., 2007. The role of lymphadenectomy in patients undergoing radical cystectomy for bladder
cancer. Curr. Oncol. Rep. 9, 213–221.
Stein, J.P., Lieskovsky, G., Cote, R., Groshen, S., Feng, A.C., Boyd, S., Skinner, E., Bochner, B.,
Thangathurai, D., Mikhail, M., Raghavan, D., Skinner, D.G., 2001. Radical cystectomy in the
treatment of invasive bladder cancer: long-term results in 1,054 patients. J. Clin. Oncol. Off. J.
Am. Soc. Clin. Oncol. 19, 666–675. https://doi.org/10.1200/JCO.2001.19.3.666
Stenzl, A., Nagele, U., Kuczyk, M., Sievert, K.-D., Anastasiadis, A., Seibold, J., Corvin, S., 2005.
Cystectomy – Technical Considerations in Male and Female Patients. EAU Update Ser. 3, 138–
146. https://doi.org/10.1016/j.euus.2005.07.004
Sylvester, R.J., Oosterlinck, W., Holmang, S., Sydes, M.R., Birtle, A., Gudjonsson, S., De Nunzio, C.,
Okamura, K., Kaasinen, E., Solsona, E., Ali-El-Dein, B., Tatar, C.A., Inman, B.A., N’Dow, J.,
Oddens, J.R., Babjuk, M., 2016. Systematic Review and Individual Patient Data Meta-analysis
of Randomized Trials Comparing a Single Immediate Instillation of Chemotherapy After
Transurethral Resection with Transurethral Resection Alone in Patients with Stage pTa-pT1
Urothelial Carcinoma of the Bladder: Which Patients Benefit from the Instillation? Eur. Urol.
69, 231–244. https://doi.org/10.1016/j.eururo.2015.05.050
Sylvester, R.J., Oosterlinck, W., van der Meijden, A.P.M., 2004. A single immediate postoperative
instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1
bladder cancer: a meta-analysis of published results of randomized clinical trials. J. Urol. 171,
2186–2190, quiz 2435.
Sylvester, R.J., van der MEIJDEN, A.P.M., Lamm, D.L., 2002. Intravesical bacillus Calmette-Guerin
reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of
the published results of randomized clinical trials. J. Urol. 168, 1964–1970.
https://doi.org/10.1097/01.ju.0000034450.80198.1c
Têtu, B., 2009. Diagnosis of urothelial carcinoma from urine. Mod. Pathol. Off. J. U. S. Can. Acad.
Pathol. Inc 22 Suppl 2, S53-59. https://doi.org/10.1038/modpathol.2008.193
Umbas, R., Hardjowijoto, S., Mochtar, C.A., Safriadi, F., Djatisoesanto, W., Oka, A.A.G., Penta, K.,
Sihombing, A.T., Warli, S.M., 2014. PANDUAN PENANGANAN KANKER KANDUNG KEMIH TIPE
UROTELIAL. Ikatan Ahli Urologi Indonesia, Jakarta.
van Rhijn, B.W.G., van der Kwast, T.H., Alkhateeb, S.S., Fleshner, N.E., van Leenders, G.J.L.H., Bostrom,
P.J., van der Aa, M.N.M., Kakiashvili, D.M., Bangma, C.H., Jewett, M.A.S., Zlotta, A.R., 2012. A
new and highly prognostic system to discern T1 bladder cancer substage. Eur. Urol. 61, 378–
384. https://doi.org/10.1016/j.eururo.2011.10.026
Witjes, J.A., Bruins, M., Compérat, E., Cowan, N.C., Gakis, G., Hernández, V., Lebret, T., Lorch, A., Ribal,
M.J., van der Heijden, A.G., Veskimäe, E., Espinós, E.L., Rouanne, M., Neuzillet, Y., 2018. EAU
Guidelines Muscle-invasive and Metastatic Bladder Cancer, in: European Association of
Urology Guidelined Compilations. EAU Guidelines Office, Arnhem, The Netherlands.
Yafi, F.A., Brimo, F., Steinberg, J., Aprikian, A.G., Tanguay, S., Kassouf, W., 2015. Prospective analysis
of sensitivity and specificity of urinary cytology and other urinary biomarkers for bladder
cancer. Urol. Oncol. 33, 66.e25–31. https://doi.org/10.1016/j.urolonc.2014.06.008
Zlotta, A.R., 2012. Limited, Extended, Superextended, Megaextended Pelvic Lymph Node Dissection
at the Time of Radical Cystectomy: What Should We Perform? Eur. Urol. 61, 243–244.
30
Squamous Cell Ca
2-5%
Epithelial Adenocarcinoma
(90%) 0.5-2%
Small Cell Ca
<1%
Keganasan Non-Urothelial
Buli (< 5%) Sarcoma
Lymphoma
Non-Epithelial
Paraganglioma
Melanoma
31
Squamous Cell Carcinoma of
the Urinary Bladder
Keganasan Non-Urothelial Epithelial Squamous Cell Ca
Buli (< 5%) (90%) 2-5%
Squamous Cell Ca
Bilharzial- Non-bilharzial-
associated SCC associated SCC
(B-SCC) (NB-SCC)
Epidemiologi
B-SCC NB-SCC
Negara-negara endemis schistosomiasis: Negara-Negara Barat

-Timur Tengah
- Asia Tenggara
- Amerika Selatan
% Keganasan Di negara-negara endemis 20-30% 2-5%

Buli (tahun 1990an >60%)
♂:♀ (5 : 1) (3 : 2)
Usia terdiagnosis 50an 70an
sumber: (Abol-Enein et al., 2007; Dahm and Gschwend, 2003; Mar n et al., 2016; Rausch et al., 2014,
2012; Siegel et al., 2016)
32
Etiologi dan Faktor Resiko
E ologi dan
Faktor resiko
Bilharzial- Non-bilharzial-
associated SCC associated SCC
(B-SCC) (NB-SCC)
Schistosomiasis
Infeksi virus dan bakteri yang

Spinal Cord Injury
berkaitan dengan schistosomiasis
(Escherichia coli, Proteus,
dan Streptococcus faecalis)
Infeksi Saluran Kemih (ISK) kronik

Neurogenic Bladder Dysfunction
Merokok
Chronic Indwelling catheter ≥ 10 years
Bladder
Kekurangan vitamin A Irrita on
Bladder Outlet Obstruc on (BOO)
virus bakteri Urinary Stasis, Bladder Stone
Merokok
Intravesika BCG
Eksposur siklofosfamid
Kekurangan vitamin A
t
Oba
Perjalanan dari faktor-faktor resiko diatas menjadi keganasan
- Growth Factor >>

- - Iritasi Kronis
Iritasi Buli Kronis - Sitokin-sitokin>> Metaplasia Squamous,
Metaplasia
- Growth Factor >>
- - Inflamasi Kronis
Inflamasi Kronis Proliferasi sel Displasia
squamous,dan
Displasia
- Sitokin-sitokin
Migrasi sel >> Metastasis
dan Kanker
- ISK
- ISK • Proliferasi sel
Angiogenesis
• Migrasi sel
Inhibisi Apoptosis
• Angiogenesis
• Inhibisi Apoptosis
sumber: (Hicks et al., 1982; Locke et al., 1985; Mar n et al., 2016; Navon et al., 1997; Pannek, 2002;
Rausch et al., 2014; Stein et al., 1993)
33
Tanda dan Gejala
- Painless gross haematuria
- Fecaluria (jarang)
Irritative LUTS
- disuria
- frekuensi bertambah
- urgensi
- inkontinensia
- Nyeri di pelvis/nyeri tulang; edema tungkai bawah,

nyeri pinggang, hidronefrosis pada penyakit
lanjut/advanced disease
- Massa terpalpasi saat pemeriksaan fisik (jarang
pada kanker superfisial)
- Berat badan turun
Sering berbarengan dengan sistitis kronis dan ISK

berulang
sumber: (Johnson et al., 1976; López et al., 1994, p.; Mar n et al., 2016; Rundle et al., 1982; Shokeir,
2004)
34
Investigasi
Sistoskopi + Biopsi
- melihat massa tunggal, besar, meluas, berkaitan dengan
leukoplakia
- dapat muncul di berbagai area, NB-SCC paling sering di
area trigonum
- sitologi Urin, mencari sel kanker dalam urin

- infeksi kronis schistosomiasis dapat ditemukan telur dan
bangkai cacing
- marker : representasi material molekular berlebih dari 5p, 6p,
7p, 8q, 11q, 17q,
dan 20q; p53 (+), mutasi Tp53, mutasi HRAS, ekspresi
berlebih EGFR dan ekspresi HER2
- deteksi awal dengan marker Galectin 3 dan Forkhead box
protein P3 (Foxp3)
- Ekspresi berlebih fibroblast growth factor 2 (FGF-2)
berhubungan dengan agresivitas kanker
USG:
- menilai obstruksi di traktus urinarius dan buli
- menilai hidronefrosis
- melihat massa di buli
- CT-Urografi menilai kalsifikasi di dinding buli, inflamasi dan

infeksi kronis pada buli dan ureter, serta adanya hidronefrosis
- Ct scan/ CT-PET dan MRI dengan kontras digunakan
apabila ditemukan MIBC pada hasil TUR-BT dan untuk
menilai perluasan tumor, keterlibatan LN dan adanya
metastasis
- NB-SCC jarang menginvasi vasa darah dan limfatik dan
jarang metastasi ke kelenjar getah bening
sumber: (Abdulamir et al., 2009; Aly and Khaled, 2002; El-Rifai et al., 2000; Gonzalez-Zulueta et al.,
1995; Guo et al., 2009; Habuchi et al., 1993; Mar n et al., 2016; Muscheck et al., 2000;
Przybojewska et al., 2000; Pycha et al., 1999; Rabbani and Cordon-Cardo, 2000; Ramchurren et al.,
1995; Shaw et al., 1999; Shokeir, 2004; Warren et al., 1995)
35
Patologi dan Faktor Prognostik
Schistosoma sp
telur Schistosoma
kalsifikasi
sel kanker
leukoplakia
urotelium
lamina propria
otot detrusor
- 60% tumor NB-SCC ditemukan saat staging T3, sekitar 2% saat T1.
- Tumor NB-SCC dan B-SCC meluas secara lokal. Pada NB-SCC diferensiasi sel
sedang-jelek, sedang B-SC diferensiasi sel baik
- 90% mortalitas karena rekurensi lokal pelvis, di anastomosis buli dengan uretra/uteter
- jarang metastasis jauh, insidensi 8-10% pada NB-SCC
Faktor-faktor Prognostik
keterlibatan kelenjar getah bening, staging dan grading saat terdiagnosis, fungsi ginjal
merupakan faktor prognostik independen
p53
Fibroblast Growth
Factor/FGF-2 Bax
5 Biomarker
Prognos k Epidermal Growth
Cyclooxygenase(COX)-2
menggambarkan Factor
luaran SCC
sumber: (Abol-Enein et al., 2007; Kassouf et al., 2007; Mar n et al., 2016; Rausch et al., 2014; Shokeir,
2004)
36
Manajemen SCC
1. Radical Cystectomy - RC dengan limfadenektomi merupakan baku emas penanganan
(RC) SCC Buli
- Rekurensi lokas post-RC masih sering terjadi
- Angka kesintasan 5 tahun pasien B-SCC sekitar 50.3%, untuk yang
mengenai kelenjar getah bening, berkisar 18-23%, dan yang tidak
mengenai kelenjar getah bening berkisar 35-53%
- Angka kesintasan 5 tahun pasien NB-SCC sekitar 48%
RIP
2. Terapi Radiasi - Pada NB-SCC radioterapi neoadjuvan + RC meningkatan Disease-

free Survival (DFS) 5 tahun, 40% banding 20% jika hanya diterapi
radiasi
- Pada B-SCC radioterapi adjuvan + RC meningkatkan DFS menjadi
40% dibanding 29% untuk yang tidak diberikan radioterapi adjuvan
3. Kemoterapi - Berbeda dengan TCC yang kemosensitif, SCC dikenal sebagai

penyakit yang kemo-resisten
- MVAC tidak efektif pada pasien non-TCC
- Keefektivitas penggunaan kemoterapi neoadjuvan atau adjuvan
masih perlu di evaluasi ulang
4. kontrol bilharziasis - Menurunkan prevalensi schistosomiasis

di daerah endemis - Mengontrol populasi siput, terapi massal di wilayah endemis
dengan praziquantel 40mg/kg
- Di Kairo, frekuensi relatif kanker buli turun dari 30% pada tahun
1975-1994 menjadi 10% pada tahun 1998-2002
5. Partial Cystectomy - Hanya pada keadaan tertentu: tumor tidak ditrigonum, tunggal,
reseksi dapat dilakukan sampai batas aman, tidak terdapat lesi pre-
kanker di sisa area mukosa buli
37
6. Manajemen untuk - Terapi paliatif
stadium lanjut/metastasis - Pasien dengan skor performa baik dapat diberikan kemoterapi
sistemik
sumber: (Abdel Raheem et al., 2011; Abol-Enein et al., 2007, 2007; Dahm and Gschwend, 2003;
Felix et al., 2008; Ghoneim et al., 1997; Higano et al., 2008; Kramer et al., 2014; Mar n et al., 2016;
Rausch et al., 2014; Richie et al., 1976; Shokeir, 2004; Sternberg et al., 1988)
38
DAFTAR PUSTAKA
Abdel Raheem, A.M., Hameed, D.A., ElGanainy, E.O., Mosad, E., Abdelwanis, M.E., Kamel, N.A.,
Hammouda, H.M., Abdelaziz, M.A., Hemeyda, K., 2011. Can Bcl-XL expression predict the radio
sensitivity of bilharzial-related squamous bladder carcinoma? A prospective comparative
study. BMC Cancer 11, 16. https://doi.org/10.1186/1471-2407-11-16
Abdulamir, A.S., Hafidh, R.R., Kadhim, H.S., Abubakar, F., 2009. Tumor markers of bladder cancer: the
schistosomal bladder tumors versus non-schistosomal bladder tumors. J. Exp. Clin. Cancer Res.
CR 28, 27. https://doi.org/10.1186/1756-9966-28-27
Abol-Enein, H., Kava, B.R., Carmack, A.J.K., 2007. Nonurothelial cancer of the bladder. Urology 69, 93–
104. https://doi.org/10.1016/j.urology.2006.08.1107
Aly, M.S., Khaled, H.M., 2002. Chromosomal aberrations in early-stage bilharzial bladder cancer.
Cancer Genet. Cytogenet. 132, 41–45. https://doi.org/10.1016/S0165-4608(01)00527-1
El-Rifai, W., Kamel, D., Larramendy, M.L., Shoman, S., Gad, Y., Baithun, S., El-Awady, M., Eissa, S.,
Khaled, H., Soloneski, S., Sheaff, M., Knuutila, S., 2000. DNA Copy Number Changes in
Schistosoma-Associated and Non-Schistosoma-Associated Bladder Cancer. Am. J. Pathol. 156,
871–878.
Felix, A.S., Soliman, A.S., Khaled, H., Zaghloul, M.S., Banerjee, M., El-Baradie, M., El-Kalawy, M., Abd-
Elsayed, A.A., Ismail, K., Hablas, A., Seifeldin, I.A., Ramadan, M., Wilson, M.L., 2008. The
changing patterns of bladder cancer in Egypt over the past 26 years. Cancer Causes Control
CCC 19, 421–429. https://doi.org/10.1007/s10552-007-9104-7
Ghoneim, M.A., el-Mekresh, M.M., el-Baz, M.A., el-Attar, I.A., Ashamallah, A., 1997. Radical
cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases. J.
Urol. 158, 393–399.
Gonzalez-Zulueta, M., Shibata, A., Ohneseit, P.F., Spruck, C.H., Busch, C., Shamaa, M., El-Baz, M.,
Nichols, P.W., Gonzalgo, M.L., Elbaz M [corrected to El-Baz, M., 1995. High frequency of
chromosome 9p allelic loss and CDKN2 tumor suppressor gene alterations in squamous cell
carcinoma of the bladder. J. Natl. Cancer Inst. 87, 1383–1393.
Guo, C.C., Gomez, E., Tamboli, P., Bondaruk, J.E., Kamat, A., Bassett, R., Dinney, C.P., Czerniak, B.A.,
2009. Squamous cell carcinoma of the urinary bladder: a clinicopathologic and
immunohistochemical study of 16 cases. Hum. Pathol. 40, 1448–1452.
https://doi.org/10.1016/j.humpath.2009.03.005
Habuchi, T., Takahashi, R., Yamada, H., Ogawa, O., Kakehi, Y., Ogura, K., Hamazaki, S., Toguchida, J.,
Ishizaki, K., Fujita, J., Sugiyama, T., Yoshida, O., 1993. Influence of Cigarette Smoking and
Schistosomiasis on p53 Gene Mutation in Urothelial Cancer. Cancer Res. 53, 3795–3799.
Hicks, R.M., Ismail, M.M., Walters, C.L., Beecham, P.T., Rabie, M.F., El Alamy, M.A., 1982. Association
of bacteriuria and urinary nitrosamine formation with Schistosoma haematobium infection in
the Qalyub area of Egypt. Trans. R. Soc. Trop. Med. Hyg. 76, 519–527.
Higano, C.S., Tangen, C.M., Sakr, W.A., Faulkner, J., Rivkin, S.E., Meyers, F.J., Hussain, M., Baker, L.H.,
Russell, K.J., Crawford, E.D., Southwest Oncology Group Trial 8733, 2008. Treatment options
for muscle-invasive urothelial cancer for patients who were not eligible for cystectomy or
neoadjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin: report
of Southwest Oncology Group Trial 8733. Cancer 112, 2181–2187.
https://doi.org/10.1002/cncr.23420
Johnson, D.E., Schoenwald, M.B., Ayala, A.G., Miller, L.S., 1976. Squamous cell carcinoma of the
bladder. J. Urol. 115, 542–544.
Kassouf, W., Spiess, P.E., Siefker-Radtke, A., Swanson, D., Grossman, H.B., Kamat, A.M., Munsell, M.F.,
Guo, C.C., Czerniak, B.A., Dinney, C.P., 2007. Outcome and patterns of recurrence of
nonbilharzial pure squamous cell carcinoma of the bladder: a contemporary review of The
39
University of Texas M D Anderson Cancer Center experience. Cancer 110, 764–769.
Kramer, C.V., Zhang, F., Sinclair, D., Olliaro, P.L., 2014. Drugs for treating urinary schistosomiasis, in:
The Cochrane Library. John Wiley & Sons, Ltd.
https://doi.org/10.1002/14651858.CD000053.pub3
Locke, J.R., Hill, D.E., Walzer, Y., 1985. Incidence of squamous cell carcinoma in patients with long-
term catheter drainage. J. Urol. 133, 1034–1035.
López, J.I., Angulo Cuesta, J., Flores Corral, N., Toledo, J.D., 1994. [Squamous cell carcinoma of the
urinary bladder. Clinico-pathologic study of 7 cases]. Arch. Esp. Urol. 47, 756–760.
Martin, J.W., Carballido, E.M., Ahmed, A., Farhan, B., Dutta, R., Smith, C., Youssef, R.F., 2016.
Squamous cell carcinoma of the urinary bladder: Systematic review of clinical characteristics
and therapeutic approaches. Arab J. Urol. 14, 183–191.
https://doi.org/10.1016/j.aju.2016.07.001
Muscheck, M., Abol-Enein, H., Chew, K., Moore, D., Bhargava, V., Ghoneim, M.A., Carroll, P.R.,
Waldman, F.M., 2000. Comparison of genetic changes in schistosome-related transitional and
squamous bladder cancers using comparative genomic hybridization. Carcinogenesis 21,
1721–1726.
Navon, J.D., Soliman, H., Khonsari, F., Ahlering, T., 1997. Screening cystoscopy and survival of spinal
cord injured patients with squamous cell cancer of the bladder. J. Urol. 157, 2109–2111.
Pannek, J., 2002. Transitional cell carcinoma in patients with spinal cord injury: a high risk malignancy?
Urology 59, 240–244. https://doi.org/10.1016/S0090-4295(01)01495-9
Przybojewska, B., Jagiello, A., Jalmuzna, P., 2000. H-RAS, K-RAS, and N-RAS Gene Activation in Human
Bladder Cancers. Cancer Genet. Cytogenet. 121, 73–77. https://doi.org/10.1016/S0165-
4608(00)00223-5
Pycha, A., Mian, C., Posch, B., Haitel, A., Mokhtar, A.A., El-Baz, M., Ghoneim, M.A., Marberger, M.,
1999. Numerical chromosomal aberrations in muscle invasive squamous cell and transitional
cell cancer of the urinary bladder: an alternative to classic prognostic indicators? Urology 53,
1005–1010. https://doi.org/10.1016/S0090-4295(98)00626-8
Rabbani, F., Cordon-Cardo, C., 2000. Mutation of cell cycle regulators and their impact on superficial
bladder cancer. Urol. Clin. North Am. 27, 83–102, ix.
Ramchurren, N., Cooper, K., Summerhayes, I.C., 1995. Molecular events underlying schistosomiasis-
related bladder cancer. Int. J. Cancer 62, 237–244. https://doi.org/10.1002/ijc.2910620302
Rausch, S., Hofmann, R., von Knobloch, R., 2012. Nonbilharzial squamous cell carcinoma and
transitional cell carcinoma with squamous differentiation of the lower and upper urinary tract.
Urol. Ann. 4, 14–18. https://doi.org/10.4103/0974-7796.91615
Rausch, S., Lotan, Y., Youssef, R.F., 2014. Squamous cell carcinogenesis and squamous cell carcinoma
of the urinary bladder: A contemporary review with focus on nonbilharzial squamous cell
carcinoma. Urol. Oncol. Semin. Orig. Investig. 32, 32.e11-32.e16.
Richie, J.P., Waisman, J., Skinner, D.G., Dretler, S.P., 1976. Squamous carcinoma of the bladder:
treatment by radical cystectomy. J. Urol. 115, 670–672.
Rundle, J.S.H., Hart, A.J.L., McGEORGE, A., Smith, J.S., Malcolm, A.J., Smith, P.M., 1982. Squamous Cell
Carcinoma of Bladder. A Review of 114 Patients. Br. J. Urol. 54, 522–526.
https://doi.org/10.1111/j.1464-410X.1982.tb13580.x
Shaw, M.E., Elder, P.A., Abbas, A., Knowles, M.A., 1999. Partial allelotype of schistosomiasis-associated
bladder cancer. Int. J. Cancer 80, 656–661. https://doi.org/10.1002/(SICI)1097-
0215(19990301)80:5<656::AID-IJC4>3.0.CO;2-A
Shokeir, A.A., 2004. Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment. BJU
Int. 93, 216–220. https://doi.org/10.1111/j.1464-410X.2004.04588.x
Siegel, R.L., Miller, K.D., Jemal, A., 2016. Cancer statistics, 2016. CA. Cancer J. Clin. 66, 7–30.
https://doi.org/10.3322/caac.21332
40
Stein, J.P., Skinner, E.C., Boyd, S.D., Skinner, D.G., 1993. Squamous cell carcinoma of the bladder
associated with cyclophosphamide therapy for Wegener’s granulomatosis: a report of 2 cases.
J. Urol. 149, 588–589.
Sternberg, C.N., Yagoda, A., Scher, H.I., Watson, R.C., Herr, H.W., Morse, M.J., Sogani, P.C., Vaughan,
E.D., Bander, N., Weiselberg, L.R., 1988. M-VAC (methotrexate, vinblastine, doxorubicin and
cisplatin) for advanced transitional cell carcinoma of the urothelium. J. Urol. 139, 461–469.
Warren, W., Biggs, P.J., el-Baz, M., Ghoneim, M.A., Stratton, M.R., Venitt, S., 1995. Mutations in the
p53 gene in schistosomal bladder cancer: a study of 92 tumours from Egyptian patients and a
comparison between mutational spectra from schistosomal and non-schistosomal urothelial
tumours. Carcinogenesis 16, 1181–1189.
41
Adenokarsinoma Buli
Epidemiologi
Urothotelial/ TCC
90-95%
1 Squamous CC
2-5%
2 Adenocarcinoma
0.5-2%
3 Small Cell Ca
<1%
4
Insidensi Kejadian
Sering pada negara-negara endemis schistosomiasis
- Pasien dengan buli ekstrofi memiliki resiko selama

hidup 4% terkena kanker buli adenokarsinoma
- 90% pasien keganasan buli karena ekstrofi bertipe
adenokarsinoma
penis
uretra terekspos
buli terekspos
sumber: (Abol-Enein et al., 2007; Dadhania et al., 2015; Dahm and Gschwend, 2003;
el-Mekresh et al., 1998; Jacobo et al., 1977; Smeulders and Woodhouse, 2001; Wilson et al., 1991)
42
Tipe Adenokarsinoma Buli
kolam mukus
Clear Cell Ca Urachal
Clear Cell Ca
Urachal
Primer/non-urachal Sekunder
Adenokarsinoma
Enterik(kolon,usus)
Kolorektal
Tipe Enterik (kolon)

Bermukus/mucinous
type
Kolorektal
kolam mukus
Prostat
Tipe bermukus/mucinous type
Signet Ring
Endometrial/ Kanker Prostat

Campuran/mixed
Signet Ring Cell cervical cancer
Not Otherwise
Specified
Kanker Cervix
sumber: (Adeniran and Tamboli, 2009; Dadhania et al., 2015; Ford et al., 1985; Gilcrease et al., 1998;
Grignon et al., 1991b, 1991a; Morton et al., 2007; Oliva et al., 2002; Poore et al., 1981; Silver and
Epstein, 1993; Svanholm, 1986)
43
Tanda dan Gejala
- Painless gross haematuria
- Mukosauria (jarang)
- Discharge umbilikus (urachal adenokarsinoma)
- fecaluria (menyebar ke kolon)
Irritative LUTS
- disuria
- frek meningkat
- urgensi
- inkontinensia
- Nyeri di pelvis/nyeri tulang; edema tungkai bawah, nyeri

pinggang supra pubik pada penyakit lanjut/advanced disease
- Massa terpalpasi saat pemeriksaan fisik (jarang pada
kanker superfisial)
- Berasosiasi dengan endometriosis/mullerianosis (Clear Cell
Adenocarcinoma)
sumber: (Adeniran and Tamboli, 2009; Dandekar et al., 1997; Drew et al., 1996; el-Mekresh et al., 1998
; Gilcrease et al., 1998; Gill et al., 1989; Gopalan et al., 2009; Grignon et al., 1991b; Jacobo et al., 1977;
Kramer et al., 1979; Matsuoka et al., 2002; Molina et al., 2007; Oliva and Young, 1996)
44
Investigasi
Sistoskopi + biopsi
- melihat bentukan keganasan, papilar/sesil
- tumor dapat muncul dimana saja sepanjang dinding lateral,
dinding posterior, trigonum, atap, dan dinding anterior
- Diagnosis adenokarsinoma buli primer tegak setelah
mengeksklusi kemungkinan lain
Histopatologi tumor dan pewarnaan Immunohistochemistry(IHC)

- melihat pola pertumbuhan sel kanker dan bentukannya
- IHC untuk membedakan primer dan sekunder
USG
- menilai adanya massa di dalam buli
CT-Urografi/MRI
infeksi kronis pada buli dan ureter
- CT scan/MRI menilai perluasan tumor, keterlibatan kelenjar
getah bening, dan metastasis jauh
- sekitar 1/3 pasien saat tediagnosis adenokarsinoma buli telah
melibatkan kelenjar getah bening
sumber: (Dadhania et al., 2015; Dean et al., 1954; Gilcrease et al., 1998; Melicow, 1955; Oliva et al.,
2002)
45
Perbandingan Clear Cell Ca, non-Urachal, Urachal, Sekunder
Clear Cell Ca Primer/non-urachal Urachal Sekunder
Asal Buli Buli sisa urakus - prostat
- trigonum - trigonum - kolorektal
- dinding posterior - dinding anterior - cervix
Lebih sering pada - dinding posterior - endometrium
uretra dibanding - dinding lateral - paru
buli
Usia terdiagnosis Rata-rata 57tahun (22-83 tahun) 60-70 tahun 50-60 tahun 60-70 tahun
Predominan > > > >
Angka Kejadian Sangat jarang Sekunder>primer>urachal Sekunder>primer>urachal Sekunder>primer>urachal
Histologi
mirip clear cell carcinoma kolam mukus kolam mukus

traktus genitalia wanita,
berkaitan dengan endometriosis
dan mullerianosis
Kolorektal:
Marker - p53 - CDX 2 - CDX 2 - CK 20
- rataan Ki67 >32/200 sel - CK 7 - CK 20 - β-catenin
- CK 7 - Thrombomodulin - CK 7 - Thrombomodulin (jarang +)
- PAX-2 - β-catenin Prostat:
- PAX-8 - High Molecular Cytokeratin - PSA - PSAP
- PSMA - Prostein (P501S)
- NKX3.1
sumber: (Bates and Baithun, 2000; Dadhania et al., 2015; Drew et al., 1996; Ford et al., 1985; Gilcrease et al., 1998; Endometrial Carcinoma:
Gopalan et al., 2009; Grignon et al., 1991b; Johnson et al., 1985; Matsuoka et al., 2002; Melicow, 1955; Oliva et al., 2002; - vimentin
Oliva and Young, 1996; Rao et al., 2013; Silver and Epstein, 1993; Sim et al., 1999; Svanholm, 1986; Tong et al., 2009, 2006; - PAX-8
Adenokarsinoma paru:
Torenbeek et al., 1994; Wang et al., 2001; Woodard et al., 2011)
- RRF-1
46
Sistem Staging Sheldon untuk Urachal Karsinoma
Stage I : Tidak ada invasi melebihi mukosa urachal
Stage II : Invasi terbatas pada urakus
Stage III: Perluasan lokal ke buli (IIIA), dinding abdomen (IIIB), peritoneum (IIIC), atau viscera
lain (IIID)
Stage IV: Metastasis ke kelenjar getah bening regional (IVA) atau area jauh/organ viscera lain
selain buli (IVB)
I IIIC
IIIA
IVB
II
IVA
mukosa urachal
jaringan ikat IIIB
otot
dinding abdomen
Urachal adenokarsinoma
Menentukan Urachal Adenokarsinoma

Kriteria diagnosis Urachal Adenokarsinoma, dimodifikasi oleh Johnson et al:
1. Lokasi Tumor di atap buli/ bladder dome
2. batas antara keganasan dan permukaan urothelium buli jelas
3. eksklusi adenokarsinoma primer organ lain yang telah menyebar ke buli
2 3
1
sumber: (Dadhania et al., 2015; Johnson et al., 1985; Sheldon et al., 1984)
47
Manajemen
Radical cystectomy + Lymphadenectomy
- RC merupakan terapi utama adenokarsinoma buli
- Sebagian besar adenokarsinoma primer buli menginvasif otot
- Angka kesintasan 5 tahun berkisar 11-61%
Radioterapi
- Adenokarsinoma bukan merupakan penyakit yang radiosensitif,
dan memberikan respon yang jelek terhadap radioterapi
- Tingkat kesintasan 5 tahun bila hanya diterapi sinar eksternal
adalah <20%
- Terapi radiasi menjadi pilihan pada pasien yang tidak dapat
dilakukan RC
Kemoterapi
- Adenokarsinoma bukan merupakan penyakit yang
kemosensitif, dan memberikan respon yang jelek terhadap
kemoterapi
- Kemoterapi adjuvan menggunakan kombinasi cisplatin (MVAC)
hanya memberikan sedikit dampak pada adenokarsinoma
Partial Cystectomy
- Standar terapi urachal adenokarsinoma adalah partial
cystectomy
dengan reseksi en-bloc atap buli (bladder dome), ligamentum
urachal, dan umbilikus serta lymphadenectomy pelvis bilateral.
- Sekitar 7% pasien urachal adenokarsinoma mengenai
umbilikus
- Angka kekambuhan lebih tinggi pada pasien yang tidak
dilakukan reseksi en-bloc
TUR-BT + Intravesical
Immunotherapy
- Pada sebagian kecil adenokarsinoma yang tidak menginvasif
otot, terapi yang dilakukan yaitu sistoskopi dengan TUR-BT
- Sebagian pasien memberikan respon terhadap pemberikan
intravesical BCG / MMC
sumber: (Black et al., 2009; Dadhania et al., 2015; Holmäng and Aldenborg, 2000; Porten et al., 2014;
Shah et al., 2011; Sie er-Radtke, 2012; Williams and Chavda, 2015)
48
DAFTAR PUSTAKA
Abol-Enein, H., Kava, B.R., Carmack, A.J.K., 2007. Nonurothelial Cancer of the Bladder. Urology 69, 93–
104. https://doi.org/10.1016/j.urology.2006.08.1107
Adeniran, A.J., Tamboli, P., 2009. Clear Cell Adenocarcinoma of the Urinary Bladder: A Short Review.
Arch. Pathol. Lab. Med. 133, 987–991. https://doi.org/10.1043/1543-2165-133.6.987
Bates, A.W., Baithun, S.I., 2000. Secondary neoplasms of the bladder are histological mimics of
nontransitional cell primary tumours: clinicopathological and histological features of 282
cases. Histopathology 36, 32–40.
Black, P.C., Brown, G.A., Dinney, C.P.N., 2009. The impact of variant histology on the outcome of
bladder cancer treated with curative intent. Urol. Oncol. 27, 3–7.
Dadhania, V., Czerniak, B., Guo, C.C., 2015. Adenocarcinoma of the urinary bladder. Am. J. Clin. Exp.
Urol. 3, 51–63.
Dandekar, N.P., Dalal, A.V., Tongaonkar, H.B., Kamat, M.R., 1997. Adenocarcinoma of bladder. Eur. J.
Surg. Oncol. J. Eur. Soc. Surg. Oncol. Br. Assoc. Surg. Oncol. 23, 157–160.
Dean, A.L., Mostofi, F.K., Thomson, R.V., Clark, M.L., 1954. A Restudy of the First Fourteen Hundred
Tumors in the Bladder Tumor Registry, Armed Forces Institute of Pathology. J. Urol. 71, 571–
590. https://doi.org/10.1016/S0022-5347(17)67827-3
Drew, P.A., Murphy, W.M., Civantos, F., Speights, V.O., 1996. The histogenesis of clear cell
adenocarcinoma of the lower urinary tract. Case series and review of the literature. Hum.
Pathol. 27, 248–252.
el-Mekresh, M.M., el-Baz, M.A., Abol-Enein, H., Ghoneim, M.A., 1998. Primary adenocarcinoma of the
urinary bladder: a report of 185 cases. Br. J. Urol. 82, 206–212.
Ford, T.F., Butcher, D.N., Masters, J.R., Parkinson, M.C., 1985. Immunocytochemical localisation of
prostate-specific antigen: specificity and application to clinical practice. Br. J. Urol. 57, 50–55.
Gilcrease, M.Z., Delgado, R., Vuitch, F., Albores-Saavedra, J., 1998. Clear cell adenocarcinoma and
nephrogenic adenoma of the urethra and urinary bladder: a histopathologic and
immunohistochemical comparison. Hum. Pathol. 29, 1451–1456.
Gill, H.S., Dhillon, H.K., Woodhouse, C.R., 1989. Adenocarcinoma of the urinary bladder. Br. J. Urol. 64,
138–142.
Gopalan, A., Sharp, D.S., Fine, S.W., Tickoo, S.K., Herr, H.W., Reuter, V.E., Olgac, S., 2009. Urachal
carcinoma: a clinicopathologic analysis of 24 cases with outcome correlation. Am. J. Surg.
Pathol. 33, 659–668. https://doi.org/10.1097/PAS.0b013e31819aa4ae
Grignon, D.J., Ro, J.Y., Ayala, A.G., Johnson, D.E., 1991a. Primary signet-ring cell carcinoma of the
urinary bladder. Am. J. Clin. Pathol. 95, 13–20.
Grignon, D.J., Ro, J.Y., Ayala, A.G., Johnson, D.E., Ordóñez, N.G., 1991b. Primary adenocarcinoma of
the urinary bladder. A clinicopathologic analysis of 72 cases. Cancer 67, 2165–2172.
Holmäng, S., Aldenborg, F., 2000. Stage T1 adenocarcinoma of the urinary bladder--complete response
after transurethral resection and intravesical bacillus Calmette-Guerin. Scand. J. Urol.
Nephrol. 34, 141–143. https://doi.org/10.1080/003655900750016797
Jacobo, E., Loening, S., Schmidt, J.D., Culp, D.A., 1977. Primary Adenocarcinoma of the Bladder: A
Retrospective Study of 20 Patients. J. Urol. 117, 54–56. https://doi.org/10.1016/S0022-
5347(17)58335-4
Johnson, D.E., Hodge, G.B., Abdul-Karim, F.W., Ayala, A.G., 1985. Urachal carcinoma. Urology 26, 218–
221.
Kramer, S.A., Bredael, J., Croker, B.P., Paulson, D.F., Glenn, J.F., 1979. Primary Non-Urachal
Adenocarcinoma of the Bladder. J. Urol. 121, 278–281. https://doi.org/10.1016/S0022-
5347(17)56753-1
49
Matsuoka, Y., Machida, T., Oka, K., Ishizaka, K., 2002. Clear cell adenocarcinoma of the urinary bladder
inducing acute renal failure. Int. J. Urol. 9, 467–469. https://doi.org/10.1046/j.1442-
2042.2002.00496.x
Melicow, M.M., 1955. Tumors of the Urinary Bladder: a Clinicopathological Analysis of Over 2500
Specimens and Biopsies. J. Urol. 74, 498–521. https://doi.org/10.1016/S0022-5347(17)67309-
9
Molina, J.R., Quevedo, J.F., Furth, A.F., Richardson, R.L., Zincke, H., Burch, P.A., 2007. Predictors of
survival from urachal cancer: a Mayo Clinic study of 49 cases. Cancer 110, 2434–2440.
Morton, M.J., Zhang, S., Lopez-Beltran, A., MacLennan, G.T., Eble, J.N., Montironi, R., Sung, M.-T., Tan,
P.-H., Zheng, S., Zhou, H., Cheng, L., 2007. Telomere shortening and chromosomal
abnormalities in intestinal metaplasia of the urinary bladder. Clin. Cancer Res. Off. J. Am.
Assoc. Cancer Res. 13, 6232–6236. https://doi.org/10.1158/1078-0432.CCR-07-0121
Oliva, E., Amin, M.B., Jimenez, R., Young, R.H., 2002. Clear cell carcinoma of the urinary bladder: a
report and comparison of four tumors of mullerian origin and nine of probable urothelial
origin with discussion of histogenesis and diagnostic problems. Am. J. Surg. Pathol. 26, 190–
197.
Oliva, E., Young, R.H., 1996. Clear cell adenocarcinoma of the urethra: a clinicopathologic analysis of
19 cases. Mod. Pathol. Off. J. U. S. Can. Acad. Pathol. Inc 9, 513–520.
Poore, T.E., Egbert, B., Jahnke, R., Kraft, J.K., 1981. Signet ring cell adenocarcinoma of the bladder:
linitis plastica variant. Arch. Pathol. Lab. Med. 105, 203–204.
Porten, S.P., Willis, D., Kamat, A.M., 2014. Variant histology: role in management and prognosis of
nonmuscle invasive bladder cancer. Curr. Opin. Urol. 24, 517–523.
https://doi.org/10.1097/MOU.0000000000000089
Rao, Q., Williamson, S.R., Lopez-Beltran, A., Montironi, R., Huang, W., Eble, J.N., Grignon, D.J., Koch,
M.O., Idrees, M.T., Emerson, R.E., Zhou, X.-J., Zhang, S., Baldridge, L.A., Cheng, L., 2013.
Distinguishing primary adenocarcinoma of the urinary bladder from secondary involvement
by colorectal adenocarcinoma: extended immunohistochemical profiles emphasizing novel
markers. Mod. Pathol. Off. J. U. S. Can. Acad. Pathol. Inc 26, 725–732.
https://doi.org/10.1038/modpathol.2012.229
Shah, J.B., McConkey, D.J., Dinney, C.P.N., 2011. New strategies in muscle-invasive bladder cancer: on
the road to personalized medicine. Clin. Cancer Res. Off. J. Am. Assoc. Cancer Res. 17, 2608–
2612. https://doi.org/10.1158/1078-0432.CCR-10-2770
Sheldon, C.A., Clayman, R.V., Gonzalez, R., Williams, R.D., Fraley, E.E., 1984. Malignant urachal lesions.
J. Urol. 131, 1–8.
Siefker-Radtke, A., 2012. Urachal adenocarcinoma: a clinician’s guide for treatment. Semin. Oncol. 39,
619–624. https://doi.org/10.1053/j.seminoncol.2012.08.011
Silver, S.A., Epstein, J.I., 1993. Adenocarcinoma of the colon simulating primary urinary bladder
neoplasia. A report of nine cases. Am. J. Surg. Pathol. 17, 171–178.
Sim, S.J., Ro, J.Y., Ordonez, N.G., Park, Y.W., Kee, K.H., Ayala, A.G., 1999. Metastatic renal cell
carcinoma to the bladder: a clinicopathologic and immunohistochemical study. Mod. Pathol.
Off. J. U. S. Can. Acad. Pathol. Inc 12, 351–355.
Smeulders, N., Woodhouse, C.R., 2001. Neoplasia in adult exstrophy patients. BJU Int. 87, 623–628.
Svanholm, H., 1986. Evaluation of commercial immunoperoxidase kits for prostatic specific antigen
and prostatic specific acid phosphatase. Acta Pathol. Microbiol. Immunol. Scand. [A] 94, 7–12.
Tong, G.-X., Melamed, J., Mansukhani, M., Memeo, L., Hernandez, O., Deng, F.-M., Chiriboga, L.,
Waisman, J., 2006. PAX2: a reliable marker for nephrogenic adenoma. Mod. Pathol. Off. J. U.
S. Can. Acad. Pathol. Inc 19, 356–363. https://doi.org/10.1038/modpathol.3800535
Tong, G.-X., Yu, W.M., Beaubier, N.T., Weeden, E.M., Hamele-Bena, D., Mansukhani, M.M., O’Toole,
K.M., 2009. Expression of PAX8 in normal and neoplastic renal tissues: an
50
immunohistochemical study. Mod. Pathol. Off. J. U. S. Can. Acad. Pathol. Inc 22, 1218–1227.
https://doi.org/10.1038/modpathol.2009.88
Torenbeek, R., Blomjous, C.E., de Bruin, P.C., Newling, D.W., Meijer, C.J., 1994. Sarcomatoid carcinoma
of the urinary bladder. Clinicopathologic analysis of 18 cases with immunohistochemical and
electron microscopic findings. Am. J. Surg. Pathol. 18, 241–249.
Wang, H.L., Lu, D.W., Yerian, L.M., Alsikafi, N., Steinberg, G., Hart, J., Yang, X.J., 2001.
Immunohistochemical distinction between primary adenocarcinoma of the bladder and
secondary colorectal adenocarcinoma. Am. J. Surg. Pathol. 25, 1380–1387.
Williams, C.R., Chavda, K., 2015. En Bloc Robot-assisted Laparoscopic Partial Cystectomy, Urachal
Resection, and Pelvic Lymphadenectomy for Urachal Adenocarcinoma. Rev. Urol. 17, 46–49.
Wilson, T.G., Pritchett, T.R., Lieskovsky, G., Warner, N.E., Skinner, D.G., 1991. Primary adenocarcinoma
of bladder. Urology 38, 223–226.
Woodard, A.H., Yu, J., Dabbs, D.J., Beriwal, S., Florea, A.V., Elishaev, E., Davison, J.M., Krasinskas, A.M.,
Bhargava, R., 2011. NY-BR-1 and PAX8 immunoreactivity in breast, gynecologic tract, and
other CK7+ carcinomas: potential use for determining site of origin. Am. J. Clin. Pathol. 136,
428–435. https://doi.org/10.1309/AJCPUFNMEZ3MK1BK
51
Urothotelial/ TCC
Small Cell Ca Buli -- Sistoskopi/TUR-BT
Histopatologi lesi
+ biopsi
90-95%
Investigasi - Marker tumor
1 Squamous CC
- CT-scan/MRI
2-5%
2 Adenocarcinoma
0.5-2% Ikhtisar
3 Small Cell Ca
<1%
TCC/UC Small Cell Ca
4
- Agresif dan mudah bermetastasis
- Kisaran usia terdiagnosis: 60-70 th
Staging dan - Staging menggunakan sistem TNM TCC/UC
- Laki-laki > perempuan (3:1) Etiologi
Grading - Grading berdasarkan klasifikasi WHO: G1,G2 dan G3
- Berupa small cell murni atau bersamaan (hipotesis)
dengan keganasan lain seperti TCC/UC Dapat direseksi (≤T1-4aN0M0)
- Transformasi maligna sel neuroendokrin buli Small Cell Cancer Buli - Multimodal terapi: kemoterapi, operasi dan/ radioterapi
menjadi small cell cancer, - Terapi paling efektif dengan Kemoterapi neoadjuvan 4
- Dari multipotent stem cell,
siklus diikuti operasi (RC)
- Perubahan metaplastik urotelial
- Hematuria
Tidak dapat di reseksi (≥cT4bN+M+)

- Gejala Iritatif LUTS - Kemoterapi paliatif dengan obat platinum (cisplatin jika
Manajemen
pasien cocok)
- Bila pasien tidak cocok dengan cisplatin, ganti
- Obstruksi, nyeri pelvis dan/
teraba massa di pelvis carboplatin AUC 5 sampai 6
Tanda dan Gejala - Prognosis jelek
- Sindrom Paraneoplastik (jarang): hiponatremia, - Angka kesintasan 5 tahun semua stadium digabung,19%
hipokalemia, hipernatremia - Kesintasan 5 tahun stadium 2, 63.6%
Kesintasan - Kesintasan 5 tahun stadium 3, 15.4%
- Sindrom Cushing - Kesintasan 5 tahun stadium 4, 10.5%
sumber: (Abenoza et al., 1986; Abrahams et al., 2005; Ali et al., 1997; Blomjous et al., 1989; Cheng et al., 2004; Choong et al., 2005;
Christopher et al., 1991; Ghervan et al., 2017; Grignon et al., 1992; Helpap, 2002; Holmäng et al., 1995; Iczkowski et al., 1999; Ismaili, 2011;
Nabil Ismaili et al., 2011; N. Ismaili et al., 2011; Lohrisch et al., 1999; Mangar et al., 2004; Mills et al., 1987; Partanen and Asikainen, 1985;
Podesta and True, 1989; Reyes and Soneru, 1985; Siefker-Radtke et al., 2009, 2004; Swanson et al., 1988; Trias et al., 2001b, 2001a;
van Hoeven and Artymyshyn, 1996)
52
Investigasi
Sitoskopi (Gold Standard) + Biopsi/reseksi
- Small Cell Ca tidak dapat dibedakan dengan TCC/UC
- Sering muncul di dinding lateral, posterior, trigonum, fundus,
dinding anterior
Sitologi Urin + Histopatologi Lesi

Marker Urin
- Ekspresi marker neural: enolase spesifik-neuron (kurang
spesifik), kromogranin A dan sinaptofisin (positif pada 50%
kasus)
- Marker antigen epithelial (CAM 5.2, Ck7 dan EMA) dan
antigen karsinoembriogenik
- Sitokeratin (CAM 5.2) pada 1/4 kasus dan pola pewarnaan
perinuklear belang-belang
- Pada histopatologi lesi ditemukan “starry sky appearance”
CT-scan/MRI
- Menilai perluasan tumor, keterlibatan LN dan adanya
metastasis
- Small Cell Cancer bersifat agresif dan cenderung
bermetastasis lebih cepat
- Area metastasis tersering yaitu kelenjar getah bening
retroperitoneal dan pelvis, diikuti hepar, tulang, otak dan paru
sumber: (Abrahams et al., 2005; Blomjous et al., 1989; Choong et al., 2005; Ghervan et al., 2017;
Grignon et al., 1992; Iczkowski et al., 1999; Ismaili, 2011; Mukesh et al., 2009)
53
Manajemen
Dapat direseksi (≤T1-4aN0M0)
Radical cystectomy + Lymphadenectomy
- Reseksi saja tidak cukup sebagai terapi small cell buli
- Kesintasan umum 5 tahun operasi dan tidak operasi, 16% dan
18%
Kemoterapi
- Small cell cancer bersifat kemosensitif
- Keuntungan kemoterapi neoadjuvan: pengobatan awal
mikrometastasis, meningkatkan toleransi pengobatan sistemik,
dan menurunkan staging sebelum operasi
- Kesintasan 5 tahun operasi dengan kemoterapi neoadjuvan
dan tanpa kemoterapi neoadjuvan yaitu 78% dan 36%
Radioterapi
- Radioterapi merupakan terapi kuratif
- Kombinasi kemoradioterapi memberikan efek yang lebih
kuratif dan merupakan terapi lini ke-2 setelah kombinasi
kemoterapi neodjuvan dan operasi
Tidak dapat di reseksi (≥cT4bN+M+)

Kemoterapi Paliatif
- Kemoterapi dengan cisplatin pada pasien dengan skor
performa/PS bagus (0-1) dan fungsi ginjal baik (glomerular
filtration rate/GFFR > 60 mL/min)
- Pengobatan dengan regimen neuroendokrin tipe etoposide
ditambah cisplatin atau ifosfamide dan doxorubicin
- Protokol sekuensial: ifosfamide ditambah doxorubicin pada
hari 1 dan etoposide ditambah cisplatin pada hari ke 14
- Untuk pasien yang tidak cocok dengan cisplatin, dapat diganti
dengan carboplatin AUC 5-6
Radioterapi Paliatif
- Diberikan sebagai pengobatan simptomatik metastasis ke
otak, tulang, dan kompresi saraf tulang belakang
- Insidensi simptomatik metastasis otak jarang. Pasien small
cell cancer buli tidak direkomendasikan untuk prophylatic brain
irradiation (PCI)
Refraktor/tidak respon terhadap terapi sebelumnya/ kambuh

- Venorelbine setiap 3 minggu
sumber: (Cheng et al., 2004; Choong et al., 2005; Ghervan et al., 2017; Grignon et al., 1992; Ismaili,
2011; More o et al., 2013; Mukesh et al., 2009; Sie er-Radtke et al., 2009, 2004)
54
DAFTAR PUSTAKA
Abenoza, P., Manivel, C., Sibley, R.K., 1986. Adenocarcinoma with neuroendocrine differentiation of
the urinary bladder. Clinicopathologic, immunohistochemical, and ultrastructural study. Arch.
Pathol. Lab. Med. 110, 1062–1066.
Abrahams, N.A., Moran, C., Reyes, A.O., Siefker-Radtke, A., Ayala, A.G., 2005. Small cell carcinoma of
the bladder: a contemporary clinicopathological study of 51 cases. Histopathology 46, 57–63.
https://doi.org/10.1111/j.1365-2559.2004.01980.x
Ali, S.Z., Reuter, V.E., Zakowski, M.F., 1997. Small cell neuroendocrine carcinoma of the urinary
bladder. A clinicopathologic study with emphasis on cytologic features. Cancer 79, 356–361.
Blomjous, C.E., Vos, W., De Voogt, H.J., Van der Valk, P., Meijer, C.J., 1989. Small cell carcinoma of the
urinary bladder. A clinicopathologic, morphometric, immunohistochemical, and ultrastructural
study of 18 cases. Cancer 64, 1347–1357.
Cheng, L., Pan, C.-X., Yang, X.J., Lopez-Beltran, A., MacLennan, G.T., Lin, H., Kuzel, T.M., Papavero, V.,
Tretiakova, M., Nigro, K., Koch, M.O., Eble, J.N., 2004. Small cell carcinoma of the urinary bladder:
a clinicopathologic analysis of 64 patients. Cancer 101, 957–962.
Choong, N.W.W., Quevedo, J.F., Kaur, J.S., 2005. Small cell carcinoma of the urinary bladder: The Mayo
Clinic experience. Cancer 103, 1172–1178. https://doi.org/10.1002/cncr.20903
Christopher, M.E., Seftel, A.D., Sorenson, K., Resnick, M.I., 1991. Small cell carcinoma of the
genitourinary tract: an immunohistochemical, electron microscopic and clinicopathological
study. J. Urol. 146, 382–388.
Ghervan, L., Zaharie, A., Ene, B., Elec, F.I., 2017. Small-cell carcinoma of the urinary bladder: where do
we stand? Clujul Medical 90, 13. https://doi.org/10.15386/cjmed-673
Grignon, D.J., Ro, J.Y., Ayala, A.G., Shum, D.T., Ordóñez, N.G., Logothetis, C.J., Johnson, D.E., Mackay,
B., 1992. Small cell carcinoma of the urinary bladder. A clinicopathologic analysis of 22 cases.
Cancer 69, 527–536.
Helpap, B., 2002. Morphology and therapeutic strategies for neuroendocrine tumors of the
genitourinary tract. Cancer 95, 1415–1420. https://doi.org/10.1002/cncr.10840
Holmäng, S., Borghede, G., Johansson, S.L., 1995. Primary small cell carcinoma of the bladder: a report
of 25 cases. J. Urol. 153, 1820–1822.
Iczkowski, K.A., Shanks, J.H., Allsbrook, W.C., Lopez-Beltran, A., Pantazis, C.G., Collins, T.R.,
Wetherington, R.W., Bostwick, D.G., 1999. Small cell carcinoma of urinary bladder is
differentiated from urothelial carcinoma by chromogranin expression, absence of CD44 variant 6
expression, a unique pattern of cytokeratin expression, and more intense gamma-enolase
expression. Histopathology 35, 150–156.
Ismaili, N., 2011. A rare bladder cancer - small cell carcinoma: review and update. Orphanet Journal of
Rare Diseases 6, 75. https://doi.org/10.1186/1750-1172-6-75
Ismaili, N., Amzerin, M., Elmajjaoui, S., Droz, J.-P., Flechon, A., Errihani, H., 2011. [The role of
chemotherapy in the management of bladder cancer]. Prog. Urol. 21, 369–382.
https://doi.org/10.1016/j.purol.2011.02.005
Ismaili, Nabil, Elmajjaoui, S., Bensouda, Y., Belbaraka, R., Abahssain, H., Allam, W., Fadoukhair, Z.,
Mesmoudi, M., Tanz, R., Mahfoud, T., Elomrani, A., Khouchani, M., Sbitti, Y., Benjaafar, N.,
Errihani, H., Tahri, A., 2011. Neoadjuvant or adjuvant chemotherapy: what is the best treatment
of muscle invasive bladder cancer? Oncol Rev 5, 185–189.
https://doi.org/10.4081/oncol.2011.185
Lohrisch, C., Murray, N., Pickles, T., Sullivan, L., 1999. Small cell carcinoma of the bladder: long term
outcome with integrated chemoradiation. Cancer 86, 2346–2352.
Mangar, S.A., Logue, J.P., Shanks, J.H., Cooper, R.A., Cowan, R.A., Wylie, J.P., 2004. Small-cell
carcinoma of the urinary bladder: 10-year experience. Clin Oncol (R Coll Radiol) 16, 523–527.
55
Mills, S.E., Wolfe, J.T., Weiss, M.A., Swanson, P.E., Wick, M.R., Fowler, J.E., Young, R.H., 1987. Small
cell undifferentiated carcinoma of the urinary bladder. A light-microscopic, immunocytochemical,
and ultrastructural study of 12 cases. Am. J. Surg. Pathol. 11, 606–617.
Moretto, P., Wood, L., Emmenegger, U., Blais, N., Mukherjee, S.D., Winquist, E., Belanger, E.C.,
MacRae, R., Balogh, A., Cagiannos, I., Kassouf, W., Black, P., Czaykowski, P., Gingerich, J., North,
S., Ernst, S., Richter, S., Sridhar, S., Reaume, M.N., Soulieres, D., Eisen, A., Canil, C.M., 2013.
Management of small cell carcinoma of the bladder: Consensus guidelines from the Canadian
Association of Genitourinary Medical Oncologists (CAGMO). Can Urol Assoc J 7, E44–E56.
https://doi.org/10.5489/cuaj.220
Mukesh, M., Cook, N., Hollingdale, A.E., Ainsworth, N.L., Russell, S.G., 2009. Small cell carcinoma of
the urinary bladder: a 15-year retrospective review of treatment and survival in the Anglian
Cancer Network. BJU International 103, 747–752. https://doi.org/10.1111/j.1464-
410X.2008.08241.x
Partanen, S., Asikainen, U., 1985. Oat cell carcinoma of the urinary bladder with ectopic
adrenocorticotropic hormone production. Hum. Pathol. 16, 313–315.
Podesta, A.H., True, L.D., 1989. Small cell carcinoma of the bladder. Report of five cases with
immunohistochemistry and review of the literature with evaluation of prognosis according to
stage. Cancer 64, 710–714.
Reyes, C.V., Soneru, I., 1985. Small cell carcinoma of the urinary bladder with hypercalcemia. Cancer
56, 2530–2533.
Siefker-Radtke, A.O., Dinney, C.P., Abrahams, N.A., Moran, C., Shen, Y., Pisters, L.L., Grossman, H.B.,
Swanson, D.A., Millikan, R.E., 2004. Evidence supporting preoperative chemotherapy for small
cell carcinoma of the bladder: a retrospective review of the M. D. Anderson cancer experience. J.
Urol. 172, 481–484.
Siefker-Radtke, A.O., Kamat, A.M., Grossman, H.B., Williams, D.L., Qiao, W., Thall, P.F., Dinney, C.P.,
Millikan, R.E., 2009. Phase II clinical trial of neoadjuvant alternating doublet chemotherapy with
ifosfamide/doxorubicin and etoposide/cisplatin in small-cell urothelial cancer. J. Clin. Oncol. 27,
2592–2597. https://doi.org/10.1200/JCO.2008.19.0256
Swanson, P.E., Brooks, R., Pearse, H., Stenzel, P., 1988. Small cell carcinoma of urinary bladder. Urology
32, 558–563.
Trias, I., Algaba, F., Condom, E., Español, I., Seguí, J., Orsola, I., Villavicencio, H., García Del Muro, X.,
2001a. Small cell carcinoma of the urinary bladder. Presentation of 23 cases and review of 134
published cases. Eur. Urol. 39, 85–90. https://doi.org/10.1159/000052417
Trias, I., Trias, I., Algaba, F., Algaba, F., Condom, E., Condom, E., Español, I., Español, I., Seguí, J., Seguí,
J., Orsola, I., Orsola, I., Villavicencio, H., Villavicencio, H., Muro, X.G. del, Muro, X.G. del, 2001b.
Small Cell Carcinoma of the Urinary Bladder. EUR 39, 85–90. https://doi.org/10.1159/000052417
van Hoeven, K.H., Artymyshyn, R.L., 1996. Cytology of small cell carcinoma of the urinary bladder.
Diagn. Cytopathol. 14, 292–297. https://doi.org/10.1002/(SICI)1097-
0339(199605)14:4<292::AID-DC3>3.0.CO;2-I
56
Sarkoma Buli
Keganasan Buli
Non-Epitelial (<5%)
Sarkoma
Leiomiosarkoma Rhabdomiosarkoma Lain-lain (Angiosarkoma,

(LMS) ( RMS) Karsinosarkoma, dll)
% Karsinoma 50% 20%

Buli
Karakteristik - 0.1% dari tumor - 4-8% dari kanker pada - sangat jarang
nonurotelial anak - usia terdiagnosis
- tipe sarkoma tersering - sebagian besar di traktus 60-70th
pada orang dewasa, genitourinari - memiliki prognosis yang
median usia - 50% penderita berusia lebih jelek di banding tipe
terdiagnosis 65 th <10th lainnya
- jarang di orang dewasa
Faktor Resiko:
- sindrom kongenital - riwayat eksposur
(sindrom Costello, siklosfosfamid, alkylating
Gorlin basal cell nevus agents
syndrome, sindrom Down
neurofibromatosis, sindrom
Rubinstein-Taybi, fetal
alcohol syndrome, Beckwith-
Wiedemann syndrome,
Li-fraumeni syndrome)
- abnormalitas p53
- riwayat radioterapi
sumber: (A lgan and Gençten, 2013; Gerbaud et al., 2017; Hamadalla et al., 2013; Kieran and
Shnorhavorian, 2016; Rodríguez et al., 2014; Spiess et al., 2007)
57
Tanda dan Gejala
Painless gross haematuria
Irritative LUTS
- disuria
- frekuensi bertambah
- urgensi
- incontinensia
- Nyeri
- Massa Terpalpasi
- Retensi Urin (akibat obstruksi oleh tumor)
- Hidronefrosis
- Stranguria
- Distensi Abdomen dan konstipasi (bila sudah parah)
sumber: (Gupta et al., 2013; Kieran and Shnorhavorian, 2016; Parekh et al., 2002; Slaoui et al., 2014)
58
Investigasi
Sistoskopi + Biopsi
- melihat massa di dalam Buli
- LMS sering muncul di fundus buli
- RMS sering di trigonum dan basal buli
- Sitologi Urin, jumlah sel kanker di urin sedikit

- Histopatologi
- Pewarnaan IHC dan marker
- Marker
USG:
- menilai obstruksi di traktus urinarius dan buli
- menilai hidronefrosis
- melihat massa di buli

infeksi kronis pada buli dan ureter, serta adanya hidronefrosis
- Ct scan/ CT-PET dan MRI dengan kontras untuk menilai
perluasan tumor, keterlibatan LN dan adanya metastasis
- RMS sering bermetastasis ke paru
- LMS sering bermetastasis ke paru, hati, tulang dan otak
- Fluorodeoxyglucose-positron emission topography (FDG-PET)
CT lebih superior dibanding CT scan saja dan MRI
- FDG-PET CT memiliki sensitivitas 94% dan spesifitas 100%
untuk penyakit nodus
sumber: (Hamadalla et al., 2013; Kieran and Shnorhavorian, 2016; Oberlin et al., 2008; Parekh et al.,
2002)
59
Marker IHC +
LMS
- Actin
- SMA
- Desmin (+/-)
RMS:
- Desmin
- Myogenin
- MyoD
Jika semuanya diperiksa, sensitivitas mencapai 95%
dan spesifitas 100%
Angiosarcoma
(tegak jika salah satu marker positif)
- F VIII
- CD 31
- CD 34
- ERG
- FLI-1
Carcinosarcoma/sarcomatoid carcinoma
- EMA
- Keratin
- vimentin
- hCG
Memorial Sloan-Kettering Cancer Centre
(MSKCC) Soft tissue Staging System
Stage Grade Ukuran Kedalaman
0 rendah(low) <5cm superfisial
1 rendah <5cm profunda
2 rendah >5cm profunda
tinggi(high) <5cm profunda
3 tinggi >5cm profunda
4 adanya metastasis
tinggi >5cm
grade ukuran
rendah <5cm
superfisial
kedalaman
profunda
sumber: (Carroll and Nodit, 2013; Gerbaud et al., 2017; Hajdu et al., 1988; Kieran and Shnorhavorian,
2016; Russo et al., 1992; Spiess et al., 2007; Torenbeek et al., 1994; Young et al., 1988)
60
Manajemen
Radical cystectomy
- RC dengan En Bloc merupakan terapi kuratif Sarkoma buli
- Dapat disertai diversi urin
- Reseksi komplit dengan batas (margin) negatif secara
mikroskopis
Radioterapi
- Pada Tumor yang tidak dapat direseksi, sisa tumor post-

operasi, dan keterlibatan nodus
- Intraoperative RT (IORT) digunakan apabilla reseksi dicurigai
tidak bersih
Kemoterapi
- Kemoterapi neoadjuvan/adjuvan pada tumor grade menengah
atau tinggi
- Vincristine, actinomycin, dan cyclosphophamide merupakan
kombinasi standar untuk RMS
Partial Cystectomy
- Dipertimbangkan apabila tumor bukan di trigonum atau leher
Buli, berukuran kecil (<4cm) dan stadium MSKCC rendah
Multimodal therapy
- Pada anak-anak dengan RMS angka kesembuhan mencapai

70%
- Pada orang dewasa dengan RMS, angka kesintasan 5 tahun
hanya 53%
sumber: (A lgan and Gençten, 2013; Childs et al., 2008; Gerbaud et al., 2017; Hamadalla et al., 2013;
Kieran and Shnorhavorian, 2016; Parekh et al., 2002; Rodríguez et al., 2014; Spiess et al., 2007)
61
Daftar Pustaka
Atılgan, D., Gençten, Y., 2013. Carcinosarcoma of the Bladder: A Case Report and Review of the
Literature. Case Rep. Urol. 2013, 1–3. https://doi.org/10.1155/2013/716704
Carroll, S.J., Nodit, L., 2013. Spindle Cell Rhabdomyosarcoma: A Brief Diagnostic Review and
Differential Diagnosis. Arch. Pathol. Lab. Med. 137, 1155–1158.
https://doi.org/10.5858/arpa.2012-0465-RS
Childs, L., Hull, D., Bostwick, D.G., 2008. Adult Urinary Bladder Rhabdomyosarcoma. Urology 72,
948.e1-948.e3. https://doi.org/10.1016/j.urology.2008.01.017
Gerbaud, F., Ingels, A., Ferlicot, S., Irani, J., 2017. Angiosarcoma of the Bladder: Review of the
Literature and Discussion About a Clinical Case. Urol. Case Rep. 13, 97–100.
https://doi.org/10.1016/j.eucr.2016.12.007
Gupta, D.K., Singh, V., Sinha, R.J., Kumar, V., Nagathan, D.S., Sankhwar, S.N., 2013. Leiomyosarcoma,
a nonurothelial bladder tumor: a rare entity with therapeutic diversity. Korean J. Urol. 54,
409–411. https://doi.org/10.4111/kju.2013.54.6.409
Hajdu, S.I., Shiu, M.H., Brennan, M.F., 1988. The role of the pathologist in the management of soft
tissue sarcomas. World J. Surg. 12, 326–331. https://doi.org/10.1007/BF01655665
Hamadalla, N.Y., Rifat, U.N., Safi, K.C., Mohammed, M., Abu-Farsakh, H., 2013. Leiomyosarcoma of the
urinary bladder: A review and a report of two further cases. Arab J. Urol. 11, 159–164.
https://doi.org/10.1016/j.aju.2013.03.004
Kieran, K., Shnorhavorian, M., 2016. Current standards of care in bladder and prostate
rhabdomyosarcoma. Urol. Oncol. Semin. Orig. Investig. 34, 93–102.
Oberlin, O., Rey, A., Lyden, E., Bisogno, G., Stevens, M.C.G., Meyer, W.H., Carli, M., Anderson, J.R.,
2008. Prognostic factors in metastatic rhabdomyosarcomas: results of a pooled analysis from
United States and European cooperative groups. J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol. 26,
2384–2389. https://doi.org/10.1200/JCO.2007.14.7207
Parekh, D.J., Jung, C., O’Conner, J., Dutta, S., Smith, E.R., 2002. Leiomyosarcoma in urinary bladder
after cyclophosphamide therapy for retinoblastoma and review of bladder sarcomas. Urology
60, 164. https://doi.org/10.1016/S0090-4295(02)01701-6
Rodríguez, D., Preston, M.A., Barrisford, G.W., Olumi, A.F., Feldman, A.S., 2014. Clinical features of
leiomyosarcoma of the urinary bladder: Analysis of 183 cases. Urol. Oncol. Semin. Orig.
Investig. 32, 958–965. https://doi.org/10.1016/j.urolonc.2014.01.025
Russo, P., Brady, M.S., Conlon, K., Hajdu, S.I., Fair, W.R., Herr, H.W., Brennan, M.F., 1992. Adult
Urological Sarcoma. J. Urol. 147, 1032–1036. https://doi.org/10.1016/S0022-5347(17)37456-
6
Slaoui, H., Sanchez-Salas, R., Validire, P., Barret, E., Rozet, F., Galiano, M., Cathelineau, X., 2014.
Urinary Bladder Leiomyosarcoma: Primary Surgical Treatment. Urol. Case Rep. 2, 137–138.
Spiess, P.E., Kassouf, W., Steinberg, J.R., Tuziak, T., Hernandez, M., Tibbs, R.F., Czerniak, B., Kamat,
A.M., Dinney, C.P.N., Grossman, H.B., 2007. Review of the M.D. Anderson experience in the
treatment of bladder sarcoma. Urol. Oncol. Semin. Orig. Investig. 25, 38–45.
Torenbeek, R., Blomjous, C.E., de Bruin, P.C., Newling, D.W., Meijer, C.J., 1994. Sarcomatoid carcinoma
of the urinary bladder. Clinicopathologic analysis of 18 cases with immunohistochemical and
electron microscopic findings. Am. J. Surg. Pathol. 18, 241–249.
Young, R.H., Wick, M.R., Mills, S.E., 1988. Sarcomatoid carcinoma of the urinary bladder. A
clinicopathologic analysis of 12 cases and review of the literature. Am. J. Clin. Pathol. 90, 653–
661.
62
Epidemiologi
- sangat jarang (0.2% dari seluruh melanoma) Malignant Melanoma Marker +
- S100 - Tyrosinase
- berdasarkan literatur, jumlah kasus tumor
melanoma primer <50 kasus of the Bladder - HMB45
- Mart-1/Melan-A
- MITF
- marker melanosit lain
- usia terdiagnosis berkisar 44-81 th
- prognosis jelek Kriteria Ainsworth et al mempertimbangan
lesi primer:
- tidak ada riwayat lesi kutaneus
- tidak terbukti adanya kutaneus melanoma
Etiologi maligna
- primer - tidak terbukti adanya melanoma visceral primer
- lesi metastasis - pola kekambuhan konsisten
lesi metastasis lebih banyak ditemukan - batas/margin lesi kulit mengandung melanosit
atipikal
Tanda dan gejala
- hematuria (gejala awal namun Terapi
Malignant Melanoma of the Bladder
merupakan tanda penyakit lanjut) - TUR-BT
- RC
- Imunoterapi (IL-2)
- irritattive LUTS - kemoterapi
disuria - radioterapi
- partial cystectomy
- massa terpalpasi di hipogastrik

Investigasi
- sistoskopi+biopsi
- sitologi + pewarnaan
- CT-scan/MRI
- pemeriksaan Wood’s light
- pasien meninggal dalam 3 tahun setelah
diagnosis karena komplikasi metastasis
- faktor prognostik:
adanya metastasis
ukuran dan kedalaman invasi melanoma
sumber: (Ainsworth Ann M. et al., 1976; Anichkov and Nikonov, 1982; Gupta and Grabstald, 1965; Kerley et al., 1991; Lee et al., 2003; Levy, 2016;
Niederberger and Lome, 1993; Pacella et al., 2006; Pa l et al., 2017; Sayar et al., 2014; Stein and Kendall, 1984; Su and Prince, 1962; Venyo, 2014;
Wheelock, 1942; Willis et al., 1980)
63
Daftar Pustaka
Ainsworth Ann M., Clark Wallace H., Mastrangelo Michael, Conger Kyril B., 1976. Primary malignant
melanoma of the urinary bladder. Cancer 37, 1928–1936. https://doi.org/10.1002/1097-
0142(197604)37:4<1928::AID-CNCR2820370444>3.0.CO;2-W
Anichkov, N.M., Nikonov, A.A., 1982. Primary Malignant Melanomas of the Bladder. J. Urol. 128, 813–
815. https://doi.org/10.1016/S0022-5347(17)53200-0
Gupta, T.D., Grabstald, H., 1965. Melanoma of the Genitourinary Tract. J. Urol. 93, 607–614.
https://doi.org/10.1016/S0022-5347(17)63838-2
Kerley, S.W., Blute, M.L., Keeney, G.L., 1991. Multifocal malignant melanoma arising in vesicovaginal
melanosis. Arch. Pathol. Lab. Med. 115, 950–952.
Lee, C.S.D., Komenaka, I.K., Hurst-Wicker, K.S., Deraffele, G., Mitcham, J., Kaufman, H.L., 2003.
Management of metastatic malignant melanoma of the bladder. Urology 62, 351.
https://doi.org/10.1016/S0090-4295(03)00354-6
Levy, G., 2016. Melanoma of bladder [WWW Document]. URL
http://www.pathologyoutlines.com/topic/bladdermelanoma.html (accessed 4.27.18).
Niederberger, C.S., Lome, L.G., 1993. Primary malignant melanoma of urinary bladder. Urology 41, 72–
74. https://doi.org/10.1016/0090-4295(93)90250-E
Pacella, M., Gallo, F., Gastaldi, C., Ambruosi, C., Carmignani, G., 2006. Primary malignant melanoma
of the bladder. Int. J. Urol. 13, 635–637. https://doi.org/10.1111/j.1442-2042.2006.01375.x
Patil, R.V., Woldu, S.L., Lucas, E., Quinn, A.M., Francis, F., Margulis, V., 2017. Metastatic Melanoma to
the Bladder: Case Report and Review of the Literature. Urol. Case Rep. 11, 33–36.
Sayar, H., Erdogan, S., Adamhasan, F., Gurbuz, E., İnci, M.F., 2014. Malignant melanoma of the bladder:
A case report. Can. Urol. Assoc. J. 8, 54. https://doi.org/10.5489/cuaj.1242
Stein, B.S., Kendall, A.R., 1984. Malignant Melanoma of the Genitourinary Tract. J. Urol. 132, 859–868.
https://doi.org/10.1016/S0022-5347(17)49927-7
Su, C.-T., Prince, C.L., 1962. Melanoma of the Bladder. J. Urol. 87, 365–367.
https://doi.org/10.1016/S0022-5347(17)64965-6
Venyo, A.K.-G., 2014. Melanoma of the Urinary Bladder: A Review of the Literature. Surg. Res. Pract.
2014, 1–13. https://doi.org/10.1155/2014/605802
Wheelock, M.C., 1942. Sarcoma of the Urinary Bladder. J. Urol. 48, 628–634.
https://doi.org/10.1016/S0022-5347(17)70753-7
Willis, A.J., Huang, A.H., Carroll, P., 1980. Primary Melanoma of the Bladder: A Case Report and Review.
J. Urol. 123, 278–281. https://doi.org/10.1016/S0022-5347(17)55897-8
64

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sumber: Antoni et al., 2017

sumber: Antoni et al., 2017

paparan tempat kerja

Sitologi urin, histopatologi

Ct scan/ CT-PET dan MRI dengan kontras digunakan

Signs and Symptoms

- Nyeri di pelvis/nyeri tulang; edema tungkai bawah,

sumber: (Epstein and Lotan, 2015)

4. Invasive Papillary Carcinoma

sumber: (Epstein and Lotan, 2015)

Muscle Invasive Bladder Cancer (MIBC)

dinding abdomen prostat/ uterus/ vagina

jantung invasi tumor

Other than Low and High

> 3cm > 3cm

Highest risk: T1,G3/HG+ CIS;

Sitologi Urin + Histopatologi Lesi + Marker Urin

Ct scan/ CT-PET dan MRI dengan kontras

otot detrusor otot detrusor

reseksi fraksi-fraksi reseksi En-Bloc

PDD (-) PDD (+) TUR-BT + Photodynamic Diagnosis (PDD)/NBI(Narrow

NBI (-) NBI (+)

Indikasi reseksi ke-2:

& dengan tuntas namun, resiko rekuren

Intravesical Immunotherapy (BCG)

KI absolut instalasi BCG:

TUR-BT + biopsy NMIBC kembali ke

Tumor primer/rekuren tanpa riwayat chemotherapy:

sumber: (Babjuk et al., 2018)

sumber: (Babjuk et al., 2018)

A IL - rekuren high grade setelah terapi BCG

sumber: (Umbas et al., 2014)

Adjuvant chemotherapy (cisplatin-based)

- Pada pasien yang tidak dapat atau tidak ingin dilakukan RC

diberikan pada pT3/4

Bila dak ada tumor,

Bila dak ada tumor,

sumber: (Spiess et al., 2017) Terapi Adjuvan

Chemoradiotherapy Chemotherapy atau

sumber: (Spiess et al., 2017)

+ rata-rata klinis adekuat,

- komplikasi renal karena infeksi

- Immunotherapy pada pasien yg KI cisplatin antibodi menyerang

sumber: (Spiess et al., 2017)

Negara-negara endemis schistosomiasis: Negara-Negara Barat

% Keganasan Di negara-negara endemis 20-30% 2-5%

Infeksi virus dan bakteri yang

Infeksi Saluran Kemih (ISK) kronik

virus bakteri Urinary Stasis, Bladder Stone

- Growth Factor >>

- Nyeri di pelvis/nyeri tulang; edema tungkai bawah,

Sering berbarengan dengan sistitis kronis dan ISK

- sitologi Urin, mencari sel kanker dalam urin

- CT-Urografi menilai kalsifikasi di dinding buli, inflamasi dan

2. Terapi Radiasi - Pada NB-SCC radioterapi neoadjuvan + RC meningkatan Disease-

3. Kemoterapi - Berbeda dengan TCC yang kemosensitif, SCC dikenal sebagai

4. kontrol bilharziasis - Menurunkan prevalensi schistosomiasis

- Pasien dengan buli ekstroﬁ memiliki resiko selama