Open AccessBladder cancer in Senegal: what's new? O Gaye, M Jalloh, M Ndoye, A Tall, NM Thiam, C Dial, I Labou, L Niang and SM Gueye O Gaye1 https://orcid.org/0000-0001-8873-9560 , M Jalloh1 https://orcid.org/0000-0002-2190-328X , M Ndoye1 , A Tall1 , NM Thiam1 , C Dial2 , I Labou1 , L Niang1 and SM Gueye1 Affiliations 1Urology Department, General Hospital Idrissa Pouye, Senegal 2Pathological Anatomy Laboratory, General Hospital Idrissa Pouye, Senegal Published Online:1 Jan 2023https://doi.org/10.36303/AUJ.0061https://hdl.handle.net/10520/ejc-mp_afurol_v3_n1_a3SectionsPDFAbstract ToolsAdd to favouritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InRedditGMailOutlookYammermore AboutAbstractBackground:The histological type determines the outcome of bladder cancers. Our study investigates the epidemiology of bladder cancer histology at our centre and compares it with previous studies carried out in Senegal.Methods:This descriptive and analytical study was conducted among 190 patients observed for bladder cancer at General Hospital Idrissa Pouye over a period of eight years. The parameters studied were age, gender, histological type, tumour stage, smoking exposure, presence of bilharzia eggs, clinical and paraclinical signs, locoregional and distant extension, treatment and recurrence.Results:The mean age of the participants was 62.37 ± 13.96 years. The gender ratio (M/F) was 1.63. Urothelial carcinoma was the most common histological type (79.5% of cases). Squamous cell carcinoma was found in 11.1% of the participants and was more frequent among patients under 40 years of age and among women. The tumour infiltrated the muscle in 78.42% of cases. Active smoking was observed in 45.2% of the participants and the presence of bilharzia eggs was found in 14.2% of cases. Haematuria was the most presenting finding of bladder cancer (91.58% of cases). Six patients had undergone endovesical chemotherapy. Twenty-one patients with non-muscle-invasive bladder tumours (NMIBT) had recurred. Cystectomy had been performed in 35 patients.Conclusion:Urothelial carcinoma has become the most common type of bladder cancer, followed by squamous cell carcinoma. It is necessary to design a care pathway for endovesical chemotherapy and appropriate monitoring.IntroductionBladder cancer is the tenth most common cancer in the world. Differences in incidence worldwide can be explained in part by differences in exposure to bladder cancer risk factors.1 The most common histological type in Africa, in the past, was squamous cell carcinoma,2-4 while urothelial carcinoma is the predominant histological type in northern countries.5,6Urogenital bilharzia is the main aetiological factor for squamous cell carcinoma of the bladder.7 In 1994, the International Agency for Research on Cancer (IARC) confirmed that Schistosoma haematobium is carcinogenic.8 However, the reason why schistosomiasis is more often associated with squamous cell carcinoma than with urothelial carcinoma, is unclear. It is known that Schistosoma haematobium eggs cause metaplastic lesions on the bladder urothelium that can progress to squamous cell carcinoma.9 Schistosomiasis is a highly endemic parasitosis in Senegal and is caused by the construction of dams.10,11 Owing to its high morbidity, a schistosomiasis control programme has been in place in Senegal since 1988.Other risk factors for bladder cancer such as smoking, occupational exposure, repeated urinary tract infections and metabolic syndrome, are more often associated with urothelial carcinoma.12Despite numerous deterrence campaigns, smoking continues to increase in our regions. Furthermore, the increase in industrialisation and a lack of suitable means to protect workers mean that they are experiencing greater occupational exposure to factors that cause bladder cancer.These lifestyle changes in our regions mean that we now share the same risk factors for bladder cancer as westerners. This may have an impact on the histological types of bladder cancer seen at our centres.The identification of histological type prior to treatment is important, as this has therapeutic implications. Endovesical chemotherapy is indicated after transurethral resection of the bladder tumour (TURBT) for non-muscle-invasive urothelial carcinomas. However, for non-muscle-invasive squamous cell carcinomas, a cystectomy is required in the same way as for muscle-invasive bladder tumours (MIBT) or non-muscle-invasive bladder tumours (NMIBT) with a very high recurrence risk. When cystectomy is indicated for urothelial carcinoma, neoadjuvant chemotherapy is recommended.12 In contrast, squamous cell carcinomas are chemoresistant and there is no proven benefit to neoadjuvant or palliative chemotherapy in this type of cancer.13As the management of bladder cancer depends on the histological type, it is necessary to evaluate the impact of preventive measures against bilharzia and of lifestyle changes on the epidemiology of bladder cancer at our centre. Thus, the aim of this study was to describe the evolution of the histological type and the clinical presentation of bladder cancer in Senegal in order to better plan the management thereof.MethodsWe conducted a descriptive and analytical study to evaluate the epidemiology of bladder cancer histology. We collected medical records and histological reports of patients over a period of eight years (January 2013 to December 2020) from the Urology Department and the Pathological Anatomy Laboratory, General Hospital Idrissa Pouye. We included patients who were observed for bladder cancer within these departments and who had complete medical records.The parameters studied were age, gender, histological type, tumour stage, smoking exposure, presence of bilharzia eggs in surgical specimens, clinical and paraclinical signs, locoregional and distant extension, treatment and recurrence. We compared these parameters for the two histological types most frequently encountered in our regions, namely squamous cell carcinoma and urothelial carcinoma.We also compared results published at the Hospital Aristide Le Dantec and those previously published at our centre as these two centres are the reference centres for the management of bladder cancer in Senegal. This comparison allowed us to observe the evolution of the epidemiology of bladder cancer, specifically in Senegal.Data analysis was done with IBM SPSS Statistic software, version 2.0 (IBM Inc., USA). We determined averages for quantitative variables. For qualitative variables, we estimated proportions. The comparison between qualitative variables was done with the chi-square test. Statistical significance was considered for alpha < 0.05.ResultsA total of 190 participants were included in this study. The mean age of the participants was 62.37 ± 13.96 years, with extremes of 21 and 90 years. Of the participants, 111 were older than 60 years. The gender ratio (M/F) was 1.63.Urothelial carcinoma was the most common histological type found in 79.5% of the participants, while squamous cell carcinoma was found in 11.1% of the participants (Table I).We observed an increase in the proportion of urothelial carcinoma between 2013 and 2018 but a decrease in the proportion of squamous cell carcinoma during the same period. We also observed that other cumulative histological types (sarcoma and adenocarcinoma) were more frequent than squamous cell carcinoma from 2017 onwards (Figure 1).Urothelial carcinoma was more common among men, while squamous cell carcinoma was more common among women (Figure 2). There was a significant relationship between gender and these two histological types (p = 0.001). Squamous cell carcinoma was predominant among patients under 40 years of age, while urothelial carcinoma was predominant among patients over 40 years of age (Figure 3). The relationship between histological type and age is statistically significant (p < 0.05) (Table I).Schistosoma haematobium eggs were found in 27 participants (14.21%). There was a relationship between the presence of bilharzia eggs and squamous cell carcinoma (p < 0.05) (Table I).Active smoking was observed in 45.2% of the participants. Urothelial carcinoma was diagnosed in 82% of the active smoking participants and there was a statistically significant relationship between active smoking and urothelial carcinoma (p = 0.01) (Table I).Haematuria was the most presenting finding of bladder cancer (91.58% of participants) and cystoscopy was the main imaging procedure used to diagnose bladder tumours (83.68%). Multifocal location was seen in the majority of participants (44.21%) and node invasion in tomodensitometry was found in 31.1% of cases. Distant metastases were found in 33.3% of cases. There was no significant difference between histological type and lymph node involvement and distant metastases (Table I).The bladder tumour invaded the muscle in 78.42% of cases. There was no significant difference between histological type and muscle invasion (p = 0.85) (Table I).Of the 41 participants with NMIBT, eight participants had papillary carcinoma. Six of them had undergone endovesical chemotherapy with gemcitabine in addition to TURBT. No Bacillus Calmette-Guérin (BCG) therapy was performed for the other NMIBT. Of the 41 participants with NMIBT, 21 had relapsed. Six of these participants had recurred in the NMIBT mode and had undergone cystectomy. Fifty-six participants had non-metastatic MIBT.Total cystectomy was performed in 32 participants and partial cystectomy in three participants, while Bricker diversion was performed in 22 participants and neo-bladder in 10 participants.DiscussionThe mean age of our patients tends to be close to that of Western series.14,15 We have observed an increase in the mean age of patients with bladder cancer in Senegal from 45 years old before 20053 to 62 years currently (Table II). This increase in the age at which cancer occurs is mainly explained by a decrease in the proportion of squamous cell carcinoma, which occurs more in younger people.3,15Like most studies published in Senegal, we observed that bladder cancer is more prominent in males.3,14 However, our study observed that females were associated more with squamous cell carcinoma. This could be explained by the fact that women are the most exposed to schistosomiasis16 and that they consume less tobacco in our regions.As in Egypt, there has also been a change in the predominant type of cancer in our country in recent years. In Egypt, squamous cell carcinoma was predominant at 73% between 2001 and 2005, while between 2006 and 2010 transitional cell carcinoma was predominant at 65%.17 In Senegal, at the Hospital Aristide Le Dantec, squamous cell carcinoma was predominant at 58.4% before 20053 and urothelial carcinoma became predominant at 51.5% between 2014 and 2018.18 This trend was also observed at our centre with the proportions of squamous cell carcinoma decreasing from 48.3%19 to 11.1% (Table II).These results could have the same explanation as in Egypt with a decrease in schistosomiasis infestation on the one hand and an increase in smoking among patients on the other hand. Indeed, in Egypt, bilharzia eggs were found in 70% of surgical parts before 2005 compared to 15% in surgical parts after 2005.17 In Senegal, Diao et al.'s study3 published in 2005 found bilharzia eggs in 29.9% of surgical specimens compared to 14.9% in our study. We also noted that smoking exposure increased from 8.1% before 201319 to 45.2% among patients at our centre.We did not observe any difference between lymph node involvement and distant metastasis, and the different histological types. However, it has been described in the literature that squamous cell carcinoma has lymph node and bloodstream extension.15,20In Senegal, urogenital bilharziasis is prevalent in all regions with a prevalence reaching more than 50% in some areas.10,11 This causes significant morbidity,21 including bladder cancer. The association between bilharzia and squamous cell carcinoma has been described as early as 1911 by Ferguson22 and has also been reported in our study and other African studies.20,22,23 To reduce the morbidity of this parasite, a control programme has been put in place by Senegal's health authorities since 1988. It consists of making regular anti-bilharzia chemotherapy available to affected communities, regularly treating school-aged children both in schools and Koranic schools (dahras), providing early treatment to cases in isolated communities, promoting clean water supply and sanitation, controlling intermediate host molluscs, and integrating a health prevention component in all hydro-agricultural development projects.This control programme could partly explain the decrease in the proportion of squamous cell carcinoma observed in our country.In addition, hybrid strains (Schistosoma haematobium and Schistosoma bovis) have been observed in northern Senegal. These strains accounted for 24% of the samples infested by Schistosoma haematobium.24 However, this study24 showed that hybrid strains cause less urogenital morbidity than the pure strain.25 Therefore, the appearance of hybrid strains of Schistosoma haematobium could also explain the decrease in squamous cell carcinoma.The predominance of urothelial carcinoma observed in Senegal requires the adaptation of management. In fact, NMIBTs have a high potential for recurrence and therefore require maintenance therapy and monitoring. A care pathway for these patients must be set up and training must be provided for paramedical staff, which is essential for the maintenance therapy to run smoothly. An effort must also be made by the authorities to make BCG therapy available. The recurrence rate of NMIBT is indeed very high in our study as none of the patients who required BCG therapy had the benefit of it.Despite a change in histological type, the majority of tumours diagnosed invade the muscle. Cystectomy still has an important place in the management of our patients. However, we have observed a low rate of cystectomy in patients requiring this treatment.More effort needs to be made for earlier diagnosis of bladder cancer. Urinary biomarkers are less invasive than cystoscopy, and do not require special skills. Therefore, it can be performed in the most remote areas and may help to obtain earlier diagnoses.ConclusionA comparison between our results and those previously published in Senegal shows that urothelial carcinoma has become the predominant histological type of squamous cell carcinoma pattern. The recurrence rate of NMIBT was very high. It is therefore necessary to adapt the management of patients by setting up a care pathway for endovesical instillation and monitoring. A prospective multicentre study will allow for better understanding each risk factor in the occurrence of bladder cancer in our country, and propose new adequate preventive measures.Figures and TablesFigure 1: Distribution of the different histological types of bladder cancer according to the years (2013–2020)Download FigureFigure 2: Distribution of the different histological types of bladder cancer according to genderDownload FigureFigure 3: Distribution of the different histological types of bladder cancer according to age groupDownload FigureTable I: Comparison of epidemiological and clinical parameters according to histological typeVariablesTCCSCCOthersp-valueNumber151 (79.5%)21 (11.1%)18 (9.4%)–Age (%)< 6028.585.755.60.00≥ 6071.514.344.4GenderMale68.223.855.60.001Female31.876.244.4Smoking (%)Ye s49.515.853.30.01Bilharziasis (%)Ye s11.938.15.60.00Pathologic stage (%)< T214.323.216.70.85≥ T285.776.883.3Lymph node (%)N070.56066.70.12N+29.54033.3Metastases (%)M064.869.2800.87M+35.230.820TCC – transitional cell carcinoma, SCC – squamous cell carcinomaTable II: Comparison of the various works published in Senegal on bladder cancerVariableH. Le Dantec 1950–2005H. Le Dantec 2014–2018HOGIP 2009–2013HOGIP 2013–2020Mean age45.555.65562.37Gender ratio1.252.11.81.6Pathologic finding (%) SCC58.432.348.311.1 TCC38.451.537.979.5 Others3.216.213.89.4Smoking (%) Yes––8.145.2Bilharziasis (%) Yes29.9–13.914.2TCC – transitional cell carcinoma, SCC – squamous cell carcinoma, H – hospital, HOGIP – General Hospital Idrissa PouyeConflict of interestThe authors declare no conflict of interest.Funding sourceNo outside funding was required.Ethical approvalThe institutional review board of General Hospital Idrissa Pouye (Dakar, Senegal) approved this study. Informed consent was waived by the ethics committee as this study is retrospective.1. Ferlay JColombet MSoerjomataram Iet al. "Cancer statistics for the year 2020: an overview" Int J Cancer2021 149477889 DOI: https://doi.org/10.1002/ijc.33588 Google Scholar2. Bowa KMulele CKachimba Jet al. "A review of bladder cancer in sub-Saharan Africa: a different disease, with a distinct presentation, assessment, and treatment" Ann Afr Med2018 17399105 DOI: https://doi.org/10.4103/aam.aam_48_17 Google Scholar3. Diao BAmath TFall Bet al. "Les cancers de la vessie au Sénégal: particularités épidémiologiques, cliniques et histologiques" Prog Urol2008 1874458 DOI: https://doi.org/10.1016/j.purol.2008.04.016 Google Scholar4. Dangou JMMendès VBoye IAGaye GWNdiaye PD "Le cancer vésical au Sénégal, expérience du laboratoire d'anatomie pathologique du C.H.U de Dakar (SENEGAL)" Méd Afr Noire1996 4363625 Google Scholar5. Al-Husseini MJKunbaz ASaad AMet al. "Trends in the incidence and mortality of transitional cell carcinoma of the bladder for the last four decades in the USA: a seer-based analysis" BMC Cancer2019 1946 DOI: https://doi.org/10.1186/s12885-019-5267-3 Google Scholar6. 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"Imagerie des tumeurs urologiques dans une zone d'endémie bilharzienne au Mali" J Afr Cancer2009 113540 DOI: https://doi.org/10.1007/s12558-009-0015-2 Google Scholar24. Léger EBorlase AFall CBet al. "Prevalence and distribution of schistosomiasis in human, livestock and snail populations in Northern Senegal: a One Health epidemiological study of a multi-host system" Lancet Planet Health2020 433042 DOI: https://doi.org/10.1016/S2542-5196(20)30129-7 Google Scholar25. Fall CBLambert SLéger Eet al. "Hybridized zoonotic schistosoma infections result in hybridized morbidity profiles: a clinical morbidity study amongst co-infected human populations of Senegal" Microorganisms2021 981776 DOI: https://doi.org/10.3390/microorganisms9081776 Google Scholar Previous article Next article FiguresReferencesRelatedDetails None InformationCopyright © 2023, the Author(s)LicensesThis work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Keywordshistologybladder cancerSenegalschistosomiasisendovesical chemotherapyAcknowledgmentsSpecial thanks to the Urology Department, General Hospital Idrissa Pouye.PDF download Disclosure The authors confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. The authors confirm that they have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. Ethical conduct of research The authors state that they have obtained appropriate institutional review board outlined in the Declaration of Helsinki for all human or animal experimental investigations. A signed informed consent document has been obtained from all participants included in the study.

ObjectifsL’objectif de cette étude était d’évaluer la sexualité des drépanocytaires SS ayant des antécédents de priapisme.MéthodesIl s’agissait d’une étude cas-témoins portant sur des drépanocytaires SS adultes. La survenue du priapisme ainsi que la nature du priapisme avaient été recherchées. Les patients étaient subdivisés en trois groupes : Groupe 1 (pas de priapisme), Groupe 2 (priapisme intermittent) et Groupe 3 (priapisme aigu). La sexualité des patients avait été étudiée à l’aide du questionnaire IIEF-15.RésultatsNous avions interrogé 191 drépanocytaires SS. L’âge moyen était de 27,1±7,1 ans. Le priapisme était observé chez 43,5 %. Seuls 77 patients étaient éligibles au questionnaire IIEF15. Les groupes 1 et 2 avaient des résultats significativement meilleurs que le groupe 3 sur les scores de la fonction érectile (EF) et de la fonction orgasmique (FO). Il n’existait pas de différence significative des scores EF et FO entre les groupes 1 et 2. Aucune différence significative n’avait été observée entre les trois groupes pour les scores du désir sexuel (SD), de la satisfaction des rapports sexuels (IS), et de la satisfaction globale (OS). L’altération de la fonction érectile du groupe 2 était liée à l’âge du premier épisode de priapisme et du dernier épisode. L’altération de la fonction érectile du groupe 3 était liée à la durée d’évolution (p<0,05).ConclusionCette étude montre que le priapisme est responsable d’une altération de la fonction érectile chez les drépanocytaires adultes SS. Un programme de prévention des épisodes de priapisme intermittent doit être mis en place.

Objectives. - The objective of this study was to evaluate the sexuality of SS sickle cell patients with a history of priapism. Methods. - This was a case-control study of adult SS sickle cell patients. The occurrence of priapism as well as the nature of the priapism had been investigated. The patients were sub-divided into three groups: Group 1 (no priapism), Group 2 (intermittent priapism) and Group 3 (acute priapism). The patients' sexuality was studied using the IIEF-15 questionnaire.Results. - We interviewed 191 SS sickle cell patients. The mean age was 27.1 +/- 7.1 years. Pria-pism was observed in 43.5 %. Only 77 patients were eligible for the IIEF15 questionnaire. Groups 1 and 2 performed significantly better than group 3 on erectile function (EF) and orgasmic func-tion (OF) scores. There was no significant difference in the EF and OF scores between groups 1 and 2. No significant difference was observed between the three groups for the scores of sexual desire (SD), intercourse satisfaction (IS), and overall satisfaction (OS). The impairment of erectile function in group 2 was related to the age of the first episode of priapism and the last episode. The impairment of erectile function in group 3 was related to the duration of evolution (P < 0.05). Conclusion. - This study shows that priapism is responsible for impaired erectile function in SS adult sickle cell patients. A program to prevent intermittent episodes of priapism should be put in place.(c) 2022 Elsevier Masson SAS. All rights reserved.