Ali RaziUrologist

Tehran Medical University2012

Clinical Picture 81 y old male Acute Urinary retention.PMH :

TUR-P 4y ago , BPH on pathologic report and one time urethral dilatation after that .

Appendectomy 3 y ago.DM : Controlled by oral antiglycemic agents .

Work Up

UltraSonography

Lt. kidney : NLRt. Kidney : Mild Hydronephrosis + 5 cm

simple cyst . Bladder : a 4*4*5 cm solid mass on Rt. Lat.

Side.

MRI

MRI

MRI

MRI

MRU

MRU

On Cystoscopy , there is a ulcerated , sessile mass on the Rt. Lat. Side of bladder.

Bimanual exam before the TUR the bladder was not fixed but there is palpable pelvic

mass with suspicion of extravesical extension.TUR-Bx was done .

Pathologic Report

High Grade Transitional Cell Carcinoma+

Deep muscle involvement

Metastatic Work up

CBC : Mild AnemiaLFT : NL.Serum electrolytes and Ca : In Nl. RangeCXR : Unremarkable Whole Body Bone Scan : No evidence of

Metastasis

Further Discussion

Options ?

First Option :

Radical Cystectomy

Second Option

Bimodality Treatment

Neoadjuvant chemotherapy +

Radical Cystectomy+

Adjuvant Chemotherapy

Third Option

Three modality Treatment

Chemotherapy+

Radiation+

TUR-BT

Debates 1Resections :

Male : bladder- Prevesical fat-Prostate – Seminal Vesicles-Prostatic urethra Modifications : Prostate Sparing _ Seminal Vesicle Sparing

Female : Ant. Pelvic Exentration : bladder- Prevesical fat-Uterine – Ant. Vaginal wall- Ovaries-Urethra Modification : Uterine Sparing _ Ovarian sparing – Urethral

Sparing

Lymph node Dissection :

Number of lymph nodesLymph node density ( LND) :Conventional Vs. Extended pelvic lymph node

dissection

Debates 2Contraindications for cystectomy

Unrespectable lymph node involvementFixed bladder to pelvic wallRectosigmoid involvement

Frozen Section for end of ureter

Prostatic urethral involvement

Thank You