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Management of High-Grade Transitional Cell Carcinoma in an 81-Year-Old Male Patient

This case presentation discusses an 81-year-old male with acute urinary retention and a history of benign prostatic hyperplasia (BPH) who was diagnosed with high-grade transitional cell carcinoma following cystoscopy and TUR-Bx. Imaging revealed a solid mass in the bladder with deep muscle involvement. Treatment options considered include radical cystectomy, bimodality treatment (neoadjuvant chemotherapy followed by radical cystectomy and adjuvant chemotherapy), and trimodality treatment (chemotherapy, radiation, TUR-BT). The complexity of surgical and oncological considerations in this elderly patient is highlighted.

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Management of High-Grade Transitional Cell Carcinoma in an 81-Year-Old Male Patient

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  1. Case Presentation Ali Razi Urologist Tehran Medical University 2012

  2. 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 .

  3. Work Up

  4. UltraSonography

  5. Lt. kidney : NL • Rt. Kidney : Mild Hydronephrosis + 5 cm simple cyst . • Bladder : a 4*4*5 cm solid mass on Rt. Lat. Side.

  6. MRI

  7. MRI

  8. MRI

  9. MRI

  10. MRU

  11. MRU

  12. 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 .

  13. Pathologic Report High Grade Transitional Cell Carcinoma + Deep muscle involvement

  14. Metastatic Work up

  15. CBC : Mild Anemia • LFT : NL. • Serum electrolytes and Ca : In Nl. Range • CXR : Unremarkable • Whole Body Bone Scan : No evidence of Metastasis

  16. Further Discussion Options ?

  17. First Option : Radical Cystectomy

  18. Second Option Bimodality Treatment

  19. Neoadjuvant chemotherapy + Radical Cystectomy + Adjuvant Chemotherapy

  20. Third Option Three modality Treatment

  21. Chemotherapy + Radiation + TUR-BT

  22. Debates 1 • Resections : • 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 nodes • Lymph node density ( LND) : • Conventional Vs. Extended pelvic lymph node dissection

  23. Debates 2 Contraindications for cystectomy • Unrespectable lymph node involvement • Fixed bladder to pelvic wall • Rectosigmoid involvement Frozen Section for end of ureter Prostatic urethral involvement

  24. Thank You

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