A Sexually Active 29-Year-Old Man With a Weak Urine Stream

Liana Meffert; Paul Gellhaus, MD

Disclosures

April 26, 2021

Bladder cystoscopy remains the criterion standard for the diagnosis of bladder cancer. In this patient, cystoscopy revealed a 3-cm papillary bladder mass (Figure 1). Transurethral resection of the bladder tumor (TURBT) was subsequently performed, with complete resection of a solitary 3-cm papillary bladder tumor.

Figure 1.

TURBT is necessary for staging and provides a histologic grade and depth of tumor invasion into the bladder wall. In addition to TURBT and a thorough pelvic examination, imaging of the upper urinary tract via CT or MRI with intravenous contrast is used to identify any secondary primary lesions or metastases. Examples of bladder tumors on CT and MRI that are similar to the tumor found in this patient are shown in Figures 2 and 3.

Figure 2.

Figure 3.

Additional delayed-phase imaging allows evaluation of upper urinary tract lesions. This patient's CT scan confirmed a single left lateral bladder wall papillary lesion, with no evidence of multifocal or metastatic disease.

His tumor cytology results were negative for high-grade urothelial cancer. The pathology report revealed a low-grade noninvasive papillary bladder tumor (LGTa) and a minute focus of high-grade morphology with lamina propria invasion (T1HG), without invasion into the muscularis propria.

As shown in this patient, the initial treatment of noninvasive bladder cancer is complete TURBT, with muscularis propria included to detect muscle invasion and to aid in staging. Patients are then stratified on the basis of the estimated rate of disease progression into low-, intermediate-, and high-risk groups.

This patient's stage T1 tumor with a small focus of high-grade morphology put him in the high-risk group. The management options ranged from cystoscopy in 3 months to repeated TURBT with intravesical therapy. For high-risk patients, a second TURBT is recommended at 4-6 weeks after the initial TURBT to avoid the risk of understaging. This restaging procedure is also recommended if the tumor was not completely removed or if muscularis propria was not present in the initial TURBT. After a discussion of the risks and benefits, the patient chose to proceed with repeated TURBT.

After resection for non–muscle-invasive bladder cancer, induction intravesical therapy is recommended in most patients. Bacillus Calmette-Guérin (BCG) is the most well-established intravesical treatment. An initial 6-week induction course is recommended for patients at medium to high risk.

A surveillance cystoscopy with cytology is recommended within 3-4 months of the start of treatment. The frequency of screening thereafter is determined by the level of risk. Fluorescence in situ hybridization and cytology may also be used in conjunction with cystoscopies for surveillance and can be particularly informative in cases with negative cystoscopy findings or equivocal cytology results for high-grade disease. However, these studies are considered supplemental and are not recommended as a replacement for cystoscopy.

About 6 weeks after his initial TURBT, this patient underwent a second TURBT, which was negative for persistent cancer. BCG therapy was then started to reduce the risk for disease recurrence.

Approximately 70% of newly diagnosed bladder cancers present as noninvasive or superficial. The recurrence rate is about 50%-70%, and 10%-20% of these cancers ultimately invade the muscularis propria. The prognosis for this patient with T1 disease is a progression-free survival of 44% and a disease-specific survival of 62%.[7]

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