Ali Razi Urologist Tehran Medical University 2012.

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Presentation transcript:

Ali Razi Urologist Tehran Medical University 2012

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

MRI

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 Anemia LFT : NL. Serum electrolytes and Ca : In Nl. Range CXR : 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 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

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

Thank You