1. 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

11. MRU

14.  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.

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

16. Metastatic Work up

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

18. Further Discussion Options ?

19. First Option : Radical Cystectomy

20. Second Option Bimodality Treatment

21. Neoadjuvant chemotherapy + Radical Cystectomy + Adjuvant Chemotherapy

22. Third Option Three modality Treatment

23. Chemotherapy + Radiation + TUR-BT

24. 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

25. 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

26. Thank You