Radical cystectomy for bladder urothelial carcinoma with variant histology
Asmaa Ismail1, Amer Alaref2, Ahmed S. Zakaria Ahmed1, Hazem Elmansy1, Walid Shahrour1, Owen Prowse1, Ahmed Kotb1.
1Department of Urology, Northern Ontario School of Medicine, Thunder Bay, ON, Canada; 2Department of Radiology, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
Introduction: The aim of our manuscript was to report our experience in managing bladder cancer in patients with variant pathology.
Methods: We conducted a retrospective data collection for all patients managed by radical cystectomy for a variant pathology over the last three years.
Results: Ten patients could be identified, including eight patients with micropapillary cancer (MPC) and two with nested variants. Nine patients were males. The median age was 75 years (56–84). The two patients with nested variant were 56- and 62-years-old, while all patients with MPC were older than 70. On transurethral resection of bladder tumor (TURBT) for patients with nested variant, one patient had a domal T1 tumor and the other had T2 small trigonal tumor. Radical cystoprostatectomy was done and the final pathology was T2No for the first patient and T4aN1 for the second case. For patients with MPC, two and six patients had T1 and T2, respectively, on TURBT. Intravesical bacillus Calmette-Guérin (BCG) induction course was tried for the T1 cases and upstaging to T2 was identified. Cystectomy was done and the pathology was T2, T3, and T4 in two, two, and four patients, respectively. Urethrectomy was done with cystectomy for the female patient and had cancer invasion. Two patients developed urethral recurrence within 4–6 months after surgery. Three patients (37.5%) had positive lymph nodes invasion at the time of cystectomy. Within a median followup of 13 months, local recurrence developed in three patients (30%), including two urethral and one new lateral pelvic mass. Figure 1 shows a large cT4 MPC and Figure 2 shows cT1 nested variant.
Conclusions: Patients with micropapillary and nested variants of bladder cancer are always muscle-invasive and cystectomy should not be delayed. Upfront urethrectomy or early and frequent postoperative urethroscopy should be offered. In our cohort, MPC affected elderly patients, while nested variant affected younger patients. Bladder-sparing protocols and prostate-sparing cystectomy may not be the best options for bladder cancer variants.
