Clinical challenge Prof. Oliver Hakenberg Section editor Rostock (DE)
The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem. Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org
Oliver.Hakenberg@ med.uni-rostock.de
Case study No. 69
Case study No. 68 This 86-year-old man was referred with painless macroscopic haematuria. A CT scan, which had been performed without contrast media because of elevated serume creatinine, showed a ‘large tumorous lesion of the left lateral bladder wall’ (Figure 1, arrow sign). Cystoscopy showed that a mesh implanted for a laparoscopic left inguinal hernia repair several years previously had ingrown into the bladder and that around this foreign body papillary formations suggestive of a bladder malignancy were present. TUR-biopsy confirmed urothelial carcinoma grade 2 without
evidence of muscle-invasion but there was no detrusor tissue in the biopsies. Discussion point • Which management and treatment is advisable?
Case provided by Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail: oliver.hakenberg@med.uni-rostock.de Figure 1
A 35-year-old man suffered a straddle injury to the urethra without pelvic fracture. A few weeks later, he complained of dysuria and a urethrogram showed a stricture which was treated by direct vision internal urethrotomy (DVIU). Already three weeks later, a recurrence occurred. During the following two years, the patient underwent eight endoscopic procedures, either dilatation or DVIU. Eventually, a urethroplasty was performed. One year later, the patient is still complaining of dysuria and was referred to our centre without any detailed reports of the previous procedures. A new urethrogram was done (Fig. 1).
Partial cystectomy en bloc with entire mesh, extraperitoneally Comments by Prof. Arnulf Stenzl Tübingen (DE)
The assumption in this case is that a papillary tumour formed around a foreign body infiltrating the bladder wall. Although we don’t know whether G2 meant Low grade or high grade it may very well have been high grade due to the CT (without contrast material though) and due to the fact that the tumour may have derived from chronic inflammation originating from a foreign body. Any further imaging including MRI (with or without VI-RADS) will not really be helpful. What are the options? In an otherwise healthy and fit man – despite his age - one would go for
another deep transurethral resection into the perivesical space, maybe even an en bloc resection might be feasible. Depending on the results in a fit patient consider radical cystectomy with maybe a ureterocutaneous diversion. In this gentleman, however, with chronic renal insufficiency and maybe other comorbidities you should consider an excision of the tumour bearing bladder wall including a safety margin and the entire mesh. I don’t favour a partial cystectomy but under these circumstances it might be an advisable option. The fact that the tumour may have originated from the mesh and the insertion of this mesh will have altered lymphatic drainage in this area makes any excision of this tumour more dangerous for spillage. Therefore, the partial cystectomy done en bloc with the entire mesh should be done extraperitoneally in
order to avoid any possible spillage into the extravesical space and peritoneum. I would strongly discourage any minimally-invasive surgery, because of the danger of spillage through a regular transperitoneal access and otherwise the limited possibility of doing a minimally invasive partial cystectomy en bloc with the tumour bearing foreign body extraperitoneally. Any chance for a non-surgical bladder preserving strategy? Radiation either as mono or part of a multimodality therapy in this case may not be a good option because of more expected side effects with a foreign body and concomitant inflammation. He is presumably unfit for any cisplatin based chemotherapy, and we don’t know his PDL-1 status.
Fig. 1
Discussion point • Which treatment is advisable?
Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunesia. E-mail: aminbouker@gmail.com
Case study No. 68 continued Since the primary histology was somewhat inconclusive, and due to the fact that the surgical mesh was incorporated into the bladder wall and the tumour, we performed partial cystectomy. The final pathology report confirmed a solid urothelial carcinoma growing through the entire bladder wall (pT3b G3), with negative surgical margins. Two lymph nodes had been removed which were negative. Since this man is 86 years old and took some time to recover from surgery no further treatment was deemed appropriate.
Base best treatment option on tumour grade, aetiology and comorbidities Comments by Prof. Morgan Rouprêt Paris (FR)
Which management and treatment is advisable ? There is no doubt in my mind that we are dealing with a difficult case of primary bladder cancer in an elderly patient. The tumour appears to be “large” on the CT. We have to be extremely careful as CT artifacts are common with foreign body in the bladder wall. Some data are missing here to make a decision. Do we have a pre-operative positive cytology? Do we have images of the upper urinary tract? Are we facing a pTaG2 tumour or a pT1G2 tumour. This is not the same, as several G2 tumours (> 60%) can be translated in high grade tumours in the most recent WHO classification. High grade includes some G2 and all G3 tumours. Consequently, we are facing a difficult situation from real life because the presence of detrusor is a surrogate of the quality of the TUR. I am a bit concerned about the term “biopsy” which seems to suggest that the endoscopic procedure was not complete and exhaustive. To be very straight forward:
March/May 2021
• I would ask the pathologist to provide the Grade of the tumour according to the WHO 2004 classification (low versus high) • I would advocate a second-look with a so-called good ‘old fashioned’ TURB as there are too many uncertainties around the T stage and the Grade of the tumour We know from clinical experience that the foreign body could have launched and triggered the carcinogenic pathway within the bladder wall. I am also concerned about the existence of histological variants within the tumour when the carcinogenic pathway has (possibly) been initiated by a foreign body. We know from the EAU guidelines that we have to base the decision on bladder-sparing treatment or radical cystectomy in elderly/frail patients with invasive bladder cancer on tumour stage and comorbidity. Management First option: Please be aware that we could also face a bladder tumour case (Ta Low Grade) on top of a foreign body which has induced a “so-called” chronic abscess imitating cancer of the bladder wall. And in that case, the problem could be solved by simple surveillance after a deep TURBT. In our department, we have had this experience in a limited number of women who had persisting disabling symptoms after conservative management of TVT mesh through the bladder wall. Urologists must be aware that a complete resection of the MESH can help resolve the symptoms and could
be advocated here. Thus complete TURBT and complete removal of the mesh (external approach) could also be an option to discuss. Second option: One can hypothesize that this man is facing a situation of high-risk urothelial carcinoma of the bladder with a kidney obstruction. Theoretically, a radical cystectomy and a ileal conduit should be proposed contingent upon the fact that the pathological assessment can confirm we are at least facing T1 high grade tumour. We cannot rely only on the size of the tumour nor on its “aspect” on CT. I would be reluctant to deliver intravesical instillation of BCG or Mitomycin in that particular situation (bladder extravasation risk). Facing a high risk bladder cancer, and regardless of his age, I would not hesitate to propose a radical cystectomy, after a careful evaluation (anaesthesiology and geriatric oncology). However, a cystectomy decision in a 86-year-old gentleman is a tough and last-resort decision which should not be made based on the existence of “a large tumour” only, but much more on what has been seen by the urologist during the TUR. Only more details from the pathologist, a discussion within a tumour board and an accurate evaluation of the patient’s comorbidities, will help us to make the best decision in such a difficult situation. References European Association of Urology Guidelines on Muscleinvasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines.
Witjes JA, Bruins HM, Cathomas R, Compérat EM, Cowan NC, Gakis G, Hernández V, Linares Espinós E, Lorch A, Neuzillet Y, Rouanne M, Thalmann GN, Veskimäe E, Ribal MJ, van der Heijden AG.Eur Urol. 2021 Jan;79(1):82-104.
European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update. Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Sylvester R, Zigeuner R, Capoun O, Cohen D, Escrig JLD, Hernández V, Peyronnet B, Seisen T, Soukup V.Eur Urol. 2019 Nov;76(5):639-657. Laparoscopic surgical complete sling resection for tension-free vaginal tape-related complications refractory to first-line conservative management: a single-centre experience. Rouprêt M, Misraï V, Vaessen C, Cour F, Haertig A, Chartier-Kastler E.Eur Urol. 2010 Aug;58(2):270-4.
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