Abstract
Clinical case presentation: An 80-year-old man was admitted to our emergency department due to fever and progressively growing mass in the urinary diversion stoma four months after a radical cystectomy for muscle invasive bladder cancer.
 Surgical resection was done, and histo-pathological examination revealed metastases of high-grade urothelial carcinoma. After almost three years of follow-up any sign of recurrence did not seen. 
 Relevance: Urothelial cancer at all stages can metastasize to other organs.
 Metastasis occurs hematogenously to all organs, most frequently the lungs, liver, bone, or lymphatically to regional lymph nodes in the pelvis, or further to retroperitoneal lymph nodes. Metastasis of bladder cancer in the ileal conduit stoma is unusual. Cancer recurrence after radical cystectomy has-been reported in ureteroileal anastomosis.
 Clinical implications: Surgical treatment is an option in these patients. Adjuvant radiotherapy and / or chemotherapy would be possible alternatives in more than one site of metastasis. There are no clinical guidelines establishing their correct management.
 Conclusion: The urinary diversion stoma metastases secondary to a urothelial carcinoma is a rare entity. Direct implantation during the surgical act, hematogenous, lymphatic or mixed dissemination, could justify metastatic implantation.
Highlights
Bladder cancer heterogeneity is based on its different progression patterns and therapeutic response
Fifty percent of muscle-invasive bladder cancer (MIBC) develop recurrence after radical cystectomy and distant metastases are more frequent than local recurrence.(1) The most common sites for bladder cancer metastases are the lymph nodes, bones, lungs, liver, and peritoneum
Tumors with a more advanced T category and an atypical histologic pattern develop early metastases more frequently.(2) The appearance of recurrence in the stoma of the urinary diversion, after radical cystectomy due to urothelial carcinoma, is an extremely rare entity, with very few cases described in the literature
Summary
Bladder cancer heterogeneity is based on its different progression patterns and therapeutic response. Non-papillary tumors have the highest risk for progression to muscle-invasive bladder cancer and metastatic disease. Tumors with a more advanced T category and an atypical histologic pattern develop early metastases more frequently.(2) The appearance of recurrence in the stoma of the urinary diversion, after radical cystectomy due to urothelial carcinoma, is an extremely rare entity, with very few cases described in the literature. A previous abdominal computed tomography scan was negative for lymph node infiltration or distant metastatic disease. An 80-year-old man, with a personal history of type 2 diabetes and an ex-smoker, was diagnosed with muscle-invasive bladder carcinoma, pT2G3, and underwent open radical cystectomy and iliac-obturator lymphadenectomy, with a urinary diversion through ureteroileostomy, using the classic Bricker technique, in May 2017. The histopathologic exam of the surgical specimen and unique lymph node reported high-grade urothelial carcinoma metastasis, with lymphovascular infiltration, and tumor-free surgical margins (Fig. 4). The patient is currently free of disease, after nearly three years of follow-up
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