Patients Undergoing Radical Cystoprostatectomy Research Articles

1830 CHARACTERIZATION AND RISK STRATIFICATION OF PROSTATIC MALIGNANCY IN PATIENTS UNDERGOING RADICAL CYSTOPROSTATECTOMY

1830 CHARACTERIZATION AND RISK STRATIFICATION OF PROSTATIC MALIGNANCY IN PATIENTS UNDERGOING RADICAL CYSTOPROSTATECTOMY

Circumcaval ureter with synchronous ipsilateral transitional cell carcinoma of the renal pelvis and the urinary bladder: Report of a case and review of the literature

We report a case of concomitant transitional cell carcinoma (TCC) in a circumcaval ureter and invasive bladder cancer. The diagnosis was based on the findings of excretory urography (IVU) and contrast-enhanced computed tomography (CT). IVU showed a typical J-shaped deformity in the dilated right proximal ureteric segment with moderate hydronephrosis and a filling defect in the renal pelvis, while abdominal CT with contrast showed right hydronephrosis with an intrapelvic tumor. The patient underwent radical cystoprostatectomy and nephroureterectomy. No recurrence was detected after 12 months of follow-up.

POD-02.03: Incidental Prostatic Adenocarcinoma in Cystoprostatectomy Specimens in Egyptian Patients Undergoing Radical Cystoprostatectomy for Bladder Cancer

Several authors have suggested an association between bladder tumors and prostate cancer. Mershimmer et al, found that a combination of bladder and prostate cancer was common, second in frequency to the combination of skin and colon cancer. The reported previous publications on incidental adenocarcinoma of the prostate in cystoprostatectomy specimens showed variable prevalence rate (27-60%) but the number of cases in these studied was low (40-165). The current study is a trial to evaluate incidence, histological features and significance of incidentally found prostatic adenocarcinomas in cystoprostatectomy specimens obtained from patients with bladder cancer.

Risk factors for urothelial carcinoma of the prostate in patients undergoing radical cystoprostatectomy for bladder cancer

To examine the risk factors for urothelial carcinoma (UC) involvement of the prostate in patients undergoing radical cystoprostatectomy (RCP) for bladder cancer, as such involvement has both prognostic and therapeutic implications. We examined 308 consecutive men from 1998 to 2005 who had RCP for UC of the bladder, with whole-mount processing of their prostate. Prostatic involvement was categorized by site of origin (the bladder or the prostatic urethra) and, in the case of prostatic urethral origin, by depth of invasion, i.e. dysplasia/carcinoma in situ (CIS), involving the prostatic urethra, prostatic ductal invasion or prostatic stromal invasion. The impact of pathological characteristics was evaluated. In all, 121 (39.3%) patients had some form of urothelial involvement of the prostate, of whom 59 (48.8%) had dysplasia/CIS of the prostatic urethra, 20 (16.5%) had ductal involvement and 32 (26.4%) had stromal involvement. Multivariate analysis showed that bladder CIS (odds ratio 2.0, 95% confidence interval, 1.2-3.6, P = 0.012) and trigonal involvement of bladder tumours (2.0, 1.1-3.7, P = 0.028) were independent risk factors for urothelial involvement of the prostate. There was prostatic involvement with UC in nearly 40% of patients undergoing RCP. In this study CIS and trigonal involvement were independent predictors of risk, but were not adequate enough to accurately identify most patients who have UC within their prostate; further prospective studies are needed to more accurately predict risk factors and depth of invasion.

Outcomes of patients undergoing radical cystoprostatectomy for bladder cancer with prostatic involvement on final pathology

To evaluate the impact of prostatic urothelial carcinoma (PUC) on survival of patients with bladder cancer undergoing radical cystoprostatectomy (RCP). From 1998 to 2005, 463 consecutive RCPs were performed for UC of the bladder. Patients with PUC at final pathology were grouped by route of prostatic invasion (bladder origin or prostatic urethral origin) and by depth of invasion (carcinoma in situ, ductal invasion, and stromal invasion). Univariate and multivariate survival analyses were performed. In all, 35% (162/463) of patients had PUC. The 3-year overall survival (OS) was 58.2% for patients who did not have PUC, 59.2%, 51.7%, and 16.8% in order of increasing depth of prostatic invasion for patients with PUC of urethral origin, and 6.7% for patients with bladder-origin PUC. Survival differed significantly between stromal and non-stromal PUC (P < 0.001). Patients with PUC of bladder origin had a higher rate of positive lymph nodes (LNs) than patients with stromal PUC of prostate origin (74.3% vs 27.8%, P < 0.001), but survival was similar (P = 0.619). On multivariate analysis, age (P = 0.035), increasing bladder stage (P = 0.003), stromal invasion (P = 0.002) and positive LNs (P < 0.001) were predictors of poor OS. Depth of prostatic invasion correlates with outcome. While prostatic involvement originating in the bladder is associated with higher rates of positive LNs, survival is similar to patients with stromal involvement of urethral origin. Age, bladder tumour stage, prostatic stromal involvement and positive LNs predict adverse outcome. Our data support separate staging of the prostate in RCP specimens.

Is Incidentally Detected Prostate Cancer in Patients Undergoing Radical Cystoprostatectomy Clinically Significant?

Cystoprostatectomy specimens obtained from patients with bladder cancer provide a unique opportunity to assess the features of silent prostate adenocarcinoma (PCa). The whole-mount prostate sections of 248 totally embedded and consecutively examined radical cystoprostatectomy (RCP) specimens were reviewed to determine the incidence and features of incidentally detected PCa. PCa was considered clinically significant if any of the following criteria were present: total tumor volume, 0.5 cc or more; Gleason grade, 4 or more; extraprostatic extension; seminal vesicle invasion; lymph node metastasis (of PCa); or positive surgical margins. PCa was present in 123 (49.6%) of 248 specimens. Features were as follows: acinar adenocarcinoma, 123 (100.0%); peripheral zone location, 98 (79.7%); pT2a, 96 (78.0%); pT2b, 11 (8.9%); pT2c, 9 (7.3%); pT3a, 5 (4.1%); pT3b, 2 (1.6%); pT4, 0 (0.0%); Gleason score 6 or less, 107 (87.0%); negative margins, 119 (96.7%); pN0 for PCa, 123 (100.0%); and tumor volume less than 0.5 cc, 116 (94.3%). Of the 123 incidentally detected cases of PCa, 100 (81.3%) were considered clinically insignificant. Incidentally detected PCa is frequently observed in RCP. The majority are clinically insignificant.

Prevalence of incidental prostate cancer in patients undergoing radical cystoprostatectomy: data from China and other Asian countries

The purpose of this study is to investigate the frequency of prostate cancer (Pca) discovered incidentally in radical cystoprostatectomy specimens in Asia and to determine the feasibility of prostate-sparing cystectomy (PSC) for Asian patients. Ninety-two male bladder cancer patients who underwent radical cystoprostatectomy at our center between January 2003 and January 2008 were included in this study. The mean age of patients was 67.1 years (range: 32-75 years). Prostate-specific antigen (PSA) levels and digital rectal examination (DRE) results before surgery were obtained retrospectively. Prostates of all patients were embedded and sectioned at 5-mm intervals. The same pathologist examined the prostatic tissues from radical cystoprostatectomy specimens. Finally, a structured literature review was performed using MEDLINE and PUBMED to estimate the occurrence of incidental Pca in Asia. Of the 92 patients, 3 (3.3%) were found to have Pca; in one out of three (33.3%) patients the disease was clinically significant due to a Gleason grade 4 carcinoma. Eight articles were included in our review. The overall incidence of Pca discovered incidentally in radical cystoprostatectomy specimens in Asia was 9.9% (64/642). When age was restricted to < 60 years, only 7 out of 222 (3.2%) patients were found to have synchronous Pca, and none of the cases was clinically significant. The occurrence of Pca in radical cystoprostatectomy specimens in Asia is much lower than that in Western countries. PSC might be feasible for Asian patients under a strict preoperative selection.

Urine Derived Cells are a Potential Source for Urological Tissue Reconstruction

Contemporary approaches to tissue engineering and cell therapy for urinary tract reconstruction require invasive tissue biopsies to obtain autologous cells. However, these procedures are associated with potential complications. We determined whether the cells present in urine have characteristics of normal bladder cells and investigated their potential uses for urological reconstructive procedures. A total of 55 urine samples were collected from 15 healthy individuals and 8 patients with vesicoureteral reflux. Urine derived cells were isolated, expanded and tested for progenitor and differentiated cell specific markers using flow cytometry, immunofluorescence and Western immunoblotting. The chromosomal stability of cultured urine derived cells was determined by karyotype analysis. Clones were successfully established from primary cultures of urine derived cells. Isolated cells showed 3 phenotypes, including fully differentiated, differentiating and progenitor-like cells. Some urine derived cells stained positive for the surface markers c-Kit, SSEA4, CD105, CD73, CD91, CD133 and CD44. Two to 7 cells per 100 ml urine were multipoint progenitors that could expand extensively in culture. Single progenitor cells had the ability to differentiate into the cell lineages expressing urothelial, smooth muscle, endothelial and interstitial cell markers. The expression of lineage markers was characterized by Western blot and immunofluorescence analysis. Urine derived cells also maintained a normal karyotype after serial culture. A subpopulation of cells isolated from urine had progenitor cell features and the potential to differentiate into several bladder cell lineages. Urine derived cells could serve as an alternative cell source for urinary tract tissue engineering and reconstruction.

Indications for Preoperative Prostate Biopsy in Patients Undergoing Radical Cystoprostatectomy for Bladder Cancer

We determined indications for preoperative prostate biopsy in patients undergoing radical cystoprostatectomy for bladder cancer. Of 316 cystoprostatectomy specimens concomitant prostate cancer was diagnosed in 21.5%. Prostate cancer was diagnosed preoperatively in 24% of cases (evident prostate cancer), 32% were suspicious for prostate cancer but no biopsy was done (suspected prostate cancer) and in 44% prostate cancer was incidental. Patients were stratified into probability groups of intermediate/high risk prostate cancer by digital rectal examination and prostate specific antigen. The incidence of unfavorable histopathology was determined in each group. Of prostate cancers 85% were organ confined and the Gleason score was favorable (2-6) in 74%. Of cases of incidental prostate cancer tumors were organ confined in 97%. There were no unfavorable Gleason scores (8-10). In the low probability group 83% of patients had organ confined prostate cancer and only 17% had an unfavorable Gleason score. In the intermediate probability group prostate cancer was organ confined in 73% of patients, 45% had a favorable Gleason score (2-6) and 55% had an intermediate Gleason score (7). In the high probability group 29% of patients had high risk prostate cancer. Most concomitant prostate cancers were organ confined and had a favorable or intermediate Gleason score when digital rectal examination was not suspicious and prostate specific antigen was less than 10 ng/ml. As a consequence, patients with a low/intermediate probability of detecting intermediate/high risk prostate cancer do not require preoperative prostate biopsy unless nerve sparing surgery is planned. In contrast, all patients should undergo preoperative biopsy for prostate cancer when digital rectal examination is suspicious or prostate specific antigen is more than 10 ng/ml because the rate of high risk prostate cancer was 29% in this group.

Prostatic biology, histologic patterns and clinical consequences of transitional cell carcinoma

To review the current fund of knowledge about prostatic transitional cell carcinoma and the implications for diagnostic and management strategies particularly as they relate to radical cystectomy. Prostatic transitional cell carcinoma (TCC) is present in up to 48% of patients undergoing radical cystoprostatectomy. Transurethral resection biopsies of the prostatic urethra are a sensitive means of detecting prostatic TCC and whole-mount step sectioning is the most accurate method for determining the presence and extent of prostatic TCC. Prostatic TCC may affect prognosis independent of the primary bladder tumor stage. Preoperative detection of prostatic TCC enables accurate staging and treatment planning, including assessment of the risk of cancer at the apical urethral margin and the risk of a second primary tumor of the retained urethra, all of which factor into decision-making around urinary diversion and urethrectomy. Recognition of true T4a stage requires consideration of neoadjuvant chemotherapy and the need for extended pelvic and iliac lymphadenectomy in order to optimize an integrated treatment strategy. Prostatic involvement with TCC in patients with bladder cancer is a common event. In patients with recurrent high-grade nonmuscle invasive cancer and patients undergoing radical cystoprostatectomy, a thorough assessment of the prostatic urethra and stroma is imperative for accurate staging and treatment planning.

Incidental prostate cancer in patients undergoing radical cystoprostatectomy for bladder cancer.

The objective of this work is to verify the incidence of incidental prostate adenocarcinoma in patients who underwent radical cystoprostatectomy for invasive bladder carcinoma. We have retrospectively reviewed patients who underwent radical cystoprostatectomy for infiltrative bladder tumors in period between 2003 and 2007 year, 94 men with bladder cancer underwent radical cystoprostatectomy at Urology Clinic-University of Sarajevo Clinics Centre. Mean age of patients was 67 years, with age limits ranging between 48 and 79 years. Pathohistological evaluation was used for all specimens from RCP. We found that 9,57% of cystoprostatectomy specimens in patients with bladder cancer also contained incidental prostate cancer. This result was much lower than overall mean frequency of incidentally detected prostate cancer in other series of cystoprostatectomy cases (range, 23%-68%). In conclusion we recommended digital rectal examination (DRE) and prostate-specific antigen (PSA) test as part of the bladder cancer work up and complete removal of the prostate at cystoprostatectomy to prevent residual prostate cancer.

Oncological Evaluation of Prostate Sparing Cystectomy: The Montsouris Long-Term Results

Prostate sparing cystectomy provides an alternative therapeutic option in highly selected patients with invasive bladder cancer who wish to avoid the significant functional side effects of traditional surgery. Concern exists regarding the oncological safety of this technique especially with regard to the presence of prostatic urothelial cancer and incidental prostate adenocarcinoma. We present the long-term oncological outcomes of a large series of patients treated at a single institution. Between October 1992 and June 2004 a total of 117 patients were selected for prostate sparing cystectomy after meeting the inclusion criteria. Nine patients underwent radical cystoprostatectomy after prostate urothelial carcinoma was diagnosed intraoperatively. Long-term oncological results (2 years minimum followup [mean 55 months]) are presented here for the remaining patients. The rate of local and distant recurrence was 4.7% and 34%, respectively, at 20 months. Overall survival at 5 years in our study was 67%, and 5-year disease-free survival rates were 77% for pT2 N0 or less, 44% for pT3 N0 or greater and 22% for pN+ disease. Of 6 patients found to have prostate adenocarcinoma in transurethral prostate resection specimens 1 was treated with high intensity focused ultrasound and 5 were followed with active surveillance, 2 of whom later died of bladder cancer. We report oncological data on the largest prospective cohort of patients, with the longest followup, treated by prostate sparing cystectomy to date. Outcomes are comparable with the largest published series of cystoprosatectomies. With appropriate screening the risk of a clinically significant prostate cancer appears to be low. For certain selected patients this technique represents a valuable additional option for treatment.

Residual Prostate Cancer After Radiotherapy: A Study of Radical Cystoprostatectomy Specimens

The incidence of histologic prostate cancer (CaP) after definitive radiation therapy (RT) for localized disease is rarely quantitated. We investigated the relationship between prostate-specific antigen (PSA) and histologically residual CaP after definitive RT in patients undergoing radical cystoprostatectomy (RCP) for unrelated indications. We reviewed our prostate cancer database to identify patients undergoing RCP who previously received definitive RT for localized CaP. Pre-radiation variables examined include PSA, Gleason score, radiation modality, and dose. Post-radiation variables reviewed include PSA, time to RCP, the presence of histologically proven prostate cancer, and Gleason score. We identified 21 patients who underwent RCP at a median of 60 months after RT for localized CaP. Pre-radiation Gleason scores were low (6 or less) to intermediate risk (3+4) in 82% (14 of 17), intermediate (4+3) to high (8 or greater) in 18% (3 of 17), and unavailable in 4 patients. Median pre-radiation PSA was 9 ng/mL. Median PSA before RCP in all patients was 0.8 ng/mL. A total of 52% (11 of 21) of patients demonstrated active CaP in the RCP specimen. Although 89% (16 of 18) of patients met the Phoenix definition of biochemical freedom from disease, 50% (8 of 16) of these patients had histologically residual CaP at the time of RCP. Median PSA was not significantly different between patients with and without active CaP. Histologic evidence of CaP was noted in 50% of patients demonstrating biochemical freedom from disease at the time of RCP. Although the biological significance of active CaP in this select population is uncertain, our findings demonstrate the limitations of PSA in monitoring CaP disease activity after definitive RT.

Evaluation of the prostate peripheral zone/capsule in patients undergoing radical cystoprostatectomy: Defining risk with prostate capsule sparing cystectomy

Objectives Prostate capsule sparing cystectomy has been performed in conjunction with orthotopic diversion to preserve sexual function and improve urinary control. Because concerns remain regarding incomplete surgical resection, we evaluated the risk of urothelial and prostate cancer in a series of patients undergoing radical cystoprostatectomy. Methods A total of 35 men undergoing radical cystoprostatectomy (August 2003–August 2005) had separate submission of the prostate peripheral zone/capsule from the prostate adenoma and bladder after surgery. These specimens were evaluated for bladder and prostate cancer grade, stage, and largest diameter of prostate cancer. Patient records were reviewed for demographic and medical information. Clinical variables were compared between patients with and without carcinoma involving the prostate using standard statistical software. Results Of patients, 57% had cancer involving the prostate at radical cystoprostatectomy. There were 9 patients (26%) who had urothelial carcinoma involving the prostate; only prostatic urethral biopsy identified these patients before radical cystoprostatectomy. Prostate adenocarcinoma was evident in 16 of 35 (47%) patients, with a majority involving the prostate peripheral zone/capsule (43%). There were 4 patients (11%) who had clinically significant prostate cancer (Gleason sum >6 or tumor volume >0.5 cm 3). Patients with prostate cancer were significantly older than patients without prostate cancer ( P = 0.01). Conclusions No clinical variable can confidently predict patients with prostate cancer involving the prostate. Because a majority of patients undergoing radical cystoprostatectomy have cancer involving their prostate, preoperative evaluation with prostatic urethral and prostate biopsy may be useful to guide patient selection for prostate capsule sparing cystectomy.

Diabetes Mellitus: Does It Impair Urinary Continence after Radical Cystoprostatectomy and Ileal Orthotopic Bladder Substitution?

ObjectiveTo assess the effect of diabetes mellitus (DM) on urinary continence after radical cystoprostatectomy and ileal orthotopic bladder substitution. MethodsPatients with DM undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution without prior radiotherapy and with a minimum follow-up of 12 mo were identified from our database. Twenty-two men met the inclusion criteria and were randomly matched to 22 nondiabetic controls for age, ileum length used for reservoir construction, attempted nerve-sparing surgery, pathologic tumour stage, and pathologic lymph node status to assess the effect of DM on urinary continence. ResultsAll 22 diabetic patients suffered from type 2 DM. Twelve were treated with oral antidiabetics and 10 required insulin. Daytime continence was significantly worse in the diabetic patients compared to nondiabetic controls 3 mo (odds ratio [OR] 21; 95% confidence interval [CI], 2.4–185; p=0.001) and 6 mo (OR 17.5; 95% CI, 2–154; p=0.002) postoperatively. Thereafter no significant difference was detectable. In diabetic patients nighttime continence was worse. The difference was statistically significant at 3 mo (OR 7.3; 95% CI, 1.9–28; p=0.002), 6 mo (OR 9.1; 95% CI, 2.3–36; p=0.001), 12 mo (OR 7.1; 95% CI, 1.9–27; p=0.003), and 24 mo (OR 5.7; 95% CI, 1.3–26; p=0.018) after surgery. ConclusionsPatients with DM take longer to regain daytime and, even more so, nighttime continence than nondiabetic patients. Diabetic patients undergoing radical cystoprostatectomy should be informed of the potential negative impact of DM on the recovery of urinary continence after an ileal orthotopic bladder substitution.

Intravesical botryoid adenocarcinoma of the prostate: report of an unusual growth pattern of prostatic carcinoma simulating a urinary bladder tumor

We report on 3 cases of prostatic carcinoma presenting with a predominant intravesical mass as to simulate clinically and macroscopically a primary tumor of the urinary bladder. The patients were 65, 66, and 68 years old and presented with dysuria and micturition. All patients had a medical history of a prostatic adenocarcinoma diagnosed between 5 and 7 years earlier and treated conservatively. Because of instrumental evidence of a large urinary bladder mass, 2 patients underwent radical cystoprostatectomy based on suspicions for a primary urothelial tumor. Either cystoscopic or direct specimen inspection revealed a lobulated, yellow-tan, and polypoid lesion with a broad implant in the trigonal bladder area in 1 case and a mixed, polypoid, and diffuse linitis plastica-like infiltration of the bladder wall in the other 2 cases. Microscopically, sections of tumor mass as well as from the prostate featured a poorly differentiated adenocarcinoma compatible with the prostatic origin. Tumor cells were positive for prostate-specific antigen and prostatic acid phosphatase. Our cases suggest that an extensive polypoid growth pattern may be added to those patterns customarily observed in presenting prostatic carcinomas, raising treatment and diagnostic challenges.

MP-18.08: Incidental prostatic neoplasia in patients undergoing radical cystoprostatectomy: does it affect the overall prognosis?

We evaluated the incidence and histological features of incidental adenocarcinoma prostate (CAP) in radical cystoprostatectomy (RCP) specimens. We also assessed the impact of incidental CAP on the oncological outcome and feasibility of prostate sparing cystectomy.

Risk Assessment of Prostatic Pathology in Patients Undergoing Radical Cystoprostatectomy

ObjectivesTo determine the incidence and location of prostate adenocarcinoma (PCa) and prostatic urothelial carcinoma (PUC) for patients undergoing radical cystoprostatectomy (RCP) for bladder cancer and to ascertain what preoperative information may be useful in predicting PUC or PCa in patients who may be candidates for prostate-sparing cystectomy. MethodsBetween 2001 and 2004, 235 consecutive patients underwent RCP and had whole-mount sections of the prostate. We reviewed our prospective radical cystectomy database for preoperative clinicopathological information associated with each patient. The bladder and whole-mount prostate sections were re-reviewed to determine the location and depth of the bladder tumor as well as the presence of any associated PCa and PUC. ResultsWe identified 113 of 235 (48%) and 77 of 235 (33%) men with PCa and PUC, respectively. Among patients with PCa, 33 (29%) had Gleason score of ≥ 7, 25 (22%) had PCa tumor volume > 0.5 cc, and 15 (13%) had extracapsular extension. On multivariable analysis, only increasing age was significantly associated with PCa (odds ratio=1.3, p=0.046). Of the 77 with PUC, 28 (36%) had in situ disease only, while 49 (64%) had prostatic stromal invasion. Bladder tumor location in the trigone/bladder neck (p<0.001) and bladder carcinoma in situ (p<0.001) was strongly associated with PUC in the final specimen. Overall, 158 (67%) had either PCa or PUC in the prostate. ConclusionsPCa and/or PUC is present in a majority of RCP specimens. Current preoperative staging and tumor characteristics are not adequate for determining who can safely be selected for prostate-sparing cystectomy.

Incidental prostatic adenocarcinoma in patients with PSA less than 4 ng/ml undergoing radical cystoprostatectomy for bladder cancer in iranian men

To assess the incidence of prostate adenocarcinoma in patients undergoing radical cystoprostatectomy due to bladder cancer in Iranian men. Fifty cystoprostatectomy specimens removed due to bladder malignancy (2004-2005) at two referral centers (Shaheed Modarress and Shaheed Labbafinejad Hospitals, Tehran, Iran) were examined for the coincidental finding of prostate cancer (PCa). At the time of surgery the patient's serum PSA was less than 4 ng/mL and there were no suspicious lesions by digital rectal examination. Pathologic grade, stage, morphometric volume, number of tumor foci and association with areas of high grade prostatic intraepithelial neoplasia (HGPIN) were assessed by light microscopy. All specimens were totally embedded and whole-mounted. Clinically significant cancers were defined as tumors with >or= 0.5 mL volume, Gleason pattern 4 or 5, pT3, positive surgical margin, and multifocality > 3. Incidentally detected cancer was found in 7 (14%) of cystoprostatectomy specimens. HGPIN was present in 1 (14.3%) of the cystoprostatectomies with incidentally detected prostate cancer. None of cystoprostatectomies without prostate cancer had HGPIN. Four (57%) of the detected cancers were significant. We conclude that incidentally detected prostate cancer in Iran is lower than the rates reported in other countries. Further studies are warranted for better declaration of variability of prostate cancer between different ethnic groups.

Lymphoepithelioma-like carcinoma of the urinary bladder—diagnostic and clinical implications

A 57-year-old man presented with a 4-week history of intermittent, painless frank hematuria. There were no other symptoms. He had no previous urologic history, is a nonsmoker, and works as a manual laborer. Physical examination, ultrasound of the urinary tract, and intravenous urography were all unremarkable. Urine microscopy confirmed more than 5 red blood cells per high-power field, but no malignant cells were seen on cytologic assessment. Flexible cystoscopy revealed a 3 cm, partially solid, solitary lesion on the right lateral wall of the bladder. The tumor was completely resected under general anesthesia. Histologically, the tumor was described as a G3 pT1 transitional cell carcinoma of the bladder. Following the resection of a solitary recurrence 6 weeks after the initial tumor resection, the patient underwent a standard course of intravesical bacillus Calmette-Guérin therapy. Despite this, another tumor was identified 3 months later. Histologically, this tumor was described as a lymphoepithelioma-like carcinoma, of at least grade G3pT1. The patient underwent radical cystoprostatectomy with ileal conduit formation; no adjuvant systemic chemotherapy was given in light of complete tumor resection. The patient is under continuing, close clinical and radiologic observation and remains free of disease recurrence, 36 months postoperatively.