Challenging Cases in Urothelial Cancer

Dear Readers,

Urothelial cancer of the urinary tract is common and affects a large number of men and women, result- ing in a reasonably large part of the work effort of urologists who take care of adults. Most of the urothe- lial tumors arise in the bladder but the same causative factors can lead similar tumors of the upper urinary tract and prostatic urethra. Due to the heterogeneous nature of these tumors as well as their propensity for “recurring” in time and location over the patient’s life the clinician is often in the position of decid- ing among often challenging treatment choices for his/her patient. Although there are published guide- lines many cases do not readily fit into a typical scenario, thus leaving ample room for decision mak- ing for the individual patient. We invite our readers to review and comment on the case and management by using the comment section below each case.


Mark S. Soloway, MD
Memorial Physician Group, Division of Urology, Memorial Healthcare System, Hollywood, FL, USA

Case 29

This is a 73 year old man who presented to his primary medical doctor with gross hematuria in 2020. He is healthy with the exception that he weighs 250 lbs with a large abdominal girth. He has not had surgery. He was a former cigarette smoker with a 30 pack years history. He stopped smoking cigarettes in 2008.

Case 28

This 60 year old healthy appearing woman with Lynch Syndrome was in excellent health until 2000 when she was diagnosed with endometrial cancer and underwent a total abdominal hysterectomy. She did well and did not have a recurrence.

Case 27

A 67 year old woman with congestive heart failure underwent an extensive medical evaluation prior to consideration for a heart transplant. She has a 20 year history of cardiomyopathy. In 2015 she developed recurrent ventricular tachycardia and had an implantable cardioverter/defibrillator (ICD) placed and underwent cardiac ablation.

Case 26

This 37 year old healthy appearing man had a seven month history of intermittent gross hematuria. He has no voiding problems beside hematuria. He has hypertension and takes losartan and hydrochlorothiazide. He has not had surgery. He has never smoked cigarettes or cigars.

Case 25

This is an 83 year old man with a several month history of gross hematuria. He smoked cigarettes and cigars for approximately 50 years. His past medical history is pertinent for a coronary artery stent placed in 2009 and a stroke in 2019 from which he recovered without neurologic impairment. He has been taking the anticoagulant apixaban (Eliquis) since.

Case 24

This 73-year-old man presented to his primary physician with a one month history of intermittent gross hematuria. He was promptly referred by an excellent community urologist. A CT scan indicated high grade right ureteral dilatation to the level of the urinary bladder (Fig. 1). There was a filling defect in the bladder (Fig. 2). There were no enlarged pelvic or retroperitoneal lymph nodes. A chest x ray was normal.

Case 23

This is a 69 year old healthy woman who has a long history of urothelial cancer of the bladder. She was a cigarette smoker from age 20 to 35 when she stopped. She smoked one pack per day. She has had an appendectomy and a total abdominal hysterectomy.

Case 22

This is a 58 year old non smoker who had intermittent gross hematuria for one year. He did not have a good reason for not seeking medical attention. He was able to function with his usual activities over this time.

Case 21

This is a 65-year-old current and longtime cigarette smoker who presented to me with an 8 month history of intermittent gross hematuria and a diagnosis of muscle invasive urothelial cancer of the bladder. He has type 2 diabetes mellitus. He had symptomatic coronary artery disease and coronary artery stents were placed in 2015. He currently has a good performance status.

Case 20

This 73 year old healthy woman saw her gynecologist for a routine evaluation and mentioned that she had increasing urinary frequency including nocturia. She is a former smoker with a 30 pack/year history. She has not had major surgery.

Case 19

RS is an 81 year old man with a history of low and high grade Ta bladder cancer in 2010. He was free of any bladder cancer until 2020. He had routine office cystoscopy and cytology through 2016 with urinalysis only from 2016 to 2020.

Case 18

This is a healthy appearing 69 year old man who presented in March 2019 with gross hematuria. A cystoscopy and CT scan disclosed multifocal papillary bladder tumors and a filling defect in the left kidney. The bladder tumors were resected. The pathology was low grade (grade 2) Ta. The upper tract was evaluated with a retrograde uretropyelogram followed by ureteroscopy, cytology, and a small biopsy of an abnormal appearing area in the renal pelvis and lower pole collecting system. 

Case 17

This is a healthy appearing 76 year old man who presented with mild gross hematuria that lasted for two days.

I performed a radical prostatectomy on him twelve years ago. His PSA has been 0 since. He is continent. A CT urogram was normal with the exception of a possible small filling defect on the left side of the bladder.

He is a former cigarette smoker with a 20 pack year history.


This is a 60 year old healthy man who presented with gross hematuria. He had a 20-pack year cigarette smoking history. He stopped smoking 10 years ago. A CT scan of the abdomen and pelvis was normal. An office flexible cystoscopy identified a 3 cm papillary tumor. A transurethral resection was performed and the pathology was a high grade Ta (non-invasive) bladder cancer.


V.L. is a 76 year old man in good health. He had a 20 pack year history of cigarette smoking. He stopped smoking at age 45. In 2003 he had an episode of gross hematuria and a work up revealed a papillary low grade Ta bladder tumor which was resected endoscopically.

Last comment on by Marko Vukovic, M.D.

Case 14

RF is a 73 year old man with his first episode of bladder cancer. He underwent a renal transplant in 2005 and his current creatinine is 1.20. His performance status is quite reasonable. He was a heavy cigarette smoker with a 30 pack/year history and stopped smoking at age 50.

Case 13

M.L. is a very healthy 60 year old woman who presented with an episode of gross hematuria in November 2018. A CT scan indicated a bladder tumor on the left wall. The upper urinary tract was normal. Her past medical history was entirely negative. An outpatient flexible cystoscopy identified a papillary exophytic solitary tumor on the left lateral wall of the bladder. The remainder of the bladder was normal.

Case 12

SK is a 64 year old healthy appearing man who is a former heavy cigarette smoker who presents with gross hematuria. Five years ago he had a left nephroureterectomy for a high grade Ta urothelial cancer in the left renal pelvis.


L.R. is a healthy appearing 83 year old woman that presented to a urologist upon referral from her primary care physician with a 6 month history of recurrent urinary tract infections and more recently some right flank discomfort. A CT scan of the abdomen and pelvis revealed moderate right hydronephrosis with a point of obstruction near or at the bladder. The left upper tract was normal. Images of the bladder indicated masses consistent with bladder cancer.


This is a healthy appearing 77 year old man with bladder cancer. He presented in April 2016 with an episode of gross hematuria. He lives in Central America and was seen by a urologist there.

His past medical history is uneventful. He has adult onset type 2 diabetes and takes metformin. He was never a cigarette smoker. The only surgery he had was a right inguinal hernia repair. He is not overweight.


MG is a 75 year old man who presented with a single episode of gross hematuria in October 2017. He is overweight and has insulin dependent diabetes mellitus. He has some lower urinary tract voiding symptoms. These consist of nocturia twice and some daytime frequency. His urinary stream is slow.

Case 8 NF

Low-grade bladder tumors are almost always confined to the urothelial surface. They are arguably the most common urothelial tumor in the urinary tract. The current grading system uses low and high grade instead of the now historical 1–3 grading system. Low-grade tumors include not only those that were previously called grade 1 but also some of the grade 2 tumors.

Case 7 UR

Approximately 80 per cent of patients who have a urothelial tumor of the bladder have a low or high grade papillary tumor which is non invasive (Ta) or is high grade papillary or sessile and invades the lamina propria (T1). The initial presentation is most commonly gross hematuria, which promptly leads to outpatient endoscopy and a subsequent transurethral resection (TUR BT).

Case 6

R.F. is a healthy appearing 55 year old man who had gross hematuria February 2016. His past medical history is negative with the exception of a 15 pack/year history of cigarette smoking. He had a normal CT scan with the exception of a bladder tumor located in the posterior wall of the bladder. He underwent an uneventful transurethral resection of a papillary bladder tumor in March 2016 at another medical center.

He received a single postoperative dose of intravesical mitomycin C 40 mg in 40 ml in the recovery room.

Case 5 – Multifocal urothelial cancer of the kidney and bladder

JP is currently a 58 year old man with multifocal urothelial tumors of the urinary bladder despite two courses of intravesical mitomycin C and one six week course of BCG.

The patient appears well but has a significant past medical history consisting of diabetes mellitus, coronary artery disease, mild congestive heart failure, chronic renal disease, and peripheral neuropathy. He stopped cigarette smoking at age 35 after 15 years of smoking 1.5 packs/day. He has had a coronary artery stent placed.

Last comment on by Georgios Gakis , MD

Case 4

S.C. is a 71 year old man with a new diagnosis of prostate and bladder cancer. This man has been in excellent health and was a long time marathon runner. His only past medical history was of a left inguinal hernia repair. He was a former cigarette smoker with a 10 pack year history. He did not have any voiding complaints. He had been taking dutasteride for LUTS.

Case 3. High grade (grade 3) Ta urothelial carcinoma of the bladder with an adjacent area of CIS

72 year old woman who had one episode of gross hematuria and saw a urologist for an investigation. Her general health is good. The only prior surgery was a cholecystectomy. She smoked cigarettes for 15 years – one pack/day. She stopped 30 years ago.

Last comment on by Marko Vukovic, M.D.

Case 2. T2 muscle invasive urothelial bladder cancer

A 61 year old previously healthy man had gross hematuria and was found to have a muscle invasive urothelial cancer of the bladder. The clinical stage was T2 and there was lymphovascular invasion.

Case 1. T1 high-grade urothelial bladder cancer

The patient is a 56 year old male practicing urologist. He had the acute onset of gross hematuria and a CT scan of the abdomen and pelvis was normal except for a possible small bladder tumor. An office cystoscopy indicated a solitary 3 cm papillary tumor at the right lateral wall. A TURBT was performed and the pathology revealed a high-grade focally invasive T1 urothelial carcinoma. Muscle was present and not involved. There was a focus of CIS adjacent to the tumor. The rest of the bladder and the prostatic urethra were visually normal but not biopsied.