Case Study: Recurrence of Urothelial Cancer Challenging in Patient With Morbid Obesity

"Medical Journeys" is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

This month: A noteworthy case study.

What to do for a morbidly obese 57-year-old woman with urothelial cancer when she presents with significant progression of a mass in the right proximal ureter? Fatimah Alawami, MBBS, of Imam Abdulrahman Bin Faisal University in Dammam, Saudi Arabia, and colleagues recently described the patient's medical journey from diagnosis to successful robotic-assisted nephroureterectomy (NU).

As the team explained in Cureus, the patient, whose body mass index was 39.56, had been diagnosed with bladder cancer 10 years previously and undergone several transurethral resections of bladder tumor during those years.

Presentation, Histology

She initially presented to the authors' hospital in 2019 due to unresolved blood in her urine and a decline in hemoglobin. At that point, she underwent an open radical cystectomy with an ileal conduit.

The histopathologic report showed a tumor of 8.5 cm, a high-grade lesion, with invasion to the muscularis propria. It was staged as p2T N0 M0.

Progression

The patient continued to be followed, and in 2021 computed tomography (CT) of the pelvis and abdomen with intravenous (IV) contrast revealed a 7 mm enhancing lesion in the right proximal ureter, which clinicians believed was a proximal ureter mass with no hydronephrosis. After consultation with a multidisciplinary team, the authors recommended the patient for a robotic right radical NU; at that point, however, she was lost to follow-up.

In 2022, though, she returned again to the outpatient clinic, and CT of the pelvis and abdomen with IV contrast showed that the mass had progressed significantly, to a size of 2×1.5 cm. No other intra-abdominal lesions were detected, and the team ordered a CT scan of the chest, which did not show any evidence of intrathoracic metastasis.

The Surgery

For the single-docking robotic-assisted radical NU, the patient was placed and secured in the left lateral decubitus position at a 45° angle, her lower limb was flexed at 90°, and the upper limb was extended and supported with adequate cushioning.

"The camera trocar was placed along the right lateral edge of the rectus sheath, slightly cephalic to the umbilicus, and the 30° lens was inserted under direct visualization," the authors continued. The abdominal cavity was examined, and additional robotic trocars were placed along the lateral edge of the rectus sheath. Clinicians placed an assistant port in the midline above the umbilicus, and another port was inserted to retract the liver.

The surgery took about 6 hours, and the patient lost approximately 100 mL of blood, the team reported, noting that she tolerated the procedure well, and after surgery was moved to the surgical ward. Her recovery was uneventful, and she was discharged from the hospital 3 days later.

Lab tests showed no significant changes in hemoglobin levels (14.7 vs 14.4 g/dL). Her creatinine was elevated (124 vs 88 umol/l), and histopathology assessment noted "non-invasive high-grade papillary urothelial carcinoma of the proximal ureter with negative margins and no lymphovascular invasion," Alawami and co-authors said.

Follow-up 2 weeks later showed that the wound was healing well, and there were no signs of infection.

Discussion

The authors noted that their literature review found no published cases about a single-docking robotic-assisted NU approach following open cystectomy with an ileal conduit in a morbidly obese patient.

They cited a 2006 case series of seven patients with upper urinary transitional cell carcinoma (TCC; another name for urothelial cancer) managed with laparoscopic NU after radical cystectomy with urinary diversion. In these patients, the operative time was an average 305 minutes -- time spent primarily on excising the ureter from the urinary diversion.

"Moreover, estimated blood loss among patients ranged from 100 to 250 mL," Alawami and co-authors noted, adding that pre- and post-surgical hemoglobin levels were not reported. Time in hospital was about 11 days, including at least 5 days before and 5 days after surgery.

In another small series, a 2008 review of laparoscopic NU and radical cystectomy in eight patients with bladder cancer and synchronous upper urinary tract tumor reported an average blood loss of approximately 755 mL, 9 hours of operative time, and 7.5 days in hospital. By comparison, the blood loss in the patient in the case study was lower, with no significant drop in hemoglobin, and surgical time and hospital stays were both shorter.

Urothelial carcinoma can arise from the entire urinary tract, with the bladder the primary site of origin in 95% of all cases. In contrast, upper tract urothelial cancer (UTUC) is uncommon, accounting for only 5-10% of all urothelial carcinomas.

Although urothelial bladder carcinoma and UTUC are histopathologically similar, carcinoma involving the upper urinary tract has a comparatively worse prognosis and is more likely to recur than urothelial bladder carcinoma.

The incidence of concomitant urothelial bladder cancer at the time of a primary UTUC diagnosis is about 17%, while the risk of developing urothelial cancer in the upper tract following diagnosis of a primary non-muscle-invasive urothelial bladder cancer is much lower, at around 2-3%.

The authors of the 2008 study called urothelial carcinoma an important risk factor for developing a subsequent tumor throughout the entire urinary tract, and noted that patients with a primary UTUC have the highest risk of developing a recurrence in the bladder.

Conclusion

In conclusion, Alawami and co-authors said, NU is the usual approach to management of invasive, high-grade, or recurrent TCC affecting the upper urinary tract. "The robotic-assisted NU approach is considered a new modality with better efficacy and safety in various conditions," the team wrote. "Moreover, performing a single-docking robotic-assisted NU in patients who previously underwent open radical cystectomy with an ileal conduit is challenging due to multiple adhesion and altered anatomy. More studies need to be published regarding the long-term outcomes of such procedures."

Read previous installments in this series:

Part 1: Urothelial Cancer: Diagnostic Evaluation

Part 2: Staging of Urothelial Cancer: Cystoscopy and CT Evaluation Remain Standard

Part 3: Non-Muscle-Invasive Bladder Cancer: Intravesical BCG and Beyond