Patient information: a 37-year-old lady presented with complaints of painless gross hematuria and dysuria for one month. In past, she had undergone augmentation ileocystoplasty at 12 years of age for a thimble bladder and left simple nephrectomy for pyonephrosis due to genitourinary tuberculosis. One year back she underwent a cystoscopy at an outside center for similar complaints that showed a tumor lesion measuring 1 x 1 cm and located at the bladder dome. The tumor was completely ablated endoscopically. There was no histopathology or urine cytology report available from that event. The patient did not have any associated chronic medical illness, or history of any substance abuse, or addiction. There was no family history of similar complaints.
Clinical findings: the patient s vital signs and abdominal exam were normal.
Diagnostic assessment: her blood investigations revealed hemoglobin of 12.4 g/dl and serum creatinine of 2.5 mg/dl. Liver function tests and serum electrolytes were in the normal range. Non-contrast computed tomography of the kidney, ureter, and bladder region (NCCT-KUB) revealed mild hydronephrosis and complete mild hydroureter of the right side. The urinary bladder was distended and showed a lobulated contour. There was an irregular, lobulated, enhancing soft tissue lesion along the anterior vesical wall in the transposed ileal segment measuring 2.1 x 4.7 x 4.8 cm with mild peri vesical fat stranding. There was no evidence of any enlarged lymph nodes on NCCT-KUB (Figure 1). Urine cytology was suspicious for malignant cells.
Therapeutic intervention: she underwent transurethral resection of bladder tumour (TURBT) under general anesthesia. On cystoscopy, there was a solid proliferative growth along the anterior vesical wall in the transposed ileal segment measuring 2 x 5 x 5 cm with evidence of neovascularization. The right ureteric orifice was not visible. The biopsy report was suggestive of adenocarcinoma of the ileum. The patient subsequently underwent anterior pelvic exenteration (open radical cystectomy and hysterectomy), and right-end ureterostomy (Figure 2). A decision for ureterostomy was taken considering her serum creatinine of 2.5 mg/dl and dilated thick-walled right ureter. The cut margin of the ureter was negative on the frozen section.
Follow-up and outcomes: the post-operative course was uneventful. The patient was discharged on post-operative day seven. The final histopathology report was suggestive of moderately differentiated adenocarcinoma, purely intestinal type. There was no urothelial differentiation. Adjacent mucosa showed intestinal metaplasia. Tumour infiltrated the deep muscle layer. All 16 lymph nodes examined were free of tumors. The right ureteric margin was also free of tumour (final stage - pT3N0M0). Flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) at 3 months postoperatively showed no evidence of abnormal uptake or suspicious metabolic active disease. At 6 months follow-up, the patient was asymptomatic with a serum creatinine of 2.2 mg/dl. A medical oncologist s opinion was taken. The patient did not receive any adjuvant treatment in view of the absence of lymph nodal involvement and the absence of any metabolic active disease on FDG PET/CT.
Patient perspective: during her hospitalization and after treatment, the patient was satisfied with the care she received.
Informed consent: written informed consent was obtained from the patient for participation in our study.