A 73-year-old male farmer presented with gross hematuria for 1 month and a history of bladder cancer 6 years ago. Physical examination and tests found an irregular mass in the right side of the bladder and a shrunken right kidney. The patient underwent surgery to remove the right kidney, ureter, and bladder along with the prostate and create a left ureterostomy. Post-operative recovery was uneventful. Final pathology revealed high-grade papillary urothelial carcinoma involving the right ureter and bladder, with one positive lymph node. The patient was referred to oncology for further management.

1. Dr Hafiz Muneeb Ur Rehman
PGR Urology Unit II
Mayo Hospital, Lahore

2.  Biodata
 Patient Name xyz
 Age 73y/M
 Resident of Wazirabad
 Profession Farmer
 MOA OPD

3.  Presenting Complaints
 Gross Hematuria for 1 month

4.  HOPI:
My patient normotensive, normoglycemic was in
usual state of health one month back when he had
multiple episodes of gross mixed painless
hematuria which was also associated with passage of
clots.
He gives history of similar episodes of gross
hematuria 6 years back when he was diagnosed with
bladder cancer

5.  No history of Retention of Urine/ Trauma/ LUTS
 No history of Fever/ Flank pain/ Stone passage or
recurrent UTIs
 No history of weight loss/ Hemoptysis/ Bone pains

6.  Systematic Review
 CNS No h/o of CVA/TIA/Epilepsy/Memory loss
 CVS No h/o dyspnea/orthopnea/IHD/ Palpitation
 Resp no h/o chronic cough/sputum/hemoptysis
 GIT No h/o constipation/malena/dyspepsia
 Past History
Diagnosed with Bladder Growth in March 2017
There was 4cm growth on base and Right Lateral wall
TURBT was performed.
Biopsy TCC pTaG1

7.  Personal History
 Farmer by profession
 Heavy smoker
 Drug & Allergies
 No h/o allergies to any drugs

8.  General Physical Exam
 A relatively old man, lying comfortably in bed, well
oriented in time,place and person and having
following vitals
 Pulse 88/m, BP 140/90mmHg, Temp A/F,
 Respiratory rate 16/m
 No pallor/cyanosis/ clubbing/periorbital or ankle
edema
 Cervical, axillary or inguinal lymph nodes were not
palpable

9.  CVS Pulse 88/m, regular, normal volume, both
heart sounds of normal intensity, no added sounds
 Respiration R.R 16/m, Abdominothoracic, chest
moving equally on both sides, NVB+0
 CNS GCS 15/15, Speech normal, Bulk, tone and
power of muscles are normal. Reflexes intact
 Abdomen Shape of abdomen is normal, Umblicus
central, no stria/scar marks. Hernial orifices intact,
no rigidity/tenderness, Bowel sounds present and
of normal intensity. Prostate not enlarged

10.  CBC Hb 8.5 g/dL, TLC 8000/uL, Platelets
235000/uL
 RFTs Urea 39mg/dL, Creatinine 0.9mg/dL
 LFTs Bilirubin 0.9mg/dL
 USG KUB 6.4 ×7.9cm irregular echogenic
area on Right lateral wall and base of
bladder. Right Kidney shrunken and Grade
III echogenic

11.  Heterogeneously enhancing endophytic
mass measuring 9×4.9×8.1cm on
posterior and lateral wall of bladder, also
involving Rt VUJ
 Rt kidney reduced in size with mild
Hydronephroureter
 No enlarged locoregional lymph nodes
 No local extension or distant metastases

13.  Right Nephroureteroctomy+ Radical
Cystoprostatectomy & Left Ureterostomy
was planned

15.  On 1st POD patient was ambulated and oral
feed was started
 Post operative recovery was uneventful
 Patient was discharged on 6th POD
 Left Ureterostomy DJ Stent was removed after
2 weeks

17.  High Grade Papillary Urothelial CA
 Resection margins free of tumor
 Right PUJ & VUJ were involved by tumor
 Left VUJ was involved by tumor
 Left Proximal Ureteric margin was free of
tumor
 Urethral margin was free of tumor
 One lymph node was positive

18.  Patient was referred to Oncology Department
due to tumor up-staging in histopathology
 Currently Follow-Up CT is planned after 1
month