Radical cystectomy for bladder urothelial carcinoma with aggressive variant histology

Purpose: The aim of this study is to report our experience in managing bladder cancer in patients with variant pathology. Methods: Retrospective data collection for all patients managed by radical cystectomy over the last 3 years for a variant pathology was completed. We specifically included micropapillary and nested variants. Results: Ten patients were identified, with eight having micropapillary carcinoma (MPC) and two having nested variants. Nine patients were male. The median age was 75. The two patients with nested variant were 56 and 62 years old, respectively, whereas all patients with MPC were over the age of 70. Upon cystectomy of all micropapillary cases, three patients (37.5%) had positive lymph node invasion and the final pathology was T2 (two patients), T3 (two patients), and T4 (four patients). Barring a grade III complication Clavien-Dindo classification due to wound dehiscence that necessitated secondary surgical closure, there were no specific perioperative complications. Given the urethral invasion, cystourethrectomy was performed on the female patient. Within a median 13-month follow-up, three patients developed local recurrence, including two urethral and one new lateral pelvic mass. Conclusions: Considering the muscle invasive nature of micropapillary and nested bladder cancer, aggressive surgical management should not be postponed. Moreover, due to notable prevalence of concurrent and/or recurrent urethral involvement, initial urethrectomy or early and frequent postoperative urethroscopy should be provided. Patients with variant histology bladder cancer may benefit from early radical cystectomy when compared to bladder sparing protocols and prostate sparing cystectomy treatment options.