膀胱腺癌合併結石造成之無功能腎之整合性手術：同時膀胱全切與腎切除

范子宣¹、陳鴻毅

基隆長庚紀念醫院 泌尿部

Integrated Surgical Management of Bladder Adenocarcinoma With a Stone-Related Non-Functioning Kidney: Concurrent Radical Cystectomy and Nephrectomy

Tzu-Hsuan Fan¹、Hung-Yi Chen

Keelung Chang Gung Memorial Hospital, Department of Urology

Abstract

Background:

Primary adenocarcinoma of the urinary bladder is a rare malignancy, accounting for less than 2% of bladder cancers. It may arise from chronic inflammation, infection, or metaplasia, and is often associated with villous adenoma as a potential precursor lesion.

Case presentation:

A 56-year-old man with a history of spinal cord injury, bilateral above-knee amputation, chronic urinary tract infection, and long-term cystostomy, presented with persistent nausea, vomiting, and fever. Initial imaging revealed bilateral hydronephrosis, bilateral renal stones, and left ureteral stone. A left percutaneous nephrostomy (PCN) was performed for drainage, but persistent right-sided hydronephrosis could not be explained radiologically and was initially suspected to result from right ureteropelvic junction (UPJ) stenosis. During ureteroscopic evaluation, multiple bladder tumors were incidentally discovered. TURBT in November 2024 revealed villous adenoma, followed by recurrence in March 2025 showing high-grade adenocarcinoma (pT1) and another in April 2025 confirming moderately differentiated adenocarcinoma (pT2).

Preoperative renal scintigraphy demonstrated poor left renal function (split function 11%) with recurrent infection, so left nephrectomy was planned concurrently with cystectomy. The patient subsequently underwent laparoscopic radical cystectomy with bilateral pelvic lymph node dissection, perineal total ureterectomy, and left radical nephrectomy. Because of severely impaired renal function, ileal conduit and orthotopic neobladder reconstruction were not considered to avoid further metabolic complications. Fianl pathology revealed moderately differentiated adenocarcinoma, NOS, pT3aN0, invading perivesical tissue with negative margins. Immunohistochemistry was positive for CDX2, CK20, and β-catenin, confirming intestinal differentiation.

Conclusion:

This case demonstrates the malignant transformation of villous adenoma into invasive adenocarcinoma in the setting of chronic infection and long-term cystostomy. The tumor progressed through repeated recurrences from pT1 to pT3a within months, emphasizing its aggressive nature. Early recognition, radical cystectomy, and management of associated infection and obstruction, including nephrectomy for a non-functioning kidney, are crucial for optimal outcomes in such complex cases.