Muscle-Invasive Bladder Cancer in a Frail Patient with Unilateral Hydronephrosis
A 74-year-old man presents with painless visible haematuria. CT urography shows a 5 cm left lateral wall bladder mass and no metastases; there is left hydronephrosis but no right-sided dilatation. TURBT histology is high-grade urothelial carcinoma invading the muscularis propria (pT2). Staging MRI shows no extravesical extension or nodal disease. He lives alone, has mild cognitive impairment and needs a walking frame indoors. Comorbidities include ischaemic heart disease and chronic kidney disease; eGFR is 32 mL/min/1.73 m² and haemoglobin is 96 g/L. ASA grade is III. The MDT must decide between radical cystectomy, bladder-preserving chemoradiotherapy and palliative TURBT. The patient understands the diagnosis but is uncertain about major surgery. A trainee has suggested a nephrostomy because of the left hydronephrosis.
1. How would you structure the MDT discussion and what additional assessment is needed before recommending treatment?
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The MDT should first confirm that staging is complete and that the histology is reviewed by a specialist uropathologist. The key issue is not simply tumour stage but physiological reserve and the patient's own goals. I would arrange a geriatric or frailty assessment, a cardiology/anaesthetic review, nutritional assessment, cognitive assessment and a social review, because he lives alone and may not manage a cystectomy and stoma. Renal function needs to be characterised: the left hydronephrosis may mean the left kidney contributes little, so split renal function, if available, is more useful than eGFR alone. A nephrostomy is not automatically indicated for asymptomatic unilateral obstruction; it may be considered if there is infection, pain, progressive renal failure or if chemoradiotherapy is planned and renal preservation would allow systemic therapy. The MDT should document options, the reasoning and the patient's preferences, and involve a clinical nurse specialist in shared decision-making.
2. Compare radical cystectomy and chemoradiotherapy for this patient, including the role of the left hydronephrosis.
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Radical cystectomy offers the most reliable local control but carries substantial perioperative risk in a frail, cognitively impaired man with cardiac disease and CKD. He would likely need an ileal conduit and may not cope alone. Neoadjuvant cisplatin-based chemotherapy is contraindicated by eGFR 32, so cystectomy would be upfront surgery. Chemoradiotherapy with a radiosensitiser such as mitomycin and 5-fluorouracil is an alternative for muscle-invasive disease, but it requires good renal function, ability to attend daily treatment, and a bladder that can be preserved; it also risks radiation cystitis and later salvage cystectomy. The left hydronephrosis suggests tumour at the left ureteric orifice. If chemoradiotherapy is chosen, the obstructed left kidney may need drainage to preserve renal function and to avoid infection during treatment. If cystectomy is chosen, the distal left ureter is removed with the bladder, and a nephrostomy is unnecessary unless the kidney is infected or symptomatic.
3. What would you tell the patient and his family about prognosis and goals of care?
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I would explain that the cancer has invaded the muscle but has not spread on scans, so the aim is curative treatment if he is fit enough. I would be honest that both cystectomy and chemoradiotherapy are major treatments with significant risks, and that his frailty, heart disease and kidney function make the decision finely balanced. I would explain that cystectomy gives the best chance of avoiding local recurrence but has a long recovery and a stoma, while chemoradiotherapy preserves the bladder but needs daily attendance and has a chance of recurrence requiring salvage surgery. I would also discuss palliative TURBT if he decides that quality of life and independence matter more than maximum cancer control. The conversation should include his values, who supports him at home, and what he understands about his memory problems. I would document the discussion and offer a second consultation with the nurse specialist.