although radical cystectomy with urinary diversion has been regarded as the standard treatment for muscle invasive bladder cancer ( mibc ) , it is associated with high postoperative complication and mortality as well as decreased quality of life . as a result , different kinds of bladder sparing approaches have been proposed for mibc treatment .
partial cystectomy ( pc ) with pelvic lymph node dissection ( plnd ) combined with chemotherapy or radiotherapy , which offers complete tumor resection , accurate staging and good quality of life , is regarded as a good bladder sparing treatment modality . even though , pc is still criticized for an unacceptable high recurrence rate .
recurrent bladder carcinoma after pc is usually correctly diagnosed by urologists , because of the appearance of typical papillary in ultrasonography or cystoscopy , and can be easily confirmed by tumor biopsy . however , in this case series , we presented 3 patients with rare deceptive benign appearance of recurrent mibc after pc , which delayed timely diagnosis and treatment for 2 of them .
from january 2010 to december 2014 , 93 consecutive patients underwent pc in our institution .
of these patients , 56 cases of pc with plnd were performed for mibc . with a median follow - up of 21 months ( range 452 months ) , 16 patients ( 28.6% )
of the 16 patients who had bladder tumor recurrence , 2 men were diagnosed as deceptive mibc recurrence after pc . during the same period of time ,
one another patient , who was referred to our hospital , presented the same characteristics of tumor recurrence in the course of disease .
all the patients declined cystectomy after transurethral resection of bladder tumors ( turbt ) confirmed mibc , and pc with plnd was thus performed instead . as lesions of the 3 patients were within 2  cm to ureteral orifice , ureteral reimplantation was performed at the same time .
all patients recovered from pc surgery uneventfully and received 6 cycles of gemcitabine and cisplatinchemotherapy after surgery .
all interventions given were part of normal health care and ethicalapproval was thus not necessary needed .
lesions , measuring 2.5    1  cm , with cystitis glandularis appearance were found at the right lateral wall of bladder when the patient underwent cystoscopy 9 months after cystectomy .
the pathology result of random biopsy at 3 different sites of the lesion showed cystitis glandularis with von brunn 's nests proliferation .
two months later , the patient presented gross hematuria , and contrast - enhanced pelvic computed tomography ( ct ) revealed irregular thickening and significantly enhanced bladder wall .
the size of the lesion was found slightly increased in cystoscopy ; however , the pathology of random biopsy still showed cystitis glandularis .
turbt was then performed , and high - grade muscle invasive urothelial carcinoma with urothelialcystitis glandularis was diagnosed by pathological examination .
cystoscopic evaluation revealed polypoidlesion , measuring 2    1  cm , on the left bladder wall 6 months after pc .
turbt was carried out and the pathology showed high - grade muscle invasive urothelial bladder cancer .
cystectomy with orthotopicneo bladder diversion was thus performed , and the patient was now still alive without bladder tumor recurrence for 48 months .
polypoid lesions , measuring 1    1  cm , on the right bladder wall near the internal urethral orifice were found at cystoscopy 3 months after pc in another hospital .
pathologic examination of biopsy showed chronic bladder inflammation with proliferation of von brunn 's nests .
he was referred into our hospital 2 months later because of right renal area dull pain .
however , computed tomography urography ( ctu ) revealed right - sided hydroureteronephrosis and thicken bladder wall with unclear boundary to the surrounding tissue ( figure 1b , figure 1c ) .
comparison between the ct scan after tumor recurrence and before pc were made in figure 1 .
turbt was performed and the pathological evaluation revealed high - grade muscle invasive bladder urothelial carcinoma .
the patient underwent cystectomy with ileal conduit diversion , and the gross pathologic examination showed that the bladder cancer had infiltrated the surrounding tissue with one lymph node metastasis .
a. cystoscopy displayed cystitis glandularis appearance lesion ( solid asterisk ) on the right bladder wall near the internal urethral orifice ; b. ctu confirmed hydroureteronephrosis ( hollow asterisk ) caused by mass on the right lateral bladder wall ( black arrow ) ; c. transverse ct image showed an irregular right lateral bladder wall thickened with unclear boundary to the surrounding tissue ( black arrow ) ; d. ct confirmed bladder mass on the right lateral bladder wall before bladder sparing treatment ( white arrow ) .
bladder sparing treatment is considered as an important alternative treatment approach for mibc . nowadays ,
various modalities of bladder - sparing methods have been reported and investigated , among which pc with plnd after completeness of turbt plus chemotherapy or radiotherapy is regarded as a rational one . it was reported that the 5-year cancer specific survival rate after pc bladder sparing treatment ranges from 67% to 69% . although the 5-year survival rate of pc is comparable to radical cystectomy , and
the quality of life for mibc patients have been greatly improved , this therapeutic approach has not yet been regarded as a standard treatment option for mibc because of lack of randomizedtrials .
critics of pc also argued that the tumor recurrence rate after pc was relatively high , which ranged from 19% to 58% , and two - thirds of tumor recurrence appeared during the first 2 years . as a result , one important component of bladder sparing
treatment modality was vigilant surveillance after surgery , because early detection of tumor recurrence resulted in excellent outcome of salvage radical cystectomy .
however , the window to salvage cystectomy was short , and the disease carried a poor prognosis once patients developed extravesical disease caused by delayed diagnosis .
regular cystoscopy and random biopsy of suspected lesion played a pivotal role in detecting early recurrence .
however , in the present study , 3 patients showed deceptive early mibc recurrence with a cystitis glandularis crust covered on the surface after bladder sparing treatment , escaping random multiple biopsies .
as a consequence , 2 patients missed the optimal opportunity for early diagnosis and delayed timely cystectomy .
enhanced ct and ctu were also the preferred method for bladder surveillance , which showed high accuracy for detecting and staging urinary tract cancer . although biopsy revealed negative results in the present cases , ct or ctu showed enhanced and thickened bladder wall , which suggested highly suspicious of bladder cancer recurrence .
therefore , patients showed suspicious lesions in cystoscopy with negative biopsy , enhanced ct or ctu should be recommended for further evaluation rather than watchful waiting .
someinvasive variants , such as nested variant and microcystic carcinoma , might even mimic benign lesions , which may cause difficulties for pathologists in the differential diagnosis .
however , in the present study , the pathological sections of the biopsy tissue obtained at cystoscopy of the 3 patients were blindly sent to 2 different pathologists for further evaluation after turbt confirmed mibc , the results were also suggestive of benign tissue , excluding the possibility of nested variant or microcysticurothelial carcinoma .
the relationship between the formation of cystitis glandularis and mibc recurrence was unknown , but several factors might contribute to the deceptive appearance formation . first , such situation potentially reflected a response to bladder injury or chronic bladder inflammation caused by bladder surgery .
in addition , ureteral reimplantation was reported to be associated with high recurrence and poor prognosis after pc .
it was interesting that all patients with deceptive mibc recurrence had undergone ureteral reimplantation , which suggested that ureteral reimplantation might be a risk factor for such kind of recurrence .
early mibc recurrence after bladder sparing therapy could simultaneously occurred with cystitis glandularis caused by bladder surgery ; this rare situation might lead to diagnosis of cystitis glandularis without realizing bladder cancer recurrence and missed the best treatment opportunity .
the present cases served to remind and alert the urologists to be aware of the possibility of bladder cancer recurrence even when the biopsy of the bladder lesion was benign . as a result , timely pelvic enhanced ct and turbt were necessary when bladder lesion occurred after pc , avoiding the possibility of missing mibc recurrence and delaying timely cystectomy .
 abstractmost of recurrent bladder carcinoma after partial cystectomy did not cause diagnostic difficulties for urologists , because of the appearance of typical papillary in ultrasonography or cystoscopy , and could be easily confirmed by tumor biopsy . 
 three patients , ages from 35 to 62 years , had undergone bladder sparing treatment for muscle invasive bladder cancer , all of them had biopsy revealed benign bladder lesion at surveillance cystoscopy . however , transurethral resection of bladder tumor showed high - grade muscle invasive urothelial bladder carcinoma for these patients . 
 two patients were thus delayed for timely cystectomy and consequently resulted in local or distal metastasis.as a result , we recommended that timely pelvic enhanced computed tomography and transurethral resection of bladder tumor were necessary when bladder lesion occurred after partial cystectomy , avoiding the possibility of missing muscle invasive urothelial bladder carcinoma recurrence and delaying timely cystectomy . 