Combined Laparoscopic and Open Surgical Approach for a Peritoneal Metastasis of a Bladder Urothelial Carcinoma Presenting Hepatic, Renal and Parietal Invasion - A Case Report.

Introduction and Objectives. We report the case of a 67 years old male patient presenting a peritoneal metastasis of an urothelial bladder carcinoma treated in our tertiary healthcare center. The tumoral mass invaded the right kidney, the liver and abdominal wall with adjacent diaphragm and ribs. The surgical treatment was successfully performed combining a transperitoneal laparoscopic approach with open surgery in November 2018. Materials and Methods. When referred to our department, the patient presented pain in the right hypochondriac region that was non responsive to anti-inflammatory and antalgic medication, without associating any low urinary tract symptoms. The patient was known with multiple transurethral resections of the bladder since 2017 for a bladder urothelial carcinoma and denied smoking habits. During the ultrasound check-up a right lumbar tumoral mass was observed, including the superior pole of the right kidney with hepatic and parietal invasion, confirmed by a CT scan with negative lymph nodes. The immunohistochemistry analysis of the ultrasound guided biopsy showed a carcinoma, raising the suspicion of a sarcoma as a primary tumor. The focus was on a wide excision of the tumoral mass with macroscopic comfortable negative surgical margins. Results. The surgical strategy started with a laparoscopic transperitoneal approach using 4 trocars and continued with open surgery. The laparoscopy showed a tumoral block including Vth and VIth hepatic segments, the right superior renal pole, the abdominal wall and the adjacent diaphragm. Hepatic resection of the affected segments, the right radical nephrectomy, the invaded abdominal wall and the adjacent diaphragm were isolated using laparoscopy. Once the hepatic and renal excision was performed, the resection continued from the outside with the involved thoracic wall, the 10th, 11th and 12th rib excision and pleurectomy. This successfully removed the specimen in one surgical block: tumor, kidney, liver and the whole abdominal wall with adjacent diaphragm and ribs, from the peritoneum to the skin in safe oncologic conditions. The post operatory evolution of the patient was favorable, the patient being discharged after 10 days of hospitalization. The pathology report showed a peritoneal metastasis of the urothelial bladder carcinoma that was prior diagnosed at this patient. The surgical margins were negative, the patient received chemotherapy with follow-up from his oncologist for extravesical and local tumor recurrences. Conclusions. A peritoneal metastasis of a bladder urothelial carcinoma in case of no anatomical vicinity to the urinary pathway on pre operatory imaging, raises the suspicion of tumoral dissemination through a clinically insignificant bladder wall perforation. This could have happened during the transurethral bladder resections that were prior performed. The combination of laparoscopic and open surgical approach improved the peri operative parameters as the laparoscopy offered a better intra operatory view, on point dissection and hemostasis, with oncologic safety. Knowing the limits and the advantages of laparoscopy allows surgeons to combine approaches in case of complex retroperitoneal tumors for the best peri and post operative outcomes. [ABSTRACT FROM AUTHOR]