Background: High Grade (HG) Urothelial Carcinoma (UC) with variant histology has historically been managed conservatively and continues to create a conundrum for clinical urologists. The presented case details a solitary lesion of Muscle Invasive Bladder Cancer (MIBC) with sarcomatoid variant (SV) histology treated by partial cystectomy and adjuvant chemotherapy without evidence of HG recurrence in 8 years of surveillance. Case Presentation: A 71-year-old male with a 15-pack year smoking history presented to clinic after outside transurethral resection of bladder tumor (TURBT). Imaging by CT abdomen and pelvis was negative for pelvic lymphadenopathy or abnormalities in either collecting system. A 2 cm broad based papillary tumor at the bladder dome was identified. Complete staging TURBT noted a final pathology of invasive HG UC with areas of spindle cell differentiation consistent with sarcomatous changes and no evidence of lymphovascular invasion. The patient was inclined toward bladder preserving options. Partial cystectomy with a 2 cm safety margin and bilateral pelvic lymphadenectomy was performed. Final pathology revealed HG UC urothelial carcinoma with sarcomatoid differentiation and invasion into the deep muscularis propria, consistent with pathologic T2bN0 disease, a negative margin, and no lymphovascular invasion. The patient subsequently pursued four doses of adjuvant doxorubicin chemotherapy though his treatment was complicated by hand-foot syndrome. The patient continued screening with cystoscopy, urine cytology, and CT. At 21 months post operatively, the patient developed a small (<1cm) papillary lesion near but uninvolved with the left ureteral orifice. Blue light cystoscopy and TURBT revealed noninvasive low grade Ta urothelial carcinoma. To date, the patient has no evidence of high-grade urothelial carcinoma recurrence; 8 years after partial cystectomy. Patient maintains good bladder function and voiding every 3-4 hours with a bladder capacity around 350 ml. Conclusion: Surgical extirpation with partial cystectomy followed by adjuvant chemotherapy may represent a durable solution for muscle invasive (pT2) UC with SV histology if tumor size and location are amenable for partial cystectomy. Due to the sparse nature of sarcomatous features within urothelial carcinoma, large multicenter studies are required to further understand the clinical significance and optimal management options for this variant histology in the management of bladder cancer.

Background Nephroureterectomy remains the gold standard treatment for upper tract urothelial carcinoma (UTUC). Considering the high risk of developing renal function impairment after surgery, the rationale for nephron sparing approaches in treatment of UTUC has been raised. In this case, renal cryoablation was able to achieve successful oncologic control while preserving renal function during 5 years of follow up without intraoperative or post operative complications. Case presentation A 79 year old male presents after three months of macroscopic hematuria. Imaging revealed a 3.6 × 3.1 × 2.7 cm endophytic mass in the interpolar region of the left kidney and an atrophic right kidney. After weighing the lesion’s location with the patient’s of complex medical history, he was counselled to undergo a minimally invasive percutaneous cryoablation as treatment for his solitary renal mass. A diagnostic dilemma was encountered as imaging suggested a diagnosis of renal cell carcinoma. However, the pre-ablation biopsy established an alternative diagnosis, revealing UTUC. Percutaneous cryoablation became an unorthodox treatment modality for the endophytic component of his UTUC followed by retrograde ureteroscopic laser fulguration. The patient was followed in 3 months, 6 months, then annually with cross sectional imaging by MRI, cystoscopy, urine cytology and renal function testing. After five years of follow-up, the patient did not encountered recurrence of UTUC or deterioration in renal function, thereby maintaining a stable eGFR. Conclusion Although evidence for nephron-sparing modalities for UTUC is mounting in recent literature, limited data still exists on cryotherapy as a line of treatment for urothelial carcinoma. We report successful management of a low-grade UTUC using cryoablation with the crucial aid of an initial renal biopsy and long-term follow-up. Our results provide insight into the role of cryoablation as a nephron-sparing approach for UTUC.