The poor prognosis of high grade muscle invasive transitional cell carcinoma (TCC), of the bladder is likely secondary to the presence of micro-metastases at the time of diagnosis. This is reflected by modest improvements in 5 year survival figures despite aggressive multimodal therapy for this aggressive cancer.We present two cases which highlight the importance of regular clinical evaluation for metatstatic disease. Case 1 A 73 year-old man with past history of Alzheimer's disease and COPD, presented to our unit with painless frank haematuria. Cystoscopy revealed a solid lesion on the base of the bladder which was resected to muscle. Histology showed high grade transitional cell carcinoma with muscle and vascular invasion (pT2a). CT Scans of chest, abdomen and pelvis showed no evidence of local, nodal or distant metastatic spread. The patient, being unfit for cystectomy was treated with radical radiation therapy and post treatment cystoscopies showed no evidence of recurrent disease. At 13 months he presented with a 2 months history of painful priapism. Attempted aspiration of the corpora cavernosa was unsuccessful and operative findings were of a dense fibrotic tissue within the corpus cavernosum with minimal back bleeding. Core biopsies taken via the glans showed metastatic transitional cell carcinoma. [Fig 1]
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