Misread Biopsy Leads to Delayed Recognition of Urothelial Carcinoma and Bladder Removal

This case involves a patient with recurrent bladder infections. The patient initially had a negative culture and was treated with antibiotics. The physician ordered no imaging or cystoscopy. The patient later presented with blood upon urination and visited his physician. Lab work and CT scan without contrast were done. A biopsy was taken, whereby tumors were removed. Later, the patient was told that the biopsy had been lost and a second biopsy that was required. The biopsy came back and as noninvasive cancer and BCG treatment was recommended. The patient sought a second opinion that reread the slides as being invasive and as urothelial carcinoma of the urinary bladder. Ultimately, the patient’s bladder and prostate had to be removed.

Question(s) For Expert Witness

1. Please elaborate on your experience in the management of patients with possible bladder cancer.

2. What diagnostic tests are warranted when a patient presents with recurrent bladder infections and blood upon urination?

Expert Witness Response E-008928

I am an expert in bladder cancer. I have performed over 1400 cystectomies, and am nationally and internationally recognized for my expertise in both early (non-muscle-invasive) as well as muscle-invasive disease. I have been in practice for 26 years, and bladder cancer treatment constitutes about 80% of my clinical practice. I am currently Professor and Director of Urologic Oncology at a major Midwestern medical center.

It sounds like this patient was likely treated for presumed prostatitis. However, it is known that bladder cancer can also give irritative symptoms and can be misdiagnosed as prostatitis early on in the evaluation. Prostatitis may have negative urine cultures but tends to improve with antibiotics. On the other hand, hematuria, gross or microscopic, nearly always requires a urologic evaluation including cytology, cystoscopy, and imaging (typically a CT scan). It is highly unusual that bladder biopsies would be lost. Inaccurate pathological staging, on the other hand, is not that infrequent, whereby one pathologist, often community-based and not specializing in genitourinary pathology, either fails to see muscle invasion or calls it when it is not there. This occurs in my own university-based practice, about 10-15% of the time when I see patients with bladder cancer as second opinions.