Urodynamic assessment of detrusor function in the very acute phase of traumatic spinal cord injury: A prospective cohort study.

Introduction: The bladder is believed to be acontractile due to the phase of spinal shock and there is a lack of data on the detrusor function within the first few days after spinal cord injury (SCI). This study intended to assess the detrusor function with invasive urodynamics (UDS) during the first 15 days of SCI. Methods: This prospective observational study was carried out from January 2020 to June 2021 and consecutive stable patients older than 18 years of age who had a history of traumatic SCI within the past 15 days were screened for inclusion. For each patient, the International Standards for Neurological Classification of SCI Worksheet was filled. All patients underwent bedside invasive UDS within 15 days of injury. Results: There were a total of 41 patients with a mean age of 35 years. The thoracic cord was most commonly involved (46.3%) with Type A AISA grade being the most common (68.2%). The mean duration of injury at the time of UDS was 6 days. Abnormality in the filling phase could be identified in six patients. Three patients had neurogenic detrusor overactivity (NDO), with one having a high-pressure phasic NDO and one having a sustained NDO. Two patients had poor compliance and one had borderline poor compliance. None of the patients generated any detrusor pressure during voiding cystometry. Conclusions: In patients with SCI, 14.5% of the patients had abnormal findings during the filling phase on the UDS performed within 15 days of the injury. These findings are in stark contrast to the traditional understanding that the detrusor is acontractile during the early phase of the SCI and merit further evaluation.

Establishing initial resting abdominal pressure in children undergoing urodynamics.

INTRODUCTION: The International Continence Society recommends zeroing of transducers to the atmospheric pressure for invasive urodynamics. The range of abdominal pressure relative to atmospheric pressure is well-known in adults but has not been described in children. This prospective observational study was carried out to establish baseline abdominal in children. MATERIALS AND METHODS: Prospective, multicenter, observational study of 100 children aged 0-18 years undergoing invasive urodynamics using water-filled systems. Initial resting abdominal pressure, intravesical pressure and detrusor pressure were recorded in supine, sitting, and standing position (as age- and diagnosis-appropriate). This data was analyzed using SPSS 20.0.0 with regard to age, gender, height, weight, body mass index, and underlying diagnosis (classified as neurogenic or non-neurogenic). Nonparametric tests were used (2-sided p < 0.05, significant). RESULTS: Initial resting abdominal pressure (inter-quartile range) in children was between 5 and 15 cmH2 O in the supine, 13-20 cmH2 O in the sitting, and 15-21 cmH2 O in the standing position. These pressures were not consistently influenced by age, gender, height, weight or underlying diagnosis. The initial resting detrusor pressure was noted to be 0-4 cmH2 O without any difference based on posture. Limitations include use of two-tube technique, relatively small number of subjects across each age group, wide range of underlying diagnoses and need for manual smoothing of some traces. CONCLUSION: This study defines initial resting abdominal pressure at urodynamics in children and notes that, as with adults, it is possible to define widely applicable ranges regardless of individual characteristics. These pressures appear lower than those noted historically in adults.

Can apparently transient life events trigger long-term lower urinary tract symptoms?

INTRODUCTION: One-time life events such as neurological injury can result in lifelong lower urinary tract symptoms (LUTS). However, it is unclear whether an apparently transient life event can also trigger long-term LUTS. This review examines the possibility of an association and hypothesizes the pathogenesis. METHODS: A pubmed search was conducted using the MeSH words "life change events," "child abuse," or "stress disorders, Posttraumatic", and LUTS. Additional manuscripts were identified by a hand and citation search. RESULTS: Long-term LUTS was noted following temporally remote childhood sexual abuse, adverse childhood experiences, and stressful experiences in adults. There was evidence for an association of childhood sexual abuse and adverse childhood events with both storage as well as voiding LUTS. There was limited evidence that the number of adverse childhood events might increase the risk and severity of LUTS. There was evidence of an association between post-traumatic stress disorder in adults and LUTS. The finding of mental health disorders in such patients could explain some but not all of the observed association suggesting that other factors might also be important. CONCLUSIONS: There is an association noted between apparently transient lifetime events and the subsequent reporting of LUTS. The timing of these adverse experiences might be important in determining the propensity for clinical manifestation. There is a need to explore this association, establish causality, and determine the underlying etiopathogenesis.

Neuro-Urology: Call for Universal, Resource-Independent Guidance.

Neurogenic lower urinary tract dysfunction (NLUTD), the abnormal function of the lower urinary tract in the context of neurological pathology, has been the subject of multiple efforts worldwide for the development of clinical practice guidelines. These guidelines are based on the same body of evidence, and are therefore subject to the same gaps. For example, sexual and bowel dysfunction in the context of NLUTD, optimal renal function assessment in those who are non-ambulatory or with low muscle mass, optimal upper tract surveillance timing, and modification of diagnostic and treatment modalities for low-resource nations and communities are inadequately addressed. In addition, many aspects of the conclusions and final recommendations of the guidelines are similar. This duplicative work represents a large expenditure of time and effort, which we believe could be focused instead on evidence gaps. Here, we call for a global unified approach to create a single, resource-independent, comprehensive guidance on NLUTD, neurogenic sexual, and neurogenic bowel dysfunction. Targeted research addressing the evidence gaps should be called for and pursued. This will allow for focus to shift to filling the gaps in the evidence for future guidelines.

Peroxiredoxins - Urinary Surveillance Biomarkers in Urothelial Cancer.

Introduction: Urinary bladder cancer ranks the fourth most common cancer in men worldwide. Peroxiredoxins (PRDXs) are antioxidant enzymes that play an important role in cell proliferation and apoptosis. In the present study, we investigated whether PRDX 1 and 2 can be used as a urinary biomarker for surveillance of recurrence in urothelial cancer. Materials and Methods: PRDX1 and PRDX2 expression levels were examined in 119 bladder tumor specimens by immunohistochemistry and in 150 urine samples (case: 100; healthy controls: 50) using ELISA and their association with recurrence and survival of patients was evaluated. Results: Immunohistochemistry on FFPE tissue showed that both PRDX1 and PRDX2 were positive in bladder tumors and expressed in the cytoplasm and membrane of tumor cells. A significant elevation of urinary PRDX1 and PRDX2 concentration was found in bladder cancer patients and recurrent cases compared to the urine of healthy controls and primary bladder cancer patients (p<0.001 & p<0.01) respectively. However, the concentration of both proteins was not found associated with survival. Conclusion: Elevated urinary PRDX1 and PRDX2 in bladder cancer patients was found to be associated with recurrence and the estimation of urinary PRDX1 and PRDX2 during follow-up may help to extend the period between cystoscopies in patient follow-up.

Neurological safety and efficacy of darifenacin and mirabegron for the treatment of overactive bladder in patients with history of cerebrovascular accident: A prospective study.

OBJECTIVES: To evaluate the neurological safety and clinical efficacy of darifenacin and mirabegron in patients with a history of cerebrovascular accident (CVA) who had overactive bladder (OAB) symptoms. METHODS: This prospective randomized study, approved by the institute's ethics committee, was carried out at a tertiary care center from December 2018 to June 2020. Treatment naïve adult patients with a past history of CVA with stable neurological status for atleast past 3 months with symptoms of OAB for 3 or more months were included. Eligible patients received either darifenacin or mirabegron for a period of 3 months and various parameters on the 3-day International Consultation on Incontinence Questionnaire (ICIQ) bladder diary, the Montreal Cognitive Assessment-Basic score (MoCA-B), and the adverse events at 3 months posttreatment were compared to that at the baseline. RESULTS: A total of 60 patients were included, 30 in each arm. After 3 months of treatment with darifenacin or mirabegron, the majority of the ICIQ bladder diary parameters improved and there was no deterioration in the cognitive function as noted on the MoCA-B score in either of the arms. On intergroup comparison, the mean change in bladder diary parameters and the MoCA-B scores was similar between the two groups. CONCLUSION: Darifenacin and mirabegron, in the short term, do not adversely affect the cognitive function in patients with a history of CVA with OAB symptoms. Both are safe and effective treatment options in patients with OAB post-CVA.

Efficacy and safety of mirabegron for the treatment of neurogenic detrusor overactivity resulting from traumatic spinal cord injury: A prospective study.

OBJECTIVE: To assess the clinical, urodynamic efficacy, and safety of mirabegron in patients with neurogenic detrusor overactivity (NDO) consequent to traumatic spinal cord injury (SCI). METHODS: This prospective cohort study was performed between January 2018 and July 2019 and included adult patients with stable traumatic suprasacral SCI, performing clean intermittent catheterization (CIC), and demonstrating NDO on urodynamic study (UDS). A 3-day bladder diary was made at the baseline after which all patients were started on Mirabegron 50 mg. They were followed up at 6 weeks with a repeat bladder diary and UDS which were compared with those at the baseline. RESULTS: A total of 30 patients (4 females, 26 males, mean age: 30.07 years) were included. After 6 weeks of treatment, 5 out of the 29 incontinent patients became completely dry. The mean frequency of CIC decreased from 6.63 at the baseline to 5.37 at 6 weeks (p = .002), the mean CIC volume increased from 275 ml to 341 ml (p = .0002), the mean number of incontinence episodes in between CIC reduced from 3.97 to 2.27 (p < .0001) and time from CIC to leakage increased from 1.73 h to 2.75 h (p < .0001). The mean cystometric capacity increased from 348 ml to 406 ml (p = .008) and the maximum amplitude of NDO decreased from 54 cm H2 O to 41 cm H2 O (p = .005) at 6 weeks. Only two patients reported new onset dry mouth. No major adverse events were noted and none discontinued treatment. CONCLUSION: Mirabegron is efficacious and safe in patients with NDO consequent to traumatic SCI.

"Mesh free" autologous transobturator mid urethral sling placement for predominant stress urinary incontinence: A pilot study.

AIMS: To assess the efficacy and safety of autologous mid-urethral sling (MUS) in women with predominant stress urinary incontinence (SUI). MATERIALS AND METHODS: This prospective cohort study included adult women with predominant SUI seen in our urology clinic between January 2018 and March 2019. Patients with: negative cough stress test, history of prior incontinence surgery, urogenital malignancy, pelvic radiation, neurological disease, body mass index more than 40 kg/m2 , the presence of more than Stage I pelvic organ prolapse, active urinary tract infection, maximum flow rate less than 15 ml/sec, postvoid residual urine more than 100 ml, abdominal leak point pressure less than 60 cm of H2 O, and pregnant women were excluded. Eligible patients underwent a transobturator MUS procedure using rectus fascia as a sling. Before the procedure, patients filled the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptom (ICIQ-FLUTS) and the Female Sexual Function Index (FSFI) questionnaire. Urinary outcomes were assessed at 3- and 12-months while sexual outcomes were assessed at 12-months. RESULTS: Thirty patients with median age of 44.5 years were included. All patients had a negative cough stress test during follow up. A significant improvement was noted in the ICIQ-FLUTS scale, bother scale, filling and incontinence subscales at 3 and 12 month follow-up. A significant improvement was also noted in the FSFI full scale score and FSFI domains of mean sexual desire, arousal and lubrication at 12 months follow-up. Two patients developed voiding dysfunction requiring urethral dilatation. CONCLUSION: Autologous transobturator MUS surgery appears to be safe and efficacious in the short term. More research is needed to clarify its role in the surgical management of SUI in women.

Benign Mimickers of Urinary Bladder Cancer: a Case Series.

Bladder cancer is one of the leading malignancies in the world associated with significant morbidity and mortality. However, several benign lesions of the bladder can mimic urothelial carcinoma clinically and radiologically owing to overlapping signs and symptoms. Thus, rendering a correct diagnosis is imperative as it will have a significant impact on the management of patients. We present an amalgamation of five cases having a high suspicion of urothelial malignancy, which were subsequently diagnosed as benign entities with better prognosis and thus warranted a different therapeutic approach.

The International Continence Society (ICS) report on the terminology for male lower urinary tract surgery.

INTRODUCTION: In the development of terminology of the lower urinary tract (LUT), due to its increasing complexity, the terminology for male LUT surgery needs to be updated using a male-specific approach and via a clinically-based consensus report. METHODS: This report combines the input of members of the Standardization Committee of the International Continence Society in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 14 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for male LUT and pelvic floor surgery, encompassing 149 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in male LUT surgery. Figures have not been included to avoid any preference or bias towards a specific procedure. CONCLUSIONS: A consensus-based Terminology Report for male LUT surgery has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Efficacy and safety of mirabegron for the treatment of low compliance bladder resulting from sacral/infrasacral lesions: A prospective study.

OBJECTIVE: To assess the efficacy and safety of mirabegron in patients with sacral/infrasacral lesions who have an acontractile detrusor and develop a low compliance bladder. METHODS: This prospective study included adult patients with acontractile detrusor as a result of sacral/infrasacral lesions who develop a low compliance bladder (compliance <20 mL/cmH2 O). All patients were asked to make a 48-h clean intermittent catheterization diary and underwent invasive urodynamics evaluation at the baseline, and were started on mirabegron 50 mg once daily. Patients were re-evaluated at 6 weeks with a repeat clean intermittent catheterization diary and invasive urodynamics, and the efficacy and safety of mirabegron was assessed. RESULTS: A total of 17 patients were included. After 6 weeks of mirabegron therapy, the number of patients reporting leakage in between clean intermittent catheterization reduced from seven to two (P = 0.02), the end filling pressures reduced from 41.4 to 15.1 cmH2 O (P = 0.003), the compliance increased from 9.8 to 99.9 mL/cmH2 O (P = 0.000), and the number of patients where the end filling pressure was >40 cmH2 O reduced from eight to one (P = 0.02). The cystometric bladder capacity did not change significantly. Similar effects were noted in patients who were already on clean intermittent catheterization or were started on clean intermittent catheterization at inclusion in the study. Mirabegron was well tolerated, none of the patients discontinued therapy or reported major side-effects. CONCLUSIONS: Mirabegron reduces end filling pressure, improves compliance and is safe in patients with a low compliance bladder resulting from a sacral/infrasacral lesion.

Frequency volume chart for the illiterate population: A simple solution.

INTRODUCTION: We aimed to assess the feasibility of a novel method of recording frequency volume chart (FVC) in adult patients who are either illiterate or are unable to make the required written record. MATERIALS AND METHODS: This prospective study included adult patients, in whom FVC was required as part of their urological evaluation, who were either illiterate or were not sufficiently literate to make the required written record. Three groups of people were involved in the study: (i) patient, (ii) nursing staff, and (iii) the investigator/coinvestigator. The investigator/coinvestigator briefed the patient and the nursing staff, separately, regarding their roles in detail. The patient-reported (investigator/coinvestigator interpreted) data were compared with the data recorded by the nursing staff to assess the feasibility of this novel method. RESULTS: A total of 30 patients were included in the study, with a mean age of 45.1 years and male: female ratio of 2:1. The patient-reported (investigator/coinvestigator interpreted) data including 24-h urine production, daytime urine volume, nocturnal urine volume, daytime urinary frequency, nocturia, average voided volume, and maximum voided volume were similar to the data reported by the nursing staff, with no significant differences. All patients completed the FVC satisfactorily, except one patient who failed to report the night time voids. CONCLUSIONS: Our novel method of recording FVC is feasible, reliable, and clinically as informative/applicable as the written FVC in patients who are illiterate/insufficiently literate to make a written record of FVC.

Comparison of percentage free PSA, MRI and GaPSMA PET scan for diagnosing cancer prostate in men with PSA between 4 and 20 ng/ml.

INTRODUCTION: We compared the diagnostic accuracy of percentage free prostate-specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI), and gallium-68 prostate-specific membrane antigen positron emission tomography (Ga-PSMA PET) to detect cancer prostate in men with PSA between 4 and 20 ng/ml in prebiopsy settings. MATERIALS AND METHODS: This prospective study evaluated men with PSA values between 4 and 20 ng/ml, and all patients underwent percentage free PSA estimation, mpMRI, and Ga-PSMA PET scan, followed by cognitive fusion/registration biopsy along with systematic 12-core biopsy to detect cancer prostate. The diagnostic accuracy of percentage free PSA, mpMRI, and Ga-PSMA PET scan was compared with results of cognitive fusion/registration biopsy. RESULTS: A total of 15 patients were included, of which 11 had an identifiable lesion on imaging and 9 had malignancy on the final histopathology report. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy of mpMRI were 62.5%, 71.4%, 71.4%, 62.5%, and 66.6%, respectively, and that of Ga-PSMA PET scan were 88.8%, 66.6%, 80%, 80%, and 80%, respectively. The sensitivity of detection of clinically significant cancers for Ga-PSMA was higher (100%) compared to MRI (33.3%). However, Ga-PSMA also detected a greater number of insignificant lesions as compared to MRI. CONCLUSION: Ga-PSMA PET scan has high NPV and accuracy in predicting presence of cancer and can also be used to direct specific biopsy cores during systematic biopsy.

Impact of monopolar TURP, bipolar TURP and photoselective vaporization of prostate for enlarged prostate on erectile function.

OBJECTIVES: To compare monopolar transurethral resection of the prostate (TURP), bipolar TURP and photoselective vaporization of the prostate (PVP) by 120-W GreenLight laser with regard to the impact on International Index of Erectile Function (IIEF)-5 score in patients presenting with lower urinary tract symptoms (LUTS) secondary to prostate >80 mL. METHODS: Between April 2012 and March 2015, 110 patients who satisfied eligibility criteria were divided into three groups according to surgical modality adopted to treat benign prostatic enlargement. Preoperative, perioperative, and follow-up data were collected. The three groups were as follows: group A, monopolar TURP; group B, bipolar TURP; and group C, PVP. RESULTS: The baseline characteristics of the three groups were similar. All the perioperative parameters were significantly favorable in group C compared with the other two groups, except for mean operative time, which was significantly higher in group C. International Prostate Symptom Score, postvoid residual urine, maximum flow rate and quality of life score had significant and similar improvement during follow up in all three groups. Also, prostate volume reduced significantly in all three groups following surgery, but it remained significantly higher in group C patients compared with groups A and B. Mean IIEF-5 score was similar between the three groups at baseline and during each of the follow-up visits. Groups A, B and C had declines of 3.27% (P = 0.34), 2.68% (P = 0.40) and 3.36% (P = 0.35), respectively, in mean IIEF-5 score at 12-month follow up compared with baseline. CONCLUSIONS: Monopolar TURP, bipolar TURP and PVP by 120-W GreenLight laser for prostate size >80 mL do not have a significant impact on IIEF-5 score at 12-month follow up.

The Urological Society of India survey on urinary incontinence practice patterns among urologists.

INTRODUCTION: The Urological Society of India guidelines panel on urinary incontinence (UI) conducted a survey among its members to determine their practice patterns in the management of UI. The results of this survey are reported in this manuscript. METHODS: An anonymous online survey was carried out among members of the USI to determine their practice patterns regarding UI using a predeveloped questionnaire on using SurveyMonkey®. A second 4-question randomized telephonic survey of the nonresponders was performed after closure of the online survey. Data were analyzed by R software 3.1.3 (P < 0.05 significant). RESULTS: A total of 468 of 2109 (22.2%) members responded to the online survey. Nearly 97% were urologists, 74.8% were working at a private, and 39.4% were in an academic institution. Almost all were managing UI. 84.2% had local access to a urodynamics (UDS) facility. 85.8% would check postvoid residual urine for all the patients. Voiding diary, symptom scores, quality of life scores, pad test, Q-tip test, stress test, uroflow, and cystoscopy were ordered as part of evaluation by 86.0%, 49.8%, 24.4%, 22.0%, 6.0%, 71.8%, 69.2%, and 34.7%, respectively. 47.6% would order a UDS for patients with urgency UI who fail conservative treatment. 36.9% would get UDS prior to all stress UI surgery. Seventy-five percent would make a diagnosis of intrinsic sphincter deficiency. Solifenacin was the first choice for urgency UI in general and darifenacin was preferred in elderly. Botulinum was the first choice for refractory urgency UI. Midurethral sling was the commonest procedure for surgical management of SUI (95.1%). 147 of the 1641 non responders were randomly sampled telephonically. Telephonic respondents had similar access to UDS facility but had performed fewer lifetime number of post-prostatectomy incontinence (PPI) surgeries. Combining data from both surveys, total number of artificial sphincters and PPI surgeries ever performed by USI members was estimated at 375 and 718 respectively. CONCLUSION: This survey provides important new data and elicits critical differences in management practices based on demographics.

Overexpression of COX2 indicates poor survival in urothelial bladder cancer.

BACKGROUND: COX2 is a cyclo-oxygenase enzyme expressed in the tumor cells, inflammatory cells, stromal and non-epithelial cells. The study was conducted to evaluate the expression of COX2 in Urothelial carcinoma and find the association with progression and recurrence. METHODS: The expression of COX2 was evaluated by real-time PCR and immunohistochemistry. RESULTS: Gene expression of COX2 was found to be upregulated >28-fold in urothelial cancer compared to adjacent normal bladder mucosa. Inflammatory cell expression of COX2 was found in 92% cases whereas only 37% cases showed COX2 overexpression in tumor cells. Tumor cell COX2 overexpression was significantly associated with invasion and recurrence. CONCLUSION: COX2 expression is a marker of invasion, recurrence and poor survival and may have a role in predicting the cases which will benefit from additional treatment with COX2 inhibitors in urothelial carcinoma.

Primary high grade testicular leiomyosarcoma: A rare malignancy in a young male.

A 27-year-old male presented with a gradually increasing left scrotal mass. There was no significant past medical history. Ultrasonography of the left scrotum showed a hypoechoic, intratesticular mass with solid and cystic components. Laboratory investigations revealed normal serum levels of alpha-fetoprotein, beta human chorionic gonadotropin and lactate dehydrogenase. He underwent left high inguinal orchidectomy due to suspicion of testicular malignancy. After histopathologic examination and immunostaining, a diagnosis of high-grade primary testicular leimyosarcoma was ascertained. Only a few cases of primary intratesticular leiomyosarcoma have been reported in literature with the mean age of presentation of 50 years. In younger individuals, these tumors have been reported in a setting of predisposing factors like anabolic steroid use, testicular germ cell tumors, chronic inflammation of testis and testicular field radiation for treatment of leukemia. We present a case of high grade leiomyosarcoma of testis in a young male without any known predisposing factors.

Prospective Randomized Comparison of Monopolar TURP, Bipolar TURP and Photoselective Vaporization of the Prostate in Patients with Benign Prostatic Obstruction: 36 Months Outcome.

OBJECTIVES: To assess durability of efficacy of monopolar transurethral resection of the prostate (TURP), bipolar TURP, and photoselective vaporization of the prostate (PVP) using 120W Green light laser at 36 months follow up. METHOD: The 186 patients who presented with benign prostatic obstruction and planned for surgery were randomized into three groups: Group A - monopolar TURP; group B - bipolar TURP; and group C - PVP. International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5) score, quality of life (QoL) score, maximum flow rate (Qmax), prostate volume and postvoid residual urine (PVRU) were analyzed up to 36 months follow up. RESULTS: The improvement observed in the mean IPSS, QoL score, Qmax, prostate volume and PVRU at 12-month was sustained till 36 months follow up. However, the mean IIEF-5 score did not show improvement in any group. Few complications noted in second and third year of follow up compared to first year follow up. The results of subgroups analysis did not reveal any significant finding, different from group analysis, for efficacy parameters. CONCLUSION: Monopolar TURP, Bipolar TURP and PVP provides durable and comparable efficacy at 36 months follow up in patients with prostate size <80 mL.

High-Grade Urothelial Carcinoma of Bladder Transforming to Micropapillary Variant on Follow-Up.

Micropapillary variant of urothelial carcinoma (UC) of the bladder is an aggressive tumour, comprising 0.6-6% of all UC. It generally presents with high-grade and stage, and has been reported as having a worse prognosis when compared to traditional UC. We report the case of a 58-year-old man who presented with macroscopic haematuria. The patient was diagnosed with high-grade urothelial carcinoma and returned with recurrence after 16 months. Histopathology after transurethral biopsy revealed a non-muscle invasive high-grade bladder tumour at first presentation, whereas tumour recurrence was reported after 1.5years. The histopathology at recurrence revealed a high-grade, muscle invasive, micropapillary variant of urothelial carcinoma with focal adenomatous morphology. Immunohistochemical expression of CK7+/CK20+ in tumour cells and negativity for PSA, AMACR, and CDX2 in paraffin section helped in identifying the tumour as primary in the urinary bladder. Radical cystectomy was performed and the patient has no distant metastases on follow-up. The specific morphology even within the high-grade urothelial cancer cases is important to discern for proper treatment.