Bladder cancer cystoscopy follow-up

Short Summary

68-year-old man with history of high-grade pTaN0M0 urothelial carcinoma (diagnosed 2023, status post BCG induction and maintenance) presents for routine surveillance cystoscopy. Cystoscopy and recent CT urogram show no evidence of disease recurrence, and he will return in 6 months for continued surveillance.

Chief Complaint

Patient presents to the office today for bladder cancer follow-up; the cancer was diagnosed in 2023 and had high-grade pTaN0M0 urothelial carcinoma.

NCCN high-risk group.

Bladder Cancer History

Originally referred by PCP Dr. Sarah Jenkins and local urologist Dr. Mark Vance for gross hematuria in 03/2023. Diagnostic cystoscopy on 03/15/2023 revealed a 2.5 cm papillary tumor on the right lateral wall. Undergoing TURBT on 04/02/2023, pathology confirmed high-grade pTa urothelial carcinoma with muscularis propria present and uninvolved; restaging TURBT on 05/10/2023 was negative for residual tumor. Completed 6-week induction BCG in 07/2023 and 1 year of maintenance BCG in 08/2024. Surveillance cystoscopies, cytologies, and upper tract imaging have remained negative for recurrence to date.

Key Information

• Diagnosis: 2023, high-grade pTaN0M0 urothelial carcinoma
• Cytology:
  • 04/2023: High-grade urothelial carcinoma
  • 09/2023: Negative for high-grade urothelial carcinoma
  • 03/2024: Negative for high-grade urothelial carcinoma
  • 09/2024: Negative for high-grade urothelial carcinoma
• Upper tract imaging history:
  • 03/2023: CT urogram showing 2.5 cm right lateral bladder wall mass, normal upper tracts
  • 03/2025: CT urogram showing normal upper tracts, no bladder lesions
• Intravesical therapy history:
  • 06/01/2023 - 07/06/2023: Induction BCG (6 doses)
  • 10/05/2023 - 10/19/2023: Maintenance BCG (3 doses)
  • 01/11/2024 - 01/25/2024: Maintenance BCG (3 doses)
  • 07/18/2024 - 08/01/2024: Maintenance BCG (3 doses)
• Other relevant information: 30 pack-year former smoker (quit 04/2023).

Procedure History

TURBTs and OR Procedures

• TURBT/biopsy history:
  • 04/2023: TURBT - High-grade pTaNxMx urothelial carcinoma
  • 05/2023: Restaging TURBT - pT0, benign urothelium with chronic inflammation

Office Cystoscopies

• Office cystoscopy history:
  • 09/2023: Normal, well-healed resection scar
  • 12/2023: Normal, no recurrence
  • 03/2024: Normal, mild erythematous changes post-BCG
  • 06/2024: Normal, no recurrence
  • 09/2024: Normal, no recurrence
• 6 months since the last cystoscopy.

HPI Today 03/24/2025

• Patient completed his 1-year maintenance BCG protocol in 08/2024 and is now transitioning to every-6-month surveillance.
• Denies gross hematuria, dysuria, frequency, or urgency; reports stable baseline mild nocturia (1-2x/night).
• CT urogram performed on 03/15/2025 at Metro Imaging Center shows unremarkable kidneys, non-dilated ureters, and a normal-appearing bladder without filling defects. I personally reviewed and independently interpreted the scan and concur with findings.
• Urinalysis today is negative for blood, leukocyte esterase, and nitrites; voided urine cytology collected on 03/15/2025 is negative for high-grade urothelial carcinoma.

PMH, PSH, Medications, Allergies, Social History, and Family History

Information reviewed with the patient and in the EMR, with changes made where appropriate.

• PMH: HTN, hyperlipidemia, BPH
• PSH: Appendectomy (1985), TURBT x2 (2023)
• Medications: tamsulosin (Flomax®) 0.4 mg PO daily, lisinopril 10 mg PO daily, atorvastatin 20 mg PO daily
• Allergies: NKDA
• Social history: Former smoker (quit 04/2023), retired machinist, occasional alcohol use
• Family history: Father with prostate cancer at age 78; no family history of bladder or renal cancer

Office Cystoscopy

Indications: Bladder-cancer surveillance. After informed consent was obtained and the procedural time-out was completed, the flexible cystoscope was passed through the urethra into the bladder. The anterior urethra showed mild, non-obstructing lateral lobe prostatic enlargement; the prostate was otherwise unremarkable. The bladder was inspected methodically, including retroflexion of the scope. The ureteral orifices were normal in number, position, and size, with clear urine efflux. The visible mucosa showed a flat, pale scar at the right lateral wall without any tumors, stones, or foreign bodies.

Assessment and Plan

68-year-old man with history of NCCN high-risk, high-grade pTaN0M0 urothelial carcinoma of the bladder, diagnosed in 2023. He completed induction and 1 year of maintenance BCG in 08/2024 and remains free of disease recurrence.

1. Malignant neoplasm of lateral wall of urinary bladder (ICD-10: C67.2)

   • Assessment: NED on today's surveillance cystoscopy, recent cytology, and CT urogram.
   • Plan: Repeat office cystoscopy and urine cytology in 6 months. Continue annual upper tract imaging (next due 03/2026).
   • Counseling: Discussed the favorable prognosis given his sustained response to BCG, while emphasizing the necessity of continued surveillance due to the baseline recurrence risk of high-grade disease.

2. Benign prostatic hyperplasia with lower urinary tract symptoms (ICD-10: N40.1)

   • Assessment: Mild nocturia, well-controlled and non-bothersome on current medical therapy.
   • Plan: Continue tamsulosin 0.4 mg PO daily.

Orders

Urine cytology ordered for next visit in 6 months; refill tamsulosin (Flomax®) 0.4 mg PO daily (90-day supply with 3 refills).

Follow-Up

Return to clinic in 6 months for office cystoscopy and voided urine cytology.

Short Summary

68-year-old man with history of high-grade pTaN0M0 urothelial carcinoma (diagnosed 2023, status post BCG induction and maintenance) presents for routine surveillance cystoscopy. Cystoscopy and recent CT urogram show no evidence of disease recurrence, and he will return in 6 months for continued surveillance.

“Consent for using AI-assisted documentation tools was obtained from the patient and all other participants before this encounter. All questions were addressed, and the patient understands that declining the use of AI-assisted documentation tools remains an option.”