Conduit Bleeding Unmasks Isolated Distal Ureter Recurrence After Radical Cystectomy: Lessons in Laparoscopic Nephroureterectomy and Surveillance

Recurrent upper-tract urothelial carcinoma (UTUC) following radical cystectomy is an uncommon but clinically significant occurrence. We present the case of a 48-year-old man with a history of muscle-invasive bladder cancer (pT2N0M0) treated with radical cystectomy and Bricker ileal conduit diversion. He remained recurrence-free on structured surveillance for 42 months before developing isolated, painless stomal bleeding without associated systemic symptoms. Cross-sectional imaging revealed a 1.6 cm enhancing mass at the left uretero-enteric anastomosis with mild proximal hydroureteronephrosis, and PET-CT confirmed localized hypermetabolic activity without nodal or distant spread. The patient underwent laparoscopic radical nephroureterectomy with en-bloc excision of the distal ureter and limited conduit revision. Histopathology confirmed high-grade invasive UTUC (pT2) with lympho-vascular invasion, negative surgical margins, and a negative hilar node. He subsequently received four cycles of adjuvant gemcitabine-cisplatin (GC) chemotherapy. 18 months postoperatively, the patient remains asymptomatic with preserved renal function and no evidence of radiological recurrence. This case highlights the importance of considering upper-tract recurrence in the differential diagnosis of conduit bleeding. It supports timely cross-sectional imaging and oncologic resection as key steps in achieving long-term disease control.