本文报道一例膀胱憩室癌患者的诊疗过程。患者因反复肉眼血尿于2023年5月就诊于当地医院，影像学检查提示膀胱右侧壁憩室肿物，膀胱镜活检病理为高级别非浸润性乳头状尿路上皮癌。患者接受开放膀胱部分切除术，术后病理提示为肌层浸润性尿路上皮癌，但未接受进一步治疗。术后患者至我院就诊，复查增强CT、MRI及膀胱镜均未发现明确肿瘤残留。但经文献回顾，结合围手术期资料，且不除外肿瘤外侵可能，建议行根治性膀胱切除术，但患者保膀胱意愿强烈，遂接受特瑞普利单抗免疫治疗3个周期。同年9月复查，常规影像学提示膀胱右侧壁增厚并强化。经广东省医学会泌尿外科疑难病例多学科会诊，意见为：综合检查结果，不能排除肿瘤残留及淋巴结转移；患者诊断为高级别膀胱憩室癌，恶性程度高，可能存在早期膀胱壁层侵犯，不符合保膀胱治疗推荐指征，且免疫治疗后仍有进展迹象。因此，建议完善PET-CT检查，并尽快行根治性膀胱切除术，后续治疗（包括放疗、化疗、免疫治疗）需依据术后病理决定，并保持密切随访。患者经慎重考虑后返院接受机器人辅助腹腔镜下根治性膀胱切除术。术中见右侧盆腔广泛粘连呈冰冻骨盆表现，冰冻病理提示右侧盆腔淋巴结转移及盆壁受侵，遂行回肠膀胱术。术后免疫组化病理确诊膀胱区域尿路上皮原位癌，伴盆腔淋巴结及盆壁转移。膀胱憩室癌患者术后复发可能不在局部，甚至伴有远处转移可能，保膀胱治疗需选择合适、有优势的患者，不能盲目追求保膀胱。

This article reports the diagnosis and treatment process of a patient with bladder diverticulum carcinoma. The patient presented to a local hospital in May 2023 with recurrent gross hematuria. Imaging studies suggested a mass in the diverticulum of the right bladder wall, and cystoscopic biopsy pathology revealed high-grade non-invasive papillary urothelial carcinoma. The patient underwent open partial cystectomy. Postoperative pathology indicated muscle-invasive urothelial carcinoma, but no further treatment was received initially. Subsequently, the patient visited our hospital, repeated contrast-enhanced CT, MRI, and cystoscopy showed no definite evidence of residual tumor. However, based on literature review, perioperative data, and the possibility of extravesical extension not being ruled out, radical cystectomy was recommended. But the patient strongly desired bladder preservation and therefore received three cycles of immunotherapy with toripalimab. Follow-up examination in September of the same year revealed thickening and enhancement of the right bladder wall on routine imaging. A multidisciplinary consultation on difficult cases in Guangdong Urological Association was conducted, the experts suggested that based on the comprehensive examination results, residual tumor and lymph node metastasis could not be excluded. The diagnosis was high-grade bladder diverticulum carcinoma, which is highly malignant and may involve early invasion of the bladder wall layers. The case did not meet the recommended criteria for bladder-preserving therapy, and there were signs of progression even after immunotherapy. Therefore, it was recommended to perform a PET-CT scan and proceed with radical cystectomy as soon as possible. Subsequent treatment (including radiotherapy, chemotherapy, or immunotherapy) would depend on the postoperative pathology, and close follow-up was necessary. After careful consideration, the patient returned to the hospital and underwent robot-assisted laparoscopic radical cystectomy. Intraoperatively, a frozen pelvis was found on the right side, and frozen section pathology confirmed metastasis to the right pelvic lymph nodes and invasion of the pelvic wall. An ileal conduit urinary diversion was subsequently performed. Postoperative immunohistochemical pathology confirmed regional urothelial carcinoma in situ of the bladder, with metastasis to the pelvic lymph nodes and pelvic wall. This case suggests that postoperative recurrence in bladder diverticulum carcinoma may not be local and could involve distant metastasis. Bladder-preserving therapy should be reserved for selected, suitable patients with favorable profiles, and should not be pursued blindly.