本文报道一例膀胱癌保膀胱综合治疗后进展的病例。患者因"确诊膀胱癌并接受保膀胱综合治疗2年余"入院。患者2022年8月初诊时经尿道膀胱肿瘤电切术（TURBt）病理提示高级别浸润性尿路上皮癌，伴部分腺性分化及固有肌层侵犯，Her-2（3+），PD-L1联合阳性分数≈10。患者基于强烈保膀胱意愿接受维迪西妥单抗联合特瑞普利单抗方案及多次TURBt治疗，用药6周期时出现免疫性药疹，同期TURBt显示部分尿路上皮重度不典型增生及癌变，但患者后续未积极配合治疗。2025年1月影像学提示膀胱后壁进展性病灶并多发盆腔/腹膜后淋巴结转移，同期TURBt病理示高级别乳头状尿路上皮癌，建议行根治性切除或系统化疗，患者再次拒绝。2025年4月PET-CT示左侧髂总血管旁及髂内外血管旁多发肿大淋巴结代谢高度活跃。行机器人辅助下根治性膀胱切除术联合盆腔淋巴结清扫及回肠通道术，术后病理示膀胱尿路上皮癌浸润固有层，左盆腔淋巴结可见癌（ypT₁N₃M₀），并基于靶向二代测序检出TP53等关键基因突变。经广东省医学会泌尿外科疑难病例多学科会诊，专家认为患者属高危人群，推荐术后化疗+免疫治疗+放疗为核心的多模式治疗。患者因既往免疫相关皮疹未予免疫巩固，改行同步放化疗并吉西他滨联合顺铂化疗巩固，目前随访病情稳定。本病例提示：保膀胱治疗失败后淋巴结阳性患者需根治性膀胱切除+术后辅助治疗；早期进展识别需结合影像学形态学标准与分子诊断，以优化个体化管理和改善长期预后。

This article reports a case of progression after bladder-preserving multimodal therapy. A 47-year-old man was admitted with a 2-year history of bladder-preserving treatment for muscle-invasive bladder cancer (MIBC). Initial transurethral resection of bladder tumor (TURBt) in August 2022 revealed high-grade invasive urothelial carcinoma with glandular differentiation and invasion of the lamina propria, with immunohistochemistry showing Her-2 (3+) and PD-L1 combined positive score≈10. Owing to his strong preference for bladder preservation, the patient received combination therapy with disitamab vedotin plus toripalimab and underwent repeated TURBt, achieving temporary disease stabilization. In January 2025, imaging studies revealed a progressive lesion in the posterior wall of the urinary bladder with multiple pelvic/retroperitoneal lymph node metastases. Concurrently, pathology results from TURBt confirmed high-grade papillary urothelial carcinoma. Radical resection or systemic chemotherapy was recommended, but the patient refused again. In April 2025, further PET-CT demonstrated multiple enlarged lymph nodes with highly active metabolism adjacent to the left common iliac vessels and internal/external iliac vessels. And then, the patient underwent robot-assisted radical cystectomy with pelvic lymph node dissection and ileal conduit. Pathology revealed urothelial carcinoma with lamina propria invasion and lymph node metastases (ypT₁N₃M₀). Next-generation sequencing identified pathogenic mutations in TP53, EP300, KMT2A, and TERT. Multidisciplinary team discussion concluded that this patient represents a high-risk subgroup requiring multimodal systemic therapy. Given prior immune-related rash, adjuvant immunotherapy was withheld, and the patient instead received concurrent chemoradiotherapy with cisplatin, followed by consolidation chemotherapy with gemcitabine plus cisplatin, achieving stable disease on follow-up. This case highlights that bladder-preserving strategies failing with nodal metastasis warrant salvage radical cystectomy combined with systemic therapy. Early recognition of nodal metastases requires not only conventional imaging size criteria but also morphologic features and integration of molecular diagnostics, which may improve individualized management and long-term outcomes.