bladder cancer ( bca ) is the fifth most common cancer in the united states . in 2012 , it is projected that 73,510 people will be diagnosed with bca and 14,880 will die from the disease .
muscle invasive bc ( nmibc ) , about 30% of patients will either initially present or later progress to muscle invasive bladder cancer ( mibc ) .
radical cystectomy ( rc ) with urinary diversion ( ud ) is the ultimate curative treatment .
diagnosis of bca in patients aged < 40 years is rare and is extremely rare in patients < 30 years of age .
however , cases of bca have been previously reported in pediatric and young adult patients [ 4 , 5 ] .
our aim is to report our experience with a young adult patient with mibc and review the literature for the natural history and outcome .
a 28year  old caucasian male patient with 10 pack  year smoking history with no family history of bca presented to the emergency department with gross hematuria and left flank pain .
the patient underwent computerized tomography ( ct ) of the abdomen and pelvis without contrast due to an elevated creatinine .
ct showed a 6 cm fungating mass at the left posterior wall of the bladder extending to the left ureteral orifice and left hydronephrosis .
no abnormal laboratory findings were noted except for a serum creatinine of 1.73 mg / dl .
the patient was initially managed by left nephrostomy tube placement and subsequent transurethral resection of bladder tumor ( turbt ) . during cystoscopy ,
multiple large masses originating from the left side of the trigone extending to the prostatic urethra and the right ureteric orifice were noted ( figure 2 ) .
no attempt was made to obtain muscle bites secondary to the large volume of disease .
serum creatinine was 1.6 mg / dl following nephrostomy tube placement . the patient was counseled about the possibility for restaging turbt , rc , and urinary diversion by either ileal neobladder or ileal conduit .
the patient then elected to undergo rc and ileal conduit urinary diversion as the patient had elevated serum creatinine and was reluctant to perform cic .
urothelial carcinoma of the bladder in the first three decades of life is extremely rare .
invasive disease and only 1.7% had high  grade tumor . since the vast majority of young patients with bca present with non 
muscle invasive low  grade disease , these patients have lower progression and recurrence rates compared to older patients .
this further suggested that the nature of bca in the younger population is different compared to elderly patients . on the otherhand , yossepowitch and dalbagni found no difference in grade or stage upon comparing 74 patients < 40 years of age to 75 patients > 65 years of age .
however , when focusing on only bca patients diagnosed in the first two decades of life , it is evident that these patients had a relatively indolent behaving bca . nevertheless , aggressive bca has been reported in children  a 31 month old   and a 14 year old .
exposure to polycyclic aromatic hydrocarbons ( pahs ) is responsible for 10% to 15% of cases as a result of bladder carcinogenesis .
genetic predisposition to bca has been suggested by reports of multiple  case families with bca .
however , it is unclear whether it resulted from a genetic predisposition or common environmental exposure among family members . as in elderly patients ,
radical cystectomy is the curative intervention for patients with mibc , recurrent high grade superficial bca , and high  grade t1 disease .
prostate and seminal vesicles sparing rc in addition to nerve sparing procedure can be a valuable option for those patients .
preservation of urinary continence by performing a nerve sparing procedure and orthotopic neobladder urinary diversion is preferred to attain a proper quality of life and body image . in our patient
, ileal neobladder urinary diversion was not performed due to the patient 's unwillingness to perform cic and the fear of chronic renal insufficiency considering the elevated baseline creatinine , ( 1.73 ) which remained elevated ( 1.6 ) following nephrostomy tube placement .
this tendency is more pronounced in patients presenting in the first three decades of life and is likely to decrease with age .
quality of life and fertility preservation is particularly significant in young patients undergoing radical cystectomy and urinary diversion .
our case demonstrates a rare example of a high  grade t2 transitional cell carcinoma in a 28 year male .
 the peak incidence of bladder cancer ( bc ) is in the sixth decade of life . 
 muscle  invasive bladder cancer ( mibc ) in young adults is extremely rare . 
 we report a case of mibc in a 28year  old smoking male patient . 
 the patient presented with hematuria and flank pain for which he underwent a computerized tomography ( ct ) scan of the abdomen and pelvis with and without contrast . 
 the ct scan showed a 6 cm mass on the left side of the trigone extending to the left urteric orifice and left hydronephrosis , but no lymphadenopathy was noted . 
 the patient then underwent a left nephrostomy tube placement followed by trans  
 urethral resection of bladder tumor ( turbt ) . 
 the tumor involved both ureteric orifices and extended to the prostatic urethra . 
 complete resection was not feasible . 
 pathology showed high  
 grade t1 urothelial carcinoma . 
 ct scan of the chest showed no distant lung metastasis . 
 the patient then elected to undergo radical cystectomy with ileal conduit urinary diversion . 
 final pathology revealed t2a n0 urothelial carcinoma of the bladder . 
 our aim is to present our experience and review the literature for the natural history and oncological and quality of life outcomes of urothelial carcinoma of the bladder in young patients . 