Diverticula typically have no muscle wall so the cancer can invade the fat rapidly. Plus become locally advanced.

My TURBT1 showed PT1AN0M0+CIS. TURBT2 (blue light) showed PT0N0M0+CIS.

RC was PT3AN1M0.

Only Mayo, MD Anderson and my local general urology group agreed with my assessment that immediate RC was warranted. Cleveland, University of Miami and Baptist South insisted on localized treatment only. The local general urology group proposed a partial RC.

High grade papillary + CIS is typically multifocal and very high risk and makes partial RC (diverticulum) infeasible.

Diverticula cannot be scoped deep enough during TURBT as the layer is thin and could seed malignant cells in the pelvic cavity

MD Anderson had no operating rooms for six weeks. Mayo did the RC exactly a week after my first meeting and I was put at the top of the list based on the risk.

We discussed neoadjuvant DDMVAC but given that it fails approximately 30% of the time and absence of a muscle wall that is risky.

Based on my RC pathology I did 4 out of 6 adjuvant DDMVAC cycles. A month later I started nivolumab ICI for 13 cycles.

I strongly recommend requesting signatera and natera. The first can provide assurance the malignant cells are still confined to the bladder, the second can provide genomic insight to guide therapy and assess risk plus assess PDL1, TMB and MSI.

Good luck!