The Unusual Clinical and Image Presentation of Huge Bladder Tumor (More Than 500 Grams) without Gross Hematuria.
Tsun-Hsiang Cheng1, Wai-Nga Chan1, Yun-Ching Huang1,2, Dong-Ru Ho1, Jian-Hui Lin1, Kuo-Tsai Huang1, Yu-Liang Liu1, Chih-Shou Chen1,2
1Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan;
2Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan;
Abstract: A 94-year-old man with chronic kidney disease, stage IV had a history of bladder stone and benign prostate hyperplasia who received transurethral resection of prostate and cystolithotripsy in 2018. However, progression of lower urinary tract symptoms (LUTS) after surgery were noted. The symptoms included small stream, urgency, nocturia and daytime frequency. Eventually, acute urine retention happened to him despite of medical treatment. He had no gross hematuria at all before indwelled Foley catheter. The initial urinalysis showed pyuria and microscopic hematuria (WBC> 500, RBC: 69). A blood clot was visible in ultrasound. The non-enhanced CT scan was obtained and showed a homogenous well-distended urinary bladder. Some small bladder stones coating on the prostate fossa were also noted. Besides, right hydroneprhosis owing to distal ureter stone was suspected at admission.
However, a huge polypoid mass almost fully occupied the urinary bladder cavity was seen under cystoscopy, which might correlate with the misinterpreted images. The operation turned out to be transurethral resection of bladder tumor (TUR-BT). The surgery was ceased due to prolonged operation time (near 8 hours) without completely resection of the bladder tumor, although a tumor stalk was suspected at TUR-BT. The resected mass was weighted more than 500 grams. The pathology was invasive urothelial carcinoma with sarcomatoid variant. The subsequent treatment will be arranged with radiation therapy alone due to the old age, poor renal function and free of distant metastasis.The lessen we learned is an extremely huge bladder tumor may be misinterpreted as a normal bladder under non-enhanced CT scan. A simple Hounsfield scale (CT number) may be an easy way to differentiate solid mass from simple distended normal bladder. In addition, gross hematuria is not a necessary clinical presentation of huge polypoid bladder tumor.