A female patient, 58 years old, farmer, married, menopausal.
Bilateral low back pain for more than one month, and space-occupying lesions of bladder found for three days.
History of present illness
One month prior to admission, the patient had persistent bilateral lumbar swelling with pain for no apparent cause, which was relieved at rest. No visual hematuria or fever was observed. CT examination of the whole abdomen suggested multiple stones in both kidneys complicated with mild hydronephrosis. The space-occupying lesions of the bladder were detected, and bladder cancer was considered. No prolonged fever and no weight loss were observed.
The patient had pain at the end of urination with interrupted urination for six months. Two years ago, both kidney stones were removed by right nephrectomy and left percutaneous nephrolithotomy, and the patient had a history of hypertension for six months.
Physical examination: T: 36.5, P: 59 beats/min, R: 18 beats/min, BP: 110/77 mmHg (maintained with antihypertensive medication). The patient’s abdomen was flat and soft, with a 6-cm surgical scar on the right lumbar region (incisional lithotomy) and a 1-cm surgical scar on the left lumbar region (percutaneous nephrolithotomy). There was no percussion pain in both kidney and ureteral stroke pressure, and no abnormality of external genitalia was observed.
Laboratory examination: Urine routine: 249 red blood cells/µL, urinary nitrite +, urinary leukocytes +++, fasting blood glucose: 8.05 mmol/L and glycosylated hemoglobin: 7.5%. No malignant cells were seen in urine-based cytology for three consecutive days. Urine culture and drug sensitivity: Escherichia coli > 10^5, sensitive to piperacillin and cotrimoxazole, levofloxacin as an intermediary agent.
(1) Computerized Tomography (CT) report: Space-occupying lesions of the bladder, high probability of bladder cancer, multiple stones in both kidneys, cysts in both kidneys, and mild hydronephrosis in the right kidney. A cauliflower-shaped soft tissue density nodular shadow (Fig. 1) was seen in the right posterior lower wall of the bladder.
(2) Magnetic Resonance Imaging (MRI) report: The space-occupying lesions of bladder neck: high probability of bladder cancer. The involute papilloma was to be removed. T1WT1 image (Fig. 2A) and STIR images (Fig. 2B) showed cauliflower- like soft tissue signal nodular shadow (white arrow) in the posterior bladder wall.
Preoperative diagnosis: 1. The space-occupying lesions of bladder: bladder cancer? 2. Multiple stones in both kidneys; 3. Urinary tract infection; 4. Hypertensive disease grade 3, high-risk group; 5. Type 1 diabetes mellitus
Diagnosis and treatment
the patient was given 4.5 piperacillin (IV, q8 h) preoperatively for anti-infection for one week, and the recheck revealed that nitrite was converted to negative in the urinary routine. On April 27, 2021, the transurethral bladder mass electrosurgery was conducted under combined spinal and epidural analgesia (with surgical pictures shown in Fig. 3).
Pathological diagnosis of specimen after electrodesiccation: Bladder malacoplakia (Fig. 4). Immunohistochemistry (Fig. 5): CK-pan (surface epithelial +), GATA-3 (surface epithelial +), CD68 (histiocytes +) Ki67 (+).
The ultrasound-guided left percutaneous nephrolithotomy (PCNL) was performed under general anesthesia, and the postoperative kidney-ureter-bladder (KUB) showed that the stone was removed (with KUB pictures shown in Fig. 6). Bacterial culture of the extracted left kidney stone indicated a large number of E. coli, a small number of fecal alkaline-producing bacilli, and the drug-sensitive results were consistent with the urine culture. Analysis of stone composition revealed calcium oxalate monohydrate, calcium oxalate dihydrate, carbapatite, and ammonium magnesium phosphate hexahydrate (infected stone).
After discharge, the patient was given oral cotrimoxazole (0.96 BID) for one month, and the urinary routine was normal on recheck. The Double J ureteral stent was removed one month after surgery, and microscopic examination revealed that the multiple spotted bladder lesions were less severe than before. She was advised to take levofloxacin for one month. At follow-up to date, the patient had a good prognosis with no discomfort, and cystoscopy showed no bladder mass and erythema lesions of bladder mucosa basically disappeared.