A 65-year-old male patient was admitted to the Department of Urology at our hospital in November 2022 due to "frequent urination for less than 5 years and hematuria for half a year ". The patient had a previous history of fracture trauma to the left femoral neck 10 years ago. Physical findings on admission were as follows: the patient was slightly short (height 135 cm), the abdomen was flat, no definite masses were palpated, and digital rectal examination did not touch the lesion occupying the space. The patient left testicular palpation was not reached, urethral visible opening hypospadias, no apparent mass in the bladder area, and no tenderness. The exfoliation cytology of the control urine showed no abnormal cells. Color ultrasound examination (intra-abdominal mass) showed: posterior accessible hypoechoic mass in the pelvic bladder, size about 70mm×36mm×42mm, circumscribed clear, regular morphology, peripheral accessible annular hyperechogenicity, posterior accompanied by acoustic shadowing, no obvious blood flow signal was seen (Fig. 1C,D). Color ultrasound examination (testis, epididymis) showed that: the right testis size was about 19 × 10mm, well-circumscribed, with regular morphology, and accessible blood flow signal. The right epididymis was slightly larger in volume, full in shape, and full of fine dense hypoechogenicity with no significant abnormal blood flow. The left epididymis was normal in size and morphology, was homogeneous in echogenicity, and showed no obvious abnormal blood flow signal. The left scrotum was empty. The left scrotum was accessible and hypoechoic at approximately 22mm × 9mm, well-circumscribed, with regular morphology, and little blood flow signal was seen (Fig. 3B,D). Check the ureter CT showed: the bladder filling was ok, the wall did not show obvious thickening, no obvious abnormal density in the cavity. A mass lesion with well-defined borders and a size of about 61 mm × 44 mm was seen in the pelvic cavity, with a rim of soft tissue density within which dense shadowing was visible (Fig. 1A,B) and a mean CT value of approximately 1052 HU. Intravenous pyelography (IVP) showed: plain film of kidney-ureter-bladder(KUB) showed the pelvic giant ovoid high-density image, the rest of the urinary tract walking area did not show a clear positive image of stones, intravenous iodixanol was injected, at 7 min, 15 min, 30 min radiographs showed bilateral renal pelvis calyces showed clear visualization, the mouth of the calyceal cup was sharp, bilateral ureters intermittent, no dilatation, bladder filling was available, and the wall was smooth (Fig. 2A). To make clear again whether this hyperdense shadow was a bladder stone, follow-up examination cystography showed: transurethral injection of contrast medium, see the bladder can be filled, the size and morphology showed no obvious abnormalities, adjacent to the bladder can be seen an oval dense shadow and the distinction of the bladder is obvious (Fig. 2B). Because the patient had absent left testis, left cryptorchidism, five items of suicidal sex hormones: luteinizing hormone (LH) 23.23 mIU/ml, follicle-stimulating hormone (FSH) 60.04 mIU/ml, estradiol (E2) 59.00 pg/ml, pituitary prolactin (PRL) 9.2 ng/ml, testosterone (testo) 157.66 ng/dl, alkaline phosphatase (ALP) 146 U/L were all higher than normal, and none of the other indicators were abnormal. CT plain scan of the pituitary continued because of the patient's abnormal hormone secretion: the pituitary structure was less clear and an empty sella was possible (Fig. 3A).
Cystoscopy performed on the patient after admission showed the following findings: The external urethral orifice was opened below the penile frenulum, the urethra was narrowed, by dilatation of the urethra from F10 once to F16, when the cystoscope was placed from the external urethral orifice, smoothly into the bladder, it was noted that the prostate did not have any obvious hyperplasia, intravesical mucosa was smooth, no obvious new organisms could be seen, bilateral ureteral apertures were clear.
After completing the relevant preparation at admission, the patient signed the informed consent for surgery and underwent laparoscopic pelvic tumor resection. After successful anesthesia, the patient was placed in the supine position, the skin was cut about 2cm longitudinally in the middle of the umbilicus, the puncture device was placed, the observation lens was placed. After the laparoscopic instruments were put in, the peritoneum was opened, and the right ureter and external iliac artery were found and dissociated. The right lateral wall of the bladder was mobilized along the contour of the bladder, and the mass was found on the right posterior wall of the bladder. During the operation, it was found that the contents of the tumor were hard and the tumor adhered heavily to the surrounding area. The pelvic mass was carefully dissociated with an ultrasonic scalpel. After ensuring that the ureter, iliac vessels, bladder, and rectum were avoided, the tumor was completely dissociated and cut. There was a yellow stone in the mass, about 6cm×3cm×3cm in size. The adhesion between the lower edge of the tumor and the rectum was heavy. The cyst wall of the tumor was pulled, the bladder, ureter, rectum, and surrounding blood vessels were carefully avoided, the adhesion between the tumor and the rectum was carefully separated, and the cyst wall of the tumor was completely removed. The incision was extended on the left puncture line, the stone and the mass cyst wall were removed, and the mass cyst wall was sent for pathological biopsy.
The operation was successful, and the pelvic stone was completely removed after the operation. The appearance of the stone was pale yellow, and the texture was hard, with a long diameter of about 7cm (Fig. 4A) and a weight of about 61g. The stone was cut, and the whole layer of the stone was hard from the outside to the inside, and a circle of concentric circles was seen on the cutting surface (Fig. 4B), and the results of the stone analysis showed: apatite carbonate and magnesium ammonium phosphate hexahydrate. Pathologic examination of the stone envelope revealed invasive urothelial carcinoma, squamous differentiation, and the tumor thrombus in the blood vessels (Fig. 4C). Immunohistochemistry: GATA3 partial +, CK5 / 6 +, P40 +, p63 +, uroplakin -, CK7 -, CK20 -. The patient was admitted to the hospital for laparoscopic pelvic mass resection, with no obvious discomfort after surgery, recovery was possible, 9 days after surgery was discharged, the total hospital stay was 16 days, and follow-up was closely followed. Discharge diagnosis: 1. Pelvic malignancy 2. Pelvic stones 3. Urethral stricture 4. Hypospadias 5. Cryptorchidism. The patient was followed up after 3 months and was informed that he did not participate in any other treatment after surgery, however, the patient was in good condition without voiding and other discomforts.