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The patient is a16 year old girl presented with transient abdominal pain with no other symptoms. She had no previous history of disease or surgical procedures. Family history was unremarkable. Her physical examinations were normal.
Thin cortex of left kidney with sever hydroureteronephrosis and hypoechoic mass in the left and posterior wall of bladder is seen.
Sever left hydroureteronephrosis and suspicious mass in the left and bottom of the bladder is noted.
Sever left hydroureteronephrosis is present with paranchymal thining. Large polypoid filling defect is noted in left lateral aspect of bladder.
Urine cytology was negative for malignancy.
Nonvisualized left kidney (nonfunctioning) and proper cortical function of right kidney.
Stiff erythematous sessile mass with ulcerative surface was seen in the left lateral wall of the bladder. The left ureteral orifice was not found and covered by the aforementioned mass but the right ureteral orifice and the other sites of the bladder were normal. In rectal examination, the mass was palpable in the anterior part of rectal wall.
Final pathology of bladder mass revealed the inflammatory pseudotumor and IHC confirmed this pathology.
The patient underwent transurethral resection of bladder mass located in the same position of previous tumor in left UVJ and marginal tissue. Final pathology of bladder mass revealed inflammatory pseudotumor but the marginal tissues were free of pseudotumor.
During one year period follow-up, she had no recurrence and follow-up imaging was negative for recurrence; but ultrasonography in Aug 2009 revealed new bladder mass in the left lateral wall of bladder.
Sonography (Aug 2009)Sever hydroureteronephrosis in left side and polypoid mass with diameter 57*19 mm in the distal part of left ureter in left lateral wall of bladder is seen. There is high suspicion to bladder mass invagination to anterior wall of uterus.
CT scan confirmed the recurrence of bladder mass in the same side of previous tumor.
Follow-up cystoscopy showed a sessile mass with ulcerative surface in the origin of left ureteral orifice; so the left ureteral orifice was not found. The other site of the bladder was normal. Then she underwent transurethral resection of the mass.Final pathology of this mass was positive for inflammatory pseudotumor and random biopsy of the other sites were negative for malignancy.
Two months later , she presented with hematuria and painful mensturation and diagnostic imaging revealed recurrence of tumor.
Sever hydroureteronephrosis in left side and 54*32 mm hypoechoic mass in the left side of bladder near to the left UVJ.
Sever hydronephrosis in left kidney with small abnormal mixed density in the anatomic area of distal left ureter is noted. Uterus is enlarged and mass effect in the bladder is noted.
Please add your comment about this challenging case according to repeat recurrences and unusual pathology and nonfunctional kidney in the same side of bladder tuomor.
This comment has been sent by Dr Darab Mehraban to uropractice by mail:
For further management you should go for a partial cystectomy and/or open resection of the mass from inside the bladder. Also, Tamoxifen oral could be of benefit.
Dear colleagues, I have had two nearly similar cases, one at last was found to be a bladder myoma(origin from uterus), she was a young married lady, after the 3rd bladder tumor resection, she underwent hormonal blockade by decapeptyl and then open surgery and removal of myoma, with partial cystectomy. The second case was lady with endometriosis, at second turt, the endometrium tissue was diagnosed, and she went under hormonal blockade, and then removing the mass ,with part of bladder. Both of cases, are symptom free. In this special case, I think you should condider genital tract , as a possible pathologic factor. I think a nephroureterectomy through laparoscopy , is logic, and then you can evaluate pelvic cavity,for continuing with laparoscopy ,or open surgery.About hormonal blckade before surgery you can ask for comment of a gynecologist, and as it is not a harmful therapy, you can even do it empiric, without any documented proof, now available for you( pathology proof). I wish success for you
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