Abstract
Clinical History:
A 47-year-old female presented with a Proteus mirabilis UTI and bacteremia, right-sided hydronephrosis, and a large water-density bladder mass. She underwent right ureteral stent placement. The mass was too large for complete endoscopic removal. Partial resection revealed inflammatory cells and debris. She was referred to our facility for further management and presented to the emergency department with fevers, suprapubic pain, acute kidney injury, and worsening bilateral hydronephrosis with persistent bladder mass on imaging.
Physical Exam:
The abdomen was soft with suprapubic tenderness, without palpable masses. The Foley catheter was draining milky white urine.
Diagnosis:
A CT of the abdomen and pelvis revealed a 10 cm low-density bladder mass with bilateral hydroureteronephrosis.
Intervention:
Cystoscopy revealed a tan, gelatinous mass occupying the entire bladder. Initial attempts with graspers, the ShockPulse-SE Lithotripter, and the bipolar resectoscope loop were ineffective given the large size of the mass. A Richard Wolf Piranha Morcellator in an offset nephroscope with dual inflow was used to morcellate the mass. The morcellator tip was maintained 2 cm proximal to the bladder neck with adequate inflow to avoid injury. Total morcellation time was 14 minutes, and 103 g of material were removed. After a period of stenting, a ureteral access sheath was placed, and similar fragments of material were extracted from the right kidney using a Cook NGage nitinol stone extractor.
Follow-Up/Outcomes:
Culture of the material revealed Lactobacillus species, and pathology showed bacterial colonies with ulcer sloughing. A 2-month CT urogram demonstrated no residual filling defects or masses. The etiology of the material is unclear.
Written informed consent was obtained from the patient for publication of this case report, including all accompanying photographs and video recordings.
Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Runtime of video: 5:00.