A 48-year-old male is referred from an outside provider for evaluation of gross hematuria for several weeks. He denies any dysuria or subjective difficulty with voiding. His medical history is remarkable for prune belly syndrome, atrial fibrillation, hypertension, and type II diabetes mellitus. Records regarding his childhood surgical history are unfortunately scant, though notable for a remote vesicostomy that was subsequently closed, an enterocystoplasty, and abdominoplasty.
More recently, he had undergone a right simple nephrectomy 5 years prior for a non-functional kidney in the setting of recurrent urinary tract infections. The patient reports a long history of intermittent management with a urethral catheter, although he notes that he currently evacuates his bladder via spontaneous voiding without difficulty. He denies any family history of malignancies and notes that he did smoke approximately a half-pack per day of cigarettes for 2 years, from 1984 to 1986.
On physical examination, the patient’s body mass index is 32 kg/m2, and he is noted to have a well-healed, large, left-sided paramedian scar from the pubic bone to above the umbilicus; a midline scar at his prior vesicostomy site; and laxity of his abdominal wall with redundancy of his overlying skin. Testes are palpable bilaterally. Laboratory evaluation reveals creatinine of 1.5 mg/dL (calculated GFR of 50 mL/min/1.73 m2); hemoglobin and hematocrit are 9.9 g/dL and 30.1%, respectively. Electrolytes, platelets, coagulation profile, liver function tests, and remainder of lab results are within normal range.
To his initial appointment, the patient brings MR images of his abdomen and pelvis, displayed in the figure. The imaging reveals a 5.6 x 4.3 x 4.5-cm mass at the anterior bladder dome with inflammation extending to the perivesical fat. No pelvic lymphadenopathy or sites of metastatic disease are found. Severe left-sided hydoureteronephrosis extends to the level of an abnormally conformed bladder, consistent with a patulous collecting system, with ureteral insertion into the dome. His abdominal wall musculature appears thin, and his prostate appears diminutive with an apparent atrophic left seminal vesicle.