PMC7596013_01
Top. CT cut through S4-S5. (05/18/2020) A tumor mass deep in the pelvis and adjacent to the bladder is depicted (indicated by an arrow).. Bottom. CT cut through the upper coccyx. The pelvic mass demonstrated on CT appears to impinge and slightly deform the urinary bladder but is not invasive. The partially calcified mass in the left inguinal region is also depicted (indicated by an arrow).
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A cystoscopy and cystogram were performed because of a mass seen on CT within the pelvis and on the right side of the bladder (Fig. 1, top and bottom).
Top. Photograph of the anterior aspect of the resected specimen (06/23/2020). A tumor mass attached to the right side of the presacral fascia is shown (indicated by an arrow). The sacrum was resected from S4 down to and including the coccyx. No remnants of a ureter were present within the specimen.. Bottom. The specimen is opened showing the mucin content of the presacral mass.
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The sacrum from the S4-S5 junction and coccyx were removed along with the underlying tumor mass (Fig. 2, top and bottom).
Cystogram (07/01/2020). A CT cystogram shows no contrast extravasation from the bladder. The closed suction drain remains in place. Lymphocoeles are present in the inguinal sites.
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A cystogram was performed on July 1, 2020 which showed no leak from the bladder (Fig. 3).
Top. CT with intravenous contrast (07/02/2020). CT slice through the pelvis at the level of S4. The distal right ureter is well demonstrated (indicated by an arrow).. Bottom. CT with intravenous contrast. CT slice just beneath the right ureter depicted in Fig. 4, top shows a stream of contrast moving from the right ureter toward the closed suction drain in the presacral space (indicated by an arrow).
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On July 2, 2020, using intravenous contrast (Omnipaque, GE Healthcare Inc., Marlborough, MA) a delayed CT of the kidneys and collecting system showed a leak from the distal right ureter into the presacral space (Fig. 4 top and bottom).
Rendezvous procedure (07/02/2020). A guidewire was passed through the right nephrostomy down the ureter to the ureteral leak and left in place. Cystoscopy and then ureteroscopy were performed. The guidewire in the right ureter was grasped through the ureteroscopy and pulled into the bladder.
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Cystoscopy and rigid ureteroscopy (Uretero-renoscope, Karl Storz Endoscopy-America, Inc., El Segundo, SA) were performed (Fig. 5).
Placement of a ureteral stent from the right kidney into the bladder (07/02/2020). Using the guidewire, a nephroureteral stent was passed into the right kidney, down the right ureter and past the ureteral leak into the bladder (indicated by an arrow). The closed-suction drain in the operative site remained in place.
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A nephroureteral stent (Percuflex, El Coyol, Alajuela, Costa Rica) was passed over the guidewire from the skin exit site of the percutaneous nephrostomy into the bladder (Fig. 6).