En Bloc Resection of a Giant Sacrococcygeal Chordoma Presenting with Urinary Bladder Distension to the L4 Level: A Case Report

Abstract

Objective: To report a previously undescribed sacrococcygeal chordoma presentation with massive bladder distension to L4 from mechanical outlet obstruction, managed with nerve-sparing en bloc resection.

Methods: A 54-year-old male presented on 10th June 2025 at JPMC, Karachi, with 5 months of progressive urinary retention and back pain. MRI, ultrasound KUB, and image-guided biopsy with immunohistochemistry were performed. Multidisciplinary planning preceded posterior en bloc sacral resection with S2–S3 osteotomy under continuous neuromonitoring, preserving bilateral S1–S2 nerve roots. Written informed consent was obtained from the patient for publication of his case.

Results: MRI showed a 6.3×8.0×7.1 cm S3–S5 mass with bladder distension to L4. Biopsy confirmed brachyurypositive chordoma. Blood loss was 1,800 mL; operative time 310 minutes. Histopathology confirmed R0 resection. Voiding was restored (residual <50 mL) with preserved bowel and limb function. One-year follow-up showed no recurrence.

Conclusion: This is the first reported sacrococcygeal chordoma with L4-level bladder distension from mechanical obstruction. Nerve-sparing en bloc R0 resection achieved full functional recovery, highlighting multidisciplinary planning and intraoperative neuromonitoring.