Silent but Invasive: A Case Report of a Sarcomatoid Bladder Carcinoma in a 29-Year-Old Male Presenting As Vesico-Cutaneous Fistula Without Hematuria

Sarcomatoid urothelial carcinoma (SUC) is a rare and aggressive variant of urinary bladder cancer and is associated with a poor prognosis. This case report presents the unusual case of a 29-year-old male who presented with a vesicocutaneous fistula causing continuous suprapubic urine leakage for four months following a previous bladder surgery for a vesical calculus. This patient had no history of hematuria, which is a common symptom of bladder cancer. Investigations, including contrast-enhanced computed tomography (CECT) and 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT), revealed a large, locally advanced bladder mass infiltrating the anterior abdominal wall with a vesicocutaneous fistula. The patient underwent a radical cystoprostatectomy, wide local excision of the fistulous tract, bilateral pelvic lymph node dissection, right cutaneous ureterostomy, and abdominal wall reconstruction with a pedicled anterolateral thigh flap. Histopathology confirmed poorly differentiated SUC. This case is unique due to the patient's young age, the atypical presentation with a vesicocutaneous fistula without hematuria, and the sarcomatoid histology. It highlights the aggressive nature of SUC, its potential for unusual presentations that can delay diagnosis, and the necessity of considering bladder cancer in young patients with urinary fistulas, even without hematuria. Radical surgery with meticulous reconstruction offers the best chance for disease control in such complex scenarios, emphasizing the importance of early suspicion and multidisciplinary management.