A 41-year-old man with a history of allergy to penicillins, arterial hypertension under medical treatment and psoriasis came to our clinic for haematuria. Urine cytology was performed with atypia suggestive of malignancy and an abdominal ultrasound scan showed a bladder mass on the left lateral side measuring 65x46 mm producing a left ureterohydronephrosis.
In view of these findings, the patient underwent TUR of the bladder and an infiltrative mass was resected, occupying the entire left lateral aspect and obscuring the ureteral orifice. A left nephrostomy was also performed. The pathological anatomy of the mass was undifferentiated undifferentiated undifferentiated urothelial carcinoma of the bladder. In view of this, an extension study was performed with a normal thoracoabdominal CT scan, normal bone scintigraphy and left retrograde pyelography, which revealed ureterohydronephrosis up to its entry into the bladder, with no mass visible within the ureteral lumen.
As the extension study was negative, a radical cystoprostatectomy with Bricker shunt was performed. The pathological anatomy showed high-grade solid urothelial carcinoma infiltrating the perivesical fat, prostate and urethra with tumour-free surgical edges. Neoplastic cells in the vascular lumen were visualised in peritumoral vessels. In the left iliobturator chain, lymph nodes infiltrated by urothelial carcinoma (pT4aN1M0). Postoperatively, the patient presented recurrent episodes of anaemia and thrombopenia that did not improve despite transfusion of red blood cells and platelets. Renal function remained normal and the bricker function was correct from the beginning. After 5 days, the patient was successfully tolerated. Given the isolated signs of anaemia (around 7 g/dl haemoglobin) and thrombocytopenia (around 20,000 platelets/ml), an abdominal CT scan was performed where no haematomas were observed and the drainage debit was low from the outset, ruling out active bleeding. Enoxaparin was withdrawn to avoid pharmacological causes of thrombopenia. Coagulation was always normal and there were no signs of bleeding, ruling out disseminated intravascular coagulation (DIC). A haemolytic picture was also ruled out as bilirubin was normal and the direct Coombs' test was negative. As the cause of the recurrent episodes of anaemia and thrombopenia was not found, a sternal bone marrow aspiration-puncture was performed and metastatic urothelial carcinoma cells were obtained. On discovering the infiltration of the bone marrow by the bladder tumour, haemotherapy substitution treatment was carried out and chemotherapy treatment was started, and the patient died 3 weeks later.