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+We describe the case of a 67 year old woman, with no urological history of interest, who presented with macroscopic monosymptomatic haematuria with clots of 2 days' evolution. Initially, conservative treatment was decided with bladder catheterisation and a saline solution washout circuit. After 24 hours the patient was anaemic and hypotensive, requiring vasoactive amines and polytransfusion of blood concentrates. An abdominal-pelvic CT scan was performed, which revealed a bladder completely occupied by a large bladder clot and secondary moderate bilateral ureterohydronephrosis.
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+The patient was operated on endoscopically and approximately 1 litre of clot was evacuated. The bladder mucosa is hyperemic, with diffuse bleeding, with no evidence of endovesical lesions. Electrocoagulation of several areas with active bleeding was performed. The patient was admitted to the Intensive Care Unit with orotracheal intubation and support treatment with vasoactive amines. Intravenous aminocaproic acid is added to the treatment. After 24 hours the bladder was again clotted and the patient continued to be anaemic and haemodynamically unstable, despite having received a transfusion of 10 blood concentrates.
+In view of this situation, we decided to perform bilateral percutaneous nephrostomy (BCN) with the dual intention of solving the obstructive problem caused by bladder obstruction and attempting to reduce bleeding at this level.
+Bilateral percutaneous nephrostomy was performed under general anaesthesia in the Valdivia position, placing 8 Ch catheters through the lower calyx, with no incidences.
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+Twenty-four hours after bilateral CPN, the patient improved significantly, ceasing haematuria and not requiring new blood transfusions. Two days later, vasoactive amines and orotracheal intubation were withdrawn, and the patient was discharged from the Intensive Care Unit on the fourth day.
+Once the acute symptoms were over, a new endoscopic examination of the bladder was scheduled with biopsies. The anatomo-pathological study revealed as the only notable alteration the presence of an eosinophilic material around the blood vessels of the submucosa. This substance stained with Congo Red stain and turned apple green under polarised light with birefringence, which confirmed that it was amyloid. The immunohistochemical study of the lesion with monoclonal antibodies (clone mc1), specific against the AA protein of amyloid was positive, allowing the diagnosis of secondary bladder amyloidosis (Type AA). The postoperative period was uneventful, the nephrostomies were removed after 20 days and the patient was discharged after one month.
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+After 6 months of follow-up, the patient has not presented haematuria again and is awaiting studies to rule out systemic involvement due to amyloidosis.
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