This is a 47-year-old patient whose only pathological history is ankylosing spondylitis with significant loss of mobility of the spine, especially at the cervical level.
From the urological point of view, the first contact with the patient was due to the study in August 2001 of a monosymptomatic and capricious haematuria, which after a urographic and ultrasound study led to the diagnosis of a 13 mm papillary neoformation on the left lateral side of the bladder.
Based on these findings, an endoscopic resection of the neoformation was performed in November of the same year, with the anatomopathological diagnosis of pTa G1 transitional carcinoma.
The patient continued with outpatient follow-up with ultrasound studies and negative urinary cytology.
In December 2003, a control cystoscopy was performed and the patient was found to be asymptomatic, with a diagnosis of papillary tumour recurrence, superficial in appearance, in the bladder floor. The preoperative study was normal, with a urine sediment of 35 red blood cells/field and 100 leukocytes/field, with a urinary pH of 7 and a negative culture for usual germs.
Three months later, endoscopic resection of the recurrence was performed, which was multifocal, with a diagnosis of pTaG1 transitional carcinoma.
Given the age of the patient, the recurrence in less than two years, and the multifocal nature of the recurrence, it was decided, despite the low tumour grade, to complete the treatment with intravesical instillation of Mitomycin C.
A weekly instillation of 40 mg of Mitomycin C was scheduled for six weeks, after instillation of an early dose within 48 hours of surgery.
Tolerance to the instillations was good and the patient was followed up again in the consultation room.
As the patient was asymptomatic, he was seen for a check-up in September 2004 with suspicious but not malignant cytology and the ultrasound finding of a significant thickening of the anterior bladder wall, with abscessation, suggestive of cystitis. In addition, in the area of the last tumour resection there is also a hyperechogenic area with a relief of 1.5 cm at the base of the implantation, highly suggestive of tumour recurrence.
Image 1
The urine culture was negative at that time, with a urinary pH of 8, and in the sediment 40 red blood cells/field and 120 leukocytes/field.
In October 2004 an endoscopic revision was performed under general anaesthesia.
The surgical findings were as follows:
- Normal bladder capacity
- Deflected area with granulation tissue on the anterior aspect of the bladder, the abscessed image of the ultrasound disappeared.
- On the left lateral side of the bladder floor there is a pseudomembrane with a necrotic appearance that detaches when it rubs against the resector.
- Under the pseudomembrane there is a very thickened, deflected and very hard mucosa with a feeling of calcification over an area of 2 cm.
The lesion described was resected to its full extent with the suspicion that it was an infiltrative neoplasm with areas of necrosis due to its endoscopic appearance.
The pathological examination revealed fragments of the bladder wall with intense inflammation, areas of necrosis and deposits of inorganic salts intermingled with necrotic tissue and fibrin, with no evidence of tumour tissue. Smooth muscle fibres with intense inflammation and areas of haemorrhage and necrosis were also observed, but no tumour infiltration was evident.
Image 2
The postoperative period was uneventful, and with the diagnosis of encrusting cystitis, the patient was discharged three days after the operation for periodic follow-up in consultation.