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+This is a 68-year-old male referred from his outpatient clinic for bilateral obstructive uropathy, in intravenous urography, performed for the study of haematuria.
+His past history included dyslipidaemia, benign prostatic hyperplasia, acute myocardial infarction and non-insulin-dependent diabetes mellitus.
+He reported three episodes of haematuria in December 2001, August 2002 and January 2003, self-limited, asymptomatic and without clots.
+Physical examination showed the patient to be in good general condition, with a globular, soft, depressible abdomen, without masses or megaliths, not painful on palpation. Rectal examination revealed a palpable prostate compatible with benign hyperplasia grade III/IV.
+Complementary analytical tests
+Blood count: parameters within normal limits.
+Blood biochemistry: glucose 145 mg/dl. The rest of the parameters were within the limits of normality. PSA 9.09 PSAl 1.43 index 15.73.
+Systematic urine study: pH6.5, density 1,016, negative for proteins, ketone bodies, bilirubin, nitrites, urobilinogen and leukocytes, 0.50 g/l of glucose and 50 µl of blood.
+Urine sediment: 1-2 red blood cells per field. Benign cytology (negative for malignancy).
+Imaging techniques
+Plain abdominal X-ray: Calcifications in the lower pelvis of possible vascular origin. Good distribution of intestinal gas. Visible psoas lines.
+IVUS: Kidneys of size, shape and location within the limits of normality. Bilateral and symmetrical renoureteral elimination with dilatation of the left renal collector, upper-middle third of the left ureter with image of decreased calibre at the level of the pelvic region that may be related to radiolucent calculi. The right renal collector shows no alteration, and at the level of the pelvic ureter there is a repletion defect possibly related to radiolucent calculus or clot. Cystography shows an irregular bladder, suggestive of trabeculations with a marked prostatic imprint.
+Left percutaneous pyelography: Hydronephrosis with passage of contrast to the bladder, showing a repletion defect at the level of the pelvic ureter, about 5 cm from the bladder.
+
+Abdominal-pelvic CT scan: Moderate bilateral hydronephrosis (26 cm in the right renal pelvis and approximately 29 cm in the left, in the transverse axis). In both distal ureters, approximately 5 cm away from the urinary bladder, intraureteral content is observed, with soft tissue density, suggestive of bilateral urothelioma, occupying practically the entire lumen of the ureters, although without totally occluding them, and occupying an approximate length of 2 cm. The rest of the abdomino-pelvic structures showed no apparent alterations.
+
+Pelvic MRI: Dilatation of the left kidney without being able to identify the exact cause of the stenosis.
+Treatment
+By means of a transperitoneal midline laparotomy, ureteral tracts from the lumbar to the juxtavesical area were exposed, revealing two intraureteral masses, mobile, approximately 2 cm in length, with periureteral tissues of normal appearance. A bilateral longitudinal ureterotomy was performed, revealing two papillary neoformations with a pedunculated implantation base, and it was decided to remove them. Placement of pig-tail and closure of the urethrotomy.
+Pathological anatomy
+Macroscopic description: Irregular white-pinkish fragment measuring 3x2.5x1.2 cm on the left and 3x2.5x1.2 cm on the right. When cut, a central axis can be seen in both.
+Microscopic description: The tumours in both ureters have a similar appearance. They correspond to papillary urothelial carcinoma, of low cytological grade, with connective-vascular axes lined by multiple rows of urothelium with slight pleomorphism and exceptional mitoses. Both have a centred muscle-vascular axis, free of tumour infiltration, although in some areas the tumour contacts the muscle apparently without underlying chorion. The resection base with signs of fulguration, free. At the level of the left tumour, there is papillary proliferation on one of its edges, while the opposite one preserves urothelium without significant dysplasia. On the right side, both edges appear to be free, although in one of them there is a remaining papillary fulgurated tumour attached.
+Final diagnosis
+Papillary urothelial carcinoma G1 stage difficult to assess, probably T1.
+Clinical course
+The patient was discharged after 14 days of hospitalisation, during which he presented febrile symptoms secondary to right basal pneumonia that responded satisfactorily to antibiotic treatment. He also presented with paralytic ileus, which recovered after the application of conservative measures.
+She attended 10 days later for pig-tail removal without any complications.
+At his first check-up after surgery, three months later, the patient was asymptomatic from the urological point of view, presenting normal intravenous urography.
+