72-year-old patient with a history of serious cardiovascular pathology: ischaemic heart disease with myocardial infarction requiring triple aorto-coronary bypass, arteriosclerosis of supra-aortic trunks and lower limbs; COPD, smoker until 2 years ago, herniated disc and canal stenosis. He consulted for lower urinary tract symptoms of one year's evolution, with nocturnal urination 4-5 times per night and daytime frequency of urination in two phases. Days before the consultation, he presented with total haematuria with clots. Physical examination revealed a deterioration of the patient's general condition, a globular abdomen and a thoracotomy scar. Rectal examination revealed a palpable prostate compatible with benign hyperplasia grade II.
Blood tests showed normal haemogram, normal renal function, mild hyperuricaemia of 7.4 and PSA 0.9 ng/ml.
Initial ultrasound showed normal kidneys and an exophytic lesion on the right side of the bladder base. Cytology was positive for malignant cells and cystoscopy confirmed the neoplastic bladder lesion. Fragment analysis after TUR showed mixed, papillary transitional cell carcinoma grade II-III infiltrating smooth muscle with areas of infiltrating mucoid adenocarcinoma associated with carcinoma in situ lesions and cystic glandular cystitis (stage pT2-pT3 G-III).
Subsequent CT scan showed only thickening of the bladder wall and calcified aorto-ilio-femoral atheromatosis, the rest of the viscera being normal, with no significant adenopathies detected.
Radical cystoprostatectomy and Camey II ileal neobladder were performed. The postoperative period was uneventful and the patient was discharged on the 10th day.
The definitive histological analysis of the specimen revealed an infiltrating ulcerative epithelial ulcerative tumour of the entire wall thickness up to perivesical adipose tissue, consisting of small nests of urothelial cells arranged in artefactual lacunae, with conclusive images of vascular invasion, with papillary formations without stalk, reminiscent of ovarian serous carcinoma. No psammoma bodies were observed. There were also associated lesions of epithelial dysplasia in the prostatic urethra and a well-differentiated prostate carcinoma in the right lobe Gleason 4 (2+2). In the left lymphadenectomy specimen, 11 lymph nodes affected by micropapillary carcinoma were isolated, while the contralateral lymph nodes were unaffected.

Immunophenotypically the micropapillary component expressed cytokeratin 7, CA125, cytokeratin 20, BX2 and P53, being negative for CEA.
Four cycles of carboplatin- and gencitabine-based chemotherapy were administered, avoiding cisplatin due to cardiac involvement. During treatment he developed several urinary tract infections, anaemia and leukopenia that required blood transfusions and colony stimulating factors (filgastrim).
After the QMT, she had an acceptable quality of life for several months, and imaging controls by ultrasound and CT at 3, 6 and 9 months showed satisfactory evolution of both kidneys and the neobladder. At 10 months she began to experience bone and abdominal pain, requiring continuous analgesia. The CT scan performed one year after the operation showed nodular images suggestive of mesenteric recurrence in the left hemiabdomen and bilateral renoureteral dilatation. The patient died 14 months after diagnosis after progressive deterioration of renal function and general condition due to intraperitoneal and retroperitoneal progression.
