A 41-year-old woman smokes a daily packet without other relevant personal history except for a brother who had undergone TUR one year before a superficial bladder tumor.
The patient consults an internist of our center for a 6-month history of pollakiuria, dysuria and tenesmus of the bladder, without hematuria or urinary incontinence, accompanied by asthenia and anorexia.
A first uroculture is requested which is negative and after several weeks of treatment with phytotherapy and without clinical improvement, sterile leukocyturia in the urinary sediment is observed; the urocultive persists negative.
A urine BK was requested, which was also negative, and a urine cytology reported suspicion of transitional carcinoma.
No significant alterations were found in the blood analysis, and in the physical examination a generalized induration of the anterior vaginal face is noteworthy in the vaginal examination.
At this time, an ultrasound and CT are requested and sent to our outpatient clinics for urological evaluation.
The CT scan showed an endovesical mass mainly the exoskeleton of the posterior face without clearly demonstrating a plane of separation with the uterus.
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At this time, it was decided to perform an endoscopic bladder revision with a broad base mass and solid consistency, occupying practically the entire urethra and the bladder floor.
The ureteral meatus was patent.
The urethra was completely destructured like an anfractuous cavity and there were signs of fighting bladder.
Partial resection was performed with biopsy.
The pathological result reported urethral adenocarcinoma of clear cells with bladder neck involvement (pT3).
The patient was referred to an anterior pelvic exertion and two possibilities of urinary diversion, Bricker type continent or reservorio type continent, carrying out the latter jointly with the patient.
The surgery was performed in 3 stages: firstly, a laparoscopic time, performing the cystectomy, hysterectomy, left adnexectomy (preserving the right ovary by the age of the patient with a possible bladder pouching mechanism).
Also during open surgery was used to perform bilateral ilioobturator lymphadenectomy, since during the laparoscopic time several large lymphadenopathies were observed and their removal with iliac vessels were adhered to.
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For laparoscopic cystectomy, we placed 5 other fistulas in the left side and transperitoneally with the patient in a forced Trendelemburg position, 3 of them 10-12 mm in both iliac and supraumbilical fossas 5
Then, the iliac vessels were dissected up to the posterior peritoneal leaves and both ureters were identified; the lateral spaces were dissected up to the endopelvic spaces; the bladder was dissected up to the distal neck ligament;
Vaginal time consisted of a wide excision of the urethral meatus that comprised a large part of the anterior vaginal wall.
An ileal loop of about 40 cm was isolated. A desubularization of the two was performed. A distal third was reconstructed using a proximal third of the stent. It was constructed through a longitudinal third.
Subsequently, this loop was attached to the right iliac fossa, prior fixation to the abdominal wall to avoid fixations and possible complications when performing future autocatheterizations.
The approximate duration of surgery was 5 hours, with a bleeding of 500 ml.
The patient suffered intestinal transit on the third day and was discharged one week after the intervention, with a catheter that tutored the reservoir.
The patient washed daily at home with saline to avoid accumulation of intestinal mucus.
The catheter was removed at 3 weeks and since then the patient autocatheterized every 3-4 hours with a smaller caliber catheter than that used during surgery.
The anatomopathological result confirmed the urethral origin of the tumor (clear cell adenocarcinoma), this time demonstrating greater involvement of the bladder (trigone, right lateral wall) and of the anterior vaginal surface; of these, 16 cm were sent positive T2.
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Microscopically, an intense lymphoplasmacytic inflammatory infiltrate and a mixed pattern with glandular and solid zones were described, consisting of clear cells (i.e., large cytoplasm that is not stained) and abundant cells.
Staining with CA-125 was positive and PSA was negative.
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The patient has received five cycles of chemotherapy (carboplatin and taxol) and pelvic radiotherapy.
Six months after surgery the patient is continent performing self-catheterization every 4 hours a day.
A control CT scan has been performed in which several lymphadenopathies are observed at the retroperitoneal level, so the patient is waiting for a new cycle of adjuvant treatment with second-line chemotherapy.
