We describe the case of a 67-year-old woman with no relevant urological history who presented with a 2-day history of macroscopic monosymptomatic hematuria with clots.
Initially, conservative treatment was decided with bladder catheterization and flushing circuit with saline.
At 24 hours, the patient is anemic and hypotensive, requiring vasoactive amines and polytransfusion of concentrates hes.
An abdominal-pelvic CT scan showed the existence of a bladder completely occupied by a large bladder clot and moderate bilateral hydronephrosis secondary.
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The patient is operated endoscopically evacuating approximately 1 liter of clots.
The bladder mucosa is hyperemic, with diffuse bleeding, with no evidence of endovesical lesions.
Electrocoagulation is performed in several areas with active bleeding.
The patient was admitted to the Intensive Care Unit with orotracheal intubation and supportive treatment with vasoactive amines.
Intravenous aminocaproic acid is added to the treatment.
At 24 hours, the bladder is newly coagulated and the patient continues to be hemodynamically anemic and hemodynamically oriented, despite having received transfusion of 10 concentrated helmets.
Percutaneous nephrostomy is performed bilaterally (NPC) with the intention of solving the obstructive problem caused by bladder occupation and trying to reduce bleeding to this level.
Percutaneous bilateral echo and radioguided nephrostomy was performed under general anesthesia in the Valdivia position, placing 8 Ch catheters through lower catheters, without incidents.
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Twenty-four hours after bilateral NPC, the patient improved significantly, with cessation of hematuria and no need for new blood transfusions.
Two days later vasoactive amines and orotracheal intubation were removed and discharged from the intensive care unit on the fourth day.
Once the acute condition has been overcome, a new bladder endoscopic revision with biopsy is programmed.
The anatomopathological study showed as the only remarkable alteration the presence of an eosinophilic material arranged around the blood vessels of the submucosa.
This substance was stained with Congo Red staining acquiring a fresh green color under the exposure of polarized light with birefringence, which confirmed that it was amyloid.
The immunohistochemical study of the lesion with monoclonal antibodies (mc1 clone), specific against the amyloid AA protein was positive allowing the diagnosis of secondary bladder amyloidosis (Type AA).
The postoperative period was uneventful, with removal of the nephrostomies at 20 days and discharge at one month.
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After 6 months of follow-up, the patient has not presented hematuria and is pending studies to rule out systemic involvement by amyloidosis.
