| A 68-year-old man presented with bilateral obstructive uropathy in an intravenous urography performed for the study of hematuria from his outpatient clinic. | |
| The patient had a history of dyslipidemia, benign prostatic hyperplasia, acute myocardial infarction, non-insulin dependent diabetes mellitus. | |
| He reported three self-limiting, asymptomatic episodes of hematuria in December 2001, August 2002 and January 2003 without clots. | |
| Physical examination revealed a patient with good general condition, bulging abdomen, bleaching, depressible, without masses or masses, painless to glpancy. | |
| A rectal examination revealed a 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 normal limits. | |
| PSA 9.09 PSAl 1.43 index 15.73. | |
| Systematic urine study: PH6.5, density 1.016, negative for proteins, colonic bodies, bilirubin, nitrites, urobilinogen and leukocytes, 0.50 g/l glucose and 50 μl blood. | |
| Urine sediment: 1-2 stools per field. | |
| Benign cytology (negative for malignancy). | |
| Imaging Techniques | |
| Plain abdominal radiography: Calcifications in the minor pelvis of possible vascular origin. | |
| Good distribution of intestinal gas. | |
| Visible psoas lines | |
| UIV: Kidneys of size, shape and location within normal limits. | |
| Bilateral and symmetrical renoureteral elimination with dilatation of the left renal collector, upper-middle third of the left ureter with image of decreased caliber at the level of the pelvic region that may be related to radiotransparent calculus. | |
| Right renal calculus does not show alteration at the level of the pelvic ureter, defect of repletion in a possible relation with radiolucent calculus. | |
| Cystography showed irregular bladder suggestive of trabeculations with marked prostatic imprint. | |
| Left pyelography: Hydronephrosis with contrast passage to bladder defect replacement at the level of pelvic ureter, about 5 cm of bladder. | |
| 1. | |
| Abdominal-pelvic CT: Moderate bilateral hydronephrosis (26 cm right renal pelvis and approximately 29 cm left in 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 approximately 2 cm non-early structures. | |
| 1. | |
| Pelvic MRI: Left kidney dilation without being able to identify the exact cause of the stenosis. | |
| Treatment | |
| Median transperitoneal midline laparotomy ureteral tracts are exposed from lumbar to juxtavesical area objectifying two mobile intraureteral masses of approximately 2 cm in length, with normal periureteral tissue appearance. | |
| A bilateral longitudinal incision was made, appreciating two papillary neoforms base of pediculae implantation and removal. | |
| Pig-tail placement and urethrotomy closure. | |
| Anatomy, Pathological | |
| Macroscopic description: An irregular, white-brown fragment measuring 3x2.5x1.2 cm on the left and 3x2.5x1.2 cm on the right. | |
| The section recognizes the central axis in both. | |
| Microscopic description: Tumors of both ureters have a similar appearance. | |
| Papillary stricture to urothelial carcinoma, low cytological grade, with connective-vascular axes covered by multiple urothelium rows with mild pleomorphism and exceptional mitosis. | |
| Both have muscle-vascular axis, tumor free contact, although in areas the tumor apparently has no underlying chorion. | |
| The resection base showed free fulguration. | |
| At the level of the left tumor in one of its edges, there is papillary proliferation, while the opposite is preserved urothelium without significant dysplasia. | |
| On the right side, both edges appear free, although in one of them there is rest of a rounded papillary tumor. | |
| Final Diagnosis | |
| Patent urothelial papillary carcinoma G1 difficult stage, probably T1. | |
| Ev | |
| The patient was discharged after 14 days of admission, during which he presented fever secondary to right basal pneumonia that responded satisfactorily to antibiotic treatment. | |
| The patient also presented with a paralytic ileus that developed after conservative measures. | |
| He came 10 days later to remove pigtail without complications. | |
| In his first review after surgery, three months later, the patient is asymptomatic from the urological point of view presenting normal intravenous urography. | |