A 59-year-old Syrian female was admitted with a 2-month history of gross hematuria associated with lower urinary tract symptoms. There were no systemic symptoms (fever, joint pain, or rash). The hematuria was red in color, fresh, and intermittent with no clotting. She was diagnosed with PUBA 18 years ago treated by transurethral resection without follow-up.
The physical examinations were unremarkable. Complete blood counts (CBCs) and routine biochemical tests (renal, liver, and bone parameters) were normal. Urinary microscopic examination showed normal pH and specific gravity, with uncountable RBCs, few WBCs, granules casts, and presence of hemoglobin. Culture and sensitivity were normal.
Ultrasound of the kidneys, ureters, and bladder showed thickening and irregularity of the bladder wall with 9 mm as the maximum thickness (Figure 1). Intravenous urography was normal. Cystoscopy showed multifocal yellowish bladder lesions (Figure 2). The pathologic examination demonstrated extensive deposits of a cellular amorphous compatible with amyloidosis. No other abnormality was detected.
To exclude systemic amyloidosis, an electrocardiogram (ECG) and chest X-ray were conducted which revealed no pathologic findings. Tuberculin reaction and tuberculosis screening in 24 hours urine were normal. There was no increased lymphocyte count and protein gap. Bone marrow examination and CT scan of abdomen were both normal.
After the exclusion of systemic amyloidosis, recurrent multifocal PUBA diagnosis was confirmed.
A new method in the treatment of PUBA with neodymium: yttrium-aluminum garnet (Nd: YAG) laser therapy had been performed. The laser intensity used was 25 Watt with pulse duration less than 3 seconds. The fibreoptic tip was placed 1-3 mm from the bladder wall using a spot size of 2 mm. The total energy was 23500 Joules.
After 18 months from treatment, the patient was normal without symptoms. She has since remained asymptomatic without progression of systemic amyloidosis. Follow-up cystoscopies performed at present have been normal.