Bladder Amyloidosis: incidental finding during pelvic organ prolapse repair surgery

Objectives: Amyloidosis is a rare disease characterized by the deposition of misfolded protein in either a systemic or localized fashion. In localized amyloidosis to the urinary tract, the bladder is the second most involved organ after the kidney. Women presenting to a Urogynecologist may complain of lower urinary tract symptoms that could be perceived as a symptom of other pelvic floor disorders. Primary amyloidosis has not been described as an incidental finding at the time of urogynecologic procedure. Due to the heterogeneity of presentation and its similarity in appearance to bladder cancer, clinical awareness of this disorder should be increased, especially among practitioners performing cystoscopy. The objectives of this case are to increase awareness of localized bladder amyloidosis, in order for it to be included as a differential for bladder mass found on cystoscopy and to discuss the evaluation and management of localized amyloidosis.

Methods: The patient is a 68 year-old female and current smoker that presented to urogynecology clinic with stage III uterovaginal prolapse and complaints of urgency-frequency. She was previously managed with a pessary and now desired surgical management. She had no other prior medical or surgical history.



She underwent a total vaginal hysterectomy, bilateral salpingo-oophorectomy, uterosacral ligament suspension, anterior and posterior repair, and cystoscopy without difficulty. Upon cystoscopy, hematuria was noted, and a friable, fungating bladder lesion was seen on the right lateral bladder wall extending from 10 o’clock to 7 o’clock. Biopsies and bladder barbotage were obtained. Barbotage was negative for high-grade urothelial carcinoma. Surgical pathology revealed squamous epithelium with underlying extensive eosinophilic, amorphous, and fissured material, and Congo red stain was positive — both findings suggestive of the deposition of amyloid. Mass spectrometry typed the amyloid as AL-lambda, consistent with localized AL amyloidosis.



She was seen by Hematology/Oncology to evaluate for systemic amyloidosis. She was also referred to Urology for further evaluation with a CT urogram, demonstrating minimal bladder wall thickening and no other masses in the bladder or upper urinary tract. A repeat cystoscopy revealed amyloid deposits throughout the bladder diffusely. A thickened area of the right lateral wall was resected with a bipolar resectoscope.

Clinical Relevance: This is a case of incidentally diagnosed bladder amyloidosis found at the time of treatment for pelvic organ prolapse. The only presenting symptom consistent with bladder amyloidosis prior to surgery was urinary frequency. Furthermore, this patient endorsed an improvement in her symptoms post-operatively.



Cystoscopy is routinely performed during urogynecologic procedures. Urogynecologists should be aware of this rare disorder, as it may be incidentally found. Patients with suspicious bladder masses should be evaluated with a biopsy and bladder barbotage. Upon diagnosis of amyloidosis, patients should undergo systemic work-up to look for involvement of other organ systems.