Haematuria and Urological Malignancies Flashcards
Causes of Haematuria
-Trauma: blunt, penetrating
-Infection: bacterial PN, TB, parasitic (schist)
-Inflammation: interstitial cystitis
-Infarction: renal infraction
-Neoplasm: RCC, UTUC, bladder cancer
-Metabolic: renal stones, bladder stones
-Autoimmune: IgA nephropathy, GN, HSP
-Psychogenic, prescription drugs: pen, cyclophos, anti-coag/ -plt
-Surgical: post TURP/TURBT
Causes of transient or spurious non-visible haematuria
urinary tract infection
menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse
Causes of persistent non-visible haematuria
cancer (bladder, renal, prostate)
stones
benign prostatic hyperplasia
prostatitis
urethritis e.g. Chlamydia
renal causes: IgA nephropathy, thin basement membrane disease
Causes of loin pain
-Trauma: blunt, penetrating
-Infection: bacterial PN, pyonephrosis, renal abscess, lobar pneumonia
-Infraction: renal
-Neoplasm: RCC, UTUC (upper tract urothelial cancer)
-Metabolic: renal stones
-Surgery: post-renal surgery, Abd-AAA, acute pancreatitis/ cholecystitis, appendicitis, ectopic pregnancy, torsion/ rupture of ovarian cyst
Causes of palpable loin mass
-Trauma: blunt, penetrating
-Infection: renal abscess/ peri-renal abscess
-Neoplasm: RCC, UTUC
-Metabolic: renal stones with associated perirenal abscess
-Surgical: post renal surgery
Definition of haematuria
-The presence of red blood cells (RBC) in the urine.
-Visible (prev Macroscopic) / VH
=Rose urine, claret
=+/- clots
=MUST be investigated
-Non-Visible (prev Microscopic) / NVH
=Trace blood is NOT haematuria
=Must have ≥ 1+ on Urinalysis on 2 or more occasions
=Symptomatic NVH or Asymptomatic NVH (age >40) MUST be investigated
Causes of haematuria
-Trauma:
=Blunt/penetrating injuries, instrumentation
-Infection:
=UTI, pyelonephritis, schistosomiasis
-Inflammation:
=Interstitial cystitis
-Neoplasia:
=BlCa, RCC, UTUC, PrCa
-BPH
-Metabolic:
=Stones / Urolithiasis – renal, Ur, bladder
-Autoimmune
=IgA nephropathy, GN, HSP
-Surgery:
=Post TURP / TURBT
-Drugs– pen., cyclophos, anti-coag/-plt
-Strenuous Exercise:
=March h’turia, Marathon-runners h’turia
Investigation of visible haematuria
-Risk of Urological Malignancy >50y: 20-25%
-History & Exam
-MSU: UA, mc&s, (cytology)
-Routine bloods (FBC, U&E)
-Flexible Cystoscopy (2 weeks)
-CTU (CT Urogram)
Investigation of non-visible haematuria
Risk of Urological Malignancy >50y: 5%
-Symptomatic NVH, or Asymptomatic NVH (in pts >40y)
=History & Exam
=MSU: UA, mc&s, (cytology)
=Routine bloods (FBC, U&E)
=Flexible Cystoscopy (4-6 weeks)
=Renal USS
Referral for haematuria
Urgent referral (i.e. within 2 weeks)
Aged >= 45 years AND:
unexplained visible haematuria without urinary tract infection, or
visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
Non-urgent referral
Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection
Since the investigation (or not) of non-visible haematuria is such as a common dilemma a number of guidelines have been published. They generally agree with NICE guidance, of note:
patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care
Prevalence of haematuria and malignancy
-Bladder cancer
=VH 20%
=NVH 5%
-Renal cell cancer
=VH 1%
=NVH 0.3%
-Upper tract urothelial carcinoma
=VH 0.1%
=NVH 0.1%
Investigation of haematuria
-Bloods: FBC, U&E
-MSU → Urinalysis
-MSU → mc&s
-MSU → urine cytology
-LUT (Lower Urinary Tract)
=Flexible Cystoscopy
-UUT (Upper Urinary Tract)
=VH: CTU
=NVH: Renal USS
Haematuria criteria for admission
-VH with sig chronic bleeding: Symptomatic Anaemia
-VH with sig acute bleed: Hypovolaemic Shock
-VH with voiding difficulties: Clot retention (may be pending)
Emergency management of haematuria
-A, B, C
-IVF +/- Blood Tx
-3-way Catheterisation
-Bladder washout: 50ml catheter-tipped syringe with N saline
-Bladder washout: remove FDPs
-Bladder washout in Theatre: if clots significant
Epidemiology of bladder cancer
-Urothelial Ca…..
=Squamous Cell C 1-7%: Schistosomiasis / Bilharzia
=Adeno Ca 2%: dome- ?patent urachus
=Urothelial transitional cell carcinoma >90%. 70% will have papillary growth pattern
=Benign: inverted urothelial papilloma and nephrogenic adenoma uncommon
-Incidence
=5th most common Ca: Lifetime risk 1-3%
=Age Standardised (AS) Incidence (UK) 18 : 100,000
-Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk
-Age
=Disease of elderly, generally… but can present in 20s & 30s
=Rise gradually from 50s…. and peak in 90s
-Sex/Gender
=M:F = 3:1
-Geography:
=Western World: UC- smoking, industrial
=Africa: SCC- Schistosomiasis / Bilharzia
Aetiology of bladder cancer
-Cigarette Smoking: active/passive
-Chemical Exposure: (Rubber, Dye, Textile Industries) Aromatic Amines, (Petroleum industry) Polycyclic aromatic hydrocarbons(PAHs), Benzenes; (Chemo Rx) Cyclophosphamide
-History of pelvic EBRT
-Previous Chemo Rx: Cyclophosphamide
-Chronic Irritation (SCC): UTIs, Schistosomiasis, Urolithiasis
Presentation of bladder cancer
-Painless VH (macroscopic)
-NVH (Asymptomatic or Symptomatic)
-Incidentally on CT imaging during unrelated investigations
Staging investigation and diagnosis of bladder cancer
-Dx: Flexible Cystoscopy
-Dx: TURBT & EUA, bladder Bx
-Staging CTU & CT C/A/P… MRI pelvis (pre-TURBT). PET CT for nodes of uncertain significance
Treatment of bladder cancer
-NMIBC (non muscle invasive): TURBT, regular check cystoscopies; BCG & MMC
-MIBC: Radical Cystectomy + Ileal Conduit / Neobladder; EBRT
Bladder cancer: TRUBT & Radical Cystectomy
-TURBT: Trans Urethral resection of Bladder Tumour
=For Dx & Mx of bladder Ca
=Treats NMIBC (non-muscle invasive BlCa)
=Dx MIBC (muscle-invasive BlCa)
-Radical Cystectomy & Ileal Conduit Urinary Diversion
=For MIBC
-Success rates: variable (40-90%), recurrent disease, depends on grade & stage
Describe Non Muscle-Invasive bladder cancer
-NMIBC (Non Muscle-Invasive Bl Ca) / Superficial: pTa, pT1
=Urothelial & suburothelial (=mucosa, submucosa) … not muscle
=TURBT both diagnostic & therapeutic (potentially curative)
=Can recur: dep on Grade (G1-3)
Installation Rx of non muscle invasive bladder cancer
-MMC (mitomycin C): reduces recurrence rate…. but not likelihood of progression to invasive disease (MIBC)
-BCG: for HG UC- G3, CIS; provokes pro-inflamm IL-response that reduces rate of progression to MIBC; sig SEs
-On-going BlCa surveillance: regular check flexi cystoscopies
Describe muscle invasive bladder cancer
-As invaded muscularis +/- beyond to adjacent tissues
-TURBT both diagnostic only: samples muscle
-Extent is det by TURBT pathology, EUA & staging CT (C/A/P) / MRI
-Rx
=Curative: Radical Cystectomy + Ileal Conduit / Neobladder; EBRT
=Neoadjuvant Chemo Rx: 5% survival advantage… but not everyone responds… Gem Cis, MVAC
=Adjuvant Chemo R: not evaluated in RCT
Prognosis of bladder cancer
Stage 1: 90% 5 years
-2: 50%
-3: 15-30%
-4: 10%
Epidemiology and aetiology of renal cell cancer
-RCC (clear cell 80%, papillary 15%, chromophobe 5%), Adenocarcinoma, Hypernephroma
-Incidence:
=7th most common malignancy: 13,000 new cases p.a. UK
=Most lethal of all urological cancers
-Age:
=Peak incidence 50-60y
-Sex/Gender:
=M:F is 3:1
-Aetiology:
=Largely unknown
=RFs: Smoking, obesity, Employment leather industry, FH vHL, middle aged men, tuberous sclerosis, PKD
Presentation and types of renal cell cancer
-Usually asymptomatic – most commonly diagnosed incidentally on USS or CT inputs undergoing investigations for other conditions
-40-50% advanced/met at presentation
-Haematuria, flank pain, palpable mass, paraneoplastic synd polycythaemia from erythropoietin, hypercalcaemia fom PTH, ACTH), pyrexia of unknown origin
-Varicocele, Stauffer syndrome (cholestasis, hepatosplenomegaly)
-Micro:
=Majority Clear Cell Ca from PCT
=Other- Papillary, Chromophobe, Collecting Duct, Medullary
-Macro:
=Typically enhancing solid tumour on CT
“Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.
Diagnosis and staging of renal cell cancer
-Diagnosis: CT scan - Enhancing solid / heterogenous tumour (triple phase contrast)
-Staging
=Triple phase contrast CT
=& CT Chest
=Consider Bone Scan
Treatment of renal cell cancer
-Depends on stage, tumour locus, pt fitness (Performance Status)
-T1-T2: LRN (lap radical nephrectomy), PN (partial nephrectomy if T1 tumour <7cm (open, robotic, lap), cryo- for small tumours, AS- in small tumoursand comorbid patients
-T3: LRN, ORN (open radical nephrectomy)
-Met: TKIs: Sunitinib, Pazopanib; cytoreductive nephrectomy
alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases
receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha
Indications for Partial Nephrectomy
-Absolute: Solitary kidney / Solitary functioning kidney
-Relative: Multifocal or bilateral renal tumours (esp with VHL) –aiming to avoid renal replacement therapy; advanced CKD
-Elective: Small (T1) peripheral tumour with normal contralat kidney
Renal cell cancer prognosis 5 years
-T1: 70-95%
-T2: 50-75%
-T3: 22-70% (25% in T3c IVC wall invasion)
-T4: 5-40%
Epidemiology of upper tract urothelial Ca/TCC
-UTUC (Upper Tract Urothelial Ca)/ UT-TCC of the renal pelvis or ureters
-Incidence: Rare - ~5% of all TCC, Less common than RCC
-Aetiol: As per bladder Ca- smoking, azo dyes etc; Also- HNPCC, Balkan nephropathy (aristocholic acid)
-Age: Peak incidence 70y+
-Sex/Gender: M:F is 3:1
Presentation of upper tract urothelial Ca/TCC
Painless visible haematuria +/- clots, Loin pain / clot colic, incidental
Investigation of UTUC
Flexi Cysto + CT Urogram (filling defect)
Management and Rx of UTUC
-Confirm Dx: Ureteroscopy + Bx
-Stage the disease: CT Urogram + CT Chest
-Rx:
=Localised-Laparoscopic Nephroureterectomy (LNU)
=Advanced- palliative chemo/EBRT for bleeding
=Prognosis: dep on stage, 90% - 20%
