Outpatient- Visible Haematuria Flashcards
You have been referred a 45 y/o male with a month’s history of VH by your GP. How you assess this patient?
Providing this patient is haemodynamically stable and not in clot retention I would review this patient in an urgent suspected cancer clinic which would normally be within 2 weeks of their GP referral. I would ask them to provide a urinalysis on arrival to the clinic.
I would take a focussed history of his VH, associated clots, dysuria or flank pain, infection or trauma. I would also ask any associated LUTs as well as red flag signs such as unintentional weight loss, anaemia, bony pain or new neurological symptoms suggestive of advanced disease.
Then I would ask for his PMHx to assess his general performance status and previous pelvic surgery or radiation. Then I would ask his DHx to clarify any anticoagulants and allergies. Then I would ask a social history to check for possible risk factors such as smoking or working in dye factories.
Then I would perform a clinical exam, starting with an abdo exam and then with a chaparone to assess the external genitalia for phimosis, infections and lesions and then a DRE to assess the prostate.
What are the causes of Visible Haematuria?
Cancer:
- Bladder TCC/SCC
- Renal cancer
- Urethral
- Ureteric
Infection:
- Schisto
- UTI
- TB
- Interstitial cystitis
- prostatitis
Trauma:
- penetrating/ blunt trauma kidney, ureter, bladder, prostate, urethra
- urethral strictures
What initial investigations would you perform for this patient?
Blood test: FBC, U&Es, Coag screen, PSA, CRP [if clinically unwell/ suspicion for infection]
Urine: MSSU
I am aware that urine cytology would also be used which would be a mid-morning sample that needs to be rapidly processed. Urine cytology is used to assess for high grade malignancy and is positive in 90% of these cases.
Imaging wise- CT urogram is the first-line investigation but I am aware that USS can be used though it cannot exclude the presence of upper tract TCC.
Then we would perform a flexible cystoscopy
How would you consent the patient for a flexible cystoscopy?
Confirm patient name, date of birth and explain the indication of the flexible cystoscopy. If possible I would have sent the patient an information leaflet prior to the flexi. This would be from local policy or from the BAUS website.
Risk and complications include dysuria, haematuria, urinary tract infection
This patient has a bladder tumour confirmed on flexible cystoscopy. How would you consent him for a TURBT?
Confirm patient name, date of birth and explain the indication of the procedure. I would consent the patient for a TURBT +/- stent insertion +/- intravesical mitomycin. Ideally I would give him a BAUS leaflet prior to consenting
Risks/Cx: Haematuria, dysuria, need for mitomycin, infection, damage to bladder causing perforation needing open procedure [2%], damage to urethra causing possible strictures, need for further procedures, GA risks, blood clots
I would forewarn them that they may need to stay overnight, withhold anticoagulants if needed as well as self-isolate for 2 weeks prior to the procedure.
Do you know any lesions that can predispose to bladder cancer?
- Keratinising squamous metaplasia
- Cystitis glandularis
Those aren’t- cystitis cystica, leucoplakia
Are you aware of any risk classification scores for bladder cancer?
I am aware of the NICE and the EUA risk classification for bladder cancer and our local services uses the NICE guidelines. This involves three low, immediate and high risk.
Low risk- solitary bladder tumour, Low grade pTa, <3cm. Any papillary urethelial neoplasm of low malignant potential
Immediate risk- Solitary LG pTa >3cm, multifocal pTa, LG/HG G2 pTa
High risk: G3 tumours, CIS, All pT1
What are the mainstay treatment of NMIBC?
Low risk: TURBT with single dose intravesical MMC post-op
Immediate risk: TURBT with MMC post op, further 6 doses MMC
High RIsk: TURBT with MMC post-op, re-do TURBT in 6 weeks, BCG treatment or radical cystectomy
What are the mainstay treatment of MIBC?
All patients should with muscle invasive bladder cancer should be discussed that the regional MDT meeting with urologist, oncologist and radiologists present. Depending on diagnosis, age and co-morbidities treatment options may include: Radical cystectomy, radiotherapy, symptomatic management and palliative chemotherapy
What is Mitomycin? What are the potential side effects?
It is an anti-tumour antibiotic, causing DNA crosslinking in bladder tumour cells.
Given at a dose of 40mg in 40mL of saline
Potential side effects would be allergy related symptoms, dysuria, suprapubic discomfort, VH, chemical dermatitis of the palms, extravasation.
What is BCG? What are the potential side effects?
It is a live attentuated dose of the mycobacterium bovis which attaches to the urothelium and then becomes internalised and then triggers a granulomatous inflammatory response.
Potential SEs include dysuria, frequency, malaise and fever
Standard regime would be one weekly instillations for 6 weeks after TUR, then at 3 months 3 weekly, 6 months 3 weekly, then every 6 months 3 weekly up to 3 years.
When would you offer a re-resection?
- incomplete TURBT
- no muscle in first resection [exception would be G1pTa tumours]
- All T1 tumours
- All high grade tumours
What would be follow up plan for NMIBC patients?
I am aware of the NICE and EAU guidelines for the monitoring of NMIBC, our local services follow the NICE guidelines.
Low risk- scope at 3 months, then 12 months. if no recurrence discharge
Immediate risk- scope at 3 months, 9 months, 18 months, then annually up to 5 years, then discharge
High risk- re-resect in 6 weeks. if BCG. scope every 3 months for first 2 years, every 6 months for next 2 years then once year after. CTIVU for 5 years
If cystectomy- urethroscopy annually for 5 years. CTCAP for 2 years then CTIVU to year 5. Annual US to year 10
In which situation is radical cystectomy the treatment of choice
High risk NMIBC and MIBC
- young patient
- previous extensive abdominal surgery
- previous pelvic radiotherapy
- CIS [rtx doesn’t treat this]
- Upper tract obstruction
- presence of severe urinary symptoms
