Urology (1) (Haematuria and cancer) Flashcards
haematuria
presence of blood in the urine
can be:
- visible
- non-visible
visible haematuria
- ‘macroscopic’ or ‘gross’ haematuria
- Pink, red, dark brown
% of patients with visible haematuria who will have cancer
20%
non-visible haematuria
confirmed by urine dipstick of microscopy
- microscopic or ‘dipstick positive)
- can be symptomatic or asymptomatic
% of patients with non-visible haematuria who will have cancer
5%
Symptomatic non-visible haematuria (s-NVH)
haematuria with associated symptoms
e.g. suprapubic pain or renal colic
Asymptomatic non-visible haematuria (a-NVH):
haematuria with no associated symptoms
malignant causes of hameaturia
urothelial carcinoma (transitional cell)
adenocarcinoma
benign causes of haematuria
- Infection: pyelonephritis, cystitis or prostatitis
- Stone disease
- Benign prostatic hypertrophy
- Trauma
- Parasitic e.g. schistosomiasis
basic investigations for haematuria
Investigation
- Urinalysis
- Presence of nitrites and/or leukocyte- infection
- Baseline bloods (FBC, U and Es and clotting)
- PSA in pt with prostatic pathology
- In pt with deranged renal function-spot albumin:creatinine ratio or protein:creatinine ratio
specialist investigations for haematuria
- Flexible cystoscopy (gold standard for assessing LUT) under local
- Urine cytology
- Upper urinary tract imaging
- US KUB imaging
- CT urogram
flexible cystoscopy
This is an examination of the inside of your bladder, using a very fine, soft, telescopic tube (the flexible cystoscope).
urological referral can be
2 week wait e.g. haematuria
urgent (if patient doesnt fit demographic for 2 week wait)
emergency e.g. renal colic
when to refer (urological)
- >45 with either: visible haematuria without UT,
visible haematuria that persists
- >60yrs with unexplained non-visible haematuria +
Dysuria or raised WCC
Management
haematuria hisotry
- Degree of haematuria e.g. pink or dark red, presence of clots
- Bright pink, orange – non-urological cause
- Timing in the stream
- Total haematuria e.g. bladder
- Terminal haematuria e.g. severe bladder irritation
- Associated symptoms
- LUTS
- Fever or rigors
- Suprapubic pain, flank pain
- Weight loss
- Recent trauma
- Drug history
- Smoking history (urological malignancies)
- Exposure to industrial carcinogens
- Recent foreign travel (schistosomiasis)
Next:
- Abdominal examination
- DRE
- External genitaliaexamination
Pseudohaematuria
is red or brown urine that is not secondary to the presence of haemoglobin.
Causes include:
- medication (such as rifampicin or methyldopa),
- hyperbilirubinuria or myoglobinuria
- certain foods (such as beetroot or rhubarb)
blood thinners e.g. DOAC can cause haematuria to be more likely
urine dipstick
renal cell carcinoma is the
most common renal cancer
where does adenocarinoma (RCC) occur
in parenchyma of the kidneys
- Pyramids
- Cortex
- Medulla
where does renal cell carcinoma spread to
- Spread
- Spread via direct invasion into perinephric tissues, adrenal gland, renal vein or inferior vena cava
- Spread via lymphatic system to pre-aortic and hilar nodes
- Haematogenous spread to bones, liver, brain, bones, lung
RF for renal cell carcinoma
- Men
- Smoking
- Industrial exposure to carcinogens
- Dialysis
- HTN
- Obesity
- Polycystic kidney disease
- Hippel-Lindau disease,
presentation of renal cell carcinoma
- Clinical features
- Haematuria (vis or non vis)
- Flank pain
- Flank mass
- Non specific: lethargy or weight loss
- Left varicocele due to compression of the left testicular veins as it joints the left renal vein
- Paraneoplastic syndromes
paraneoplastic syndromes associated with RCC
- Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
- Polycythaemia – due to secretion of unregulated erythropoietin
- Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
microscopic features of RCC
composed of polyhedral clear cells, with dark staining nuclei and cytoplasm rich with lipid and glycogen granules
investigations for RCC
- Bloods (FBC, urea, U&Es, calcium, liver function tests, CRP)
- Urinalysis- non-visible haematuria and cytology
- Imaging
- CT CAP pre and post IV contrast (gold standard)
- Chest for staging after
- US
- Biopsy of renal lesion
staging of RCC
management of localised RCC: surgery
- Laparoscopic or open approaches
- Small tumours- partial nephrectomy
- Larger tumours- radical nephrectomy
- Remove kidney, perinephric fat and local lymph nodes
adrenal glands should be spared if poss
management of localised RCC: those not fit enough for surgery
- Renal artery ablation
- Percutaneous radiofrequency ablation
- surveillance
management of metastatic RCC
Chemotherapy ineffective in pts with RCC
- In otherwise fit patients with metastatic disease, nephrectomy combined with immunotherapy (such as IFN-α or IL-2 agents) is often recommended.
- Biological agents that can be used in combination for metastatic disease include Sunitinib (a tyrosine kinase inhibitor) and Pazopanib (also a tyrosine kinase inhibitor)
- Metastasectomy (surgical resection of solitary metastases) is recommended where the disease is resectable and the patient is otherwise well.
chemotherapy and RCC
doesnt work
transitional cell carcinomas
also known as urothelial cancer
Can affect anywhere from the calyx to the bladder.
i.e. upper tract TCC or bladder cancer
upper tract transition cell carcinoma refers specifically to
renal pelvis and ureters
risk factors for upper tract TCC
- Smoking
- Analgesic misuse
- Exposure to aniline dyes
- Male to female ratio is 3:1
presentation of Upper tract transitional cell carcinoma
- Haematuria
- Incidental finding on imaging (US or CT)
- Weight loss
- Back pain
- Loss of appetite/ tiredness/ painful or frequent urination
- Signs and symptoms of obstruction
investigations for TCC
- Abdominal examination and history
- Bloods (FBC, U&Es, CRP, LFTs)
- Urinalysis- protein, blood, bacteria
- Urine cytology
- Ureteroscopy
-
CT scan- CT urogram (test using a CT scan and contrast to look at the urinary system)
- Better than CT KUB
- US
- PET scan- malignancy
- Bone scan
management of upper tract TCC
- Surgery
- Nephroureterectomy
- Segmental resection of the ureter
- Chemotherapies
bladder cancer is most commonly
Most commonly transitional cell carcinoma (90%) or squamous cell carcinoma. Most bladder cancers are superficial with a good prognosis.
bladder cancer risk factors
- Schistosomiases
- Exposure to aniline dyes used in the industrial manufacture of dyes, rubber and plastics
- Smoking
- Male to female ratio is 3:1
main risk factor for squamous cell carcinoma of the bladder
schistosomiasis
think recent travel to africa
presentation of bladder cancer
- Painless haematuria either visible or non-visible
- Recurrent UTIs or LUTS (freq, urgency or feeling of incomplete voiding)
- Locally advanced disease may present with localised symptoms
- Pelvic pain
- Metastatic disease may present with systemic symptoms- weight loss or lethargy
investigation for bladder cancer
- Flexible cystoscopy under local anaesthetic
- If suspicious lesion identified then a rigid cystoscopy will be required (under general)
- Biopsy- Transurethral resection of bladder tumour (TURBT) can be used for diagnosis and resection
imaging
- CT staging
- Urine cytology- to identify cancerous cells in urine- poor sensitivity and specificity
Transurethral Resection of Bladder Tumour (TURBT)
Transurethral Resection of Bladder Tumour (often termed TURBT) involves resection of bladder tissue by diathermy during rigid cystoscopy.
Typically, the procedure is performed under general or regional anaesthesia. The biopsy samples obtain can aid in assessing the stage of the disease.
Depending on the disease, intravesical treatments may be instilled into the bladder following the procedure.
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classification of bladder cancer
- Non-muscle-invasive bladder cancer – does not penetrate into the deeper layers of the bladder wall (around 70-80% cases)
- Muscle-invasive bladder cancer – penetrates into the deeper layers of the bladder wall
- Locally advanced or metastatic bladder cancer – spreading beyond the bladder and distally
staging o d bladder cancer
management of non-muscle invasive bladder cancer
i.e. caricnoma in-situ or T1 tumours
- can typically be resected via TURBT, the mainstay of management.
non-muscle invasive bladder cancer with higher risk of disease (even in non invasive) may require
- TURBT + adjuvant intravesicle therapy
or
- radical cystectomy
adjuvant intravesical therapy in those with non-muscle invasive bladder cancer during TURBT
such as Bacille Calmette-Guerin (BCG) or Mitomycin C
superficial bladder tumours prognosis
- Unfortunately, superficial bladder tumours have a high rate of recurrence, with around 70% recurring within 3 years, and these recurrences are more likely to be more invasive. Consequently, these patients require routine follow-up with regular surveillance via cytology and cystoscopy.
management of muscle-invasive bladder cancer
-
Radical cystectomy- complete removal of the bladder
- Neoadjuvant chemo (cisplatin)
- Following radical cystectomy
- Illeal conduit formation with urine draining via a urostomy
- Bladder reconstruction – from a segment of small bowel (neobladder) and urine draining urethrally or via catheter
- Require regular follow up with CT
management of locally advance or metastatic bladder cancer
- Chemotherapy (cisplatin-based regime)
- Any symptoms of the disease, such as pelvic pain, ongoing bleeding, or urinary frequency, should be also be managed appropriately with specialist advice and input through the MDT. Palliative options should also be discussed with the patient when appropriate.
types of urinary diversion after a radical cystectomy
- Ileal conduit formation with urine draining via a urostomy
- Bladder reconstruction, from a segment of small bowel* (often termed a neobladder) and urine draining urethrally or via catheter
prostate cancer
Most common cancer in men
- Most prostate cancers very slow growing and pt will out live
- Advanced prostate cancer spread to the lymph nodes and bones à poorer prognosis
- Adenocarcinomas that are androgen dependent (e.g. testosterone)
- Grow in the peripheral zone of the prostate
- Cause change in urination late on
risk factors for prostate cancer
- Age
- Fx
- Black African or caribbean origin
- Tall stature
- Anabolic steroids
presentation of prostate cancer
- May be asymptomatic
- LUTs
- Hesitancy
- Frequency
- Weak flow
- Terminal dribble
- Nocturia
- Other symptoms: haematuria
- Symptoms of metastasis
- Weight loss
- Bone pain
- Cauda equina syndrome
investigations for prostate cancer
- DRE
- Prostate specific antigen
- Multiparametric MRI of prostate
- Prostate biopsy
- Isotope bone scan
DRE - prostate cancer
- evidence of asymmetry, nodularity, craggy or fixed irregular mass
- Benign prostate feels smooth, symmetrical and slightly soft, with maintained central sulcus
- Infected- enlarged, tender and warm
prostate specific antigen
Produced by both malignant and normal healthy cells in the prostate gland- not very specific
PSA can be raised due to
- Prostate cancer
- BPH
- Prostatitis
- Vigorous exercise
- Ejaculation
- Recent DRE
screening for prostate cancer
Controversial since may cause distress to patient due to its lack of specificity i.e. just because its raised doesn’t mean its cancer and similarly just because its not raised doesn’t mean its not cancer
False positives may lead to further investigations inc prostate biopsies- may be unnecessary
False negatives lead to false reassurance
grading system for prostate cancer
Gleasons grading system
The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
- The first number is the grade of the most prevalent pattern in the biopsy
- The second number is the grade of the second most prevalent pattern in the biopsy
A Gleason score of:
- 6 is considered low risk
- 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
- 8 or above is deemed to be high risk
The TNM staging system can be used for prostate cancer, rating the T (tumour), N (lymph nodes) and M (metastasis).
investigations for prostate cancer
- Multiparametric MRI
- Prostate biopsy
- isotope bone scan
Multiparametric MRI
of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:
- 1 – very low suspicion
- 2 – low suspicion
- 3 – equivocal
- 4 – probable cancer
- 5 – definite cancer
prostate biopsy
- Transperineal (Template) biopsy – this involves sampling prostatic tissue transperineally in a systematic manner, done as a day case under general anaesthetic. The transperineal approach allows better access to the anterior part of the prostate and also has a lower risk of infection
- TransRectal UltraSound-guided (TRUS) biopsy – this involves sampling the prostate transrectally, usually under local anaesthetic. Generally 12 cores are taken bilaterally in equal distribution from base to apex. Transrectal biopsies are associated with a 1-2% risk of sepsis.
risk of prostate biopsy
- Pain (particularly lower abdominal, rectal or perineal pain)
- Bleeding (blood in the stools, urine or semen)
- Infection
- Urinary retention due to short term swelling of the prostate
- Erectile dysfunction (rare)
isotope bone scan
(radionuclide scan or bone scintigraphy)
- Radioactive isotope given by IV injection, 203 h wait for bone to take up isotope
- Gamma camera used to take pics of entire skeleton
- Metastatic bone lesion take up more of the isotope- stand out on scan
management of prostate cancer
- surveillance in early prostate cance
- radiotherapy
- brachytherapy
- chemotherapy
- hormon therapy
- surgery
prostate cancer radiotherapy
2 types
-
External beam radiotherapy directed at the prostate (radiotherapy)
-
Complications: proctitis – inflammation in the rectum
- Pain
- Altered bowel habits
- Rectal bleeding and discharge
- Prednisolone used to reduce inflammation
-
Complications: proctitis – inflammation in the rectum
-
Brachytherapy (radiotherapy)
- Involves implanting radioactive emtal ‘seeds’ in the prostate
- Targeted, continuous radiotherapy to the prostate
- Complication: radiation to bladder (cystitis) or rectum (prostatitis) and cancer, ED, incontinences
chemotherapy and prostate cancer
- Only indicated in those with metastatic prostate cancer
hormone therapy and prostate cancer
- Aims to reduce testosterone that stimulates cancer to grow
- Sometimes used with radiotherapy
-
Or when cure isnt possible
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
- Bilateral orchidectomy to remove the testicles (rarely used)
side effects of hormonal treatment of prostate cancer
- Hot flushes
- Sexual dysfunction
- Gynaecomastia
- Fatigue
- Osteoporosis
surgery for prostate cancer
-
Radical prostatectomy
- Complications: ED and UI
