Urology: Hematuria and Bladder CA Flashcards
What is microscopic hematuria?
Greater than or equal to 3 RBC/hpf in 1 of 3 properly collected urine specimens
*NOT ON DIPSTICK…lots of things can cause + dipstick
What is gross hematuria?
Any episode of visible blood in the urine (you can see it with your eyes)
What is the DDx for hematuria?
PEE PEE ON THIS (with 4 T’s)
P - Period - (menses)
P - Prostate (prostatitis, prostate cancer)
O - Obstructive Uropathy (passing stone, enlarged prostate
N - Nephritis (Inflammed kidney…drugs/viral)
T - Trauma (MVC, fall)
T - Tumor
T - TB
T – Thrombosis (Renal vein)
H – Hematologic(anticoagulation, sickle cell disease)–> Supra therapeutic INR: Bleeding
I – Infection/Inflammation (Rule out UTI)
S - Stones
Is urolthelial carcinoma more common in patients with gross hematuria or microscopic hematuria?
Gross hematuria (23%) is more common than microscopic (5%), but both warrant a workup
What is the most common site of cancer in the urinary stream?
Bladder (but you can’t assume this so work up the upper tract too)
What is the 4th leading cause of cancer death in males?
Bladder
- 60,000 new cases anually
- 13,000 deaths
What do most patients with bladder cancer die from?
Other causes: Older, smoke, heart disease, other comorbidities
What are the 2 categories of bladder cancer?
- Primary
2. Secondary (metastatic to bladder)
Of primary bladder cancer what is the most common kind?
Urothelial carcinoma (UC) -Over 90% of cases in the US
What some of the non-urothelial cancers (primary bladder cancer)?
- Squamous cell carcinoma (SCC)- 5% of US cases
- Adenocarcinoma- 1% of cases in US
- Other: Small cell, rhabdomyosarcoma (most common in children), pheochromocytomas, lymphoma
What are the secondary bladder cancers from most to least common?
- Melanoma
- Colon
- Prostate
- Lung
- Breast
- All of these are RARE
What is the workup for bladder cancer?
- History and physical
- Cystoscopy and biopsy (any suspicious or weird lesions)
- Urine cytology
- Upper tract imaging (CT-urogram or retrograde pyelogram)
- Metastatic work-up
What is included in a metastatic workup?
- Abdominal/pelvis CT/MRI
- LFT (Bladder CA loves the liver)
- CXR (Bladder CA loves the lungs)
- Bone Scan: Recommended in patients with bone pain, elevated Ca, or evelated alkaline phosphatase
When do you do a metastatic workup?
When where is an sign of muscle invasion
What is used for the diagnosis of bladder cancer?
Transurethral resection of bladder tumor (TURBT)
-This is essentially scraping off the tumor from the bladder
What is carcinoma in situ (CIS)?
A urothelial cancer that is flat, high grade, and non-invasive (this is a high grade lesion)
What does CIS appear as?
A velety patch of erythematous urothelium, but may look normal
Who is carcinoma in situ more common in?
Patients with multiple or high grade tumors (ie. multiple lesions in their bladder)
What symptoms does CIS produce?
Irritative voiding symptoms (frequency, urgency, ect.)
What % of patients is urine cytology positive in with CIS and what is this due to?
-Urine cytology + in ~95% of patients with CIS and this is due to poor cohesiveness of the cells
If cytology is positive, but visually the bladder doesn’t look bad, what do you do?
Take random multiple biopsies
What is urine cytology looking at?
The cells the body sheds when you pee
What is the treatment for CIS? (3)
- Transurethral resection of bladder tumor (TURBT)
- Intravesical Therapy
- Radical cystectomy
What is intravesical therapy indicated for?
Stage Ta, T1, or CIS urothelial carcinoma of the bladder (into the lamina propria, but not muscle
What does intravesical therapy do?
Reduces tumor recurrence and progression
Is intravesical therapy effective for stage T2-T4 (muscle invasive or higher) or non-urothelial tumors (rare adenocarcinomas or squamous cell carcinomas)?
NO
When is radical cystectomy used?
Is it the gold standard treatment for non-metastatic, muscle invasive primary bladder UC
Can radical cystectomy be paired with chemotherapy?
Yes, neoadjuvent chemotherapy can be used 6 weeks before surgery and then the radical cystectomy
What is removed in men for a radical cystectomy?
- Bladder
- Pelvic lymph nodes
- Prostate
- Seminal vesicles
What is removed in women for a radical cystectomy?
- Bladder
- Pelvic lymph nodes
- Uterus
- Fallopian tubes
- Ovaries
- Anterior vagina
What is the % of incidental prostate cancer detected in men during radical cystectomy?
28-61%
if their 80, 80% have prostate CA
What % of radical cystectomy specimens are p10 (no CA found) and how is this possible?
10% – TURBT completely excises invasive tumors 10% of the time…the scraper removed CA so none was found in the bladder
What are the 4 options for urinary diversion?
- Ilieal conduit
- Neobladder
- Catheterizable continent diversion
- Ureterosigmoid-ostomy
What is an ilieal conduit?
You hook it up to the ileum to collect urine (so there is no bad over the stoma)
-This is well tolerated
What is a neobladder?
This is better tolerated in a younger patient (not good if they have underlying renal disease)
-The bladder is made from bowel (which can absorb electrolytes and toxins) so the electolytes can get messed up
What is a catheterizable continent diversion?
It is a stoma and catheter… you drain it every 3-4 hours
What is an ureterosigmoid-ostomy?
Void through the rectum…. you need good rectal sphincter tone, but this is associated with increased risk of adeno and colon carcinomas (need to monitor patients)
What are the 4 Cs in analysis of hematuria?
- C&S
- Cytology
- CT Urogram (look at upper tract)
- Cystoscopy (camera in bladder to look)
What is the first thing to do in evaluating hematuria?
H&P
Why must you to a repeat UA after treatment of other causes?
You need to rule out infection
What do you to if red cell morphology or proteinuria is present with hematuria?
Consult a nephrologist (any signs that indicate nephrological cause)
What is done if renal function testing, cystoscopy, and imaging is negative?
Follow up with at least one UA/micro yearly for at least 2 years
If a patient has persistent microscopic hematuria, what do you do?
Annual UA, consider a nephrologic evaluation
-Maybe repeat anatomic evaluation in 3-5 years
If your patient can’t undergo CTU, what are less optimal imaging options?
- MR Urogram
2. Retrograde pyelogram in combination with non-contrast CT, MRI, or US
When should urine cytology be done?
With the 1st urine specimen in the AM (this has the highest cell yield)
What are common RF for UT Malignancy in patients with microhematuria?
- Male
- Over 35
- Past or current smoking ***** (even 2nd hand)
- Occupational or other exposure to chemicals or dyes (benezenes or aromatic amines) (Mentioned leather tanneries, aniline dye)
- Analgesic abuse
- History of gross hematuria
- History of urologic disorder or disease
- History of irritative voiding symptoms
- History of pelvic irradiation
- History of chronic UT infection
- History of exposure to known carginogenic agents or chemotherapy such as alkylating agents
- History of chronic indwelling FB (indwelling catheter)
What were 2 things she verbally mentioned as being RF for UT malignancy in patients with microhematuria?
- Phenacetin abuse
2. Cyclphosphamide: Given with mensa to decrease risk of hemorrhagic cystitis
What is Tis?
Carincoma in situ (this is a high grade lesion)
Is Ta superficial or deep?
Superficial
Describe T1 bladder CA.
-Invades the lamina propria, often requires a re-resection for other CA cells and intravesicular therapy
What are chracteristics of T2 and higher (T3a, T3b, T4)
-Muscle invasive
-Need to remove bladder, uterus, ovaries, fallopian tubes, anterior vagina, seminal vesicles, postate, lymph nodes
-Reattach ureters to pouch
-T2 invades muscular layer
T3A invades perivesical fat
T3B branches out of the perivesical fat
T4 goes to adjacent organs
What is a goal when resecting bladder CA?
Resect lesion with wide margins via endoscope (based on grade/stage this can be curative)
What are the 2 immunomodulatory agents mentioned that are used in intravesical immunotherapy?
- Bacillus Calmette-Guerin (BCG)
2. Interfereons
What is the MOA of BCG?
- Inflammatory host response, release of cytokines
2. May be combined with interferons
What is the MOA of interferons?
- Lymphocyte activation, cytokine release, phagocyte stimulation
- Antiproliferative actions
- Antiangiogenic
What are the 4 chemotherapeutic agents mentions that are used in intravesical chemotherapy?
- Thiotepa
- Mitomycin C
- Doxorubicin, epirubicin, valrubicin
- Gemcitabine
What is the MOA of thiotepa?
Alkylating agent (cross links nucleic acids)
What is the MOA of mitomycin C?
Antibiotic (inhibits DNA synthesis)
What is the MOA of doxorubicin, epirubicin, valrubicin?
Intercalating agents (inhibits DNA synthesis)
What is the MOA of gemcitabine?
Deoxycytidine analog (inhibits DNA synthesis)
