Post on 07-May-2015
description
HEMATURIA andCarcinoma Urinary Bladder
Learning Objectives
to enumerate causes of hematuria To enlist positive features on elaborate history
and relevant clinical examination in a case of hematuria and of a bladder tumour
able to suggest and interpret relevant investigations in a case of hematuria and of a bladder tumour
to give justification for and against a diagnosis Classify bladder tumours Enlist steps in management of hematuria & TCC Enlist differents roles an internist has to play in
TCC
Bladder tumours
Primary Urothelial, 95% Con tissue
Angioma, fibroma, myoma, sarcoma Extra adrenal pheochromocytoma
Secondary Sigmoid, rectum, prost, uterus, ovary,
bronchus
Types
Benign papillary tomours Simple frond with villi on vascular core Sea anemone
Inverted papiloma Proliferation under normal mucosa ( covered)
Carcinomas TCC, (mix, metaplasia in TCC) 90 % Squmous cell (bilharzia, stone irritation) 5% Adenocarcinoma, ( urachal remnents, fundus)
2%
Urothelial tumours
TCC Risk factors
Smoking 40% Occupation /exposure to chemicals
Oncogenes ras, c-erb B 1 & 2, E2F3 Suppersor p53, p21, p16, retinoblastoma
genes mettaloproteinases
Clinical features
Hematuria, may not be reported Clot retention LUTS Dysurea ( malignant cystitis)
Pain Pelvic, suprapubic, genital, thigh Advance malignancy, nerve involvement Loin– pyelonephritis, ureteric
obs/hydronephrosis
Hematuria
Gross blood in urine Microscopic 3 to 5 RBCs per HPF Always abnormal =
whether macro, micro, single episode or patient on anticoagulants
3 glass test
Terminal : proximal urethra, baldder neck/trigone,
Initial: distal to ext sphincter,
total : baldder / upper tract
Bleed per urethra
History & exam not sufficent to make diagnosis, so always needs investigations.
Degree bears no relation with severity of disease.
Always take it serious until proved otherwise
Cause may be any where in urinary tract Kidneys ----- Surgical Causes
Congenital – polycystic, PUJ, medullary sponge kidney
Trauma – stone, rupture, runner’s hematuria Inflammation – Nonspecific, TB, Neoplastic – RCC, TCC pelvis, Wilm’s papillary necrosis Vascular / Congestion – AV malformations, RHF,renal
vein thrombosis, Infarction – arterial thrombosis / embolism Medical causes Glomerular disorders – glomerulonephritis, IgA
nephropathy, Benign idiopathic hematuria Lymphoma, multiple myeloma, amiloidosiss
Surgical Causes
Ureters Stones, TCC ureter, VUR, stricture,
Bladder Trauma, stone, catheter trauma Inflammation – cystitis, TB, Bilharzia,
post-radiation cystitis, cyclophosphamide chemo.
Neoplastic – TCC, adeno squaamous Prostate
BPH, CaP, prostititis,
Surgical Causes
Urethra Trauma, rupture, stone, catheter trauma Inflmmation – urethritis Neoplaastic – TCC urethra, penile Ca Atrophic urethritis
Surgical Causes
Miscellaneous Endometriosis Diverticulitis Appendicitis Abdominal aortic aneurysm Foreign body
Surgical Causes
False hematuria food colors / drugs staining red (beet roots, Dindevan, pyridium,furadantin, rifampicin,= differentiation made with microscopy (RBCs)
False +ve dipstick test. hemoblobin, erthrocytes, myoblobin, pigmenturia. DD= microscopy
Factitious = source outside urinary system Vaginal bleeding, malingering
Medical Causes, cause of hematuria may not be in urinary tract but outside it
Systemic disorders Haematological
Bleeding disorders purpura, sickle cell disease, hemophilia, scurvy
therapeutic anticoagulants, Miscellaneous
Malaria, SLE, Henoch Schonlein purpura, hypersensitivity angiitis, bacterial endocarditis, Wegener’s granulomatosis, Good pastures Syndrome
Points in history
Pain – renal, ureteric stone, clot, cysts, hydronephrosis, adv. Tumors, trauma
Trauma, wt. loss, LUTS, dysuria, fever, riger, constitutional symptoms
Pattern of hematuria- gross, micro, partial, total, persistant/continuous, intermittent,
Clots long threadlike, amorphous, fresh, old Smoking, occupaton, travel to schist areas, Rash, joint pain (SLE) URTI-PSGN Purpura, rash, echymosis, easy bruiseability, bleed
from multiple sites Medication – color, anticoagulants Exercise, sepsis, systemic diseases = liver, renal failue Mass, TB
Management Steps
History Presenting complaints with details Direct questions regarding other urinary
symptoms Differential Diagnosis
Direct questions regarding stage of disease
Direct questions regarding systemic illnesses.
Direct questions regarding risk factors
Management Steps
Examination Appearance Vitals GPE Systemic exam
Abdomen ----- DRE Chest
Clinical examination
No physical sign / Anything could be found Disoriented – liver / renal failue Catheter / irrigation / drip / canulla Pain agony – stone, HN, retention Cechhexia, Pulse shock, sepsis BP , normal, shock, high ( HTN, renal failure) Temp infection Resp renal failure, acidosis Purpura, rash, echymosis Pallor / degree, anemia hematuria, renal failure Jaundice, edema, L.nodes Palpable visreras, L,S,K,K,UB,LN, masses, prostate, urethra, testes, epid- vas (TB),
meatus,stricure, retention
Workup
Esteblish hematuria - dipstick
Urine RE/microsscopy-RBCs
Urine CS – infection, doesn’t rule out other causes
flow cytometery
Urinary cytology May be helpful, being noninvasive, but
not established to a point to replace routine workup.
tumour markers-NMP22, BTA Yield varies from study to study &
grade and type lesion
Management Steps
Investigations Base line
urea creatinine Hb
Specific IVU ? Contrast CT Scan/ MRI, local & nodal staging Ultrasound Sophisticated tests timour markers
cystoscopy
Advantages of US
cheap, easy, easily available, noninvasive,
no countraindication, nontoxic, no side eff/reaction
Disadvantages US
good for renal parenchyma but not for pelvicaliceal system and ureter
not very good for bladder, small lesions-miss
Observer dependant, inter and intraobserver variability
Imaging: US findings Kidney: size, echogenicity, cortical
thickness, cysts, mass, hydronephrosis, stone, C/m ratio
Ureter: dilated, stonne, mass, ureterocele
Bladder: stone, wall thickness / smooth, mass, clot, diverticula, capacity, pre- and postvoid volume
Prostste size, echogenicity
IVU
Conventional, NOW CONTROVERTIAL Invasive IV contrast, side eff/ adverse eff – anaphylaxis, toxicity,- drug, radiation)
Very good for pelvicaliceal system and ureter
May not be diagnostic Many would proceed to cystoscopy after USG
leaving IVU
IVU
Demonstrates anatomy –normal / cong
abormalities function
secretion thru kidney, transport thru collecting system, storage in bladder and
evacuation.
IVU
Principle Indications
Stone, hematuria, trauma, congenital abnormalities, mass, assessment of function, obstruction
Preparation Purgation, hydration
Precautions Not during pain, renal status, hydration, clear KUB, allergy
Procedure Test dose, procedure – timings
Side / adverse reactions – management of Contra-indications Interpretation Disadvantages Constrast and other things required
radiation
IVU Findings
Faint mass shadow on plain film,
ROS, Hydronephrosis Wall smoothness filling defect,
mass shadow, Radiolucent stone clot, fungus, FB
Management Steps
Prepare for surgery / aneasthesia
Fitness Co-morbidities ( smoking = IHD, COPD)
Hb. Transfusions
Cloting profile
Cysto-urethro-scopy Visualizes lower tract starting at ext
meatus, leading to bladder.( U, P, BN, ) bladder
capacity, bleeding site, edema/ congestion,ulcer, mass, granuloma, orifices, diverticula, trabeculations, stone,
Biopsy, brushings cytology, Retrograde uro/pyelography / uretero-
renoscopy USG+cystoscopy +/_ RPG may obviate
need for IVU in most but not all cases, in which case a formal IVU or a constrast CT scan is required
Management Steps
EUA, Bimanual examination Cystoscopy, Flexible / Rigid
Inspection Resection, as complete as possible
Superficial biopsy A Deep / base biopsy B Random mucosal biopsies C irrigation
Bimanual examination
Management Steps
Histopathology report should include Type of lesion Type of tumour Grade of tumour (degree of
differentiation) Muscle included / involved
Superficial disease ========= 85% Invasive disease ========= 15%
Random mucosal biopsies ? CIS
Open excision or biopsy
Avoided Up-staging Radiation cauterize
Management Steps
? Further staging Superficial disease not required Invasive disease / CIS
Bone scan CXR LFTs / ultrasound Ct scan abdomen pelvis with double contrast
/ MRI Local invasion, liver, lymph nodes
3 biological behaviral pattrens
Non-muscle invasive (superficial) disease
Muscle invasive disease
Flat noninvasive CIS(primary CIS)
pTa, pT1 pT2+ CIS
70% new cases 25% 5%
Good prognosis Bad, 5 yr survival 50%
Poor unless treated early
Recur 70%, invade 15%
Invade, metastasize Invade, metastasize
Exophytic, papillarySingle, multiple
Solid, large,1 or moreIrregular, ulcerated
Flat, velvety mucosa, angry looking vessels
Pedunculated (stalk) Broad base
Field change +/_ (con CIS)
Lamina propria muscularis Intra epithelial
Comptete resection Persist on Bim Exam
Met death 30-50% 50% deaths mets
Down stage/salvage cyst
Endoscopic + intravesical
Primary surgical treatme
Endo+intrrav+/-surgry
Stage wise treatment Stage Description Traetment
Tis Ca insitu Complete TURBTIntravesical BCG-> repeat-> RC*
Ta Single, low to moderate grade, not recurent
Complete TUR alone
Ta Large, multiple, high grade, recurrent
Complete TUR intravesical chemo- or immunotherapy
T1 Complete TUR-> intravesical chemo- or immunotherapy
T1G3 Complete TUR ->Intavesical BCG
-> repeat ->radical cystectomy
T2 Radical Cystectomy (RC) *
T2-4 RC, Radiation , •Neoadj Radiation -> RC ( salvage)•Neoadj chemo -> RC•RC -> adj chemo•Combined chemo-radio
Any T, N+, M+
•Systemic chemo followed by selective surgery or irrediation
Metastatic disease
Systemic Chemotherapy Radiotherapy Combined chemo-radio
Intravesical Chemo- or Immunotherapy Mytomycin C Thiotepa Doxyrubicin BCG Newer agents
Alpha interferon bropiramine
Systemic Chemotherapy
MVAC (methotraxate, vinblastine, doxyrubicin,
Cisplatin) CMV
(Cisplatin, methotraxate, vinblastine) CISCA
(Cisplatin, doxyrubicin, cyclophosphamide)
New Systemic Chemotherapy Gemcitabine Paclitaxel ifosfamide
Radical Cystectomy
pT2-3, M0N0, CIS Incision Pelvic
Lymphadenectomy Frozen sections Organs Urethractomy diversion
diversions
Incontenant reservoirs Ileal condouit
Contenant reservoirs Ureterosigmoidostomy Orthotopic neobladder Catheterizable stoma pouches
Metrofenof ‘s Indiana struder
Open Procdures / Biopsy
Should never be performed Cauterize Radiotherapy
Radiation
External beam Radiation 5000 –7000 cGy 5 –8 weeks
Local Beads / wires
Management of associated problems Pain Bleed renal failure others
Follow Up
Cystoscopy 3 monthly for 2 years 6 monthly for 3years Yearly upto 10 years Recurrence ===== new cycle
IVU yearly for upper tract
Prognosis
Treatment option wise prognosis
Resident’s Role History & Exam & Investigations Identify active problems n treat
Retention ------ catheter Clots ------- bladder wash , 3 ways foley and
irregation Persistant hematutia ------- ‘alam‘ washes Systemic illnesses medical conslt Metastatic disease problems oncologist
conslt Transfusions donor orgs Fitness for aneasthesia Surgical items donor orgs Pre- and postop care Bowl preparation Stoma counsilling and care Counselling and moral build up Coordination with different consultants
remember
Hematuria, many causes, always abnormal
Antibiotic, not sole treatment of Ultrasound, not good in IVU / cystoscopy, essential in Histopath, details are imp Followup, key to avoid recurence
Hematuria of obscure origin 20% Just explain that investigations that are
usually carried oout have not demonstrated any cause -
Do reassure but Never explain that all is OK, a future investigation may show some cause in evolution or appearing then
Follow up is required Emmergency cystoscope in cases of
active rebleed