The Royal Marsden

MDT case study

Mr Alan Thompson Consultant Urological Surgeon The Royal Marsden

The Royal Marsden

Case history

– 56 year old lady from Bangladesh with 5 children

– Rarely seen her GP over the last 10 years

– Complains of increasing urinary frequency, nocturia and malaise

– Slight weight loss – 1Kg

– On statins and antihypertensives but otherwise well

2

The Royal Marsden

Q1. What are you thinking?

1. I need more information

2. I need to examine her and do some tests

3. This sounds serious

4. You are just getting old!

I need m

ore in

form

ation

I need to

exa

min

e her a

n...

This so

unds serio

us

You are ju

st ge

tting o

ld!

29%

0%3%

68%

The Royal Marsden

Q 2. What are the possible diagnoses for this patient?

1. Diabetes

2. Renal stone disease

3. Lifestyle – fluid intake / 5 children

4. UTI

5. Interstitial cystistis

6. Tuberculosis

7. STD

8. All of the above

Diabete

s

Renal sto

ne dise

ase

Lifest

yle –

fluid

inta

ke / 5... UTI

Inte

rstit

ial cy

stist

is

Tuberculo

sis STD

All of t

he above

3% 4%1%

80%

0%1%3%8%

The Royal Marsden

The following history and investigations were obtained

− No history of recent travel

− No history of exposure to TB

− There may be some associated night sweats but she is a poor historian

− Abdominal examination is unremarkable

− Urine dip test negative for glucose

− Urine positive for nitrites, protein and haem

5

The Royal Marsden

Q3. What is the possible diagnosis for this patient now?

1. Diabetes

2. Renal stone disease

3. Lifestyle – fluid intake / 5 children

4. UTI

5. Interstitial cystistis

6. Tuberculosis

7. STD

8. All of the above Diabete

s

Renal sto

ne dise

ase

Lifest

yle –

fluid

inta

ke / 5... UTI

Inte

rstit

ial cy

stist

is

Tuberculo

sis STD

All of t

he above

1%

7%

0%

20%

0%3%

8%

62%

The Royal Marsden

Q 4. What would you do next?

1. Send off MSU and wait for the results

2. Treat empirically

3. Send MSU, treat empirically and re-assess after MSU back

4. Refer to Urologist

5. Refer on two week rule

Send off

MSU

and wait

fo...

Treat e

mpiri

cally

Send MSU, t

reat e

mpiri

ca...

Refer t

o Uro

logis

t

Refer o

n two w

eek rule

8%12%

0%1%

79%

The Royal Marsden

Q 5. 5 weeks later she returns with the same symptoms. What is the likely diagnosis?

1. Diabetes

2. Renal stone disease

3. Lifestyle – fluid intake / 5 children

4. Recurrent UTI’s

5. Interstitial cystistis

6. Tuberculosis

7. All of the above Dia

betes

Renal sto

ne dise

ase

Lifest

yle –

fluid

inta

ke / 5...

Recurr

ent UTI’s

Inte

rstit

ial cy

stist

is

Tuberculo

sis

All of t

he above

1%4%

1%

28%

4%6%

55%

The Royal Marsden

What actually happened

– GP performed sent off MSU on this occasion and treated with appropriate antibiotic

– Symptoms recurred after 3 months

– Symptoms recurred again after 4 months

– Referred to Urologist

9

The Royal Marsden

Discussion point – What is a recurrent UTI?

– Episode of UTI after a documented UTI with successful resolution of an earlier episode + occurring 2x in last 6 months or 3x in last 12 months. Subclassified into:

– Persistent infection – UTI caused by the same organisms.

– Poss focus of infection e.g. stone/TCC/diverticulum/fistula

– Reinfection – UTI caused by different organisms. Usually indicates susceptibility to UTI

– Post menopause/sexual intercourse/poor hygiene/genetic

– 95% recurrent UTI’s in a female are due to re-infection

10

The Royal Marsden

In the urology clinic – History – rec UTI?/pyelonephritis/STD/complicated

infection

– MSU results checked – is there a non-infective process e.g. stones, interstitial cystitis, cis (carcinoma in situ)

– PMH – including constipation, childhood UTI, neurological illness, diabetes

– Pregnant?

– On OCP

– Family history – UTI’s associated with ABO blood group antigen non-secretors, Lewis non-secretor or P blood group secretors

- Examination – Including vaginal to ascertain oestrogenisation, genital prolapse, urethral diverticulum

11

The Royal Marsden

Investigations

– MSU

– Cytology

– If sterile pyuria – AFB

– CT urogram or KUB/USS residual

– Possibly flexible cystoscopy

12

The Royal Marsden

Q 6. She has been found to have recurrent UTI’s. What are your favoured treatment strategies?

1. Lifestyle changes

2. Lactobacilli topically

3. Oestrogen pessaries/cream

4. Antimicrobial therapy – Low dose long-term

5. Antimicrobial therapy – Post coitus

6. Antimicrobial therapy – Intermittent self-start

Lifest

yle ch

anges

Lact

obacilli t

opically

Oestro

gen pess

aries/

cream

Antimicr

obial t

herapy –...

Antimicr

obial t

herapy – ..

.

Antimicr

obial t

herapy – I.

..

11%

0%

8%3%

54%

24%

The Royal Marsden

Case history

− 65 year old man from Bangladesh – wife known to you

− Rarely seen his GP over the last 10 years

− Epigastric discomfort, pain occasionally intense but vague

− Slight weight loss – 2.5 Kg over 2 months

− On statins and antihypertensives but otherwise well

14

The Royal Marsden

What are you thinking?

1. I need more information

2. I need to examine him and do some tests

3. This sounds serious

4. You are just getting old!

I need m

ore in

form

ation

I need to

exa

min

e him

...

This so

unds serio

us

You are ju

st ge

tting o

ld!

15%

0%

17%

68%

The Royal Marsden

Examination and investigation

− Examination reveals slight tenderness in right upper quadrant

− You arrange an USS

− This reveals gall stones but also a large right renal cyst

− What next?

The Royal Marsden

Q 2. What next?

1. Dietary advice and re-assure?

2. Refer to Upper GI surgeon and ignore cyst?

3. Refer to Urologist and ignore gall stones?

4. Refer to both?

Dieta

ry advic

e and re

-ass

...

Refer t

o Upper G

I surg

eo...

Refer t

o Uro

logis

t and ig

...

Refer t

o both

?

3%

57%

24%

16%

The Royal Marsden

Differential diagnosis of the cystic renal lesions

– Simple renal cysts

– Cystic renal-cell carcinoma

– Autosomal dominant polycystic kidney disease

– Multicystic dysplastic kidney disease

– Multilocular cyst

– VHL syndrome

18

The Royal Marsden

In Urological clinic

– History etc

– Confirmation of normal renal function

– CT urogram – pre and post contrast

– Bosniak cyst classification – I-IV

– I – benign and smooth with no enhancement/septae

– II – thin septae + minimal Ca. No enhancement

– III – Irregular/mod Ca/thick septae/enhancement

– IV – Solid enhancing elements

19

The Royal Marsden

Bosniak and clinical management

– Type I – benign and require no follow-up

– Type II – 10 to 20% risk malignant transformation (IIF)

– Type III – 40-50% chance malignancy therefore operate

– Type IV - > 90% malignant therefore operate

The Royal Marsden

Q 3. Above patient presented with haematuria and CT revealed a fatty lesion in the kidney. Diagnosis?

1. Renal cell carcinoma

2. Lipoma

3. Cyst

4. AML - Angiomyolipoma

Renal cell c

arcin

oma

Lipom

aCyst

AML -

Angio

myolip

oma

31%

54%

1%

13%

The Royal Marsden

Angiomyolipoma - AML

– 80% sporadic. Female : Male ratio is 4:1 (rest tuberous sclerosis)

– Middle aged

– 80% right sided

– 5 % growth rate per year

– 4cm diameter or recurrent bleeding is indication for intervention (selective embolisation or partial neph)

– Tuberous sclerosis – bilateral, smaller and younger – 20% growth per year

22