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Haematuria and Urinary Tract Tumours

Haematuria and Urinary Tract Tumours. Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital. Haematuria. Macroscopic vs Microscopic Painful vs Painless Initial, terminal, or mixed with urinary stream. Microscopic Haematuria.

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Haematuria and Urinary Tract Tumours

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  1. Haematuria and Urinary Tract Tumours Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital

  2. Haematuria • Macroscopic vs Microscopic • Painful vs Painless • Initial, terminal, or mixed with urinary stream

  3. Microscopic Haematuria • “Excretion of abnormal quantities of erythrocytes in the urine” • Red blood cells identified by colour and shape (Yellow-red / biconcave)

  4. Dipstick testing for haematuria • Hb from red cells catalyses conversion of indicator by peroxide • Test detects intact RBC’s, free Hb, and myoglobin • Oxidising agents - false positives • Reducing agents - false negatives

  5. Dipstick testing for haematuria • Dipsticks not sensitive for screening (miss 10% of patients with microscopic haematuria) • Best accomplished by microscopy of freshly voided, concentrated urine sample • > 3 RBC’s / hpf in a centrifuged specimen considered abnormal

  6. Nephrologic vs Urologic haematuria • Look for casts and protein • Haematuria associated with ++ or +++ proteinuria should always be assumed to be of glomerular or interstitial origin • Most common glomerular causes of haematuria are • IgA Nephropathy • Mesangioproliferative GN • Focal segmental proliferative GN

  7. Investigation of Haematuria • MSU and Urinary Cytology • IVU [KUB and Renal U/S) • Cystoscopy [Flexible Cystoscopy] • Always do a DRE! • 21% have a malignancy • 10% have bladder cancer (99% TCC) • 10% have Ca Prostate

  8. Urothelial tumours of the Urinary Tract • Predominantly TCC (>90%) • SCC shows great variability worldwide • 75% of bladder cancers in Egypt • only 1% of bladder cancers in England • Adenocarcinoma - <2% of primary bladder cancers • Primary vesical • Urachal • Metastatic

  9. Epidemiology - Incidence • Bladder most common site • 47000 new cases in U.S. in 1990 • M:F 2.7:1 • Men - 4th most common cancer (Prostate, lung, colorectal - 10% of all) • Women - 8th most common cancer (4% of all) • Median age of diagnosis 67-70 yrs

  10. Epidemiology - Mortality • 10200 bladder cancer deaths in U.S. in 1990 • Accounts for 5% of all cancer deaths in men, and 3% in women • Mortality rates in Whites similar to Blacks • Younger patients have more favourable prognosis (present with lower grade) but risk of disease progression is the same grade-for-grade

  11. Aetiology • Occupational Exposure to chemicals • Cigarette smoking • Analgesics • Artificial sweeteners • Bacterial / Parasitic infections • Bladder calculi • Pelvic irradiation • Cytotoxic chemotherapy

  12. Theory of Carcinogenesis • Oncogenes • Deletion or inactivation of Supressor genes • Amplification of expression of gene products

  13. Clinical presentation • Painless haematuria (85% of patients) • “bladder irritation” (frequency, urgency, dysuria) - often associated with diffuse Cis or invasive cancer • Flank pain (ureteric obstruction) • Pelvic mass

  14. Investigation • Cytology • IVU • Cystoscopy

  15. Cystoscopic appearance of TCC • Carcinoma in situ • Papillary (70%) • Nodular (10%) • Mixed (20%)

  16. TNM Staging

  17. Bladder Cancer • The Good • The Bad • The Ugly

  18. The Good • T0/T1 superficial / exophytic papillary TCC • 70% 5 year survival • 15% Transformation each 10 years • Surveillance cystoscopy - more about spotting change than treatment

  19. The Good... • Initial, low-grade, small tumours low risk of progression - TUR followed by surveillance • T1, multiple, large, recurrent tumours, or Cis in random biopsy - consider intravesical chemotherapy • T1 G3 - high rate of progression - consider cystectomy

  20. The Bad • Any Invasive TCC • 25-30% 3 year survival • No real advance in 50 years • T2 / T3 - partial or radical cystectomy, radiotherapy, or combination of both • T4 - Chemotherapy, followed by radiation or surgery

  21. The Ugly • Diffuse Cis, overtly Malignant • 78% risk of invasion • Intravesical chemotherapy preferred primary treatment for Cis - treatment effective in 30%. Intravesical BCG produces complete regression in 50-65% of patients • Radiotherapy and chemotherapy ineffective

  22. Tumours of the renal pelvis and ureter • 2-4% of patients with bladder cancer • [30-75% patients with upper tract tumours will develop bladder TCC] • Pelvic tumours • 5-10% all renal tumours • 5% all urothelial tumours

  23. Tumours of the renal pelvis and ureter • Ureteric tumours 1-2% all urothelial tumours • Rare before 40 yrs, peak incidence 60-70 • Bilateral involvement 2-5% • Association with Balkan nephropathy • Other aetiological factors similar to Bladder TCC

  24. Diagnosis of Upper tract tumours • Usually seen as a filling defect on IVU or retrograde • Cystoscopy mandatory to rule out coexisting bladder tumour • Cytology less helpful as may be normal in low grade tumours

  25. Treatment of upper tract tumours • Renal pelvis - Nephroureterectomy with excision of cuff of bladder • Upper/mid ureter • Segmental resection if solitary or low grade • Nephroureterectomy if multifocal or high grade • Lower ureter - distal ureterectomy and reimplantation

  26. Renal tumours

  27. Benign Renal tumours • Cysts account for 70% asymptomatic renal masses • Cortical adenoma • Oncocytoma • Angiomyolipoma (80% assoc with tuberous sclerosis)

  28. Renal cell carcinoma • 3% adult cancers • M:F 2:1 • High incidence of carcinoma in patients with von Hippel Lindau disease • No specific causative agent detected

  29. Presentation • Classic triad of pain, haematuria, and flank mass (rare) • More commonly just pain and haematuria • Symptoms of metastatic disease • Paraneoplastic syndromes

  30. Investigation • Ultrasound - distinguish solid from cystic mass • CT - Staging, prior to surgery • MRI - less sensitive than CT for lesions less than 3cm • Angiography - tumour in solitary kidney if partial nephrectomy considered

  31. Treatment • Radical nephrectomy remains only effective method of treating primary renal carcinoma • 5 year survival • 60-82% Stage I • 47-80% Stage II • 35-51% Stage III • Survival increased by pre-op radiotherapy in some studies

  32. Tumour in solitary kidney / bilateral tumours • Partial nephrectomy gives excellent short term results (72% tumour free survival at 3 yrs) • Survival independent of whether tumour present in other kidney • Survival dependent on stage of local tumour

  33. Treatment of metastatic disease • Chemotherapy • Hormonal therapy • Immunotherapy • “adjunctive” nephrectomy

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