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

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Presentation on theme: "Haematuria and Urinary Tract Tumours Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital."— Presentation transcript:

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

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

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

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

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

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

7 Investigation of Haematuria n MSU and Urinary Cytology n IVU [KUB and Renal U/S) n Cystoscopy [Flexible Cystoscopy] n 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 n Predominantly TCC (>90%) n SCC shows great variability worldwide –75% of bladder cancers in Egypt –only 1% of bladder cancers in England n Adenocarcinoma - <2% of primary bladder cancers –Primary vesical –Urachal –Metastatic

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

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

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

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

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

14 Investigation n Cytology n IVU n Cystoscopy

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

16 TNM Staging

17 Bladder Cancer n The Good n The Bad n The Ugly

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

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

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

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

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

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

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

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

26 Renal tumours

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

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

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

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

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

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

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

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