Download FRCS_TCC - Urology Information Site

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
“Excretion of abnormal quantities of
erythrocytes in the urine”
 Red blood cells identified by colour and
shape (Yellow-red / biconcave)

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

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

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
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
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
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

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-forgrade
Aetiology








Occupational Exposure to chemicals
Cigarette smoking
Analgesics
Artificial sweeteners
Bacterial / Parasitic infections
Bladder calculi
Pelvic irradiation
Cytotoxic chemotherapy
Theory of Carcinogenesis
Oncogenes
 Deletion or inactivation of Supressor
genes
 Amplification of expression of gene
products

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

Investigation
Cytology
 IVU
 Cystoscopy

Cystoscopic appearance of
TCC
Carcinoma in situ
 Papillary (70%)
 Nodular (10%)
 Mixed (20%)

TNM Staging
Bladder Cancer



The Good
The Bad
The Ugly
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

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

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

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 5065% of patients
 Radiotherapy and chemotherapy
ineffective

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
Tumours of the renal pelvis
and ureter
Ureteric tumours 1-2% all urothelial
tumours
 Rare before 40 yrs, peak incidence 6070
 Bilateral involvement 2-5%
 Association with Balkan nephropathy
 Other aetiological factors similar to
Bladder TCC

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

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
Renal tumours
Benign Renal tumours
Cysts account for 70% asymptomatic
renal masses
 Cortical adenoma
 Oncocytoma
 Angiomyolipoma (80% assoc with
tuberous sclerosis)

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

Presentation
Classic triad of pain, haematuria, and
flank mass (rare)
 More commonly just pain and
haematuria
 Symptoms of metastatic disease
 Paraneoplastic syndromes

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

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
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

Treatment of metastatic
disease
Chemotherapy
 Hormonal therapy
 Immunotherapy
 “adjunctive” nephrectomy
