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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