FRCS_TCC - Urology Information Site
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Transcript 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