Your SlideShare is downloading. ×
Carcinoma urinary bladder
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Carcinoma urinary bladder

3,086

Published on

lecture by Dr. Ahmed Rehman

lecture by Dr. Ahmed Rehman

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,086
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
212
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. HEMATURIA and Carcinoma Urinary Bladder
  • 2.  
  • 3. Learning Objectives
    • to enumerate causes of hematuria
    • To enlist positive features on elaborate history and relevant clinical examination in a case of hematuria and of a bladder tumour
    • able to suggest and interpret relevant investigations in a case of hematuria and of a bladder tumour
    • to give justification for and against a diagnosis
    • Classify bladder tumours
    • Enlist steps in management of hematuria & TCC
    • Enlist differents roles an internist has to play in TCC
  • 4. Bladder tumours
    • Primary
      • Urothelial, 95 %
      • Con tissue
        • Angioma, fibroma, myoma, sarcoma
      • Extra adrenal pheochromocytoma
    • Secondary
      • Sigmoid, rectum, prost, uterus, ovary, bronchus
  • 5. Types
    • Benign papillary tomours
      • Simple frond with villi on vascular core
      • Sea anemone
    • Inverted papiloma
      • Proliferation under normal mucosa ( covered)
    • Carcinomas
      • TCC , (mix, metaplasia in TCC) 90 %
      • Squmous cell (bilharzia, stone irritation) 5%
      • Adenocarcinoma , ( urachal remnents, fundus) 2%
  • 6. Urothelial tumours
    • TCC
      • Risk factors
        • Smoking 40%
        • Occupation /exposure to chemicals
        • Oncogenes ras, c-erb B 1 & 2, E2F3
        • Suppersor p53, p21, p16, retinoblastoma genes
            • mettaloproteinases
  • 7. Clinical features
    • Hematuria , may not be reported
    • Clot retention
    • LUTS
    • Dysurea ( malignant cystitis)
    • Pain
      • Pelvic, suprapubic, genital, thigh
      • Advance malignancy, nerve involvement
      • Loin– pyelonephritis, ureteric obs/hydronephrosis
  • 8. Hematuria
    • Gross blood in urine
    • Microscopic 3 to 5 RBCs per HPF
    • Always abnormal =
      • whether macro,
      • micro,
      • single episode
      • or patient on anticoagulants
  • 9. 3 glass test
    • Terminal : proximal urethra, baldder neck/trigone,
    • Initial: distal to ext sphincter,
    • total : baldder / upper tract
    • Bleed per urethra
  • 10.
    • History & exam not sufficent to make diagnosis, so always needs investigations.
    • Degree bears no relation with severity of disease.
    • Always take it serious until proved otherwise
  • 11. Cause may be any where in urinary tract
    • Kidneys ----- Surgical Causes
      • Congenital – polycystic, PUJ, medullary sponge kidney
      • Trauma – stone, rupture, runner’s hematuria
      • Inflammation – Nonspecific, TB,
      • Neoplastic – RCC, TCC pelvis, Wilm’s
      • papillary necrosis
      • Vascular / Congestion – AV malformations, RHF,renal vein thrombosis,
      • Infarction – arterial thrombosis / embolism
      • Medical causes
      • Glomerular disorders – glomerulonephritis, IgA nephropathy, Benign idiopathic hematuria
      • Lymphoma, multiple myeloma, amiloidosiss
  • 12. Surgical Causes
      • Ureters
        • Stones, TCC ureter, VUR, stricture,
    • Bladder
      • Trauma, stone, catheter trauma
      • Inflammation – cystitis, TB, Bilharzia, post-radiation cystitis, cyclophosphamide chemo.
      • Neoplastic – TCC, adeno squaamous
    • Prostate
      • BPH, CaP, prostititis,
  • 13. Surgical Causes
    • Urethra
      • Trauma, rupture, stone, catheter trauma
      • Inflmmation – urethritis
      • Neoplaastic – TCC urethra, penile Ca
      • Atrophic urethritis
  • 14. Surgical Causes
    • Miscellaneous
      • Endometriosis
      • Diverticulitis
      • Appendicitis
      • Abdominal aortic aneurysm
      • Foreign body
  • 15. Surgical Causes
    • False hematuria food colors / drugs staining red (beet roots, Dindevan, pyridium,furadantin, rifampicin,= differentiation made with microscopy (RBCs)
    • False +ve dipstick test. hemoblobin, erthrocytes, myoblobin, pigmenturia. DD= microscopy
    • Factitious = source outside urinary system
      • Vaginal bleeding, malingering
  • 16. Medical Causes, cause of hematuria may not be in urinary tract but outside it
    • Systemic disorders
      • Haematological
        • Bleeding disorders
          • purpura, sickle cell disease, hemophilia, scurvy
        • therapeutic anticoagulants,
    • Miscellaneous
      • Malaria, SLE, Henoch Schonlein purpura, hypersensitivity angiitis, bacterial endocarditis, Wegener’s granulomatosis, Good pastures Syndrome
  • 17. Points in history
    • Pain – renal, ureteric stone, clot, cysts, hydronephrosis, adv. Tumors, trauma
    • Trauma, wt. loss, LUTS, dysuria, fever, riger, constitutional symptoms
    • Pattern of hematuria- gross, micro, partial, total, persistant/continuous, intermittent,
    • Clots long threadlike, amorphous, fresh, old
    • Smoking, occupaton, travel to schist areas,
    • Rash, joint pain (SLE)
    • URTI-PSGN
    • Purpura, rash, echymosis, easy bruiseability, bleed from multiple sites
    • Medication – color, anticoagulants
    • Exercise, sepsis, systemic diseases = liver, renal failue
    • Mass, TB
  • 18. Management Steps
    • History
      • Presenting complaints with details
      • Direct questions regarding other urinary symptoms
          • Differential Diagnosis
      • Direct questions regarding stage of disease
      • Direct questions regarding systemic illnesses.
      • Direct questions regarding risk factors
  • 19. Management Steps
    • Examination
      • Appearance
      • Vitals
      • GPE
      • Systemic exam
        • Abdomen ----- DRE
        • Chest
  • 20. Clinical examination
    • No physical sign / Anything could be found
    • Disoriented – liver / renal failue
    • Catheter / irrigation / drip / canulla
    • Pain agony – stone, HN, retention
    • Cechhexia,
    • Pulse shock, sepsis
    • BP , normal, shock, high ( HTN, renal failure)
    • Temp infection
    • Resp renal failure, acidosis
    • Purpura, rash, echymosis
    • Pallor / degree, anemia hematuria, renal failure
    • Jaundice, edema, L.nodes
    • Palpable visreras, L,S,K,K,UB,LN, masses,
    • prostate, urethra, testes, epid- vas (TB), meatus,stricure, retention
  • 21. Workup
    • Esteblish hematuria - dipstick
    • Urine RE/microsscopy-RBCs
    • Urine CS – infection, doesn’t rule out other causes
  • 22. flow cytometery
    • Urinary cytology
    • May be helpful, being noninvasive, but not established to a point to replace routine workup.
    • tumour markers- NMP22, BTA
    • Yield varies from study to study & grade and type lesion
  • 23. Management Steps
    • Investigations
      • Base line
        • urea creatinine
        • Hb
      • Specific
        • IVU
        • ? Contrast CT Scan/ MRI, local & nodal staging
        • Ultrasound
        • Sophisticated tests timour markers
        • cystoscopy
  • 24. Advantages of US
    • cheap,
    • easy,
    • easily available,
    • noninvasive,
      • no countraindication,
      • nontoxic,
      • no side eff/reaction
  • 25. Disadvantages US
    • good for renal parenchyma but not for pelvicaliceal system and ureter
    • not very good for bladder, small lesions-miss
    • Observer dependant, inter and intraobserver variability
  • 26. Imaging: US findings
    • Kidney : size, echogenicity, cortical thickness, cysts, mass, hydronephrosis, stone, C/m ratio
    • Ureter : dilated, stonne, mass, ureterocele
    • Bladder : stone, wall thickness / smooth, mass, clot, diverticula, capacity, pre- and postvoid volume
    • Prostste size, echogenicity
  • 27. IVU
    • Conventional, NOW CONTROVERTIAL
    • Invasive
    • IV contrast,
    • side eff/ adverse eff – anaphylaxis, toxicity,-
    • drug,
    • radiation)
    • Very good for pelvicaliceal system and ureter
    • May not be diagnostic
    • Many would proceed to cystoscopy after USG leaving IVU
  • 28. IVU
    • Demonstrates
    • anatomy –normal / cong abormalities
    • function
    • secretion thru kidney,
    • transport thru collecting system,
    • storage in bladder and evacuation.
  • 29. IVU
    • Principle
    • Indications
      • Stone, hematuria, trauma, congenital abnormalities, mass, assessment of function, obstruction
    • Preparation
      • Purgation, hydration
    • Precautions
      • Not during pain, renal status, hydration, clear KUB, allergy
    • Procedure
      • Test dose, procedure – timings
    • Side / adverse reactions – management of
    • Contra-indications
    • Interpretation
    • Disadvantages
    • Constrast and other things required
      • radiation
  • 30. IVU Findings
    • Faint mass shadow on plain film,
    • ROS,
    • Hydronephrosis
    • Wall smoothness
    • filling defect,
      • mass shadow,
      • Radiolucent stone
      • clot, fungus, FB
  • 31. Management Steps
    • Prepare for surgery / aneasthesia
      • Fitness
        • Co-morbidities ( smoking = IHD, COPD)
      • Hb. Transfusions
      • Cloting profile
  • 32.  
  • 33. Cysto-urethro-scopy
    • Visualizes lower tract starting at ext meatus, leading to bladder.( U, P, BN, )
    • bladder
      • capacity, bleeding site, edema/ congestion,ulcer, mass, granuloma, orifices, diverticula, trabeculations, stone,
    • Biopsy , brushings cytology,
    • Retrograde uro/pyelography / uretero-renoscopy
    • USG+cystoscopy +/_ RPG may obviate need for IVU in most but not all cases, in which case a formal IVU or a constrast CT scan is required
  • 34. Management Steps
    • EUA, Bimanual examination
    • Cystoscopy , Flexible / Rigid
      • Inspection
      • Resection, as complete as possible
        • Superficial biopsy A
        • Deep / base biopsy B
        • Random mucosal biopsies C
        • irrigation
      • Bimanual examination
  • 35. Management Steps
    • Histopathology report should include
      • Type of lesion
      • Type of tumour
      • Grade of tumour (degree of differentiation)
      • Muscle included / involved
        • Superficial disease ========= 85%
        • Invasive disease ========= 15%
      • Random mucosal biopsies ? CIS
  • 36. Open excision or biopsy
    • Avoided
    • Up-staging
    • Radiation
    • cauterize
  • 37. Management Steps
      • ? Further staging
        • Superficial disease not required
        • Invasive disease / CIS
          • Bone scan
          • CXR
          • LFTs / ultrasound
          • Ct scan abdomen pelvis with double contrast / MRI
            • Local invasion, liver, lymph nodes
  • 38. 3 biological behaviral pattrens Non-muscle invasive (superficial) disease Muscle invasive disease Flat noninvasive CIS (primary CIS) pTa, pT1 pT2+ CIS 70% new cases 25% 5% Good prognosis Bad, 5 yr survival 50% Poor unless treated early Recur 70%, invade 15% Invade, metastasize Invade, metastasize Exophytic, papillary Single, multiple Solid, large,1 or more Irregular, ulcerated Flat, velvety mucosa, angry looking vessels Pedunculated (stalk) Broad base Field change +/_ (con CIS) Lamina propria muscularis Intra epithelial Comptete resection Persist on Bim Exam Met death 30-50% 50% deaths mets Down stage/salvage cyst Endoscopic + intravesical Primary surgical treatme Endo+intrrav+/-surgry
  • 39. Stage wise treatment Stage Description Traetment Tis Ca insitu Complete TURBT Intravesical BCG-> repeat-> RC* Ta Single, low to moderate grade, not recurent Complete TUR alone Ta Large, multiple, high grade, recurrent Complete TUR intravesical chemo- or immunotherapy T1 Complete TUR-> intravesical chemo- or immunotherapy T1G3 Complete TUR ->Intavesical BCG -> repeat ->radical cystectomy T2
      • Radical Cystectomy (RC) *
    T2-4
      • RC, Radiation ,
    • Neoadj Radiation -> RC ( salvage)
    • Neoadj chemo -> RC
    • RC -> adj chemo
    • Combined chemo-radio
    Any T, N+, M+
    • Systemic chemo followed by selective surgery or irrediation
  • 40. Metastatic disease
    • Systemic Chemotherapy
    • Radiotherapy
    • Combined chemo-radio
  • 41. Intravesical Chemo- or Immunotherapy
    • Mytomycin C
    • Thiotepa
    • Doxyrubicin
    • BCG
    • Newer agents
      • Alpha interferon
      • bropiramine
  • 42. Systemic Chemotherapy
    • MVAC
      • (methotraxate, vinblastine, doxyrubicin, Cisplatin)
    • CMV
      • (Cisplatin, methotraxate, vinblastine)
    • CISCA
      • (Cisplatin, doxyrubicin, cyclophosphamide)
  • 43. New Systemic Chemotherapy
    • Gemcitabine
    • Paclitaxel
    • ifosfamide
  • 44. Radical Cystectomy
    • pT2-3, M0N0, CIS
    • Incision
    • Pelvic Lymphadenectomy
    • Frozen sections
    • Organs
    • Urethractomy
    • diversion
  • 45. diversions
    • Incontenant reservoirs
      • Ileal condouit
    • Contenant reservoirs
      • Ureterosigmoidostomy
      • Orthotopic neobladder
      • Catheterizable stoma pouches
        • Metrofenof ‘s
        • Indiana
        • struder
  • 46. Open Procdures / Biopsy
    • Should never be performed
    • Cauterize
    • Radiotherapy
  • 47. Radiation
    • External beam Radiation
      • 5000 –7000 cGy
      • 5 –8 weeks
    • Local
    • Beads / wires
  • 48. Management of associated problems
    • Pain
    • Bleed
    • renal failure
    • others
  • 49. Follow Up
    • Cystoscopy
      • 3 monthly for 2 years
      • 6 monthly for 3years
      • Yearly upto 10 years
      • Recurrence ===== new cycle
    • IVU yearly for upper tract
  • 50. Prognosis
    • Treatment option wise prognosis
  • 51. Resident’s Role
    • History & Exam & Investigations
    • Identify active problems n treat
      • Retention ------ catheter
      • Clots ------- bladder wash , 3 ways foley and irregation
      • Persistant hematutia ------- ‘alam‘ washes
      • Systemic illnesses medical conslt
      • Metastatic disease problems oncologist conslt
      • Transfusions donor orgs
      • Fitness for aneasthesia
      • Surgical items donor orgs
      • Pre- and postop care
      • Bowl preparation
      • Stoma counsilling and care
      • Counselling and moral build up
      • Coordination with different consultants
  • 52. remember
    • Hematuria, many causes, always abnormal
    • Antibiotic, not sole treatment of
    • Ultrasound, not good in
    • IVU / cystoscopy, essential in
    • Histopath, details are imp
    • Followup, key to avoid recurence
  • 53. Hematuria of obscure origin
    • 20%
    • Just explain that investigations that are usually carried oout have not demonstrated any cause -
    • Do reassure but Never explain that all is OK, a future investigation may show some cause in evolution or appearing then
    • Follow up is required
    • Emmergency cystoscope in cases of active rebleed

×