Lecture on haematuria & urinary tract malignancy for medical students. Encompasses basic sciences, classification,staging and principles of management. Specifically on renal and bladder carcinoma.

1. Haematuria & Urinary Tract
Malignancy
Chea Chan Hooi
Surgeon
Sibu Hospital

2. Content
• Definition
• Classification
• Etiology
• Clinical features
• Investigations
• Principles of management

3. Definition
• Haematuria = presence of blood in urine
• 40% have significant pathology, about ½ will
be urological malignancy
• All patients with haematuria must be
investigated further

4. Classification
• Macroscopic haematuria
– Alarming symptom
– Initial, terminal or through out
• Microscopic haematuria
– ≥5 RBC/HPF detected upon microscopy of centrifuged sediments of
macroscopically clear urine
– > 48 hours after strenuous exercise
– Glomerular vs. non-glomerular origin
• Dipstick haematuria
– Use of reagent strip to detect peroxidase in urine
– False positive
• Haemoglobinuria, myoglobinuria, oxidising agents, menstruation
– False negative
• High vitamin C intake, nitrite

5. Etiology
• Infection
• Neoplasm
• Degenerative
• Inflammatory
• Congenital
• Autoimmune
• Trauma
• Iatrogenic
• Vascular
• Endocrine

7. History taking – salient features
Feature Reasoning
Age Young – intrinsic renal pathology
Older – malignancy
Gender Male – malignancy
Female – infection
Occupation Dye or rubber industries
Social Cigarette
Drugs Anti-platelets, anti-coagulants, cyclophosphamide
Family history Stone, malignancy, PCKD
Misc Pelvic irradiation

8. Feature Reasoning
Classification Dipstick, micro or macro
Other symptoms Pain, dysuria
LUTS
Microscopic Hypertension
Macroscopic Intermittent, painless
Initial – urethra
Terminal – bladder neck, prostate
Thru out – bladder & proximal
Clots Significant bleed
Acute retention

9. Physical examination
• Periorbital edema
• Pallor
• Rashes, arthritis
• Abdominal mass
• External genitalia

10. Investigations
• Urine
– Dipstick, FEME, C&S, cytology
• Blood
– FBC, BUSEC
• Imaging
– KUB radiograph
– IVU
– USG KUB
– CTU
– CT abdomen
• Endoscopy
– Flexible cystoscopy
– Ureterorenoscopy

11. Renal cell carcinoma

12. Introduction
• Majority 40 – 60y/o
• M : F 2 – 3 : 1
• Risk factors
– Aging, smoking, occupational exposure (heavy
metal, asbestos), obesity, long-term ESRF on
dialysis
– Genetic (p53, vHL genes), PCKD

13. • Potentially deadly cancer
• Characterised by
– A lack of early warning signs
– Diverse clinical manifestations
– Resistance to radiation and chemotherapy
– Infrequent but reproducible response to
immunotherapy agents (e.g. interferon-α,
interleukin-2)

14. Presentation
• Classical triad (10%)
– Flank pain, gross haematuria & abdominal mass
• IVC infiltration
• Left varicocele (2%)
• Metastatic symptoms (30%)
– Liver, lung & bone
• Paraneoplastic syndrome (20 – 30%)
– AKA physicians’ tumour
• Incidental – 50%
• Synchronous contralateral tumour (5%)

15. Paraneoplastic syndromes

16. Investigations
• Confirm diagnosis
– KUB x-ray
• The simplest, therefore first line
• Associated stone
– USG KUB
• The standard routine investigation
– CECT abdomen with excretory phase
• Tumour size, location, invasion of Gerota fascia
• Extension into vein & IVC
• Abdominal metastases – liver, paraaortic nodes
• Concurrent ureteric tumour, contralateral tumour, presence of contralateral kidney
• Stage disease
– CECT thorax
– Bone scan
• Especially in patients with hypercalcaemia
• Assess for surgery
– Blood – FBC, BUSEC, LFT, PT/PTT, GSH
– Imaging – angiography (NSS)

20. Treatment options
• Surgery
– Radical nephrectomy
• Removal of the Gerota fascia and its contents (kidney, perirenal fat
&adrenal)
– Nephron-sparring nephrectomy
• AKA partial nephrectomy, kidney-sparring nephrectomy
• <7cm, at kidney poles, exophytic
• Indications
– Syncronous bilateral tumours, single functioning kidney with tumour, poorly
functioning contralateral kidney, vHL syndrome
– Modes of nephrectomy
• Open
– Transabdominal approach
– Flank approach
– Thoracoabdominal approach
• Laparoscopic
– Conventional
– Robotic-assisted

22. • Targeted therapy
– Multikinase inhibitors – sunitinib, sorafenib
– mTOR inhibitors – everolimus, temsirolimus
– Anti-VEGFs – bevacizumab
• Immunotherapy
– Interferons, interleukins
– Relatively more adverse effects
• Chemotherapy
– Gemcitabine + fluorouracil
– Relatively poor response

23. Bladder carcinoma

24. Incidence
High incidence regions: Egypt, Western Europe & North America

25. • 7 – 8th decade
• Male
• UKM study:
• 2.9 per 100,000
• Chinese 56.6%, Malay 34.9%, Indian 6%
• Male : female 9.4 : 1

26. Histology
• Transitional cell carcinoma (90%)
– WHO grading – urothelial papilloma, PUNLMP, low &
high grade papillary urothelial ca
• Squamous cell carcinoma (8%)
– Chronic irritation
• Adenocarcinoma (1%)
– Chronic infection, bladder extrophy, urachal remnant
• Others (1%)
– Small cell ca, sarcoma, melanoma, NET, lymphoma

27. Risk factor
• Aging
• Male
• Cigarette
– 4-aminobiphenyl and 2-naphthylamine
• Iatrogenic
– Pelvic radiotherapy
– Cyclophosphamide
• Occupational exposure
– Aromatic hydrocarbons like aniline
– Rubber manufacturers
– Paint and dye
– Gas and tar manufacture
– Iron and aluminium processing
– Hairdressers
– Leather , plumbers, painters, drivers exposed to diesel exhaust
• Chronic inflammation of bladder
– Stones, long term catheter, Schistosoma haematobium

28. Symptoms
• Painless hematuria
– 80% gross
– 20% solely microscopic
– 30% dysuria and irritative symptoms
• Irritative symptoms  CIS or invasive bladder cancer
– 10% symptoms of metastasis
– Advanced disease
• Upper tract obstruction
• Abdominal mass
• Lower limb edema

29. Examination
• Ballotable kidney
• Lower abdominal mass
• Bimanual examination
• Lower limb lymphoedema
• Virchow’s node
• Metastatic signs

30. Investigations
• USG KUB
– Evaluate upper tract
– Bladder mass
– TRO other cause of lower abdominal pain, esp. women
• CECT scan thorax, abdomen & pelvis
– Staging
– Extra vesical extension (T), nodal involvement (N), distant
mets (M)
– Thickened bladder wall  muscle invasion
– To accurately assess the depth of penetration, CT should
be done before TUR

32. • Cystoscopy
– Gold standard
– Flexible scope under local anaesthesia
• Document location , size, numbers, appearance
• Papillary TCC
– Exophytic frond lesion
– Commonest type of TCC
– Small and non invasive
• Sessile TCC
– Broad base
– Solid lesion
– > tendency to be invasive
– Rigid
• Transurethral resection of bladder tumour (TURBT)
• + intravesicle mitomycin x1
– Destroy circulating intraluminal tumour cells
– Ablate tumour cells on resection bed (chemoresection)
– Reduces recurrence rates up to 13% vs. TURBT alone

34. Presentation
• Haematuria
• Mass in bladder seen in imaging
Investigation
• TURBT + intravesicle mitomycin x1
• Review HPE
Further
management
• Decide either for 2nd look, BCG treatment or
surveillance cystoscopy
• Cystectomy if muscle invasive bladder ca

35. Treatment options
• Cystectomy
– Radical
• Resection specimen differs by gender
– Males – bladder, distal ureters, prostate, seminal vesicles & regional LNs
– Females – bladder, distal ureters, urethra, uterus, vagina & regional LNs
• Urinary diversion needed
– Ileal conduit, continent cutaneous reservoir, orthotopic neobladder
– Partial
• Full-thickness surgical removal of bladder tumour and surrounding
bladder wall
• Solitary, non-trigonal tumour with surrounding 1 – 2cm wall
excisable to give adequate bladder remnant capacity

37. Urinary diversion

39. TQ!
Q&A?