Urinalysis Urothelial Tumor Markers Serum PSA Testicular tumor markers

1. 1
UROLOGICAL LABORATORY
INVESTIGATIONS
DR MUSAB UMAIR KHALID
Armed Forces Institute of Urology, Rawalpindi.
1

2. 2
Macroscopic & microscopic
examination of urine.03 Indications for checking serum
PSA09
Specimen collection and transport02 Normal PSA and PSA range08
01 Urinalysis and types of urine samples. Prostate Specific antigen (PSA)07
Biochemical examination of urine04 Management of patient with elevated
PSA.10
Urothelial Cancer tests05 Role of testicular tumors
markers.11
Sensitivity and Specificity of Urine
Cytology06 Prognostic Importance and
response to therapy.12
Table of Contents

3. 3
WHAT IS URINE ANALYSIS ?
Analysis of urine by physical and chemical means to test for the presence
of disease and drugs.
01
It is the oldest laboratory procedures in the practice of
medicine.
02
Also known as urine routine and microscopy.
03

4. 4
WHY URINALYSIS ?
Monitoring of
patient with
diabetes
Diagnosis of disease
or disorders of
urinary tract.
General evaluation
of health.
Diagnosis of other
systemic disease that
affect kidney functions.
Screening for
drug abuse.
01
02
03
04
05

5. 5
Sample Type Sampling Purpose
Random Specimen Most common, taken anytime of
the day.
Routine Screening
Morning Sample First urine in the morning,
usually concentrated.
Pregnancy test.
Clean catch midstream Discard first few ml, collect the
rest.
Culture.
24 hours All the urine passed in 24 hours
is collected.
Used for quantitative and
qualitative assessment.
Post-prandial 2 hours after meal Glucose monitoring in diabetics
Suprapubic aspired Needle aspiration Obtaining sterile urine.
TYPES OF URINE SAMPLE

6. 6
SPECIMEN COLLECTION & TRANSPORT
Midstream Specimen Of Urine
The typically acidic and concentrated early morning urine (EMU) samples
are more likely to detect a urinary tract infections (UTI).
01
Overnight bacterial proliferation and RBC’s , WBC’s and casts are
best preserved in such a medium.
02
Collect a midstream sample without stopping urine flow.
03

7. 7
SPECIMEN COLLECTION & TRANSPORT
Suprapubic Aspiration Of Urine
Gold standard technique for the diagnosis of UTI.
01
Indicated in patient with an equivocal result from MSU.
02
Best achieved with a spinal needle under ultrasound guidance.
03

8. 8
SPECIMEN COLLECTION & TRANSPORT
Fractionated Urine Samples
Voided Bladder 1 (VB1) – first 5-10 ml of voided urine represents urethral flora.
01
Voided Bladder 2 (VB 2) – midstream urine correlates with bladder urine.
02
Voided Bladder 3 (VB 3) – After prostatic massage , initial 2-3 ml of urine
containing expressed prostatic secretions (EPS).
03
Used in different clinical conditions (Prostatitis, urethritis) for diagnostic purposes.

9. 9
SPECIMEN COLLECTION & TRANSPORT
Fractionated Urine Samples
A bacterial count greater than 10 times in VB3 compared to VB1 or VB2
is diagnostic of prostatitis.
01
A leucocyte count >10 per high-power field in VB3 compared to
VB1 0r VB2 is diagnostic of prostatitis.
02
An EPS or VB3 pH of >8 is suggestive of prostatitis.
03
04
A high bacterial count in VB1 compared to VB3 is diagnostic of urethritis.

10. 10
Urine From Indwelling Catheters
SPECIMEN COLLECTION & TRANSPORT
A urine sample should only be sent if a UTI is suspected in a systemically unwell patient.
Bladder colonization is inevitable and can occur within 4 days.
A positive bacterial growth does not necessarily suggest a significant UTI.
Unnecessary treatment may result in the emergence of antibiotic-resistant organisms.
Antibiotic therapy is unlikely to eradicate the targeted pathogens while the patient remains
catheterized.
01
02
03
04
05

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SPECIMEN COLLECTION & TRANSPORT
Urine From Ileal Conduit
Skin organism contamination is inevitable in patients with urinary
diversions.
01
Urine collection should be via a catheter introduced as far into
the conduit as it will go.
02

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SPECIMEN COLLECTION & TRANSPORT
Transport
Specimen must reach laboratory within 2 hours.
01
If delay is encountered store at a temperature of 4 C.
02
Refrigeration can result in decreased number of urinary leucocytes.
03

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URINALYSIS ; WHAT TO LOOK FOR?
Macroscopic or physical measurement
01
Microscopic examination of sediment
02
Biochemical Analysis
03
It consist of following measurements

14. 14
MACROSCOPIC EXAMINATION OF
URINE
Volume
Color
Odor
01
02
03

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MACROSCOPIC EXAMINATION OF URINE - VOLUME
NORMAL VOLUME 1-1.5 L/DAY
Oliguria: <400ml/day
1. Dehydration
2. Shock
3. Acute Glomerulonephritis
4. Renal Failure
Polyuria: >2.5 L/day
1. Increased Water Intake
2. Diabetes Mellitus
3. Diabetes Insipidus
Anuria: Absence/ <100ml/day
1. Acute Renal Failure

16. 16
04
MACROSCOPIC EXAMINATION OF URINE - COLOR
Normal- pale yellow in color due to pigments urochrome, urobilin and
uroerythrin.
01
Color of urine depend upon it’s constituents
02
Colorless – diabetes, diuretics.
03
Deep Yellow – concentrated urine, excess bile pigments, jaundice.

17. 17
Blue / Green Orange / Red Red / Brown / Black
Methylene Blue Rifampicin Hemoglobin
Pseudomonas Porphyrins Myoglobin
Riboflavin Phenolphthalein Methyldopa
Hemoglobin L-dopa
Myoglobin Melanin
MACROSCOPIC EXAMINATION OF URINE - COLOR

18. 18
MACROSCOPIC EXAMINATION OF URINE - ODOR
Normal - aromatic due to the volatile fatty acids.
On long standing – ammoniac (decomposition of urea forming
ammonia).
01
Foul, offensive - pus or inflammation
02
Sweet – Diabetes.
03
04
Fruity - Ketonuria

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MICROSCOPIC EXAMINATION OF
URINE
A variety of normal and abnormal cellular
elements may be seen in urine sediment such as:
Red blood cells
White blood cells
Renal Tubular Casts
Squamous Cells
01
02
03
04
05 Epithelial Cells

20. 20
MICROSCOPIC EXAMINATION OF URINE

21. 21
False Positive False Negative
Urine Contamination Poorly mixed urine
Dehydration High doses of Vit C.
Excercise
MICROSCOPIC EXAMINATION OF URINE
Hematuria
It is the presence of abnormal numbers (>3 RBCs/HPF) in urine.
Detection of blood is due to peroxidase like activity of hemoglobin.
01
02

22. 22
MICROSCOPIC EXAMINATION OF URINE
Features indicative of True UTI include
 Pyuria (>10WBC/HPF)
 Significant bacteruria (>10cfu/ml suprapubic
aspiration or >104 cfu/ml from MSU).
 Symptomatic patient.
 Single isolated organism.
 Repeat cultures identifies same organism.
Leucocytes (WBCS)
Pyuria refers to the presence of abnormal
numbers of WBC (>10 WBC/HPF) that may
appear with infection in the urinary tract.
Found in UTI , active proliferative
glomerulonephritis, acute or chronic
interstitial nephritis, and urological disorders.
01
02

23. 23
These come from the urothelium, lining the urinary excretory tract from the
calyces to the bladder in the female and to the proximal urethra in the male.
Urothelial Cells
MICROSCOPIC EXAMINATION OF URINE
Squamous Cells
They are the largest cells found in the urine, with a mean diameter
of about 55 μm.
01
They are found routinely in small numbers, being
exfoliated from the urethra.
02
When found in large numbers, they indicate contamination of urine from
vaginal discharge.
03

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MICROSCOPIC EXAMINATION OF URINE
Casts are elongated elements with a basic cylindrical shape.
Kidney is the sole site of origin.
Casts:
Classification Of Casts
INCLUSIONS
MATRIX
01
 Hyaline.
 Waxy.
02
 Granules- proteins, cell debris.
 Fat globules- triglycerides, cholesterol esters.
 Crystals- uncommon.

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03
PIGMENTS
 Hemoglobin.
 Myoglobin.
 Bilirubin .
CELLS
04
Erythrocyte casts.
Leucocytes : neutrophils, lymphocytes, monocytes.
Renal tubular epithelial cells.
Mixed cells : erythrocytes, neutrophils.
MICROSCOPIC EXAMINATION OF URINE

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Renal Tubular Casts
Round to ovoid mononucleated cells, >2 are abnormal .
Rectangular, polygonal and columnar in shape.
01
02
Tubular cells are found in:
acute tubular necrosis
acute interstitial nephritis
acute cellular allograft rejection and
acute nephritic or nephrotic syndrome
MICROSCOPIC EXAMINATION OF URINE

27. 27
MICROSCOPIC EXAMINATION OF URINE
Hyaline Casts
Most frequently observed casts.
Consists almost entirely of Tamm-Horsfall protein.
01
02
Tamm-Horsfall protein is a glycoprotein secreted by thick part of
ascending loop of Henle and early distal convoluted tubules.
Constitutes 1/3 of total urinary protein.
Forms the matrix of all casts.

28. 28
In chronic renal diseases some casts become denser in appearance and
known as waxy casts.
MICROSCOPIC EXAMINATION OF URINE
WAXY CASTS
SEEN IN
 Chronic renal failure.
 Acute and chronic renal allograft rejection.
01
02
03
When unusually broad waxy casts are found known as renal failure casts.
04
They imply advanced tubular atrophy and/or dilatation , in turn reflecting
ESRD and extreme stasis of urine flow.

29. 29
MICROSCOPIC EXAMINATION OF URINE
PIGMENT CASTS
Drugs- phenazopyridine cause a bright yellow to orange color in acid urine
and will color casts and cells.
04
Haemoglobin Casts- erythrocytes embedded in the matrix of
cast undergo degenerative processes
01
Myoglobin Casts- red brown in color and occur with myoglobinuria
following acute muscle damage. May be associated with acute renal failure.
02
Bilirubin Casts- seen in obstructive jaundice as deep yellow brown colored.
03

30. 30
MICROSCOPIC EXAMINATION OF URINE
Crystals
Formed by precipitation of urinary salts when alteration in multiple
factors affect their solubility like pH, temperature, concentration.
They are found in both acidic urine and alkaline urine.
01
02

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MICROSCOPIC EXAMINATION OF URINE

32. 32
MICROSCOPIC EXAMINATION OF URINE

33. 33
MICROSCOPIC EXAMINATION OF URINE
Bacteriuria for the diagnosis of UTI
Females
 MSU showing >103 cfu/ml with acute uncomplicated cystitis.
 MSU showing >104 cfu/ml with acute uncomplicated pyelonephritis.
 MSU showing >105 cfu/ml with complicated UTI.
01
Males
 MSU showing >104 cfu/ml with a complicated UTI.
02

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BIOCHEMICAL EXAMINATION
OF URINE
pH
Specific Gravity
Glucose
Ketones
Proteins
Nitrates
01
02
03
04
05
06

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BIOCHEMICAL EXAMINATION OF
URINE - PH
 Alkaline: vegetarian diet, UTI.
Reflects ability of kidney to maintain normal
hydrogen ion concentration in plasma & ECF
Urine pH ranges from 4.5 to 8.
It is seldom of diagnostic importance
Diet can alter pH
 Acidic: high protein diet, ketoacidosis.
01
02
03
04

36. 36
BIOCHEMICAL EXAMINATION OF URINE –
SPECIFIC GRAVITY
For urine, the specific gravity is a function of the number and weight of the
dissolved solute particles.
01
Measures the concentrating and diluting abilities of the kidney.
02
Normal adults with adequate fluid intake: 1.010 and 1.022 (in a 24 hours
specimen).
03

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Normal Specific
Gravity (1.010-1.022)
Hyposthenuria (dilute urine)
1. Diabetes Insipidus
2. Excessive amount of fluid
3. Diuretic
Hypersthenuria
(Concentrated urine)
1. Dehydration
2. Diabetes mellitus
3. Adrenal insufficiency
Isosthenuria (Specific gravity
fixed at 1.010)
1. Severe renal damage
BIOCHEMICAL EXAMINATION OF URINE – SPECIFIC GRAVITY

38. 38
BIOCHEMICAL EXAMINATION OF URINE
Glucosuria
Under normal circumstances glucose is not
excreted in urine.
Glucose is freely filtered then reabsorbed in the
proximal tubule but restorative capacity is limited.
Glucosuria occurs when : blood glucose exceeds this
renal threshold, for example Diabetes mellitus.
Glucosuria in the absence of hyperglycemia reflects: a
tubular resorption defect.
01
02
03
04

39. 39
BIOCHEMICAL EXAMINATION OF URINE
Ketonuria
Ketonuria is usually associated with diabetic
ketoacidosis and starvation.
Dipsticks detect acetoacetate and to a lesser
extent acetone.
01
02

40. 40
BIOCHEMICAL EXAMINATION OF URINE
Proteinuria
It is defined as excretion of >150mg of protein per day.
Dipstick analysis will detect concentrations as
low as 10mg/dl.
The detection of proteinuria on a dipstick is a measure
of protein concentration and not protein excretion.
01
02
03

41. 41
BIOCHEMICAL EXAMINATION OF URINE
Nitrite Testing
Nitrite in urine suggest the possibility of bacteriuria.
Gram negative bacteria convert nitrates to nitrites with a reagent on dipstick
which form a red azo dye.
The specificity for detecting bacteriuria is >90% while sensitivity is 35-85%.
Cloudy urine that is positive for white blood cells and nitrite positive is very likely
to be infected.
01
02
03
04

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UROTHELIAL CANCER TESTS
The most common tests are
Urine Cytology
Bladder tumor antigen test
Nuclear matrix protein 22
Immunocyt
01
02
03
04

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URINE CYTOLOGY
Urothelial cells are constantly being exfoliated
into urine.
Due to absence of urinary markers for
detection of TCC, urine cytology have
widespread use for high risk patients.
It is most sensitive (90-100%) in patients
with high grade TCC & CIS.
False negative cytology (40-70%) is
frequent in patients with papillary TCC.
False positive cytology can arise due to infection,
inflammation, stones and instrumentation.
01 02
03 04
05

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URINE CYTOLOGY
Indications
Screening for TCC or CIS in the urinary tract.
Frank hematuria in any patient >40 years of age.
Irritative lower urinary tract symptoms in any patient >40 years of age.
Interpretation
Primary goal of urine cytology is to
 Recognize early flat lesions such as CIS before they invade.
 Detect the 10% of superficial lesions destined to invade.
01
02

45. 45
URINE CYTOLOGY
01
02
03
04
Disadvantages
Subjectivity : Depends on level of cytopathologist expertise.
High False negative rate : 80% for low grade , 20% for high grade.
Artifacts : Inflammation, instrumentation, chemotherapy or radiotherapy
Contamination : Vaginal , cervical or endometrial cells will result in misinterpretation.

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BLADDER TUMOR ANTIGEN TEST
It is of two types
BTA-TRAK – Quantitative assay
BTA-STAT – Qualitative assay
Both are more sensitive than cytology but less specific.
Surveillance of patients already diagnosed with bladder cancer
Unreliable in patients with active infection and intravesical therapy
01
02
03

47. 47
NUCLEAR MATRIX PROTEIN 22
It is unable to detect recurrent disease.
Compared with cytology NMP22 is more sensitive for detecting low
grade tumors but is equivalent in detection of high grade cancers.
01
02
Immunocyt
It uses fluorescent labeled antibodies to three markers found on exfoliated
malignant urothelial cells.
19A211
LDQ10
M344

48. 48
PROSTATE SPECIFIC ANTIGEN (PSA)
Screening tool (in conjunction with DRE).
Annual examinations in men over 50 years of age.
High-risk groups from 40 years of age. (family history , African-American).
Patients suspected of having CAP.
Surveillance and monitoring of CAP patients.
Is a glycoprotein produced by the prostatic secretory epithelial cells.
Has a half-life of 3.2 days
Indications
01
02
03

49. 49
AGE RANGE PSA (NG/ML)
40-49 0-2.5
50-59 0-3.5
60-69 0-4.5
70-79 0-6.5
PROSTATE SPECIFIC ANTIGEN (PSA)
Factors Affecting Serum PSA
 Age
BPH
 More PSA per gram is produced by BPH (0.2 ng/mL of serum PSA per
1 g of BPH) than by normal prostatic tissue.

50. 50
PROSTATE SPECIFIC ANTIGEN (PSA)
Cancer Of Prostate (CAP)
 In 80% of patients with CAP, the PSA will increase sequentially.
 As a screening tool, it has a greater sensitivity than DRE though
lacking in specificity.
Prostatic Inflammation/Prostatitis
 Both acute and chronic prostatitis can result in marked serum PSA elevations, with
levels frequently estimated at >20 ng/mL.
 In patients with suspected prostatic inflammation with elevated PSA, it is common
clinical practice to treat patients with antibiotics and then repeat the PSA at least 6
weeks later, before proceeding to prostate biopsies

51. 51
PROSTATE SPECIFIC ANTIGEN (PSA)
Digital Rectal Examination
 Transient minor elevations in serum PSA which are not clinically significant.
Instrumentation
 Cystoscopy will generate small rises in serum PSA, which may alter patient
management.
 It is recommended that PSA testing be deferred by at least 4 weeks.
 TRUS in isolation does not elevate results significantly, but post-biopsy testing
should be deferred for a minimum period of 6 weeks.
 TURP can cause abnormally increased serum PSA levels for up to 30 days, and
a 6-week interval is recommended for a reliable result.

52. 52
PROSTATE SPECIFIC ANTIGEN (PSA)
Modifications Of PSA Testing
 PSA density
 In an attempt to resolve the considerable overlap in serum PSA
between patients with BPH and early cancer of prostate.
 PSAD = serum PSA divided by prostatic volume in mL (as
estimated by TRUS).
 Traditional recommended cut-off of 0.15.
 PSAD was not recommended in patients with a low(<4.0 ng/mL) or
high (>20 ng/mL) PSA.
 PSAD levels of <0.15 were said to be predictive of BPH, while levels
of >0.15 were associated with malignant pathology.

53. 53
PROSTATE SPECIFIC ANTIGEN (PSA)
Shortcomings Of PSAD
In issues of decision-making, PSAD does not appear to have any significant advantage
over age-specific PSA reference range.
A cut-off of 0.15 has a reasonable specificity (81%) but a low sensitivity (52%).
The requirement of a TRUS-derived volume considerably elevates expense and
discomfort to the patient
Measurement inaccuracies can also result in wide variations on repeat testing
01
02
03
04

54. 54
PROSTATE SPECIFIC ANTIGEN (PSA)
 A value of 0.75 ng/mL /year is likely to result in a significant proportion of cancers being missed.
 Abnormal age-specific PSA is likely to undergo biopsies at the earliest opportunity.
 PSAV offers little additional benefit in screening programs for CAP.
PSA Velocity (PSAV)
A consistent upward trend in the serum PSA level is more likely to be
secondary to a malignant process rather than BPH.
PSAV of >0.75 ng/mL per year to distinguish patients with CAP from BPH with a sensitivity
and specificity of 72% and 90%, respectively.
PSAV has been shown to be of limited value for a number of reasons.
01
02
03

55. 55
PROSTATE SPECIFIC ANTIGEN (PSA)
PSA And TRUS Biopsy
 There is a direct relationship between tumor volume and serum PSA.
 As a general rule, the majority of men (80%) with CAP and a PSA of
<4 ng/mL will have organ-confined disease.
 With a PSA of >10 ng/mL ,<50% of patients having organ-confined disease.

56. 56
PROSTATE SPECIFIC ANTIGEN (PSA)
Lymph Node Metastases
PSA is the best predictor of the possibility of lymph node
metastases.
 Rare in patients with PSA of <4 ng/mL.
 Found in 20% of those with a PSA of >20 ng/mL.
 Found in over 75% of patients with PSA >50 ng/mL.
01

57. 57
PROSTATE SPECIFIC ANTIGEN (PSA)
Skeletal Metastases
PSA has also been shown to be the best individual predictor of results of a bone scan
in patients with CAP.
01
The majority of patients with a significantly elevated PSA (>50 ng/mL) will have a
positive bone scan.
02

58. 58
TESTICULAR TUMOR MARKERS
A biomarker found in blood, urine or body tissues that can be
elevated by the presence of one or more types of cancer.
01
02
Four markers have been described:
 Beta human chorionic gonadotropin (β-hCG)
 Alpha fetoprotein (AFP)
 Lactate dehydrogenase (LDH)
 Placental alkaline phosphatase (PALP).

59. 59
TESTICULAR TUMOR MARKERS
Role Of Tumor Markers
Helps in Diagnosis - 80 to 85% of Testicular Tumors have Positive Markers.
Most of Non-Seminomas have raised markers
Degree of marker elevation appears to be directly proportional to tumor burden.
May predict the responsiveness to treatment.
01
02
03
04

60. 60
TESTICULAR TUMOR MARKERS
Indications
Diagnosis and management of suspected testicular tumors.
Timing Of Evaluation
 Suspected testicular tumor
 Prior to radical orchiectomy.
 Following radical orchiectomy or chemo-radiation.
 Weekly till levels back to normal.
 2–3 monthly for the first 2 years.
 6 monthly after the second year.

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TESTICULAR TUMOR MARKERS

62. 62
TESTICULAR TUMOR MARKERS
Prognostic Value
The International Germ Cell Cancer Collaborative Group (IGCCCG) have now
included serum levels of testicular markers as independent prognostic indicators, and
three risk categories have been identified:
Good Prognosis
01
 NSGCT
AFP <1,000 ng/mL
Β-hCG <5,000 mIU/mL
LDH <1.5 times upper limit of normal
 Seminoma
Normal AFP
Any level of β-hCG or LDH

63. 63
TESTICULAR TUMOR MARKERS
Intermediate Prognosis
 NSGCT
 AFP 1,000–10,000 ng/mL
 Β-hCG 5,000–50,000 mIU/mL
 LDH 1.5–10 times upper limit of normal
 Seminoma
 Normal AFP
 Any level of β-hCG or LDH.
Poor Prognosis
 NSGCT
 AFP >10,000 ng/mL
 β-hCG >50,000 mIU/mL
 LDH >10 times upper limit of normal.
02
03

64. 64
TESTICULAR TUMOR MARKERS
Response To Therapy
The time taken for normalization of markers should be :
• β-hCG—2 weeks
• LDH—2 weeks
• AFP—4 weeks
Should the marker levels remain elevated following
orchidectomy, this often indicates systemic metastatic disease
rather than nodal disease.
02
03

65. 65
Thankyou.