Hematuria Donald L. Lamm, MD, FACS Bladder Cancer, Genitourinary Oncology Phoenix, AZ BCGOncology.ComSlide 2
Objectives Define hematuria and signs for assessment Describe causes and differential determination Indications for urologic assessment/referral Advances in kidney disease Update on bladder malignancySlide 3
Examination of the Urine " The apparitions of dead patients that frequent us don\'t inquire as to why we didn\'t utilize the most recent prevailing fashion of clinical examinations; they inquire as to why did you not test my urine?" Sir Robert Hutchinson 1871-1960Slide 4
Hematuria: Definitions Gross or minute blood in the pee at least 3 RBC/HPF in 2 of 3 examples, or at least 4 RBC/HPF Normal: up to 100,0000 rbc discharged per 12 hours Microhematuria happens in 2.5 to as much as 21% of the populace 1ml or less of blood is noticeableSlide 5
Hematuria Other reasons for pee staining: color from beets, rifampin, pyridium. Porphyria Centrifuge: shading in silt Dipsticks are exceedingly delicate, as few as 1-2 RBC, affirm with tiny examinationSlide 6
Hematuria at least 10% have favorable hematuria or hematuria of obscure cause Symptom of bladder malignancy, kidney disease, contamination, stones, and so forth control workup Risk variables for tumor: smoking, radiation, compound presentation, ageSlide 7
Bladder growth Kidney growth Ureteral growth Urethral growth Prostate disease Stones Pyelonephritis Cystitis BPH Glomerulitis Radiation cystitis Chemical cystitis Prostatitis Exercise Hematuria: Common CausesSlide 9
Clues From the History Pyuria, bacteriuria and dysuria-recommend UTI, yet be careful, high review bladder growth causes dysuria and pyuria URI or skin disease 10-21 days prior or more propose post-strep or IGa nephropathy Family history of kidney disappointment? Inherited nephritis or polycystic kidney maladySlide 10
Clues From the History Flank torment: renal/ureteral stone or blood clump. Once in a while, tireless flank agony may happen: loin torment hematuria disorder Spontaneous seeping at different locales propose coagulopathy, however hematuria still needs assessment Lower tract obstructive side effects Vigorous work out, injurySlide 11
Clues From the History/PE Cyclic hematuria in ladies: endometriosis of the urinary tract, menstrual sullying People of Mediterranean starting point: sickle cell characteristic or malady Glomerular dying: RBC throws, protein>500mg/d without gross hematuria, dysmorphic RBC, renal inadequacy: nephrology as opposed to urology referralSlide 12
Workup of Hematuria History and physical exam Urinalysis for protein, crenated RBC, RBC throws, microorganisms Cytology Creatinine Imaging contemplates: ultrasound, IVP, CT, MRI, RPG Cystoscopy www.bcgoncology.comSlide 13
Negative Evaluation? Found in no less than 10% of cases Cancer later found in 1-3% of these patients Consider rehashing UA and cytology in 6, 12, 24, 36 months Consider quick rehash assessment for repetitive gross hematuria, anomalous cytology, or lower urinary tract side effects of recurrence and dysuriaSlide 14
Unexplained Hematuria Focal glomerulitis Metabolic inclination to stone development Children: 33% of idiopathic hematuria is because of hypercalciuria; 5-20% hyperuricosuria; once in a while hypocitruria AV contortions/fistula-normally net hematuriaSlide 15
Asymptomatic Microhematuria 100 back to back cases 13% had critical urologic infection: 8 urinary calculi 3 kidney tumors 2 bladder tumors 43/44 subjects (98%) with dysmorphic RBC or RBC throws had no noteworthy urologic source, i.e. had a parenchymal source Urology 46:484-9, 1995Slide 16
Persistent Microhematuria 372 successive cases asymptomatic microhematuria assessed with IVP and cystoscopy 43% had GU pathology found Of 212 with a negative workup, 75 (35%) had determined microhematuria Repeat assessment demonstrated variations from the norm in 11 of these 75 (15%) Urology 56:889-94, 2001Slide 17
CT for Microhematuria 115 pts: CT with 5mm cuts in addition to IVP Xray anomalies: 38%. 100% affectability for CT and 60% for IVP. CT specificity/exactness 97%/98% versus 91%/81% for IVP 40 non-urological judgments were additionally made with CT is more delicate and particular and recognizes other pathology J Urol 268:2457-60, 2002Slide 18
Renal Cancer Incidence, 2005 36,160 cases; 22,490 men, 13,670 ladies 3% of disease in men 12,660 assessed passings in 2005 Relative mortality/rate: 39%, contrasted and 23% for bladder, 17% prostate, and 5% testisSlide 19
Renal Cancer, 1975 to 1995 JAMA. 1999;281:1628-1631 Annual increment: 2.3% white men, 3.1% white ladies, 3.9% dark men, and 4.3% dark ladies; most noteworthy for confined tumors additionally propelled tumors interestingly, renal pelvis malignancy declined among white men and stayed stable among white ladies and blacks Mortality expanded in all gatheringsSlide 20
Renal Cancer Etiology Tobacco, cadmium, radiation, dialysis Risk variables: hypertension, expanded body mass file, and red meat consumption; converse connection with admission of carotenes Four-overlap expanded hazard with family history Seminars in oncol. 27:115-123, 2000 Curr opin oncol. 12:260-4, 2000Slide 21
Renal Cancer Etiology Clear hereditary elements: VHL quality on chromosome 3, change of VHL in clear, granular and sarcomatoid RCC yet not papillary RCC Trisomy of 7 and 17 and loss of the sex chromosome: papillary tumors Chromophobe RCC : loss of chromosomes with a mix of monosomies Deletion (8p)/ - 8, +12, and +20: more regrettable anticipationSlide 22
Renal Cell Carcinoma Urology, 55:31-5, 2000 Onset age 62, 82% with confined sickness 41% T1 ailment, 15% T2, 39%T3, 4% T4 Fuhrman review 1 or 2 in 51% of patients and 3 or 4 in 45%. Guess connected with Fuhrman review Stage and grade related with survival (P=.0001 and P = .0028, separately) In stage M0, smokers had an essentially more terrible general survival (P = 0.039)Slide 23
Workup of Renal Masses Intravenous pyelogram is no longer the most widely recognized imaging concentrate Most are determined to have CT, ultrasound, or MRI Angiography assumes a less successive part and is presently utilized just for flawed cases or as a guide to halfway nephrectomySlide 24
Controversies in Renal Tumors Partial nephrectomy Laparoscopic Nephrectomy in metastatic renal cell carcinoma Resection of singular and various metastasis Medical treatment of metastatic maladySlide 25
Bladder Cancer Statistics, 2005 New cases: 63,210 Men: 47,010; #4 women: 16,200 #8 Estimated passings: 13,180 Men: 8,970; #9 women: 4,210 Incidence/mortality: 20.8% Men: 19% women: 26% Prevalence: more than 600,000 in USSlide 26
Bladder Cancer Etiology Initial connection to aniline colors made in 1895 Industrial presentation: elastic and materials Aromatic amines: 30x hazard Tobacco: 3x expanded hazard, 60% of cases Treatment complexity: 9x chance with cyclophosphamide or ifosfamide; 4x RT Schistosoma hematobium, contamination, outside body: squamous cell carcinomaSlide 27
Bladder Cancer PathologySlide 28
Bladder Cancer, 2005 Peak onset: sixth to eighth decades Men/ladies: 3 to 1 Twice as regular in white men contrasted and African American men Genetic transformations: qualities on chromosome 9 including p16. Intrusion p53, rb, p21 Screening: hematuria identification decreases mortalitySlide 29
Bladder Cancer Signs and Symptoms 85% present with gross or minute hematuria. Draining is normally irregular and not identified with grade/organize 20% have irritative voiding indications: smoldering, recurrence. All the more generally connected with CIS and higher review tumorsSlide 30
"Repetitive" High Grade Bladder 58y/o man with 4 yr Hx small scale hematuria, not assessed Presented with gross hematuria Cysto indicates BT, resection G3,TA No muscle in example CT urogram demonstrates ordinary upper tracts, injury in bladder Repeat resection affirms remaining TCC, luckily not intrusiveSlide 31
66y/o with 4 year Hx of recurrence, dysuria & hematuria. Suspicious DRE Voided Cytology positive Needle biopsy of prostate positive for TCC Cysto/TUR: bladder neg. Intrusive TCC prostate CT check: broad nodal metastasisSlide 32
CT Scan 11/03: CR after 4 cycles of CGP TUR 11/3: 6 of 40 +TCC XRT to prostate, hubs TUR 3/4: bladder and prostate negativeSlide 33
Diagnosis Cystoscopy is vital: papillary tumors are effectively observed. High review, strong, level or in situ tumors may not be seen Urinary cytology: 80% + affectability in high review tumors with 95% specificity. Affectability enhanced with FISH IVP, CT check for upper tract assessmentSlide 34
Grade I, Stage Ta TCCSlide 35
Cystoscopy demonstrating bladder tumorSlide 36
Bladder Cancer: Natural History About 70% present with resectable, shallow tumors, however up to 88% repeat by 15 yrs Patients can and ought to be observed with cystoscopic examination at continuous interims to straightforwardly evaluate ailment status Accessible for illness appraisal, topical and systemic treatmentSlide 40
Risk Factors in Superficial Bladder Cancer Recurrence: 51% for single, 91% different; as low as 20% @ 5 years if 3month cysto clear Progression: 4% for TA, 30% for T1; 2% for G1,TA; 48% for G3,T1 Mortality: 6% G1, 21% G3 CIS: 52% movement T2 or higher if untreated T2(+): 45% 5yr survival with cystectomySlide 41
Risk Groups Improve Treatment Selection Low hazard: G1,TA singular tumor with no repeat at 3 months Intermediate hazard: numerous or intermittent G1,TA; G2,TA High hazard: any G3, lamina propria attack (T1), CIS, or 3 month repeatSlide 42
Treatment Options in Superficial Bladder Cancer Transurethral resection: best quality level, yet 88% 15 year repeat Intravesical chemotherapy: 20% decrease 2 year repeat, 6% > 5 year No diminishment in sickness movement Intravesical immunotherapy: BCG: 40% lessening 2 yr repeat, 20% >5 year Alpha 2b interferon: 47% CR in CISSlide 43
Progress in Bladder
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