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Urology 2 Clinical Fellow in UrologySocial Medias Case 1 Question A 71 year old man is referred to 2 week wait clinic. He reports worsening haematuria at the start of the stream for the last three months. He reports poor flow and getting up four times a night to empty his bladder. His urine sample is blood streaked, with blood on the dipstick but nothing else. He has had several negative MSUs. Relevant examination findings and bloods are shown below. Which of the following is not an appropriate next step of management? A. Flexible cystoscopy Examination: B. CT Urogram Bloods: Abdomen soft and non Hb 112 tender C. Prostate MRI WCC 4.6 No bony tenderness eGFR 52 Prostate mildly D. Bone scan Adj. Calcium 2.3 enlarged, firm and E. USS kidneys PSA 16 irregular on the left Case 1 Answer A. Flexible cystoscopy A bone scan is only indicated when there is clinical B. CT Urogram or biochemical (PSA) evidence of metastatic C. Prostate MRI prostate cancer. D. Bone scan Although that may become necessary, at present E. USS kidneys we have not yet investigated the patient’s haematuria or prostate • Flexible cystoscopy is the gold standard for identifying lower tract causes of haematuria • CT Urogram is the best imaging modality to investigate upper tract causes of haematuria • Prostate MRI is required to identify prostate lesions for targeted biopsies in patients with no suspicion of metastatic disease, suitable for radical treatment • USS is not ideal for upper tract imaging as it cannot identify ureteric lesions consistently Case 1 Explanation • Haematuria at the start of the stream is more closely linked to prostatic source of bleeding, although this is not exactly a strict science • Prostatic bleeding is not necessarily malignant, but elevated PSA and a suspicious examination make malignancy more likely • Investigating prostate cancer with low PSA, no signs of distant disease, and fit for radical treatment, should begin with MRI prostate followed by biopsies • A bone scan should be used with higher PSAs and when there is clinical suspicion of bony metastasis Case 2 Question days ago with a STEMI and had a primary PCI. She has started aspirin andd three ticagrelor. For the last three hours she has been unable to pass urine and the nurses report her urine was very red earlier in the day. You check her notes and see that she has been treated twice for UTIs in the last 6 months and was a 40/day smoker for 20 years. What is the likely underlying diagnosis? A. Adenocarcinoma of bladder B. Transitional cell carcinoma of bladder C. Haemorrhagic cystitis D. Squamous cell carcinoma of bladder E. Bleeding due to antiplatelets Case 2 Answer A. Adenocarcinoma of bladder TCC of the bladder is the most common form of B. Transitional cell carcinoma of bladder cancer and is very closely associated bladder with smoking. C. Haemorrhagic cystitis It is often completely asymptomatic, but can be D. Squamous cell carcinoma of a cause of UTIs. bladder Antiplatelets and anticoagulants exacerbate E. Bleeding due to antiplatelets underlying bleeding but are not a cause. • Adenocarcinoma of the bladder is rare, about 1% of bladder cancers • Haemorrhagic cystitis could be a cause, but without concurrent symptoms of UTI this is less likely, and less concerning • SCC bladder is associated with chronic inflammation, classically schistosomiasis • Antiplatelets and anticoagulants might exacerbate an underlying cause of bleeding, but will not be a primary cause Case 2 Explanation • Transitional cell carcinoma of the bladder is heavily associated with smoking • It is often asymptomatic, with the main symptom being bleeding • Can be associated with UTIs due to bacterial colonisation of the tumours • TCC can often be endoscopically managed • But the heavy smoking patient cohort can make this challengin Case 3 Question After two years of endoscopic management a repeat resection found disease that was no longer amenable to endoscopic resection, and the patient was referred for consideration of cystectomy. Which is the most superficial layer of the bladder that, if invaded, indicates endoscopic management is no longer possible? A. Urothelium B. Lamina propria C. Superficial muscle D. Perivesical fat E. Deep muscle Case 3 Answer A. Urothelium Invasion into any of the muscle layers means B. Lamina propria that bladder cancer can no longer be C. Superficial muscle controlled endoscopically. D. Perivesical fat E. Deep muscle Case 3 Answer A. Urothelium Invasion into any of the muscle layers means B. Lamina propria that bladder cancer can no longer be C. Superficial muscle controlled endoscopically. D. Perivesical fat E. Deep muscle • The urothelium and lamina can be safely resected endoscopically • Tumour infiltrating deep muscle would certainly not be curable endoscopically, but this is not the most superficial layer for which this is true • If a resected sample contained tumour infiltration of the perivesical fat then a large defect was made during the operation and there are bigger problems • Also this is not the most superficial layer for which it is true Case 4 Question An 84 year old lady presents to the acute surgical unit with sudden onset unilateral loin to groin pain. She has had visible haematuria intermittently for the last few months, but no dysuria. Her bloods show a drop in renal function and as such she has a CTKUB. She has mild unilateral hydronephrosis but no calculus is seen. The kidney appears non-specifically abnormal. What is the most probable underlying diagnosis? A. Renal TCC B. Pyelonephritis C. Renal cell carcinoma D. Renal angiomyolipoma E. Bosniak 2 renal cyst Case 4 Answer A. Renal TCC Bleeding from renal tumours can cause B. Pyelonephritis ureteric clots that act like ureteric calculi, C. Renal cell carcinoma causing loin-to-groin pain and D. Renal angiomyolipoma hydronephrosis. E. Bosniak 2 renal cyst • Renal TCC is possible but is significantly less common than RCC, and should not affect radiological appearances of the kidney • Pyelonephritis could cause bleeding but should not have a chronic course • Renal AMLs are rare and benign, usually asymptomatic • Bosniak 2 renal cysts are benign and do not cause bleeding Case 4 Explanation • The most common renal cancers are renal cell carcinomas • These can be clear cell (80%), papillary (15%) or chromophobe (~5%). • They are usually asymptomatic and are picked up incidentally • They can also cause microscopic or visible haematuria • There are several different benign renal lesions, most commonly cysts, which are classified by the Bosniak system • Other types include angiomyolipomas, cortical adenomas…. • CTKUB is inadequate to assess renal cancers, as it cannot assess vascularity RCC TCC Infection TCC Calculi TCC SCC Infection Inflammation Calculi prostate BPH Prostate cancer Bonus An anecdote • You are asked to see a 67 year old man who has reported ongoing haematuria for three months • He has been admitted with chest pain, and the medical team want to assess his ongoing bleeding risk after starting antiplatelets • His ultrasound is unremarkable • His urine dip shows no evidence of blood, but the urine is definitely pink tinged • He has had no pain, no urinary symptoms Bonus An anecdote • Examination findings: • End of the bed inspection, you note “super red” vitamin supplementsAny questions? 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