Urology Hematuria Stones Tumours. Outline Hematuria ▫DDx ▫General Work up Renal Colic ▫Stones Malignancy ▫Renal ▫Bladder Scrotal masses.

UrologyHematuria Stones Tumours

Outline

•Hematuria▫DDx ▫General Work up

•Renal Colic▫Stones

•Malignancy▫Renal▫Bladder

•Scrotal masses

Hematuria

•Objectives▫1. Taking a Hx.▫2. Lab & Radiologic Invx’s.▫3. Which pt’s to refer to

Urologist.

Hematuria

Hematuria General Approach

•Myo/hemoglobinuria•Coagulation disorders•Pseudohematuria

• (beets, dyes, laxatives)

•Glomerulonephritities•AV Fistulas•Vascular Malformations•Infection•Tumor

• Stones•Infection• Trauma•Tumors•GU Endometriosis

Hematuria•Etiology by Age

Age Etiology in order of frequency

0-20 Glomerulonephritis, UTI, congenital anomalies

20-40 UTI, stones, bladder tumor

40-60 Male: Bladder tumor, stones, UTIFemale: UTI, stones, bladder tumor

>60 Male: BPH, bladder tumor, UTIFemale: Bladder tumor, UTI

Hematuria General Approach

•Myo/hemoglobinuria•Coagulation disorders•Pseudohematuria

• (beets, dyes, laxatives)

•Glomerulonephritities•AV Fistulas•Vascular Malformations•Infection•Tumor

• Stones•Infection• Trauma•Tumors•GU Endometriosis

Hematuria DDx▫Stones▫Infections▫Tumours▫Trauma

Hematuria HPI• Stones:

▫Flank/Abdo pain, dysuria, PHx Stones.• Infection:

▫Suprapubic pain, dysuria, frequency, fever/chills +/- flank pain.

• Malignancy▫Wt loss, night sweats, flank pain, voiding

changes, Occupational Hx (petroleum exposure), smoking Hx, FMHx of Cancer

• Trauma▫Recent encounters with Chuck Norris.

Gross Hematuria Invx • Laboratory Work up:

▫1. CBC Hgb - severity of blood loss. WBC – infection. Platelet loss/coagulopathy.

▫2. Cr Renal impairment.

▫3. INR/PTT Coagulopathy.

▫4. U/A Leukocytes, Nitrites – Infection. R&M – if dysmorphic RBC’s +/- Protein = Glomerular cause,

crystals stones. C&S – Infection.

Hematuria InvxRadiology Investigations

• Painless Gross Hematuria ▫ Triphasic CT: arterial/venous/ureteric phases

• Microscopic Hematuria▫ Start with Renal U/S.

• Flank Pain ▫ Plain film KUB, CT KUB (non con).

• Signs of infection ▫ Start with U/S, if findings may consider CT with contrast

Hematuria

Imaging Modality Pros Cons

IVP 1. Good choice for suspected stones or Transitional tumors of bladder or ureter.

1. Expensive.2. Radiation.3. May miss small renal

Tumors.4. Contrast allergies,

Nephrotoxic

U/S 1. No ionizing radiation.

2. Inexpensive.3. Can identify tumor or

stone

1. May miss stones, ureteric & bladder tumors.

2. Unable to differentiate tumors from blood clot.

CT non contrast 1. Used for Renal Colic – best at identifying stones

2. Accurate staging of Malignancy if present

1. Ionizing radiation exposure.

2. Risk to fetus in Pregnancy

CT contrast (triphasic) 1. Useful identifying abscesses, fluid collections.

2. Ureteric phase – identifies filling defects.

1. Contrast allergy.2. Contrast makes

visualizing stones difficult

Hematuria Referral

•When to refer to Urologist?▫Gross hematuria NEED cystoscopy +/-

Retrograde Pyelogram!! ▫Pt’s with GU Malignancies, stones, trauma.

•What should be done prior to referral?▫Hx, PE, Lab Invx’s, Imaging▫Initial management and stabilization of pt.

Retrograde Pyelogram

Hematuria Acute Rx• ABC’s.

▫Stabilize Pt, Blood products if needed.• Invx to determine cause

▫Treat underlying cause.• Continuous Bladder Irrigation

▫Call Urology.▫Manually irrigate all clots out of bladder first!

• Surgical management▫Cystoscopy + Fulgaration.▫Hyperbaric Oxygen▫IR embolization.▫Cystectomy and Urinary diversion.

Hematuria Summary1. Painless Gross Hematuria

▫ Malignancy until proven otherwise.2. Stones, infections & trauma

▫ Rarely asymptomatic Hx.. Hx.. Hx..3. Workup

▫ Hx, PE ▫ Lab: CBC, Cr, U/A C&S, INR/PTT▫ Imaging: CT or U/S▫ Referral to Urologist: cystoscopy +/-

Retrograde pyelogram4. Management

▫ Stabilize Pt, +/- CBI, +/- Surgical intervention

Hematuria Cases• Geeyu Malignansey, a 67 yo female with 114 pk/yr

smoking hx presents with Gross Hematuria.

• Wazun Mi, 23 yo male minding his own business gets stabbed to the flank, while voiding and notices he urine becomes red…

• 24 yo Engineering student comes in with dysuria after holding her urine for 14 hours playing ‘Call of duty’, she has leuks, nitrites and RBC’s on U/A…

Outline

•Hematuria▫DDx ▫General Work up

•Renal Colic▫Stones

•Malignancy▫Renal▫Bladder

•Scrotal masses

Stones

Renal Colic

Objectives;1. Give a differential diagnosis for acute

flank pain including two life-threatening conditions

2. Describe the laboratory and radiologic evaluation of a patient with renal colic

3. Know 4 different kinds of kidney stones and the risk factors for stone formation

4. Know 3 indications for emergency drainage of an obstructed kidney

Renal Colic DDx• Life Threatening:

▫ Abdominal Aortic Dissection▫ Abdominal Aortic Aneurysm

Rupture▫ Appendicits▫ Ectopic Pregnancy▫ Septic Stone

• GI▫ Cholecystitis▫ Biliary Colic▫ Acute Pancreatitis▫ Diverticulitis▫ Duodenal Ulcer▫ Inflammatory Bowel Disease▫ Viral gastritis▫ Splenic Infarct

•Gyne• Pelvic inflammatory

Disease• Ovarian Torsion/Rupture• Endometriosis

•GU• Renal/Ureteric Calculi• Renal Abscess• Pyelonephritis• Renal Vein Thrombosis• Acute Glomerulonephritis

•Other• Acute lumber disc

herniation• Herpes Zoster• Fitz-Hugh-Curtis

Syndrome

Renal Colic Invx

•Rocky, a 32 yo Male comes to ED with microscopic hematuria and is writhing with Lt Flank pain.

•What Laboratory Invx’s do you order?

•What initial imaging do you order?

Stones – Acute Lab Invx’s

•CBC▫WBC – increased indicates inflammation or

infection.

•Creatinine▫Assess for impaired renal function

(obstruction).

•Urine Microscopy▫Bacteriuria, pyuria, pH

Renal Colic – 1st Imaging Test

•Plain Film KUB!▫~85% of stones

are Radio-opaque on plain film.

▫No info on degree of obstruction though.

Renal Colic – Other imaging optionsIVP• Intravenous Pyelogram• Visualizes most stones

(radiolucent stones will appear as filling defects)

• Excellent Functional Study

• Requires IV contrast, thus risk of allergic reactions and nephrotoxicity

Renal Colic – Radiologic Evaluation•CT Scan, hold the

contrast.•Aka CT-KUB.•Fast Inexpensive• Imaging choice in

most emergency rooms.

•Degree of obstruction inferred by presence of hydronephrosis.

Stones - Factoids• They are common!

▫Lifetime risk in North American Male is 1 in 8.▫M:F ratio is 3:1

• Presenting complaint▫Renal colic due to acute obstruction of ureter by

stone.• Initial Evaluation

▫Focuses on excluding other potential causes of abdominal or flank pain.

• Non-obstructing stones▫Should not cause pain unless they are associated

with Urinary tract infection.

Ureteric Stone

•3 Common sites of Obstruction

Ureteric Stones

•Spontaneous passage?

•Pharmacologic aid in spontaneous passage?▫Alpha blockers! Flomax

Size Likelihood

4mm or less 90%

5-7mm 50%

8mm or larger 20%

Renal and Ureteric Stones

•So you have established that there is a stone.▫When is ‘immediate’ referral to a Urologist

Necessary?

Immediate Referral to Urology

•Obstructed ureter + Fevers/chills, bacteriuria or elevated WBC▫Risk of Urosepsis - emergency

•Obstructed Ureter + Insulin dependent DM▫Risk of papillary necrosis or

emphysematous pyelonephritis•Solitary Kidney•Significant co-morbid conditions

▫Eg. CHF, pregnancy etc.

Common Types of Stones

Calcium Oxalate

•Most common type.•Risk Factors:

▫Dietary Hyperoxaluria: chocolate, nuts, tea, strawberries, peanut butter, cabbage or excessive restriction of dietary calcium.

•Hypercalciuria▫Inherited increased absorption, or incr PTH

•Dietary Hypercalciuria

Calcium Phosphate

•Second most common stone type.•Often seen in pt’s with Metabolic

Abnormalities:▫Primary Hyperparathyroidism.▫Distal Renal tubular acidosis.▫Hypercalcemia due to Malignancy or

Sarcoid.

Uric Acid•Radiolucent on Plain X-Rays, but is

visualized on CT scan•Risk Factors:

▫Persistent Acidic urine: ie l Low urine volumes

Chronic diarrhea Excessive sweating Inadequate fluid intake

▫Gout (Hyperuricemia)▫Excess dietary purine (Meataholics)▫Chemotherapy for lymphoma, leukemia

Struvite (Infection Stones)

•Composed of MAP ▫Magnesium + Ammonium Phosphate &

Calcium•Can only form if urine pH >8.0!

▫Thus: usually only in presence of urease +ve bacteria Proteus, Klebsiella, Providentia,

Pseudomonas, Staph Aureus Note: E Coli does NOT produce urease

•Tend to form Staghorn stones

Relieving Obstruction

Ureteric Stents

•“Double J Stents”▫Stay in place b/c of

curled ends▫Can place these

Antegrade or Retrograde

▫Typically requires General Anesthetic.

▫Low risk of bleeding.

Percutaneous Nephrostomy Tubes•“Neph Tubes”

▫Placed under local anesthetic by Interventional Radiology

▫Increased Risk of Bleeding.

Treating/Removing Stones

•Ways to Treat stones.▫Conservative passage + Alpha Blocker

(Flomax) + Hydration + NSAID (if Normal GFR)

▫Extracorporeal Shockwave Lithotripsy (ESWL)

▫Ureteroscopy + Basket or Laser▫Percutaneous Nephrolithotomy

Treating Stones• Conservative passage + Alpha Blocker

(Flomax) + Hydration + NSAID (if Normal GFR)▫Indications

Pain can be controlled with Ketorolac + Narcotic

No renal impairment No Intractable Vomiting (aka pt not

hypovolemic) No sign of infection. No previous failed trials of conservative

passage.

Treating Stones• Extracorporeal

Shockwave lithotripsy▫ Indication:

<~1.5cm renal or ureteric stone.

▫Stone is localized by X-Ray.

▫~3000 Shocks targeted to gradually fragment stone.

▫Fragments passed in urine.

Treating Stones

•Ureteroscopy▫+ Basket

If stone is small enough to adequately remove by basket.

▫+ Holmium Laser If stone is ‘impacted’ or cannot simply be

basketed out.

Treating Stones

•Percutaneous Nephrolithotomy▫Indications

Large Proximal ureteric or Renal Calculi >~1-1.5cm

Treatment of Staghorn Calculi

▫Risks: Bleeding Renal Perforation or Avulsion

•http://www.youtube.com/watch?v=irKCgFrAORA

Outline

•Hematuria▫DDx ▫General Work up

•Renal Colic▫Stones

•Malignancy▫Renal▫Bladder

•Scrotal masses

Renal Mass

Objectives:1. Give a differential diagnosis for a solid

mass in the kidney.2. Describe the evaluation of a patient with

a suspected renal cell carcinoma3. Give three indications for a partial

nephrectomy rather than a radical nephrectomy for renal cell carcinoma.

Renal Tumors

•Presentation:▫Incidental finding!▫Triad: Flank pain, hematuria, palpable

mass (not common)

•How do you ‘work-up’ a Renal mass?

Renal Mass Investigations• Imaging

▫ CT Abdo pelvis + contrast Characterize Mass and assess for tumor extension, IVC

thrombus, Nodes, Mets, abnormalities to contralateral kidney.▫ CXR

Assess for mets

• Laboratory▫ Alk Phos (bone mets)▫ LE’s hepatic/portal vein involvment▫ Calcium

• Biopsy?▫ Recommended only when Dx is unclear.

Why Investigate Calcium?•Bone Mets or Paraneoplastic syndrome!

▫20-30% of RCC have Paraneoplastic Syndrome Increased ESR Wt loss, cachexia Fever Anemia Hypertension (incr Renin) Hypercalcemia (PTH-like Substance) Incr ALP Polycythemia (incr EPO production) Stauffer’s syndrome – reversible hepatitis

Renal Tumors

•Oncocytoma•Angiomyolipoma•Psuedotumour

• Dromedary Hump• Hypertrophied column of Bertin• Compensatory Hypertrophy etc

•Renal Cell Carcinoma•Transitional Cell Carcinoma•Wilms Tumour (peds)•Metastasis

• Lymphoma/leukemia• Lung• Breast

Benign Tumors• Know that they exist.

• DDx:• Oncocytoma, angiomyolipoma (1-2% malignant),

papillary adenoma, pseudotumors etc….

• Differentiating pseudotumors from real tumors.▫DMSA scan

Pseudotumors will have normal uptake, tumors will be decreased.

Benign Renal Masses•Angiomyolipoma

▫Diagnosed if any part of renal mass consists of adipose. Composed of Fat –

smooth muscle – blood vessels

▫Risk of hemorrhage near 50% once size >4cm

Malignant Renal Cell Carcinoma•Accounts for 90% of solid renal masses.•Several different subtypes

▫Clear Cell is most common

•25% present with Mets

Renal Cell Carcinoma

•Treatment▫Local confined mass

Nephrectomy Partial Nephrectomy

▫Solitary kidney or significant renal impairment▫Bilateral tumors▫Von Hippel-Lindau Syndrome▫Small tumor <4cm

▫Metastatic RCC Combination of Nephrectomy + Chemo

(Sunitinib)

Renal Cell CarcinomaFive year disease-specific survival (following most effective treatment)

T1 95%T2 90%T3a 60%T3b, c 25% (following complete removal of IVC thrombus)T4 20%

N1, 2 10% – 20%

M1 0%

Other Malignant Renal Tumors• Renal Transitional Cell Carcinoma

▫Because Transitional cells line renal pelvis, ureters & bladder, must perform nephroureterectomy to Rx.

• Wilm’s Tumor▫Peds

• Sarcoma• Metastasis to Kidney

▫Leukemia, lymphoma▫Lung▫Breast

Bladder Cancer

Objectives:

1. State 3 risk factors for transitional cell carcinoma of the bladder

2. State the treatment options for superficial and invasive TCC of the bladder

Bladder Cancer• Often presents as painless

gross hematuria!▫ Recall workup for gross

hematuria: Upper tract imaging CT

Abdo/pelvis Cystoscopy

• Diagnosis▫ Cystoscopy + Biopsy

Transurethral resection of lesion and underlying detrusor muscle to stage tumor

▫ Urine Cytology▫ Ct Abdo/pelvis for staging.

Bladder Cancer

•Risk Factors▫SMOKING (RR 4 vs non smokers)▫Occupational Exposure

Aniline dyes, aromatic amines Ie. Textile manufacturing, dry cleaning,

painting)▫Previous Cyclophosphamide

(ie chemo for lymphoma)▫Previous Radiaiton Rx in pelvis

Bladder Cancer

•DDx•Transitional Cell carcinoma

▫Most common!•Adenocarcinoma

▫Dome of bladder, associated with Urachus.•Squamous Cell Carcinoma

▫Associated with chronic inflammation Indwelling foley’s, bladder stones.

Transitional Cell Carcinoma

•Staging▫Non-invasive

Tis, Ta, T1 disease▫Invasive

>T1 disease (muscle invasive

Treatment of Non-invasive TCC

•1. Transurethral resection of lesion•2. PLUS intravesical chemotherapy IF:

▫Carcinoma in-situ▫Multi focal tumors▫Unable to completely resect transurethrally▫Rapid recurrence after initial resection▫Superficial, high grade tumor▫Lamina propria invasion (Stage T1)

Treatment of Non-invasive TCC

•Intravesical Chemotherapeutic Agents:▫Bacille Calmette-Guerin (BCG)▫Mitomycin▫Doxorubicin▫Thiotepa

Treatment of Non-Invasive TCC

•But….IF:▫Persistent CIS after intravesical

chemotherapy▫Extensive superficial tumors that cannot be

resected.

•Then Pt will require Radical Cystectomy and Urinary diversion for curative intent.

Treatment of Invasive TCC

•Radical Cystectomy•+/- Chemotherapy for metastatic disease

•If palliative, may still require cystectomy if uncontrollable hematuria (requiring transfusions etc)

Radical Cystectomy + Urinary Diversion•Once Bladder is removed…

•Urinary diversion is needed▫Ileal Conduit

Pros – simple, least complications Cons – abdominal stoma, no continence.

▫Neobladder Pros – continent with use of catheters Cons – Increased surgical complications,

increased risk of metabolic derrangements.

Ileal Conduits

Neobladders

Scrotal Mass

Objectives

•Differential diagnosis of a scrotal mass•Know how to diagnose and treat testicular

torsion•Classify testicular tumors•Treatment of testicular malignancies

Approach to Scrotal Mass

•Epididymitis**•Orchitis**

•Testicular tumor•Paratesticular tumor

• Cystadenoma of epididymis

•Hydrocele•Inguinal hernia•Varicocele•Spermatocele•Testicular Torsion**•Appendix Testi Torsion**

** = painful

Approach to Scrotal Mass• Hx

▫Pain, onset, firmness, hx of undescended testis, STD’s, LUTs, urethral discharge

• PE▫Location of mass (testis, epididymis, scrotum)▫Tenderness▫Transilluminance

• Invx’s▫U/A – pyuria with epididymitis▫U/S – ++ Sensitive and specific for testicular

tumors

Approach to Scrotal Mass

•Epididymitis•Orchitis

•Testicular tumor•Paratesticular tumor

• Cystadenoma of epididymis

•Hydrocele•Inguinal hernia•Varicocele•Spermatocele•Testicular Torsion•Appendix Testi Torsion

Infectious Scrotal Mass

Epididymitis▫Young adults – often associated with STI,

chlamydia▫Older adults – often non-STI, E Coli.▫Tender, indurated epididymis

•Orchitis▫AKA Mumps virus.▫Swollen ++ tender testicles, often bilateral.

Approach to Scrotal Mass

•Epididymitis•Orchitis

•Testicular tumor•Paratesticular tumor

• Cystadenoma of epididymis

•Hydrocele•Inguinal hernia•Varicocele•Spermatocele•Testicular Torsion•Appendix Testi Torsion

Anatomic Scrotal Mass• Hydrocele• Fluid within tunica vaginalis• Called “communicating

hydrocoele” if processus vaginalis is patent

• Hx• Typically painless

• PE• Transilluminates• Cannot palpate testicle

• Treatment• No Rx required unless for

cosmetic reasons

Anatomic Scrotal Mass

Spermatocele

Inguinal hernia

Anatomical Scrotal MassSpermatocele• Cystic dilatation (aneurysm)

of epididymal tubule • Hx

• Painless• PE

• Transilluminates• Can palpate body of testicle

separate from the mass• Rx

• No treatment required unless for cosmetic reasons

Anatomical Scrotal Mass

•Varicocele

Anatomical Scrotal Mass• Varicocele

▫ Varicosities of pampiniform plexus 90% on left side; seen in 15% of male population. Associated with male factor infertility but most men with

varicocoeles can expect normal fertility.▫ Hx

Typically asymptomatic, cosmetically “bag of worms” Increases in size with valsalva or standing position.

▫ PE Bag of Spaghetti in scrotum palpating cord.

▫ Rx Surgical or angiographic sclerosis

Results in improvement in semen parameters (number, motility, morphology) in 70% to 90% of cases

Torsion – it hurts!

Anatomical – Acute Scrotum

•Testicular torsion▫Surgical Emergency!!▫Only definitive Diagnosis is Surgical Scrotal

Exploration.▫Typically in 12-18yr olds▫6 hr window prior to irreversible testicular

ischemia▫Associated with ‘Bell Clapper Deformity”▫Detort – “like opening a book”

Testicular Torsion

Anatomic Scrotal Mass/Pain

•Testicular Torsion▫PE

High riding, horizontal testicle. Absent cremasteric reflex Prehn Sign – relief of pain when supporting the

scrotum suggests epidiymitis.▫Investigations

U/A – R/O pyuria (epidiymitis) Doppler U/S

▫Rx Surgical detorsion and Orchidopexy.

Acute Scrotum• Epididymitis

▫ Infection of the epididymis <35yrs of age – Chlamydia, gonorrhea >35yrs of age – E. Coli

▫Hx Pain, Swelling testicle +/- dysuria +/- fever

▫PE Indurated, swollen and acutely painful epididymis, +/-

erythema▫ Invx’s

CBC, U/A +/- Doppler US of testis.▫Rx

Antibiotics x4 weeks + NSAIDS, and Ice PRN

Epididymitis

Acute Scrotum• Torsed Appendix testi

▫May mimic Testicular Torsion▫?Blue Dot sign▫Testi may be inflamed/tender, point tenderness to

appendix testi.▫Not likely elevated, NO horizontal lie

• Invx▫Doppler US to assess testi perfusion▫U/A

• Rx▫Conservative, symptom management if confirmed▫Urological assessment.

Approach to Scrotal Mass

•Epididymitis•Orchitis

•Testicular tumor•Paratesticular tumor

• Cystadenoma of epididymis

•Hydrocele•Inguinal hernia•Varicocele•Spermatocele•Testicular Torsion•Appendix Testi Torsion

Testicular Cancer

•Typically occurs in young healthy Men.

•Very good cure rates Even for Metastatic Disease!

Testicular Cancer

Testicular Cancer

Germ Cell Testicular Cancer

•Seminoma•Non-Seminoma

▫Embryonal Carcinoma▫Teratoma▫Teratocarcinoma (Teratoma +Embryonal

Carcinoma)▫Choriocarcinoma▫Yolk Sac Tumour (typically infants)

Testicular Cancer

Non-Germ Cell Testicular Cancer•Leydig Cell Tumor•Sertoli Cell Tumor

Testicular Cancer

Secondary Testicular Cancer

•Lymphoma•Leukemia

Testicular Cancer

•Presentation▫Typically painless intratesticular mass

discovered on self examination▫Age 15-35

Albeit some tumor subytpes cluster in infancy and 60’s

Testicular Cancer• Investigations

▫Lab B-HCG

Produced by choriocarcinoma & in some Seminomas Alpha-fetoprotein

Produced by Yolk Sac, Embryonal Carcinoma & Teratocarcinoma

LDH Correlates with tumor volume

▫ Imaging Scrotal U/S CT Abdo and Pelvis CXR

Testicular Cancer

•Treatment:▫Radical

Orchiectomy ALWAYS Inguinal

approach NEVER scrotal

approach▫PLUS…

Testicular Cancer•Treatment:

Testicular Cancer

•Seminoma Treatment:▫ Negative CT scan or low volume retroperitoneal

nodes Treated with external beam radiotherapy (2500 cGy)

to the retroperitoneum and ipsilateral pelvic nodes.

• Large volume retroperitoneal dz / Metastatic Dz • Treated with chemotherapy; cis-platinum, bleomycin,

vinblastine is a typical regimen

Testicular Cancer• Non-Seminoma Treatment:

▫Negative CT scan & N tumour markers post orchiectomy Surveillance. OR, Retroperitoneal lymph node dissection may be

done to determine the actual stage and potentially cure patients with low volume nodal mets.

▫Large volume retroperitoneal disease or mets Chemotherapy

cisplatinum, VP-16, bleomycin. Residual teratoma may be seen after successful

chemotherapy and should be excised (RPLND).

Retroperitoneal Lymph Node Dissection