Bladder-Renal Cancer – Suspected Nice guidance link: https://www.nice.org.uk/guidance/ng2 Bladder/renal cancer - clinical presentation Click for more info Visible haematuria (VH) Suspicious kidney/ bladder lesion on imaging (e.g. incidental finding) Non-visible haematuria (NVH) Click for more info Aged ≥ 60 years and recurrent/persistent unexplained UTI Initial investigations - excluding UTI Click for more info Abnormal DRE+/- raised age-specific PSA Click for more info See pathway Prostate Cancer - Suspected pathway UTI excluded or haematuria persists after treatment Click for more info AGE ≥ 45 years and visible haematuria without UTI or persists/ recurs after successful treatment of UTI URGENT 2WW referral for suspected urology cancer All other patients with VH, consider non-urgent referral to urologist/ nephrologist If aged <40 years refer to a nephrologist If aged ≥ 40 years refer to a urologist Initial investigations - excluding UTI Click for more info UTI - treat and repeat dipstick following treatment No UTI See pathways UTI in Females Symptomatic NVH - dysuria Age ≥60 years Age <60 years URGENT 2WW referral for suspected urology cancer Asymptomatic NVH Repeat dipstick Click for more info Click for more info Persistent aNVH (2/3 samples) NVH is not persistent Low risk of cancer Investigations: FBC, creatinine & eGFR, urine for ACR or PCR Click for more info Any age & persistent aNVH - no proteinuria & normal eGFR Age ≥ 60 years and raised WBC URGENT 2WW referral for suspected urology cancer GP to order ultrasound of kidneys Non-urgent referral regardless of ultrasound result If aged <40years non- urgent referral to a nephrologist If aged ≥ 40years non- urgent referral to a urologist Significant proteinuria Reduced eGFR Click for more info for patients URGENT 2WW referral for suspected urology cancer Consider non-urgent referral to urology for bladder cancer Click for more info Click for more info Refer to urology Click for more info Click for more info Click for more info No follow-up needed unless patient presents with other symptoms or re-present Click for more info If proteinuria significant refer to nephrology (non-urgent) Click for more info Manage and consider referring to nephrology Click for more info See pathway UTI in Males
19
Embed
Bladder-Renal Cancer Suspected Bladder/renal cancer ... · Visible haematuria (VH) · VH should be investigated and managed in the same way irrespective of any anticoagulant or antiplatelet
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Clinical presentation· painless haematuria is the most common presentation
· may also present with:
· dysuria
· increased frequency
· pelvic pain and symptoms related to urinary tract obstruction - may occur in more advanced tumours
· persistent or recurrent urinary tract infections associated with haematuria
· rarely patients will present with symptoms of metastases
Visible haematuria (VH)· VH should be investigated and managed in the same way irrespective of any anticoagulant or antiplatelet medication
· also referred to as 'macroscopic', 'gross', or 'frank' haematuria
· urine that is coloured pink or red - occasionally appearance of 'coca cola' urine in acute glomerulonephritis
· includes symptom reported by patient or seen by healthcare professional
· any single episode of VH is considered significant haematuria
Other causes of urine discoloration:
· exercise induced haematuria
· beeturia
· drug discolouration – rifampicin, doxorubicin
· myoglobinuria – rare
Back to pathway
Back to pathway
Non-visible haematuria (NVH)Also called 'microscopic' or 'dipstick positive' haematuria
NVH can be divided into:• symptomatic non-visible haematuria (sNVH):
• occurs in the presence of symptoms, such as LUTS:• hesitancy• frequency• urgency• dysuria
• any single episode of sNVH is considered significant haematuria - UTI and other transient causes must be excluded first
• asymptomatic non-visible haematuria (aNVH):• is an incidental detection of haematuria in the absence of LUTS or upper urinary tract symptoms• persistent aNVH is considered significant haematuria:
• persistent is defined as 2 out of 3 positive urine dipstick results for non-visible haematuria (NVH)• must exclude UTI and transient causes first
Use urine dipstick samples where possible as this is considered a sensitive method of haematuria detection:• samples should be fresh voided urine without preservatives• significant haematuria is 1+ or greater - trace haematuria is not significant• both non-haemolysed and haemolysed dipstick positive haematuria should be considered of equal significance• routine microscopy to confirm dipstick haematuria is not needed• NB: community based urine samples sent for microscopy have a significant false negative rate
Back to pathway
Initial investigations - includes excluding UTI
• exclude transient causes of haematuria, including UTI:
• a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites
• if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture – negative pyuria and culture excludes UTI
• urine dipstick should be repeated following treatment of a UTI
• consider a PSA test and a digital rectal examination to assess for prostate cancer in men with visible haematuria
• consider direct access ultrasound scan to assess for endometrial cancer if vaginal bleeding cannot be excluded.
Back to pathway
Abnormal DRE+/- raised age-specific PSA
Suspect prostate cancer if:• DRE abnormal or• Raised age-specific PSA levels (ng/ml):
• Age <50yrs = >2.5• Age 50-59 = >3.0• Age 60-69 = >4.0• Age 70-79 = >5.0• Age >80 = >20.0
Reference: Best Practice Commissioning Pathway: Prostate Cancer, East Midlands Strategic Clinical Networks, 2015.
Back to pathway
UTI excluded or haematuria persists after treatment
If UTI excluded or haematuria persists after treatment conduct any investigations not already performed above plus plasma
creatinine and estimated glomerular filtration rate (eGFR).
Guidelines differ regarding referral for visible haematuria:
• recently published guidelines by NICE recommend urgent referral using a suspected cancer pathway referral for renal and bladder cancer, to be seen within 2 weeks for:
• patients age 45 years and older with:
• unexplained visible haematuria without UTI; or
• visible haematuria that persists or recurs after successful treatment of a UTI
• the 2008 British Association of Urological Surgeons (BAUS) haematuria guidelines recommend referral to urology for all patients with visible haematuria, regardless of age
Some patients younger than age 40 years with cola-coloured urine and an intercurrent infection (usually an upper respiratory tract infection) will have acute glomerulonephritis:
• refer to nephrology if suspected
NB: It is unclear from current guidelines how to optimally monitor patients with recurrent intermittent visible haematuria (VH), who have had negative investigations in secondary care. Expert opinion suggests a pragmatic approach is that such patients should be investigated every 5 years.
Back to pathway
Initial investigations
• urine dipstick:
• haematuria:
• significant haematuria is 1+ or greater
• trace haematuria is not significant and should be considered negative
• proteinuria
Transient causes must be excluded before the presence of significant haematuria can be established:
• UTI:
• a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites
• if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture – negative pyuria and culture excludes UTI
Back to pathway
Repeat Dipstick
Asymptomatic non-visible haematuria (aNVH) should be confirmed by a repeat dipstick of the urine:
· persistent aNVH is considered significant haematuria - persistent is defined as 2 out of 3 positive urine dipstick results for nonvisible haematuria (NVH)
Use urine dipstick samples where possible as this is considered a sensitive method of haematuria detection:
· samples should be fresh voided urine without preservatives
· significant haematuria is 1+ or greater - trace haematuria is not significant
· both non-haemolysed and haemolysed dipstick positive haematuria should be considered of equal significance
· routine microscopy to confirm dipstick haematuria is not needed
NB: community based urine samples sent for microscopy have a significant false negative rate
Back to pathway
Investigations: FBC, creatinine & eGFR, urine for ACR or PCR
Full blood count (to exclude raised white cell count as per NICE cancer guidelines)• urine protein: creatinine ratio (PCR) or albumin:creatinine ratio (ACR):
• evaluate the presence of significant proteinuria:• ACR of 30mg/mmol or more; or• PCR 50mg/mmol or more
• plasma creatinine and estimated glomerular filtration rate (eGFR)• DRE in males
Consider:• prostate specific antigen (PSA) testing in male patients, especially if prostate feels abnormal, in the absence of a proven UTI• consider direct access ultrasound scan to assess for endometrial cancer if vaginal bleeding cannot be excluded.
Back to pathway
No UTI
· a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites· if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture - negative pyuria and culture excludes UTI
No UTI
· a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites· if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture - negative pyuria and culture excludes UTI
Back to pathway
Symptomatic NVH – dysuria
Recently published guidelines by NICE recommend referring urgently for suspected bladder cancer (within 2 weeks) if:· 60 years and older with unexplained non-visible haematuria and either:
· dysuria; or· raised white cell count on a blood test
Symptomatic NVH – dysuria
Recently published guidelines by NICE recommend referring urgently for suspected bladder cancer (within 2 weeks) if:· 60 years and older with unexplained non-visible haematuria and either:
· dysuria; or· raised white cell count on a blood test
Back to pathway
Refer to urology
The 2008 British Association of Urological Surgeons (BAUS) guidelines recommend referral to a urologist for:
· all patients with symptomatic non-visible haematuria (s-NVH), regardless of age
Refer to urology
The 2008 British Association of Urological Surgeons (BAUS) guidelines recommend referral to a urologist for:
· all patients with symptomatic non-visible haematuria (s-NVH), regardless of age
Back to pathway
Persistent aNVH (2/3 samples)
Persistent aNVH is considered significant haematuria - persistent is defined as 2 out of 3 positive urine dipstick results for non-visible haematuria (NVH). These patients should be further investigated
Persistent aNVH (2/3 samples)
Persistent aNVH is considered significant haematuria - persistent is defined as 2 out of 3 positive urine dipstick results for non-visible haematuria (NVH). These patients should be further investigated
Back to pathway
NVH is not persistent
If subsequent two dipstick samples are negative; i.e. only one out of three (the first of three) samples was positive and the subsequent samples were negative
NVH is not persistent
If subsequent two dipstick samples are negative; i.e. only one out of three (the first of three) samples was positive and the subsequent samples were negative
Back to pathway
Any age & persistent aNVH - no proteinuria & normal eGFR
GPs should order:· ultrasound of the kidneys and· refer if aged ≥40 to a urologist or· refer if aged <40 to a nephrologist
Any age & persistent aNVH - no proteinuria & normal eGFR
GPs should order:· ultrasound of the kidneys and· refer if aged ≥40 to a urologist or· refer if aged <40 to a nephrologist
Back to pathway
Significant proteinuria
Evaluate the presence of significant proteinuria:· albumin: creatinine ratio (ACR) of 30mg/mmol or more; or· urine protein: creatinine ratio (PCR) 50mg/mmol or more
Significant proteinuria
Evaluate the presence of significant proteinuria:· albumin: creatinine ratio (ACR) of 30mg/mmol or more; or· urine protein: creatinine ratio (PCR) 50mg/mmol or more
Back to pathway
Manage and consider referring to nephrology
For patients with reduced eGFR manage according to results in the context of patients preferences and co-morbidities
Manage and consider referring to nephrology
For patients with reduced eGFR manage according to results in the context of patients preferences and co-morbidities
Back to pathway
Recommended resources for patients and carers
Action Bladder Cancer UK - http://actionbladdercanceruk.org/
Bladder Cancer from Cancer Research UK - http://www.cancerresearchuk.org/about-cancer/type/bladder-cancer/
Bladder Cancer leaflet - http://patient.info/health/bladder-cancer-leaflet
Bladder Cancer from Macmillan - http://www.macmillan.org.uk/cancerinformation/cancertypes/bladder/bladdercancer.aspx