Hematuria and Related Urologic Oncology Jamison S. Jaffe, D.O. Director of Minimally Invasive Urologic Surgery Director of Robotic Surgery Drexel University.

Hematuria and Hematuria and Related Urologic Related Urologic

OncologyOncologyJamison S. Jaffe, D.O.Jamison S. Jaffe, D.O.

Director of Minimally Invasive Director of Minimally Invasive Urologic SurgeryUrologic Surgery

Director of Robotic SurgeryDirector of Robotic Surgery

Drexel University College of Drexel University College of Medicine Hahnemann University Medicine Hahnemann University

HospitalHospital

Urologic OncologyUrologic Oncology

Renal cancerRenal cancer Bladder cancerBladder cancer Ureter / Renal pelvis cancerUreter / Renal pelvis cancer

Renal Cell CarcinomaRenal Cell Carcinoma

3% of all adult malignancies3% of all adult malignancies Male-to-female ratio is 2:1 Male-to-female ratio is 2:1 Projections for 2007Projections for 2007

51,190 estimated cases of RCC 51,190 estimated cases of RCC 12,890 deaths from RCC12,890 deaths from RCC

American American Cancer Society 2007Cancer Society 2007

Increased incidence of 100% Increased incidence of 100% since 1970since 1970

Chow et al. JAMA 1999Chow et al. JAMA 1999

Renal Cell CarcinomaRenal Cell Carcinoma

Typically presents in the 6Typically presents in the 6thth to 7 to 7thth decadedecade

Most lethal of all GU Most lethal of all GU malignanciesmalignancies 40% mortality rate vs. 20% 40% mortality rate vs. 20%

bladder/prostatebladder/prostateLandis et al. J Clin Landis et al. J Clin

Cancer 1999Cancer 1999

Renal Cell CarcinomaRenal Cell Carcinoma EtiologyEtiology

TobaccoTobacco High fat / protein diet (obesity)High fat / protein diet (obesity) CoffeeCoffee Occupational exposuresOccupational exposures

Metal / coke oven / asbestos / cadmiumMetal / coke oven / asbestos / cadmium IatrogenicIatrogenic

RadiationRadiation FamilialFamilial

Von Hippel-Lindau DiseaseVon Hippel-Lindau Disease Hereditary Papillary Renal Cell CarcinomaHereditary Papillary Renal Cell Carcinoma

Renal Cell CarcinomaRenal Cell Carcinoma PresentationPresentation

Classic triad (10%)Classic triad (10%) Hematuria (40%)Hematuria (40%) Flank pain (40%)Flank pain (40%) Palpable mass in the flank or abdomen (25%) Palpable mass in the flank or abdomen (25%)

Asymptomatic – 25% Most common presentationsAsymptomatic – 25% Most common presentations Other signs and symptomsOther signs and symptoms

Weight loss (33%)Weight loss (33%) Fever (20%)Fever (20%) Hypertension (20%)Hypertension (20%) Hypercalcemia (5%)Hypercalcemia (5%) Night sweatsNight sweats MalaiseMalaise Varicocele, (2% of males)Varicocele, (2% of males)

Renal Cell CarcinomaRenal Cell Carcinoma Paraneoplastic syndromes – due to Paraneoplastic syndromes – due to

cytokine releasecytokine release HypercalcemiaHypercalcemia ErythrocytosisErythrocytosis Nonmetastatic hepatic dysfunction (ie, Stauffer Nonmetastatic hepatic dysfunction (ie, Stauffer

syndrome)syndrome) AnemiaAnemia FeverFever CachexiaCachexia Weight lossWeight loss Increased erythrocyte sedimentation rateIncreased erythrocyte sedimentation rate Hypertension Hypertension

Renal Cell CarcinomaRenal Cell Carcinoma

DiagnosisDiagnosis Radiographic diagnosis (CT/MRI)Radiographic diagnosis (CT/MRI) Do not biopsy the mass (not exactly)Do not biopsy the mass (not exactly)

SpreadSpread Needle track seedingNeedle track seeding BleedingBleeding

Surgical removalSurgical removal

Renal Cell CarcinomaRenal Cell Carcinoma PathologyPathology

Conventional (Clear Cell)Conventional (Clear Cell) 70-80%70-80% PapillaryPapillary 10-15%10-15% ChromophobicChromophobic 4-5%4-5% Collecting DuctCollecting Duct <1%<1% Medullary CellMedullary Cell <1%<1%

* Sarcomatoid lesions represent poorly * Sarcomatoid lesions represent poorly differentiated elements of above cell differentiated elements of above cell typestypes

Storkel et al. Storkel et al. Cancer, 1997Cancer, 1997

Renal Cell CarcinomaRenal Cell Carcinoma

TreatmentTreatment Surgery remains the mainstay of Surgery remains the mainstay of

curative treatmentcurative treatment Radical nephrectomyRadical nephrectomy Nephron-sparing surgeryNephron-sparing surgery

Partial nephrectomyPartial nephrectomy Ablative techniquesAblative techniques

CryosurgeryCryosurgery RFARFA

*Open vs. laparoscopic *Open vs. laparoscopic Chemotherapy and radiation not usefulChemotherapy and radiation not useful

Bladder CancerBladder Cancer Bladder cancer is the second most common Bladder cancer is the second most common

GU tumorGU tumor 2004 statistics2004 statistics

60,200 new patients diagnosed60,200 new patients diagnosed 12,700 of those patients died from the disease12,700 of those patients died from the disease

Bladder cancer is more common in whites Bladder cancer is more common in whites than in blacks; however, blacks have a worse than in blacks; however, blacks have a worse prognosis than whites. prognosis than whites.

Male-to-female ratio is 3:1 Male-to-female ratio is 3:1 Women generally have a worse prognosis than Women generally have a worse prognosis than

men. men. The median age at diagnosis is 68 years, and The median age at diagnosis is 68 years, and

the incidence increases with age. the incidence increases with age.

Bladder CancerBladder Cancer EtiologyEtiology

SmokingSmoking – most common – most common Industrial exposuresIndustrial exposures

Aromatic amines in dyes, paints, solvents, Aromatic amines in dyes, paints, solvents, metals, leather dust, inks, combustion metals, leather dust, inks, combustion products, rubber, and textilesproducts, rubber, and textiles

Prior exposure to radiation treatment of Prior exposure to radiation treatment of the pelvisthe pelvis

Chemotherapy with Chemotherapy with cyclophosphamidecyclophosphamide increases the risk of bladder cancerincreases the risk of bladder cancer

AcroleinAcrolein Long-term indwelling catheters Long-term indwelling catheters Coffee – not trueCoffee – not true Artificial sweeteners – not trueArtificial sweeteners – not true

Bladder CancerBladder Cancer PresentationPresentation

Painless gross hematuria (80-90%)Painless gross hematuria (80-90%) Consider all patients with gross hematuria to Consider all patients with gross hematuria to

have bladder cancer until proven otherwisehave bladder cancer until proven otherwise Suspect bladder cancer if any patient presents Suspect bladder cancer if any patient presents

with unexplained microscopic hematuriawith unexplained microscopic hematuria Irritative bladder symptoms (20-30%)Irritative bladder symptoms (20-30%)

DysuriaDysuria UrgencyUrgency Frequency of urination Frequency of urination

Pelvic or bony painPelvic or bony pain Lower-extremity edema Lower-extremity edema Flank pain from ureteral obstructionFlank pain from ureteral obstruction

DefinitionsDefinitions

Microscopic HematuriaMicroscopic Hematuria Presence of 3 or more RBC per hpfPresence of 3 or more RBC per hpf 3 % of normal individuals will 3 % of normal individuals will

excrete up to 3 RBCexcrete up to 3 RBC Gross HematuriaGross Hematuria

Presence of blood in the urine that Presence of blood in the urine that is visible to the naked eyeis visible to the naked eye

Hematuria EvaluationHematuria Evaluation

UA UA Urine cultureUrine culture ± Cytology± Cytology Upper tract imaging Upper tract imaging

CT/MRI ± contrastCT/MRI ± contrast CystoscopyCystoscopy

Hematuria DDxHematuria DDx

S – StonesS – Stones H – HematologicH – Hematologic I – InfectionI – Infection T – TumorsT – Tumors T – TraumaT – Trauma T – TBT – TB S - StricturesS - Strictures

Diagnosis and StagingDiagnosis and Staging

CystoscopyCystoscopy

Diagnosis and StagingDiagnosis and Staging

Transurethral ResectionTransurethral Resection

Bladder CancerBladder Cancer

PathologyPathology Transitional cell carcinomas (TCC) (90%)Transitional cell carcinomas (TCC) (90%) Squamous cell carcinoma (SCC) (5%)Squamous cell carcinoma (SCC) (5%) Adenocarcinomas (2%)Adenocarcinomas (2%) Nonurothelial primary bladder tumors Nonurothelial primary bladder tumors

(<3%)(<3%) Small cell carcinomaSmall cell carcinoma CarcinosarcomaCarcinosarcoma Primary lymphomaPrimary lymphoma Sarcoma Sarcoma

Bladder CancerBladder Cancer

Pathology tidbitsPathology tidbits SCC is the most common form SCC is the most common form

worldwide (75%)worldwide (75%) US associated with persistent inflammation US associated with persistent inflammation

from long-term indwelling Foley catheters from long-term indwelling Foley catheters and bladder stonesand bladder stones

Underdeveloped nations, SCC is associated Underdeveloped nations, SCC is associated with bladder infection by with bladder infection by Schistosoma Schistosoma haematobium haematobium

Adenocarcinomas Adenocarcinomas Observed most commonly in bladders Observed most commonly in bladders

extrophy or in the urachusextrophy or in the urachus

Bladder Cancer StagingBladder Cancer Staging

Bladder CancerBladder Cancer

Superficial bladder cancerSuperficial bladder cancer 75% recurrence75% recurrence 25% progress to muscle invasive25% progress to muscle invasive

Bladder CancerBladder Cancer TreatmentTreatment

Superficial cancerSuperficial cancer ± Intravesical treatment (BCG/Mitomycin C)± Intravesical treatment (BCG/Mitomycin C) Surveillance cystoscopySurveillance cystoscopy Repeat TURBT if it recursRepeat TURBT if it recurs

Muscle invasive cancerMuscle invasive cancer Radical cystectomyRadical cystectomy

Male – bladder and prostateMale – bladder and prostate Females – bladder, urethra, uterus, ovaries, and Females – bladder, urethra, uterus, ovaries, and

anterior vaginal wallanterior vaginal wall Diversion vs. neobladderDiversion vs. neobladder

Bladder preservationBladder preservation Chemotherapy and radiation (gemcitabine and Chemotherapy and radiation (gemcitabine and

cisplatin)cisplatin)

Urothelial Tumors of the Urothelial Tumors of the Renal Pelvis and UreterRenal Pelvis and Ureter

BackgroundBackground RareRare

Renal pelvis – 10% of all renal tumorsRenal pelvis – 10% of all renal tumors Ureter – ¼ the incidence of renal pelvis Ureter – ¼ the incidence of renal pelvis

tumorstumors Mean age – 65 yearsMean age – 65 years Male to female ratio 3:1Male to female ratio 3:1 Balkan nephropathyBalkan nephropathy

100-200x increase risk of upper tract 100-200x increase risk of upper tract TCCTCC

Urothelial Tumors of the Urothelial Tumors of the Renal Pelvis and UreterRenal Pelvis and Ureter

EtiologyEtiology Tobacco (3x ↑)Tobacco (3x ↑)

Most strongly associated with upper tract TCCMost strongly associated with upper tract TCC Coffee (> 7 cups/day)Coffee (> 7 cups/day) Analgesic abuseAnalgesic abuse Occupational exposureOccupational exposure

Petrochemical, plastic, and tar industriesPetrochemical, plastic, and tar industries Chronic infectionsChronic infections Chronic irritationChronic irritation CyclophosphamideCyclophosphamide

Urothelial Tumors of the Urothelial Tumors of the Renal Pelvis and UreterRenal Pelvis and Ureter

PathologyPathology Transitional cell carcinoma – 90%Transitional cell carcinoma – 90% Squamous cell carcinoma - 1-7%Squamous cell carcinoma - 1-7% Adenocarcinoma - <1%Adenocarcinoma - <1%

LocationLocation Renal pelvis - 58% Renal pelvis - 58% Ureter - 35% Ureter - 35% Both renal pelvis and ureter - 7% Both renal pelvis and ureter - 7% Bilateral - 2-5% Bilateral - 2-5%

Urothelial Tumors of the Urothelial Tumors of the Renal Pelvis and UreterRenal Pelvis and Ureter

SymptomsSymptoms Gross or microscopic hematuria Gross or microscopic hematuria

(75%) (75%) Flank pain (18%) Flank pain (18%) Dysuria (6%) Dysuria (6%) Advanced diseaseAdvanced disease

Weight loss, anorexia, flank mass, or Weight loss, anorexia, flank mass, or bone pain bone pain

Urothelial Tumors of the Urothelial Tumors of the Renal Pelvis and UreterRenal Pelvis and Ureter

DiagnosisDiagnosis CT scan / MRI (hematuria CT scan / MRI (hematuria

evaluation)evaluation) Cystoscopy ± retrograde pyelogramCystoscopy ± retrograde pyelogram

““Goblet sign”Goblet sign” Ureteroscopy with biopsyUreteroscopy with biopsy

““Goblet Sign”Goblet Sign”

Urothelial Tumors of the Urothelial Tumors of the Renal Pelvis and UreterRenal Pelvis and Ureter

TreatmentTreatment Nephroureterectomy with excision Nephroureterectomy with excision

of the bladder cuff (gold standard)of the bladder cuff (gold standard) Nephron sparring surgeryNephron sparring surgery

Segmental ureterectomy coupled with Segmental ureterectomy coupled with ureteral reimplantation ureteral reimplantation

Tumors located in the distal ureter Tumors located in the distal ureter Ipsilateral recurrence rate is 25%Ipsilateral recurrence rate is 25%

Ureteroscopic treatment Ureteroscopic treatment Small, low-grade superficial lesions are the Small, low-grade superficial lesions are the

best candidates for this approachbest candidates for this approach