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
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 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
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