Urology Hematuria Stones - PowerPoint Presentation

1. UrologyHematuria Stones Tumours

2. OutlineHematuriaDDx General Work upRenal ColicStonesMalignancyRenalBladder Scrotal masses

3. HematuriaObjectives1. Taking a Hx.2. Lab & Radiologic Invx’s.3. Which pt’s to refer to Urologist.

4. Hematuria

5. Hematuria General ApproachMyo/hemoglobinuriaCoagulation disordersPseudohematuria(beets, dyes, laxatives)GlomerulonephrititiesAV FistulasVascular MalformationsInfectionTumor StonesInfection TraumaTumorsGU Endometriosis

6. HematuriaEtiology by Age AgeEtiology in order of frequency0-20Glomerulonephritis, UTI, congenital anomalies20-40UTI, stones, bladder tumor40-60Male: Bladder tumor, stones, UTIFemale: UTI, stones, bladder tumor>60Male: BPH, bladder tumor, UTIFemale: Bladder tumor, UTI

7. Hematuria General ApproachMyo/hemoglobinuriaCoagulation disordersPseudohematuria(beets, dyes, laxatives)GlomerulonephrititiesAV FistulasVascular MalformationsInfectionTumor StonesInfection TraumaTumorsGU Endometriosis

8. Hematuria DDxStonesInfectionsTumoursTrauma

9. Hematuria HPIStones:Flank/Abdo pain, dysuria, PHx Stones.Infection:Suprapubic pain, dysuria, frequency, fever/chills +/- flank pain.MalignancyWt loss, night sweats, flank pain, voiding changes, Occupational Hx (petroleum exposure), smoking Hx, FMHx of CancerTraumaRecent encounters with Chuck Norris.

10. 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.

11. Hematuria InvxRadiology InvestigationsPainless Gross Hematuria Triphasic CT: arterial/venous/ureteric phasesMicroscopic HematuriaStart 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

12. HematuriaImaging ModalityProsConsIVP1. Good choice for suspected stones or Transitional tumors of bladder or ureter.Expensive.Radiation.May miss small renal Tumors.Contrast allergies, NephrotoxicU/SNo ionizing radiation.Inexpensive.Can identify tumor or stoneMay miss stones, ureteric & bladder tumors.Unable to differentiate tumors from blood clot.CT non contrastUsed for Renal Colic – best at identifying stonesAccurate staging of Malignancy if presentIonizing radiation exposure.Risk to fetus in PregnancyCT contrast (triphasic)Useful identifying abscesses, fluid collections.Ureteric phase – identifies filling defects.Contrast allergy.Contrast makes visualizing stones difficult

13. Hematuria ReferralWhen 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, ImagingInitial management and stabilization of pt.

14.

15.

16. Retrograde Pyelogram

17. Hematuria Acute RxABC’s.Stabilize Pt, Blood products if needed.Invx to determine causeTreat underlying cause.Continuous Bladder IrrigationCall Urology.Manually irrigate all clots out of bladder first!Surgical managementCystoscopy + Fulgaration.Hyperbaric OxygenIR embolization.Cystectomy and Urinary diversion.

18. Hematuria Summary1. Painless Gross HematuriaMalignancy until proven otherwise.2. Stones, infections & trauma Rarely asymptomatic  Hx.. Hx.. Hx..3. Workup Hx, PE Lab: CBC, Cr, U/A C&S, INR/PTTImaging: CT or U/SReferral to Urologist: cystoscopy +/- Retrograde pyelogram4. ManagementStabilize Pt, +/- CBI, +/- Surgical intervention

19. Hematuria CasesGeeyu 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…

20. OutlineHematuriaDDx General Work upRenal ColicStonesMalignancyRenalBladder Scrotal masses

21. Stones

22. Renal ColicObjectives;Give a differential diagnosis for acute flank pain including two life-threatening conditionsDescribe the laboratory and radiologic evaluation of a patient with renal colicKnow 4 different kinds of kidney stones and the risk factors for stone formationKnow 3 indications for emergency drainage of an obstructed kidney

23. Renal Colic DDxLife Threatening: Abdominal Aortic DissectionAbdominal Aortic Aneurysm RuptureAppendicits Ectopic PregnancySeptic Stone GICholecystitisBiliary ColicAcute PancreatitisDiverticulitisDuodenal UlcerInflammatory Bowel DiseaseViral gastritisSplenic InfarctGynePelvic inflammatory DiseaseOvarian Torsion/RuptureEndometriosisGURenal/Ureteric CalculiRenal AbscessPyelonephritisRenal Vein ThrombosisAcute GlomerulonephritisOtherAcute lumber disc herniationHerpes ZosterFitz-Hugh-Curtis Syndrome

24. Renal Colic InvxRocky, 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?

25. Stones – Acute Lab Invx’sCBCWBC – increased indicates inflammation or infection.CreatinineAssess for impaired renal function (obstruction).Urine MicroscopyBacteriuria, pyuria, pH

26. Renal Colic – 1st Imaging TestPlain Film KUB!~85% of stones are Radio-opaque on plain film.No info on degree of obstruction though.

27. Renal Colic – Other imaging optionsIVPIntravenous PyelogramVisualizes most stones (radiolucent stones will appear as filling defects)Excellent Functional StudyRequires IV contrast, thus risk of allergic reactions and nephrotoxicity

28. Renal Colic – Radiologic EvaluationCT Scan, hold the contrast.Aka CT-KUB.Fast InexpensiveImaging choice in most emergency rooms.Degree of obstruction inferred by presence of hydronephrosis.

29. Stones - FactoidsThey are common! Lifetime risk in North American Male is 1 in 8.M:F ratio is 3:1Presenting complaintRenal colic due to acute obstruction of ureter by stone.Initial EvaluationFocuses on excluding other potential causes of abdominal or flank pain.Non-obstructing stonesShould not cause pain unless they are associated with Urinary tract infection.

30. Ureteric Stone3 Common sites of Obstruction

31. Ureteric StonesSpontaneous passage?Pharmacologic aid in spontaneous passage?Alpha blockers! FlomaxSizeLikelihood4mm or less90%5-7mm50%8mm or larger20%

32. Renal and Ureteric StonesSo you have established that there is a stone.When is ‘immediate’ referral to a Urologist Necessary?

33. Immediate Referral to UrologyObstructed ureter + Fevers/chills, bacteriuria or elevated WBCRisk of Urosepsis - emergencyObstructed Ureter + Insulin dependent DMRisk of papillary necrosis or emphysematous pyelonephritisSolitary KidneySignificant co-morbid conditions Eg. CHF, pregnancy etc.

34. Common Types of Stones

35. Calcium OxalateMost common type.Risk Factors:Dietary Hyperoxaluria: chocolate, nuts, tea, strawberries, peanut butter, cabbage or excessive restriction of dietary calcium.HypercalciuriaInherited increased absorption, or incr PTHDietary Hypercalciuria

36. Calcium PhosphateSecond most common stone type.Often seen in pt’s with Metabolic Abnormalities:Primary Hyperparathyroidism.Distal Renal tubular acidosis.Hypercalcemia due to Malignancy or Sarcoid.

37. Uric AcidRadiolucent on Plain X-Rays, but is visualized on CT scanRisk Factors:Persistent Acidic urine: ie lLow urine volumesChronic diarrheaExcessive sweating Inadequate fluid intake Gout (Hyperuricemia)Excess dietary purine (Meataholics)Chemotherapy for lymphoma, leukemia

38. Struvite (Infection Stones)Composed of MAP Magnesium + Ammonium Phosphate & CalciumCan only form if urine pH >8.0!Thus: usually only in presence of urease +ve bacteriaProteus, Klebsiella, Providentia, Pseudomonas, Staph AureusNote: E Coli does NOT produce ureaseTend to form Staghorn stones

39.

40. Relieving Obstruction

41. Ureteric Stents“Double J Stents”Stay in place b/c of curled endsCan place these Antegrade or RetrogradeTypically requires General Anesthetic.Low risk of bleeding.

42. Percutaneous Nephrostomy Tubes“Neph Tubes”Placed under local anesthetic by Interventional RadiologyIncreased Risk of Bleeding.

43. Treating/Removing StonesWays to Treat stones.Conservative passage + Alpha Blocker (Flomax) + Hydration + NSAID (if Normal GFR)Extracorporeal Shockwave Lithotripsy (ESWL)Ureteroscopy + Basket or LaserPercutaneous Nephrolithotomy

44. Treating StonesConservative passage + Alpha Blocker (Flomax) + Hydration + NSAID (if Normal GFR)IndicationsPain can be controlled with Ketorolac + NarcoticNo renal impairmentNo Intractable Vomiting (aka pt not hypovolemic)No sign of infection.No previous failed trials of conservative passage.

45. Treating StonesExtracorporeal Shockwave lithotripsyIndication: <~1.5cm renal or ureteric stone.Stone is localized by X-Ray.~3000 Shocks targeted to gradually fragment stone.Fragments passed in urine.

46. Treating StonesUreteroscopy+ BasketIf stone is small enough to adequately remove by basket.+ Holmium LaserIf stone is ‘impacted’ or cannot simply be basketed out.

47.

48.

49. Treating StonesPercutaneous NephrolithotomyIndicationsLarge Proximal ureteric or Renal Calculi >~1-1.5cmTreatment of Staghorn CalculiRisks:BleedingRenal Perforation or Avulsion

50.

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

52. OutlineHematuriaDDx General Work upRenal ColicStonesMalignancyRenalBladder Scrotal masses

53. Renal MassObjectives:Give a differential diagnosis for a solid mass in the kidney.Describe the evaluation of a patient with a suspected renal cell carcinomaGive three indications for a partial nephrectomy rather than a radical nephrectomy for renal cell carcinoma.

54. Renal TumorsPresentation:Incidental finding!Triad: Flank pain, hematuria, palpable mass (not common)How do you ‘work-up’ a Renal mass?

55. Renal Mass InvestigationsImagingCT Abdo pelvis + contrastCharacterize Mass and assess for tumor extension, IVC thrombus, Nodes, Mets, abnormalities to contralateral kidney.CXRAssess for metsLaboratoryAlk Phos (bone mets)LE’s  hepatic/portal vein involvmentCalcium Biopsy?Recommended only when Dx is unclear.

56. Why Investigate Calcium?Bone Mets or Paraneoplastic syndrome!20-30% of RCC have Paraneoplastic SyndromeIncreased ESRWt loss, cachexiaFeverAnemiaHypertension (incr Renin)Hypercalcemia (PTH-like Substance)Incr ALPPolycythemia (incr EPO production)Stauffer’s syndrome – reversible hepatitis

57. Renal TumorsOncocytomaAngiomyolipomaPsuedotumourDromedary HumpHypertrophied column of BertinCompensatory Hypertrophy etcRenal Cell CarcinomaTransitional Cell CarcinomaWilms Tumour (peds)MetastasisLymphoma/leukemiaLungBreast

58. Benign TumorsKnow that they exist.DDx:Oncocytoma, angiomyolipoma (1-2% malignant), papillary adenoma, pseudotumors etc….Differentiating pseudotumors from real tumors.DMSA scanPseudotumors will have normal uptake, tumors will be decreased.

59. Benign Renal MassesAngiomyolipomaDiagnosed if any part of renal mass consists of adipose.Composed of Fat – smooth muscle – blood vesselsRisk of hemorrhage near 50% once size >4cm

60. Malignant Renal Cell CarcinomaAccounts for 90% of solid renal masses.Several different subtypesClear Cell is most common25% present with Mets

61. Renal Cell CarcinomaTreatmentLocal confined massNephrectomy Partial NephrectomySolitary kidney or significant renal impairmentBilateral tumorsVon Hippel-Lindau SyndromeSmall tumor <4cmMetastatic RCCCombination of Nephrectomy + Chemo (Sunitinib)

62. 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%

63. Other Malignant Renal TumorsRenal Transitional Cell CarcinomaBecause Transitional cells line renal pelvis, ureters & bladder, must perform nephroureterectomy to Rx.Wilm’s TumorPedsSarcomaMetastasis to KidneyLeukemia, lymphomaLungBreast

64.

65. Bladder CancerObjectives:State 3 risk factors for transitional cell carcinoma of the bladderState the treatment options for superficial and invasive TCC of the bladder

66. Bladder CancerOften presents as painless gross hematuria!Recall workup for gross hematuria:Upper tract imaging CT Abdo/pelvisCystoscopyDiagnosisCystoscopy + BiopsyTransurethral resection of lesion and underlying detrusor muscle to stage tumorUrine CytologyCt Abdo/pelvis for staging.

67. Bladder CancerRisk FactorsSMOKING (RR 4 vs non smokers)Occupational ExposureAniline dyes, aromatic aminesIe. Textile manufacturing, dry cleaning, painting)Previous Cyclophosphamide(ie chemo for lymphoma)Previous Radiaiton Rx in pelvis

68. Bladder CancerDDxTransitional Cell carcinomaMost common!AdenocarcinomaDome of bladder, associated with Urachus.Squamous Cell CarcinomaAssociated with chronic inflammation Indwelling foley’s, bladder stones.

69. Transitional Cell CarcinomaStagingNon-invasiveTis, Ta, T1 diseaseInvasive>T1 disease (muscle invasive

70.

71. Treatment of Non-invasive TCC1. Transurethral resection of lesion2. PLUS intravesical chemotherapy IF:Carcinoma in-situMulti focal tumorsUnable to completely resect transurethrallyRapid recurrence after initial resectionSuperficial, high grade tumorLamina propria invasion (Stage T1)

72. Treatment of Non-invasive TCCIntravesical Chemotherapeutic Agents:Bacille Calmette-Guerin (BCG)MitomycinDoxorubicinThiotepa

73. Treatment of Non-Invasive TCCBut….IF:Persistent CIS after intravesical chemotherapyExtensive superficial tumors that cannot be resected.Then Pt will require Radical Cystectomy and Urinary diversion for curative intent.

74. Treatment of Invasive TCCRadical Cystectomy+/- Chemotherapy for metastatic diseaseIf palliative, may still require cystectomy if uncontrollable hematuria (requiring transfusions etc)

75. Radical Cystectomy + Urinary DiversionOnce Bladder is removed…Urinary diversion is neededIleal ConduitPros – simple, least complicationsCons – abdominal stoma, no continence.NeobladderPros – continent with use of cathetersCons – Increased surgical complications, increased risk of metabolic derrangements.

76. Ileal Conduits

77. Neobladders

78. Scrotal MassObjectivesDifferential diagnosis of a scrotal massKnow how to diagnose and treat testicular torsionClassify testicular tumorsTreatment of testicular malignancies

79. Approach to Scrotal MassEpididymitis**Orchitis**Testicular tumorParatesticular tumorCystadenoma of epididymisHydroceleInguinal herniaVaricoceleSpermatoceleTesticular Torsion**Appendix Testi Torsion**** = painful

80. Approach to Scrotal MassHxPain, onset, firmness, hx of undescended testis, STD’s, LUTs, urethral dischargePELocation of mass (testis, epididymis, scrotum)TendernessTransilluminanceInvx’sU/A – pyuria with epididymitisU/S – ++ Sensitive and specific for testicular tumors

81. Approach to Scrotal MassEpididymitisOrchitisTesticular tumorParatesticular tumorCystadenoma of epididymisHydroceleInguinal herniaVaricoceleSpermatoceleTesticular TorsionAppendix Testi Torsion

82. Infectious Scrotal MassEpididymitisYoung adults – often associated with STI, chlamydiaOlder adults – often non-STI, E Coli.Tender, indurated epididymisOrchitisAKA Mumps virus.Swollen ++ tender testicles, often bilateral.

83. Approach to Scrotal MassEpididymitisOrchitisTesticular tumorParatesticular tumorCystadenoma of epididymisHydroceleInguinal herniaVaricoceleSpermatoceleTesticular TorsionAppendix Testi Torsion

84. Anatomic Scrotal MassHydroceleFluid within tunica vaginalisCalled “communicating hydrocoele” if processus vaginalis is patentHxTypically painlessPETransilluminatesCannot palpate testicleTreatmentNo Rx required unless for cosmetic reasons

85. Anatomic Scrotal MassSpermatoceleInguinal hernia

86. Anatomical Scrotal MassSpermatoceleCystic dilatation (aneurysm) of epididymal tubule HxPainlessPETransilluminatesCan palpate body of testicle separate from the massRxNo treatment required unless for cosmetic reasons

87. Anatomical Scrotal MassVaricocele

88. Anatomical Scrotal MassVaricoceleVaricosities 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.HxTypically asymptomatic, cosmetically “bag of worms”Increases in size with valsalva or standing position. PEBag of Spaghetti in scrotum palpating cord.RxSurgical or angiographic sclerosisResults in improvement in semen parameters (number, motility, morphology) in 70% to 90% of cases

89. Torsion – it hurts!

90. Anatomical – Acute ScrotumTesticular torsionSurgical Emergency!!Only definitive Diagnosis is Surgical Scrotal Exploration.Typically in 12-18yr olds6 hr window prior to irreversible testicular ischemiaAssociated with ‘Bell Clapper Deformity”Detort – “like opening a book”

91. Testicular Torsion

92. Anatomic Scrotal Mass/PainTesticular TorsionPEHigh riding, horizontal testicle.Absent cremasteric reflexPrehn Sign – relief of pain when supporting the scrotum suggests epidiymitis.InvestigationsU/A – R/O pyuria (epidiymitis)Doppler U/SRxSurgical detorsion and Orchidopexy.

93. Acute ScrotumEpididymitisInfection of the epididymis<35yrs of age – Chlamydia, gonorrhea>35yrs of age – E. ColiHxPain, Swelling testicle +/- dysuria +/- feverPEIndurated, swollen and acutely painful epididymis, +/- erythemaInvx’sCBC, U/A +/- Doppler US of testis.RxAntibiotics x4 weeks + NSAIDS, and Ice PRN

94. Epididymitis

95. Acute ScrotumTorsed Appendix testiMay mimic Testicular Torsion?Blue Dot signTesti may be inflamed/tender, point tenderness to appendix testi.Not likely elevated, NO horizontal lieInvxDoppler US to assess testi perfusionU/ARxConservative, symptom management if confirmedUrological assessment.

96. Approach to Scrotal MassEpididymitisOrchitisTesticular tumorParatesticular tumorCystadenoma of epididymisHydroceleInguinal herniaVaricoceleSpermatoceleTesticular TorsionAppendix Testi Torsion

97. Testicular CancerTypically occurs in young healthy Men.Very good cure rates Even for Metastatic Disease!

98. Testicular Cancer

99. Testicular Cancer

100. Germ Cell Testicular CancerSeminomaNon-SeminomaEmbryonal CarcinomaTeratomaTeratocarcinoma (Teratoma +Embryonal Carcinoma)ChoriocarcinomaYolk Sac Tumour (typically infants)

101. Testicular Cancer

102. Non-Germ Cell Testicular CancerLeydig Cell TumorSertoli Cell Tumor

103. Testicular Cancer

104. Secondary Testicular CancerLymphomaLeukemia

105. Testicular CancerPresentationTypically painless intratesticular mass discovered on self examinationAge 15-35Albeit some tumor subytpes cluster in infancy and 60’s

106. Testicular CancerInvestigationsLabB-HCGProduced by choriocarcinoma & in some SeminomasAlpha-fetoproteinProduced by Yolk Sac, Embryonal Carcinoma & TeratocarcinomaLDHCorrelates with tumor volumeImagingScrotal U/SCT Abdo and PelvisCXR

107. Testicular CancerTreatment:Radical OrchiectomyALWAYS Inguinal approachNEVER scrotal approachPLUS…

108. Testicular CancerTreatment:

109. Testicular CancerSeminoma 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

110. Testicular CancerNon-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).

111. Retroperitoneal Lymph Node Dissection