a 62 year-old man with painless hematuria

1

Norifumi Kamo, HMS III

Gillian Lieberman, MD

A 62 Year-Old Man with Painless Hematuria

Norifumi Kamo, HMS IIIGillian Lieberman, MD

Beth Israel Deaconess Medical Center

2



Patient PresentationCC: Painless hematuria

HPI: AS is a 62 y/o M who presents with gross painless hematuria for the past 2 months

PMH/PSH: s/p MI (s/p CABG), NIDDM

Meds: Avandia, glyburide, metoprolol

Allergies: NKDA

3



Patient Presentation (cont’d)SH: smoked 4 PPD for 40 years

FH: not significant

PE: obese male, AVSS in NAD

Labs:Chem 7, CBC wnlBUN 13 and Creatinine 0.9U/A: 10 RBC/hpf, Urine cx negative

4



Differential Diagnosis: Painless Hematuria

Kidney StonesUrinary Tract InfectionTumors/Neoplasms

Bladder, Kidney, ProstateInflammation

Cystitis, Prostatitis, PyelonephritisBPHTraumaGlomerular Disease

5



Menu of Radiologic TestsAbdominal Ultrasound

CT scanKidney stone protocol (CT w/o contrast)

CT urogram

MRI

Radionuclide Scan

Historical tests: IVP, Retrograde pyelography

6


Gillian Lieberman, MD Patient AS: Abdominal CT

Axial CT +/- contrast reveals benign renal cyst, nml renal cortical thickness w/o evidence of obstruction, hydronephrosis, renal mass, kidney stones

No evidence of hydronephrosis, kidney stones

Renal cyst

Patient AS

PACS, BIDMCPatient AS

PACS, BIDMC

Nml cortical thickness, no signs of obstruction

7


Gillian Lieberman, MD Patient AS: Pelvic CT

Axial CT cystogram with contrast reveals symmetric posterior bladder wall thickening

Thickened bladder wall

Patient AS

PACS, BIDMC

8



Differential DiagnosisKidney StonesUrinary Tract InfectionTumors/Neoplasms



9



Differential DiagnosisKidney StonesUrinary Tract InfectionTumors/Neoplasms



10



Transitional Cell Carcinoma of the Bladder4th most common CA in men, 9th most common in womenIncidence: 67,000/yr, Mortality: 13,750/yrRisk factors:

TobaccoSchistosomiasisChemicals: Aromatic Amines, Phenacetin, Cyclophosphamide

Clinical Presentation:Gross painless hematuriaPain from locally advanced or metastatic tumorVoiding symptoms - dysuria, frequency, urgency, obstructionConstitutional symptoms - fatigue, weight loss, anorexia

SH: smoked 4 PPD for 40 yrs

11



TCC of Bladder: DiagnosisU/A: hematuria

When bacteruria or pyuria present urine cxto r/o UTI

Cystoscopy and biopsyUrine cytologyOther

ImmunocytochemistryProteomicsBiomarkers

http://www.urologychannel.com/bladdercancer/sptumor.shtml

Companion Patient 1

12



http://urology.jhu.edu/bladder/bladder_cancer _diagnosis.php

Companion Pt 2

Radiologic Features of TCCIVP - historicalCT

Staging: TNM systemT1: invades subepithelialconnective tissueT2 - invades muscleT3 - invades perivesicaltissueT4 - invades beyond

Further ImagingCXR - pulmonary metsMRI - tumors at base and dome of bladder

Bone Scan

Kim et al.

Companion Pt 3

Patient AS

PACS, BIDMC

< T2, N0, M0

http://urology.jhu.edu/bladder/bladder_cancer_diagnosis.php

Companion Pt 4

Companion Pt 5 PACS, BIDMC

13



Treatment Options for TCCTURBT +/- chemotherapyPrimary radiation therapyPartial cystectomyRadical cystectomy indications:

Infiltrating muscle-invasive bladder CA w/o evidence of metastatic disease (T2M0)Superficial bladder tumors (CIS, T1) refractory to chemotherapy, other surgery

Patient AS: Pathology report revealed high grade papillary TCC with invasion of lamina propria and muscularis propria

14



Bladder Anatomy - Male

Posterior and superior to the pubic bones, inferior to peritoneum, superior to the prostate, anterior to rectum

http://urologyhealth.org

15



Radical CystectomyMale - removal of prostate and bladderBilateral pelvic lymphadenectomyUrethrectomy

Tumor in prostatic urethra

Urinary DiversionIleal loop conduit - urine directed from uretersthrough segment of isolated ileum to abd wall http://community.nursingspectrum.com/MagazineArticles/

article.cfm?AID=18622

AS underwent radical cystectomy with ileal loop diversion

16


Gillian Lieberman, MD Patient AS: Post-Op CT

Post-Op Ileus

CT Abd/Pelvis with IV contrast revealed dilated loops of bowel with air-fluid levels and no signs of obstruction

No hydronephrosis, symmetrical excretion

of contrast

Patient ASPACS, BIDMC

17


Gillian Lieberman, MD Patient AS: Post-Op CT

CT Pelvis with contrast reveals multiple surgical clips, ureteral stents are seen in bilateral ureters, exiting abdomen through urostomy


Ureteral stents in place, no contrast in ileal

conduit

Urostomy bag

Surgical Clips


Bilateral ureters entering ileal conduit

18



Ileal Conduit ComplicationsLeak

Urine, Bowel

FistulasInfection

Wound infection, Abscess, UTI, Pyelonephritis, Sepsis

GIBleeding, Ileus, Obstruction

Urinary Tract ObstructionStones, Strictures, Hydronephrosis

Diminished renal function, Renal failure

19



Pt presents with abdominal pain, nausea, lethargy, feverCT with IV contrast reveals fluid collection at level of ileal conduit, which could represent urine collection or abscess

AS: CT 1 mo s/p surgeryFluid Collectionw/ thick border


20



Pt underwent CT-guided drainage of the fluid collection50cc of purulent aspirated and was positive for mixed bacteriaRepeat CT 1wk s/p drainage shows drainage catheter within abscess, which has decreased in size, with residual fluid with air seen in the cavity

AS: CT-guided IR drainagePatient AS

PACS, BIDMC


Pig-tail catheterAbscess w/ fluid and air

21



Fluoroscopy-guided loopogram to assess leakContrast injected through urostomyContrast filled the ileal conduitNo evidence of leakNo reflux into the ureters

Patient AS: Loopogram

Stoma

Catheter w/ contrast Ileal conduit

+ contrast


Pig-tail Catheter

22



Patient AS: Hospital CourseStarted on antibioticsNPO, started on TPNNo evidence of fistulous connectionReduction in size of abscessGood urostomy outputDiet was advanced and tolerated wellCBC, electrolytes remained stablePt discharged with plans for close follow-up

23



BUN: 44, Creatinine: 1.6Abd/Pelv CT with contrast reveals cortical atrophy of left kidney with no excretion of contrast and hydronephrosis, air in right collecting system, possible stricture of left ureter

AS: CT 5 yrs s/p surgery

Cortical atrophy and hydronephrosis

Air

No excretion of contrast



Stricture

24



Conclusions: Role of RadiologyWorkup for painless hematuria

Staging bladder TCC

Assess for post-operative complications

IR-guided abscess drainage

25



AcknowledgmentsDr. Andrew Hines-PeraltaDr. Gillian LiebermanMaria Levantakis

26



ReferencesBochner BH. Urinary diversion and reconstruction following cystectomy. UpToDate

Online. Last updated 8/27/07. Retrieved 11/07/07. http://utdol.com/utd/content/topic.do?topicKey=gucancer/13454

Donat SM, Dalbagni G, Herr H. Clinical presentation, diagnosis, and staging of bladder cancer. UpToDate Online. Last updated 1/25/07. Retrieved 11/08/07. http://utdol.com/utd/content/topic.do?topicKey=gucancer/6264

Eggener SE, Campbell SC. Cystectomy, Radical. eMedicine from WebMD. Last updated 10/11/07. Retrieved 11/08/07. http://www.emedicine.com/med/topic3061.htm

Kim JK, Park S, Ahn HJ, Kim CS, Cho K. Bladder cancer: analysis of multi-detector row helical CT enhancement pattern and accuracy in tumor detection and perivesical staging. Radiology 2004; 231:725-731

“Bladder; Lower Genitourinary Calculi and Trauma” in Campbell-Walsh Urology, 9th ed. Eds Wein, Kavoussi, et al. Saunders Elsevier Philadelphia. 2007. 2418-2566.

http://utdol.com/utd/content/topic.do?topicKey=gucancer/13454

http://utdol.com/utd/content/topic.do?topicKey=gucancer/6264

http://www.emedicine.com/med/topic3061.htm

a 62 year-old man with painless hematuria

Documents