Haematuria –Investigations and when to refer

1. Haematuria –Investigations and when to refer Mr Peter Liodakis Urological Surgeon Austin Hospital, Box Hill Hospital Epworth Richmond Warringal Private Hospital

3. All macroscopic haematuria should be investigated

4. malignancy & macroscopic haematuria cystoscopy • urine cytology • USS ± IVP cancer 24.7 % Alishahi S; J R Coll Surg Edinburgh 47 2002 422-427 maligna

5. Macroscopic Haematuria • always abnormal but a cause is not always found • may not represent serious life threatening disease • always a need to seek an explanation • cancer always needs exclusion • cancer unlikely age < 40

6. Causes • Cancer • Infection, Injury , Inflammation • BPH and prostatitis • Stones • interstitial kidney disease • cystitis & urethritis • Urethral caruncle • no cause found

7. Macroscopic Haematuria • Clot retention versus episodic • Clot retention- management • Refer to emergency department • Large irrigating catheter • Bladder washouts • Investigate cause

8. Episodic Haematuria • More commonly seen in General practice • Time to investigate • All patients require: • MSU • Urine cytology • Upper tract imaging • Cystoscopy • PSA for male

9. MSU, M,C +S • infection, morphology of red cells • Cytology- not if current frank haematuria • Good for high grade urothelial lesion • Low sensitivity for low grade TCC • Therefore negative cytology and imaging does not preclude need for cystoscopy • Newer Markers (NMP -22, FISH)

10. Upper Tract Imaging • Traditionally- Ultrasound and IVP • U/S- to exclude cortical lesion • 80-90% sensitivity • IVP- to exclude urothelial lesion • 60-70% sensitivity

11. CT-IVP- • Highest sensitivity>90% sensitivity • Looks at both cortex and urothelium • Significant radiation exposure

12. Cystoscopy • Flexible or rigid cystoscopy • Flexible- if all preceeding tests are normal • Rigid- if any abnormality in tests or higher index of suspicion

13. Microscopic Haematuria • Not Evident to the naked eye • More than 3-5 cells per HPF • More than 10 RBC’s per microlitre • If found on dipstick – should have a formal urine microscopy

14. How common is microscopic haematuria? point prevalence in asymptomatic adults: • < 1% < age 40 & 13% age > 40 • 4 - 13 % healthy adults * • 9.4 % in Australian community ** • 2.0 % insurance applicants *** * International Journal of Clinical Practice 61(5) May 2007 ** Chadban SJ ANZ Society Nephrology 2000 *** Wright WT Archives Internal Med 1959

15. Likelihood of finding Cancer % females vs age microscopic macroscopic 10-19 0.0 0.0 20-29 0.0 0.0 30-39 0.0 4.0 40-49 2.9 10.8 50-59 1.9 8.9 60-69 4.5 21.1 70-79 4.5 20.5 80-89 15.8 41.7 Khadra J Urology 2000

16. Microscopic Haematuria • Diagnostic yield is lower • All potential causes of Macro can cause micro • Stratify investigations • Exclude menstruation, exercise induced, trauma • Imapaired renal function, FHx of renal disease , HT – suggestive of renal cause

17. Microscopic Haematuria • If persistent proteinuria is present , should see a Renal Physician (>2gm in 24 hour collection) • Low protein to creatinine ratio is a reliable indicator of low urinary protein • Up to 40% may have nephropathy not all of which will progress to ESRF

18. Case 1 • 70 y/o male • 3 year moderate LUTS • Treated with Flomaxtra • 2 x frank haematuria • Baseline bloods –NAD, PSA 2.7 • Urine Micro – no growth, Cytology - Neg • CT IVP – NAD • Cystoscopy – Large vasc Prostate

20. Options • Finasteride (Proscar) or Dutasteride (Avodart) • Inhibits conversion Testosterone to DHT • Up to 85% reduction in incidence of bleeding • At least 3 weeks to take effect • Surgery • TURP • Green Light Laser • Open prostatectomy

21. Case 2 • 68 y/o female • HOPC • Worsening frequency past 4 months • Frank Haematuria 2 days • PHx • HT, Chol, OA • Smoker (40 pkt year history) • Examination • unremarkable

22. FBE, U+E’s, LFT’S, COAGS – NAD • MSU • RBC’s +++ • No Growth • Cytology • No malignant cells • CT IVP • Bladder filling defect, could be TCC, could be blood clot • Cystoscopy

24. Bladder TCC • Males 3 : 1 Females • Women have more than a 30% higher chance of dying of bladder cancer • 4th most common cancer in men • Rare in persons younger than the age of 50 • median ages at diagnosis of 70 yrs

25. Bladder Cancer Risk Factors • Cigarette smoking increases risk fourfold • Environmental carcinogens • Aromatic amines • Painter, autoworker, metal worker, dry cleaner • Previous Irradiation • Cyclophosphamide • Long term catheters (SCC) • Analgesic Abuse (Phenacetin) • 90% Bladder cancers are TCC (others SCC Ad)

26. Case 3 • 61 y/o male • Previously fit and well • 3 episodes of frank haematuria • No LUTS • Ex-smoker (20 pkt year History) • Worked in Dry cleaning Business 15 yrs

27. Examination – Unremarkable • FBE, U+E’s, LFT’S, COAGS, PSA – NAD • Renal Tract U/S • Normal renal contours • No Hydronephrosis or hydroureter • 46 gm prostate • MSU • RBC’s +++ • No Growth • Cytology • Suspicious cells for TCC • Cystoscopy

32. Upper Tract TCC • Same risk factors as for bladder TCC • Nephro-ureterectomy is treatment of choice (laparoscopic) • 75% involve renal pelvis • Ureteric tumours can be adequately treated with ureteric excision and re-implantation of ureter • Ongoing surveillance for recurrence

33. Case 4 • 64 yo male with flank pain • Anorexia past 2 months • Weight loss 7kg • Previously fit and well • Palpable mass in L) UQ • L) varicocele

34. Investigation results • Hb 110, plt 478 • ESR 139 • Calcium 2.71 • LFT’s, Coags, U+E’s – NAD • CT scan

38. Renal cell Cancer • Haematuria, flank pain, mass (10%) • 70% incidental finding • 30% present with metastases • (6-12 month median survival) • Paraneoplastic syndrome in up to 30% • Hypercalcaemia, anaemia, ESR, CRP • Associated with poor prognosis

40. Small renal Masses • 70% less than 4 cm • Up to 15% are benign • Renal Biopsy accuracy 72% • Risk of metastases -2% • Growth rate 0.3 cm year

41. Management • Active Surveillance • 3000 pts, median size 2.5 cm • 30 month follow up, <1% metastases • Nephrectomy • Lap vs open • Partial Nephrectomy • Lap vs open • Ablative treatment