37 - Hematuria & RCC

Hematuria and Transitional
Cell Carcinoma
Rami Al-Azab,MD
Onco- urologist
Definitions
Hematuria
is presence of blood in urine ,

this is a misnomer.
This is detected by either dipstick and/or
microscopy.
The urinalysis also looks at different
factors that may point out certain crucial
points
??? Medical causes
Presence of casts.
Fixed specific gravity,
Glucosuria.
significant proteinuria.
red cell casts.
renal insufficiency.
Predominance of dysmorphic RBCs in the urine.
Presence or absence of symptoms is weak relevant
information
Classifying hematuria
According to the act of void:
-Initial.
-Terminal.
-Total.
Symptomatic vs. Asymptomatic.
Mode of discovery: Gross vs. microscopic
The
recommended definition of microscopic

hematuria is three or more red blood cells
per high-power field on microscopic
evaluation of urinary sediment from two of
three properly collected urinalysis
specimens.
the
chances of identifying significant

pathology increase with the degree of
hematuria.
Significance of hematuria
Hematuria
is a sign of malignancy until

proven otherwise.
Microscopic
hematuria is more dangerous

because; time can elapse before diagnosis. and
maignancy is more likely to present as
microscopic hematuria .
Severity of the condition can be proportionate to
the severity of hematuria.
Initial questions
Is the hematuria gross or microscopic?

At what time during urination does the
hematuria occur (beginning or end of
stream or during entire stream)?
Is the hematuria associated with pain?
Is the patient passing clots?
If the patient is passing clots, do the clots
have a specific shape?
Total
hematuria is most common

and indicates that the bleeding is
most likely coming from the bladder
or upper urinary tracts.
the most common cause of gross
hematuria in a patient older than
age 50 years is bladder cancer.
Initial
hematuria usually arises from

the urethra; it occurs least commonly and
is usually secondary to inflammation.
Terminal hematuria occurs at the
end of micturition and is usually
secondary to inflammation in the area
of the bladder neck or prostatic
urethra.
is
usually not painful unless it is

associated with inflammation or
obstruction.
pain in association with hematuria
usually results from upper urinary tract in
the LUT the associated symptoms are
usually irritative.
Presence of Clots
The
presence of clots usually indicates a

more significant degree of hematuria, and,
accordingly, the probability of identifying
significant urologic pathology increases.
What's next?
In
a patient who presents with gross

hematuria, cystoscopy should be
performed as soon as possible, because
frequently the source of bleeding can be
readily identified.
Cystoscopy will determine whether the
hematuria is coming from the urethra,
bladder, or upper urinary tract .
Work up
Cystoscopy, Cystoscopy
and Cystoscopy.
UA for confirmation, Urine C&S.
Urine Cytology.
Upper tract imaging (CT, IVU, U/S, Angio)
Retrograde pyelography.
Possible outcome
All
over above the age of 50, TCC is the

most common cause of gross hematuria.
BPH is the most common cause in aging
men.
UTI is the most common cause in
females.
Risk Factors for Significant Disease

in Patients with Microscopic Hematuria
Smoking history
Occupational exposure to chemicals or dyes
(benzenes or aromatic amines)
History of gross hematuria
Age >40 years
History of urologic disorder or disease
History of irritative voiding symptoms
History of urinary tract infection
Analgesic abuse
History of pelvic irradiation
Summary of the AUA Best Practice Policy Recommendations
Urolthelial not Bladder cancer

Transitional
epithelium lines the urinary

tract from the minor calyces to the end of
the prostatic urethra.
It
is the most commonly diagnosed

malignancy in patients with hematuria.
Bladder
cancer is more than 2.5 times

more common in men than in women.
bladder
cancer has rarely been found

incidentally at autopsy
Risk
Factors
Risk factors
Dyes, paints and other industrial exposure.
Aniline and benzene based dyes, Most bladder
carcinogens are aromatic amines.

Chronic irritation (chronic cystitis), more with
squamous and adeno.

Pelvic irradiation
. Risk factors
p53 The p53 gene is the most frequently
altered gene in human cancers .

Human Oncogene, or inactivation of
suppressor gene.
Different genes are linked to different TCC
grades .
Patients treated with cyclophosphamide have up to a
ninefold increased risk of developing bladder cancer
Presentation
Hematuria
Irritative
Distant
85% .
LUTS.
mets
Work up
That
of the presentation.
Importance of cytology (flow cytometry).
Work up of Hematuria should be directed
to rule out Urological malignancy not TCC.
Again cystoscopy retrograde
pyelography
Grading and Staging

Strong
correlation between tumor grade

and stage.
Grade
from 1-3 , only grade 3 is

considered high grade and is by itself a
poor prognostic factor.
The concept of field change effect.
Pattern
of spread.
Natural History
Grade
and stage related.
Different
modalities of spreading.
Independent
prognostic factors.
Treatment options
Driven
by Stage , Grade and mode of

recurrence.
All
prognostic factors are considered

independent.
Intravesical Chemotherapy
Indications:
Large tumour size ,rapid and frequent
recurrences, multicentricity, presence of
Cis,
Common Agents: BCG,Metamycin C,
Adriamycin,thiotepa,.
BCG is the most commonly used
,cheapest and has best results regarding
recurrence rate.
Inravesical Chemotherapy
Does
not affect progression.
Failure
of IV chemotherapy denotes bad

prognosis.
Contraindicated
in: immunosupression ,
Hematuria or active UTI, Active TB
TURBT.
TURBT +
Intravesical chemotherapy.
Partial cystectomy (Only in selected
patients).
Radical cystectomy neo or adjuvant
Chemotherapy.
Chemo-Radio combination
Radical Cystectomy
In males : Resection of the bladder,
prostate, seminal vesicle, and the urethra
(in selected cases)
In females : Resection of the Bladder,
Anterior vagina, uterus and cervix,
fallopian tube, ovaries and the urethra.
In both this is followed by extended pelvic
lymph node disection.
Whatever
we do TCC has high recurrence

rate : 50% , ( 80% of recurrences are
distant and 20% are local)
Our
only chance in winning this war is by

diagnosing the disease in an early stage .
Remember
It all starts with

Hematuria

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Hematuria and Transitional

is presence of blood in urine ,

??? Medical causes

recommended definition of microscopic

chances of identifying significant

is a sign of malignancy until

hematuria is more dangerous

Is the hematuria gross or microscopic?

hematuria is most common

hematuria usually arises from

usually not painful unless it is

presence of clots usually indicates a

a patient who presents with gross

over above the age of 50, TCC is the

Risk Factors for Significant Disease

Urolthelial not Bladder cancer

epithelium lines the urinary

is the most commonly diagnosed

cancer is more than 2.5 times

cancer has rarely been found

carcinogens are aromatic amines.

squamous and adeno.

altered gene in human cancers .

ninefold increased risk of developing bladder cancer

Grading and Staging

correlation between tumor grade

from 1-3 , only grade 3 is

The concept of field change effect.

and stage related.

by Stage , Grade and mode of

prognostic factors are considered

not affect progression.

of IV chemotherapy denotes bad

we do TCC has high recurrence

only chance in winning this war is by

It all starts with

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