a 62 year-old man with painless hematuria
TRANSCRIPT
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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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
Differential Diagnosis: Painless Hematuria
Kidney StonesUrinary Tract InfectionTumors/Neoplasms
Bladder, Kidney, ProstateInflammation
Cystitis, Prostatitis, PyelonephritisBPHTraumaGlomerular Disease
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
Menu of Radiologic TestsAbdominal Ultrasound
CT scanKidney stone protocol (CT w/o contrast)
CT urogram
MRI
Radionuclide Scan
Historical tests: IVP, Retrograde pyelography
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Norifumi Kamo, HMS III
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
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Norifumi Kamo, HMS III
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
Differential DiagnosisKidney StonesUrinary Tract InfectionTumors/Neoplasms
Bladder, Kidney, ProstateInflammation
Cystitis, Prostatitis, PyelonephritisBPHTraumaGlomerular Disease
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
Differential DiagnosisKidney StonesUrinary Tract InfectionTumors/Neoplasms
Bladder, Kidney, ProstateInflammation
Cystitis, Prostatitis, PyelonephritisBPHTraumaGlomerular Disease
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
Bladder Anatomy - Male
Posterior and superior to the pubic bones, inferior to peritoneum, superior to the prostate, anterior to rectum
http://urologyhealth.org
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
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
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Norifumi Kamo, HMS III
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
Patient ASPACS, BIDMC
Ureteral stents in place, no contrast in ileal
conduit
Urostomy bag
Surgical Clips
Patient ASPACS, BIDMC
Bilateral ureters entering ileal conduit
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
Patient ASPACS, BIDMC
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
Patient ASPACS, BIDMC
Pig-tail catheterAbscess w/ fluid and air
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
Patient ASPACS, BIDMC
Pig-tail Catheter
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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
Patient ASPACS, BIDMC
Patient ASPACS, BIDMC
Stricture
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
Conclusions: Role of RadiologyWorkup for painless hematuria
Staging bladder TCC
Assess for post-operative complications
IR-guided abscess drainage
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
AcknowledgmentsDr. Andrew Hines-PeraltaDr. Gillian LiebermanMaria Levantakis
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Norifumi Kamo, HMS III
Gillian Lieberman, MD
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.