Norifumi Kamo, HMS III Gillian Lieberman, MD A 62 Year-Old Man with Painless Hematuria Norifumi Kamo, HMS III Gillian Lieberman, MD Beth Israel Deaconess Medical Center 1 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient Presentation CC: 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 2 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 wnl BUN 13 and Creatinine 0.9 U/A: 10 RBC/hpf, Urine cx negative 3 Norifumi Kamo, HMS III Gillian Lieberman, MD Differential Diagnosis: Painless Hematuria Kidney Stones Urinary Tract Infection Tumors/Neoplasms Inflammation Bladder, Kidney, Prostate Cystitis, Prostatitis, Pyelonephritis BPH Trauma Glomerular Disease 4 Norifumi Kamo, HMS III Gillian Lieberman, MD Menu of Radiologic Tests Abdominal Ultrasound CT scan Kidney stone protocol (CT w/o contrast) CT urogram MRI Radionuclide Scan Historical tests: IVP, Retrograde pyelography 5 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient AS: Abdominal CT No evidence of hydronephrosis, kidney stones Nml cortical thickness, no signs of obstruction Renal cyst Patient Patient AS AS PACS, BIDMC PACS, BIDMC Axial CT +/- contrast reveals benign renal cyst, nml renal cortical thickness w/o evidence of obstruction, hydronephrosis, renal mass, kidney stones 6 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient AS: Pelvic CT Thickened bladder wall Patient AS PACS, BIDMC Axial CT cystogram with contrast reveals symmetric posterior bladder wall thickening 7 Norifumi Kamo, HMS III Gillian Lieberman, MD Differential Diagnosis Kidney Stones Urinary Tract Infection Tumors/Neoplasms Inflammation Bladder, Kidney, Prostate Cystitis, Prostatitis, Pyelonephritis BPH Trauma Glomerular Disease 8 Norifumi Kamo, HMS III Gillian Lieberman, MD Differential Diagnosis Kidney Stones Urinary Tract Infection Tumors/Neoplasms Inflammation Bladder, Kidney, Prostate Cystitis, Prostatitis, Pyelonephritis BPH Trauma Glomerular Disease 9 Norifumi Kamo, HMS III Gillian Lieberman, MD Transitional Cell Carcinoma of the Bladder 4th most common CA in men, 9th most common in women Incidence: 67,000/yr, Mortality: 13,750/yr Risk factors: SH: smoked 4 Tobacco PPD for 40 yrs Schistosomiasis Chemicals: Aromatic Amines, Phenacetin, Cyclophosphamide Clinical Presentation: Gross painless hematuria Pain from locally advanced or metastatic tumor Voiding symptoms - dysuria, frequency, urgency, obstruction Constitutional symptoms - fatigue, weight loss, anorexia 10 Norifumi Kamo, HMS III Gillian Lieberman, MD TCC of Bladder: Diagnosis U/A: hematuria Companion Patient 1 When bacteruria or pyuria present urine cx to r/o UTI Cystoscopy and biopsy Urine cytology Other Immunocytochemistry Proteomics Biomarkers http://www.urologychannel.com/bladdercancer/sptumor.shtml 11 Norifumi Kamo, HMS III Gillian Lieberman, MD Radiologic Features of TCC Companion Pt 2 IVP - historical CT T1: invades subepithelial connective tissue T2 - invades muscle T3 - invades perivesical tissue T4 - invades beyond Companion Pt 4 Further Imaging < T2, N0, M0 Staging: TNM system Companion Pt 3 CXR - pulmonary mets Patient AS MRI - tumors at base and Kim et al. PACS, BIDMC dome of bladder Bone Scan http://urology.jhu.edu/bladder/bladder_cancer _diagnosis.php http://urology.jhu.edu/bladder/bladder_cancer_diagnosis.php Companion Pt 5 PACS, BIDMC 12 Norifumi Kamo, HMS III Gillian Lieberman, MD Treatment Options for TCC TURBT +/- chemotherapy Primary radiation therapy Partial cystectomy Radical 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 13 Norifumi Kamo, HMS III Gillian Lieberman, MD Bladder Anatomy - Male http://urologyhealth.org Posterior and superior to the pubic bones, inferior to peritoneum, superior to the prostate, anterior to rectum 14 Norifumi Kamo, HMS III Gillian Lieberman, MD Radical Cystectomy Male - removal of prostate and bladder Bilateral pelvic lymphadenectomy Urethrectomy Tumor in prostatic urethra Urinary Diversion Ileal loop conduit - urine directed from ureters through segment of isolated ileum to abd wall http://community.nursingspectrum.com/MagazineArticles/ article.cfm?AID=18622 AS underwent radical cystectomy with ileal loop diversion 15 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient AS: Post-Op CT Post-Op Ileus No hydronephrosis, symmetrical excretion of contrast Patient AS PACS, BIDMC CT Abd/Pelvis with IV contrast revealed dilated loops of bowel with air-fluid levels and no signs of obstruction 16 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient AS: Post-Op CT Urostomy bag Ureteral stents in place, no contrast in ileal conduit Bilateral ureters entering ileal conduit Surgical Clips Patient Patient AS AS PACS, PACS, BIDMC BIDMC CT Pelvis with contrast reveals multiple surgical clips, ureteral stents are seen in bilateral ureters, exiting abdomen through urostomy 17 Norifumi Kamo, HMS III Gillian Lieberman, MD Ileal Conduit Complications Leak Fistulas Infection Bleeding, Ileus, Obstruction Urinary Tract Obstruction Wound infection, Abscess, UTI, Pyelonephritis, Sepsis GI Urine, Bowel Stones, Strictures, Hydronephrosis Diminished renal function, Renal failure 18 Norifumi Kamo, HMS III Gillian Lieberman, MD AS: CT 1 mo s/p surgery Fluid Collection w/ thick border Patient AS PACS, BIDMC Pt presents with abdominal pain, nausea, lethargy, fever CT with IV contrast reveals fluid collection at level of ileal conduit, which could represent urine collection or abscess 19 Norifumi Kamo, HMS III Gillian Lieberman, MD AS: CT-guided IR drainage Patient AS Pig-tail catheter PACS, BIDMC Abscess w/ fluid and air Patient AS PACS, BIDMC Pt underwent CT-guided drainage of the fluid collection 50cc of purulent aspirated and was positive for mixed bacteria Repeat CT 1wk s/p drainage shows drainage catheter within abscess, which has decreased in size, with residual fluid with air seen in the cavity 20 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient AS: Loopogram Fluoroscopy-guided loopogram to assess leak Contrast injected through urostomy Contrast filled the ileal conduit No evidence of leak No reflux into the ureters Stoma Catheter w/ contrast Patient AS PACS, BIDMC Ileal conduit + contrast Pig-tail Catheter 21 Norifumi Kamo, HMS III Gillian Lieberman, MD Patient AS: Hospital Course Started on antibiotics NPO, started on TPN No evidence of fistulous connection Reduction in size of abscess Good urostomy output Diet was advanced and tolerated well CBC, electrolytes remained stable Pt discharged with plans for close follow-up 22 Norifumi Kamo, HMS III Gillian Lieberman, MD AS: CT 5 yrs s/p surgery Air Cortical atrophy and hydronephrosis Stricture No excretion of contrast Patient AS Patient AS PACS, BIDMC PACS, BIDMC BUN: 44, Creatinine: 1.6 Abd/Pelv CT with contrast reveals cortical atrophy of left kidney with no excretion of contrast and hydronephrosis, air in right collecting 23 system, possible stricture of left ureter Norifumi Kamo, HMS III Gillian Lieberman, MD Conclusions: Role of Radiology Workup for painless hematuria Staging bladder TCC Assess for post-operative complications IR-guided abscess drainage 24 Norifumi Kamo, HMS III Gillian Lieberman, MD Acknowledgments Dr. Andrew Hines-Peralta Dr. Gillian Lieberman Maria Levantakis 25 Norifumi Kamo, HMS III Gillian Lieberman, MD References Bochner 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. 26