1. Hematuria and Related Urologic Oncology
Jamison S. Jaffe, D.O.
Director of Minimally Invasive Urologic Surgery
Director of Robotic Surgery
Drexel University College of Medicine Hahnemann University Hospital

3. Urologic Oncology Renal cancer Bladder cancer
Ureter / Renal pelvis cancer

5. Renal Cell Carcinoma 3% of all adult malignancies
Male-to-female ratio is 2:1
Projections for 2007
51,190 estimated cases of RCC
12,890 deaths from RCC
American Cancer Society 2007
Increased incidence of 100% since 1970
Chow et al. JAMA 1999

6. Renal Cell Carcinoma Typically presents in the 6th to 7th decade
Most lethal of all GU malignancies
40% mortality rate vs. 20% bladder/prostate
Landis et al. J Clin Cancer 1999

7. Renal Cell Carcinoma Etiology Tobacco
High fat / protein diet (obesity)
Coffee
Occupational exposures
Metal / coke oven / asbestos / cadmium
Iatrogenic
Radiation
Familial
Von Hippel-Lindau Disease
Hereditary Papillary Renal Cell Carcinoma

8. Renal Cell Carcinoma Presentation Classic triad (10%)
Hematuria (40%)
Flank pain (40%)
Palpable mass in the flank or abdomen (25%)
Asymptomatic – 25% Most common presentations
Other signs and symptoms
Weight loss (33%)
Fever (20%)
Hypertension (20%)
Hypercalcemia (5%)
Night sweats
Malaise
Varicocele, (2% of males)

9. Renal Cell Carcinoma
Paraneoplastic syndromes – due to cytokine release
Hypercalcemia
Erythrocytosis
Nonmetastatic hepatic dysfunction (ie, Stauffer syndrome)
Anemia
Fever
Cachexia
Weight loss
Increased erythrocyte sedimentation rate
Hypertension

10. Renal Cell Carcinoma Diagnosis Radiographic diagnosis (CT/MRI)
Do not biopsy the mass (not exactly)
Spread
Needle track seeding
Bleeding
Surgical removal

11. Renal Cell Carcinoma Pathology
Conventional (Clear Cell) 70-80%
Papillary %
Chromophobic 4-5%
Collecting Duct <1%
Medullary Cell <1%
* Sarcomatoid lesions represent poorly differentiated elements of above cell types
Storkel et al. Cancer, 1997

12. Renal Cell Carcinoma Treatment
Surgery remains the mainstay of curative treatment
Radical nephrectomy
Nephron-sparing surgery
Partial nephrectomy
Ablative techniques
Cryosurgery
RFA
*Open vs. laparoscopic
Chemotherapy and radiation not useful
Lap is associated with diminished pain, shorter hospital stay, and quicker recovery. Good option for small volume tumors < 8cm

14. Bladder Cancer Bladder cancer is the second most common GU tumor
2004 statistics
60,200 new patients diagnosed
12,700 of those patients died from the disease
Bladder cancer is more common in whites than in blacks; however, blacks have a worse prognosis than whites.
Male-to-female ratio is 3:1
Women generally have a worse prognosis than men.
The median age at diagnosis is 68 years, and the incidence increases with age.
Mostly from SEER data.

15. Bladder Cancer Etiology Smoking – most common Industrial exposures
Aromatic amines in dyes, paints, solvents, metals, leather dust, inks, combustion products, rubber, and textiles
Prior exposure to radiation treatment of the pelvis
Chemotherapy with cyclophosphamide increases the risk of bladder cancer
Acrolein
Long-term indwelling catheters
Coffee – not true
Artificial sweeteners – not true

16. Bladder Cancer Presentation Painless gross hematuria (80-90%)
Consider all patients with gross hematuria to have bladder cancer until proven otherwise
Suspect bladder cancer if any patient presents with unexplained microscopic hematuria
Irritative bladder symptoms (20-30%)
Dysuria
Urgency
Frequency of urination
Pelvic or bony pain
Lower-extremity edema
Flank pain from ureteral obstruction

17. Definitions Microscopic Hematuria Gross Hematuria
Presence of 3 or more RBC per hpf
3 % of normal individuals will excrete up to 3 RBC
Gross Hematuria
Presence of blood in the urine that is visible to the naked eye

18. Hematuria Evaluation UA Urine culture ± Cytology Upper tract imaging
CT/MRI ± contrast
Cystoscopy

19. Hematuria DDx S – Stones H – Hematologic I – Infection T – Tumors
T – Trauma
T – TB
S - Strictures

20. Diagnosis and Staging Cystoscopy
Important to note that the exam was performed AFTER the TUR. If you remove the bulk of intravesicle tumor, anything left palpable can be assumed extravesicle.
80% of patients with bladder CA present with gross hematuria.

21. Diagnosis and Staging Transurethral Resection
Important to note that the exam was performed AFTER the TUR. If you remove the bulk of intravesicle tumor, anything left palpable can be assumed extravesicle.
80% of patients with bladder CA present with gross hematuria.

22. Bladder Cancer Pathology Transitional cell carcinomas (TCC) (90%)
Squamous cell carcinoma (SCC) (5%)
Adenocarcinomas (2%)
Nonurothelial primary bladder tumors (<3%)
Small cell carcinoma
Carcinosarcoma
Primary lymphoma
Sarcoma

23. Bladder Cancer Pathology tidbits
SCC is the most common form worldwide (75%)
US associated with persistent inflammation from long-term indwelling Foley catheters and bladder stones
Underdeveloped nations, SCC is associated with bladder infection by Schistosoma haematobium
Adenocarcinomas
Observed most commonly in bladders extrophy or in the urachus

24. Bladder Cancer Staging

25. Bladder Cancer Superficial bladder cancer 75% recurrence
25% progress to muscle invasive

26. Bladder Cancer Treatment Superficial cancer Muscle invasive cancer
± Intravesical treatment (BCG/Mitomycin C)
Surveillance cystoscopy
Repeat TURBT if it recurs
Muscle invasive cancer
Radical cystectomy
Male – bladder and prostate
Females – bladder, urethra, uterus, ovaries, and anterior vaginal wall
Diversion vs. neobladder
Bladder preservation
Chemotherapy and radiation (gemcitabine and cisplatin)

27. Urothelial Tumors of the Renal Pelvis and Ureter
Background
Rare
Renal pelvis – 10% of all renal tumors
Ureter – ¼ the incidence of renal pelvis tumors
Mean age – 65 years
Male to female ratio 3:1
Balkan nephropathy
x increase risk of upper tract TCC

28. Urothelial Tumors of the Renal Pelvis and Ureter
Etiology
Tobacco (3x ↑)
Most strongly associated with upper tract TCC
Coffee (> 7 cups/day)
Analgesic abuse
Occupational exposure
Petrochemical, plastic, and tar industries
Chronic infections
Chronic irritation
Cyclophosphamide

29. Urothelial Tumors of the Renal Pelvis and Ureter
Pathology
Transitional cell carcinoma – 90%
Squamous cell carcinoma - 1-7%
Adenocarcinoma - <1%
Location
Renal pelvis - 58%
Ureter - 35%
Both renal pelvis and ureter - 7%
Bilateral - 2-5%

30. Urothelial Tumors of the Renal Pelvis and Ureter
Symptoms
Gross or microscopic hematuria (75%)
Flank pain (18%)
Dysuria (6%)
Advanced disease
Weight loss, anorexia, flank mass, or bone pain

31. Urothelial Tumors of the Renal Pelvis and Ureter
Diagnosis
CT scan / MRI (hematuria evaluation)
Cystoscopy ± retrograde pyelogram
“Goblet sign”
Ureteroscopy with biopsy

32. “Goblet Sign”

33. Urothelial Tumors of the Renal Pelvis and Ureter
Treatment
Nephroureterectomy with excision of the bladder cuff (gold standard)
Nephron sparring surgery
Segmental ureterectomy coupled with ureteral reimplantation
Tumors located in the distal ureter
Ipsilateral recurrence rate is 25%
Ureteroscopic treatment
Small, low-grade superficial lesions are the best candidates for this approach