Urology

CASE 61: renal maSS

history

A 61-year-old male presented to his GP complaining of intermittent left-sided loin pain for 2 months. An ultrasound scan of the urinary tract was organized, which showed a large central mass in the left kidney. His previous medical history included a recent diagnosis of hypertension, hypothyroidism and non-insulin-dependent diabetes mellitus. He currently takes thyroxine 100 mg od, bendrofluazide 2.5 mg od and metformin 850 mg bd. He lives alone and drinks 5–10 units of alcohol per week. He is a lifelong smoker.

examination

His temperature is 37°C, his blood pressure is 165/99 mmHg and his pulse is 84/min. Heart sounds are normal and his chest is clear. He has a soft non-tender abdomen with no palpable masses. A left-sided varicocoele is present. Digital rectal examination is unremarkable.

INVESTIGATIONS

Urinalysis: blood: ++

leucocytes: negative protein: negative glucose: +

Ultrasound of the urinary tract: there is a solid central mass measuring 3.6 cm in the left kidney. the right kidney appears normal. there is no evidence of pelvi-calyceal dilatation or calculi on either side. the bladder was not filled and was therefore difficult to examine.

Questions

•What investigation is now required?

•Can you explain why the patient may have a varicocoele?

•Do you know of a genetic condition that may predispose individuals to renal cell carcinoma?

•Why may the patient be hypertensive?

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ANSWER 61

The patient has been found to have a renal mass on ultrasound scan. The most likely diagnosis is renal cell carcinoma and the patient now requires a contrast CT scan of the abdomen and pelvis to confirm the diagnosis and to stage his disease. A chest x-ray should also be organized to screen for chest metastases (if a CT of the chest is not performed at the same time of his staging). Approximately one-quarter to one-third of patients with renal cell carcinomas have metastases at presentation.

The venous drainage from the testes (pampiniform plexus) is into the gonadal (testicular) veins. On the left, the gonadal vein drains into the left renal vein and on the right the vein drains directly into the inferior vena cava. Tumours extending into the left renal vein will obstruct the venous drainage from the left testicle, leading to a left-sided varicocoele.

The most common genetic abnormality associated with renal cell carcinoma is von Hippel– Lindau syndrome. This is an autosomal dominant disease characterized by phaeochromocytoma, pancreatic and renal cysts, cerebellar haemangioblastoma and the development of renal cell carcinoma, which is often bilateral. Lifelong follow-up is required and nephronsparing surgery employed in view of the recurrent nature of the disease.

Other non-genetic aetiological factors associated with renal cell carcinoma include:

•Smoking

•Anatomical: horseshoe kidney; polycystic disease; cystic disease of dialysis

•Hypertension

•Obesity

•Environmental: cadmium, asbestos exposure, phenacitin (analgesic)

•Low social class

The classic presenting triad of loin pain, a mass and haematuria only occurs in about 10 per cent of patients. More commonly, one of these features appears in isolation. Other presentations include left-sided varicocoele (5 per cent) and paraneoplastic syndromes (10–40 per cent).

!Paraneoplastic syndromes

•Endocrine (ectopic hormone production):

•erythropoietin: polycythaemia

•renin: hypertension

•insulin: hypoglycaemia

•adrenocorticotrophic hormone (aCth): Cushing’s syndrome

•parathyroid hormone: hypercalcaemia

•gonadotrophins: gynaecomastia, amenorrhea, reduced libido, baldness

•Haematological: anaemia

•Metabolic: pyrexia

KEY POINTS

•the classic presenting triad of loin pain, a mass and haematuria only occurs in a small proportion of patients.

•patients may present with a paraneoplastic syndrome.

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Urology

CASE 62: haematuria

history

A 60-year-old woman attends the emergency department complaining of a 3-week history of blood in the urine. She has also noted the passage of some small blood clots. She has had an intermittent urinary stream for the past 24 h and complains of pain in the suprapubic region on voiding. She has been complaining of urinary frequency and urgency for the past 6 months. She smokes ten cigarettes per day and takes warfarin for atrial fibrillation.

examination

On examination of the abdomen, there is some minor suprapubic tenderness and a palpable bladder. The rest of the examination is unremarkable. Her pulse rate is 100/min and the blood pressure is 105/70 mmHg.

INVESTIGATIONS

Questions

•What is the differential diagnosis, and what is the most important diagnosis to exclude in this woman?

•What factors are relevant in taking a history in this case?

•What is the initial management in this woman?

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100 Cases in Surgery

ANSWER 62

Haematuria can be classified as visible (frank or macroscopic) or non-visible microscopic (picked up on dipstick testing). Non-visible haematuria is further classified into symptomatic (with voiding LUTS) or asymptomatic (no voiding LUTS).

!Causes of haematuria

•Kidneys: neoplasia (benign, e.g. angiomyolipoma; malignant, e.g. renal cell carcinoma, transitional cell carcinoma), polycystic kidneys, calculi, pyelonephritis, tuberculosis, glomerulonephritis or immunoglobulin a (iga) nephropathy

•Ureter: transitional cell carcinoma or calculi

•Bladder: neoplasia, e.g. transitional cell carcinoma, squamous cell carcinoma, calculi, inflammatory or infective causes – cystitis, schistosomiasis

•Prostate: prostatitis, carcinoma or benign prostatic hyperplasia

•Urethra: neoplasia, e.g. transitional cell carcinoma, urethritis, calculi or foreign bodies

•Other: anticoagulants, urinary tract instrumentation, clotting abnormalities, trauma to the urinary tract, right-sided heart failure or renal vein thrombosis

•Rare: strenuous exercise, bacterial endocarditis or embolism

In this case the most likely diagnosis is a transitional carcinoma of the bladder. When taking the history, it is important to elicit the following:

•Visible or non-visible: duration of haematuria

•Age: cancers are more common with increasing age

•Sex: females more likely to have urinary tract infections

•Location: during micturition, was the haematuria always present (indicative of renal, ureteric or bladder pathology) or was it only present initially (suggestive of anterior urethral pathology) or present at the end of the stream (posterior urethra, bladder neck)?

•Pain: more often associated with infection/inflammation/calculi, whereas malignancy tends to be painless

•Associated lower urinary tract symptoms that will be helpful in determining aetiology

•History of trauma

•Travel abroad, e.g. swimming in lakes is Africa and Egypt and the risks of schistosomiasis

•Previous urological surgery/history/recent instrumentation/prostatic biopsy

•Medication, e.g. anticoagulants

•Family history

•Occupational history, e.g. rubber/dye occupational hazards are risk factors for developing transitional carcinoma of the bladder due to exposure of chemicals such as b-naphthalene

•Smoking status: increased risk, particularly of bladder cancer

•General status, e.g. weight loss, reduced appetite

The patient should be resuscitated with intravenous fluids and a blood crossmatch taken. The INR of 2.2 is in the therapeutic range for her atrial fibrillation, but is unlikely to be the sole cause of her bleeding. Anticoagulation can often unmask other pathology in the urinary tract. Blood clots can cause urethral obstruction so a three-way catheter should be inserted and the bladder initially washed to remove all clots. The irrigation is continued until the haematuria begins to settle. The haemoglobin should be monitored and the patient transfused as necessary. A mid-stream urine should be sent for culture and

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Urology

antibiotic sensitivities. Urine cytology should also be sent to detect the presence of abnormal cells in the urine (once the haematuria has settled and the irrigation has stopped). The patient will require a urinary tract ultrasound to image the upper tracts and a flexible cystoscopy when the urine is clear. If the two latter tests are negative, a CT urogram (CT IVU) should be organised to exclude upper tract pathology in selected patients, e.g. all visible haematuria/non-visible haematuria and age > 50/strong risk factors or good history for transitional cell carcinoma.

KEY POINTS

•patients with visible haematuria and persistent non-visible haematuria need investigating with mSu, urine cytology, cytoscopy and upper tract imaging (ultrasound +/− Ct ivu).

•patients on oral anticoagulation who develop haematuria still require investigation.

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