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Microhematuria Case Study
MEDICAL STUDENT CASE-BASED LEARNING
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Patient: Presentation
75-year-old Caucasian male referred for asymptomatic (painless) microhematuria
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What additional history would be pertinent?
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Patient: History & Physical Exam • Denies gross hematuria, dysuria, irritative voiding symptoms, or difficulties
with urination • No fevers, abdominal or flank pain • Endorses 17 lb. weight loss over 10 months • PMH: HTN. No prior GU history • PSH: None • Meds: Metoprolol, aspirin • FHx: No known history of stones or malignancies • SH: Retired veteran, 50 pack-year smoking history
• PE: No abdominal tenderness or distension, no costovertebral angle
tenderness bilaterally, normal phallus with orthotopic meatus
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What is your differential diagnosis?
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Differential Diagnosis
• Urolithiasis • Malignancy
– Bladder cancer – Upper tract
urothelial carcinoma – Renal cell carcinoma
• UTI • BPH • Non-infectious cystitis • Glomerulonephritis • Trauma • Strenuous exercise
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What laboratory evaluation would be appropriate?
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Patient: Laboratory Evaluation • Urinalysis:
– Color: yellow – SG: 1.015 – pH: 5.5 – Nitrite: neg – Leukocyte esterase: neg – RBC: 3-5 / hpf (no RBC casts) – WBC: 0-2 / hpf – Protein: none – Bacteria: none – Squamous epithelial cells: none
• Cr: 1.1 • Hgb / Hct: 13.5 / 40.5
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Define microhematuria. How does this differ from gross hematuria?
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Types of Hematuria
Microhematuria • >3 RBC/hpf on a single
urinalysis • Not visible to the naked eye
Gross Hematuria • Blood in the urine visible to
the naked eye
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Is a urine dipstick sufficient to diagnose microhematuria?
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No! • Must obtain urinalysis with reflex microscopy to confirm
the presence of RBC’s • False positives can occur with dipstick testing:
– Myoglobinuria – Hemoglobinuria – Povidone-iodine
• False negatives can also occur: – Vitamin C ingestion – Urine pH <5.1 – Prolonged exposure of dipstick to air prior to testing
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What is the chance of malignancy in the setting of hematuria?
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Malignancy in Hematuria
• Likelihood of identifying malignancy depends on type of hematuria: – Microhematuria: 3-5% chance of malignancy – Gross hematuria: 23% chance of malignancy
• Varies based on risk factors
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What risk factors does the patient have that would predispose him to
urologic malignancy?
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Patient: Risk Factors/Clues for Malignancy
• Older age • Male gender • History of cigarette smoking • Weight loss
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What would be your next step in evaluating this patient’s hematuria?
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Cystoscopy: Findings • No urethral strictures • Prostatic enlargement • Orthotopic ureteral orifices with clear efflux of
urine bilaterally • No abnormal lesions or tumors • No active bleeding • Cytology wash obtained: “atypical cells”
identified
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Upper Tract Evaluation • CT urography (CTU) • What alternative modalities can be used to
evaluate the upper tracts (e.g. if Cr elevated or patient allergic to iodine)? – MR urography – Retrograde pyelography with non-contrasted renal
imaging
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Is the excretory phase really necessary?
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Can you see an abnormality (non-contrasted imaging)?
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How about now (excretory phase)?
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What would you do next?
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Diagnostic Ureteroscopy
• Right-sided retrograde ureteroscopy was performed, revealing large papillary-appearing protrusion into the renal pelvis, which was biopsied – Dx: high-grade urothelial carcinoma
• Tissue diagnosis can be obtained via retrograde or antegrade ureteroscopy or via percutaneous approaches if amenable
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What is the incidence of upper tract urothelial carcinoma (UTUC)?
What are some unique risk factors for
this disease?
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UTUC
• Incidence: 2 new cases per 100,000 people
• 5% of all urothelial carcinomas
• Can occur in renal pelvis or ureter
• Risk factors: – Tobacco use – Cyclophosphamide exposure – Phenacetin use – Aristolochic acid use – Balkan nephropathy – Lynch syndrome – Chronic inflammation – History of bladder cancer
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What is the surgical management of non-metastatic UTUC?
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Surgical Management
• Gold standard: radical nephroureterectomy – Performed in index patient
• Nephron-sparing approaches: must be considered on a case-by-case basis (e.g. tumor location, multifocality, grade, renal function, comorbidities) – Partial ureterectomy – Endoscopic resection/fulguration
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What principles are important in surveillance of UTUC patients
following treatment?
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Post-op Surveillance in UTUC • Periodic cystoscopy
– Risk of metachronous bladder cancer: 22-47% • Excretory urography of upper tracts (consider surveillance
ureteroscopies following nephron-sparing approaches) – Risk of metachronous contralateral UTUC: 2-8%
• Monitor renal function – After nephroureterectomy – Following receipt of platinum-based chemotherapy
(nephrotoxic)