Technology
Urinary Tract Malignancies
In this episode of the Ninja Nerd Podcast, we delve into urinary tract malignancies, focusing on renal cell carcinoma and its presentation. Through a clinical case discussion, we explore symptoms, dif...
Urinary Tract Malignancies
Technology •
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Interactive Transcript
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Welcome back to the Ninja Nerd Podcast.
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Today we're talking about urinary tract malignancy.
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We're continuing our discussion through oncology.
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Urinary tract malignancy is up next.
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Zach, any big things we should be worried about with this one?
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Their piss and blood be concerned.
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In all seriousness, like jokes aside, the hematuria, especially painless, gross hematuria
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that should bring about at least some degree of ringing bells for urinary tract malignancy.
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Things like renal cell carcinoma or bladder cell cancer or bladder cancer.
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Usually that's transitional or we call it urothelial.
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But those are the two ones that I would think about right off the get-go for a patient
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presenting with hematuria that is painless, it's gross.
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Think about a urinary tract malignancies.
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Alright, let's get right into it here.
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Case 1.
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We have a 58 year old male, 35 pack year smoker.
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He also has hard to control hypertension.
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He shows up with three weeks of intermittent painless, gross hematuria and dull left flank
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pain.
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On exam, you feel a mobile, non-tender flank mass.
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Where is your mind going immediately?
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This seems like if you had a step 2 question like this, like a vignette that set you up,
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they'd be like, you know, like Jordan Slam Dunk and renal cell carcinoma.
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That's what it seems like.
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And the reason why is like 10 to 15% of patients in a true clinical world present with the
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triad of renal cell carcinoma, which is hematuria, flank pain and a palpable mass.
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Oftentimes more than not, you may not even see any of these symptoms, but usually out
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of these the most common ones are going to be hematuria.
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So this tells me that it really screams renal cell carcinoma off the get-go.
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Alright.
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So first differential renal cell carcinoma, you're not concerned with like bladder cancer
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or you have to further elucidate that.
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It could be bladder cancer, but the lack of usually in bladder cancer, they don't have
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like flank masses or any kind of flank pain.
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So that's less on my differential.
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Now bladder cancer is one of the urothelial carcinomas.
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And what I mean by that is that there's a mucosa that we talk about in like, you know,
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our basic foundational sciences and it's called transitional epithelial tissue.
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And that lines pretty much your ureter and we can carry that thing down all the way to
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the bladder.
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And so if you have a cancer of the urothelial tract, you can have what's called urothelial
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carcinoma out of that tract.
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The most common location is the bladder.
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But the fact that they have against other symptomatology, like a palpable mass and flank pain,
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it's less likely that I think that it's bladder cancer.
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It could be a stone.
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I mean, palpable mass less likely, but I definitely that would want to get, you know, maybe
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some kind of imaging to think about that.
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But I want to think about nephrolothiasis or perinephric abscess.
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But usually with a perinephric abscess, you'd have like a history of pylon or fritis.
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You'd have some kind of like history that would make me think about that.
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So I don't think it's pylon or fritis, but I would still want to consider that.
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I'd want to consider a stone.
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I think it could be a carcinoma of the transitional epithelial, maybe at the renal pelvis of the
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ureter, but I think that's low on my differential right at the top is renal cell carcinoma, especially
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with the history of smoking.
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Having hard to control hypertension is kind of interesting and the reason why is if patients
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have renal cell carcinoma in a perfect world, what happens is they, the tumor can release
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renal cell carcinoma.
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And so if it releases an increase in amounts of renal cell that can help to activate
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angiotensinogen and to turn it into angiotensin 1, angiotensin 1 gets renal cell carcinogen
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2, angiotensin 2 helps to squeeze the heck out of your vessels and your pressure can go
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up.
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And that's why they can have hard to control hypertension.
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It's usually a secondary cause.
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So that's one thing I'd be looking for.
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The other thing here is with renal cell carcinoma, they have other perineoplastic symptoms.
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So they make not only lots of renal cell carcinoma, but they can make epo.
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So I would actually consider checking this in to see if they have a high hemoglobin in
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the matacrit for polycythemia.
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I check like a CMP to make sure that the calcium is like not elevated as well because that
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can also be a potential cause as well.
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So these are all things that I'm thinking about.
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Yeah, renal cell carcinoma is definitely at the top, but really I got to get some labs.
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I got to get some imaging to really kind of like start checking with those off.
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So what would you go with then?
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Your analysis, I'm guessing a CT, like BMP.
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I'd probably expand it to maybe a CMP just to get some liver function as well.
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And then in baseline CBC.
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Yeah, I think they're covered.
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I think the reason why I do that is the ear analysis is if they're ping blood, what
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looks like blood, I need to make sure it's blood.
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And then with the ear analysis, it's always good if you have a patient with hematuria.
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It's always good to rule out other causes.
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And so you always want to rule out things like an infection, like pylon and fritis can
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cause that.
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So I would do a U.A.
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probably even with like my cross-capine of culture potentially.
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And then I would also want to look for red blood cell cast.
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I'd want to look for protein to see if there's like an euphrodic.
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I'm sorry, an euphrodic syndrome or a glemarular disease kind of present.
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So that's why I would get that one.
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I'd get the CT admin pelvis with IV contrast probably first because I think that this is
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going to be a real mass.
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And so that's going to give me a really good look at the mass and say, is this a mass?
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Is this a stone?
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Is this pylon and fritis?
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Is this something else going on in the kidney first?
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The baseline CBC is going to help me to see if they have any high hemoglobin hematocrit.
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And the CMP will just help me to look at their liver function.
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It also will just give me a good idea of particularly their alkaline phosphatase,
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which can also be elevated in bone mets.
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And then on top of that, it can show me the calcium.
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So the calcium will be helpful to see if they have a high calcium level.
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So that's kind of what I would start with if I could.
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Okay, cool.
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Well, we do those results.
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We perform those tests and we get the following back.
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We have a urinalysis, which does show us hematuria, no cast or protein area present.
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Okay.
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We do the CT admin pelvis with IV contrast.
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We have a heterogeneous enhancing 5.8 centimeter cortical mass, no renal vein or IVc thrombus.
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Okay.
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Some baseline labs you were interested in are a hemoglobin of 19 creatinine of 1.0 and
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a calcium of 11.2.
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Our chest CT, we also do a chest CT.
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The chest CT shows no mets, bone scan is negative, and there's no bone pain or ALP rise.
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Okay.
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CMP looks normal.
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All right.
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So yeah, with your liver tests.
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Yeah.
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So I think with this right here, we definitely got a pretty good answer that the urinalysis,
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it shows that there's hematuria, but there's no glomerular disease because there's no
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cast, there's no protein.
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I would get a culture.
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You always should get a culture just to make sure that they don't have like pylope.
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I'm going to suspect that the pylope is not going to come back because they usually
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would have a fever.
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They'd have some CVA tenderness as well, but I don't think that this is pylope.
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And then on top of that, I know it's not pylope because the CT admin showed me that I got
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a big honken tumor inside of the renal cortex.
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And so that right there tells me it's likely a renal cell mass, like renal cell carcinoma.
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And then on top of that, the hemoglobin is elevated.
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So they got polycythemia.
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The creatinine's fine.
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I don't know what their baseline is, but the creatinine's still fine even at one.
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And the calcium is 11.2.
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That's elevated.
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So they have hypercalcemia.
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They have polycythemia.
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And on top of that, they get a tumor with hematuria.
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That's likely not glomerular, likely not pylorelated or any kind of stone or any kind of other
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renal pathology related.
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So this is pretty interesting.
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And on top of that, once they found the real mass, usually you do go to the route of a chest
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CT and you can consider a bone scan if they have bone pain or they have an outfaw.
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So if they didn't have bone pain and their alkaline phosphatase was like normal, I wouldn't
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have gotten the bone scan.
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But the CT chest you should always get just to look to see if it spread to the lungs.
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Another common location is the brain.
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I've actually seen this once where a patient came in seizing.
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And then I'm getting a CT.
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They had a bleed in their brain.
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And then they're beginning MRI.
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MRI showed an actual brain mass.
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So they had a met and we were trying to figure out where it came from.
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And so we ended up getting a CT of their chest, abdomen and pelvis.
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And we found that they had a renal cell carcinoma.
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So it's a very common source of bleeding, met in the brain.
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So that's another one I get scared of.
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But yeah, this is definitely a renal cell carcinoma.
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Given the size, given that it hasn't metastasized, this is resectable.
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We can actually treat this pretty well.
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I was going to ask, would you do partial or would you get rid of the kidney?
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So we go size.
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So usually if it's greater than 7 centimeters, we'll cut the whole dang thing out.
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And so you'll tie off.
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You'll tie off the vessels, remove the actual kidney itself.
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So that'd be like a radical nephrectomy.
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I would do if the tumor was a gargantuan, it was like greater than 7 centimeters,
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where it was also taking up a large location too.
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So if it's a little bit more centrally kind of seeded, it's also hard to get those out
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without sparing a lot of the nephrons.
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That's why it's a little bit more challenging.
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So our patient was 5.8 centimeters.
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Yeah.
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That would qualify for a partial.
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Yeah, and it's cortical, which is good.
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So that means it's a little bit more peripheral, so you could cut that out
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and hopefully spare a lot of the remaining nephrons, so they could at least have
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some decent renal function after that.
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So yeah, you could cure this.
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If it hasn't spread and it hasn't seeded anywhere, it's always good to just cut that out.
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Partial refractomy, follow up and just keep monitoring them afterwards on their renal function
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to make sure it doesn't decline.
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You should probably even see an improvement in their hematuria, you should see an improvement
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on their hemoglobin.
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It should start coming down.
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Their blood pressure will probably improve, the hypercalcemial will probably improve.
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So a lot of the perineal plastic stuff would also kind of go away with some time as well.
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So our patient's prognosis is relatively favorable, especially since it's, well, one, it's
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a kind of peripheral location and then it didn't metastasis.
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No, yeah.
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So once you get metastasis, it's a different story.
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It's hard.
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You can still try and refractamies.
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The thing is, they always do this on the exam and they'll try to trip people up until
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they say, like, okay, here, you have a patient who, you have a renal mass and you have a
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high suspicion that it's renal cell carcinoma and they'll give you an option.
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What would you do first?
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An refractomy or a biopsy and you should never pick a biopsy.
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The reason why you never pick a biopsy is because if you stick a needle in the risk
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of hemorrhage, but also you can see the actual tumor and you can actually micrometase
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size.
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That's always better to do just go and cut it out.
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But when it's a lot of metastasis, so if I, let's say that the CT-ChS did show that there
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was metz to the lungs or they had a bone metz because their alfos was elevated or we had
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bone pain and we got the bone scan or we got a brain MRI and we found that they had metz
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in the brain or whatever it may be.
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We find that they have metastasis.
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But then it's a little bit more challenging and then cutting out the kidney itself may
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not only, it can actually help.
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So you could potentially remove the source but the most important thing now is trying to
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just limit metastasis.
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So that's when we reach on to immunotherapies.
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There's newer therapies that we use now if they have metastatic renal cell carcinoloma
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and they're called checkpoint inhibitors.
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And we check point inhibitors.
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Often the abs will abbreviate them as MABs because it's easy.
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It's like Ipilimimab, Pimberlizimab and so we just call them MABs.
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These are pretty good.
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They actually become, I'd say like the standard nowadays of what we use in patients of metastatic
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renal cell carcinoloma is giving usually a combination to immune checkpoint inhibitors.
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One that hits a PD1 protein and the other one that hits the CTLA4 protein and it helps
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to basically tell the T cells, hey get revved up baby, get revved up start ripping these
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tumor cells up and so that's what we would do if they have, I'd say metastatic renal
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cell carcinoloma is immune checkpoint inhibitors.
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That's the preferred method nowadays.
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Now remember before his underlying finding, his blood pressure was hard to control.
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Can we kind of now after doing the freck to me and it's almost like it's curative?
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Can we expect that these would result?
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Yeah, I would say that you still may need depending upon it.
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You may need a little bit of usually an arb or an ACE inhibitor because you could be
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targeting that pathway but I'd say oftentimes usually because they're having an amplified
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run and they have no other comorbidities that's causing their blood pressure, yeah you
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should be okay then because you're getting rid of that source.
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Again this person is a smoker, they're 58, they're getting older so there could all
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there be secondary reasons for why they get a high blood pressure but I think if it's
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hard to control which is meaning the prior multiple agents it's prior because of the renal
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cell carcinoloma and we could probably get that down where they could maybe need less
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of their anti-operatives.
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Sure, yeah that'd be great for him.
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Yeah.
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Alright well hey let's move on the case too then.
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We have our second patient, it's a 70 year old woman.
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She has a 40 pack year history, a long term cyclophosphamide for vasculitis, now notes
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bright red painless hematoria with clots.
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Her creatinine crept from 0.9 to 2.1 over the past six months.
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So we have another patient, smoker, painless hematoria, clots and we're noticing a creep
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in her creatinine.
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What's your mind thinking here?
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Smoking, big one, cyclophosphamide, what's she on that one for again?
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Vascularitis.
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Vascularitis.
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So that's two things there, cyclophosphamide is a pretty big one too, that's kind of a carcinogen.
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Also vasculitis potentially can go as hematoria too, so we always got to think about that, especially
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things like wegners, potentially church strouse.
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Any kind of like vasculitis, even polyardiritis and those that can do that too, so I would
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definitely be even considering vasculitis as a part of the work up as well, that's definitely
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something to consider.
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But right off the get go, I'm definitely thinking bladder cancer, given that this is a significant
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smoking history, cyclophosphamide use and they have hematorie with clots in it, that's
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always another way of like a buzz term, somewhat like pathomonic for bladder cancer.
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So that's definitely at the top of my list is a bladder cancer, which is usually most
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often more than not, there's two types, squamous cell and transitional cell.
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Squamous cell significantly less common.
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That one we see in people who live over in Egypt or like Sub-Sahara Africa who get exposed
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to like chis-to-some, which is like this nasty worm, and that can penetrate through the skin,
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it can go up into your actual, or when actually gets into your bloodstream, then it goes
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to your liver, to your lungs, and then it spreads to your bladder and it literally gets stuck
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into the bladder wall.
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So that's one, chis-to-some as a nasty one, or chronic like catheter use, that can cause
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squamous cell.
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We don't see that one too often, that one's just, it's not very common.
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The more common one is transitional cell.
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And transitional cell is usually seen with smoking.
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As I said, psychophosphamide or any person who's working in an industry that is exposed
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to like rubber dies of sorts.
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Those are the biggest, biggest, biggest risk factors.
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So that's what I'm thinking about.
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Could it be renal cell cars in Oma?
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It could.
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They're not presenting with flank pain and pobble mass, but that doesn't mean that they
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can't still have it.
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That's still possible.
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A stone.
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They haven't presented with any flank pain.
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Again, I think it's possible, but I think it's less likely.
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So those are the things I'm thinking about.
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That's what I would start off with first, because I would say it could be still renal pathology
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of sort.
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I'd say it's less likely.
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I'm going to say it's going to be more likely lower urinary tract pathology.
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And then what about the rising creatinine?
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Does that tell you anything?
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Yeah.
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Yeah.
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So if you go in from 0.9 to 2.1 per liter, pretty quickly, that's an acute kidney injury.
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That's definitely scary.
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It says over six months.
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Again, I don't know how quickly that did rise, but that's definitely a concerning feature.
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So theoretically, this could be an AKI.
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It could be CKD.
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It kind of just depends.
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All I know is that from six months ago, their creatinine shot up.
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Yeah.
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So that's how quickly it went from 0.9 to 2.1 in that six months span.
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I don't know, but I definitely would be concerned about that.
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So there's a couple things that you would want to be concerned about.
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What the rising creatinine could be pre-renal.
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I don't see any risk factors here for dehydration or any kind of mary.
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Medication or anything that would make me think about that.
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Intrurinal cycle of fausumide, it does have that vasculitis, can also cause an intrurinal
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AKI as well.
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But what the hematuria, I definitely would want to be considering.
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Could it be in his rare that bladder cancer is near the trigon, right at the bladder outlet,
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obstructing that actual like the trigon, obstructing the actual outlet, leading to a build-up
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of fluid in the bladder, backing up through the ureters and then causing hydrogen
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afrosis.
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And that can potentially be a cause.
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So that's something I'm thinking about, but I would definitely have to do a workup on
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this one.
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And one of the beauties of this is that if I did one study, two studies, maybe, a CT urogram,
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which is, it's kind of like an abdominal CT with IV contrast.
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So what you do is, is you look at a phase where there's no contrast going into the kidney.
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Then you look at another phase where there is contrast running through the kidney.
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Then you look at a phase where it's running down the uroder and into the bladder.
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And so it just kind of just evaluates that and looks to see if anything kind of shows
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up as abnormal.
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And the kidney, the ureter, and the bladder.
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So it's a great study for that.
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It also tells me if it's a stone, it would tell me if it's a tumor in the kidney, it would
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tell me if it's a tumor in the bladder for the most part.
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And on top of that, I would show me any kind of complications like you're saying, like,
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what's the cause for the AQI?
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Is there hydrogen afrosis?
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If I saw a gargantua's kidney and I saw that there was a potentially an obstruction
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at the bladder, it's the side, then I'd say, okay, that could have been really reason
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why.
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So that's something I would think about right away I'm going to say, let's get a CT
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uregram.
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And let's combine that with scheduling them a cystoscopy.
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A cystoscopy is great because CT uregram is better for upper tract imaging.
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So it's going to get a better look at the kidney and a better look at the ureters.
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It can find decent sized tumors in the bladder.
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But if it's a smaller or flat like tumor, it may miss it.
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So that's when a cystoscopy is, it's a flexible thing.
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It's a scope.
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It goes right up through the urethra and goes up into the bladder.
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And you can literally visualize the inside of the bladder and see if you can find a tumor
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in there.
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And so that's what I would do for that.
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And if I do see a tumor, I would take like a little piece of the biopsy there.
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So that's the first thing I would do for this case because they have smoking as a risk
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factor, cycle phosphamide.
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They have painless hematuria.
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And on top of that, they're older.
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I'm definitely concerned that this is definitely a bladder cancer.
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And that's my higher concern, but I want to rule out anything else.
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That's what I'd start off with first is doing those.
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Perfect.
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So CT ureogram, we have a polypoid bladder dome mass.
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And then you note bilateral hygenophrosis, kind of like you were expecting.
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So that's the cause for their kidney.
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I'd say a acute kidney injury in my case.
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Okay.
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All right.
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And then for our cystoscopy with biopsy, we have a friable urethelial lesion.
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And then with the trans-yerethral resection of the bladder or the tumor is performed
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for staging.
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And I'm kind of curious to know about the staging.
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And then for pathology, it's high grade non-muscle invasive bladder cancer.
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Right.
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That's not bad.
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And it's not great, but it's not bad.
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So that's a good thing.
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So, when we do a CT ureogram, we found the mass.
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That's good.
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Because sometimes you miss them.
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Then we did the cystoscopy, confirmed that there was a lesion there.
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It took the biopsy and usually they can do a small superficial one.
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Often times you have to do a turbid, which is like the trans-yerethral resection of the
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bladder tumor.
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And you literally cut out a good chunk.
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You actually get into the muscle.
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Okay.
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So you have to get pretty deep.
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You got to go through me and then get into the actual muscularis layer and take that
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out.
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Because what you want to see is how deep has the tumor penetrated.
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And if it's in the mucosa and it hasn't invaded the detrusor muscle yet, that's a good
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sign.
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That's called non-muscular invasive bladder cancer, which is what this patient has.
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If they got into the muscle or beyond the muscle, then it's muscular invasive bladder cancer.
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That's not a good one.
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Okay.
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Often times we got to cut the bladder out in that case.
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So what does this tell us then overall?
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I'd say from this one, we definitely have bladder cancer and I'd say that this is going
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to be so it says high grade.
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All right.
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So, but it is non-muscle.
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So it means it did not invade the muscle.
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So it's called non-muscular invasive bladder cancer and it's high grade.
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Okay.
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So that's how they stage it down.
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Yeah.
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Exactly.
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So throughout all of the ecology, all the staging we've done.
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Yeah, you do the TNM stuff.
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Yeah.
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It's kind of confusing.
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Yeah, it's a lot.
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So every topic we've done though, there's some sort of variation.
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Yeah.
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Exactly.
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And this is the easiest way to make it simple for determining prognosis or treatment for
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these patients.
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So you just want to know if it invaded the muscle or not.
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If it did invade the muscle, then you take it a little step further and you try to determine
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if it metastasized to any nodes or to any other organs.
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So if it did, you oftentimes you don't do a lot.
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You usually just do like chemotherapy, aggressive chemotherapy.
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So we're not going to talk about that one.
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Usually the two things that you usually get tested on is if it's non-muscular invasive
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or muscular invasive and then what do you do with those usually?
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All right.
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So overall, then if you had to say a treatment, how would you treat this patient then?
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So we already started off with the turb.
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So we already cut out a good chunk of it.
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And that's pretty much, it's kind of nice because that test is diagnostic and therapeutic.
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So if you do the turb during like whenever you actually done this is theoscopy, you look,
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you visualize it, maybe you take a little lesion.
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Sometimes if you're a urologist present, they will actually go in and they'll actually
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do the turb for you.
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Once you've done that, you can stage it and then also you remove the good chunk of the
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tumor.
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But if there is any kind of residual tumor left, what you do is right after the procedure,
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if they're low risk, which this patient isn't, if they were low risk, I would actually
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fill their bladder with what's called chemotherapy.
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It's called intra vesicular or intra vesicle chemotherapy and we give them something called
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mitomycin C. Usually it's done like a couple hours after you get the turp and you actually
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fill that bladder and that's going to help to kind of kill off some of the remaining
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or residual tumor cells and prevent recurrence.
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If they're high grade, you can't do it right away.
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You got to give it a little bit of time because then you're going to give them something
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called BCG.
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Whenever you give BCG, it's a little bit, it's rare.
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It's rare but it can potentially theoretically cause sepsis and that's why you don't want
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to give it right away.
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You want to allow for the kind of bladder to heal a little bit and then you're going to
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give them BCG.
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I would only give them BCG if they were high risk or they had a high grade.
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So as a tumor was like decent size, pretty big but more particularly when you look at
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it under pathology and they mentioned the term high grade, you can't give them mitomycin
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and see you want to give them BCG.
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It's going to help to really activate and amplify their immune system to kill off these
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actual tumor cells.
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That's what I would do.
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I would start off with, we've done the turp, I'd then wait a little bit and maybe after
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a couple of weeks fill their bladder with the BCG and then they have a tumor there.
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It should help to improve their flow afterwards but if they have that bad of an acute kidney
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injury and it continues to rise even after trying to decompress by removing the tumor,
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even if we try to put a fully catheter in, I'd probably do nephrostomy tubes just to
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kind of get them by if they have a significant acute kidney injury or if they started getting
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like, I'd say if they started getting like pylote too, that's a pretty scary one.
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So sometimes we'll do bilateral perknefs and help to drain the actual urine there, help
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to allow for the creatine to improve and then you can just pop those out.
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So that's something to consider.
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But that's only something I would do if they didn't improve after I actually tried to
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remove that tumor and also if I needed to put in like a fully catheter.
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Now if this patient did have muscle invasion, that's different.
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We don't, the turp is not going to be the answer anymore and neither will any
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intravascular chemotherapy. We actually have to give them systemic chemotherapy.
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Like through their venous circulation, usually it's like cisplatin and gymsitamine and then we
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got to cut the whole bladder out and then even nearby organs.
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So not only do you cut the bladder out like if they're female, you remove the vagina,
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you remove the actual entire philopian tubes, everything.
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And so you remove a lot of the nearby structure, the uterus, etc.
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If it's the male, you remove a lot of the associated structures there as well,
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such as the prostate, the seminal vesicles.
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So it's a pretty drastic type of procedure that you'd have to do.
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And if you think about it, you removed a source of how you've emptied urine into the urethra.
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So now you have to know of another way to pee.
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And so what they do is they divert the urine. So they take the ureters and they take a
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stump of your ilium, usually is the conduit. And they'll externalize that ilium into a stoma,
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like on a bag. And it's going to be like a urostomy bag now. And so they'll take your ureters and
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the ureters will go and empty their urine into the ilium, this little piece of the ilium,
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and that'll come out into this bag that, you know, via the stoma.
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So sometimes that way, it's what we would have to do if they had muscle invasive.
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So in other words, you did the turp, you found, oh,
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shit, the tumors all the way deep down into the muscle. Okay, that sucks.
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All right, what do we do? All right, so now we're going to go ahead and we're going to give them
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chemo, and then we're going to get them set up to do a radical cystectomy, cut the bladder out,
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and divert the urine another way. And so that's unfortunately the way that we usually go with these.
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But how do you monitor these patients? Let's just say our current patient. How would you monitor
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that for hopefully resolving and getting better? If we didn't do, so if you do the radical cystectomy,
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you can't do another cystoscopy anymore because you don't have a bladder anymore. But if I did
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just go the route of the turp and the like our patient. Yeah, yeah. Okay, if I had that one,
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I'd do a cystoscopy again. I would do it probably like maybe like six to 12 months, make sure that
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the lesions actually not there anymore, make sure that there's not any kind of problems. That's what
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I would probably do. I'd probably do that. Usually I do six to 12 months. That's probably the
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best way of starting off with it. And then from there, you can kind of adjust based upon the
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results of that. Okay. And how about the any more CT orographies at all? Or is it just themes?
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It's a cystoscopy. I'd say I would do the CT orography if I had upper
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urethelial tract carcinomas. I'd say I probably wouldn't do any kind of like CT orography.
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You can sometimes, but I don't think that that's usually going to be necessary. Okay.
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Well, that's all I had for case two. Hopefully if you're not, if you're up for it, we can do a quick
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rapid recap. Yeah, sure. But you know, keep it high yield. I don't want to hear you keep
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labyrinth on. Okay. Okay. Okay. Quick rapid recap. So if I had to give some big things for each
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one like renal cell carcinoma first, I would say the big thing is to remember with these patients,
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you got to think about a patient who presents with hematoria, flank pain and a palpable mass.
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If they have that definitely in the clinical world, it's not as common, but in the exams, it's
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the classic triad. Other things that you want to think about for this patient is the perineo
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plastic syndrome. You want to go to a polycythemia. You want to think about hypercalcemia. You want
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to think about potentially any kind of resistant hypertension that you could see in this condition.
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Usually with these patients, the only way that you can truly find this is an abdominal CT,
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usually with the IV contrast showing a mass. If you see the mask, don't buy obfsy to call on a
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surgeon to for your your logical kind of surgery, surgery evaluation to see if they can do a
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fracture to me. If it's less than seven centimeters, you can do partial. If it's greater than seven,
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then you're going to do a full radical nephrectomy. The other thing is that sometimes if it's like an
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old patient, it's a smaller tumor and it's they got a lot of comorbidities, you can just watch them,
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and you can just do CT scans every like six months or three months or whatever, however kind of like
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a you know aggressive you want to be in surveying it, but oftentimes we prefer to just cut that tumor
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out if we can. If it's metastatic, you don't really do that, you do immunotherapy, dual combination of
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that. Bladder cancer, two types, transitional, urethelial, urethelial, much more common. Squamous,
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that's less common. You're going to see that more in the cis soma and the Egypt, sub-Saharan Africa
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population. Transitional, more common here in our neck of the woods, and you're going to see the
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more smoking, you know drugs like cyclophosphamide or any kind of like rubber dye factories where they
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have exposure. That's painless hemateria. You just the most common presentation, maybe some visible
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clots, they don't usually have any other symptoms. From here, if you see that a CT urgam is good to see if
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you rule out anything in the upper tract, and then cystoscopy falls for the lower urinare tract to
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see, hey, is there any kind of renal, I'm sorry any bladder lesion present that I saw in the CT
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urgam or I didn't see. Oftentimes we prefer to do a turb, because that's going to tell you if it's
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muscular invasive or non muscular invasive. It's non muscular invasive, that's great. You're going to go
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ahead and you've done the turp at this point, is it low grade displays you high grade. Low grade,
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you fill the bladder with mitamysin C, high grade, you wait a little bit, a couple weeks, and you fill
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it with the BCG. If it's muscular invasive, ultimately they're going to have to get chemo and you're
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going to have to remove the bladder and a lot of other structures and then divert the urgators to
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empty into the ilium, into the stoma and a bag. That's usually the way that we would end up with
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that one. A lot of the times with these patients, you got to be careful when you take a kidney out,
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full, like nephrectomy, renal function monitoring is really, really important, but you should see a lot
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of their parenting, a plastic stuff improve. Bladder cancer, you probably just got to keep falling
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up with this cystoscopy, is falling up with the UAs, even urine cytologies or something that we would
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even do as well. Just making sure that you're not missing any lesion that resurfaces or recurs.
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Especially if you haven't removed the bladder in that case. That's what I would hit everybody with,
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and I hope that that made sense. Did you like this one? I sure did. I sure did.
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Common theme here, don't ignore painless hematoria. Don't ignore it, man. Yeah, so I really hope that
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you guys enjoyed this podcast. I'll be learned a lot. I hope you had fun. I hope that you now can
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appreciate if a patient comes in with hematoria, how to be able to work them up, how to be able to
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kind of see that there is a common thread between renal cell cars and omen, bladder cell cancer,
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but trying to be able to differentiate which one it is, I hope that now you have an understanding of that.
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Well, I love you guys and thank you guys, and as always, until next time.