2. Enfermería
• Consulta de
enfermería:
• Tengo un paciente con
disuria y hematuria.
• ¿Dime que antibiótico
le receto?
¿ Qué haceis?
3. Entrevista médica
Hematuria hace 2 años,
le diagnosticaron un
pólipo en Barcelona.
Le citaron para
cistoscopia pero no le
fue bien el día- no fue
Se olvidaron de el –dice
Desde hace meses tiene
incontinencia, disuria y
hematuria constante
Tiene miedo no se
atreve a consultar
Hace un año consultó
informalmente a un
urólogo ¿?
Se le cita al final de la
mañana para una ECO AP
4. Ecografía de AP
Pared de la vejiga
urinaria muy
engrosada que ocluye
la luz de la misma.
Diferentes
ecogenicidades
7. Ecografía del riñón
Dilatación importante
de la luz pélvica.
Estasis renal
No aumento del
tamaño. (RD 10,44 cm,
RI 10,86)
Adelgazamiento de la
cortica
No cálculos
11. TAC abdominal del paciente
• TAC Vejiga urinaria con múltiples engrosamientos murales nodulares y
difusos que alcanzan al menos los 31 mm de grosor. Múltiples
calcificaciones groseras de predominio en las zonas superficiales de
las lesiones.
• No se identifican ganglios linfáticos mesentéricos, retroperitoneales ni
pélvicos de tamaño significativo.
• No líquido libre ni colecciones intraabdominales. Resto del estudio sin
alteraciones.
CONCLUSIÓN:
• Múltiples engrosamientos nodulares y difusos de las paredes de la
vejiga urinaria que sugieren proceso neoformativo primario vesical,
condicionando hidronefrosis bilateral por obliteración de los meatos
ureterales. No se identifican signos que sugieran la existencia de
extensión a distancia en el área explorada.
12. Intervención. RTU- Biopsia
• Intervención quirúrgica. Vejiga urinaria ocupada
en su práctica totalidad por neoformación papilar
de base sólida, con muy extensa superficie de
implantación, sin llegarse a apreciar en ningún
momento áreas mucosas de aspecto sano. Lesión
irresecable. Se realiza RTU biopsia.
• Shock hemorrágico en el postoperatorio de RTU
• Pasa a UCI para control hemodinámico.
13. Diagnóstico
No se cree el
diagnóstico y le
asusta la operación
pues se le ha
propuesto una
cistectomia radical.
Quiere una segunda
opinión
Anatomía patológica:
Carcinoma urotelial
papilar de alto grado
con extenso
componente de bajo
grado que infiltra la
submucosa y que
respeta los
fragmentos de la capa
muscular estudiados
No invasión vascular
linfática
14. Cistoprostatectomia radical
Cistoprostatectomia radical más lindadenectomia
iliaco-obturatriz bilateral con derivación urinaria
heterotópica ureteroileal tipo Bricker.
- Carcinoma urotelial papilar y sólido de alto grado con
extenso componente de bajo grado. - localización: la
practica totalidad de la vejiga, dejando preservada
parte de la cúpula vesical.
- Extensión microscópica: el tumor infiltra la capa
muscular profunda. se extiende a la desembocadura
de ureter derecho e izdo.
- Invasión vascular linfática: no se observa.
16. Conclusión:
• Paciente de 50 años, fumador con clínica de
hematuria, incontinencia y disuria presenta
neoformación vesical de 2 años de evolución
con infitracción de toda la vejiga urinaria que
es diagnosticado de Carcinoma urotelial
papilar y sólido de alto grado con extenso
componente de bajo grado sin metástasis ni
infiltración de ganglios locoregionales
• Cistoprostatectomia radical- No citostaticos
17. Cáncer de vejiga urinaria
• El cáncer más común del tracto
urinario
• Carcinoma urotelial (células
transicionales) 90%
• No músculo invasivo (superficial) 75-80%
Músculo invasivo
Metastático
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
18. Cáncer de vejiga: Incidencia
Incidencia de 10,1 por 100.000
varones y 2,5 por 100.000 en
mujeres
Mayor incidencia en el oeste y sur
de Europa (27,1/4,1)
Varía entre 5,6/3,1
varones/mujeres según países
occidentales.
X 14 a nivel mundial
-Jiménez JA, Campbell SC, Jones S, Lerner S, Fletcher RH, Deputy M,Park L.Screening for bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jan 07, 2014.
-Nielsen ME, Smith AB, Meyer AM, Kuo TM, Tyree S, Kim WY, et al. Trends in stage-specific incidence rates for urothelial
carcinoma of the bladder in the United States: 1988 to 2006. Cancer. 2014 Jan 1;120(1):86-95. doi: 10.1002/cncr.28397. Epub 2013 Oct
19. Cáncer de vejiga-Factores de riesgo
• Irradiación pélvica
• Ciclofosfamida
• Tabaco (x3 RR)
• Carcinógenos químicos (aminas,
emisiones diesel, aluminio, cuero,
caucho..)
• Infecciones: squistosoma
hematobium
• Varón y anciano (80% > 60 años)
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
20. Cáncer de vejiga urinaria-Clínica
• Hematuria no dolorosa
• Pueden haber signos irritativos
(disuria, urgencia miccional…)
• Diagnóstico demorado (infección
urinaria, prostatitis…) + en mujeres
• A veces clínica de metástasis
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
21. Cáncer de vejiga urinaria-Hematuria
• Síntoma más común
• Macroscópica e
intermitente
• No dolorosa
• 10-20% de las
hematurias
macroscópicas
• 61% no anormalidades
• 12% Cáncer vejiga
• 13% infecciones
urinarias
• 10% Enfermedades
riñón
• 4% litiasis renal
• 0,6 % Cáncer renal
• 0,4% Cáncer próstata
-MARSHALL VF. Current clinical problems regarding bladder tumors. Cancer 1956; 9:543. Khadra MH, Pickard RS, Charlton M, et al.
A prospective analysis of 1.930 patients with hematuria to evaluate current diagnostic practice. J Urol 2000; 163:524.
.
22. Cáncer de vejiga urinaria-Clínica
• Síntomas irritativos:
• Aumento de la
frecuencia,
urgencia, disuria,
incontinencia (1/3
de los pacientes)
• Carcinoma in situ
• Síntomas
obstructivos:
• Esfuerzo para orinar,
chorro intermitente,
nicturia, disminución
del chorro, sensación
de vaciado
incompleto
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
23. Cáncer de vejiga urinaria-Examen
físico
• Habitualmente normal
• Masa sólida en hipogastrio
• Induración glándula prostática (TR)
• Adenopatías inguinales
• Nódulo periumbilical
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
24. Cáncer de vejiga urinaria- Diagnóstico
• Hematuria inexplicada
en mayores de 40 años
• Descartar problema
glomerular (proteinuria,
células dismórficas,
acantocitos…)
• Pielografía o ecografía
• TAC de pelvis con
contraste EV, o RMN en
caso de alergia al
contraste
• Cistouretroscopia
• Cistoscopia: GOLD STANDARD
• Mínimo riesgo de sangrado o
infección
• Permite biopsiar y resecar
• Cistoscopia fluroescente
(contraste y luz)
• Citología (especificidad >
98%)
• Marcadores solo en pacientes
con historia de CV (menos
sensibilidad que la
cistoscopia)
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
25. Cáncer de vejiga urinaria- ECOGRAFIA
• No es muy útil
frente a otras
técnicas
• No determina la
invasión ni la
extensión
• Útil evaluar tracto
superior
(hidronefrosis)
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
26. Cáncer de vejiga urinaria- Metástasis
Pulmón: RX torax (no < 1 cm). TAC
muchos falsos positivos.
Gammagrafía ósea, fosfatasas
alcalina, TAC, RMN
Positron emission tomography
(PET)
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
27. Cáncer de vejiga urinaria-Grado
histológico y estadiaje
• Neoplasias del
sistema urotelial
(células
transicionales)
• Bajo grado
• Alto grado
●Ta lesions – Ta tumors are exophytic
(papillary) lesions that tend to recur, but
these are relatively benign and generally
do not invade.
●Tis – Carcinoma in situ (CIS), or flat
tumors.
●T1 lesions – If a tumor invades the
submucosa or lamina propria
●T2 lesions – In T2 lesions, invasion into
muscle is present. For T2 tumors,
cystectomy is considered "standard
therapy
●T3 lesions – T3 tumors extend beyond
muscle into the perivesical fat.
●T4 lesions – The TNM system
differentiates tumors extending into
adjacent organs (T4) from those
extending into perivesical fat (T3).
Tumor invading the prostate, vagina,
uterus, or bowel is classified as T4a,
while tumor fixed to the abdominal wall,
pelvic wall, or other organs is T4b
-Lotan Y, Choueiri TK, Lerner SP, Dizon DS.Clinical presentation, diagnosis, and staging of bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jun 05, 2014.
28. Cáncer de vejiga-Cribado
• Cistoscopio (gold standard)
alta sensibilidad y VPP
• Tiras reactivas hematuria
VPP < 10%, poco específico
• (+ 0,18-16,1% EEUU)
• Citología orina (sensibilidad
34%). Especificidad 99% en
recurrencias: Caro
• Biomarcadores
• Cistoscopia virtual (TAC).-
radiaciones, menos efectivo
que el cistoscopio
-Jiménez JA, Campbell SC, Jones S, Lerner S, Fletcher RH, Deputy M,Park L.Screening for bladder cancer.
Literature review current through: May 2014. | This topic last updated: Jan 07, 2014.
Guidelines on non-muscle invasive bladder cancer. European Association of Urology 2011.
http://www.uroweb.org/gls/pdf/05_TaT1_Bladder_Cancer.pdf
29. Cáncer de vejiga-Cribado
• Efectos secundarios: falsos positivos,
perforación, sangrado e infeccion
• Sobrediagnóstico
• US Preventive Services Task Force
(USPSTF): no hay evidencia de alta calidad,
o la que hay es insuficiente (2011)
• American Cancer Society.- no
recomendada
-Moyer VA, U.S. Preventive Services Task Force. Screening for bladder cancer:
U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2011; 155:246
-American Cancer Society guidelines for the early detection of cancer.
http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection--.
Hinweis der Redaktion
CLINICAL PRESENTATION — Patients with bladder cancer classically present with painless hematuria (grossly visible or microscopic), although irritative voiding symptoms (frequency, urgency, dysuria) can be the initial manifestation. The diagnosis is often delayed due to the similarity of these symptoms to those of benign disorders (urinary tract infection, interstitial cystitis, prostatitis, passage of renal calculi), and delays can lead to a worsened prognosis due to more advanced stage at diagnosis [1]. There is evidence to suggest that delayed diagnosis accounts for the poorer survival in women diagnosed with bladder cancer compared with men [2]. Furthermore, symptoms are often intermittent. In some patients, metastases will cause the initial symptoms. Incidental bladder cancer is rare at autopsy, suggesting that most cancers eventually become symptomatic [3].
Hematuria — The most common presenting symptom is hematuria, which is typically intermittent, gross, painless, and present throughout micturition. (See &quot;Etiology and evaluation of hematuria in adults&quot;.)
The likelihood of bladder cancer increases when the hematuria is gross (visible) or microscopic,
CLINICAL PRESENTATION — Patients with bladder cancer classically present with painless hematuria (grossly visible or microscopic), although irritative voiding symptoms (frequency, urgency, dysuria) can be the initial manifestation. The diagnosis is often delayed due to the similarity of these symptoms to those of benign disorders (urinary tract infection, interstitial cystitis, prostatitis, passage of renal calculi), and delays can lead to a worsened prognosis due to more advanced stage at diagnosis [1]. There is evidence to suggest that delayed diagnosis accounts for the poorer survival in women diagnosed with bladder cancer compared with men [2]. Furthermore, symptoms are often intermittent. In some patients, metastases will cause the initial symptoms. Incidental bladder cancer is rare at autopsy, suggesting that most cancers eventually become symptomatic [3].
Hematuria — The most common presenting symptom is hematuria, which is typically intermittent, gross, painless, and present throughout micturition. (See &quot;Etiology and evaluation of hematuria in adults&quot;.)
The likelihood of bladder cancer increases when the hematuria is gross (visible) or microscopic,
Flank pain may result when a tumor obstructs the ureter at any level (bladder, ureter, or renal pelvis). Although obstruction usually is associated with muscle-invasive disease, large non-invasive tumors at the ureteral orifice may also cause symptoms. The pain is similar to that experienced with the passage of urinary stones and may or may not be associated with hematuria. (See &quot;Diagnosis and acute management of suspected nephrolithiasis in adults&quot;.)
●Suprapubic pain is usually a sign of a locally advanced tumor that is either directly invading the perivesical soft tissues and nerves or obstructing the bladder outlet and causing urinary retention.
●Hypogastric, rectal, and perineal pain can be signs of disease invading the obturator fossa, perirectal fat, presacral nerves, or the urogenital diaphragm.
●Abdominal or right upper quadrant pain may signal the presence of abdominal lymph node or liver metastases.
●Bone pain may indicate the presence of bone metastases.
●Significant and persistent headache or disordered cognitive function may suggest the presence of intracranial or leptomeningeal metastases.
PHYSICAL EXAMINATION — A complete physical examination should be performed in patients with bladder cancer, including a digital rectal examination in men and a bimanual examination of the vagina and rectum in women.
Although the physical examination is unremarkable in most patients, abnormal findings that can be seen include the following:
●A solid pelvic mass may be felt in advanced cases.
●Induration of the prostate gland can sometimes be felt on digital rectal examination if the bladder cancer involves the bladder neck and invades the prostate. An attempt to palpate the base and lateral walls of the bladder should be made, looking for induration or fixation.
●Inguinal adenopathy can be present, although the inguinal region is not a common site of node metastases.
●Nodularity in the periumbilical region can be seen in advanced lesions involving the dome of the bladder. This is often seen with urachal cancers, which typically are adenocarcinomas rather than urothelial tumors.
●Abdominal examination may reveal the presence of substantially enlarged para-aortic lymph nodes or hepatic metastases.
DIAGNOSTIC APPROACH
Overview — The presence of otherwise unexplained hematuria denotes a urothelial cancer in individuals over the age of 40 until proven otherwise. The goal of the diagnostic evaluation is to determine the diagnosis, site, and extent of cancer, and the presence or absence of muscle-invasive disease.
A full urologic evaluation of the entire urinary tract is indicated in such patients unless there is clear evidence of glomerular bleeding (eg, red cell casts, proteinuria, dysmorphic red cells [particularly acanthocytes], and in patients with gross hematuria, a smoky brown color). (See &quot;Etiology and evaluation of hematuria in adults&quot;, section on &apos;Glomerular versus nonglomerular bleeding&apos;.)
This evaluation should consist of cystourethroscopy, urinary cytology, and an evaluation of the upper tracts, since urothelial malignancy can be multifocal, with one or more lesions anywhere from the renal pelvis to the proximal urethra.
Radiographic imaging of the upper tract can consist of either a computed tomography (CT) scan of the abdomen/pelvis with urography with oral and intravenous contrast or intravenous pyelography (IVP) plus nephrograms or renal ultrasound (US) to evaluate both the collecting systems and the renal cortex. IVP is rarely used and has been largely replaced by CT. Contrast magnetic resonance imaging (MRI) may be used in patients with allergy to iodinated contrast.
Although CT provides better visualization of tumors than US, it may miss tumors &lt;1 cm in size, particularly those in the bladder trigone or dome, and it cannot differentiate depth of bladder-wall invasion (ie, mucosal versus lamina propria or muscularis propria).
The sensitivity of CT for identification of nodal involvement is relatively low (false-negative rate 68 percent, false-positive rate 16 percent) and requires a needle or excisional biopsy for confirmation [16].
MRI — MRI is as reliable as CT for staging of invasive or locally advanced disease and may be better at evaluating tumors at the base and dome of the bladder. Gadolinium-enhanced MRI may be superior to CT to detect superficial and multiple tumors, extravesical tumor extension, and surrounding organ invasion [20-23].
Cystoscopy — Cystoscopy is the gold standard for the initial diagnosis and staging of bladder cancer. This procedure is done in the office with a flexible cystoscope and only has minimal risks such as bleeding and infection. Risk of infection is minimal using sterile techniques. In the United States, this is typically done with white light; fluorescence cystoscopy has been available in Europe and was approved for use in the United States in 2010. (See &apos;Fluorescence cystoscopy&apos; below.)
●Any visible tumor or suspicious lesion seen at the initial (diagnostic) cystoscopy should be either biopsied or resected transurethrally to determine the histology and depth of invasion into the submucosa and muscle layers of the bladder.
●In patients who presented with a positive urine cytology and whose initial cystoscopy showed no visible tumor (or suspicious lesion) within the bladder, biopsy of apparently normal appearing urothelium, prostatic urethra, and selective catheterization of the ureters/renal pelvis with urine specimens for cytology from upper tract is required.
For patients with documented high-risk disease confirmed on a diagnostic transurethral resection of bladder tumor (TURBT), repeat cystoscopy may be indicated to eliminate the risk of understaging.
None of these markers have sufficient sensitivity to replace cystoscopy in the assessment of an individual suspected to have bladder cancer, and their clinical use has not been recommended by consensus panels. There is a potential benefit for surveillance in patients with a history of urothelial cancer by reducing the interval for cystoscopy.
Ultrasound — US is not very useful for the diagnosis or staging of bladder cancer. US can confirm the presence of a soft tissue mass, but usually cannot determine depth of invasion, extravesical extension, or nodal status. US may be useful in evaluating the upper tracts for renal parenchymal disease, hydronephrosis, and to differentiate a non-radiopaque stone from a soft tissue mass by differences in echogenicity [24]. (See &quot;Diagnostic approach to the patient with acute kidney injury (acute renal failure) or chronic kidney disease&quot;.)
Flank pain may result when a tumor obstructs the ureter at any level (bladder, ureter, or renal pelvis). Although obstruction usually is associated with muscle-invasive disease, large non-invasive tumors at the ureteral orifice may also cause symptoms. The pain is similar to that experienced with the passage of urinary stones and may or may not be associated with hematuria. (See &quot;Diagnosis and acute management of suspected nephrolithiasis in adults&quot;.)
●Suprapubic pain is usually a sign of a locally advanced tumor that is either directly invading the perivesical soft tissues and nerves or obstructing the bladder outlet and causing urinary retention.
●Hypogastric, rectal, and perineal pain can be signs of disease invading the obturator fossa, perirectal fat, presacral nerves, or the urogenital diaphragm.
●Abdominal or right upper quadrant pain may signal the presence of abdominal lymph node or liver metastases.
●Bone pain may indicate the presence of bone metastases.
●Significant and persistent headache or disordered cognitive function may suggest the presence of intracranial or leptomeningeal metastases.
Tumor (T) stage
●Ta lesions – Ta tumors are exophytic (papillary) lesions that tend to recur, but these are relatively benign and generally do not invade.
●Tis – Carcinoma in situ (CIS), or flat tumors.
●T1 lesions – If a tumor invades the submucosa or lamina propria, it is classified as a T1 tumor.
●T2 lesions – In T2 lesions, invasion into muscle is present. For T2 tumors, cystectomy is considered &quot;standard therapy.&quot; When muscle invasion is present, the probability of nodal and distant metastases is increased. The 2010 TNM staging system divides muscle-infiltrating (T2) disease into superficial (T2a) or deep (T2b) invasion, with disease still confined within the bladder [31].
●T3 lesions – T3 tumors extend beyond muscle into the perivesical fat. CT or magnetic resonance imaging (MRI) scans may help to identify disease that has spread outside the bladder. T3 stage is stratified between T3a (microscopic) and T3b (macroscopic).
●T4 lesions – The TNM system differentiates tumors extending into adjacent organs (T4) from those extending into perivesical fat (T3). Tumor invading the prostate, vagina, uterus, or bowel is classified as T4a, while tumor fixed to the abdominal wall, pelvic wall, or other organs is T4b.
Flank pain may result when a tumor obstructs the ureter at any level (bladder, ureter, or renal pelvis). Although obstruction usually is associated with muscle-invasive disease, large non-invasive tumors at the ureteral orifice may also cause symptoms. The pain is similar to that experienced with the passage of urinary stones and may or may not be associated with hematuria. (See &quot;Diagnosis and acute management of suspected nephrolithiasis in adults&quot;.)
●Suprapubic pain is usually a sign of a locally advanced tumor that is either directly invading the perivesical soft tissues and nerves or obstructing the bladder outlet and causing urinary retention.
●Hypogastric, rectal, and perineal pain can be signs of disease invading the obturator fossa, perirectal fat, presacral nerves, or the urogenital diaphragm.
●Abdominal or right upper quadrant pain may signal the presence of abdominal lymph node or liver metastases.
●Bone pain may indicate the presence of bone metastases.
●Significant and persistent headache or disordered cognitive function may suggest the presence of intracranial or leptomeningeal metastases.
Flank pain may result when a tumor obstructs the ureter at any level (bladder, ureter, or renal pelvis). Although obstruction usually is associated with muscle-invasive disease, large non-invasive tumors at the ureteral orifice may also cause symptoms. The pain is similar to that experienced with the passage of urinary stones and may or may not be associated with hematuria. (See &quot;Diagnosis and acute management of suspected nephrolithiasis in adults&quot;.)
●Suprapubic pain is usually a sign of a locally advanced tumor that is either directly invading the perivesical soft tissues and nerves or obstructing the bladder outlet and causing urinary retention.
●Hypogastric, rectal, and perineal pain can be signs of disease invading the obturator fossa, perirectal fat, presacral nerves, or the urogenital diaphragm.
●Abdominal or right upper quadrant pain may signal the presence of abdominal lymph node or liver metastases.
●Bone pain may indicate the presence of bone metastases.
●Significant and persistent headache or disordered cognitive function may suggest the presence of intracranial or leptomeningeal metastases.
