case study - Hematuria

Copyright © 2018 by Elsevier Inc. All rights reserved.

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

Hematuria

Case Studies

A 55-year-old male developed painless hematuria. He was otherwise completely asymptomatic.

The results of his physical examination were within normal limits (WNL).

Studies Results

Routine laboratory studies WNL

Urinalysis, p. 896

Blood Positive (normal: no blood)

Red blood cells (RBCs) Too numerous to count (TNTC) (normal: up to 2)

Intravenous pyelogram (IVP), p.

1001

1. Distortion of renal outline, compatible with a right renal

mass

2. Questionable bladder tumor

3. Mild right ureteral dilation

Computed tomography (CT)

scanning of the mass, p. 962

Normal kidneys, probable renal cyst present

Renal ultrasound, p. 810 Mass in the right kidney is a fluid-filled cyst

Cystography, p. 978 Bladder tumor

Cystoscopy, p. 538 Bladder tumor seen lying near the right ureteral orifice

Renal biopsy, p. 706 Transitional cell carcinoma

Retrograde pyelography, p. 1001 Bladder tumor involving right distal ureter

Bladder tumor markers, p. 856 BTA: 23 units/mL

NMP22: 32 units/mL

Survivin: 700 pg/mL

Diagnostic Analysis

The urinalysis results documented this patient’s hematuria. Three distinct abnormalities on IVP

could have been responsible for the hematuria. The renal mass could have been a solid tumor or

a benign cyst. CT scanning and ultrasonography indicated that the mass was the result of a

benign renal cyst and was not the cause of the hematuria. No treatment was required for the cyst.

The questionable bladder tumor seen on IVP was more clearly demonstrated by cystography, and

a specimen for biopsy was taken during cystoscopy. The diagnosis was transitional cell

carcinoma of the bladder. The bladder tumor markers were consistent with that diagnosis. Right

ureteral dilation (seen on IVP) implied possible ureteral involvement by the bladder tumor. A

retrograde pyelography study indicated that this was indeed the situation.

After 2 months of preoperative radiation, the patient had a total cystectomy and ileal urinary

diversion. Tumor markers returned to normal 6 months after surgery. Two years later the tumor

markers began to rise, and the patient was found to have bladder metastasis to the lung.

Case Studies

Copyright © 2018 by Elsevier Inc. All rights reserved.

2

Studies Results

Blood urea nitrogen

(BUN), p. 453

58 mg/dL (normal: 7–20 mg/dL)

Creatinine, p. 171 3.2 mg/dL (normal: 0.7–1.5 mg/dL)

Renal ultrasound, p. 830 Dilated ureters bilaterally

Antegrade pyelography,

p. 1001

Obstruction of both ureters where the ureters join into the ileal

conduit (new bladder made at the time of the previous surgery)

caused by recurrent tumor

Bilateral nephrostomies (tubes placed in the ureter to relieve obstruction) were placed at the time

of antegrade pyelography. The patient died of his recurrent bladder cancer 8 months later.

Critical Thinking Questions

1. Why did this patient require a retrograde pyelography and an antegrade pyelography?

2. If, after cystoscopy, this patient had complained of lower abdominal pain and had

developed a temperature, what would you suspect?