A 62 Year-Old Man with Painless Hematuria

Norifumi Kamo, HMS III 

Gillian Lieberman, MD 

A 62 Year-Old Man with Painless 

Hematuria 



Beth Israel Deaconess Medical Center 

1



Patient Presentation 

CC: Painless hematuria 

HPI: AS is a 62 y/o M who presents with gross painless 

hematuria for the past 2 months 

PMH/PSH: s/p MI (s/p CABG), NIDDM 

Meds: Avandia, glyburide, metoprolol 

Allergies: NKDA 

2



Patient Presentation (cont’d) 

SH: smoked 4 PPD for 40 years 

FH: not significant 

PE: obese male, AVSS in NAD 

Labs: 

Chem 7, CBC wnl 

BUN 13 and Creatinine 0.9 

U/A: 10 RBC/hpf, Urine cx negative 

3



Kidney Stones 

Differential Diagnosis: 

Urinary Tract Infection 

Tumors/Neoplasms 

Painless Hematuria 

Bladder, Kidney, Prostate 

Inflammation 

Cystitis, Prostatitis, Pyelonephritis 

BPH 

Trauma 

Glomerular Disease 

4



Menu of Radiologic Tests 

Abdominal Ultrasound 

CT scan 

MRI 

Kidney stone protocol (CT w/o contrast) 

CT urogram 

Radionuclide Scan 

Historical tests: IVP, Retrograde pyelography 

5



Patient AS: Abdominal CT 

No evidence of hydronephrosis, 

kidney stones 

Nml cortical thickness, 

no signs of obstruction 

Patient Patient AS AS 

PACS, PACS, BIDMC BIDMC 

Renal cyst 

Axial CT +/- contrast reveals benign renal cyst, nml renal cortical thickness 

w/o evidence of obstruction, hydronephrosis, renal mass, kidney stones 

6



Patient AS: Pelvic CT 

Thickened bladder wall 

Patient AS 

PACS, BIDMC 

Axial CT cystogram with contrast reveals symmetric posterior bladder wall thickening 

7



Kidney Stones 

Differential Diagnosis 




Inflammation 


BPH 

Trauma 


8



Kidney Stones 

Differential Diagnosis 




Inflammation 


BPH 

Trauma 


9



Transitional Cell Carcinoma of the Bladder 

4th most common CA in men, 9th most common in 

women 

Incidence: 67,000/yr, Mortality: 13,750/yr 

Risk factors: 

Tobacco 

Schistosomiasis 

Chemicals: Aromatic Amines, Phenacetin, Cyclophosphamide 

Clinical Presentation: 

Gross painless hematuria 

SH: smoked 4 

PPD for 40 yrs 

Pain from locally advanced or metastatic tumor 

Voiding symptoms - dysuria, frequency, urgency, obstruction 

Constitutional symptoms - fatigue, weight loss, anorexia 

10



TCC of Bladder: Diagnosis 

U/A: hematuria 

When bacteruria or 

pyuria present urine cx 

to r/o UTI 

Cystoscopy and 

biopsy 

Urine cytology 

Other 

Immunocytochemistry 

Proteomics 

Biomarkers 

Companion Patient 1 

http://www.urologychannel.com/bladdercancer/sptumor.shtml 

11



Radiologic Features of TCC 

IVP - historical 

CT 

Staging: TNM system 

T1: invades subepithelial 

connective tissue 

T2 - invades muscle 

T3 - invades perivesical 

tissue 

T4 - invades beyond 

Further Imaging 

CXR - pulmonary mets 

MRI - tumors at base and 

dome of bladder 

Bone Scan 

Companion Pt 3 

< T2, N0, M0 



Patient AS 

Kim et al. PACS, BIDMC 

http://urology.jhu.edu/bladder/bladder_cancer 

_diagnosis.php 

http://urology.jhu.edu/bladder/bladder_cancer_diagnosis.php 


PACS, BIDMC 

12



Treatment Options for TCC 

TURBT +/- chemotherapy 

Primary radiation therapy 

Partial cystectomy 

Radical cystectomy indications: 

Infiltrating muscle-invasive bladder CA w/o evidence 

of metastatic disease (T2M0) 

Superficial bladder tumors (CIS, T1) refractory to 

chemotherapy, other surgery 

Patient AS: Pathology report revealed high grade papillary TCC 

with invasion of lamina propria and muscularis propria 

13



Bladder Anatomy - Male 

http://urologyhealth.org 

Posterior and superior to the pubic bones, inferior to peritoneum, 

superior to the prostate, anterior to rectum 

14



Male - removal of 

prostate and bladder 

Bilateral pelvic 

lymphadenectomy 

Urethrectomy 

Radical Cystectomy 

Tumor in prostatic urethra 

Urinary Diversion 

Ileal loop conduit - urine 

directed from ureters 

through segment of 

isolated ileum to abd wall 

http://community.nursingspectrum.com/MagazineArticles/ 

article.cfm?AID=18622 

AS underwent radical cystectomy with ileal loop diversion 

15



Patient AS 

PACS, BIDMC 

Patient AS: Post-Op CT 

Post-Op Ileus 

No hydronephrosis, 

symmetrical excretion 

of contrast 

CT Abd/Pelvis with IV contrast revealed dilated loops of bowel with 

air-fluid levels and no signs of obstruction 

16



Ureteral stents in place, 

no contrast in ileal 

conduit 

Patient Patient AS AS 

PACS, PACS, BIDMC BIDMC 

Patient AS: Post-Op CT 

Urostomy bag 

Bilateral ureters 

entering ileal conduit 

Surgical Clips 

CT Pelvis with contrast reveals multiple surgical clips, ureteral stents are 

seen in bilateral ureters, exiting abdomen through urostomy 

17

Leak 



Ileal Conduit Complications 

Urine, Bowel 

Fistulas 

Infection 

GI 

Wound infection, Abscess, UTI, Pyelonephritis, Sepsis 

Bleeding, Ileus, Obstruction 

Urinary Tract Obstruction 

Stones, Strictures, Hydronephrosis 

Diminished renal function, Renal failure 

18



Fluid Collection 

w/ thick border 

Patient AS 

PACS, BIDMC 

AS: CT 1 mo s/p surgery 

Pt presents with abdominal pain, nausea, lethargy, fever 

CT with IV contrast reveals fluid collection at level of ileal conduit, 

which could represent urine collection or abscess 

19



Patient AS 

Pig-tail catheter 

PACS, BIDMC 

Patient AS 

PACS, BIDMC 

AS: CT-guided IR drainage 

Abscess w/ fluid and air 

Pt underwent CT-guided drainage of the fluid collection 

50cc of purulent aspirated and was positive for mixed bacteria 

Repeat CT 1wk s/p drainage shows drainage catheter within abscess, 

which has decreased in size, with residual fluid with air seen in the cavity 

20



Fluoroscopy-guided 

loopogram to assess 

leak 

Contrast injected 

through urostomy 

Contrast filled the 

ileal conduit 

No evidence of leak 

No reflux into the 

ureters 

Patient AS: Loopogram 

Stoma 

Catheter w/ 

contrast Ileal conduit 

+ contrast 

Patient AS 

PACS, BIDMC 

Pig-tail 

Catheter 

21



Patient AS: Hospital Course 

Started on antibiotics 

NPO, started on TPN 

No evidence of fistulous connection 

Reduction in size of abscess 

Good urostomy output 

Diet was advanced and tolerated well 

CBC, electrolytes remained stable 

Pt discharged with plans for close follow-up 

22



Air 

Patient AS 

Patient AS 

PACS, BIDMC 

PACS, BIDMC 

AS: CT 5 yrs s/p surgery 

Stricture 

Cortical atrophy and 

hydronephrosis 

No excretion 

of contrast 

BUN: 44, Creatinine: 1.6 

Abd/Pelv CT with contrast reveals cortical atrophy of left kidney with 

no excretion of contrast and hydronephrosis, air in right collecting 

system, possible stricture of left ureter 

23



Conclusions: Role of Radiology 

Workup for painless hematuria 

Staging bladder TCC 

Assess for post-operative complications 

IR-guided abscess drainage 

24



Acknowledgments 

Dr. Andrew Hines-Peralta 

Dr. Gillian Lieberman 

Maria Levantakis 

25



References 

Bochner BH. Urinary diversion and reconstruction following cystectomy. UpToDate 

Online. Last updated 8/27/07. Retrieved 11/07/07. 

http://utdol.com/utd/content/topic.do?topicKey=gucancer/13454 

Donat SM, Dalbagni G, Herr H. Clinical presentation, diagnosis, and staging of bladder 

cancer. UpToDate Online. Last updated 1/25/07. Retrieved 11/08/07. 

http://utdol.com/utd/content/topic.do?topicKey=gucancer/6264 

Eggener SE, Campbell SC. Cystectomy, Radical. eMedicine from WebMD. Last updated 

10/11/07. Retrieved 11/08/07. http://www.emedicine.com/med/topic3061.htm 

Kim JK, Park S, Ahn HJ, Kim CS, Cho K. Bladder cancer: analysis of multi-detector row 

helical CT enhancement pattern and accuracy in tumor detection and perivesical 

staging. Radiology 2004; 231:725-731 

“Bladder; Lower Genitourinary Calculi and Trauma” in Campbell-Walsh Urology, 9th ed. 

Eds Wein, Kavoussi, et al. Saunders Elsevier Philadelphia. 2007. 2418-2566. 

26

A 62 Year-Old Man with Painless Hematuria

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