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
- Distortion of renal outline, compatible with a right renal
mass - Questionable bladder tumor
- 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 - Why did this patient require a retrograde pyelography and an antegrade pyelography?
- If, after cystoscopy, this patient had complained of lower abdominal pain and had
developed a temperature, what would you suspect?
