The Royal Marsden. MDT case study. Mr Alan Thompson Consultant Urological Surgeon The Royal Marsden

Transcription

1 MDT case study Mr Alan Thompson Consultant Urological Surgeon The Royal Marsden

2 2 The Royal Marsden Case history 56 year old lady from Bangladesh with 5 children Rarely seen her GP over the last 10 years Complains of increasing urinary frequency, nocturia and malaise Slight weight loss 1Kg On statins and antihypertensives but otherwise well

3 Q1. What are you thinking? 1. I need more information 2. I need to examine her and do some tests 3. This sounds serious 4. You are just getting old! 29% 68% 3% 0% I need more information I need to examine her an... This sounds serious You are just getting old!

4 Q 2. What are the possible diagnoses for this patient? 1. Diabetes 2. Renal stone disease 3. Lifestyle fluid intake / 5 children 4. UTI 5. Interstitial cystistis 6. Tuberculosis 7. STD 8. All of the above 3% 4% 1% 8% 3% Diabetes Renal stone disease Lifestyle fluid intake / 5... UTI Interstitial cystistis Tuberculosis 80% 1% 0% STD All of the above

5 5 The Royal Marsden The following history and investigations were obtained No history of recent travel No history of exposure to TB There may be some associated night sweats but she is a poor historian Abdominal examination is unremarkable Urine dip test negative for glucose Urine positive for nitrites, protein and haem

6 Q3. What is the possible diagnosis for this patient now? 1. Diabetes 2. Renal stone disease 3. Lifestyle fluid intake / 5 children 4. UTI 5. Interstitial cystistis 6. Tuberculosis 7. STD 8. All of the above 1% 7% 0% 62% 8% Diabetes Renal stone disease Lifestyle fluid intake / 5... UTI Interstitial cystistis Tuberculosis 20% 3% 0% STD All of the above

7 Q 4. What would you do next? 1. Send off MSU and wait for the results 2. Treat empirically 3. Send MSU, treat empirically and reassess after MSU back 4. Refer to Urologist 5. Refer on two week rule Send off MSU and wait fo... Treat empirically Send MSU, treat empirica... 79% 8% 12% 1% 0% Refer to Urologist Refer on two week rule

8 Q 5. 5 weeks later she returns with the same symptoms. What is the likely diagnosis? 1. Diabetes 2. Renal stone disease 3. Lifestyle fluid intake / 5 children 4. Recurrent UTI s 5. Interstitial cystistis 6. Tuberculosis 7. All of the above Diabetes Renal stone disease 1% 4% 1% Lifestyle fluid intake / 5... Recurrent UTI s Interstitial cystistis 55% 28% 6% 4% Tuberculosis All of the above

9 9 The Royal Marsden What actually happened GP performed sent off MSU on this occasion and treated with appropriate antibiotic Symptoms recurred after 3 months Symptoms recurred again after 4 months Referred to Urologist

10 10 The Royal Marsden Discussion point What is a recurrent UTI? Episode of UTI after a documented UTI with successful resolution of an earlier episode + occurring 2x in last 6 months or 3x in last 12 months. Subclassified into: Persistent infection UTI caused by the same organisms. Poss focus of infection e.g. stone/tcc/diverticulum/fistula Reinfection UTI caused by different organisms. Usually indicates susceptibility to UTI Post menopause/sexual intercourse/poor hygiene/genetic 95% recurrent UTI s in a female are due to re-infection

11 11 The Royal Marsden In the urology clinic History rec UTI?/pyelonephritis/STD/complicated infection MSU results checked is there a non-infective process e.g. stones, interstitial cystitis, cis (carcinoma in situ) PMH including constipation, childhood UTI, neurological illness, diabetes Pregnant? On OCP Family history UTI s associated with ABO blood group antigen non-secretors, Lewis non-secretor or P blood group secretors - Examination Including vaginal to ascertain oestrogenisation, genital prolapse, urethral diverticulum

12 12 The Royal Marsden Investigations MSU Cytology If sterile pyuria AFB CT urogram or KUB/USS residual Possibly flexible cystoscopy

13 Q 6. She has been found to have recurrent UTI s. What are your favoured treatment strategies? 1. Lifestyle changes 2. Lactobacilli topically 3. Oestrogen pessaries/cream 4. Antimicrobial therapy Low dose long-term 5. Antimicrobial therapy Post coitus 6. Antimicrobial therapy Intermittent selfstart 11% 0% Lifestyle changes Lactobacilli topically 54% 24% 3% Oestrogen pessaries/cream Antimicrobial therapy... Antimicrobial therapy... Antimicrobial therapy I... 8%

14 14 The Royal Marsden Case history 65 year old man from Bangladesh wife known to you Rarely seen his GP over the last 10 years Epigastric discomfort, pain occasionally intense but vague Slight weight loss 2.5 Kg over 2 months On statins and antihypertensives but otherwise well

15 What are you thinking? 1. I need more information 2. I need to examine him and do some tests 3. This sounds serious 4. You are just getting old! 15% 68% 17% 0% I need more information I need to examine him... This sounds serious You are just getting old!

16 Examination and investigation Examination reveals slight tenderness in right upper quadrant You arrange an USS This reveals gall stones but also a large right renal cyst What next?

17 Q 2. What next? 1. Dietary advice and reassure? 2. Refer to Upper GI surgeon and ignore cyst? 3. Refer to Urologist and ignore gall stones? 4. Refer to both? 3% Dietary advice and re-ass... Refer to Upper GI surgeo... Refer to Urologist and ig... 57% 24% 16% Refer to both?

18 18 The Royal Marsden Differential diagnosis of the cystic renal lesions Simple renal cysts Cystic renal-cell carcinoma Autosomal dominant polycystic kidney disease Multicystic dysplastic kidney disease Multilocular cyst VHL syndrome

19 19 The Royal Marsden In Urological clinic History etc Confirmation of normal renal function CT urogram pre and post contrast Bosniak cyst classification I-IV I benign and smooth with no enhancement/septae II thin septae + minimal Ca. No enhancement III Irregular/mod Ca/thick septae/enhancement IV Solid enhancing elements

20 Bosniak and clinical management Type I benign and require no follow-up Type II 10 to 20% risk malignant transformation (IIF) Type III 40-50% chance malignancy therefore operate Type IV - > 90% malignant therefore operate

21 Q 3. Above patient presented with haematuria and CT revealed a fatty lesion in the kidney. Diagnosis? 1. Renal cell carcinoma 2. Lipoma 3. Cyst 4. AML - Angiomyolipoma 31% 13% 1% 54% Renal cell carcinoma Lipoma Cyst AML - Angiomyolipoma

22 22 The Royal Marsden Angiomyolipoma - AML 80% sporadic. Female : Male ratio is 4:1 (rest tuberous sclerosis) Middle aged 80% right sided 5 % growth rate per year 4cm diameter or recurrent bleeding is indication for intervention (selective embolisation or partial neph) Tuberous sclerosis bilateral, smaller and younger 20% growth per year