Discussion

DISCUSSION Diseases of the urinary tract are affecting mankind since the pristine of civilization. Many different aspects of these diseases are still in the dark. One of the frightening symptoms, Haematuria is a herald sign of genitourinary disease, although the degree (amount) of haematuria does not predict the degree of injury. Thus, scant haematuria should be investigated as thoroughly as more significant haematuria. There are numerous clinical methods to be applied, which may open up new vistas leading to knowledge of the disease. The literatures on urological problems are vast and reveals excellent of the magnitude of the problem. The illustration of the various sophisticated technical expertise in the search for establishing the diagnosis and mode of management are used to serve primarily the academic interests and they are mostly available in the well equipped urological centers only. A number of workers have performed clinical studies on the various aspects of haematuria and put forward their views regarding the general incidence in a particular place or a region, incidence in relation to age and sex, aetiological factors and different methods of investigation and managements. The present study deals with a series of 42 patients, done within a limited period of time. An effort is made here to study some of the clinical aspects of the diseases that frequently presents with haematuria, their diagnosis by different methods and their management accordingly with the limited facilities available in our set up.

DISCUSSION

97

Age incidence Sharfi AR and Hasan O studied 450 patients over 10 years and found that the mean age of presentation was 35 years. East Afr Med J. 1994 Jan; 71(1):29-31. In this present study highest incidence is found in the 3rd decade (in about 21.4% of the total cases) which is comparable to the above study. Sex incidence Goonewardena SA et al studied 174 consecutive new patients with macroscopic haematuria and found that 130 of the patients were male and 26 were female. (Ceylon Med J. 1998 Sep; 43(3):156-8.) In this present study out of 42 patients 35 were male and 7 were female. This is comparable to the above study. Occupation and social status: In this part of the country incidence was most common among farmers as most of the patients were from the village area and were of the low socio-economic status. Symptomatology Sharfi AR and Hasan O studied 450 patients over 10 years and found that 46% of the patients were associated with loin pain. East Afr Med J. 1994 Jan; 71(1):29-31. Pain is the most common accompanying complains of the patients in this study which was 66.67%. Other complains noted were increased frequency 38.09%, burning micturition 23.8%, stranguary 19.05%, Fever 21.43%, urgency 21.43%, poor stream 14.29%, hesitancy 14.29%, terminal dribbling 14.29% etc. Majority of the patients had multiple complaints and very few had presented with a single complaint. This is very much comparable to the above study.

DISCUSSION

98

Aetiology In this present study the most common cause of haematuria is found to be urinary calculus (47.6%). Other causes are found to be carcinoma bladder (28.57%), BEP (7.14%), urethral trauma (4.76%), carcinoma prostate (4.76%) and cystitis (4.76%). In our study we have not found any case of Renal Cell Carcinoma and stricture urethra. Sharfi AR and Hasan O in their study found most common cause to be urinary calculi (46%) and bladder carcinoma (10%). Table 28: Aetiology in various studies Study

Urinary

Carcinoma

Renal

Sharfi AR et al

calculi 46%

bladder 10%

tumour 2.4%

6.89%

2%

-

7.14%

4.76%

Present study

47.6%

28.57%

BEP

Cystitis

Vesical

Others

calculus 3.56%

29.15%

2.38%

9.55%

In this present study 35.71% of the cases of haematuria are due to malignant diseases of the urinary system and 64.28% are due to benign causes. Hans Boman et al in their study found that the incidence of malignancies high in patients with macroscopic haematuria (24%), especially if it was asymptomatic (32%). Table 29: Aetiology in various studies Study Hans Boman et al Present study

Benign cause

Malignant cause

76% 64.28%

24% 35.71%

URINARY CALCULUS DISEASE

DISCUSSION

99

Age incidence R. N. Sharma et al [1985] from Jammu reported that the commonest age incidence for upper urinary tract calculi is in the 3rd and 4th decades. S. Aydin et al [1994] found that the peak incidence was between the ages of 30-39 years. In our study we have found that urinary calculus disease is most commonly occur in the 3rd and 4th decade of life. Youngest patient we have noted is 17 years and the eldest was 75 years of age. These findings are is at per with the previous study. Table 30: Age incidence in various studies Author Hermon et al (1925) R. N. Sharma et al (1985) Present study (2005-06)

Total no. of cases 880 170 42

Highest age incidence 20-49 yrs 20-49 yrs 20-49 yrs

Sex incidence Aydin S. et al [1994] studied 390 patients with urinary tract calculi. They observed that male and female ratio was found to 2.2:1. Ekwere P.D. [1995] reported a prospective observation on 96 south eastern Nigerians with urinary calculi during a period of 5 years in which the male-female ratio was found to be 2.7:1. In our present study we have noted a male female ratio of 2.33:1

Table 31: showing male female ratio in different study Author Aydin S.(1994)

Total no. of cases 390

Male: female ratio 2.2:1

DISCUSSION

Ekwere P.D.(1995) Present study(2005-06)

96 42

100

2.7:1 2.33:1

Blood Investigation Findings On Blood examination, no gross abnormality was detected. However there were few cases in which Hb% was found to be lower and increased ESR levels. Serum creatinine levels were found to be within normal limits in most of the cases except for a case of bilateral ureteric calculi where serum creatinine level was 1.7mg%. Urinary findings Urinary pH was found to be acidic in most of the cases. Urine culture was found to be positive in 6 cases with evidence of growth of E. coli were detected. Boyce et al [1958] in his study found that 38% came with sterile urine on culture and 14% had urinary tract infection by specific organism like proteus and a variety of organisms in the remainder were observed. Plain-X-ray Abdomen [KUB] Plain-X-ray Abdomen [KUB] was done in almost all the cases. Only in one case it fails to detect in a case of urolithiasis (1 out of 20). This almost tallies with the finding that about 90% urinary stones are radioopaque [Smith D.R. 1978, Bailey and Lobe 1995] and readily visible on a plain film of abdomen.

Ultrasonography Ultrasonography was carried out in all cases and found to be sensitive. Ultrasonography could detect the presence of echoreflective

DISCUSSION

101

substances in the KUB region and could confirm the obstructive effects on kidneys. Hydronephrosis was seen in 2cases. Intravenous Urography Intravenous urography was performed in all cases with upper urinary tract calculi. It showed delayed excretion of dye in one patient with B/L renal calculus with ureteric calculus. Pathology in the kidney In this series of studies, 2 cases of hydronephrotic kidneys were observed and no congenital anomaly in the kidney was found in this study. R. N. Sharma et al [1985] reported about 170 cases and found ydronephrosis in 17 cases and pyonephrosis in 5 cases. Management All the cases included in our study were found have calculus more than 1 cm of size and hence all the cases were subjected to open surgical procedures. Ureteric calculus The cases of upper ureteric calculus were approached through the extraperitoneal flank approach, the mid ureteric via the modified Gibson’s incision while the lower ureteric calculi were approached via the midline, Pfannensteil or Gibson’s incision. The ureter was incised longitudinally in all the cases directly over the calculus, which was extracted and the defect repaired with interrupted 3-0 Vicryl sutures. The abdominal wound was then closed in layers and a drain kept in situ. Renal calculus

DISCUSSION

102

All the cases of renal calculi were approached through the extraperitoneal twelfth rib approach. In our series of cases, two (2) cases treated with Pyelolithotomy and Nephrolithotomy was done in three (3) cases. Intraoperative blood loss was minimal. The rent in the pelvis and ureter was sutured with 3-0 Vicryl interrupted sutures in all the cases. The abdominal wound was closed in layers in all the cases with 1-0 Vicryl and 2-0 Mersilk. A drain was put in the retroperitoneum in all the cases. Out come of surgical treatment Complications following surgical management for calculi in the early post operative period were found to be very minimal. Post operatively leakage of urine was seen from the drain site in two cases which resolved spontaneously Post operative haematuria was encountered in 10 cases while surgical wound infection was also found in one case. Incidence of mortality was not encountered in any case of this study. Except in two cases of B/L renal calculus and one case of carcinoma bladder with staghorn calculus operated on only on one side, others didn’t revile any calculus in follow up X-ray KUB. Assimos et al (1989) found the stone free rate after open stone surgery to be 100%. Kare et al (1994) found the stone free rate to be 71% while Paik et al (1998) found it to be 93%. Thus excluding cases of B/L calculus diseases the stone free rate in this study conforms to the above mentioned studies.

CARCINOMA BLADDER

DISCUSSION

103

Age incidence Age as a prime epidemiological factor for Carcinoma of the urinary bladder is universally accepted to be a disease of the elderly people. Melicow (1974) remarked that, the incidence of the condition increase with age. He showed that, the peak age of the disease is between 50-79yrs of age. The present series conforms to the above findings to show the peak incidence at 7th decade. Findings in a few series are quoted below along with that of the present study. Table 32: Age distribution of carcinoma bladder Series Melicow(1974)

Peak age groups (yrs) 50-79

Schwartz et al (1994)

50-70

Airds et al (1994)

7th decade

Present study

7th decade

Sex: The incidence of carcinoma of the urinary bladder in male is shown to be quite high in different studies at different time period. Table 33: The sex ratio of different studies are shown below Series Melicow(1974) Gilbert et al(1976) Airds et al(1992) Present study

Male 3 2.8 3 11

Female 1 1 1 1

From the above table, it is observed that the ratio between male and female is quite high in comparison to other studies. In the present study,

DISCUSSION

104

the lower incidence rate in female may reflect some epidemiological differences between studies in western world and in our setting. In the present study, the lower incidence may reflect less exposure of the female to carcinogens in comparison to male. Another important factor contributing to such differences in incidence rate may be that, the habit of smoking is far less in females in this part of the country. Irritative bladder symptoms Miller et al (1969) reported that the increased frequency of micturition is another common presenting feature of this disease. He showed that there are about 61% of patients who presented with these features along with haematuria. Riddle et al (1976) found that 56.2% of his series presented with dysuria. In the present study around 66% of patients were having frequency. Urgency was present in 25% of patients; in 33.33%of patients dysuria was present. Ultrasonography: Ultrasonography has been adopted as a useful means of detecting tumours of urinary bladder which may be either Trans abdominal, transrectal or transvaginal. Its accuracy for diagnosis varies. Here transabdominal USG was used.

DISCUSSION

105

Table 34: Different studies showed different rate for diagnosis of carcinoma bladder.

Authors

Years

Accuracy rate

Berlac

1992

84.6%

Skdas

1992

96.5%

Present study

2006

100%

In the present study, all the 42 patients were investigated by USG and in out of these it gave 100% accuracy in diagnosis of the bladder tumours. The diagnostic rate was in conformity with the study by Skdas (1992) Cystoscocpic examination The diagnosis and initial staging of bladder cancer is made by cystoscopy and bimanual examination. Superficial, low-grade tumours usually appear as single or multiple papillary lesions. Higher grade lesions are larger and sessile. Random or selected site mucosal biopsy specimens also may be obtained. These observations are made by eminent persons. Our present study conforms to the above observations. Type of Tumours according to Histological pattern: In our study, we found all the 12 cases to be transitional cell carcinoma. This finding resembles with those of Mostofi FK (1975) and Melicow MM (1974).

DISCUSSION

106

Table 35: Distributions according to cell type Study Mostofi FK

90%TCC

Type of Histology 6-7% sq. cell ca, 1-2% adenocarcinoma

Melicow MM

90-95% TCC

5-10% sq. cell carcinoma

Present study

100% TCC

-

CT Scans: As stated by Lautz and Hettery in 1984, CT scan in addition to assessing the extent of the primary tumours also provides information about the presence of pelvic, para-aortic lymphadenopathy and also the possible presence of liver metastasis. Nurmi et al, 1988; Voges et al, 1989, stated that CT scanning is limited in accuracy because it can detect only gross extravesical tumour extension, lymph nodes that are grossly enlarged and liver metastasis that are larger than 2cm in diameter. CT scan fails to detect nodal metastasis in up to 40% of patients having them as reported by Lautz and Hattery, 1984. Thus in view of the conflicting reports made by various observations we also in our present study could not come to a definite conclusion except for confirming the diagnosis. Treatment: a. Management of superficial Bladder cancer

DISCUSSION

107

Most patients with superficial bladder cancer can be adequately treated with transurethral resection. The overall survival rate for these patients are excellent as stated by Nicholes Marshall, 1956 and Barnes et al, 1967. Rubben

et

al,

1988,

showed

that

adjuvant

intravesical

immunotherapy or chemotherapy is beneficial in patients who are at a high risk of recurrence by virtue of multiple tumours, sessile growth or associated CIS or urothelial atypia in random biopsies. BCG as immunotherapy appears to be the most effective. In our study, we had 7 cases with grade I- TCC tumour. Six (6) of them were treated with TURBM and with subsequent intravesical BCG in three (3) cases. One case was treated with open excision through suprapubic approach and intravesical BCG. b. Management of invasive Bladder cancer In our present study none of the cases was found to be fit for partial cystectomy. All the 4 cases were subjected to combination of TURBM and radiotherapy. As stated by Grossmann & Prez- Tamayo 1993; Wijnmaalen et al, 1997, overall survival rates for low-stage tumours T-T2, 60 to 80% can be achieved with TURBM combined with radiotherapy. Locally advanced disease: External beam irradiation can be given to deeply infiltrating bladder cancer with or without local spread. Five year survival rates range from 18% to 41% as stated by Corcoran et al, 1985. Conventional external beam radiation therapy controls locally invasive tumours in 30-50% cases, as stated by Wallace & Bloom 1976; Jenkins et al 1988; Fossa et al 1993; Hayter et al 1999.

DISCUSSION

108

In our present study one patient of grade III tumours who was offered radiotherapy as monotherapy. He had a recurrence within 5 month of treatment. The patient was 78 years old and had severe co-morbid conditions and couldn’t tolerate the full dose and durations of radiotherapy. OUT COME Complications in early post operative period: The most common complication of TURBM was haematuria followed by retention and cystitis closely. Haematuria occurred in 70% of the cases. Three of the cases receiving radiotherapy showed complication solely depicted to radiotherapy. Recurrence: For superficial bladder cancers the majority of recurrences are in the first five year of follow up as stated by Herr et al, 1992 .In a study by Herr and colleagues in 1992, after a complete course of intravesical BCG, progression at five years was 19% in initial responders but 95% in non responders in a study of 180 patients. Patients with low-stage ,low-grade disease have a low risk <5% of progression of disease, while as many as 40% of patients with high grade will progress with extended follow up as stated by Herr in 2000. In our present study of 12 cases, 7cases were of grade I, 4cases of grade II and 1 case were of grade II TCC. There was recurrence in 15% of cases of grade I, 50% of grade II and in the lone case of grade III TCC. This is higher than the above study; this is mainly due to lack of facilities, co-morbid conditions, ignorance and lack of compliance on the part of the patients.

DISCUSSION

109

BENIGN PROSTATIC HYPERPLASIA By the age of 60 years, 50 percent men have histological evidence of BPH. It is a common cause of significant lower urinary tract symptoms in man and is the most common cause of bladder out flow obstruction in men > 70 years of age. Age is a prime etiological factor in benign prostatic enlargement. Franks (1954) remarked that the incidence of this condition increases with age. Gordon Smith (1972) found age of presentation between 50 years and 80 years. Singh et al (1976) observed the peak age of incidence in the range of 61-70 years. In our study we have found that all the 3 cases were in the 60-80 yrs age group. Riches and Muir (1933) reported a series of BPH in the incidence of increased frequency of micturation in 82% cases dysuria in 37% cases, acute retention of urine in 34% cases and haematuria in 11% cases. Sharma et at (1972) recorded frequency as a predominant symptom in all 100 BPH cases of his series. Dysuria was present in 74% cases, acute retention was found 83%cases, haematuria was recorded in 21% cases, and vesical calculi in 9% cases. In our study all the cases were associated with hesitancy, urgency, increased frequency and nocturia. Serum creatinine level was taken as indices of urinary physiology and all the patients in the study had normal level of blood urea and creatinine. Preliminary decompression of acute, painful, distended bladder was done in all cases. Then all patients were treated with transurethral resection of prostate. Secondary haemorrhage occurred in 1 case and temporary incontinence in another patient in the early post operative

DISCUSSION

110

period. All the patients showed improvement of symptoms in subsequent follow up. PROSTATIC CANCER In this study three patients with prostatic cancer were admitted with complain of haematuria followed by retention of urine. Carcinoma of the prostate is the most common malignant tumour in men over the age of 65 years. Incidence in men over 80 is in the region of 50% (Franks). In the excellent study of Guinan and associates, the digital rectal examination had the highest overall efficiency of ten screening tests for prostate cancer. In our study also on Digital Rectal Examination the glands were indurated and there was obliteration of lateral sulci in each of them. USG abdomen detected gland irregularity, hypertrophied bladder wall, but no lymph nodal or hepatic metastasis. Skiagrams of the lumbar vertebrae were normal. The bladder was evacuated by catheterization all the patients. Histopathological confirmation was made in each case from the tissue obtained by USG guided FNAC. Bilateral orchidectomy under spinal anaesthesia was done in all the cases. Unfortunately neither of the patients reported during the follow up period. URETHRAL TRAUMA: There were 2 patients in our study, who were diagnosed to be cases of urethral trauma. Table 36: Showing mode of injury Mode of injury

No of patients

Road traffic accident

1

Fall from height

1

DISCUSSION

111

Table 37: Showing mode of injury Signs & symptoms

No of cases

Urethral bleeding

2

Retention of urine

1

In one case the site of injury is not clear clinically. But the mode of injury may be sometime suggestive of anterior including bulbar urethral involvement. Another case was associated with multiple fractures of the pelvic bones. Management: One of the patients had suprapubic cystostomy done for relieving urinary retention. Delayed repair of the ruptured urethra done after 4 months and Catheter was kept for 3 weeks. Another patient responded to conservative treatment and no further surgical measure taken. The patient treated with urethroplasty needed to be dilated intermittently as he developed urethral stricture.

CYSTITIS In the present study two cases were diagnosed to be caused by acute cystitis. Urine culture study was found to be positive for E. Coli in both the cases. Both the cases were treated with oral antibiotics and they responded well.