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SU29.1-11 | Urinary System Surgery — Assignment
CLINICAL SCENARIO
A 66-year-old man, a smoker of 45 pack-years, presents to the surgical outpatient clinic with two episodes of painless visible (gross) haematuria over the past six weeks. The urine cleared completely between episodes. He has mild lower urinary tract symptoms (a weak stream and nocturia twice nightly) but no fever, dysuria or loin pain. On examination his abdomen is soft with no palpable mass; digital rectal examination reveals a moderately enlarged, smooth prostate. Urine dipstick confirms blood but no nitrites or leucocytes, and urine culture is sterile.
Instructions
Working from this scenario, write a structured clinical account that demonstrates how you would evaluate and manage an adult presenting with painless gross haematuria. Reason from first principles, justify each investigation by what it tests, and make explicit the red-flag thinking that drives the work-up. Refer to the patient's specific risk factors throughout.
Length: 1200-1600 words
What to Submit
1. Significance and differential diagnosis
Explain why painless gross haematuria in this man must be regarded as malignancy until proven otherwise. List a structured differential diagnosis for haematuria spanning the upper tract (kidney, ureter), bladder, prostate and urethra, and identify which causes his risk profile makes most likely.
Guidance: Anchor the differential to anatomy — work down the urinary tract. Highlight smoking as a shared risk factor for urothelial cancers.
2. Focused history and examination
Describe the additional history and examination findings you would seek, and explain what each would tell you. Address occupational exposures, pattern/timing of bleeding, associated LUTS, and the role and limitations of the digital rectal examination and abdominal examination in this patient.
Guidance: Tie each item to a differential — e.g. initial vs terminal vs total haematuria, dye/rubber industry exposure, clot colic.
3. Investigation plan
Set out an investigation plan that evaluates the WHOLE urinary tract. Justify cystoscopy for the lower tract and CT urogram for the upper tract, state the role of urine cytology and baseline bloods (including renal function and PSA with its caveats), and explain why a sterile culture and clear urine do not end the work-up.
Guidance: Make the upper-tract vs lower-tract split explicit. State clearly that PSA is organ-specific not cancer-specific.
4. Management according to findings
Outline how management would differ depending on what is found: a bladder transitional cell carcinoma, a renal cell carcinoma, and a benign finding (e.g. BPH alone). Include the principle that small superficial bladder tumours are resected and that prostate enlargement causing LUTS is managed on its own merits.
Guidance: Keep to principles of management, not operative detail. Note the need for follow-up surveillance in urothelial cancer.
5. Communication and safety-netting
Briefly describe how you would explain the urgency and the planned tests to this patient in clear, non-alarming language, and what safety-netting advice you would give while investigations are pending.
Guidance: Demonstrate that urgency can be conveyed without causing undue fear; address smoking cessation.
Grading Rubric — 30 points
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Recognises painless gross haematuria as a red flag (malignancy until proven otherwise) and gives a structured anatomical differential | 8 pts | Clearly states the red-flag principle and constructs a complete tract-based differential matched to the patient's risk factors |
| Targeted history and examination linked to the differential | 5 pts | Elicits occupational/risk history, bleeding pattern, LUTS and examines appropriately, with each item justified |
| Investigation plan evaluates the whole tract (cystoscopy + CT urogram) with correct justification and PSA caveats | 9 pts | Correctly splits upper- vs lower-tract work-up, justifies cystoscopy, CT urogram, cytology, bloods and explains why clear urine/sterile culture do not end the work-up |
| Management principles appropriate to each finding | 5 pts | Gives sound, finding-specific principles for bladder cancer, RCC and benign disease, including surveillance |
| Clear clinical writing, communication and safety-netting | 3 pts | Well-organised, accurate prose with patient-centred communication and safety-netting |