Differential diagnosis and appropriate steps to take

[dgoslin]

My 54 y.o. husband has had a two yr. hx of sporadic episodes of gross hematuria (disregarded by his primary M.D. as "normal sluffing" of his urinary tract lining).  He presented in the ER this weekend with difficulty in urination and was worked up with an IVP that confirmed a 4.5cm bladder mass.  His inability to void was so significant that he has been catheterized and is now at home on prophylactic anitbiotic therapy. Still with significant hematuria. UA was negative for infection.   Cytology results will not be avalable for 48 hours. We want to get him in to see a bladder specialist at UCSF ASAP for biopsy and any required surgery but expect to have to wait for possibly a few weeks before his first appointment.  



My questions are: Should we proceed with a local Urologist to do a biopsy and TUR as soon as possible, without allowing for more radical surgery by the less experienced local doctor(to possibly have to remove the bladder if the tumor is malignant and invasive)?  Do we risk compromising my husband's final outcome if we do not have a Urologist do what needs to be done all in one process?  (I understand bladder extraction and reconstruction using a piece of the small intestine is a very specialized skill set. We do not want him to be left with incontinence and/or sexual impotence due to poor technique.)  How do we balance our need for immediate action versus waiting for the best surgeon for the job?  



Any help you can offer in our quest for the right moves to make next is greatly appreciated.  Thank you for doing this imporant educational work.  dgoslin

[Kevin Pho, MD]

There is no right answer to this question.  I would think that obtaining a diagnosis as fast as possible would be reasonable.  



Once the diagnosis is confirmed, you do not have to stick with the local urologist or group who did the biopsy.  You can then consider another surgeon or academic medical center after you obtain the diagnosis.  



I cannot comment on whether the prognosis will suffer if the diagnosis is delayed.  



Another academic medical center with better availability (i.e. UC-Davis) can be considered if the wait at UCSF is too long.



These questions can be discussed with your husband's primary care physician.



Followup with your personal physician is essential.



This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.



Kevin, M.D.

kevinmd_

[dgoslin]

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[dgoslin]

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