Urooncology

“Malignancy of Urinary Tract(UT)”

By
Dr.Radwan Amro
 Malignancy UT
• Prostate cancer

• Urothelial cancer (bladder cancer, TCC)

• Testicular cancer

• Renal cancer.
 Definition of Cancer
• Cancer is a disease of damage DNA and
altered genetic code.

• Four Halmarks for cancerous cell;

1-Loss of growth regulation
2-Immortalization.
3-Induction of angiogenesis.
4-Capability of metastasize.
 Prostate Cancer
• Prostate cancer;
The most common cancer in males and the second
most common cause of cancer death in USA.

The incidence of cancer 30% at 50 year-old increase

to 75% in men 75 years or older.

Causes;
-no definite cause.
-Genetic predisposition, hormonal influence? dietary influence,
environmental factor.
 Prostate Cancer
• Symptoms;
-The same like that of benign lesion of the
prostate (BPH);
frequency, urgency, hematuria, hesitancy
nocturia,……ext.
 BPH

-IPSS(International prostate symptoms score);

0-7 mild …………………Observation
8-19 moderate……… Medical therapy
20-35 severe…………..Surgery
 Diagnosis
• Prostate specific antigen(PSA)
More than 4ng/ml ?

• Digital rectal examination(DRE)(nodule).

• Definite diagnosis;
Transrectal ultrasound guided biopsy (TRUSG).
 Diagnosis
• Staging and grading of the prostate cancer are important to arrange
treatment protocol;

• Staging ;
Cancer limited to prostate cancer.
(T1a,T1b,T1c, T2b,T2c)
Cancer outside the prostate.
(T3,T4).

• Grading system ;
Sum of the gleason score
˂ 6 well differentiated, 7 moderate, 8 and 9 poor differentiated.
 Therapy
1-Active surveillance; well differrentiated, low volume of cancer and PSA
< 10. ng/ml.

2- Surgery;
Radical prostatectomy is safe procedure for
localized prostate cancer and decrease
mortality rate of prostate cancer.

• Indication of surgery;
Preferred to localized cancer who are no
eligible for active surveillance and have life
expectation more ten years of survivals.
 Therapy
3- Radiation therapy;
Comparable results to the surgery although it is difficult
to do definite comparison to that of
given to localized prostate cancer.

• In 2008 alone, an estimated 186320 new cases of

prostate cancer were diagnosed in USA and 45 % of
those patients (80000) choose RT as initial treatment.

• Preferred to locally advanced prostate cancer.

 Therapy
4-Hormonal therapy;
LHRH agonist and antiandrogen.

5-Orchioectomy;
The most effective form of androgen ablation for
androgen or testicular origin.

• This kind of therapy is given to metastatic cancer.

 Minimally invasive kind of treatment

• Cryoablation………freezing of the
prostate(L.Pisters et al)

• HİFU (high intensified focused

ultrasonography) ……heating the prostate.

• Brachytherapy…..radioactive seeds implant.

 Bladder Cancer
• Incidence of any disease is the number of the
new cases diagnosed per 100,000 person per
year (50500 cases in 1995 in USA).

• Prevelanc is the number of the cases per

100.000 person.

• Male to female ration is 2.7:1

 Causes
No definite cause;

1-Cigarette smoking account for 50% of cases,

Cigarette smoker have up to a fourfold higher incidence than
nonsmokers.

The causative agent are thought to be alpha and beta-naphthylamine

which are secreted in urine of smoker.

2-infection
Chemical agent …..cyclophosphamide.
Bladder calculi.
Pelvic radiation.
 Symptoms

• Painless hematuria is presenting in 85-95% of

the patients.
 Diagnosis

1-Laboratory findings;
urine analysis
Cytology examination can be used when cytoscopy is negative or when there is no
macroscopic lesion.

2-Some surface antigenes(BTA,NMP22).

3-İmaging
-Intravenous peylography (IVP)…..radiolucent filling defect
-Ultrasonogarphy …….echogenic foci projecting in the lumen.

4-Definite diagnosis;
Cystoscopy and transurethral resection.
 Kinds of Bladder tumors

1-Transitional cell carcinoma (TCC);

represent 90% of bladder tumor.

2-Sequamous cell carcinoma( SCC);

mostly seen in conjunction with infection and calculi, chronic infection.

3- Adenocarcinoma-rare cancer.

In Egypt 60% of bladder tumor due to bilharzial infection i.e schistosoma

haematobium.
Endoscopic View of Bladder Tumor
 Staging of the TCC
1-Superficial tumor; (50-70%)
• -Tis……..carcinoma insitu
• -Ta……….epithelium
• - T1………Lamina propia

2-Muscle invasive tumor;

• -T2 ………Muscle ( look for new classification.

• -T3a……..deep muscle
• -T3b………perivesical fat or peritenoum
• -T4…………contigous organ (prostate)
 Grading sysytem
• According to urothelial architecture, cell size,
pleomorphisim, nuclear polarization,
hyperchromatism and the number of mitosis;

• Grade I (Well differentiated)

• Grade II (moderate differentiated)
• Grade III (poor differentiated)
 Treatment Options

1-Transurethral resection (TURB) is the back

bone in the treatment of superficial bladder
tumor ± intravesical therpay (immunotherapy
(BCG) or chemotherapy).
 Controversies on
T1G3 bladder tumor
• Superficial tumor but, transurethral resection
seem to be not enough.
• Management of T1G3 bladder transitional cell carcinoma.

• -Repeated TURBT.
- Immediate cystectomy .
- Deferred cystectomy after BCG failure.
 Surgical Therapy
2-Radical cystectomy and urinary diversion or
orthotopic new bladder. (Hassan Aboul-Enein)

• Done of muscle invasive bladder tumor(T2).

• Bilateral pelvic lymph node dissection……!!!.

 Radiotherapy and Chemotherapy
3-Radiotherapy;
- given for T2 or T3 without lymph nodes metastasis;
-5 years survival rate for stages T2 and T3 is 18-41%.

4-Chemotherapy;
-15% of bladder tumor who present with bladder cancer
are found to have regional or distance metastasis.
-30-40% of patients who undergo surgery due to invasive
bladder tumor develop distant metastasis despite surgery.
5-Combination therapy; radiotherapy , Chemo therapy or
Surgery.
 Total Nablus Ramllah Hebron Other
s

Male 254 (84%) 156 (66%) 38(16%) 43(18%) NI 237

Female 47 (16%) 33(75%) 7(16%) 4(9%) NI 44

Total number 301 189 (67 %) 45(16%) 47(17% ) 18 281

21%(F/m) (18%f/m) (9% f/m)

TCC 286

scc 1

others 14 165 total grades 38 total grades 38 total grades 241

Grade I 86 55(70%) 20(25%) 4(5%) 79

86/257=33% 55/165= 33% 20/38=53% 4/38=11%

Grade2 124 86(73%) 12(10%) 20(17%) 118

124/257=48% 86/165= 52% 12/38=32% 20/38=53%

Grade III 47 24(54%) 6(14%) 14(32%) 44

47/257=18% 24/165=16% 6/38=16% 14/38=37%

Muscle invasive 30 17(68%) 6(24%) 2(8%) 25

30/241=15% 17/165=10% 6/38=16% 2/38=5%
 Renal Cancer
• Renal cell Carcinoma; 85% of all kidney tumor.

• Male to female ratio is 2:1.

• Cigarate smokers is the only known risk factor.

• At least 2 fold increase in risk for the

development of RCC.
 Symptoms &Diagnosis
• No definite symptoms.

• Hematuria, paraneoplastic syndrom, anemia, high sedimentation rate,

hypercalcemia.

• Intravenous urography (IVP)

• Ultrasonography.

• CT scanning more sensitive than USG and IVP.

• MRI (magnetic resonance imaging) has primary advantage to evaluate

patients with suspected vascular extension.
 Treatment
• Radical nephroectomy is the primary
treatment of localized renal cancer.

• Surgical removal of the early-stage lesion is

the only potential curative therapy.

• Partial nephroectomy for masses ˂ 5 cm.

Metastatic RCC
 Testicular Cancer
• Testicular cancer is most common in young or middle-aged
men.

• Most testicular cancers begin in germ cells (cells that make

sperm) and are called testicular germ cell tumors. 

• Estimated new cases and deaths from testicular cancer in

the United States in 2011:
New cases: 8,290
Deaths: 350
 Testicular cancer

• Risk factors;
1-Undesecnding tests.
2-Family history.
3-conralateral testicular cancer
3-Maternal smoking…….!!!
 Kinds of Testicular Cancer
1- Seminomas (35%); classic, anaplastic, or
spermatocytic.

2-Nonseminomatos;

-Embryonal carcinoma (20%)

-Choriocarcinoma (extraembroyonic
differrentiation) (˂1%)
-teratoma (intraembroyenic)(5%)
-Yolk sac tumors. (extraembroyonic
differrentiation).
-Mixed cell type (40%)(teratoma and embroyonal)
 Symptoms & Diagnosis
• Symptom;
painless mass in the scrotum.

Diagnosis;
Physical examination.
Scrotal USG.
B HCG, Alpha beta protein.
Definite diagnosis; inguinal orchioectomy
 Tumor Markers
• Pure seminoma produce only B-HCG (7%)
• Choriocarcinoma produce only BHCG (100%)
• Yolk sac produce alpha-phetaprotein

• The remaining tumors produce mix of both

markers
 Therapeutic Options
1-Inguinal orchioectomy( diagnostic and
therapeutic).

2-Radiation therapy; 95% of low satge seminoma

are cured with orchioectomy and low dose
retroperitoneal radiation)

3-RPLND; for low stage seminoma in USA(Pisters L.

MD Anderson Cancer Center)
4-Chemotherapy; For high stage seminoma and
non-seminamatos(BEP protocol)
 Urologic Emergency
• Renal Colic
• Urinary retention
• Renal Trauma
• Acute Renal Failure
• Anuria
 Renal Colic
• Physical examination………..Costovertebral
tenderness

• History……colicy pain.
 Renal colic
• Diagnosis;
-KUB
-urine analysis
-ultrasonography
-blood analysis
 Managment
• Hydration.
• Analgesics.
• Antibiotics.
• Plane for the managment of the ureter stone;
-Conservative approach.
-ESWL.
-Ureterorenoscopy/PCNL.
-Open Surgery.
 Urinary Retention
• Definition urinary bladder is full of urine
• Causes; bladder outlet obstruction:
- BPH.
-Forigen bodies.
-Strictures.
-Neurogenic bladder.
 Managments

• Catheterization

• Suprapupic cystofix placment

• Cystoscopy and folley catheter placment