Uro Oncology

1. Prostate Cancer

What is the prostate gland?

The prostate is a walnut-sized gland weigh around 20 gram. It is part of male reproductive system. It is located below the urinary bladder and surrounds the upper portion of the urethra (the tube that carries urine out of the body). Its growth is dependent on male hormone Testosterone

What does the prostate do?

The prostate gland is a part of the male reproductive system. It develops at puberty and continues to enlarge throughout life. The prostate gland makes the fluid portion of the semen. This fluid energizes the sperm and makes the vaginal canal less acidic.The seminal vesicles consistent of two pouches that provide nutrients for the sperm and lie immediately behind the prostate. At the point of orgasm , sperm, seminal vesicle fluid and prostatic secretions enter the urethra and mix together, forming semen. This is then ejaculated out through the penis by rhythmic muscular contractions.

What controls the prostate gland?

The growth of the prostate is controlled by testoserone, the male sex hormone. Most testosterone is made by the testicles and a small amount by the adrenal gland. The hormone is converted into dihydro-testosterone (DHT), a more active form that stimulates growth of the gland. The prostate gradually enlarges with ageing, resulting in symptoms such as reduced urine flow and a feeling of incomplete emptying of the bladder having passed urine. This enlargement is usually benign (non-cancerous).

What is prostate cancer?

Normally in the prostate, as in the rest of the body, there is a continuous turnover of cells, with new ones replacing old, dying ones. In a cancer, the balance between the new and old cells is lost, with many more new ones being made and older cells living longer, as the process of planned cell death has been disrupted. The malignant growths are known as prostate cancer. They differ from benign enlargements (BPH) in that the cancerous cells can spread (metastasise) to other areas in the body.

How does prostate cancer spread?

Cancer cell can spread by directly growing outwards through the capsule of the gland into the neighbouring parts of the body, such as the seminal vesicles, bladder or rectum. They may spread through the bloodstream and implant in the bones of the spine and pelvis. Finally, cells can spread through lymphatics to Lymph nodes.

How common is prostate cancer?

Prostate cancer is one of the most common cancer in males, affecting many thousands of men. A man has an estimated 15% chance of developing prostate cancer in his lifetime, that means 1 out of 6 men will develop prostate cancer in their lifetime and a 3% chance of dying from it. Prostate cancer is a disease of men older than 60yrs, rare before 40yrs. Autopsy evidence of prostate cancer is 30% in 4th decade (30s), 50% in 6th decade (50s) and >75% in older than 85yrs.

Why does Prostate Cancer occur

The real answer to this question is not known.Some known risk factors are :

  • African American are the highest risk group of people for prostate cancer.
  • Genetic and familial disease- Relatives of patients with prostate cancer have an increased risk of developing the disease themselves, especially if their father or brother were affected.  Risk doubles if one family member is affected with cancer prostate, if two or more family members are affected risk increases to 7-10 fold.
  • There also appears to be a link with obesity, sedentary life style, high non-vegetarian/ fatty diet and sexually transmitted disease.

What are the symptoms of Prostate Cancer?

There are often no symptoms associated with early stage prostate cancer and patients may remain unaware of their disease. As the disease progresses and the tumour enlarges, it may press on the urethra and obstruct the flow of urine. Symptoms in early stage are similar to that of (noncancerous) benign enlargement of prostate, like-

  • Weak, interrupted stream of urine
  • Straining
  • On completion he may sill feel that the bladder is not empty.
  • Increased day and night frequency of urination
  • Blood in the semen may be a sign of prostate cancer, although again this is a common finding and not normally related to malignancy.
  • Blood in urine rarely
  • If the tumour is spread to the bones, it may cause pain /backache. Spine is the most common site for this to occur. 
  • Decreased appetite and early fatigue-ability.
     

How is prostate cancer diagnosed ?

This is the job of a specialist doctor, an Urologist. The doctor will initially ask the patient questions to check their general medical health and see if they are experiencing any symptoms associated with prostate cancer.

Digital rectal examination

 Having made a general examination, the doctor will then need to perform a digital rectal examination to feel the gland. A gloved, lubricated finger is inserted into the rectum to check the size, shape, consistency and any abnormal growth if any of the prostate gland

Blood Test-PSA

The prostate cancer can be evaluated by testing for the level of a particular protein in the blood called PSA (Prostate Specific Antigen). Prostate enlargement tends to cause an increase in the level of PSA, with malignant tumours producing a greater increase than benign enlargements. However, other conditions can also cause PSA to rise, such as a urinary infection or urinary retention. So slight increase in psa level is not specific for prostate cancer.

Ultrasound Examination

The Prostate gland can be imaged with ultrasound for its size, capsule, homogenous/ hetrogenous , any abnormal growth and surrounding  structures like seminal vesicles and bladder

Prostate biopsy

If urologist finds any abnormality in above mentioned examination and tests then he will take the patient for prostate biopsy. Prostate biopsy is done under trasrectal ultrasound guidence or finger guided. With proper preparation under local anaesthesia multiple small pieces of prostate tissue are obtained by a special needle through rectum. The procedure is no more painful than giving an injection, but may occasionally cause a momentary shooting pain in the base of the penis. The doctor will usually give the patient an antibiotic to help prevent any infection occurring.

Between10-12 biopsy cores are normally taken, which are then analysed by histo-pathologist. After the procedure, it is quite common for the patient to see some blood in his urine, semen and stools, but this usually settles over a week or two. 

Other Tests

A computer tomography (CT) scan or a magnetic resonance imaging (MRI) scan are sometimes used to obtain pictures of the prostate and the surrounding tissue for staging of prostate cancer.

A bone scan is done to see any bony metastasis.

General Advise/ guidelines

According to American association of urologist (AUA) every men above 55yr should have a urologist consultation, examination and serum PSA test done to rule out prostate cancer and if there is a family history of prostate cancer then at the age of 40 yrs

Stages and Grade of Prostate Cancer

  • The earliest stage, where the cancer is so small that it cannot be felt on rectal examination, but is discovered in a prostate biopsy if raised PSA, or in a prostate tissue that has been surgically removed (as is a transurethral resection of the prostate - TURP) in BPH.
  • The tumour can now be felt on rectal examination, but is still confined to the prostate gland and has not spread.
  • The tumour has spread outside the gland and may have invaded the seminal vesicles.
  • The tumour has spread to involve other surrounding tissues such as rectum, bladder or muscles of the pelvis or bones.

How is prostate cancer treated?

Treatment of prostate cancer depends upon its stage, grade and patients general condition. Prostate cancer is a very slow growing cancer, many patients live with it without even knowing this. If diagnosed in early stage then after treatment around 90% patients can live normal life for 10 or more years. In western country because of public awareness around 70% patients are diagnosed at early stage but in our country it is just reverse, because of negligence or unawareness more than 70% patients are diagnosed in stage III or IV. There are a number of treatment options for every stage, each with their own advantages and disadvantages. Thus, the therapy needs to be tailored to suit each individual patient. It is possible to cure patients with prostate cancer at an early stage, but in advanced stage when disease is spread in body even if cure is not a possibility, the disease can normally be kept in check for a number of years.

What are the treatment options in prostate cancer?

The different treatment options available for management of prostate cancer are described below. It is important that every patient with such a diagnosis is aware of the different treatments, and they should feel free to discuss these with their Urologist. Whatever therapy is undertaken the patient will need regular follow-up examinations, which may involve a PSA blood test and scans or x-rays, for a number of years.

 

(A) Active Surveillance and watchful waiting

If the cancer has been discovered accidentally following TURP for BPH or by Biopsy for raised PSA and the patient has no symptoms and disease is localized, "wait and see" policy may be chosen. This does not mean, "do nothing", but the patient will be regularly monitored by the doctor by digital rectal examination, PSA and may be prostate biopsy and if problems develop or disease progresses appropriate action taken. These actions will often involve the use of hormone therapy, and on such a regime patients commonly live for many years. This choice is most frequently made by those patients with low grade disease specially if elderly. 

Advantage : avoid possible side effects of surgery or radiotherapy.

Disadvantage : multiple biopsies and you may miss the chance to   cure the disease

(B) Prostatic Surgery- Radical prostatectomy

A radical prostatectomy is an operation to remove the entire prostate and seminal vesicles. This operation is performed through an incision in the lower abdomen. This is a complex and major operations that usually require a hospital stay about a week. Such procedures should not be confused with conventional prostate surgery (TURP) done for non cancerous prostate enlargement. The advantage of surgery is that it is one off procedure and provided the cancer is confined to the prostate (stage I&II), will hopefully cure the disease. It avoids side effects of radiotherapy and is considered the most effective form of treatment for early prostatic cancer. However, there are risks associated with radical prostatectomy. It is a major operation, and involves a number of week's convalescence to make a full recovery. Unfortunately, the prostate lies very close to both the sphincters that control urinary continence and the nerves that produce penile erection. In the past, removal of the gland often caused damage to these structures, resulting in postoperative urinary incontinence and impotence. Newer surgical techniques have reduced the occurrence of impotence and severe incontinence is now less common. Furthermore, there are a number of new therapies to treat such side effects, should they occur. Radical prostatectomy can now be performed with minimal invasive techniques like Laparoscopic RP or Robot assisted RP. Advantage is short convalescence with similar outcome.

(C) Radiotherapy

Radiotherapy involves high energy radiation aims to destroy the cancerous cells and leave the healthy ones intact. It is a painless procedure, like having an X-ray, although there can be troublesome side effects associated with the treatment. It may be used in two situations: 1. Early cancers confined to the gland or the surrounding tissues 2. For treatment of bony pain in metastatic prostate cancer Radical radiotherapy for a tumour localized to the prostate may be given in two ways. Conventionally, the rays are directed by a machine through the body into the prostate, as with an x-ray. The treatment is given on an out patient basis for five days a week for 4 - 6 weeks. Radiotherapy can also be given using radioactive seeds that are approximately half the size of a grain of rice. These seeds, typically 80-100 in number, are inserted through needles into the prostate. The procedure is performed under anaesthesia. The side effects of radiotherapy are nausea, diarrhea, frequent and painful urination as well as bleeding both in the stools and urine, and local skin reactions. The advantage of radical radiotherapy is that it can cure early prostate cancer without the need of a major surgery. It seldom causes loss of urinary control, and impotence is less common than with surgery.

(D) Hormone Therapy

When the cancer has spread beyond the prostate, going to either the lymph nodes or bones, hormonal therapy is effective at shrinking the tumour, and reducing the side effects of the disease. It does not provide a cure, but may keep the cancer in check for a number of years.

The prostate gland and prostate cancer are under the influence of testosterone, the male sex hormone, which drives the tumour to grow and spread. By blocking the body's production of testosterone or blocking its action, the growth of the tumour may be greatly reduced. Hormone therapy can be Medical or surgical with similar results.

1)Surgery

The testicles that produce testosterone may be surgically removed by a small operation, called "Orchidectomy" that can be performed as a day care procedure. This has the advantage of being a one off treatment with quickest action, it is most cost effective hormonal treatment.

2)Medical therapy

An injection known as an "LHRH Analogue" is given once a month or every three months and this has a similar effect to removing testicles, but is reversible and does not involve surgery. some medication is prescribed before this to avoid the side effects. Although the result is same but it is a costly treatment and depends on patients compliance.

3)Antiandrogen Tablets

This therapy involves taking daily tablets to block the action of testosterone. The drugs have dual action -

(1) they reduce the production of testosterone by the testicles,

(2) avoid side effects like hot flushes, breast tenderness and impotence. However, Antiandrogen tablets can cause nausea and diarrhea.

(E) Chemotherapy

Chemotherapy is usually in tablet form, involves powerful drugs to attack the cancer cells and try to prevent them growing. It is a second line of defence for patient with advanced stage prostate cancer that is no longer controlled by hormonal therapy

2. Urinary Bladder Cancer

Urinary bladder cancer

Urinary bladder stores urine formed in kidney, when you urinate, the muscles in the bladder contract and urine is forced out.

What are the layers of the bladder?

The bladder consists of 3 layers of tissue. The innermost layer which comes into contact with the urine is called the “mucosa” and consists of “transitional cells or urothelium”. These same cells also form the inner lining of the ureters, kidneys and a part of the urethra. The middle layer is known as the “lamina propria”. This layer has a network of blood vessels and nerves and is an important landmark in terms of the staging of bladder cancer. The outer layer of the bladder comprises of the “detrusor muscle” and is called the “muscularis”. Its main function is to relax slowly as the bladder fills up and then to contract to expel the urine out during voiding.

What is bladder cancer?

Bladder cancer is an uncontrolled abnormal growth and multiplication of cells in the urinary bladder. Most bladder cancers start in the innermost layer of the bladder called the urothelium or transitional epithelium. As the cancer grows into or through the deeper layers in the bladder wall, it becomes more advanced and can be harder to treat. Over time, the cancer might grow outside the bladder and into nearby structures. It might spread to nearby lymph nodes, or to other parts of the body like bones, lungs or liver. Most common type of bladder cancer is Urothelial carcinoma, also known as transitional cell carcinoma (TCC).

Bladder cancers are often described based on how far they have invaded into the wall of the bladder:

  • Non-muscle invasive cancers are still in the inner layer of bladder (mucosa or lamina propria) and have not invaded into the deeper muscle layers.
  • Muscle invasive cancers have grown deeper into muscle layers of the bladder wall. These cancers are more likely to spread and are harder to treat.

What are the causes and risk factors of bladder cancer?

  • Smoking, Tobacco chewing- most common
  • Exposure to toxic chemicals such as arsenic, phenols, aniline dyes, arylamines etc
  • Radiotherapy or chemotherapy for any other disease
  • Long term or chronic infection of bladder
  • Bladder stone or foreign body in bladder

What are bladder cancer symptoms and signs?

  • Bleeding in urine or haematuria- most common.
  • Usually painless and associated with clots.
  • Irritative urinary symptoms like increased frequency, urgency and dysuria

How is bladder cancer diagnosed?

  • Urinanalysis
  • Urine cytology
  • Ultrasonogrphy
  • Cystoscopy and biopsy/ TURBT- This is probably the single most important investigation for bladder cancer. Since there is always a chance to miss small or flat bladder tumors on imaging investigations (ultrasound/CT/MRI) and urine cytology, it is recommended that all patients with bleeding in the urine, without any obvious cause, should have a cystoscopy performed by a urologist as a part of the evaluation and biopsy can be taken.
  • CT Scan

Treatment of bladder tumor

Initial treatment of any bladder tumor is TRANSURETHRAL RESECTION OF BLADDER TUMOR (TURBT), this is done with a special instrument cystoscope introduced through urethra and bladder tumor is resected without any cut or stich on body. This step is most important for confirmation of diagnosis (bladder cancer), staging and grading of tumor.

Treatment of superficial bladder cancer? (after TURBT)

Small low grade, superficial bladder cancers may not require aggressive management after the initial TURBT and may be simply followed up by doing repeated cystoscopy examinations at regular intervals. It is very important to know that 30-40% of these tumors tend to recur after initial TURBT. High grade, larger, multiple or recurrent superficial bladder cancers may require additional treatment after the initial TURBT. One of the most effective and widely used medications is BCG. It is instilled into bladder through urethra. BCG therapy decreases recurrence and invasiveness of tumor.

Treatment of muscle-invasive bladder cancer?

Surgical removal of the bladder and diversion of the urinary stream using intestinal segments, known as radical cystectomy. This is a major operation.

What is the prognosis for bladder cancer?

The most important factors that impact the prognosis (or the chances of control and cure) of bladder cancer are the Stage and Grade of the tumor. Lower the Stage and Grade, better the outlook

3. Kidney Cancer