Urogenital cancers

Renal Cell Ca
Bladder Ca
Renal pelvis & ureter
BPH & Prostate Ca

Bladder Cancer
Transitional epithelium:

Renal pelvis
Ureter
Bladder
Prox 2/3 urethra, distal 1/3 squamous

90% bladder
8% renal pelvis
2% ureter, urethra
Median age 65

Risk factors
Smoking
Polycyclic aromatic,
manufacture of aluminum
Dry cleanrs

High consumption of fried meats & fats

Chronic cyclophasphamide exposure
Schistosoma haematobium
Squamous 70%
Transitional 30%

Vit A protective

Presentation

Hematuria, in 80-90% 1st symptom

Urinary frequency / irritative symptoms
Ureteral obstruction results in flank pain
Diagnosis: Cytology & imaging

USG / IVP
Cystoscopy & biopsy
CT, MRI
Bone scan

Staging TNM

Treatment
Superficial tumors bu endoscopic
resection + intravesical therapy
Surgical removal of bladder
Chemotherapy
5 yr Survival
90% for superficial
10 20 % for invasive /N / M

Renal Cell Ca
Refractory to cytotoxic agents
Biologic response modifiers
Interferon alpha
Interleukin 2

Variable clinical course

Risk factors
Smoking
Obesity
Renal cysts in ESRD

Clinical presentation
Classic triad:
Hematuria
Flank pain
Flank mass

Increased ESR
Weight loss, anemia
Fever, hypertension
Abnormal liver function
Hyper Ca, erythrocytosis, neuropathy,
amyloidosis

Staging & Prognosis

Stage I : confined to kidney, 5 yr 66%
Stage II: extend through renal capsule, but
confined by Gerotas fascia; 5 yr 64%
Stage III: renal vein / vena cava (IIIA), hilar
lymph nodes (IIIB) ; 5 yr 42%
Stage IV: locally invasive / M+; 5 yr 11%

Treatment
Radical nephrectomy, adrenal gland &
lymph nodes
Immunotherapy : IFN-a, IL2
Resection of solitary M
Chemotherapy

Renal pelvis & Ureter

90% transitional
Ssmoking, chemical hydrocarbon
Chronic phenacetin abuse, Balkan
nephropathy
Painless gross hematuria
Resection for localized ds
chemotherapy

Hyperplasia of the prostate

Growth spurts
Puberty, androgen mediated
5th decade

Affects men > 45 & increases in frquency

8th decade, >90% of men at autopsy
Most common cause of obstruction
Hyperplasia begins in the periurethral region
Compress & obstruct the urethra, can also grow
posteriorly to obstruct the rectum
Aging & Testis: dihydrotestosteron, estrogen

Diagnosis
Obstructive symptoms

Diminution of urinary flow

Hesitancy in initiating voiding
Postvoiding dribbling
Sensation of incomplete emptying

Urinary retention, can be precipitated by

Infection, tranquilizers, antihistamine, alcohol

Nocturia
Overflow incontinence
Palpable bladder
ARF/AKI
Anamnesis, digital rectal exam, PSA, uroflowmetry,
postvoid residual urine volume
imaging

Treatment
Medical
Finasteride, competitive inh of 5 -reductase
Alpha1- adrenergic blockers

Surgery
TURP
Open prostatectomy
Newer: laser, thermal, stents

Prostate Ca
Most common Ca in men
3rd most common cause of cancer death in men
above age 55
> 95% adenocarcinoma, predilection for the
periphery
Squamous cell, transitional, carcino sarcomas,
metastatic from other ca
Gleason histologic grading
May be asymptomatic, or symptomatic
Dysuria, frequency, difficult voiding, increased urinary
frequency, urethral obstruction
DVT, PE, spinal cord compression, etc

DRE: hard, nodular, irregular

 Biochemical markers
PSA, most sensitive test, nonspecific
Combined with DRE
BPH, prostatitis, prostatic infarct
Correlate PSA with

prostate volume (PSA density),

patient age (age-specific ref range),
rate of rise in PSA with time (PSA velocity)
Free and protein bound forms of serum PSA

In patients with known prostatic Ca

Staging
Response to treatment
Relapse

 Imaging
TRUS
MRI
CT

Biopsy
Essential for diagnosis
Pos DRE, any PSA
Neg DRE, PSA>10

Neg DRE, PSA 4.1-10

TRUS biopsy / biopsy if abnl TRUS
PSA refinement

 3 routes of spreading, correlate with size & Gleason

grade
Direct extension
Lymphatics
Bloodstream, bone > viscera

TNM staging
Bone scan
Surgical staging for LN involvement

Treatment
Surgery
radiation (incl bone M)
Androgen deprivation
Surgical: castration/orchiectomy & adrenalectomy
Inhibition of pituitary gonadotropin: estrogen, hypophysectomy,
LHRH analogues (leuprolide, buserelin)
Inhibition of androgen synthesis: aminoglutethimide
Androgen receptor blocker: cyproterone, flutamide, bicalutamide

Chemotherapy: hormone unresponsive, palliation,