UROLOGY RENAL CANCER PENIS TESTICULAR CANCER PENILE CANCER BLADDER CANCER KIDNEY CANCER PROSTATE CANCER

1. Urologic Malignancies

2. General Outline of Presentation
Urological Malignancies :
• Renal
• Bladder
• Penis
• Prostate
• Testicular

3. RENAL MALIGNANCIES

4. Classification of Neoplasms of The
Kidney
Benign neoplasms
• Adenoma
• Angioma
• Angiomyolipoma
Malignant neoplasms
• Wilms’ tumour (nephroblastoma in children)
• Grawitz’s tumour (adenocarcinoma,
hypernephroma)
• Transitional cell carcinoma of the renal pelvis
and collecting system
• Squamous cell carcinoma of the renal pelvis

5. Renal Cell Carcinoma
• Grawitz’s/Hypernephroma/Adenocarcinoma
• The most common neoplasm of the kidney (75%
incidence), arises from renal tubular cells.
• Male predominance (1.6:1.0 M:F)
• Highest incidence between age 50-70
• Majority of RCC occurs sporadically
• Highest incidence in Scandinavia and North
America, lowest in Africa

6. Pathology
• Surface – white to
yellowish
• Semi transparent
• Areas of
haemorrhage and
necrosis

7. Spread
• Direct/ Lymphatic/Blood

8. Clinical Features -1
• Asymptomatic in the beginning
• Triad of loin pain, loin mass, haematuria
(10%) and usually indicate advanced disease
• Haematuria is common complaint
• Dragging discomfort in the loin
• Mass
• Rapidly developing varicocele

9. Clinical Features -2
• Paraneoplastic syndrome : hypercalcemia,
erthrocytosis, non metastasis hepatic
dysfunction (Stauffer syndrome)
• Metastasis symptoms : Bone pain , chronic
cough, hemoptysis

10. Left Varicocele

11. Clinical Features -3
Atypical symptoms :
Persistent pyrexia (37.8–38.9ºC) with no
evidence of infection
 Cachexia
Anaemia.
Polycythaemia
Raised ESR
Nephrotic syndrome

12. Recommended Initial Test
TEST REASON
Renal Function Test Assess remaining renal function
Full Blood Count Polycythemia, Anaemia
ESR Increased in renal cell carcinoma
Serum calcium Hypercalcaemia (paraneoplastic syndrome)
Coagulation Profile Pre-surgery investigation
Liver Function Test Impaired in metastases or paraneoplastic
syndrome, ALP increase in bone metastasis
Chest x-ray Canon ball appearance (metastasis)

13. Staging of disease
TEST REASON
Transabdominal
Ultrasound
Origin of mass, cystic/solid, sign of
metastasis in liver and lymph nodes
enlargement
Contrast CT Abdomen TNM Staging
MRI Abdomen If renal function is impaired to permit
contrast
Transesophageal
Echocardiogram
If suspected spread of tumour from inferior
vena cava involving right atrium
Excretory Urography Able to access renal function and any filling
defect indicating presence of mass
PET Scan Most sensitive but not widely available

14. Robson Modification Of the Flocks &
Kadesky Staging of RCC

15. Staging of RCC

17. Chest x-ray
• Lung
Metastasis
•Canon ball
appearance

18. Intravenous urogram
•Hypernephroma of
the left kidney
•Displacement of the
upper pole calyces by
the mass.

19. Arteriogram
•Vascular ‘blush’
due to metastasis
in the femur from
a Grawitz’s
tumour

20. CT scan
Large bilateral
renal
adenocarcinomas

21. Principles of Treatment
• Radiotherapy, Chemotherapy – minimal
respond
• Surgical
• Immunotherapy – Cytokine IL-2, Chemokines

22. Surgical
• Surgical removal of affected kidney - partial or
complete nephrectomy
• 2 types of approach
 Loin
 Transabdominal
• Vascular control by first ligation of renal artery
and then ligation of renal vein

23. Indications
1. Bilateral RCC
2. RCC in a solitary functioning kidney
3. Unilateral RCC with contralateral kidney under threat of
its future function
4. Tumour less than 4cms with normal opposite kidney.
5. Five year survival rate 75% to 85%
6. Local tumour recurrence of 10% is reported.
Other Approaches
1. Radio frequency ablations
2. Cryoablation
Nephron Sparing Surgery

24. • Gold standard treatment for localized RCC with
contralateral normal kidney, adequate surgical
margin.
• Principles of Surgery- Early ligation of renal artery
and vein , removal of kidney including Gerota’s
fascia, removal of ipsilateral adrenal gland,
regional lymphadenectomy from crus of
diaphragm to aortic bifurcation.
Radical nephrectomy

26. Prognosis
• In operable cases, 70% of patients are well
after three years and 60% after five years.
• Worse prognosis –
- Macroscopic involvement of the renal vein or
its tributaries
- Invasion beyond the capsule
- Lymphatic involvement

27. Transitional Cell Carcinoma of Kidney
• Less common
• May invade the renal parenchyma, be
multifocal and metastasize.
• Multiple ureteric tumours are thought to arise
from a field change that predisposes the whole
urothelium to metaplasia rather than seeding
down the ureter.
• Carcinogen is chemical or viral is uncertain

29. Diagnostic Work Up
• Clinical - Haematuria
• Investigations :
Presence of malignant cells in the urine may
indicate well or poorly differentiated.
Obtain cells from the tumour by sampling
using a brush or catheter
Intravenous urography
Retrograde pyelography

31. Treatment
• Conventional surgical - nephroureterectomy.
• Conservative resection - well-differentiated
upper urinary tract transitional tumours

32. Squamous Cell Carcinoma of Kidney
• This is rare and often associated with chronic
inflammation and leucoplakia resulting from
stone.
• The tumours are radiosensitive but
metastasise early
• Prognosis is poor

33. BLADDER CANCER

34. • Rare before 50 years old.
• Male > Female
• 95% of primary bladder tumor originate in
transitional epithelium (TCC)
• Secondary tumors : Sigmoid & rectum,
prostate, uterus or ovaries
• Histological Types : Urothelial, Squamous and
Adenocarcinoma
INTRODUCTION

35. • Cigarette Smoking (40%)
• Long term use Analgesic
• Occupational risk factors
- Textile, Dye, Tyre rubber, Petrol etc.
• SCC: Schistosoma Haematobium (in Endemic
areas), usage of catheter, bladder stone.
RISK FACTORS

36. • Hematuria. Painless, end micturition
• Bladder Outlet Obstruction (Male)
• Cystitis (Female)
• Constant pain in Pelvis
• Referred pain to suprapubic region, groins,
perineum, anus & into thigh
• Loss of Weight, Loss of Appetite
CLINICAL FEATURES

37. • Usually negative
• Maybe a palpable suprapubic mass
• Rectal Examination:
- May reveal large tumors (Invaded pelvic side
walls)
• Bimanual Examination:
- Necessary for staging evaluation.
PHYSICAL EXAMINATION

38. • URINE
• BLOOD
• IMAGING
INVESTIGATIONS

39. URINE TESTS
 Urine FEME
- Hematuria, WBC
 Urine Cytology
- Malignant cell.
 Urine CnS
- To rule out Infection
INVESTIGATIONS

40. BLOOD TEST
• Full Blood Count
• Renal Profile
• Liver Function Test
• Random Blood Sugar
• Coagulation Profile
• Prostate Specific Antigen (PSA)
• GXM and GSH

41. IMAGING
Ultrasound/IVU
– Most common defect: Filling defect
– Irregularity of bladder wall (Invasive tumor)
Contrast CT/MRI
– For staging
– Demonstrate lymph node & muscular invasion
Cystourethroscopy
– Mainstay of Diagnosis

42. Ultrasound of Bladder
• Irregular, echogenic mass

44. Cystourethroscopy

45. Cystoscopy of Bladder Cancer
See the cauliflower
appearance of the
tumor?

46. • Carcinoma In Situ
Superficial Tumor
• Ta. Confined to urothelium
• T1. Lamina propia involvement
Invasive Tumor
• T2a. Sup. Muscle involvement
• T2b. Deep muscle involvement
• T3a. Invades perivesicle tissue
microscopically
• T4. Extravesicle mass (macro)
Fixed Tumor
• T4a. Prostate, uterus, vagina
• T4b. Fixed to pelvic wall.
STAGING (UICC SYSTEM)

47. STAGING
• Stage 0. pTa & TIS
• Stage 1. T1N0M0
• Stage 2. T2N0M0
• Stage 3. T3 (a/b)
• Stage 4. Any metastasis

48.  Superficial Tumor (Ta, T1)
 Invasive Tumor ( T2, T3)
 Fixed & Metastatic Tumor (T4)
- Poor prognosis
MANAGEMENT

49. 1. Superficial Tumor (pTa, pT1)
• Trans Urethral Resection Bladder Tumor
(TURBT) and send tissue for HPE
• pT1
- Repeat Cystoscopy & resection
of tumor base after 6 weeks
- Followed by Intravesical BCG
Regular follow up for cystoscopic exam : Every
3monthly for 3 years -> 6 monthly for 2 years

50. Trans Urethral Resection Bladder
Tumor (TURBT)

51. TURBT

52. Cystoscopy
• Endoscopy of the urinary bladder

53. Intravesical Chemo/Immunotherapy
• Used after TURBT for Stage 0 or Stage 1 Ca.
• It’s used only for early stage Ca – affect
mainly the cell lining inside bladder, no effects
on cells elsewhere.
• BCG : Is put directly into bladder through a
catheter- attract immune system cells to the
bladder –attack the cancer cells.

54. 2. Invasive Tumor (pT2, pT3)
• Partial Cystectomy. Limited to small adenocarcinoma
• Radical Cystectomy.
- Followed by chemotherapy/radiotherapy
- Localised pT2-3 that has no spread and CIS
refractory to BCG, Pt >70 years old
• Neoadjuvant Chemotherapy. To shrink tumor before
surgery
• Chemotherapy & Radiotherapy. Unfit, Older or
decline cystectomy

55. • Orthotopic Bladder Replacement. If urethra
can be retained, reconstruct new bladder from
intestine
• Ileal Conduit.

56. 3. Metastatic Tumor (pT4)
• Poor prognosis. Incurable
• Palliative. No surgery
• Treat with chemotherapy

57. PROGNOSIS
• Mucosal Tumor- 50-60% 5 years survival
• Deep muscle invasion: 20-30% 5 years survival
rate
• Overall 1/3 patient survive for 5 years

58. PROSTATE CANCER

59. Epidemiology
• Age > 65 years old
• 10-15% of younger men with positive family
history but unclear etiology
• Rates of clinically evident disease are low in
Japan & China
• In Malaysia :6th among top 10 cancers for
men

60. Risk Factors
• Age >65 years old
• Family history :first degree relatives
• Hormonal : high testosterone
• Exposure to cadmium

61. Pathology
• Almost all adenocarcinoma
• Origin : peripheral zones of prostatic glands
• Gleason scoring – degree of glandular
differentiation & relationship to stroma

63. Mode of presentation
i. Found on autopsy or at cystoprostatectomy
ii. Accidental findings during TURP (T1a & T1b)
or by PSA (T1c)
iii. Early, palpable, localised prostate cancer (T2)
iv. Advanced local prostate cancer (T3 & T4)
v. Metastatic disease

64. Spread
Local
• Seminal vesicle
• Bladder : neck
& trigone
• Lower end of
ureter
• rectum
Hematogenous
• Bone
Lymphatics
• External iliac
• Internal iliac
• Mediastinal
• supraclavicular

65. Clinical Features - History
• Asymptomatic – screening by per rectal
examination and PSA
- Suspiciously raised serum PSA
- Found on histological examination after TURP
• Only advanced disease gives rise to symptoms,
but even advance disease may be
asymptomatic

66. • Symptoms of advanced disease
- Bladder outlet obstruction
- Pelvic pain & hematuria
- Bone pain
- Renal failure

67. Clinical Features – Physical
Examination
• Sign of anaemia
• Nodular, irregular, stony hard, fixed prostate
on per rectal examination

68. TNM Staging
TUMOUR
• T1 – clinically inapparent tumour neither palpable
nor visible by imaging
• T2a – tumour confined within prostate & 1 lobe
T2b – tumour involved both lobes
• T3 – tumour extends through prostate capsule
T3a – uni or bilateral extension
T3b – seminal vesicle extension
• T4 – tumour is fixed or invades adjacent structure
other than seminal vesicles

70. NODAL
• N1 – lymph node metastasis
METASTASIS
• M1 – distant metastasis
* If prostate Ca is palpable it is
incurable

71. Investigations
Diagnostic
• Prostate Specific Antigen (PSA)
- Cancer detection rate 2-4%
- Lack sensitivity & specificity
- 30% men with PSA, cancer confirmed by
biopsy
- 20% men with prostate Ca have normal PSA
- Good at following course of advanced disease

72. • Also raised in : Acute Urinary Retention, TURP,
prostatitis, large BPH, catheterization
Level Possibility
<4ng/ml Normal
4-10ng/ml Benign prostate hyperplasia, prostatitis
>10ng/ml Suggestive malignancy
>35ng/ml Diagnostic for advanced cancer
>100ng/ml Distant bone metastasis

73. • Trans-rectal ultrasound (TRUS)
- Image the prostate irrespective findings on
palpation
- Guide transrectal needle biopsy
- Diagnosis of locally extensive disease (T2)
• Prostate biopsy (transrectal)
- Take multiple biopsy
- If patient has bladder outlet obstruction, then
can do transurethral resection of prostate
(TURP)

74. Transrectal US showing
normal seminal vesicles
Transrectal US showing
local extension of T3
prostate cancer

75. Obtaining a specimen
of prostatic tissue by
means of a biopsy
needle

76. Investigation
Routine
• Full blood count
- Anaemia (leucoerytroblastic anaemia, renal
failure or hematuria)
- Thrombocytopenia (DIC)
• Liver function test
- Abnormal if liver metastasis present (ALP in both
bone & liver metastasis)

77. • Chest X-ray
- Lung metastasis
• Pelvic & lumbar X-ray
- Sclerotic / osteolytic metastasis in lumbar
vertebrae & pelvic bones
• MRI/CT scan
- Local staging, node & metastasis

78. Osseous metastasis of
the pelvic bones in
carcinoma of the
prostate

79. • Bone scan
- After establish diagnosis, as part of diagnosis
- If PSA >10nmol/ml or biopsy showed high
grade cancer
- If PSA <10nmol/ml with clinical indication

80. Bone scan showing
multiple hot spots
suggestive of metastatic
disease in a man with
prostate cancer

81. Management
Treatment Modalities
• Surgery – radical prostectomy
- Removal of whole prostate until distal
sphincter & seminal vesicle
- Complications : impotence, stress
incontinence

82. • Radiotherapy
- External Beam : T1, T2, locally advanced T3
- Brachytherapy : T1 disease (Iodine 125,
Palladium 103)
- General radiotherapy : for metastasis

83. • Androgen ablation
- Orchidectomy : bilateral, subscapular
- Medical : LHRH agonist like goserelin
: anti androgen like flutamide,
bicalutamide or cyproterone
- Anti androgen drugs can cause hormone
resistance & hepatotoxic

84. Treatment Summary
• At any stage, transurethral resection for bladder
outlet obstruction
Stage T1 & T2
- Active monitoring or radical local treatment i.e.
prostectomy or radiotherapy
Stage T3
- Radiotherapy, often with neoadjuvant or adjuvant
hormonal therapy

85. Stage T4
- Anti androgen therapies (bilateral
orchidectomy) plus
- Radiotherapy ; painful bone metastases or
spinal cord compression or
- Drug treatment with LHRH agonist anti
androgen drugs

86. PENILE CARCINOMA

87. Epidemiology
• Uncommon malignancy
• Elderly man, 50-70 years old
• Mostly squamous cell carcinoma, other rare
carcinomas are melanoma,
haemangiosarcoma or fibrosarcoma

88. Aetiology & Risk Factors
• Phimosis
- Circumcision at birth confer’s immunity & at
later ages has no immunity
• Pre cancerous lesion :
- Genital warts : HPV, condyloma acuminate
- Leucoplakia, Paget’s Disease of the penis
- Bowen’s Disease (carcinoma in situ)

89. • Poor hygiene & smoking
• Chronic inflammatory condition of the penis
(balanophostitis)

90. Pathology
• Typically squamous cell carcinoma arising
from skin of the glans/prepuce
• May be flat & infiltrating - arises from
leukoplakia
• Papillary projections – exists from papilloma,
more common

91. Penile squamous cell
carcinoma appearing as a
reddish, raised, and firm
nodule in the inner portion
of the foreskin

92. Spread
• Direct spread
• Lymphatic spread
• Blood spread

93. Clinical Features
• Many present late (due to embarrassment/
misdiagnosis)
• Growth is often large with foul bloody
discharge (2nd infection)
• Typically little/no pain
• 50% have inguinal lymph node enlargement,
often reflects infection
• The prepuce is non-retractile & must be split
to view the lesion

94. A squamous cell cancer
of the penis with an
ulcerating groin node

95. • The whole glans may be replaced by fungating
mass (untreated)
• Later, the inguinal nodes can erode the skin of
the groin

96. Physical Examination
• Site : glans penis or inner surface of foreskin
• Inspection
- Painless ulcer, irregular margin, rolled edges &
indurated or gray, crusted popular lesion
- Bleeding & yellowish discharge can be seen

97. • Palpation
- Firm to hard
- Retract foreskin ( some are found under the
foreskin )
- Check for phimosis
- Feel for inguinal lymph nodes

98. Staging
• Jackson’s staging
Stage 1 Tumour confined to the glans/ prepuce
Stage 2 Tumour invade shaft or corpora but no
nodes involvement
Stage 3 Tumour confined to the penis & operable
nodes involvement
Stage 4 Tumour involves adjacent structures &
inoperable nodes metastasis

99. TNM staging
Tumour Tis : carcinoma in situ
Ta : noninvasisve verrucous tumour
T1 : Tumour invading subepitelial
connective tissue
T2 : Tumour invading corpora
T3 : tumour invading urethra or prostate
T4 : tumour invading other adjacent
structures

100. Node N1 : 1 superficial inguinal lymph node
N2 : multiple bilateral inguinal lymph
nodes
N3 : deep inguinal & pelvic lymph
nodes, bilateral or unilateral
Metastasis M1 : distant metastasis

101. A late presenting
squamous cell cancer of
the penis

102. Investigations (special)
• Punch or excisional biopsy of the lesion
• Fine needle aspiration for palpable lymph
nodes
• CT/MRI to evaluate metastasis

103. Management
• Divided into treatment of primary tumour &
inguinal lymph nodes
• Primary treatment : 2 methods
i. Radiotherapy
- Indicated for small & well differentiated growth
limited to penis glans
- Disadvantage : scarring caused painful erection

104. ii. Surgery
- Indicated : anaplastic growth, big growth,
infiltrate shaft of penis & radiotherapy failed
- Methods of surgery
A. partial amputation of penis : distal growth
limited to glans penis & prepuce
B. total amputation of penis : lesions affecting
the shaft of penis & anaplastic lesions

105. • Secondary tumour – associated with inguinal
lymph nodes
- No nodes enlarged : follow up carefully
- LN enlarged which are not fixed : wait for 3
weeks after treating primary growth
- LN enlarged are massive & inoperable : deep
radiotherapy is given & may be treated with
chemotherapy
- Sentinel node biopsy

106. REFERENCES
• William NS, Bulstrode CJK, O’connell PR,
Cholelithiasis. Bailey & Love’s Short Practice
of Surgery. 26th edition, CRC press

107. THANK YOU!