Urologic Cancers
Urologic Cancers
What is urologic cancer?
Urologic cancers affect the organs of the male and female urinary system and the male reproductive system.
What is genitourinary oncology?
Genitourinary Oncology affects the male reproductive organs, as well as the urinary systems in both men and women.
Types
Prostate cancer
Prostate cancer is one of the most common types of cancer in men. It usually affects men after 55 years of age, but now is progressively found in men at a lower age group as well. The common problems arising in this gland includes benign (non-cancerous) enlargement or cancer of the prostate.
Prostate cancer grows slowly and initially remains confined to the organ. However, in certain cases the growth is rapid and can spread quickly to other organs. Early detection allows patients to choose from a range of treatment options with excellent outcomes.
Bladder cancer
Bladder cancer is any of several types of cancer arising from the tissues of the urinary bladder. Symptoms include blood in the urine, pain with urination, and low back pain. It affects the cells that line the urinary bladder, a small sac that collects urine for excretion.
Kidney cancer
Kidney cancer, also known as renal cancer that starts in the kidney.
Testis cancer
Adrenal cancer
Penile cancer
Urethral cancer
What is prostate cancer?
The prostate gland and seminal vesicles are part of the male reproductive system. The prostate is about the size of a walnut and lies below the urinary bladder and in front of the rectum. The seminal vesicles are two smaller glands behind the prostate. The prostate gland surrounds the urethra or the water-pipe in full circumference, which is a tube carrying urine from the bladder out through the penis. With the age, prostate gland grows in size leading to pressure on the urethra causing difficulty in passing urine. These symptoms are labelled as lower urinary tract symptoms (LUTS) which include frequent urination, increased night time urination, sensation of urgency or poor flow. Important function of the prostate and seminal vesicles is to make fluid to bathe semen which helps in sperm maturation. During ejaculation, sperm is made in the testicles, and then moves to the urethra.
Prostate cancer is a form of cancer that develops in the prostate gland. It is the second-leading cause of cancer related death for men across the globe with nearly 1.3 million cases getting diagnosed every year.
Who is most likely to get prostate cancer?
Prostate cancer is the second most common cancer diagnosed in men worldwide and autopsy studies do show that prevalence beyond the age of 79 years is more than 59%. Though all the patients of prostate cancer do not have hereditary transmission, the relative risk of getting it is 5.51 (RR) in case your brother of father has had it.
What causes prostate cancer?
There are many genes (BRCA2, BRCA1, ATM, CHEK2, HOXB13) implicated in prostate cancer pathogenesis, however true hereditary cancers will be nearly less than 10%. The genetic mutations can be either hereditary or somatic which are acquired after birth due to some inciting events. Apart from this there are many environmental factors which have a role to play in this carcinogenesis. Multiple studies have evaluated the role of different factors but the results are by and large variable.
Risk Factors of prostate cancer
Family history of prostate cancer is the most important factor as a part of risk based evaluation. Relative risk of getting prostate cancer is 1.8 for men with single first degree relative having prostate cancer, 5.5 if either father or brother has it and 7.7 if two brothers have it. African American ethnicity is also a risk factor and apart from this the data on environmental exposure is quite variable.
Stages of prostate cancer
Prostate cancer can be either localised which means it is completely inside the prostate and not going beyond the capsule of the prostate. Locally advanced stage is when the cancer is coming out of the gland to adjacent organs called seminal vesicle or the lymph nodes in the local area.
Any further spread in the nodes in in abdomen of the bones or the solid organs would be called as metastatic stage.
Types of prostate cancer
Majority cancers arising from prostate gland are adenocarcinoma. Rare variations do exist but are highly uncommon, namely small cell variant, neuroendocrine variant.
What are the symptoms of prostate cancer in men?
Generally speaking, prostate cancer localised to the gland does not cause any direct symptoms. Age related enlargement of the prostate (benign prostatic enlargement) leads to lower urinary tract symptoms. Prostate cancer generally occurs on the background of the benign enlargement and hence may have similar symptoms. ‘Blood in pee’ can be a rare symptom due to prostate cancer. Once the cancer cells come out of prostate and get deposited elsewhere in the body, they lead to local symptoms which can vary from bone pain to back ache or weakness in lower extremities due to compression on the spinal column, but it may happen only in very late stages.
Does an enlarged prostate affect a man sexually?
Enlarged prostate may not affect man directly for sexual functions but sexual activity existing at the time of diagnosis of prostate cancer has implications in treatment as hormonal therapy affects libido leading to sexual dysfunction. Nerve sparing radical prostatectomy is the procedure which spares the nerves responsible for the erectile function and offers curative treatment while giving maximum chance of recovery of sexual functions.
Does a blood test detect prostate cancer?
Prostate specific antigen (PSA) levels correspond with the likelihood of having prostate cancer. Though it is not a specific marker for the cancer, the increased levels are most likely to happen in case of cancers. Guidelines do recommend that the screening is essential in healthy population between the age of 55 and 69 years (American Urological Association Guidelines) and beyond 50 years (European Urological Association Guidelines). Recommended frequency is once a year and it has to be combined with digital rectal examination (DRE) of the prostate by an expert. Advantages of screening being, diagnosis of cancer in early stage with lesser likelihood of progression to advanced or metastatic stage and hence reduction in prostate cancer specific mortality.
Diagnosis of prostate cancer
Diagnostic work up would essentially involve initial screening based assessment (PSA plus DRE). If any of the tests is abnormal the next step is to evaluate the prostate by doing a multiparametric MRI (mp MRI). Biopsy done either through the rectum (trans-rectal) or through the skin between scrotum and the rectum (trans-perineal) is the gold standard for diagnosis and is an essential element of prostate cancer in any stage. After the cancer is been diagnosed, the next test is to rule out any distant spread by doing either a bone scan or a dedicated PET scan called PSMA PET CT scan for the whole body.
Is prostate cancer in men curable?
Any cancer behave a typical pattern of origin and progression in sequential stages. Prostate cancer is not an exception to this. There is afinite period until which the cancer cells are located only inside the prostate gland. They usually come out of the capsule locally and may invade seminal vesicles. After a certain interval, these cancer cells travel through blood vessels or lymph nodes to reach other parts of the body. After spreading, cancer cells may attach to other tissues and grow to form new tumors, causing damage where they land which is similar to a ‘seed and soil concept’. This patterns of spread would depend on the aggressiveness of the cancer also called as a biology of the disease.
Prostate cancer is indeed a curable disease and the intention of cure can very well be achieved until the cancer cells are restricted to only local (prostate) or loco-regional area (seminal vesicles or pelvic lymph nodes). Once the cancer cells come out completely and get deposited in some other part of the body like bone, the intention of the treatment in this setting changes from cure to long term control. In both the intents of treatment (cure or control) depending upon the stage, most pivotal is to maintain good quality of life.
How long can you live with prostate cancer?
Prostate cancer is a relatively slow growing disease and overall longevity would be fairly good, however it would revolve around the stage of diagnosis and the type of treatment and the response to the treatment.
What happens if you don’t treat prostate cancer?
Prostate cancer cells would eventually spread to different body parts including bones and the quality of life would be troubled due to the implications of the spread. This may include, fractures, compression of the spinal cord leading to the weakness in the lower limbs, obstruction to the ureters, bleeding in urine and retention of urine meaning inability to pass urine requiring placement of the catheter tube.
Treatment options of prostate cancer
Treatment of prostate cancer can be two fold depending upon the stage in which it is diagnosed. In a localised or locally advanced stage the intention of treatment would be for cure, however if the cancer is diagnosed in a metastatic stage the intention of treatment is long term control vis a vis maintaining good quality of life.
Under the curative modality of intent there are two major options, first being surgical removal of the prostate gland and second being combination of radiation therapy with hormonal therapy. Surgical treatment of the prostate cancer entails removal of the entire prostate gland with seminal vesicles with or without lymph nodes depending upon the indications. This particular surgery is defined as radical prostatectomy with or without pelvic lymph node dissection. Radiation would either be external beam radiation or implantation of seeds in prostate which is called as brachytherapy.
In metastatic stage, the main treatment revolves around the concept of supressing testosterone levels in the body as prostate cancer cell is fed by testosterone levels in the body. Hormonal therapy essentially reduces the testosterone levels achieving long term control of the cancer. Role of chemotherapy does exist and it is reserved in select stage and select patient.Most important aspect in this metastatic stage is to maintain good bone health as the main morbidity in the late stages is due to pathological fractures. Bone protecting measures need to be taken to prevent or minimise these skeletal related events (SRE).
How does Robotic Surgery for prostate cancer work?
Conventionally it is performed in an open manner with an incision on the lower abdomen. With the advent of newer modalities and era of miniaturisation, keyhole surgery for the prostate cancer is feasible now. Robotic surgery started from year 2000 and there has been a sea change in last two decades especially for the prostate cancer. For the very same reasons, it is the most commonly performed robotic procedure across the globe. The functionality is similar to ‘master slave concept’. The chief operating surgeon performs the surgery on the console and the exactly same movements are transferred to the robot which stands by the side of the patient with the help of connecting network. To the fullest extent, each and every step of the procedure is governed by the surgeon in the console and robot just reciprocates these movements live inside the patient’s body. The distinct advantages being, better precision, better control, 3 dimensional magnified vision, motion scaling, lesser blood loss, faster post-operative recovery and early discharge. Needless to say that more than 90% of the radical prostatectomies are done with the robot now.
Is Robotic surgery the same as laparoscopic?
Robotic procedure is a minimally invasive procedure also called as a ‘keyhole surgery’ similar to the laparoscopic procedure. Only difference would be that the surgeon stands by the side of the patient in laparoscopic procedure holding the instruments himself or herself whereas in the robotic procedure the surgeon manoeuvres the entire procedure on the console and he is assisted by another colleague who sits at the bedside next to the patient and the robot. Distinct advantages of the robotic procedure over the conventional laparoscopic procedure would be three dimensional vision, higher level of magnification, better precision, elimination of tremors, motion scaling, use of newer technologies like firefly and better ergonomic configuration. Overall it is a very safe procedure and highly recommended in expert hands for better oncological and functional outcomes.
How long can you live with prostate cancer in the bones?
The survival would depend upon the response to the treatment. In good responder it may go beyond 75 months and in poor responders it may be limited to lesser than that.
Prevention of prostate cancer
Preventive strategies have been explored to the fullest extent by using some medicines (Dutasteride or Finasteride) or dietary modifications or vitamin (Vitamin D, selenium) supplements, however none of the factors has been precisely show to have a large benefit. There is a trend towards favourable effects of consumption of cooked tomatoes and lycopenes.
Inputs by Dr. Ashwin Tamhankar Consultant Uro-oncology and Robotic Surgery at Apollo Hospitals, Navi Mumbai.