Cancers in the urinary tract ( kidney, bladder, ureter, penis , testis and urethra) are part of uro-oncology and is dealt by Uro-Oncologist
It is the commonest amongst urological cancers. Usually happens with aging population but of late detected increasingly amongst men in their 40's and 50's. Increasingly seen in Indian men as well, perhaps related to progressive westernisation.
It is a cancer fully treatable when picked up early with excellent functional outcomes and hence early detection is a key. However , even when detected at a later stage good treatment options are available for controlling the disease.
PSA , a simple blood test is used as a screening tool for patients with prostate cancer aiding both in diagnosis and follow up. Whilst it is not a completely fool proof test, it is the best we have at this time. Adding value to this is a digital rectal examination by a urologist.
If PSA and \ or examination is abnormal , patients are advised to undergo prostatic biopsy. It is an invasive test performed by a urologist where cores of prostatic tissue taken with a help of a needle , guided by a ultrasound scanner through the rectum ( back passage).
Once again , this test is not completely fool-proof. Hence a comprehensive review by a urological surgeon is essential in guiding patients through this journey.
Once diagnosed, patient is counselled regarding the various treatment options depending upon the stage and grade of the disease. Some patients will require combinations of treatment to achieve optimal control of the cancer.
One of the treatments is Radical prostatectomy where the whole prostate along with the structures attached to it are removed . The urinary bladder is then joined to the urethra(water pipe). This operation can be done as Robotic or by laparoscopic or by open method. The urological surgeon will guide you as the best method depending on various factors.
Postoperatively majority of the patients are fit for discharge by the next day. A urinary catheter, which is fitted at the end of the operation is ready for removal on day as decided by your surgeon. Subsequent to the removal , patient notices two common side effects - incontinence of urine and impotence.
Incontinence improves with time and is accelerated by effective pelvic floor exercises. It is best taught by a doctor and a physiotherapist.
Impotence improves with time aided by preservation of nerves during the operation as well as post operative usage of medications. It is best to consult the treating urological surgeon who will guide you.
The patient also requires regular follow up with the urological surgeon for 5 to 10 years in order to identify problems early and treat them.
( also see Ureteric cancers in the Kidney cancer section)
Urinary bladder cancer is usually picked in patients with blood in the urine (Hematuria) which could visible (seen by the patient) or non-visible (picked up by a doctor from urine test). A small number of patients with this cancer get to be diagnosed due to other symptoms as well ( for.e.g urinary symptoms, pain , incidental finding etc.).
Usually picked up at a cystoscopy( camera examination of the urinary bladder), the diagnosis is confirmed after a tumour resection with a help of a rescetoscope ( TURBT- Transurethral resection of Bladder Tumour). The removed tissue is examined by a pathologist who then gives a grade and possible stage of the disease. In addition, the examination by the urologist during anesthesia as well as additional scans ( CT or MRI) will help us understand the stage and extent of the disease.
The most common type of the cancer is called Transitional cell carcinoma (TCC). The well established risk factors are smoking and working with chemicals. It arises from the lining of the urinary tract. The same lining exists from the urine collecting system in the kidney ( renal pelvis and ureter), in the urinary bladder and extends to the proximal aspect of the water pipe (urethra).
Once a clear cut grade and stage is obtained, the treating urologist will discuss with you the next follow up about treatment plan . For low to intermediate grade disease, patients usually require a periodic examination with a camera and resection as and when necessary. In addition , instillation of certain chemicals in the bladder at times helps.
For high grade+\- invasive disease removing the bladder (radical cystectomy) is one of the best choices of treatment. This is a major operation and the pros and cons of this operation needs to weighed carefully with a urological surgeon. This operation (Cystectomy) can be done as Robotic or by laparoscopic or by open method. The urological surgeon will guide you about the best method depending on various factors.
In addition the surgeon will also discuss the best method of diverting the urine which could be achieved by a neobladder reconstruction, or an ileal conduit diversion or a continent urinary diversion. Once again, a detailed discussion with your surgeon will help you understand the advantages and disadvantages of each method.
The patients with these cancers needs periodic follow up depending upon the grade , stage of the cancer and the method of treatment offered.
Cancer of the kidney and Cancers of the Renal Pelvis and Ureter
Kidney cancer can either arise from the cortex (meat) of the kidney (termed as Renal Cell Cancer) or from the part where the urine is collected and drained ( renal pelvis and ureter- usually called Transitional cell Cancers).
The two cancers behave in different fashion and the treatment is different as well.
Both the above type are found in patients with or without symptoms (therefore called incidental tumours as the patient would have had a scan for an unrelated reason.) or in patients who had scans for symptoms ( such as blood in the urine, pain in the loin, weightloss, unexplained symptoms etc.).
The scans gives the surgeon a good idea about nature of the tumour. At times, (additional procedures) ( ureteroscopy - a camera examinations under anaesthesia or a radiological guided biopsy or both) may be required to make a complete diagnosis
Once identified, the best way to manage these problems is operative intervention. Renal cell cancers usually require removal of the whole (radical Nephrectomy) or part ( partial nephrectomy or nephron sparing surgery) of the kidney depending upon the size, location and extent of the tumour.
For patients with transitional cell cancers, the kidney and the ureter ( the tube that drains the urine from kidney to the bladder may have to be removed.
These operation can be done with a help of a robot(Robotic Nephrectomy or Partial Nephrectomy) or a laparoscope as well as by open method. The urological surgeon will guide you about the best method depending on various factors.
The patients with these cancers needs period follow up depending upon the grade , stage of the cancer and the method of treatment offered.
Cancer arising from the penis ( male organ) is usually called squamous cell carcinoma. There are other rarer varieties of cancers as well. The risk factors for this cancer includes smoking, poor hygiene and certain sexually transmitted diseases.Presenting as a lump of a red area or a bleeding and nonhealing ulcer, these cancers could potentially be picked up early. However many men tend to ignore these symptoms and because of embarrassment tends to present at a late stage.
A simple biopsy proves the diagnosis and can be performed under local or general anaesthetic. If picked up early organ preserving surgery could be contemplated depending upon the extent and nature of the tumour. Such a surgery helps to preserve the length of penis as well helps in patients confidence.Presenting at an advance stage may require removal of part or total male organ and may need alternative way of arranging the urine flow. Your treating surgeon will discuss with you the details of such an operation.
In addition , penile cancer may spread to the regional lymphnodes in the groin . These needs to be tested with scans and biopsy and if needed operation will be required. Like any cancer, penile cancer patients needs long term follow up and the treating surgeon will guide you in this process.
Testicular cancer usually presents in young to middle aged men . Usually picked as an abnormal feeling testis or a lump in the testis, these cancer may occasionally be found as incidental tumours found on scans.The commonest cancer is called seminoma. On the other hand there are group of less common cancers grouped together called NonSeminomatous Germ Cell Tumours. Whatever be the variety, the first step is to remove the whole testis. Extremely rarely, in patients with single testis, a more conservative surgery is undertaken. Being young, most of these men may also choose to preserve the semen for future fertility use (cryopreservation).
Done as a day case operation , radical orchidectomy (testis removing operation) is reasonably quick and simple. Once recovered and the histology obtained , these patients need further staging scans (either before or after the operation) , to plan further treatment. The further treatment usually depends upon various factors (nature of the cancer, grade , stage, extent and risk factors). This further management could be observation, single dose chemotherapy, a course of chemotherapy or a radical surgery to remove lymphnodes in the abdomen (retroperitoneal lymphnode dissection).
Your treating surgeon will discuss these issues with you and may send your to see an medical oncologist to discuss.In long term , follow up is required for 5-10 years atleast with periodic scans , blood tests and Xrays.