Urological Divisions 1、Pediatric urology， 2、Urologic Oncology 3、Renal Transplantation 4、Male Infertility 5、Urinary Tract Stones 6、Endourology 7、Female Urology 8 、Urinary Incontinence 9、Genitourinary Trauma 10、Erectile Dysfunction 11、Genitourinary Reconstruction） 12、Voiding Disorders

TUMORS OF GENITOURINARY TRACT Yiran Huang Department of Urology, Renji Hospital, SSMU,

Renal cell carcinoma Renal cell carcinoma (RCC) is the most common type of kidney cancer. These tumors occur twice as often in men as in women and usually occur in adults between the ages of 50 and 70. Between 25 and 30% of patients have metastases at the time of diagnosis.

Environmental risk factors include smoking , Phencetin-containing painkillers abused or over-used, some heavy metals exposure ( lead and cadmium). Other risk factors include long-term dialysis, overweight, a high fat diet.

There are also hereditary risk factors There are also hereditary risk factors. There are some genes mutations in rare syndromes like tuberous sclerosis and von Hippel Lindau Disease that are associated with an increased risk of developing kidney tumors.

Von Hipple-Lindau (VHL) disease is an autosomal dominant disorder in which affected individuals are at risk for retinal angiomas, central nervous system hemangioblastomas, renal cysts and carcinomas, pancreatic cysts and tumor, pheochromocytomas,endolymphatic sac tumors, and/or epididymal cystadenomas.

Types of renal cell carcinoma: Clear cell RCC (60 to 75 percent), papillary RCC (15 percent), chromophobe RCC (5 percent), collecting duct carcinoma (less than I percent), and unclassified carcinoma (up to 5 percent).

Clinical Presentation 1 Clinical Presentation 1. Renal cell carcinoma can become quite large without causing any symptoms. Many tumors are found incidentally. 2. Hematuria is the most common symptom. Other signs and symptoms include low back pain, a mass in the abdomen,

3. General symptoms. fatigue, weight loss, fever, anemia, swelling of the legs and night sweats 4. Paraneoplastic syndromes. Hypercalcemia , Stauffer's syndrome protein-wasting enteropathy, erythrocytosis, neuromyopathy, and gonadotropin production. Amyloidosis is present in approximately 2 percent of patients.

There are multiple imaging studies, including intravenous pyelogram (IVP), ultra-sonography, computerized tomographic (CT) scans, magnetic resonance imaging (MRI) which can produce images of the kidney.

Arteriography and angiography can demostrate blood vessels and image the kidney. A chest x-ray is used to evaluate the lungs metastases. A bone scan can identify cancer in bone.

Staging of Renal Cell Carcinoma Stage Ⅰ cancer is confined to the kidney, Stage Ⅱ means the cancer has broken through the kidney capsule and has spread into adjacent tissue, Stage Ⅲ indicates that it may have spread further into lymph nodes or blood vessels, Stage Ⅳ indicates that it is more wide-spread, particularly in other organs

Treatment Radical nephrectomy is the gold standard treatment for localized RCC. Components of a radical nephrectomy include early vascular ligation and en bloc removal of the kidney, Gerota's fascia, ipsilateral adrenal, upper ureter, and, for some, lymph nodes from the crus of the diaphragm to the aortic bifurcation.

Laparoscopic radical nephrectomy Nephron sparing surgery Absolute indications: include a solitary kidney, bilateral tumors, poor bilateral or contralateral renal function. Relative indications: smaller tumors (4 cm or smaller) with a normal contralateral kidney. Approaches include segmental polar nephrectomy, wedge resection, or tumor enucleation

Imunotherapy: Interferon alpha provides a 15 percent partial response rate and I percent CR.     lnterleukin-2. The only drug approved by the FDA specifically for metastatic carcinoma. A partial response rate of 14 percent with 5 percent CR. Continuous infusion or subcutaneous injections are less toxic. Chemotherapy Radiation therapy

NEPHROBLASTOMA ( Wilms’ Tumor )

Wilms’ tumor, is exclusively a disease of children under age 4 years Wilms’ tumor, is exclusively a disease of children under age 4 years. It is a highly malignant mixed tumor consisting of tissues of connective tissue origin and epithelial structures.

It is usually discovered as a palpable mass by the mother or by an examining physician. Treatment of the primary tumor is radical nephrectomy. Adjunctive therapy with irradiation and chemotherapy is important in improving survival.

TUMOR OF THE RENAL PELVIS

The transitional epithelium of the renal pelvis may arise to malignant tumors that are similar to lesion that occur in the bladder. Hematuria is the most commonly the presenting complain. Intravenous urography and retrograde urography can show the filling defect.

Laparoscopic nephrourectomy Treatment Nephroureterectomy The classic therapy for upper tract TCC is nephroureterectomy with excision of a bladder cuff. Laparoscopic nephrourectomy

BLADDER CANCER

Bladder cancer is the most common urologic malignancy The most common histologic diagnosis is transitional cell carcinoma (TCC). Sixty to 75 percent of these lesions are noninvasive, superficial tumors, but 10 to 20 percent of these tumors will progress to muscle-invasive disease, especially patients with high-grade disease and transitional cell carcinoma in situ.

Several factors are associated with the development of bladder cancer Several factors are associated with the development of bladder cancer. 1.Occupational exposure to chemicals is thought to cause the disease. 2.Smoking is also related to developing bladder cancer. The risk of developing the disease in smoking is four times that in non-smoking. 3.Chronic cystitis and bladder stone can cause squamous cell carcinoma.

Pathology Types of bladder tumor: transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma, and others. More than 95% primary bladder carcinomas are transitional cell carcinoma. Squamous cell carcinoma and adenocarcinoma account for approximately 2-3% respectively. Adenocarcinoma may arise from an urachal remnant at the dome of the bladder or from submucosal gland in the vicinity of the bladder neck.

Grade The grade is based on the degree of cellular differentiation gradeⅠbeing well differentiation, and gradeⅡ being moderate differentiation grade Ⅲ being poorly differentiation.

Stage The stage of Bladder carcinoma includes tumor in situ (Tis), papillary tumor confined to mucosa (Ta), invades submucosa only (T1), invades superficial muscle (T2), invades deep muscle (T3), spreads beyond the bladder, including into the prostate or other organs (T4).

Transitional cell carcinoma has three features: multiple lesions in bladder, multiple organs (pelvis, ureter, and post urethral can develop transitional cell carcinoma at same time.), recurrence (more than 50% patient will recur after the operations).

Location of Bladder Tumor Most are located on lateral and posterior wall of bladder, then on the top and the triangle.

Transitional cell carcinoma of the bladder develops more frequently in men than in women, and its frequency increases with age. The Prognosis is poor for aging patient and female. Carcinoma of bladder is quite rare in children.

Clinical presentations Hematuria Clinical presentations Hematuria. Either gross or microscopic hematuria is present in 85 percent of cases. The amount of hematuria is not necessarily proportional to the severity of the lesion, and intermittence is not a reason to exclude an evaluation. Hematuria in older patients may result in the diagnosis of a urologic malignancy in 10 percent of patients, with the majority of these lesions being TCC.

Microscopic or gross hematuria indicates cancer until proven otherwise and must be evaluated. Irritative voiding symptoms. Increased frequency of urination, dysuria, and urgency may be present in up to 20 percent of patients with bladder cancer, particularly CIS.

Diagnosis 1.The diagnosis is established by cystoscopy and biopsy of the tumor. 2.Urinary cytological test may be used to find the cancer cell. 3.Intravenous urography is essential for the bladder carcinoma. 4.Ultrasound, CT scan, and MRI detect the tumor in bladder, especially for the tumor stage.

Treatment Superficial bladder tumors (Ta and T1) are often amenable to transurethral resection or transurethral coagulation of laser. Invasive bladder tumors (T2 and T3) may require partial cystotectomy, or radical cystotectomy.

Systemic chemotherapy with multiple drug regimens incorporating cisplatin has shown promise for the advanced disease. Intravesical chemotherapy may be effective in controlling superficial disease but is ineffective for treatment of invasive lesion.

The most effective agent is bacillus Calmette-Guerin (BCG) intravesical immunotherapy, which decreases tumor recurrence by 40 to 70 percent. In the case of transitional cell carcinoma in situ (CIS), it may reduce tumor progression.

After treatment of the superficial tumor, periodic cystoscopy and urinary cytological examination is necessary for at least 5 years. New tumors may also be well controlled by transurethral means, but if they tend to recur they apt to become progressively invasive and of higher grade. Cystectomy must then be considered.

PROSTATE CARCINOMA

Prostate carcinoma is the most common malignance in the West countries, and the second death after lung cancer. Although the incidence of prostate carcinoma is low in China and eastern countries, remarkable increase has been found recently.

It occurs predominantly in old men It occurs predominantly in old men. It has the capacity to grow and invade locally and to metastasize by blood and lymph. There is a strong predilection for metastases to bone, and these metastases have the unique characteristic of being osteoblastic.

Prostate cancer has few dramatic primary signs or symptoms Prostate cancer has few dramatic primary signs or symptoms. It can be associated with urinary obstructive symptoms or hematuria, although these findings are usually due to other causes. Bone pain can unfortunately be an initial symptom, but it represents very advanced disease.

Diagnosis 1. digital rectal examination, 2 Diagnosis 1. digital rectal examination, 2. prostate specific antigen, 3. transrectal ultrasound exam, 4. biopsy, 5. bone scan, and so on.

Androgen blockade is the best method for the treatment of advanced prostate carcinoma. Radical prostatectomy and Radiation can be used for early stage patient.

TESTICULAR TUMORS

Testis tumors most commonly occur in men between 18 and 35 years of age. Tumors arising from the Leydig’s cell and Sertoli’s cells are rarely seen. Most of the testis tumors arise from the germinal epithelium, and all of these tumors should be considered malignant except for teratomas that occur before puberty.

The histologic types of germinal tumors of the testis are seminoma, and non-seminoma (embryonal carcinoma, teratoma, and choriocarcinoma). The diagnosis is usually suspected because of discomfort and enlargement of the testis. а-FP and β-HCG are the tumor markers, and the later is a poor prognosis marker.

Radical orchetectomy is the initial treatment Radical orchetectomy is the initial treatment. Seminoma is quite radiosensitive, and metastatic disease may be definitively treated with radiotherapy. Non-seminoma is usually managed by a combination of retroperitoneal lymph node dissection and multiple drupe chemotherapy.

CARCINOMA OF THE PENIS

Squamous cell carcinoma of the penis is encountered most often in older men who have not been circumcised. It has a tendency to invade the erectile tissue of the penile shaft and to metastasize to inguinal lymph nodes. Penectomy is usually required.

Questions of the lessons What paraneoplastic syndromes are associated with renal cell carcinoma? What are the indications for intravisical therapy for bladder carcinoma? What are the indications for radical cystotectomy? The diagnosis of prostate carcinoma.

Thank You