Urologic and Male Genital Cancer

 

Our Multimodal Urology Team

The management of urologic cancers (prostate cancer, bladder cancer, penile and urethral cancer, renal cell carcinoma, testicular cancer, and epinephrine cancer, etc) requires attention from a multimodal team for the surgery, radiation and chemo therapy as well as the post treatment long-term follow-up care.  On our team, we have urologic surgeons, radiologists, pathologists, nuclear medicine doctors, radio oncologists, and medical oncologists.  During the entire treatment course, there are also case managers, nursing staff, radiation technicians, and social workers who play important roles in securing the quality of life for our patients. 

 

Symptoms

The early stage of urologic cancers does not always cause systemic or specific symptoms.  Some common symptoms seen in urologic cancers are: blood in the urine, a swelling or lump in the area of the kidney, fevers and night sweats, fatigue,unexplained weight loss, muscle spasms in the bladder, a burning pain when passing urine (this could also be a symptom of a non-cancerous bladder infection, which is easily treated with antibiotics), difficulty and/or pain when passing urine, a need to pass urine more frequently particularly during the night, and abnormality in testicles or penis.   

A few patients may experience symptoms of distant metastasis such as back pain, and weakness or numbness of the limbs. 

 

Diagnosis

Urine analysis
Urine analysis is essential in the diagnosis of urologic diseases.  There are several ways to collect the urine specimen.  The most common one is midstream clean catch specimen or first morning specimen.  When a patient is bedridden or cannot urinate independently, we insert a Foley catheter into the bladder through the urethra to collect the urine specimen. Suprapubic aspiration specimen is used when a bedridden patient cannot be catheterized or a sterile specimen is required. The urine specimen is collected by needle aspiration through the abdominal wall into the bladder.  Urine cytology offers valuable clinical information for the diagnosis and tracking of epithelial urinary tumors. 

Ultrasound exam
In the event of any suspicious urinary tumors, the doctors will order ultrasound exam of the kidneys, urinary tract, bladder, urethra, testis, or the prostate glands.  The ultrasound can be used to detect the size and site of the tumor and renal abscess.  During a transrectal ultrasound of the prostate, an ultrasound guided prostate biopsy can be done, which is currently the most accurate method of prostate diagnosis. 

 

Intravenous urography (IVU)
A urography is an X-ray examination used to visualize the kidneys and the ureters with the injection of a contrast dye.  A radiologist can assess the function and detect abnormalities of the urinary system. This test is usually ordered when there is suspected kidney disease or urinary tract disorders such as renal calculi (kidney stones), urinary tumors, or urinary injury caused by colorectal or gynecological tumors.

 

CT and MRI
CT and MRI of the pelvis are helpful in the evaluation of the urologic diseases and especially for cancer staging.  These imaging tools can help to detect any masses or abnormalities in the kidneys, ureters, bladder, or urethra. The CT can show the extent of a cancer, determine if there is a blockage in the urinary tract, and determine if the cancer has spread outside the bladder. MR urography provides both functional and morphological imaging of the urinary system. 

 

Chest X-ray and whole body bone scan

Chest x-ray and whole body bone scan are used to detect any possible distant mets to the lungs or bones.

 

Cyctography/cyctoscopy

With local sedation, this endoscopy of the urinary bladder via the urethra is done with a cystoscope (a thin lighted tube) where contrast is inserted into the bladder and images are obtained. This test allows your doctor to look at the inside of the bladder and urethra. Tiny surgical instruments can be inserted through the cystoscope for the removal of samples of tissue or samples of urine.  Small bladder stones and some small growths can be removed during cystoscopy. This may eliminate the need for more extensive surgery.  This test is also very important as a post-surgery follow-up tool for patients with renal epithelial tumors.

 

Treatment

Treatment strategies and purposes

The primary treatment of urologic tumors is surgery with the purpose to remove the whole tumor and/or involved lymph nodes, or to reduce the number of tumors to achieve maximum result from adjuvant therapy.  

Prostate cancer

Prostate cancer is a male-specific cancer and also the most common cancer in men seen in our hospital.  In 2011 alone, four percent of new prostate cancer patients in Taiwan were treated in our center. 

1.       Radical prostectomy with bilateral pelvic lymph node dissection

2.       Laparoscopic radical prostectomy with bilateral pelvic lymph node dissection

Usually the surgery is reserved for patients with T1 or T2 (stage 1 or 2) disease and are also physically fit to be candidates for major surgery.   The cure rate is more than 90% with a small chance for urinary incontinence at 2%.  In selected younger patients, “nerve sparing” prostectomy is an option to preserve the sexual function.  Laparoscopic prostectomy is associated with less pain which can reduce the need for pain control and also shorten the recovery time.   In order to achieve more accurate staging, we use the ‘whole-mount section’ of the prostate and scrotum specimen for our pathological investigation as opposed to the conventional method of slice sampling.  For T3 patients, radiotherapy with adjuvant hormone therapy is the main choice of treatment.  

Between 1990 and 2011, there were 1,635 patients with new prostate cancer first diagnosed and treated in our center. The median follow-up time was 56 months（2-258）and the median age was 69 years (41-92)，which means more than half the patients were 69 years old or older at the time of diagnosis, with the majority having stage 3 or 4 disease（55.8%）.  Stage 1 patients only make up 2.1% of this population, indicating a great need for early detection。

 

Prostate Cancer Survival by AJCC Stage1990-2011

Stage	0	I	II	III	IV	Unclear	Total
# of patients	1	34	595	561	351	93	1,635
% of patients	0.1%	2.1%	36.4%	34.3%	21.5%	5.7%
5-year Survival	-	87.5%	91.5%	89.5%	61.0%		83.5%
10-year Survival	-	87.5%	81.1%	76.8%	34.8%		67.2%

Data source: KFSYSCC Annual Report 2011

 

Comparisons of survival by stage between KFSYSCC and all hospitals in Taiwan 2006-2010（%）

Survival	KFSYSCC		Island wide
	1990-2011	2006-2010	2006-2010
1-year	98.0	97.8	91.1
2-year	95.3	95.7	82.4
3-year	91.5	92.2	74.4
4-year	88.0	88.9	67.8
5-year	83.3	84.5	61.7

Data source: Health Promotion Administration, Ministry of Health and Welfare (2013)
                       KFSYSCC Annual Report 2011

 

Comparisons of 5-year survival between KFSYSCC and the US SEER 2004-2010（%）

	KFSYSCC	US SEER#
Survival Rate	84.0	98.9

# SEER Cancer Statistics Review 1975-2011, relative survival rates 
Relative survival is a net survival measure representing cancer survival in the absence of other causes of death, and, generally speaking, it is higher than the corresponding absolute survival by 1-3%.  The difference is greater in older patient populations.  
Data source: KFSYSCC Annual Report 2011

 

Bladder cancer

1.      Transurethral resection

2.      Selective bladder conservation using partial cystectomy followed by chemotherapy

3.      Radical cystectomy with ileal conduit (also called urostomy), which is an isolated bowel loop that the urinary stream is diverted into

For stage 0 or 1 patients, the transurethral resection combined with local chemotherapeutic instillation can help preserve the bladder function.  For invasive bladder cancer, partial or radical cystectomy will be considered. If the entire bladder is removed, one of the following procedures will be needed to redirect the urine:

• Urostomy (ileal conduit): where patient wears a urostomy bag outside the body
• Continent urinary diversion: a more complicated procedure but patient won’t have to wear a bag for urine collection
• Bladder reconstruction (Studer Pouch): for selected patients only
• Recto sigmoid pouch (Mainz 2): the urine is passed out with the stool from the back passage

In our hospital, we offer the options of Mainz and Studer’s ileal neobladder so patients do not have to suffer inconvenience from altered life style. 

 

Upper urinary tract transitional cell carcinoma

Laparoscopic nephroureterectomy with bladder cuff excision has been the gold standard treatment for the removal of the ipsilateral kidney, ureter and bladder cuff.  The laparoscopic approach reduces the size of the surgical wound and shortens the recovery time which noticeably reduces the pain caused by the surgery. 

 

Renal cancer

1.     laparoscopic partial nephrectomy 

2.    laparoscopic simple nephrectomy 

Surgery is the preferred treatment for resectable renal cancer.  Radical nephrectomy is useful for localized cancer and for palliation of intractable bleeding and pain.   For some selected patients with small localized cancer or compromised renal function, partial nephrectomy would be an option that could avoid renal failure, reduce the need for hemodialysis, and improve the quality of life. 

 

Life after Urologic and Male Genital Cancer

Depending on what type of surgery the patient received, different segments of the patient’s life will be affected on different levels.   The patient’s job, relationships, sexual life, sports and social life represent the major areas of concerns.  Coping with life after cancer requires more than just patient education or group support, education and support for the family is just as important.  We have well trained staff and social workers who have the resources to accompany the patients and their family on their journey to starting a new life after the treatment.