This document discusses the clinical features, prognostic factors, investigations and guidelines for diagnosis of renal cell carcinoma (RCC). It covers the typical presentations of RCC including incidental discovery, localized symptoms like flank pain, and symptoms of advanced disease. Investigations discussed include blood tests, CT, MRI, renal angiography and PET. Guidelines from AUA, EAU, NCCN and ESMO are summarized, emphasizing use of CT for diagnosis and staging, and recommending biopsy for small lesions before treatment.
This document discusses the management of small renal masses (SRMs). It provides an overview of diagnosis and treatment options for SRMs, including:
- SRMs are detected more frequently with improved imaging and account for about 20-25% of renal masses.
- Biopsy and advanced imaging can help differentiate between benign and malignant SRMs and determine tumor aggressiveness.
- Treatment options include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Partial nephrectomy aims to preserve renal function while providing cancer control comparable to radical nephrectomy.
- Factors such as tumor size, location, and patient comorbidities help determine the optimal surgical approach and extent of surgery
Non-muscle-invasive bladder cancer is typically treated with transurethral resection of bladder tumors (TURBT) to diagnose, stage, and remove visible tumors, followed by intravesical chemotherapy or immunotherapy to prevent recurrence depending on risk level. Bacillus Calmette-Guerin (BCG) immunotherapy is recommended for high-risk non-muscle-invasive bladder cancer to elicit an immune response against tumor cells. Patients undergo cystoscopy surveillance following treatment to monitor for recurrence.
This document discusses various minimally invasive and endoscopic procedures for treating benign prostatic hyperplasia (BPH), including bipolar transurethral resection of the prostate (B-TURP), transurethral vaporization of the prostate (TUVP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral incision of the prostate (TUIP), and various laser treatments such as photoselective vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP). Many of the procedures provide improvements in urinary symptoms comparable to traditional TURP but with benefits such as less
This document discusses pelvic fracture urethral distraction defects (PFUDD). It provides classifications for pelvic fractures and urethral injuries. For urethral injuries, it describes the Colapinto-McCallum and Goldman classifications based on radiological findings. Clinical features, diagnostic evaluations including retrograde urethrography, and management approaches for immediate vs delayed treatment are covered. Goals of treatment include re-establishing urethral continuity while reducing risks of stenosis, incontinence and impotence.
This document provides information about extracorporeal shockwave lithotripsy (ESWL). It discusses the physics behind shockwaves, different lithotripter generators (electrohydraulic, electromagnetic, piezoelectric), focusing systems, imaging for stone localization, and mechanisms of stone fragmentation. It also covers indications and contraindications for ESWL, factors influencing success rates like stone size and composition, and preoperative considerations like antibiotic prophylaxis and stenting. The goal of ESWL is to pulverize kidney stones into small enough fragments that can pass spontaneously without invasive procedures.
This document provides information about Peyronie's disease, including its epidemiology, etiology, symptoms, evaluation, and treatment protocols. It defines Peyronie's disease as a wound-healing disorder of the penis that results in scar formation. Evaluation involves assessing the location and size of plaques, penile deformity, and erectile function. Treatment options include nonsurgical approaches like intralesional injections and surgical options like plaque incision or grafting to correct the curvature.
This document discusses the management of small renal masses (SRMs). It provides an overview of diagnosis and treatment options for SRMs, including:
- SRMs are detected more frequently with improved imaging and account for about 20-25% of renal masses.
- Biopsy and advanced imaging can help differentiate between benign and malignant SRMs and determine tumor aggressiveness.
- Treatment options include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Partial nephrectomy aims to preserve renal function while providing cancer control comparable to radical nephrectomy.
- Factors such as tumor size, location, and patient comorbidities help determine the optimal surgical approach and extent of surgery
Non-muscle-invasive bladder cancer is typically treated with transurethral resection of bladder tumors (TURBT) to diagnose, stage, and remove visible tumors, followed by intravesical chemotherapy or immunotherapy to prevent recurrence depending on risk level. Bacillus Calmette-Guerin (BCG) immunotherapy is recommended for high-risk non-muscle-invasive bladder cancer to elicit an immune response against tumor cells. Patients undergo cystoscopy surveillance following treatment to monitor for recurrence.
This document discusses various minimally invasive and endoscopic procedures for treating benign prostatic hyperplasia (BPH), including bipolar transurethral resection of the prostate (B-TURP), transurethral vaporization of the prostate (TUVP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral incision of the prostate (TUIP), and various laser treatments such as photoselective vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP). Many of the procedures provide improvements in urinary symptoms comparable to traditional TURP but with benefits such as less
This document discusses pelvic fracture urethral distraction defects (PFUDD). It provides classifications for pelvic fractures and urethral injuries. For urethral injuries, it describes the Colapinto-McCallum and Goldman classifications based on radiological findings. Clinical features, diagnostic evaluations including retrograde urethrography, and management approaches for immediate vs delayed treatment are covered. Goals of treatment include re-establishing urethral continuity while reducing risks of stenosis, incontinence and impotence.
This document provides information about extracorporeal shockwave lithotripsy (ESWL). It discusses the physics behind shockwaves, different lithotripter generators (electrohydraulic, electromagnetic, piezoelectric), focusing systems, imaging for stone localization, and mechanisms of stone fragmentation. It also covers indications and contraindications for ESWL, factors influencing success rates like stone size and composition, and preoperative considerations like antibiotic prophylaxis and stenting. The goal of ESWL is to pulverize kidney stones into small enough fragments that can pass spontaneously without invasive procedures.
This document provides information about Peyronie's disease, including its epidemiology, etiology, symptoms, evaluation, and treatment protocols. It defines Peyronie's disease as a wound-healing disorder of the penis that results in scar formation. Evaluation involves assessing the location and size of plaques, penile deformity, and erectile function. Treatment options include nonsurgical approaches like intralesional injections and surgical options like plaque incision or grafting to correct the curvature.
Minimally invasive and endoscopic management of benign prostaticDr. Manjul Maurya
The document discusses various minimally invasive procedures for treating benign prostatic hyperplasia (BPH), including transurethral resection of the prostate (TURP), bipolar TURP, and prostatic urethral lift. TURP uses an electrified loop to remove prostatic tissue, while bipolar TURP incorporates both the active and return portions on the same electrode to avoid risks of traditional TURP like TUR syndrome. Prostatic urethral lift mechanically opens the urethra using permanent implants rather than ablating tissue. The document provides details on techniques, risks, and benefits of these various procedures for treating BPH.
This document provides an overview of the history and current practices of prostate biopsy. It discusses the evolution from open transperineal biopsy to current standard of care transrectal ultrasound (TRUS)-guided biopsy. Recent studies have shown multiparametric MRI can improve detection of clinically significant cancer and potentially reduce unnecessary biopsies. The document reviews patient preparation, biopsy techniques including systematic and targeted biopsy approaches, complications, and post-biopsy management. It provides guidance on appropriate patient selection and when to consider additional investigation or repeat biopsy.
This document discusses several tumor nephrometry scoring systems used to assess renal cell carcinoma complexity and predict surgical outcomes of partial nephrectomy. It describes the RENAL, PADUA, Centrality Index (C-Index), and DAP scoring systems, including their components, development, validation studies, limitations, and comparisons. The goal of these systems is to standardize reporting on tumor characteristics, surgical complexity, and allow for better patient counseling and comparisons between studies. Later systems like DAP aimed to improve on earlier ones by integrating and optimizing their individual strengths.
This document discusses imaging modalities used in prostate cancer, including transrectal ultrasound (TRUS), multiparametric MRI, CT, and others. TRUS is commonly used to assess prostate size and guide biopsies, but has limitations. Multiparametric MRI, which combines T2-weighted imaging with diffusion-weighted imaging and dynamic contrast enhancement, provides the best imaging for detecting and staging prostate cancer, with a sensitivity of 81% and specificity of 91%. The document recommends a multiparametric MRI protocol using a pelvic phased array coil and optionally an endorectal coil on a 1.5T or 3T magnet for prostate imaging.
This document discusses the management of ureteral strictures. It provides details on various endourologic and surgical options for treating ureteral strictures, including balloon dilation, ureteroscopic endoureterotomy, ureteral stenting, ureteroureterostomy, and ureteroneocystostomy. The success rates and approaches for different procedures are described. Postoperative care is also outlined.
The document provides information about urodynamics testing performed at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the professors and assistant professors who moderate the tests. It then describes the purpose and components of urodynamics testing, which involves a series of tests to evaluate urine storage and evacuation. The key components reviewed include uroflowmetry, measurement of post-void residual urine, cystometrogram, pressure flow studies, and videourodynamics. The document provides details on performing each test and interpreting the results.
Metabolic evaluation and medical management of urolithiasis aims to prevent recurrent stone formation and complications. It should be simple, economically viable, and provide targeted treatment. Patients at high risk for recurrence include those with family history, intestinal diseases, or anatomical abnormalities. Evaluation includes history, blood tests, urine tests, imaging and stone analysis to identify metabolic derangements. Treatment is tailored based on stone composition and includes increased fluid intake, dietary modifications, and medications to correct underlying causes and reduce stone risk factors.
This document discusses multiparametric MRI and its use in guiding prostate biopsies. It provides information on anatomic, diffusion-weighted, and dynamic contrast-enhanced MRI and how they help visualize prostate tumors with high sensitivity and specificity. It then describes different approaches to targeted prostate biopsies using MRI information, including cognitive fusion, software-based fusion, and in-bore fusion biopsies. It discusses limitations and advantages of each method and concludes that while targeted biopsies improve cancer detection, mapping biopsies supplemented with targeted biopsies remain the standard for identifying clinically significant tumors.
This document discusses diuresis renography, a technique used to differentiate patients with equivocal obstruction of the upper urinary tract. It involves injecting a patient with a radiopharmaceutical and obtaining images as a diuretic is administered. The resulting renogram curves are analyzed to identify four potential curve patterns: normal washout indicating no obstruction; continued rise indicating obstruction; initial rise falling with diuresis indicating hypotonicity rather than obstruction; and delayed decompensation indicating subtotal obstruction. Using different timing protocols for diuretic administration, such as F-15 where it is given 15 minutes before imaging, can reduce equivocal results from 15-17% to 3%.
This document discusses the management of kidney stones during pregnancy. It notes that kidney stones are the most common cause of abdominal pain requiring hospitalization during pregnancy. While conservative management is usually first-line, surgical intervention may be needed in cases of obstruction of a solitary kidney, sepsis, or refractory pain. For imaging, ultrasound is typically first choice, while MRI or low-dose CT can help if needed. Risks of radiation to the fetus are also discussed for different imaging modalities. The document provides guidelines on analgesic use, antibiotics, ureteroscopy, and other surgical procedures for treating stones during pregnancy.
This document discusses ureteral stents used in urology. It provides a brief history of stent development and outlines ideal stent properties. Common stent materials like silicone, polyethylene and polyurethane are described. The document also discusses various stent designs, coatings, and indications for stent placement including for conditions like ureteral obstruction, urinary stone treatment, and transplantation. Complications are minimized by using the shortest possible indwelling time.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
This document discusses the surgical management of upper urinary tract urothelial cell carcinomas. It covers radical nephroureterectomy as the gold standard treatment and explores laparoscopic versus open approaches. For localized low-grade tumors, conservative kidney-sparing options are discussed, including endoscopic tumor ablation using ureteroscopy or percutaneous access. Follow-up includes potential adjuvant instillation of bacillus Calmette-Guérin or mitomycin C into the renal collecting system.
Prostate carcinoma- Castrate Resistant Prostate Cancer (crpc)GovtRoyapettahHospit
This document discusses castrate resistant prostate cancer (CRPC). It defines CRPC and outlines various treatment options including androgen receptor directed therapies like abiraterone and enzalutamide, cytotoxic chemotherapies like docetaxel and cabazitol, immunotherapies, and targeted therapies. It also discusses mechanisms of castration resistance like AR amplification and activation by alternative ligands.
The document discusses the etiopathogenesis of urolithiasis or kidney stone formation. It covers topics like epidemiology, risk factors related to gender, age, geography, occupation and diet. It then describes the pathophysiological processes involved - supersaturation of urine, crystal nucleation, growth and aggregation. It discusses theories around crystal fixation and Randall's plaques. Various inhibitors that prevent stone formation are also outlined. The role of the non-crystalline matrix component of stones is briefly mentioned.
This document discusses complications that can occur after augmentation cystoplasty, a surgery to enlarge the bladder using intestinal tissue. It describes various early and long-term complications that are specific to the bowel segment used (ileum, colon, stomach, or jejunum) as well as general complications like metabolic abnormalities, infections, leakage, and effects on bone and kidney function. The document provides details on indications for surgery, surgical techniques, and treatments for various complications.
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)Urovideo.org
Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
This document discusses various methods for diagnosing and staging bladder cancer, including urinary biomarkers. It covers several imaging and endoscopic techniques such as cystoscopy, fluorescence cystoscopy, narrow-band imaging, and optical coherence tomography that can aid in visualizing bladder tumors. Urinary biomarkers like NMP22, BTA stat, immunocyt/uCyt+, and uroVysion are discussed as noninvasive alternatives to cystoscopy that have higher sensitivity but lower specificity than urine cytology. The document suggests that while newer techniques have improved tumor detection rates, urine cytology remains the gold standard due to its specificity, and no single test has replaced it in bladder cancer management.
This document discusses the management of metastatic renal cancer. It notes that approximately 1/3 of newly diagnosed renal cancers are metastatic and 20-40% of localized cancers eventually metastasize. Metastatic renal cancer is usually fatal with 5-year survival rates under 5%. The document outlines treatment approaches including local therapies like cytoreductive nephrectomy and metastasectomy as well as systemic therapies like immunotherapy, targeted therapy and chemotherapy. It provides details on specific immunotherapy agents, targeted therapies including several tyrosine kinase inhibitors, and recommendations on treatment sequencing.
This document provides guidelines for the evaluation and management of hematuria from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the classification, timing, differential diagnosis, and evaluation of hematuria. The evaluation includes history, physical exam, urinalysis, urine culture if indicated, renal function testing, cystoscopy, and imaging such as CT urogram. The goal of evaluation is to identify any underlying causes of hematuria such as infection or malignancy. Close follow up is recommended depending on the diagnosis and persistence of microscopic hematuria.
This document discusses imaging modalities used in diagnosing and staging testicular cancer, including ultrasonography, CT, MRI, and PET/CT. Ultrasonography of the scrotum is the initial imaging method used to evaluate suspected testicular masses and can differentiate intratesticular from extratesticular lesions. CT of the abdomen and pelvis is the reference standard for staging retroperitoneal lymphadenopathy and assessing abdominal organs. MRI of the scrotum provides additional information about tissue characteristics. Together, various imaging techniques help diagnose testicular lesions, determine if they are benign or malignant, and stage the extent of disease.
Minimally invasive and endoscopic management of benign prostaticDr. Manjul Maurya
The document discusses various minimally invasive procedures for treating benign prostatic hyperplasia (BPH), including transurethral resection of the prostate (TURP), bipolar TURP, and prostatic urethral lift. TURP uses an electrified loop to remove prostatic tissue, while bipolar TURP incorporates both the active and return portions on the same electrode to avoid risks of traditional TURP like TUR syndrome. Prostatic urethral lift mechanically opens the urethra using permanent implants rather than ablating tissue. The document provides details on techniques, risks, and benefits of these various procedures for treating BPH.
This document provides an overview of the history and current practices of prostate biopsy. It discusses the evolution from open transperineal biopsy to current standard of care transrectal ultrasound (TRUS)-guided biopsy. Recent studies have shown multiparametric MRI can improve detection of clinically significant cancer and potentially reduce unnecessary biopsies. The document reviews patient preparation, biopsy techniques including systematic and targeted biopsy approaches, complications, and post-biopsy management. It provides guidance on appropriate patient selection and when to consider additional investigation or repeat biopsy.
This document discusses several tumor nephrometry scoring systems used to assess renal cell carcinoma complexity and predict surgical outcomes of partial nephrectomy. It describes the RENAL, PADUA, Centrality Index (C-Index), and DAP scoring systems, including their components, development, validation studies, limitations, and comparisons. The goal of these systems is to standardize reporting on tumor characteristics, surgical complexity, and allow for better patient counseling and comparisons between studies. Later systems like DAP aimed to improve on earlier ones by integrating and optimizing their individual strengths.
This document discusses imaging modalities used in prostate cancer, including transrectal ultrasound (TRUS), multiparametric MRI, CT, and others. TRUS is commonly used to assess prostate size and guide biopsies, but has limitations. Multiparametric MRI, which combines T2-weighted imaging with diffusion-weighted imaging and dynamic contrast enhancement, provides the best imaging for detecting and staging prostate cancer, with a sensitivity of 81% and specificity of 91%. The document recommends a multiparametric MRI protocol using a pelvic phased array coil and optionally an endorectal coil on a 1.5T or 3T magnet for prostate imaging.
This document discusses the management of ureteral strictures. It provides details on various endourologic and surgical options for treating ureteral strictures, including balloon dilation, ureteroscopic endoureterotomy, ureteral stenting, ureteroureterostomy, and ureteroneocystostomy. The success rates and approaches for different procedures are described. Postoperative care is also outlined.
The document provides information about urodynamics testing performed at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the professors and assistant professors who moderate the tests. It then describes the purpose and components of urodynamics testing, which involves a series of tests to evaluate urine storage and evacuation. The key components reviewed include uroflowmetry, measurement of post-void residual urine, cystometrogram, pressure flow studies, and videourodynamics. The document provides details on performing each test and interpreting the results.
Metabolic evaluation and medical management of urolithiasis aims to prevent recurrent stone formation and complications. It should be simple, economically viable, and provide targeted treatment. Patients at high risk for recurrence include those with family history, intestinal diseases, or anatomical abnormalities. Evaluation includes history, blood tests, urine tests, imaging and stone analysis to identify metabolic derangements. Treatment is tailored based on stone composition and includes increased fluid intake, dietary modifications, and medications to correct underlying causes and reduce stone risk factors.
This document discusses multiparametric MRI and its use in guiding prostate biopsies. It provides information on anatomic, diffusion-weighted, and dynamic contrast-enhanced MRI and how they help visualize prostate tumors with high sensitivity and specificity. It then describes different approaches to targeted prostate biopsies using MRI information, including cognitive fusion, software-based fusion, and in-bore fusion biopsies. It discusses limitations and advantages of each method and concludes that while targeted biopsies improve cancer detection, mapping biopsies supplemented with targeted biopsies remain the standard for identifying clinically significant tumors.
This document discusses diuresis renography, a technique used to differentiate patients with equivocal obstruction of the upper urinary tract. It involves injecting a patient with a radiopharmaceutical and obtaining images as a diuretic is administered. The resulting renogram curves are analyzed to identify four potential curve patterns: normal washout indicating no obstruction; continued rise indicating obstruction; initial rise falling with diuresis indicating hypotonicity rather than obstruction; and delayed decompensation indicating subtotal obstruction. Using different timing protocols for diuretic administration, such as F-15 where it is given 15 minutes before imaging, can reduce equivocal results from 15-17% to 3%.
This document discusses the management of kidney stones during pregnancy. It notes that kidney stones are the most common cause of abdominal pain requiring hospitalization during pregnancy. While conservative management is usually first-line, surgical intervention may be needed in cases of obstruction of a solitary kidney, sepsis, or refractory pain. For imaging, ultrasound is typically first choice, while MRI or low-dose CT can help if needed. Risks of radiation to the fetus are also discussed for different imaging modalities. The document provides guidelines on analgesic use, antibiotics, ureteroscopy, and other surgical procedures for treating stones during pregnancy.
This document discusses ureteral stents used in urology. It provides a brief history of stent development and outlines ideal stent properties. Common stent materials like silicone, polyethylene and polyurethane are described. The document also discusses various stent designs, coatings, and indications for stent placement including for conditions like ureteral obstruction, urinary stone treatment, and transplantation. Complications are minimized by using the shortest possible indwelling time.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
This document discusses the surgical management of upper urinary tract urothelial cell carcinomas. It covers radical nephroureterectomy as the gold standard treatment and explores laparoscopic versus open approaches. For localized low-grade tumors, conservative kidney-sparing options are discussed, including endoscopic tumor ablation using ureteroscopy or percutaneous access. Follow-up includes potential adjuvant instillation of bacillus Calmette-Guérin or mitomycin C into the renal collecting system.
Prostate carcinoma- Castrate Resistant Prostate Cancer (crpc)GovtRoyapettahHospit
This document discusses castrate resistant prostate cancer (CRPC). It defines CRPC and outlines various treatment options including androgen receptor directed therapies like abiraterone and enzalutamide, cytotoxic chemotherapies like docetaxel and cabazitol, immunotherapies, and targeted therapies. It also discusses mechanisms of castration resistance like AR amplification and activation by alternative ligands.
The document discusses the etiopathogenesis of urolithiasis or kidney stone formation. It covers topics like epidemiology, risk factors related to gender, age, geography, occupation and diet. It then describes the pathophysiological processes involved - supersaturation of urine, crystal nucleation, growth and aggregation. It discusses theories around crystal fixation and Randall's plaques. Various inhibitors that prevent stone formation are also outlined. The role of the non-crystalline matrix component of stones is briefly mentioned.
This document discusses complications that can occur after augmentation cystoplasty, a surgery to enlarge the bladder using intestinal tissue. It describes various early and long-term complications that are specific to the bowel segment used (ileum, colon, stomach, or jejunum) as well as general complications like metabolic abnormalities, infections, leakage, and effects on bone and kidney function. The document provides details on indications for surgery, surgical techniques, and treatments for various complications.
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)Urovideo.org
Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
This document discusses various methods for diagnosing and staging bladder cancer, including urinary biomarkers. It covers several imaging and endoscopic techniques such as cystoscopy, fluorescence cystoscopy, narrow-band imaging, and optical coherence tomography that can aid in visualizing bladder tumors. Urinary biomarkers like NMP22, BTA stat, immunocyt/uCyt+, and uroVysion are discussed as noninvasive alternatives to cystoscopy that have higher sensitivity but lower specificity than urine cytology. The document suggests that while newer techniques have improved tumor detection rates, urine cytology remains the gold standard due to its specificity, and no single test has replaced it in bladder cancer management.
This document discusses the management of metastatic renal cancer. It notes that approximately 1/3 of newly diagnosed renal cancers are metastatic and 20-40% of localized cancers eventually metastasize. Metastatic renal cancer is usually fatal with 5-year survival rates under 5%. The document outlines treatment approaches including local therapies like cytoreductive nephrectomy and metastasectomy as well as systemic therapies like immunotherapy, targeted therapy and chemotherapy. It provides details on specific immunotherapy agents, targeted therapies including several tyrosine kinase inhibitors, and recommendations on treatment sequencing.
This document provides guidelines for the evaluation and management of hematuria from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the classification, timing, differential diagnosis, and evaluation of hematuria. The evaluation includes history, physical exam, urinalysis, urine culture if indicated, renal function testing, cystoscopy, and imaging such as CT urogram. The goal of evaluation is to identify any underlying causes of hematuria such as infection or malignancy. Close follow up is recommended depending on the diagnosis and persistence of microscopic hematuria.
This document discusses imaging modalities used in diagnosing and staging testicular cancer, including ultrasonography, CT, MRI, and PET/CT. Ultrasonography of the scrotum is the initial imaging method used to evaluate suspected testicular masses and can differentiate intratesticular from extratesticular lesions. CT of the abdomen and pelvis is the reference standard for staging retroperitoneal lymphadenopathy and assessing abdominal organs. MRI of the scrotum provides additional information about tissue characteristics. Together, various imaging techniques help diagnose testicular lesions, determine if they are benign or malignant, and stage the extent of disease.
This document discusses retroperitoneal lymph node dissection (RPLND) and its complications. It provides a history of RPLND, describes the lymphatic drainage patterns of the testis and rationale for RPLND. It outlines the evolution of surgical templates for RPLND including modifications to reduce complications like loss of antegrade ejaculation. The document discusses indications for primary, post-chemotherapy and salvage RPLND. It provides details of surgical techniques including approaches, lymphadenectomy procedures and nerve-sparing techniques.
This document discusses tumor markers and staging of testicular cancer. It provides information on common tumor markers such as AFP, HCG, and LDH, which are elevated in many testicular cancers and help with diagnosis and monitoring. It also describes the TNM staging system for testicular cancer, including classification of the primary tumor, lymph node involvement, and distant metastasis. Clinical and pathologic staging is explained. In summary, the document is an overview of tumor markers and staging approaches used in the management of testicular cancer.
This document discusses the diagnosis and staging of prostate cancer. It begins by covering risk factors for prostate cancer like increasing age and ethnicity. It then discusses methods for diagnosing prostate cancer which include a digital rectal exam, PSA testing, prostate biopsy, and various imaging tests. Imaging tests covered include transrectal ultrasound, MRI, CT, bone scan, and PET which can help determine if the cancer has spread. Factors that increase the need for bone scans are outlined. The document provides details on how each diagnostic and imaging test is performed and what they can indicate regarding prostate cancer detection and staging.
This document provides information on carcinoma of the penis, including risk factors, clinical presentation, investigations, staging, and treatment approaches. It discusses the anatomy and lymphatic drainage of the penis. The main types of carcinoma of the penis are described, as is the TNM staging system. Treatment options for primary tumors include local excision, laser therapy, Mohs micrographic surgery, partial or total penectomy. Management of inguinal lymph nodes is stratified based on risk, and may include surveillance, fine needle aspiration, sentinel lymph node biopsy, or modified inguinal dissection procedures.
This document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It lists the professors and assistant professors in the department and provides information on various benign renal lesions, including cysts, angiomyolipomas, oncocytomas, renal adenomas, and metanephric adenomas. For each lesion, it discusses epidemiology, clinical presentation, imaging appearance, histopathology, genetics, and management. The focus is on accurately differentiating these benign lesions from renal cell carcinomas.
This document discusses bladder outlet obstruction (BOO) and its causes such as benign prostatic hyperplasia (BPH). It describes the primary and long term effects of BOO on the bladder, including decreased urinary flow rates and increased voiding pressures. For BPH, it notes the causes include hyperplasia of the prostate gland that typically begins in the third decade. The document outlines the diagnosis, evaluation and treatment of BOO, including medical management with medications like alpha blockers and 5-alpha reductase inhibitors, as well as surgical treatments like transurethral resection of the prostate (TURP).
This document provides information about a KUB (kidney, ureter, bladder) x-ray performed at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the professors and assistant professors in the department and provides details on the history, physics, techniques, anatomical landmarks, disorders, and interpretations of renal calculi, ureter, bladder, and other findings that can be seen on a KUB x-ray.
This document provides information on the management of non-muscle invasive bladder cancer at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the moderators and professors in the department and provides details on the diagnosis, staging, treatment options including transurethral resection of bladder tumor, adjuvant therapies, and follow-up for non-muscle invasive bladder cancer. It discusses the use of techniques like laser therapy, intravesical chemotherapy and immunotherapy, with a focus on bacillus Calmette-Guérin as options to prevent recurrence of superficial bladder cancer after resection.
This document discusses emphysematous pyelonephritis (EPN), a rare necrotizing infection of the renal parenchyma that causes gas formation. It provides details on the typical presentation, risk factors, diagnosis and classification of EPN. The document is authored by professors and assistant professors from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India. It covers epidemiology, pathogenesis, clinical features, investigations including CT findings, classification systems for EPN, treatment approaches including antibiotics and percutaneous drainage, and outcomes.
The document discusses emphysematous pyelonephritis (EPN), a severe necrotizing infection of the renal parenchyma that causes gas accumulation. EPN most often occurs in persons with uncontrolled diabetes, especially women. It requires prompt diagnosis using CT scan and treatment with IV antibiotics and percutaneous drainage to drain abscesses. Factors like altered mental status, thrombocytopenia and elevated creatinine indicate higher risk cases that may require emergency nephrectomy. With aggressive treatment, reported mortality has improved but remains at 20-25%.
This document discusses the evaluation of hematuria from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It defines hematuria and describes its classification. Potential causes of hematuria are outlined, including urinary tract infections, kidney stones, trauma, exercise, and tumors. The evaluation of hematuria involves examination of the urine, including a dipstick test and microscopic analysis to characterize the red blood cells. Further tests may include imaging like ultrasound, CT, cystoscopy and renal biopsy to identify the source and cause of the bleeding. The document distinguishes between glomerular and non-glomerular causes based on urine characteristics.
INVESTIGATIONS OF A PATIENT WITH OBSTRUCTIVE JAUNDICE -LETS GODr.Manojit Sarkar
Routine tests like liver function tests, urine analysis, and hematological investigations are used to determine if a patient's symptoms suggest obstructive jaundice. Imaging tests like ultrasound, MRCP, ERCP, and CT scan help locate the cause by visualizing the biliary tree and detecting any dilations, masses, or other abnormalities. ERCP can both diagnose the specific cause by visualizing structures and performing biopsies and also treat certain conditions like gallstones through procedures such as sphincterotomy and stent placement. The combination of biochemical and imaging tests aims to determine if the jaundice has an obstructive etiology, identify suspected causes like cancer or gallstones, and assess if the patient is a surgical candidate.
This document discusses stricture urethra and its management. It provides details on the epidemiology, etiology, clinical evaluation and surgical options for urethral strictures. Key points include that bulbar strictures are the most common, iatrogenic causes have increased in prevalence, clinical evaluation involves uroflowmetry, retrograde urethrogram and cystoscopy, and surgical options range from dilation and direct visual internal urethrotomy for short strictures to various types of urethroplasty using grafts or flaps for longer or complex strictures.
This document discusses the classification and pathogenesis of renal cystic diseases, with a focus on autosomal dominant polycystic kidney disease (ADPKD). It provides definitions and classifications of renal cystic diseases. It describes the genetic basis and inheritance pattern of ADPKD, caused by mutations in PKD1 and PKD2 genes. Clinical features include flank pain, hematuria, hypertension, and renal failure typically developing in the 4th-6th decades. Treatment focuses on controlling hypertension and complications to delay renal failure for which there is no cure.
This document describes the renogram procedure. It provides details on:
- The radiopharmaceuticals used, including 99mTc-DTPA, 99mTc-MAG3, and 99mTc-DMSA
- How the procedure is performed, including patient preparation, image acquisition, and time-activity curve analysis
- The roles of the radiopharmaceuticals in evaluating renal blood flow, glomerular filtration rate, and renal handling and excretion
- Factors that can affect the procedure such as hydration, medications, and kidney positioning
This document discusses various cystic diseases of the kidney. It begins with an introduction to renal cysts and their classification as genetic or non-genetic. It then focuses on Autosomal Recessive Polycystic Kidney Disease (ARPKD), the most severe form which presents in infancy. ARPKD is caused by mutations in the PKHD1 gene and is characterized by enlarged, echogenic kidneys with hepatic fibrosis. Clinical features range from respiratory distress in newborns to hypertension in older children. The document also briefly discusses other genetic cystic kidney diseases including Autosomal Dominant Polycystic Kidney Disease and Juvenile Nephronophthisis. Evaluation and treatment options for ARPK
This document discusses 4 case scenarios of renal cell carcinoma (RCC). Case 1 involves an incidental small renal mass found on imaging. Case 2 describes a patient with locally advanced RCC presenting with hematuria. Case 3 involves a patient with metastatic RCC and pathological fracture. Case 4 is about an elderly patient with metastatic RCC presenting with systemic symptoms. For each case, the document discusses relevant imaging findings, biopsy results, staging, prognosis and management options. It also reviews topics like RCC subtypes, grading, risk stratification, nephrometry scores, nephrectomy approaches and adjuvant therapies.
Prostate diseases are common among aging men. Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate that leads to urinary symptoms. BPH prevalence increases with age, affecting 20% of men aged 41-50 and over 80% of men aged 81-90. Treatment options for BPH include lifestyle changes, watchful waiting, medical therapy with alpha blockers or 5-alpha-reductase inhibitors, and surgical procedures like TURP. Prostate cancer is the second most common cancer in men. Screening includes a PSA test and digital rectal exam. Treatment depends on cancer risk and may include active surveillance, surgery, radiation, or hormone therapy.
Similar to CLINICAL FEATURES & PROGNOSTIC FACTORS OF RCC (20)
This document provides information about an X-ray KUB (kidneys, ureters, bladder) exam performed by the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India. It lists the moderators and their qualifications. It then discusses the history of X-rays, how they are produced, standard views, and how to systematically read an X-ray KUB. It describes how to assess technical quality and what to look for, including renal calcifications which are most commonly due to kidney stones. It also discusses mimics of urinary calcifications like gallstones.
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CLINICAL FEATURES & PROGNOSTIC FACTORS OF RCC
1. Renal cell carcinoma
CLINICAL FEATURES & PROGNOSTIC
FACTORS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1
2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
5. Localised
Disease
“TOO LATE TRIAD”
• Flank pain
• Abdominal mass
• Hematuria
Spontaneous Perirenal hematoma
• More than 50% of patients with perirenal
hematoma of unclear etiology have an
occult renal tumor
• Most common – AML or RCC
5
Dept of Urology, GRH and KMC, Chennai.
6. Advanced
disease
Constitutional
symptoms
• Weight loss
• Fever
• Malaise
Obstruction
of IVC
• Bilateral lower extremity edema
• Non reducing varicocele
Metastatic
disease
• Persistent cough
• Bone pain
• Cervical lymphadenopathy
6
Dept of Urology, GRH and KMC, Chennai.
7. PARANEOPLASTIC
SYNDROMES
10 – 20%
1,25-dihydroxycholecalciferol, renin, erythropoietin, and
various prostaglandins - pathologic amounts
Elaborate a variety of other physiologically important factors
• Parathyroid hormone–like peptides
• Lupus-type anticoagulant
• Human chorionic gonadotropin
• Insulin
• Various cytokines and inflammatory mediators
Responsible for the development of constitutional symptoms
such as weight loss, anemia, and paraneoplastic syndromes
7
Dept of Urology, GRH and KMC, Chennai.
9. HYPERCALCEMIA
Reported in upto 13%
Due to either paraneoplastic syndrome or
osteolytic metastasis
Most common paraneoplastic etiology –
parathyroid hormone like peptide
Others – Tumor derived 1,25
dihydroxycholecalciferol, Prostaglandins
C/F - Nonspecific and include nausea, anorexia,
fatigue, and decreased deep tendon reflexes
9
Dept of Urology, GRH and KMC, Chennai.
10. HYPERTENSION
Increased production of renin
Compression or encasement of renal artery or its
branches
Arteriovenous fistula within the tumor
Polycythemia
Hypercalcemia
Ureteral obstruction
Increased intracranial pressure with cerebral
metastasis
10
Dept of Urology, GRH and KMC, Chennai.
12. STAUFFER SYNDROME
Nonmetastatic hepatic dysfunction
3% to 20%
Findings
• Elevated serum alkaline phosphatase level – in almost all
• 67% - elevated prothrombin time or hypoalbuminemia
• 20% to 30% - elevated serum bilirubin or transaminase levels
• Other - thrombocytopenia and neutropenia, fever, weight loss - discrete regions
of hepatic necrosis.
12
Dept of Urology, GRH and KMC, Chennai.
13. STAUFFER
SYNDROME
Hepatic metastases must be excluded.
Biopsy - nonspecific hepatitis associated with a prominent
lymphocytic infiltrate.
Elevated serum levels of IL-6 and other cytokines may play a
pathogenic role.
Hepatic function normalizes after nephrectomy in 60% to
70% of cases.
Persistence or recurrence of hepatic dysfunction is almost
always indicative of the presence of viable tumor and thus
represents a poor prognostic finding
13
Dept of Urology, GRH and KMC, Chennai.
14. OTHER
PARANEOPLASTIC
SYNDROMES
• Cushing syndrome
• Hyperglycemia
• Galactorrhea
• Neuromyopathy
• Clotting disorders
• Cerebellar ataxia
In general, treatment of paraneoplastic
syndromes associated with RCC has required
surgical excision or systemic therapy and, except
for hypercalcemia, medical therapies have not
proved helpful
14
Dept of Urology, GRH and KMC, Chennai.
16. INITIAL
LABORATORY
INVESTIGATIONS
Urinalysis (UA) with urine cytology (if central lesion)
Urine cytology (if central lesion is present, to evaluate for
urothelial carcinoma)
Complete blood cell (CBC) count with differential
Electrolytes
Renal profile
Liver function tests (LFTs): Aspartate aminotransferase (AST)
and alanine aminotransferase (ALT)
Serum calcium
Other tests as indicated by the patient’s presenting symptoms.
16
Dept of Urology, GRH and KMC, Chennai.
19. CT KUB
A dedicated renal CT examination consists of thin-
section (2.5-5 mm) helical imaging of the kidneys
before the intravenous administration of contrast
agent, followed by imaging 60-70 seconds and 3-5
minutes after administration of the contrast agent.
The imaging parameters (kilovoltage,
microamperage, field of view, section thickness)
should be kept constant for all phases of imaging to
enable comparison of the attenuation
measurements.
The addition of an arterial phase CT (either with
bolus tracking or after a 20-25 second delay) with
thin slices (1-2 mm)
19
Dept of Urology, GRH and KMC, Chennai.
20. CT SCAN
•Non-contrast CT the lesions are
soft tissue attenuation between
20-70 HU
•Larger lesions - frequently have
areas of necrosis
•Approximately 30%
demonstrate some calcification
20
Dept of Urology, GRH and KMC, Chennai.
23. CECT KUB –
CORTICOMED
ULLARY PHASE
• 25-70 seconds after administration of
contrast
• Renal cell carcinomas - variable
enhancement, usually less than the
normal cortex.
• Small lesions may enhance a similar
amount and be difficult to detect
• Small lesions enhance homogeneously,
whereas larger lesions have irregular
enhancement due to areas of necrosis
• Clear cell subtype may show much
stronger enhancement
• Also best for assessing vascular anatomy
23
Dept of Urology, GRH and KMC, Chennai.
24. CECT KUB
• The nephrogenic phase (80-180
seconds) is the most sensitive
phase for detection of abnormal
contrast enhancement.
• Enhancement more than 15 HU –
RCC until proved otherwise
• Excretory phase - In assessing the
collecting system anatomy
especially if the candidate is a
potential candidate for a partial
nephrectomy.
24
Dept of Urology, GRH and KMC, Chennai.
28. MRI
• Infrequently used
• Indications :
• ALLERGY
• RENAL COMPROMISE
• PREGNANCY
• CONCERN FOR RADIATION
EXPOSURE
• EQUIVOCAL CT FINDINGS
28
Dept of Urology, GRH and KMC, Chennai.
29. MRI
• Excellent at imaging the kidneys and
locally staging tumours
• Suggest the likely histology, on the
grounds of T2 differences.
• T1: often heterogeneous due to necrosis,
haemorrhage and solid components
• T2: appearances depend on histology
• clear cell RCC: hyperintense
• papillary RCC: hypointense
• T1 C+ (Gd): often shows prompt arterial
enhancement
29
Dept of Urology, GRH and KMC, Chennai.
30. MRI
• Tumor pseudo capsule - hypointense rim
between the tumour and the adjacent
normal renal parenchyma
• For imaging renal vein and IVC tumour
thrombus – preoperative planning
• Enhancement in the thrombus
• Diffusion-weighted sequences -
indeterminate small renal lesions
• Inflammatory or malignant in nature
• Both exhibit restricted diffusion
• Restriction is greater with abscess than
tumour
30
Dept of Urology, GRH and KMC, Chennai.
35. Renal Angiography
• Limited role
• Establishment of
neovascularity in
equivocal cases – RCC
• Primarily reserved for
concomitant renal
artery disease
35
Dept of Urology, GRH and KMC, Chennai.
36. Positron Emission
Tomography
• Not routinely used
• Indications :
• High risk for RCC but with
equivocal findings on
conventional imaging
• Metastatic RCC
• Good specificity, but low
sensitivity
• Immunoscintigraphy with
radiolabelled monoclonal Ab to
CA-9 – investigational stage
36
Dept of Urology, GRH and KMC, Chennai.
37. Tissue
diagnosis
• Traditionally been of limited value
• Indications :
• Suspected renal abscess or
infected cyst
• Renal lymphoma
• Metastatic malignant RCC
Dept of Urology, GRH and KMC, Chennai.
38. RENAL MASS
BIOPSY –
TISSUE
DIAGNOSIS
Indications :
1. Metastatic RCC
2. Unresectable
primary tumors
3. Indeterminate
recurrences
4. Cancers metastatic
to kidney
5. Precious kidney
with doubtful
diagnosis
Complications:
➢Bleeding (5-
7%)
➢Infection
➢Arteriovenous
fistula
➢Needle track
seedling
(0.01%)
➢Pneumothorax
➢Usually, morbidity
rate is 5%
38
Dept of Urology, GRH and KMC, Chennai.
39. Immunohistochemistry
•Just in the evolution stage
•FNAB combined with CA-9 –
improved sensitivity
•Positive immuno reactivity for
HMB-45, a melanoma
associated antigen –
characteristic of AML
•To differentiate AML from
sarcoma of kidney
Dept of Urology, GRH and KMC, Chennai.
41. AUA
GUIDELINES
2017
• For the management of clinically localized
sporadic renal masses suspicious - high-
quality, multiphase, cross-sectional
abdominal imaging to optimally
characterize and clinically stage the renal
mass
• Characterization of the renal mass should
include assessment of the following:
• Tumor complexity
• Degree of contrast enhancement (where
applicable)
• Presence or absence of fat
41
Dept of Urology, GRH and KMC, Chennai.
42. AUA
GUIDELINES
2017
• Biopsy should be considered when a mass is
suspected to be hematologic, metastatic,
inflammatory, or infectious
• In the setting of a solid renal mass, biopsy is
not required for either of the following:
• Young or healthy patients who are unwilling
to accept the uncertainties associated with
biopsy
• Older or frail patients who will be managed
conservatively independent of biopsy
findings
• For patients with a solid renal mass who elect
biopsy, multiple core biopsies are preferred
over fine needle aspiration
42
Dept of Urology, GRH and KMC, Chennai.
43. EAU
GUIDELINES
2018
• Multi-phasic contrast-enhanced computed
tomography (CT) of abdomen and chest for
the diagnosis and staging of renal tumours.
• MRI to better evaluate venous involvement,
reduce radiation or avoid intravenous CT
contrast medium.
• Non-ionising modalities, mainly contrast
enhanced ultrasound (CEUS), for further
characterisation of small renal masses,
tumour thrombus and differentiation of
unclear renal masses.
• NO ROUTINE bone scan and/or positron-
emission tomography (PET) CT for staging of
RCC.
43
Dept of Urology, GRH and KMC, Chennai.
44. EAU
GUIDELINE
2018
• Renal tumour biopsy before ablative
therapy and systemic therapy without
previous pathology.
• Percutaneous biopsy in select patients
who are considered for active
surveillance;
• Coaxial CORE BIOPSY technique when
performing a renal tumour biopsy
• Do not perform a renal tumour biopsy
of cystic renal masses
44
Dept of Urology, GRH and KMC, Chennai.
45. NCCN
GUIDELINES
• History and physical examination
• Complete blood count, comprehensive
metabolic panel, and urinalysis
• Abdominal/pelvic CT or abdominal MRI,
with contrast when clinically indicated
• Chest x-ray
• Bone scan, brain MRI, chest CT, if clinically
indicated
• Recommends considering needle biopsy of
small lesions if clinically indicated
• Recommends considering urine cytology
and ureteroscopy if urothelial carcinoma is
suspected (eg, a central mass is present).
45
Dept of Urology, GRH and KMC, Chennai.
46. ESMO 2016
• Diagnosis is usually suggested by ultrasound
and further investigated by CT scan.
• Magnetic resonance imaging (MRI) may
provide additional information in investigating
local advancement and venous involvement by
tumour thrombus.
• Contrast-enhanced chest, abdominal, and
pelvic CT is mandatory for staging; In case of
an allergy to CT contrast medium, a high-
resolution CT scan of the chest without
contrast medium, together with an abdominal
MRI may be used.
• Unless clinically indicated, the use of bone
scan or CT (or MRI) of the brain is not
recommended for routine clinical practice
46
Dept of Urology, GRH and KMC, Chennai.
47. ESMO 2016
• Positron emission tomography is not a
standard investigation in the diagnosis
and staging of RCC
• A diagnostic biopsy is required before
treatment with ablative therapies; it is
also indicated in patients with metastatic
disease before initiating systemic
treatment.
• The final histopathologic diagnosis,
classification, grading, and evaluation of
prognostic factors should be based on
the nephrectomy specimen when
available
47
Dept of Urology, GRH and KMC, Chennai.
52. PATHOLOGICAL STAGE
• Single most important prognostic factor
• Extent of locoregional or systemic disease at
diagnosis is the primary determinant of outcome
for this disease
• Higher T stage, lymph node and distant metastasis
– worse prognosis; shorter survival
52
Dept of Urology, GRH and KMC, Chennai.
55. PERIRENAL / RENAL SINUS FAT INVASION
Renal sinus fat involvement
along with perinephric fat
invasion (T3a) - higher risk
for metastasis related to
increased access to the
venous system
Collecting system invasion -
poorer prognosis in
otherwise organ-confined
RCC
55
Dept of Urology, GRH and KMC, Chennai.
56. VENOUS
INVOLVEMENT
• Even microscopic venous or lymphatic
involvement - poor prognostic sign
• Involvement of IVC whether above or below
diaphragm – not prognostically different; better
prognosis when compared with perinephric fat
or nodal involvement
• Direct invasion of the wall of the vein appears
to be a more important prognostic factor than
level of tumor thrombus and is now classified as
pT3c independent of the level of tumor
thrombus
56
Dept of Urology, GRH and KMC, Chennai.
57. ADRENAL
INVOLVEMENT
• 1 – 2%
• Most patients with direct or metastatic
ipsilateral adrenal involvement eventually
succumb to systemic disease progression
• Involvement of ipsilateral adrenal gland –
outcomes equivalent to stage IV disease
• Suggesting - hematogenous route of
dissemination or a highly invasive phenotype
57
Dept of Urology, GRH and KMC, Chennai.
58. STAGE T4
• Poor prognosis with extension beyond the
Gerota fascia to involve contiguous organs
(stage T4) and in patients with lymph node or
systemic metastases
• Synchronous metastases
• Worse outcome
• Many patients dying of disease progression
within 1 to 2 years
• Asynchronous metastases
• Metastasis-free interval - prognosticator
• Reflects the tempo of disease
progression
58
Dept of Urology, GRH and KMC, Chennai.
59. PROGNOSTIC FACTORS IN METASTASES
• Performance status
• Number and sites of metastases
• Anemia, hypercalcemia, elevated alkaline phosphatase or lactate
dehydrogenase levels, thrombocytosis
• Sarcomatoid histology
• Presence of bone, brain, and/or liver metastases and multiple
metastatic sites
59
Dept of Urology, GRH and KMC, Chennai.
60. TUMOR SIZE
• Independent prognostic factor for both organ-confined and
invasive RCC
• Larger tumors are more likely to exhibit clear cell histology and
high nuclear grade
• Both of these factors correlate with a compromised prognosis
60
Dept of Urology, GRH and KMC, Chennai.
61. HISTOLOGICAL FEATURES
FUHRMAN NUCLEAR GRADE
HISTOLOGIC SUBTYPE
PRESENCE OF SARCOMATOID COMPONENT
MICROVASCULAR INVASION
TUMOR NECROSIS
COLLECTING SYSTEM INVASION
61
Dept of Urology, GRH and KMC, Chennai.
62. FUHRMAN’S NUCLEAR GRADE
More effective than other parameters in predicting distant metastasis following nephrectomy
NUCLEAR GRADE 5 YEAR SURVIVAL
1 64%
2 34%
3 31%
4 10%
Prognostic significance in clear cell and papillary RCC
Other histological subtypes – not entirely clear 62
Dept of Urology, GRH and KMC, Chennai.
63. HISTOLOGIC
SUBTYPE
• Clear cell – most aggressive
• Followed by – papillary and chromophobe
• RCC with sarcomatoid features
• Renal medullary or unclassified histology
• Papillary tumors
• Type I – low grade, multifocal, favourable
outcome
• Type II – high grade, increased metastatic
potential
63
Dept of Urology, GRH and KMC, Chennai.
65. MOLECULAR
FACTORS
Ki67
• Increased proliferative index
• Reduced survival in clear cell RCC
CARBONIC ANHYDRASE IX
• REGULATED BY VHL GENE
• Decreased expression associated with poor survival in metastatic RCC
• Marker for response to systemic therapy
B7-H1
• T cell coregulatory molecule
• Strong independent predictor of disease progression
Other Factors
• Cell cycle regulators like TP53
• Growth factors and their receptors – VEGF
• Adhesion molecules
• Survivin
• Down regulation of genes involved in TCA cycle and upregulation of
pentose phosphate pathway 65
Dept of Urology, GRH and KMC, Chennai.
67. SCORING
SYSTEMS
• Preoperative Aspects and Dimensions
Used for an Anatomical (PADUA)
classification system
• R.E.N.A.L. nephrometry score
• C-index
• Arterial Based Complexity (ABC)
Scoring System
• Zonal NePhRO scoring system
67
Dept of Urology, GRH and KMC, Chennai.
70. C INDEX
• Ratio of the distance (c) between the tumor center
and the kidney center, and the tumor radius (r)
• Measure tumor centrality
• C index of less than 1 has some portion of the
tumor superimposed on the kidney center
• C index of 1 equates to a tumor with its edge lying
on the center
• As the centrality index increases, the tumor
periphery becomes more distant from the kidney
center (less complexity).
70
Dept of Urology, GRH and KMC, Chennai.
71. ABC SCORING
SYSTEM
• Category 1 - Tumors of renal cortex -
interlobular and arcuate arteries
• Category 2 - included tumors
originating from or extending to the
renal - interlobar arteries
• Category 3S - Extending into the renal
sinus towards the central collecting
system - segmental arteries and their
branches
• Category 3H - Tumors in proximity of or
involving the renal hilar vessels
71
Dept of Urology, GRH and KMC, Chennai.
73. RISK STRATIFICATION SYSTEM
UCLA INTEGRATED
STAGING SYSTEM
(UISS)
MAYO CLINIC
STAGE, SIZE, GRADE
AND NECROSIS
(SSIGN) SCORE
MSKCC STAGING
SYSTEM
73
Dept of Urology, GRH and KMC, Chennai.
74. SSIGN
• Mayo clinic
• Assess cancer specific survival in patients with
clear cell RCC who underwent radical
nephrectomy
• Factors included
• TNM stage, tumor size, nuclear grade and
tumor necrosis
• Predictive accuracy – 81-88%
74
Dept of Urology, GRH and KMC, Chennai.
75. UISS
UCLA integrated staging system
Developed using kidney cancer databes from University
of California Los Angeles Kidney Cancer Program
Goal – Predicting survival
Factors – Tumor stage, Fuhrman nuclear grade, ECOG
performance status
Used to stratify both localized and metastatic RCC into
three different risk groups
Predictive accuracy – 86%
75
Dept of Urology, GRH and KMC, Chennai.
77. Leibovich
Nomogram
Developed by Leibovich et.al (2003)
Algorithm to predict progression to
metastases after radical nephrectomy
in clinically localized clear cell RCC
Tumor stage, size, grade, necrosis and
regional lymph node status
77
Dept of Urology, GRH and KMC, Chennai.
78. Karakiewicz
Nomogram
Developed in 2007
Prediction of RCC specific survival
Similar to UISS except ECOG performance status
is replaced by symptoms that distinguish
asymptomatic, local and systemic symptoms
Predictive accuracy – 89% (highest)
78
Dept of Urology, GRH and KMC, Chennai.
80. FRENCH GROUP
IMMUNOTHERAPY
• 782 mRCC patients
• Factors – performance status, number &
location of metastases; interval between
diagnosis and systemic treatment; Hemoglobin
level, neutrophil count and other biological
signs of inflammation
• Designed to predict progression and survival
following cytokine based immunotherapy
• Stratified patients according to the number of
adverse prognostic factors into – good,
intermediate and poor risk with median survival
of 42, 15 and 6 months respectively
80
Dept of Urology, GRH and KMC, Chennai.
81. FRENCH
GROUP
IMMUNOTHERAPY
• Four independent factors predictive of rapid
progression under treatment
• Presence of hepatic metastases
• Short interval from RCC to metastases (<1yr)
• More than one metastatic site
• Elevated neutrophil counts
• Patients with atleast three of these factors –
0ver 80% probability of rapid progression
despite treatment.
81
Dept of Urology, GRH and KMC, Chennai.
82. MSKCC
MODEL
• 670 patients with advanced RCC who received
treatment with IFN alpha
• Retrospective study – to define pretreatment
features predictive of survival
• Five risk factos associated with shorter survival
• Low Karnofsky performance status (<80%)
• High lactate dehydrogenase (>1.5 times upper
limit of normal)
• Low serum hemoglobin (< lower limit of normal)
• High corrected serum calcium (>10md/dL)
• Interval from diagnosis to systemic treatment
(<1year)
82
Dept of Urology, GRH and KMC, Chennai.
83. MSKCC
• In addition to MSKCC criteria, prior radiotherapy and presence of more
than one site of metastases – negative prognostic value
GROUPS THREE YEAR
SURVIVAL
MEDIAN
SURVIVAL
FAVOURABLE RISK
(0)
31% 20 MONTHS
INTERMEDIATE RISK
(1-2)
7% 10 MONTHS
POOR RISK (>3) 0% 4 MONTHS
83
Dept of Urology, GRH and KMC, Chennai.
85. SUMMARY
• Wide spectrum of clinical
manifestations
• CECT – Gold standard in diagnosis and
staging
• Clinical TNM stage and Histological
grade – most important predictors of
prognosis
• Future – molecular biomarkers
85
Dept of Urology, GRH and KMC, Chennai.