This document discusses various urological malignancies including: 1. Renal masses like renal cell carcinoma which can be clear cell, chromophobic, or chromophilic subtypes. Symptoms include flank pain and masses. Treatment involves surgery or immunotherapy. 2. Bladder cancer which is usually transitional cell carcinoma caused by smoking. Symptoms include hematuria and can be staged from superficial to muscle invasive to metastatic. Treatment depends on stage. 3. Prostate cancer which spreads via bone and lymph nodes and is staged using TNM. It is assessed using PSA and treated with surgery, radiation or hormone therapy depending on risk level.

1. Urological
Malignancies
DR SANTOSH AGRAWAL
Chief Urologist and KidneyTransplant Surgeon
Bansal Hospital , Bhopal, MP
MBBS, MS, MCh (PGI, Chandigarh), FIAGES, FALS
Fellow in Robotic Surgery, Roswell Park Cancer Institute, Buffalo , USA

2.  Kidney mass/ renal mass
 Carcinoma urinary Bladder
 Prostate cancer
 Penile cancer
 Testicular cancer

3. Renal mass (neoplasm)
Benign
 Adenoma
 Angiomyolipoma
( AML)
 Oncocytoma
 Simple cyst
 Fibroma
 angioma
Malignent
 Renal cell carcinoma
(RCC)
 Urothelial carcimona
(TCC- transitional cell
carcinoma of renal pelvis)
 Kidney sarcoma
 Squamous cell carcinoma
 wilm’s tumor

4. Renal cell carcinoma
1. Clear cell carcinoma ( conventional type) – most common
( 70- 80%)
2. Chromophobic carcinoma ( 10-15%)
3. Chromophilic (papillary) 3-5 %
4. Collecting duct carcinoma(1%)

5. Clinical features
 Asymptomatic
 Hematuria
 Flank mass
 Flank pain
 Dragging sensation in flankm
 Rapidly devoloping left varicocele
 Metastatic symptoms

6.  Paraneoplastic symptoms/consitutional symtoms
 Fever
 Polycythemia ( increased erythropoetin production)
 Raised ESR
 Hypertension ( increased renin production)
 Hypercalcemia ( increased PTH like substance)
 Stauffer’s syndrome- nonmetastatic hepatic dysfunction (
raised ALP, SGOT/PT, prothombin time)

7. Investigation
 Ultrasonography
 Contrast enhanced CECT scan of Abdomen± chest
 CXR –PA veiw
 CBC
 Urea/creatinine
 LFT
 Serum calcium

8. Staging
 Robson’s staging

9. TNM staging
 T staging-
 T1: tumor < 7 cms , confined to kidney
 T2 : tumor > 7 cms confined to kidney
 T3 : perinephric fat invasion or Renal vein thrombus
 T4: adjacent organ involvement
 N staging
 N0
 N1
 M staging
 Mo
 M1

10. Treatment
 Surgery - primary therapy
 Radiotherapy and chemotherapy – no role
 Immunotherapy – interlekin 2 and interferon – α
 Newer therapy – sunitinib and sorafenib ( tyrosin kinase
inhibiter)

11. Surgery
 Localized tumor
 Partial nephrectomy
 Radical nephrectomy ( removal of kidney , perinephric fat,
Gerota’s fascia, upper third of ureter)
 Locally advanced
 Radical nephrectomy with removal of renal vein thrombus or
IVC trombactomy
 Metastatic- palliative nephrectomy

13. Partial
nephrectomy

14. Wilm’s tumor
 Most common solid renal tumor of child hood.
 Usually present before 5 years age ( peak age = 3 years)
 Usually unilateral ( 5% bilateral)
 Two forms
1. Familial
2. Non familial

15. Associated syndomes
 WAGR syndrome
 Beck with Weid man syndrome
 Isolated hemihypertrophy
 Trisomy 18

16. Gross pathology
 large, multilobulated, and gray or tan in color with focal
areas of hemorrhage and necrosis. A fibrous
pseudocapsule is occasionally seen.

17. Clinical features
 Abdominal pain/distensioon
 Nausea/vomiting
 Hematuria
 hypertension

18. Investigation
 Blood investigation –
 CXR
 Contrast enhanced CT scan

19. treatment
 Nephrectomy
 Chemotherapy followed by nephrectomy

20. Carcinoma urinary bladder
1. Transitional cell ( urothelial) carcinoma ( > 90%)
2. Squamous cella carcinoma
3. Adenocarcinoma
1. Urachal adenocarcinoma
2. Glandular metaplasia

21. Etiology
 Smoking
 Anniline dye
 Cyclophosphamide
 bilharziasis

22. Clinical features
 Painless gross hematuria
 Clot retention of urine
 Flank pain
 Pelvic or perineal pain
 Frequency urgency
 Microscopic hematuria
 Asymptomatic incidentally detected

23. investigation
 Urine microscopy – RBCs, pus cells
 Urine for malignant Cytology
 Ultrasonography
 IVP ( intravenous pyelography) – not done
 CECT ( contrast enhanced CT scan) – most common and useful
 MRI
 CXR – PA veiw to rule out chest mets
 Blood investigation-
 Bone scan to rule out bony metastasis

24. Staging of bladder tumor
 Cystoscopy and trans urethral endoscopic resection of
bladder tumor (TURBT)
 Resected tumor and biopsy from tumor base sent for
histopathological examination
 Intravesical Mitomycin- C 40 mg dissolved in 50 ml of NS (
normal saline ) retained for 45 minutes to 1 hr.

27. 1. Superficial disease – tumor not invading detrusor muscle
(Ta-T1 diseas)
1. Low grade
2. High grade
2. Muscle invasive disease (T2 disease)
3. Locally advanced disease (T3-4, N positive)
4. Metastatic disease ( M1 disease)

28.  Superficial disease -TURBT
 Low grade : intravesical mitomycin C, thiotepa
 Muscle invasive disease
 Radical cystetcomy with formation of ileal conduit
 Or orthotopic neobladder

29.  Radiotherapy- external beam radiotherapy
 30-50% response rate
 Non surgical candidate
 Chemotherapy
 MVAC( methotrexate, vancomycin, adriamycin,cisplatin)
 GC (gemcitabin, cisplatin)

30. Prostate carcinoma
 Most comman carcinoma in US after age of 65 years
 TURP for BPH does not give protection
 Arises from peripheral part of prostate.

31. Clinical features
 Asymptomatic
 Difficulty is passing urine , hematuria, acute retention
 Severe back pain
 Paralysis
 Limb edema
 p/r- hard nodules

32. Spread of prostate Ca
 Hematogenous
 Mulple osteoblastic bone metastasis
 Lymphatic spread
 Internal iliac to supraclavicular
 Local spread
 urehtra;: retention of urine
 Bladder: hematuria
 Rectum
 Seminal vesicle

33. Staging prostate Ca(TNM)
 T
 T1a
 T1b
 T2
 T2a
 T2b
 T2c
 T3
 T4
 N
 M

34. Investigation/ work up
 Serum PSA
 Serene protease enzyme
 Organ specific not cancer specific
 Release from prostate gland into circulation
 Used in screening and assessing treatment response

35.  Biopsy of prostate
 X ray of bone
 Alkaline phosphatase
 Acid phosphatase
 CT scan and MRI – for local and LN staging
 Bone scan-nuclear medicine scan picks up bone metastasis

36. Prostate Ca - treatment
 Treatment options
 1. radical prostatectomy
 2. radical radiotherapy
 3. watchful waiting
 4. androgen blockade only

37.  Treatment depends upon-
 Stage of the disease (TNM staging, gleason score and PSA
level)
 Life expectancy
 Comorbidity
 Patient wishes

38.  Localized prostate cancer
 Locally advanced
 Metastatic
 Pathological fracure – surgery
 Local radiotherapy
 Hemibody radiation
 Bilateral orchidectomy
 Bicalutamaide
 Honvan ( oral DES – estrogen)

39. Carcinoma penis
 Etiology
 Phimosis
 Premalignant condition
 Erythroplasia of Queyrat- red velvety lesion
 Bowen’s disease – eczematous plaque
 Buschke Lowenstien tumor- cauliflower like lesion rarely
malignant foci

40. Clinical features
 Present after the age of 50 years
 Non healing ulcer over penis
 Foul smelling blood stained discharge
 Phimosis
 Inguinal swelling

41. Spread
1. Direct spread
2. Lymphatic spread
3. Hematogenous spread

42. Diagnosis
 Wedge biopsy of growth
 FNAC

43. Treatment
 Primary tumor
 inguinal LN

44. Primary tumor
 Circumcision
 Partial penectomy
 Total penectomy

45. Inguinal lymph node
 Superficial lymph node dissection
 Sentinel lymph node biopsy
 Ilio-inguinal lymph node disssection

46. Testicular tumor