Genitourinary Tumors

Urology Division, Department Of Surgery

Faculty Of Medicine
University Of Sumatera Utara
Learning Objective
 Mengetahui etiologi
 Mampu menjelaskan klasifikasi
 Mampu mendiagnosa secara klinik berdasarkan anamnesis, pemeriksaan fisik, lab
dan Radiologi
 Mampu menjelaskan penatalaksanaan
 Mampu merujuk ke spesialis
Renal Tumor

Bladder Tumor

Penile Tumor

Testicular Tumor
Standar Kompetensi Dokter Indonesia (SKDI)

Tingkat
No Topik Tingkat Kemampuan
Kompetensi
• Mendiagnosis
1 Genitourinary Tumor 2
• Merujuk

Lulusan dokter mampu :

• Membuat diagnosis klinik
• Memberikan terapi pendahuluan pada keadaan yang gawat darurat demi menyelamatkan nyawa atau
mencegah keparahan dan/atau kecacatan pada pasien
• Menentukan rujukan yang paling tepat bagi penanganan pasien selanjutnya.
• Menindaklanjuti sesudah kembali dari rujukan.
References
Renal Neoplasma
Signs and Symptoms

 Most renal masses remain asymptomatic until the late disease stages.
 Triad : flank pain, visible haematuria, palpable abdominal mass
 Paraneoplastic syndromes are found in approximately 30% of patients with
symptomatic.
 Some symptomatic patients present with symptoms caused by metastatic
disease, such as bone pain or persistent cough
Physical Examination

 Physical examination has a limited role in RCC diagnosis

 Following findings should prompt radiological examinations:
 Palpable abdominal mass;
 Palpable cervical lymphadenopathy;
 Non-reducing varicocele and bilateral lower extremity oedema, which
suggests venous involvement.
Laboratory Findings

 Laboratory parameters :
 Serum Cr, GFR, CBC, LED, LFT, LDH, Ca
 Urinalysis
 Urine cytology  For central renal masses abutting or invading the
collecting system
 Renal scintigraphy
 Patients at risk of future renal impairment due to comorbid disorders.
Imaging Investigations

 Abdominal US
 CT Scan with Contrast
 MRI
 Angiomyolipoma
Benign
Oncocytoma
Renal Tumor
Wilm's Tumor
Malignant Clear Cell (ccRCC)
RCC papillary RCC
Non Clear Cell
Chromophobe RCC
Renal Cell Carcinoma
 Mostly in male, aged 60s-70s, uncommon in childhood
 Renal cell carcinoma arise from the renal epithelium and
account for about 85 percent of renal cancers.
 A quarter of the patients present with advanced disease,
(mRCC).
 A third of the patients who undergo resection of localized
disease will have a recurrence.
Renal Cell Carcinoma

 Incidental findings on USG

 Symptoms:
 Hematuria
 Flank pain
 Abdominal/flank mass
 Others: Varicocelle / Lower extremity oedema
 Para-neoplastic symptoms:
 Increased LED / LDH / Ca+
 Unexplained fever
Renal Cell Carcinoma
 Initial workup:
 CBC, metabolic panel (ESR, LDH, Ca+ )
 Urinalysis
 Abdominal/pelvic ultrasound / CT or MRI with or without contrast
 Imaging
 Chest imaging
 Bone scan, if clinically indicated
 Brain MRI, if clinically indicated
 If urothelial carcinoma suspected, consider urine cytology, URS or retrograde
pyelography
 Consider needle biopsy, if clinically indicated
Renal Cell Carcinoma

Treatment:
 Nephron-sparing surgery
 Radical Nephrectomy
 Chemotherapy
 Immunotherapiy
Wilm’s Tumor

 Occurs in children, aged 2-3 years old until 8 years old

 First symptom is abdominal mass
 Abdominal pain, hematuria, and fever are rarely found
 Tumor rupture with intra-abdominal bleeding can lead to acute
abdomen
 Tumor extension into the renal veins will cause varicocele,
hepatomegaly due to obstruction of hepatic veins, and heart failure
Wilm’s Tumor

 Physical examination: aniridia,

hemihypertrophy, genitourinary anomalies
 CT scan & MRI are often used to diagnose
a kidney mass
 If CT-scan if unavailable, USG and BNO-
IVP can be used
Wilm’s Tumor

 The stadium of Wilm’s tumor is based on tumor size and

involvement
 Histological classification:
 Favorable histology (FH), consists of three types of cells, blastemal,
epitelial, stromal.
 Anaplastic (10%)
 Nephrogenic rests (1%)
Wilm’s Tumor Treatment

 Chemotherapy
 Radiotherapy: whole abdominal irradiation (WAI)  for
intraperitoneal tumors, bleeding, and positive cytology results for
ascites fluid
 Surgery. In radical nephrectomy, transabdominal approach is used.
Lumbotomi incision is not recommended due to limitation of
exposure
Renal Angiomyolipoma
 A benign renal neoplasm
 It is composed of variable amounts of
fat, vascular and smooth muscle
elements
 The fat density of the tumour on CT
has been regarded to be
pathognomonic
 It occurs in more than 50% of
individuals with tuberous sclerous,
often bilaterally. Angiomyolipomata
also occur in 40% of women who
have a rare, cystic lung disease called
lymphangioleiomyomatosis, or LAM.
Renal Angiomyolipoma

 Management
 Tumor < 4 cm can be observed
 Nephrectomy in patients with acute or potentially life-threatening
hemorrhage
 Selective embolization in patients with bilateral disease
Bladder Carcinoma
Risk Factors
 Genetic  The most-studied genes associated with bladder cancer are N-
acetyltransferase 2 (NAT2) and a deletion of glutathione S-transferase μ (GSTM1)
 Tobacco smokers have a 2- to 3-fold increased risk of bladder cancer
 Hereditary More likely the cause is multifactorial, in which certain genes magnify
environmental exposures
 Body Mass Index  Increasing BMI has been shown in multiple meta-analyses to be a
risk factor for bladder cancer development
 Occupational Risk  Occupational exposures account for between 5%
and 10% of all bladder cancer
 Medical Conditions  Medical conditions have the potential to increase
bladder cancer risk directly or indirectly as a toxicity of treatment. Typically,
direct carcinogenesis is mediated by chronic inflammation and the development
of keratinizing squamous metaplasia.
 Schistosomiasis  Schistosomes are parasitic blood flukes that have mammalian hosts as
well as intermediate hosts (e.g., freshwater snails). Of the four human schistosomes, S.
haematobium is the one linked to squamous cell bladder cancer.

 Recurrent Infection  Multiple investigators have suggested that persistent or recurrent

bacterial UTIs may increase the risk of bladder carcinogenesis. Multiple epidemiologic
studies suggest that there may be a modest, increased risk of bladder cancer associated with
chronic UTIs

 Pioglitazone  In 2005 the PROactive randomized trial reported an unexpected finding

that the pioglitazone arm had higher cases of bladder cancer compared with placebo

 Radiation  The association of radiation exposure with bladder cancer has been noted
since atomic bomb survivors were found to have markedly increased rates of urothelial
carcinoma
 Environmental Pollution  Exposure to arsenic in drinking water has been
associated with the development of urothelial bladder cancer

 Diet  Similar to other cancers, dietary factors have been an area of much study
with regard to bladder cancer risk .

 Foods  malignancies dietary intake of meat has been associated with increased
risk.
Relative Risk of Bladder Cancer by Occupation
Signs and Symptoms

 Haematuria is the most common finding in NMIBC. Visible

haematuria was found to be associated with higher stage disease
compared to nonvisible haematuria at first presentation
 Carcinoma in situ might be suspected in patients with lower urinary
tract symptoms, especially irritative voiding.
Imaging

 Computed tomography (CT) urography is used to detect papillary

tumours in the urinary tract, indicated by filling defects and/or
hydronephrosis
 Intravenous urography (IVU) is an alternative if CT is not available
 Ultrasound (US) may be performed as an adjunct to physical
examination as it has moderate sensitivity to a wide range of
abnormalities in the upper and lower urinary tract.
Urinary Cytology

 Cytology is useful, particularly as an adjunct to cystoscopy,

 Positive voided urinary cytology can indicate an urothelial tumour
anywhere in the urinary tract; negative cytology, however, does not
exclude the presence of a tumour.
Disease Management

Lifestyle Modification

• Stop Smoking

Surgery

• TURBT
• Radical Cystectomy

Other modalities

• Intravesical chemotherapy
• BCG Instillation
• Chemotherapy
• Radiotherapy
Penile Carcinoma
Penile Carcinoma

 Penile carcinoma is usually a SCC and there are several recognised

subtypes of penile SCC with different clinical features and natural
history.
 Penile SCC usually arises from the epithelium of the inner prepuce
or the glans.
Risk Factors
Premalignant Lesions

 Squamous cell carcinoma accounts for over 95% of penile

malignancies
 It is not known how often SCC is preceded by premalignant lesions
Premalignant Lesions
Diagnosis

 Primary Lesion:
 Usually a clinically obvious lesion but may be hidden under a
phimosis.
 Physical examination
 Palpation of the penis to assess the extent of local invasion
 Palpation of both groins to assess the lymph node status.
 Additional examinations: ultrasound, MRI, penile doppler ultrasound
Diagnosis

 Distant Metastases
 Staging for systemic metastases should be performed in patients
with positive inguinal nodes
 Abdominal and pelvic CT should be done plus a chest X-ray,
although a thoracic CT is more sensitive. PET/CT is an option
Treatment

 The aims of the treatment of the primary tumour are complete

tumour removal with as much organ preservation as possible,
without compromising oncological control. Local recurrence has
little influence on long-term survival, so organ preservation
strategies are justified
 Penile preservation appears to be superior in functional and
cosmetic outcomes to partial or total penectomy, and is considered
to be the primary treatment method for localised penile cancer.
Testicular Tumours
Classification

You might sensibly start classifying testicular tumours into benign and malignant.
In fact benign solid tumours of the testis are extremely rare.

The classification of malignant tumours is complicated by the fact that there are
different classification systems used in the UK and USA and consequently it’s
easy to get confused if you read textbooks from the different countries.
Classification

divided into:

1 Germ Cell Tumours

2 Other tumours, the commonest of which is lymphoma, which is the
commonest testicular malignancy in the older patient.
Germ cell tumours can be divided into

1 Seminomas
2 Non-seminomatous germ cell tumours

40% of testicular tumours are mixed, i.e. they have both

seminomatous and non seminomatous elements
Peak Age Incidence

Seminomas 40 years
NSGCTs 30 years
Symptoms & Signs

Symptoms: Painless scrotal swelling

Chance discovery
Testis feels “heavier”

Signs: Scrotal swelling which you can get above

The lump is craggy & does not transilluminate
May be associated with hydrocele
May have palpable liver due to metastases
 Investigations

Radiology: Ultrasound of testis

CT of abdomen to assess spread
Chest X Ray for metastases
Blood Tests: AFP (alpha feto-protein)
b-hCG (human chorionic gonadotrophin)
LDH (lactate dehydrogenase)

The blood tests are known as tumour markers.

Surgery

An inguinal orchidectomy is performed

The testis is taken out through an incision in the groin
This is because the lymphatic drainage of the testis is to the para-aortic
nodes. An incision in the scrotum risks spreading the tumour to the
superficial inguinal lymph nodes which drain the scrotal skin
Other Treatments

If the tumour has metastasised, other options for treatment include:

 Radiotherapy for seminoma

 Chemotherapy for NSGCTs

Sometimes a combination of the two is required

Tumors of Urethra
Tumors of the Urethra

 Benign tumors of the urethra are rare and generally only described in small case
reports. Leiomyoma, hemangioma, and fibroepithelial polyp are most frequently
reported.
Urethral Leiomyoma

 Leiomyomas are mesenchymal tumors that arise from urethral or paraurethral

smooth muscle and are most commonly seen in reproductive-aged women

 These tumors often are accompanied by obstructive voiding symptoms,

dyspareunia or hematuria, and occasionally are diagnosed incidentally

 These tumors can grow during pregnancy and regress post- partum, suggesting
they are hormonally sensitive (Fry et al., 1988; Kato et al., 2004). They can occur
anywhere along the urethra but most commonly arise within the posterior wall
Urethral Hemangioma

 Urethral hemangiomas are benign vascular tumors that are thought to arise from
angioblastic cells within the urethra. They tend to be more common in men,
although there are several reports of female urethral hemangiomas

 The most common symptoms of a urethral hemangioma are intermittent

hematuria and bloody urethral discharge

 The diagnosis of a urethral hemangioma is made by cystoscopy and biopsy. The

most common appearance is that of a bluish sessile lesion with associated
varicosities, with pathology demonstrating cavernous hemangioma in most cases
Urethral fibroepithelial Polyp

 Urethral fibroepithelial polyps (FEPs) are rare benign tumors of mesodermal

origin most commonly found in males

 Most male FEPs arise within the bulbar and posterior urethra, and the most
common clinical presentation in adults is obstructive urinary symptoms,
hematuria, dysuria, and rarely urinary retention
Epidemiology,
 Male primary urethral cancer (PUC) is a rare disease that usually manifests after
the sixth decade of life and is more common in African Americans than
Caucasians

Etiology
 Most patients with anterior PUC have a history of chronic urethral inflammation
with urethral stricture disease being the most common risk factor.

 Other risk factors for anterior PUC include sexually transmitted diseases, lichen
sclerosis, urethritis, pelvic radiation, trauma, and instrumentation
Pathology

 Carcinoma of the male urethra is categorized according to location

and histology. Because there is a change in cell type along the length of the urethra, male
PUCs vary by site of origin. Among urethral cancers described in population-level studies,
50% to 80% are urothelial carcinomas, 10% to 30% are squamous cell carcinomas, and 5% to
10% are adenocarcinomas.

Adenocarcinoma tends to be more common in the bulbar urethra (Kaplan et al., 1967; Tsai et
al., 2005). Among anterior urethral tumors, 60% are located in the bulbar urethra and 30% are
in the pendulous urethra
Evaluation and Staging

 The tumor, node, metastases (TNM) staging classification is based on depth of

invasion of the primary tumor, and presence or absence of regional lymph node
involvement and distant metastasis.
Prostate Cancer
Anamnesis

• Onset
• LUTS symptoms
• IPSS Score
• QoL
• Sign of neoplasm : General weakness, weight loss
• Sign of metastasis : Flank pain, cough, headache
• eliminate DD : is there any hematuri?, passing stone, pain during voiding ?
• Risk Factor
• Previous medical treatment
• History of illness
• Family medical History
• Surgical history
Risk Factors
Physical Examination

 General condition (Vital sign, BMI)

 Urological Evaluation (Flank, Suprasymphisis, Genitalia
Eksterna)
 Digital Rectal Examination (DRE)  mandatory
 DRE alone <60% sensitivity and specificity
 Most of the PCa are located in the peripheral zone and may
be detected by DRE when the volume if >= 0.2 ml
 18% cases are detected by DRE alone
 Abnormal DRE associated with increased risk of a higher
ISUP grade and is an indication for biopsy
Diagnosis of PCa

DRE PSA

BIOPSY
Diagnosis of PCa

DRE PSA

BIOPSY
Diagnosis of PCa

DRE PSA

AFTER 2019 Why mpMRI first?

BEFORE 2019 mpMRI • For biopsy indication

• As a guidance for
biopsy

BIOPSY
Prostate cancer treatment

 Active surveillance  conversion to potentially curative treatment (every 6

months monitoring)
 Very low risk man with life expectancy ≥ 20 years
 Low risk man with life expectancy ≥ 10 years
 Observation  monitoring continues until symptoms develop or are imminent,
then begin palliative ADT (every 6 months monitoring)
 Low risk men with life expectancy < 10 years
 Radical prostatectomy  Gold Standard therapy for localized prostate cancer
Prostate cancer treatment

 Androgen Deprivation Therapy (ADT)

 For localized PCa with <5 years of life expectancy and comorbidities
 Persistent/recurrence PSA after RP
 Gold standard for metastatic prostate cancer
 Target testosterone (< 50 ng/dL)
 Systemic Therapy
 Docetaxel, Cabazitaxel
 Mainly for metastatic prostate cancer
 Radiotherapy
 External Beam (EBRT)
 Brachitherapy (internal radiation therapy) places radioactive material directly inside or next to the
tumor.
Androgen Deprivation Therapy

 GnRH Agonis
 Leuprolide Acetate, Gosereline Acetate, Buserelin, Desorelin, Histrelin, Nefarelin,
Triptoreline
 GnRH Antagonist
 Abarelix, Degarelix, Orteronel
 Anti-Androgen
 Bicalutamide, Cyproterone acetate, Flutamide, Nilutamide
 Second Generation: Abiraterone, Enzalutamide, Apalutamide
 Surgical Therapy: Bilateral Subcapsular Orchidectomy
Prostate Biopsy
References

 European Association of Urology Guideline 2019 edition.

THANK YOU