Uro-Oncology (Diagnosis and Treatment of Urological Cancers)

Our Urology Department provides world-standard services in the field of uro-oncology. Nerve-sparing radical prostatectomy for prostate cancer and radical cystectomy for bladder cancer are performed routinely. In addition, surgical treatment and follow-up of kidney tumors, testicular tumors and adrenal masses are carried out. In some urological cancer cases, treatment options are offered to patients in coordination with the medical oncology and radiotherapy departments. At the Urology Department of Hisar Hospital Intercontinental, TUR-P, Plasmakinetic TUR and Greenlight 180 W systems are used as surgical methods for benign prostatic enlargement (BPH).

Open and laparoscopic prostatectomy operations are performed for prostate cancer.

What is the prostate?

The prostate, a part of the male reproductive system, is a walnut-sized gland located just below the bladder, in front of the rectum, which surrounds the urethra on all sides. It weighs approximately 15-20 grams. Its function is to liquefy semen and enable the sperm cells within it to become active and fertilize the female egg.

What are the diseases of the prostate?

There are 3 types of prostate disease:

• Prostatitis (inflammation of the prostate): This is seen more commonly in young men. Acute and chronic bacterial prostatitis develops when infected urine enters the prostate gland and is carried through the prostatic ducts. Bacterial prostatitis is not contagious and should not be considered a sexually transmitted disease.

• Benign prostatic enlargement (BPH - Benign Prostatic Hyperplasia)

• Prostate cancer.

Is every enlargement of the prostate benign?

Not every enlargement of the prostate means benign enlargement; sometimes it may also present as prostate cancer.

What is benign prostatic enlargement (BPH), and what are its risk factors?

It is the benign enlargement of the prostate gland that occurs in aging men. It may also be called prostatism. Advancing age, hypertension and a family history of BPH are considered risk factors for BPH.

Does benign prostatic enlargement cause prostate cancer?

BPH is not cancer and does not cause cancer. However, both diseases may coexist. Since there are usually no complaints in the early stages of prostate cancer, an annual physical examination and a PSA blood test are recommended.

In which age group is prostate enlargement seen most often?

With the rising average age in recent years, a significant increase in frequency has been detected. BPH is quite common. It is found in 50% of men aged 51-60 and in 90% of men over 80.

What are the complaints that accompany prostate enlargement?

• Frequent urination,

• Urgent need to urinate,

• Urinary incontinence immediately after the urgent need to urinate,

• Nocturia (urinating at night),

• Hesitancy when urinating,

• Straining while urinating,

• Decreased urinary flow,

• Difficulty in urination,

• Burning during urination,

• Dribbling after urination,

• A feeling of not being able to fully empty the bladder after urination.

How should examination and follow-up be done?

Digital rectal examination and measurement of the level of a substance called PSA in the blood are the most important diagnostic tools. Generally, an annual check-up with PSA and digital rectal examination is recommended for healthy men over 50. However, men with a family history of prostate cancer are advised to start these checks from age 40. Digital rectal examination can only detect a mass that has reached a certain size. Therefore, measuring the PSA level is very important for early diagnosis.

Which tests should be performed for prostate enlargement?

• Complete urinalysis

• PSA

• Examination of the amount of urine remaining in the bladder with a urinary system ultrasound

• Uroflowmetry tests are performed.

What is PSA?

PSA (Prostate Specific Antigen) is a substance produced only in the prostate and is measured from the blood. Its normal value is below 4 ng/ml; however, the PSA range varies by age. When there is a problem with the prostate, more of it mixes into the blood, and an increase in the blood PSA level is noticed. An elevated PSA is not caused by prostate cancer alone. Benign prostatic enlargement and prostatic inflammations also raise PSA. Prostate cancer is detected in approximately 30% of those with PSA between 4-10 ng/ml, while this rate exceeds 50% above 10 ng/ml.

What are the treatment options?

• Monitoring: Patients whose complaints are not severe, whose PSA value is normal and who have no suspicious findings on prostate examination can be enrolled in an annual monitoring protocol.

• Medical treatment: There is a group of medications that relax the smooth muscles around the prostate and bladder neck and facilitate urinary flow. With a 4-week course of treatment, they cause an increase in urinary flow rates and a reduction in complaints in 60% of patients.

• Surgical treatment: Surgical treatment is applied to patients who have complications due to prostate enlargement, whose complaints do not improve despite drug therapy, or who prefer a more effective treatment method. The choice among surgical methods is made by evaluating many factors, including the patient's prostate size, general condition, whether they have any other disease, and the medications they use for that disease. Depending on the decision, either an open or a closed surgical procedure is applied. Closed methods can be applied in 90% of patients. These operations can be performed under spinal, epidural or general anesthesia. An improvement in complaints and an increase in urinary flow rate can be achieved in 70-90% of patients. Among closed surgical methods, the TUR operation is accepted as the gold standard worldwide. Alternative treatment methods to the TUR operation include laser prostate surgeries, prostate stents, shrinking the prostate with heat, opening the bladder neck with a surgical incision, and removing the prostate with plasmakinetic technique.

Kidney Tumors

Masses detected in the kidney are divided into 2 groups: benign tumors and malignant tumors. There are many classifications of kidney tumors. The most common mass found in the kidney is the simple renal cyst. Simple cysts usually do not cause symptoms, make up 70% of all kidney masses, and may be single or multiple. They are seen in 50% of people over 50 years of age. These cysts can be easily distinguished with radiological imaging. Kidney cysts, which usually appear incidentally, never threaten human life. Kidney cysts often do not even require treatment; annual follow-up of the cyst size is sufficient. Intervention is needed if they grow to a large size and cause pain or lead to impairment of the kidney structure. Kidney cysts are classified radiologically into 4 categories. In this classification, no further investigation is needed for categories 1 and 2. In category 3, further investigation should be performed and the cysts should be surgically removed. Cysts in category 4 are called cancer and must definitely be removed surgically.

Other benign tumors of the kidney;

Angiomyolipoma: Benign kidney tumors composed of smooth muscle, fat and thick-walled vessels in varying proportions. These tumors are seen more commonly in patients with tuberous sclerosis. Malignant transformation of these tumors is very rare. They can present with flank pain, a palpable mass and blood in the urine; shock due to bleeding may develop in 10% of patients. Pregnancy may increase bleeding. Most cases can be diagnosed easily with ultrasound and tomography. Masses under 4 cm should be followed with checks at 6 months and annually. Surgical removal of masses over 4 cm is beneficial. In patients who present with acute bleeding, kidney-sparing surgery is usually difficult, and nephrectomy is necessary.

Oncocytoma: It constitutes 3-7% of benign kidney tumors. It is common after the age of 50 and is seen more often in men than in women. It is usually unilateral, but it can also be bilateral and multiple. It is difficult to make a diagnosis radiologically, but the diagnosis is definitively established pathologically. Most often, a diagnosis of kidney cancer is made and a nephrectomy or partial nephrectomy is performed; after pathological examination, it is understood to be an oncocytoma.

Renal Adenoma: Generally, they are 1-3 mm in diameter and rarely exceed 1 cm. They are seen more often in men and do not cause symptoms. They are difficult to distinguish from cancer on imaging; generally, a partial nephrectomy is performed.

Kidney Cancer

Kidney cancer originates from the cells (epithelium) lining the small urine-collecting tubules within the kidney. Histologically, it can be classified as clear cell carcinoma, papillary cell carcinoma, collecting duct carcinoma and chromophobe cell cancer. Also, urothelial cancer, which originates from the renal pelvis and is similar in many respects to the cancers seen in the bladder, can occur in the kidney. Nephroblastoma (Wilms' tumor), seen in childhood, constitutes 80% of kidney tumors. It is most commonly seen at ages 2-4. Renal cell carcinoma (RCC) constitutes 85% of all malignant kidney tumors and approximately 3% of adult cancers. Even today, approximately 30% of patients with kidney cancer are already disseminated at the time of initial diagnosis. In addition, metastatic disease develops at a later stage in 20-30% of patients who underwent nephrectomy for localized cancer. It should not be forgotten that kidney cancer can be completely cured if it is diagnosed early and appropriate treatment is given. When diagnosed at an early stage, the survival rates of kidney cancer patients can be between 70% and 100%. The most important feature of renal cell carcinomas is that they are resistant to radiotherapy or chemotherapy. They also respond poorly to hormonal therapy. Renal cell carcinomas can be surgically removed if they are caught early, that is, while still confined to the kidney. This is the most effective treatment method for renal cell carcinoma cases confined to the kidney.

What are the risk factors for the development of kidney cancer?

Kidney cancer generally appears between the ages of 50 and 60. It is seen twice as often in men as in women. The cause of kidney cancer is not yet fully known. However, researchers have identified some risk factors for the development of kidney cancer. However, not everyone with these risk factors will develop kidney cancer, and these risk factors may not be present in every patient with kidney cancer. Hereditary characteristics also play an important role in the origin of kidney cancers. If kidney tumors are seen at an early age, are bilateral, and are multiple within the kidney, hereditary kidney cancers should come to mind. Examples of these cancers include von Hippel-Lindau syndrome, hereditary papillary cancer, hereditary clear cell cancer and hereditary renal oncocytoma.

Other non-hereditary risk factors are listed below.

• End-stage renal failure and dialysis

• Acquired polycystic kidney disease together with end-stage renal failure

• Smoking and tobacco use

• Obesity

• Metal workers

• Asbestosis

• Exposure to cadmium

• Exposure to arsenic

• Dry cleaning workers

• Hypertension

• Polycystic kidney disease

• Long-term phenacetin use

• Long-term use of diuretics

What are the symptoms and how is it diagnosed?

The most common clinical symptoms of kidney cancer are blood in the urine, a hard mass that can be felt in the abdomen, and pain, which together form what we describe as a triad. In early-stage kidney cancers, there are generally no symptoms at all, and they are detected incidentally during ultrasonography or radiological examinations performed for other reasons. Diagnosis is most often made in patients with stage 2 disease. Complaints from a kidney tumor arise for several reasons. These are. In other words, when an early diagnosis is made, treatment is both easier and the likelihood of completely recovering from cancer increases. However, as the tumor grows and spreads, the likelihood of complete cure decreases. Routine checks increase the chance of early diagnosis and make complete recovery from the disease possible. Depending on how frequently they occur, one or more of the symptoms listed below may be a harbinger of kidney cancer. Pain is the most common complaint; 41% of patients consult a doctor with pain complaints. The second important complaint is bleeding, which appears as a change in urine color or dark urine; hematuria is seen in 38% of patients. Another important complaint is swelling and a mass palpable in the kidney on that side, which is seen in 24% of patients. Other complaints are generally those seen in cancer patients: weight loss, weakness and fatigue. In addition, fever and hypertension caused by substances released by kidney cancer may also be seen. These complaints may be a sign of kidney cancer, but they may also be caused by other diseases such as infection. People who have these complaints should definitely see a urology specialist. Cancer diagnosed early is treatable.

Imaging in Kidney Cancer: Generally, patients with blood in the urine first undergo ultrasound and an intravenous urogram (contrast kidney film). Ultrasound is currently the first choice for imaging the urinary system; because it is inexpensive, easy to perform and can be done under emergency conditions, it should be the first step. Intravenous Pyelography (IVP, contrast kidney film): Deposits called calcifications may be seen as white spots on these films. The accuracy rate of intravenous pyelography alone is 75%.

Computed tomography: It is more sensitive than ultrasound and contrast kidney film in the diagnosis of kidney cancers. The accuracy rate of CT alone is 95%. It provides information about the location and size of the mass, its local involvement and its spread to surrounding tissues.

MRI; Its most important advantages are few side effects, its ability to show the structure of masses with high accuracy, its applicability in patients with kidney failure and contrast agent allergy, and its ability to show renal vein and vena cava thrombi without the need for a contrast agent.

Scintigraphy: It is useful in cases where bone metastasis is suspected, when there is bone pain and elevated alkaline phosphatase.

PET (Positron Emission Tomography): It is a guide for the treatment and course of patients with metastases.

Biopsy; In some cases, it may be considered when there is great suspicion regarding the diagnosis, and it can usually be performed under computed tomography guidance. However, there are difficulties in evaluating the biopsy.

Metastasis and Spread Sites in Renal Cell Carcinoma:

Site Rate(%)

• Lung 50-60

• Bone 30-40

• Regional lymph nodes 15-30

• Main renal vein 15-20

• Perirenal fat tissue 10-20

• Adrenal (same side) 10-15

• Vena cava 8-15

• Brain 10-13

• Contralateral kidney 1-2

Treatment of Kidney Cancer

Treatment of a kidney tumor is determined according to the patient's general condition, the diameter of the tumor, the extent of the disease and the patient's age. Since kidney tumors are generally cancers that are resistant to radiotherapy and chemotherapy, surgical treatment remains as our only treatment option. Surgery is the standard method in the treatment of kidney cancers. Surgically, either the entire kidney is removed or the tumor is removed together with part of the kidney. Radical nephrectomy refers to the complete removal of the kidney, the adrenal gland and the surrounding membranes and fat layers. Removal of the tumor together with part of the kidney is called partial nephrectomy. Technically, either open surgery or laparoscopic or robotic surgery can be performed. After surgery, the patient may experience pain and discomfort.

Additional Treatments in Kidney Cancer

Radiation therapy: Radiation therapy is based on using high-energy rays from a radioactive source outside the body to kill cancer cells. The effectiveness of radiotherapy varies across different cancer types. However, kidney cancer is one of the cancers least affected by radiation therapy. For this reason, it is accepted that it has no place in the definitive treatment of kidney cancer.

Biological therapy (immunotherapy): Interleukin-2 and interferon are substances used in biological therapy, which can be described as weapons of the immune system that are naturally produced in the body. By administering them from outside into the body, the aim is to make better use of and strengthen the patient's immune system. Approximately 20% of patients with disseminated cancer respond to this treatment. These substances are administered within a program determined by the physician. Because of their side effects, they should be given in highly careful and experienced centers. During biological therapy, the patient often stays in the hospital so that side effects can be monitored. These treatments may cause side effects such as muscle pain, weakness, loss of concentration, fever, vomiting and diarrhea. Patients generally feel very tired. Some experience skin peeling. These problems can be very serious, but these effects disappear once treatment is over.

Chemotherapy: Chemotherapy is the use of drugs to kill cancer cells. Although it is effective in many other cancers, it has a very limited effect in kidney cancer. Nevertheless, researchers are testing new drugs and drug combinations. The side effects of chemotherapy vary depending on the drugs given. In general, cancer drugs affect rapidly growing blood cells and cause hair loss. As a result, patients lose resistance to diseases and experience loss of energy.

Hormone therapy: Attempts are made to control the growth of cells with hormones. Hormone therapy is used in advanced kidney cancers. Progesterone is the hormone most commonly used in kidney cancer. It is often used as "palliative treatment" to temporarily reduce complaints. Today it is no longer considered curative. Side effects are generally moderate. Progesterone-containing drugs may cause weight changes. They can cause sweating and fluid loss. When treatment is stopped, the side effects disappear.

How is patient follow-up carried out?

Follow-up of kidney cancer patients after treatment is very important. They are monitored with physical examination, chest X-ray and laboratory tests at intervals determined by the physician. The physician may also request ultrasonography, computed tomography or other tests when necessary. Patients should consult their doctor immediately if they encounter a problem other than those explained to them. After radical nephrectomy, patients should be followed regularly every 3-6 months. It should be evaluated whether there is any progression of the disease. There are factors that affect the prognosis (course of the disease) and the type of treatment that should be applied.

Bladder Tumor

It is one of the cancers. Tumors originating from the urothelium, the epithelium lining the urinary system from the kidney down to the bladder, are called bladder tumors.

Cause of bladder tumors

The most important cause is smoking. Certain chemical substances in cigarette smoke, other than nicotine, are excreted in the urine and come into contact with the urothelium, where they produce the harmful effects we call carcinogenesis. The most classic of these substances is aminobiphenyl. Hundreds of chemicals like these cause damage to the urothelium when they are in contact with it for a very long time. Smoking is a risk factor. Bladder tumors can also occur in non-smokers. It is not that 'only smokers will develop them'. However, the risk is much higher compared to non-smokers.

Most common age group and gender

It is generally not seen at a young age. The likelihood is very low, but the probability of occurrence increases from certain ages onward. It is seen several times more often in men than in women. The main reason was previously that men smoked more. However, as smoking has increased among women, the rate of occurrence in women is also steadily increasing.

Those at greater risk

In fact, there is no particular group of diseases associated with bladder tumors. They can be seen in all types of people. Especially in smokers… They are at risk due to air pollution, exhaust fumes and chemical products.

The effect of genetic factors

It is not a hereditary disease passed from father to son, as everyone understands it. However, in terms of genetic factors, deficiencies in tumor suppressor genes accelerate the development of these tumors. This also causes these tumors to be more aggressive. It is not possible to make a generalization and proceed on that basis in this regard.

The role of recurrent urinary tract infections in bladder tumors

Classically, I should answer 'No', but I say this so as not to be misleading. In 90% of cases, no; however, in people with very frequent recurrent urinary infections, cancers we call squamous cell carcinoma can develop. But these may occur in patients who have had stones in the bladder for a very long time and have not had them checked, in neglected patients, or in untreated patients. Simple cystitis that may occur a few times a year does not cause bladder tumors. There is also what we call schistosomiasis, seen mostly in Egypt, which settles in the bladder after being transmitted through ordinary water and rivers. Because of this, cystitis is very common.

Symptoms
The most important symptom is blood in the urine. This can often be visible to the naked eye. Sometimes it may be found during routine tests, in urine analyses. Here there is a problem: bleeding may occur and stop immediately. The patient may not take it seriously, thinking "my bleeding has stopped." Later, after 6 months or a year, it may recur. Again, it lasts a day or half a day. In the meantime, if complaints similar to cystitis, such as frequent urination and burning during urination, occur, and the tumor invades the bladder muscles, the tumor may appear with such complaints. If not taken into account, it can lead to poor outcomes.

Presence of blood

It can be seen at any stage. It can be seen in early-stage cancers and also in advanced-stage cancers. Blood in the urine is the most important symptom.

Checkups

Since we recommend an annual prostate examination, if there are no symptoms such as blood in the urine during that period, one or two urine tests per year will be sufficient. We recommend an annual urinary system ultrasonography. Ultrasonography can detect even small tumors. With advances in radiology, ultrasonography captures tumors larger than 3 cm to a large extent. However, in suspicious cases or cases where there is a possibility of a miss, and in patients who have blood in the urine but no image can be obtained on ultrasound, the most definitive and reliable diagnostic method is "cystoscopy", which involves filling the bladder with water and viewing the inner surfaces of the bladder with an illuminated instrument.

Treatment of bladder tumors

The initial diagnosis is made by a surgical intervention for biopsy, using a method abbreviated as TUR (Transurethral Resection), in which we enter the bladder through the urethra inside the penis, endoscopically remove the tumor within the bladder, and send it to pathology. This gives us information about the stage of the tumor, which tells us how deep it has gone into the layers of the bladder and how aggressive it is. This information is sufficient as a starting point. In superficial bladder tumors, that is, tumors that have not invaded the muscle tissue of the bladder, taking a sample with TUR is sufficient. To prevent recurrence afterwards, in some cases we apply intravesical drug treatments. If the tumor has invaded the muscle tissue of the bladder in the tissue sample, the treatment options are divided into two. The most effective treatment option is surgery. There is open surgery to completely remove the bladder, which is 85% effective in tumors that have not penetrated very deeply into the muscle layer of the bladder. Following this, of course, there is urinary diversion, a method we use to direct where urine will flow when there is no bladder. Here, a 15-20 cm segment of intestine is taken, which we call an "ileostomy", one end is connected to the ureter and the other end to the skin, with a bag applied outside. This is a system we call a urinary conduit. In suitable cases, it is also possible to create a new bladder, called an orthotopic bladder, using a larger amount of small intestine. Apart from this, in some cases, radiotherapy combined with chemotherapy is also among the options that are effective in the treatment of bladder tumors.

Bladder tumors after treatment

Superficial bladder tumors, that is, tumors located in the bladder muscle tissue, carry a risk of recurrence of 70% within five years, in proportion to the stage of the tumor and its degree of differentiation. With certain drug applications, chemotherapy or methods called immunotherapy, administered into the bladder once a week for 6 or 8 weeks, this rate of 70% is reduced to around 30%. In the very superficial layer of the bladder and in low-risk bladder tumors, the recurrence risk is around 5%. For these, we do not apply this drug treatment. For tumors that have gone somewhat deeper, the rate is 50%. Here there is a possibility of both recurrence and muscle involvement. The rate of progression to bladder removal surgery is also 50%. It must definitely be kept under control. For superficial tumors and invasive tumors with muscle involvement, we perform cystectomy. We remove the bladder and then, in order to monitor the upper urinary system rather than the inside of the bladder, we perform at least yearly radiological imaging, ultrasound every 3 months and blood tests. For superficial bladder tumors, we carry out checks every 3 months in the first year, every 6 months in the second year, and yearly thereafter. Generally, we monitor patients for life, but the first 5 years are very important.

Early diagnosis

With early diagnosis, superficial tumors are completely cured in 85-90% of cases.

Bladder tumors in the world and in Turkey

After lung, gastrointestinal and prostate cancers, bladder tumors come next. They are among the top 5 both in Turkey and in the world. As smoking rates decrease, these rates will also fall.

Diet and lifestyle to prevent bladder cancer

Apart from smoking, no lifestyle change is required, if we need to mention one. Eating fresh vegetables and fruit is very important. Getting enough vitamin C is necessary. Since there is no way to escape the environmental pollution brought by industry, there is currently nothing to be done about it.