Genitourinary Oncology

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Genitourinary Oncology

• April 17, 2007
• Benjamin Lowentritt, MD

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Why should you care?
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Goals

• Board Preparation
• Answer questions for your dad, uncle, brother,
  husband, boyfriend, etc.
• Help us out

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• Renal Cell Carcinoma

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Differential Diagnosis for Renal Masses

• Renal Cell Carcinoma
• Hydronephrosis
• Cyst
• Adenoma
• Urothelial Carcinoma (TCC)
• Angiomyolipoma
• Leiomyoma
• Lymphoma, Sarcoma, etc.

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Etiology

• No clear causative agent
• Genetic Conditions
• Von Hippel Lindau (3p tumor suppressor gene),
  associated with pheochromocytoma, retinal
  angiomas, hemangioblastoma of CNS
• Familial Papillary Renal Cell Carcinoma (7q)

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Histology

• Most arise from proximal convoluted tubule
• Clear Cell
• Papillary
• Granular
• Chromophobe

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Presentation of RCC

• Classic Triad Hematuria, flank pain,
  abdominal mass
• Now, 85 found incidentally on CT/Ultrasound for
  other reasons

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The Internists Tumor

• Paraneoplastic syndromes very common
• Hypercalcemia
• Hypertension
• Anemia
• Polycythemia
• Stauffers syndrome

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Preoperative Evaluation

• CT scan with and without contrast
• CBC, Comprehenseive metabolic panel, coags
• Urinalysis
• Chest x-ray
• ? Renal vein/Vena caval thrombus MRI
• Biopsy ?

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Treatment for Localized RCC

• Radical nephrectomy
• Removal of All organs within Gerotas fascia
• Recently, adrenal has been spared for tumors not
  in the upper pole
• Partial nephrectomy
• For tumors 4cm or less, 5 year survival data is
  90-100 with 2 local recurrence
• Ablative techniques
• Early data promising

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Staging

• Stage

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What about Laparoscopy?
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Laparoscopic Kidney Surgery

• Studies show no long term differences in
  oncologic outcome vs. open surgery
• Partial nephrectomy data shows enucleation is
  equivalent to a 1cm border of resection

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Laparoscopy will prevail!
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Treatment for Metastatic RCC

• Chemo?
• XRT?
• Surgery?
• Immunotherapy
• Interferon
• IL-2

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• Bladder Cancer

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Demographics

• More common in men, shorter survival in women
• Incidence linked to environmental factors
• Aniline Dyes
• Heredity
• ? Tea drinking
• ? Artificial sweeteners
• SMOKING!!!!
• Smokers have 4x risk
• 20 year washout once you quit

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Histology

• Most common in U.S. is Urothelial Carcinoma (TCC)
• Squamous cell is most common in world
• Adenocarcinoma rare
• Associated with congenital abnormalities

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Presentation

• Hematuria
• Microhematuria gt2rbc/hpf on multiple urinalyses
  should be evaluated!!!
• Voiding symptoms
• Urinary urgency refractory to normal treatments
  can be cancer

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Evaluation

• Upper tract evaluation
• IVP
• Ultrasound
• CT with and Without IV contrast
• Urine Cytology
• Cystoscopy

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Two Behavior Patterns

• Good Bladder Cancer
• Superficial
• Multifocal
• Low Grade
• High Recurrence Rate (70)
• Bad Bladder Cancer
• Invasive
• High Grade
• Associated with Carcinoma in situ (CIS)
• If untreated, approximate 2 year survival

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Management of Superficial Bladder Cancer

• Local resection (Trans-Urethral Resection of
  Bladder Tumor TURBT)
• Frequent surveillance cystoscopies
• Every 3 months for 2 years
• Every 6 months for 2 years
• Yearly thereafter
• Intravesical therapy

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Intravesical therapy

• BCG
• Stimulates local immune response
• Reduces Recurrence, not Progression
• Many other medications have been tried, many have
  failed

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Treatment for Muscle Invasive Bladder Cancer

• Radical cystectomy/cystoprostatectomy
• Urinary Diversion has several options
• Continent vs. Incontinent
• Orthotopic vs. Heterotopic
• Which bowel segment?
• Common Principles low pressure, ability to empty

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Continent Diversions Indiana Pouch
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UCLA Pouch
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Studer Pouch
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Hautmann Pouch
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Post-operative considerations

• Stoma complications
• Difficulty catheterizing
• Incontinence
• Electrolyte abnormalities
• Differs depending on intestinal segment used
• Pop Quiz!

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• Prostate Cancer

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Prostate Cancer Facts

• Prostate cancer
• Leading type of cancer in men (over 200,000
  diagnosed each year in U.S.)
• Second leading cause of cancer death in American
  males
• Over 30,000 deaths each year in U.S.
• Early Detection
• Best prognosis is early detection
• Recent data on lower mortality rates of prostate
  cancer
• Affords patients many options for treatment

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Early Detection

• Digital Rectal exam (DRE)
• Prostate Specific Antigen blood test (PSA)
• Age Adjusted
• Any abnormality in the PSA or DRE will require
• Biopsy of the prostate
• Ultrasound guided
• Usually performed in the office
• Short procedure

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Biopsy Results

• Prostate cancer graded on appearance of cancer
  cells
• Gleason grading system
• Gleason grade ranges from 1 (least aggressive) to
  5 (most aggressive)
• Gleason score (2-10)
• Most common cell grade (first) added to second
  most common cell grade
• i.e Gleason 7 (34)

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Staging of Prostate Cancer

• PSA
• Digital Rectal Exam
• Trans Rectal Ultrasound
• Gleason Score
• Bone Scan
• /- CT scan or MRI
• Biopsy and TNM staging system
• Tumor, Nodes, Metastases

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Prostate Cancer T1 Disease

• Cannot be felt
• T1a cancer found in 5 TURP specimen
• T1b cancer found in 5 TURP specimen
• T1c cancer found as a result of PSA elevation
  only

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Prostate Cancer T2

• Can be felt during DRE (digital rectal exam)
• T2a felt on one side of prostate
• T2b felt on both sides of prostate

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Prostate Cancer T3

• Has spread beyond the prostate
• T3a extra capsular extension
• T3b tumor invades seminal vesicle(s)

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Prostate Cancer T4

• Cancer has invaded local organs
• Bladder invasion
• Invasion into surrounding pelvic side wall
• May cause pain in joints and back

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Treatment Options

• Dependent upon
• Stage of disease
• Patients age and health
• Patients personal preference
• Urologists experience
• Technology available

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Prostate Cancer Treatment Menu

• Watchful waiting
• External Beam Radiation Therapy
• Brachytherapy (Radioactive seeds)
• Cryosurgery (Freezing prostate)
• Surgery (Radical Prostatectomy)
• Open Surgery (Retropubic and Perineal)
• Conventional Laparoscopic Surgery
• da Vinci Prostatectomy (Robotic Laparoscopic
  Surgery)

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Goals of Radical Prostatectomy

• Remove the prostate and cancer
• High cure rates for localized disease
• Preserve urinary function
• Preserve erectile function
• Analyze the prostate after surgery to assess risk
  of recurrence of cancer

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Nerve-sparing Prostatectomy

• Preserve nerves responsible for erections
• Nerves run alongside prostate

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Laparoscopic Surgery

• Minimally invasive surgery
• Ability to operate through small keyhole
  incisions
• Camera and instruments fit through the keyhole
  incisions
• Better visualization than open surgery

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Conventional Laparoscopic Surgery Drawbacks

• 2D flat image video
• Rigid instruments - chopsticks
• Instruments controlled at a distance - fulcrum
  effect
• Decreases your surgeons precision, dexterity and
  control
• Higher surgeon fatigue
• Makes complex operations more difficult

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How can we overcome these drawbacks?

• Provide a high resolution 3D color image
• Interpose a computer between the surgeons hand
  and the instrument tip
• Increase the surgeons dexterity for the
  difficult aspects of the procedure
• Sparing the nerves to preserve erectile function
• Preserving continence
• Vesical-urethral anastamosis
• Preserving quality of life

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da Vinci Surgical System (Technology Overview)
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What is the da Vinci Surgical System?

• A computer enhanced surgical system
• The system places the surgeon in control
• Surgeon operates at the console
• Bedside surgeon is next to the patient

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da Vinci System Console

• Surgeon is immersed in 3-Dimensional image of
  surgical field

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Wrist and Finger Movement

• Traditional laparoscopic instruments are straight
  and do not bend
• da Vinci instruments move like a human wrist
• Allows increased dexterity, maneuverability, and
  precision

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The Surgeon Directs The Instruments

• The surgeons hands are placed in special devices
  that direct the instrument movement

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Small Instruments through Keyhole Incisions

• Instruments of the da Vinci Surgical System are
  small and fit through keyhole incisions
• A wide range of instruments are available

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Robotic-Assisted Radical Prostatectomy Surgical
Steps
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Ligation of Dorsal Vein Complex
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Urethrovesical Anastomosis
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Data Outcomes
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Continence Overview
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Bilateral Nerve Sparing
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Positive Margins
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Open vs. Robotic Radical Prostatectomy

• Single surgeon experience Me vs. Me
• Data showed only advantage to robotic approach
  was decreased EBL
• This surgeon now only does robotic prostatectomy
• Why? Because his patients prefer it.

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Patient Benefits
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Benefits of the da Vinci Prostatectomy

• Decreased blood loss
• Shortened length of hospital stay
• Decreased postoperative pain
• Less scarring
• Shorter urinary catheter time
• Faster return to regular activities
• Anticipation of improved potency and continence

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Robotic-Assisted Surgery Access
Open Surgical Incision da Vinci
Surgical Incision
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Compare the Benefits

• Open Procedure
• Long Incisions
• Hospital stay of 3.5 days
• Blood loss 900 ml
• Catheter removal 14 to 21 days
• Robotic-Assisted Procedure
• 5 or 6 small keyhole incisions
• Hospital stay of 1.2 days
• Blood loss 153 ml
• Catheter removal 5 to 7 days

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• The benefits of the da VinciTM robot
• Center for high tech health care
• Maintain and increase referral patterns
• Brings in new patients
• Enhances residency and fellowship training
  programs

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Thank you!!

• I hope this was adequate.