Bladder and prostate cancer

• Mahmoud Al-Akraa
• Consultant Urological Surgeon
• The Royal Free Hospital
 Bladder cancer/ anatomy

•• The bladder wall

– Inner layer ( urothelium) is transitional cells type
epithelium, It is the same for renal collecting system,
ureters, prostate collecting ducts and urethra
– Second layer is lamina propria
– Then superficial and deep muscle layers
– And outer coat( serosa)
 Bladder/ Histology

Cancer arises on the urothelium - Transional cell

carcinoma in 90% of cases
Different types of bladder cancer occur either because
of fetal reminent (Urachus) or bladder urothelial
metaplasia to intestinal/glandular type,
Squamous metaplasia in chronic infectios, long term
catheterisation or others these give riseadeno
carcinoma, squamous cell carcinoma
In addition there are less frequent tumours e.g.
small cell carcinomas.
 Bladder cancer incidence

• 5th most common cancer

• Affect about 10.000 a year
• Mostly superficial (do not invade bladder
wall muscularis) and of low grade
• Affect men more than women
• Not familial but gene mutation as in P53 is
a high risk
 Risk factor
• Age; rare in less than 30 years old and more
common over 60 year old
• Smoking implicated in 40%
• Dye industry, beta naphthalene other
chemicals
• Medications, Cyclophosphamide,
analgesics (Phenacetin),
• Bladder augmentation, long term catheter
 Bladder cancer / presentation

• Haematuria
– 90% painless frank or microscopic
• Painful haematuria
• Clot retention
• Incidental at cystoscopy or bladder
imaging, positive urine cytology or Mets
• LUTS
 Haematuria
• Urological instrumentation and trauma
• Urothelial tumours
• Bening hyperplasia and malignant prostate
• Urinary tract stones, inflammations, infections,
TB, Schistosomiasis
• Clotting disorders or anticoagulants
• Medications which make urine red i.e.
Rifambicine and potaba
• Food; beetroot
Haematuria and upper tract
The bladder and haematuria
Bladder cancer/ clinical findings

• Anaemia, Wt loss
• Palpable bladder/mass (abdominal, rectal or
vaginal examination
• Large/suspicious prostate gland
• Invasion of the vagina or pelvic organs
• Vesico vaginal or colo vesical fistula
• Generally minimal clinical findings
 Haematuria/ investigation
• Investigations are directed towards diagnosing
bladder cancer or any other cause of haematuria
• Routine and non specific (FBC, Clotting, LFTs
and U&Es)
• Investigations to cover the whole urothelium
• 90% of TCC in the bladder
• The prostate is the main cause for haematuria
 Haematuria/ investigation

• PSA if high ?Ca Prostate

• Urine cytology looking for malignant cells
• IVU, filling defect in renal pelvis, ureter or
bladder
• Flexible cysto-urethroscopy, direct vision
• Retrograde study and endoscopy of upper
tract
Bladder tumour staging and grading

• For prognosis, treatment option,

communication and publication
• By histopathologist from resected tumour
• CT scan IVU, abdo pelvis and chest only fo
muscle invasive or high grade tumours
• Bone scan
 Bladder tumour treatment
• TURBT and surveillance, majority of patients/
good pronosis for non muscle invasive/ low grade
• Intravesical agents, Mitomycine C, or BCG
• Systemic chemotherapy
• Radical surgery /cystoprostatectomy +/-
urethrectomy and either bladder reconstruction or
ileal conduit urinary diversion
The Prostate
Prostate anatomy
Zonal anatomy of the prostate
Prostate cancer
 Prostate cancer

• 2nd most common male tumours

• From 40th onwards and increased incidence
with older age, much higher after 65
• Major concern to males and very costly for
the government
• More common in black WI, and whites less
in far east
 Prostate cancer

• About 10-15% familial

• Increased risk of 1st and 2nd degree male
relatives
• High fat diet is a risk factor
 Prostate cancer Presentation

• LUTs
• Mets and pathological fructures
• Complications of enlarged Ca Prostate
– Retention of urine
– Haematuria
– Urine infection and bladder stones
– Obstructive renal failure
 Lower urinary tract symptoms
Voiding (obstructive)
Poor/variable flow, Hesitancy, intermittency,
straining, incomplete emptying and terminal
dribbling

Storage/filling (irrigative)
Frequency of micturation, urgency, nocturia and
urge urinary in continence
• Haematuria, Incontinence and pain are part but not
LUTs
 Prostate cancer/ presentation
• Incidental
– Rectal examination
– High PSA
– TURP for BPH
– Abnormal X ray or CT scan
– Pathological #s
– Bone pain
– general
 Prostate cancer clinical

• Rectal examination
– Large, firm, asymmetrical
– Discrete hard nodule
– Hard rock one or both lobes
– Fixed to pelvic organs
• Palpable bladder
 Digital Rectal Examination
DRE1

• Size: Size of a chestnut - normal

Size of a satsuma - BPH

• Consistency: Smooth or elastic - normal

Hard or woody - may indicate cancer
Tender - suggests prostatitis

Reproduced with kind permission of Martin Dunitz Ltd

1. Kirby R, et al. Shared Care for Prostatic Diseases (2nd Edition). ISIS Medical Media. 2000.
Palpable and visible bladder
 Investigations

Trans rectal ultrasound scan and biopsy of the

prostate gland, LA 14 cores or more IF
• Rectal examination is abnormal
• OR High PSA for patient age
• OR Both
• OR unexplained sclerotic bone lesions
 Prostate cancer investigation
• Urinary flow measurement
• Urinary tract ultrasound scan to asses
bladder emptying and upper tract
obstruction
• U&Es, PSA, Serum calcium, Alk.phos.
• If biopsy confirms cancer then to proceed
for staging investigations MRI scan pelvis
and Bone scan
 Prostate cancer , Grading

• Gleason grade
– It looks at prostate cancerous gland by
microscope at power 10
– Gleason 2 glands smaller and crowded and
packed
– Gleason 3 Glandular anastomosis
– Gleason 4 fracture/damaged glands
– Gleason 5 loss of glandular pattern
 Prostate cancer Gleason grade
• It is made of 2 numbers
• All areas of cancer in the prostate specimen
are graded from 2 to 5
• The highest number first
• Gleason grading is the best so far
• It is very important prognostic factor and
has implication on diagnosis, treatment
choice and prognosis
Prostate cancer staging
Prostate cancer mets