Bladder and prostate cancer

‡ Mahmoud Al-Akraa ‡ Consultant Urological Surgeon ‡ The Royal Free Hospital

Bladder cancer/ anatomy
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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.

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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 .

long term catheter . analgesics (Phenacetin). Cyclophosphamide. rare in less than 30 years old and more common over 60 year old ‡ Smoking implicated in 40% ‡ Dye industry. ‡ Bladder augmentation.Risk factor ‡ Age. beta naphthalene other chemicals ‡ Medications.

positive urine cytology or Mets ‡ LUTS .Bladder cancer / presentation ‡ Haematuria ± 90% painless frank or microscopic ‡ Painful haematuria ‡ Clot retention ‡ Incidental at cystoscopy or bladder imaging.

e. infections. TB. inflammations.Haematuria ‡ ‡ ‡ ‡ Urological instrumentation and trauma Urothelial tumours Bening hyperplasia and malignant prostate Urinary tract stones. beetroot . Schistosomiasis ‡ Clotting disorders or anticoagulants ‡ Medications which make urine red i. Rifambicine and potaba ‡ Food.

Haematuria and upper tract .

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The bladder and haematuria .

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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 .

Clotting.Haematuria/ investigation ‡ Investigations are directed towards diagnosing bladder cancer or any other cause of haematuria ‡ Routine and non specific (FBC. LFTs and U&Es) ‡ Investigations to cover the whole urothelium ‡ 90% of TCC in the bladder ‡ The prostate is the main cause for haematuria .

filling defect in renal pelvis.Haematuria/ investigation ‡ PSA if high ?Ca Prostate ‡ Urine cytology looking for malignant cells ‡ IVU. direct vision ‡ Retrograde study and endoscopy of upper tract . ureter or bladder ‡ Flexible cysto-urethroscopy.

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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 staging and grading ‡ For prognosis.

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or BCG ‡ Systemic chemotherapy ‡ Radical surgery /cystoprostatectomy +/urethrectomy and either bladder reconstruction or ileal conduit urinary diversion . Mitomycine C.Bladder tumour treatment ‡ TURBT and surveillance. majority of patients/ good pronosis for non muscle invasive/ low grade ‡ Intravesical agents.

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The Prostate .

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Prostate anatomy .

Zonal anatomy of the prostate .

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Prostate cancer .

and whites less in far east . much higher after 65 ‡ Major concern to males and very costly for the government ‡ More common in black WI.Prostate cancer ‡ 2nd most common male tumours ‡ From 40th onwards and increased incidence with older age.

Prostate cancer ‡ About 10-15% familial ‡ Increased risk of 1st and 2nd degree male relatives ‡ High fat diet is a risk factor .

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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 .

nocturia and urge urinary in continence ‡ Haematuria. intermittency. straining. Incontinence and pain are part but not LUTs . Hesitancy.Lower urinary tract symptoms Voiding (obstructive) Poor/variable flow. urgency. incomplete emptying and terminal dribbling Storage/filling (irrigative) Frequency of micturation.

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 .

ISIS Medical Media. 2000. et al.suggests prostatitis Reproduced with kind permission of Martin Dunitz Ltd 1. .normal Hard or woody . Shared Care for Prostatic Diseases (2nd Edition).may indicate cancer Tender .BPH Smooth or elastic . Kirby R.normal Size of a satsuma .Digital Rectal Examination DRE1 ‡ Size: ‡ Consistency: Size of a chestnut .

Palpable and visible bladder .

LA 14 cores or more IF ‡ Rectal examination is abnormal ‡ OR High PSA for patient age ‡ OR Both ‡ OR unexplained sclerotic bone lesions .Investigations Trans rectal ultrasound scan and biopsy of the prostate gland.

phos. Alk.Prostate cancer investigation ‡ Urinary flow measurement ‡ Urinary tract ultrasound scan to asses bladder emptying and upper tract obstruction ‡ U&Es. ‡ If biopsy confirms cancer then to proceed for staging investigations MRI scan pelvis and Bone scan . Serum calcium. PSA.

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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 .

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Prostate cancer staging .

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Prostate cancer mets .

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