Urological Oncology is one of the fields of medicine that has seen the evolution of the medicine as a whole. It has varied from application of Laparoscopy, minimally invasive techniques to the field and now Robot-assisted procedures. This foray has been supplanted by the inclusion of many newer and advances Oncological products such as Chemotherapy and other targeted therapies. Theses newer modalities have been increasing the survival and mitigating side effects of the chemotherapy.
Add to it and we have immunological modulators that have potentiated many breakthroughs.
As far as Cancer Care in Urology is concerned, it can be looked upon as preventive, treatment guided and metastatic and palliative therapies.Or they can be taken organ of concern by the order: Kidney, Ureter, Bladder, Prostate, and Urethra.
All strategies of treatment and cure i.e preventive, treatment and palliative have seen a steady breakthrough in the last two decades for Urology.
Starting with Preventive therapies
Universal application for Ultrasound in detecting an early disease has been a significant tool in early diagnosis of tumors and change in the character of seemingly benign disease on Ultrasound scans. More important than universal availability has been the harmless nature of these scans and the ease of application.
Also, these Ultrasound scans can be combined with biopsy and therapeutic procedures also
Also PSA or Prostate Specific Antigen screening that spearheaded cancer Prostate control, awareness, and treatment and led to a phase shift in the management of the disease in the west.
This protein secreted by the prostatic epithelium has been utilized in deciding the disease management and therapy in many areas especially detecting treatable cancer Prostate
Multiparametric MRI ( Magnetic Resonance Imaging ) has imitated the advancements in cross-sectional imaging and solid-state physics of the last century,This has taken the tissue characteristic of cancer versus normal tissue to the molecular levels and the alteration of ‘signal’ by these tissue under MRI can help us detect the significant disease versus nonsignificant ones. These also help in evaluating the disease spread as well an ‘operability’ or ‘spread’ of the disease especially prostate.
MRI has also been applied in various settings in the kidney cancer management and detecting the disease in time.
Of late has been a thrust on the diagnosis of cancer of Bladder with reasonable certainty using’Urine tests’ alone. These newer markers such as UROVYSION has found a reasonable place and approval in the international studies testing the reliability and retest ability.
Amongst the therapeutic enhancements, there has been the arrival of the surgical robot the Da Vinci platform that has evolved over laparoscopy and take the surgical frontiers forward to 3 D image-guided surgery. This has been especially helpful in painstaking pelvic surgeries such as prostate cancer surgeries which need painstaking anastomosis and nerve preservation for potency preservation and urine control.
But these have been successfully applied to other cancers as well such as bladder cancer as well as kidney cancers where smaller kidney masses have been removed from the kidneys instead of the whole kidney itself.
The da Vinci system especially and evolving generations of these surgical robots have contributed immensely to development and facilitation of surgical expertise in cancer care for every organ.
Palliative and advanced cancer management :
Targeted therapy: This is designated to therapies that target an organ and its disease at a molecular level and slow down the progression.
These are likely to slow down a certain step of progression fo the cell cycle division by slowing down the enzyme or catalyst looking at the division of cells.
A number of these molecules have seen evolution throughout the years and include Tyrosine kinase inhibitors and their congeners
These have seen an application, particularly in advanced kidney tumors.
Chemotherapy such as Taxanes has been applied in Prostate cancer survivors after they tend to have an elevated PSA.
Drugs like Abiraterone and Enzulatemide have seen an arrival on the Uro Oncology scenario after they have been approved by various trials ( STAMPEDE, LATITUDE) which are multi-armed trials that have seen improvement in the survival chances as well as the reduction in side effects.
FAQs
1. What are the chances of cancer if I have blood in urine
Although it is the non cancerous diseases that are more commonly the cause of blood in urine but one needs to be evaluated in detail before coming to a conclusion. These usually need a battery of tests including urine examination, History and general physical examination which may include a digital rectal examination.
Also, a Contrast-enhanced CT may be required before detecting the elusive disease
Blood in urine may be due to tumors of the kidney, cancer of ureter, cancer of bladder and cancer of prostate
2. Does an elevated PSA mean I have prostate cancer
PSA or Prostate Cancer Antigen is a protein secreted into the blood by the prostatic epithelium and can be elevated in myriad of causes such as infection, inflammation and digital rectal examination. A baseline test only gives us informationa bout further evaluation. The history and examination of the patient must be taken into due consideration before coming to any conclusion.
These may include antibiotic therapy, repeat value after 4 weeks and MRI to further evaluate doubtful areas.
3. What is the most common sign of bladder cancer
The most common sign of bladder cancer is bleeding in urine or haematuria. It may be associated with an Ultrasound detectable bladder mass or tumor or clots filling the bladder
4. What if I have elevated PSA
Elevated PSA means the evaluation of the cause and if no infection or Beni clinical cause can be found then arranging a Trans-Rectal Ultrasound guided biopsy of the prostate. These days if the PSA is only slightly elevated MRI has been seen helpful in avoiding unintended biopsies which carry a definitive risk of sepsis and haematuria itself.
Also now we have MRI TRUS fusion guided biopsies which have been helpful in detecting significant disease at the right time.
5. What after I have detected Bladder mass
If you have on evaluation found to be harbouringa bladder mass then the next step in diagnosis and management is Transurethral resection of a tumor or TURBT. This helps in rendering the mass or a tumor to pathological or microscopic examination. The procedure as name suggests is an endoscopic procedure and is done through a device that passes through the urinary meatus
6. What is muscle-invasive bladder cancer
MIBC or Muscle invasive bladder cancer is a disease diagnosed after TURBT which characterizes the tissue resected into superficial or deep ( Invading the detrusor) disease.
The Urinary bladder has a middle layer of detrusor muscle that helps contract the bladder upon filling with urine. It is this layer which if invaded implies a poorer type of cancer and define the next step of therapy i.e Radical Cystectomy. But this radical procedure may also be needed in many other indications such as when the disease burden of noninvasive disease in very high or flagrant CIS
7. How long is the hospital stay after Robot-assisted radical prostatectomy
If you are found to have prostatic cancer on biopsy of prostate then there are chances that you will be advised between Robot-assisted radical prostatectomy or radiotherapy. RARP, as it is called, has manifold reduced the hospital stay and complications associated with this procedure. The ease of application and reliability of replication at other centres has helped patient accept the procedure and take a positive outlook towards the disease.
Usually expected : discharge at day 2 to 3
Catheter removal at day 7 to 14
Chances of return of urine control 50% by 3 months, 75% by 6 montsh and over 95% after 1 year
8. What is partial Nephrectomy
Robot assisted partial Nephrectomy or RAPN id robot assisted procedure used for small renal masses or kidney tumours that have been removed in to from the kidney using the Da Vinci Platform. These tumor excision surgeries have been found to be as safe and effective and with adequate cancer control as compared to a radical nephrectomy. These are complex surgeries which detail into the blood supply of the kidney and many times need temporary occlusion of theses blood vessels for adequate removal
