Kidney Cancer

About Our Chief URO Surgeon DR.AVISHEK MUKHERJEE

Dr Avishek Mukherjee has pioneered the first totally laparoscopic nephron sparing surgery for early kidney cancer, in Eastern India in the year 2005. He has also performed total laparoscopic radical prostatectomy for prostate cancer in the year 2005, also the first in Eastern India.

WHY DO KIDNEY CANCERS OCCUR?

Kidney cancers are most commonly renal cell cancers, which can occur due to multiple reasons, but smoking is the commonest and most frequent reason for development of kidney cancers. However some patients may have genetic predisposition for the development of renal cancers.

WHAT IS THE USUAL PRESENTATION OF KIDNEY TUMORS?

The most common presentation is bleeding in the urine. However some patients may have a feeling of heaviness in the upper and lateral part of the abdomen. When a large amount of bleed occurs some patients have clot colic, due to passage of clots within the ureter. With routine screening ultra-sonography some tumors can be detected in the preclinical stage, which is ideal since these patients can almost always be cured after treatment, with very high success rate.

HOW ARE THEY DIAGNOSED?

When a kidney mass is suspected then the uro-surgeon advises initial ultrasonography and later for accurate staging a ct scan of the abdomen is always performed. To assess the extent of the spread of the tumor, a chest xray and liver function test are also performed.

Today PET CT scan is performed to assess more accurately the spread of the disease, since even small distant spread can be accurately diagnosed therefore better treatment can be planned.

WHAT IS THE CURRENT DAY GOLD STANDARD MANAGEMENT FOR RENAL TUMORS?

The best treatment for renal tumors is surgical excision using advanced laparoscopy. This allows the tumor along with the affected damaged kidney to be removed, along with the envelope of fat and fascia surrounding the kidney. Along with removal of the tumor, the lymph nodes are also removed.

WHAT IS NEPHRON SPARING SURGERY?

In early detected kidney cancers, nephron sparing approach is recommended. This means removal of the smaller early detected renal mass, generally less than 4 cm, but sparing the rest of the unaffected kidney, allowing the patient to be cancer free at the same time preserving as much renal function as possible. This procedure was earlier performed by open surgery, however with advent of advanced laparoscopy, now this surgery can be best performed by minimal access route, allowing the patient the benefit of cancer freedom and early and rapid recovery

Bladder Cancer

WHAT IS THE USUAL PRESENTATION FOR BLADDER TUMORS?

The commonest presentation for bladder tumors is bleed in the urine which is generally painless. However if a large volume of bleed occurs then the patient may have clot retention of the urine, which can be very painful.

HOW ARE SUPERFICIAL BLADDER TUMORS BEST DIAGNOSED?

Initial ultra-sonography is the best screening tool for bladder mass detection. However the gold standard for bladder mass detection is flexible cystoscopic evaluation of the patient. This procedure is performed on an outdoor basis. The procedure is done under local anesthesia. Since the patient is fully conscious he can see the procedure while having little or no pain, since the examining telescope is flexible.

WHAT IS THE MANAGEMENT FOR SUPERFICIAL BLADDER CANCERS?

The most common variety of bladder tumors are the superficial tumors. These are not invasive and therefore do not breach the bladder muscle wall. Therefore although these tumors can recur they do not change or reduce the life expectancy of the patient. These tumors generally are caused by habitual smoking.

WHAT IS TURBT?

Trans-urethral resection of bladder tumor or TURBT, is the gold standard treatment for superficial bladder tumors. This procedure is performed via the urine passage without the need to place any incision. The uro-surgeon using a resectoscope can visualize the tumor and resect the tumor using electrical or laser energy. Once the tumor is resected then the base of the tumor is sealed to control the chance for bleed. The patient is usually discharged after three days, and needs to take rest at home for 2 weeks after the procedure. This is essential since the bladder tumor resection wound heals completely in 2 weeks time, therefore the rest allows unhindered healing of the tumor scar.

WHAT IS THE PROGNOSIS AND FOLLOW UP FOR SUPERFICIAL BLADDER CANCERS ?

The prognosis of superficial bladder tumor management is excellent, provided the patient quits smoking completely. The patient leads a normal and healthy life with normal life expectancy. However the patient is maintained on follow up with periodic check cystoscopy. This procedure is performed at increasing interval of time, and since it is a painless day care procedure therefore the patients quality of life remains excellent.

WHAT ARE INVASIVE BLADDER CANCERS?

One out of ten bladder cancers can be aggressive and invasive. These tumors have the tendency to spread locally outside the bladder wall and also spread via the blood stream to distant organs like the liver and the lungs. This tumor has to be diagnosed by a transurethral bladder biopsy. Once diagnosed the tumor along with the affected bladder should be removed without further delay.

WHAT IS THE MANAGEMENT FOR INVASIVE BLADDER CANCERS, RADICAL CYSTO-PROSTATECTOMY?

Radical cysto-prostatectomy is the gold standard and till date the best curative option for the management of bladder tumors which are invasive in nature. This surgery performed by laparoscopy or by open surgical incision removes the entire bladder along with its enveloping fat, its drainage lymph nodes along with the prostate. After such a surgery the ureters are drained via an ileal conduit. This conduit drains the urine through a urostomy bag attached by adhesive to the lower part of the abdomen.

CONTINENT URINARY DIVERSION AFTER RADICAL CYSTOPROSTATECTOMY

After the bladder and the prostate has been removed in a case with advanced cancer of the bladder, the kidneys cannot drain the urine directly to outside the body via the penis.

In this case a new bladder can be created. This neobladder can be used to replace the cancer damaged older bladder. This bladder is created from the patient’s small intestine.

The surgeon harvests 70 cm of the intestine, this tubular structure is then de-tubularized to create a pouch. This pouch is then attached to the two ureters. (Ureters are the tube via which the kidneys drain the urine into the bladder)

The surgeon then attaches this bladder to the urethra, which is the tube which drains the urine via the penis in the male to outside the body.

This procedure is possible in organ confined cancer, wherein the cancer is removed and the patient is able to get a new bladder created replacing the older damaged bladder. He is also able to pass urine via the normal urine passage.

NEO BLADDER RECONSTRUCTION

NEO BLADDER SUBSTITUTION

Bladder invasive cancer in females

Bladder cancer is more common in males. And has a direct correlation with smoking cigarettes and Bidi. However females can also be affected by this cancer.

When the cancer becomes invasive then there is a chance of spread to distant sites in the body and there is risk to life.
In these cases the best management is laparoscopic radical cystectomy. This sugery can cure these patients since the affected bladder along with the uterus and a cuff of the vagina is removed .
This surgery can nowadays be performed by laparoscopy wherein the patient has lesser invasion and therefore faster recovery. Laparoscopy means the organ removal is performed via five small ports (small incisions)

After removal of the bladder cancer we also create a new passage for passage of urine. We can create a new bladder in patients with early bladder cancers. This bladder is created from the patients own intestine. And patient can pass urine via the normal urine passage. However in advanced cancer we create a new passage called an ilial conduit for the urine to pass from a new opening created in the right lower part of the abdomen. A bag can be attached to this mouth so urine can be collected within this bag. Therefore bladder cancer even if life threatening, can be cured today by keyhole surgery.

Prostate Cancer

Prostate Cancer and its management. Prostate cancer is one of the commonest cancers affecting males above the age of 50 years.

RISK FACTORS FOR PROSTATE CANCERS.

Men who consume diet rich in fats are more prone to development of prostate cancer. Also men with family history of prostate cancer are more likely to develop prostate cancer, therefore they should be screened regularly after the age of 40 years.

Prostate Cancers

HOW ARE PROSTATE CANCERS DETECTED?

Prostate cancers are best detected by trans-rectal prostratic sampling using a trucut needle. This procedure is used when the PSA is more than 4ng/ml or shows a rising trend in spite of medication.

HOW TO PREVENT PROSTATE CANCERS?

Prostate cancers are best prevented by leading a active and healthy physical and sexual life. Food which are red in color like tomato, carrots, pomegranate and papaya can also reduce the chance of prostate cancer development. Intake of green tea also reduces chance of development of prostate cancer.

WHAT IS THE MANAGEMENT FOR ORGAN CONFINED PROSTATE CANCER?

Organ confined cancers are early prostate cancers which have not spread beyond the limits of the prostate. This is confirmed by a PSA level less than 15, and a MRI pelvis scan demonstrating no local spread. Also a bone scan demonstrates the absence of bone spread. In these cancers the surgeon performs laparoscopic radical prostatectomy to resect the tumor and remove the prostate along with its fascial envelope and lymph nodes. This entire procedure is performed by five small puncture incision in the abdominal wall, therefore allowing the patient rapid recovery from the surgery.

WHAT IS TESTOSTERONE DEPRIVATION TREATEMENT?

For advanced prostate cancers, which have PSA more than 15, a gleason grade more than 7, and evidence of spread in MRI and bone scan, the best management is deprivation of the male hormone testosterone. Prostate cancer cells are hormone dependent and therefore deprivation of testosterone reduces the tumor volume and rate of growth of the tumor. This is performed by removal of the testicle using local anesthesia as a day care procedure. For patients who do not want surgery, an alternative injection therapy is also available. This injection is to be repeated at every six monthly interval lifelong. Prostate cancer is a slow progressing cancer. Therefore even among patients with advanced disease, a fairly long life expectancy is achievable using hormone deprivation therapy.

WHAT IS THE MANAGEMENT FOR HORMONE DEPRIVATION REFRACTORY PROSTATE CANCER?

In later stages when the cancer cells become even more aggressive and refractory to testosterone deprivation, then the patient demonstrates increase in levels of PSA, which indicates return of the active malignancy. In this stage second line medication like abiritarone are available, which can provide an extension of the disease symptom free survival of the patient.