CANCER OF THE URINARY BLADDER

Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra). The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and excreted from the bladder through the urethra.

Bladder cancer usually originates in the bladder lining, which consists of a mucous layer of surface cells called transitional epithelial cells, smooth muscle, and a fibrous layer. Tumors are categorized as low-stage (superficial) or high-stage (muscle invasive).

More than 90% of cases originate in the transitional epithelial cells (called transitional cell carcinoma; TCC). Then next most common type is squamous cell carcinoma caused by Schistosoma haematobium (parasitic organism) infection and is often times associated with a long standing urinary bladder stone. Rare types of bladder cancer include small cell carcinoma, carcinosarcoma, primary lymphoma, and sarcoma.

Incidence of bladder cancer increases with age. People over the age of 70 develop the disease 2 to 3 times more often than those aged 55–69 and 15 to 20 times more often than those aged 30–54.
Bladder cancer is 2 to 3 times more common in men. Bladder cancer is the fourth most common type of cancer in men and the eighth most common type in women.

CAUSES AND RISK FACTORS
Cancer-causing agents (carcinogens) in the urine may lead to the development of bladder cancer. Cigarettte smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk.

Other risk factors include the following:

• Age
• Chronic bladder inflammation (recurrent urinary tract infection, urinary stones)
• Consumption of Aristolochia fangchi (herb used in some weight-loss formulas)
• Diet high in saturated fat
• Exposure to second-hand smoke
• External beam radiation
• Family history of bladder cancer (several genetic risk factors identified)
• Gender (male)
• Infection with Schistosoma haematobium (parasite found in many developing countries)
• Personal history of bladder cancer
• Treatment with certain drugs (e.g., cyclophosfamide—used to treat cancer)

Exposure to carcinogens in the workplace also increases the risk for bladder cancer. Medical workers exposed during the preparation, storage, administration, or disposal of antineoplastic drugs (used in chemotherapy) are at increased risk. Occupational risk factors include recurrent and early exposure to hair dye, and exposure to dye containing aniline, a chemical used in medical and industrial dyes.

Workers at increased risk include the following:

• Hairdressers
• Machinists
• Printers
• Painters
• Truck drivers
• Workers in rubber, chemical, textile, metal, and leather industries

SIGNS AND SYMPTOMS

The primary symptom of bladder cancer is blood in the urine (hematuria). Hematuria may be visible to the naked eye (gross) or visible only under a microscope (microscopic) and is usually painless.
Other symptoms include frequent urination and pain upon urination (dysuria).

DIAGNOSIS

Diagnosis of bladder cancer includes urological tests and imaging tests. A complete medical history is used to identify potential risk factors (e.g., smoking, exposure to dyes).

LABORATORY TESTS

• Urinalysis (to detect microscopic hematuria)
• Urine cytology (to detect cancer cells by examining cells flushed from the bladder during urination)

IMAGING TESTS

Ultrasound

This is the initial test performed and most patients come to the urologist with an ultrasound report.

Computed Tomography

More and more frequently computed tomography (CT) without and with intravenous contrast has replaced intravenous pyelography (IVP) the evaluation of hematuria. With computer-assisted reconstruction, longitudinal views of the urinary tract can now be made, although their sensitivity in detecting small or flat tumors of the urothelium is limited.

Intravenous Pyelography

If CT is not performed, IVP is indicated in all patients with signs and symptoms suggestive of bladder cancer. Urography is not a sensitive means of detecting bladder tumors, particularly small ones. However, it is useful in examining the upper urinary tracts for associated urothelial tumors. Large tumors may appear as filling defects in the bladder on the cystogram phase of the urogram. Ureteral obstruction caused by a bladder tumor is usually a sign of muscle-invasive cancer. Additionally, of course, IVP can assess other upper tract abnormalities that may affect management decisions.

Treatment
Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and the patient's age and overall health. Options include surgery, chemotherapy, radiation, and immunotherapy. In some cases, treatments are combined (e.g., surgery or radiation and chemotherapy, preoperative radiation).

Cancer of the Kidney

There are several types of cancer found in the kidneys. Renal cell carcinoma (RCCA), the most common form, accounts for approximately 85% of all cases. In RCCA, cancer (malignant) cells develop in the lining of the kidney's tubules and grow into a tumor. In most cases, a single tumor develops, although more than one tumor can develop within one or both kidneys.

Early diagnosis of kidney cancer is important. As with most types of cancer, the earlier the tumor is discovered, the better is the patient's chances for survival. Tumors discovered at an early stage often respond well to treatment. Survival rates in such cases are high. Tumors that have grown large or spread (metastasized) through the bloodstream or lymphatic system to other parts of the body are more difficult to treat and present an increased risk for mortality.

Studies have shown that certain lifestyle factors can increase the risk of developing kidney tumors. Smoking, having high blood pressure, eating a high-fat diet, and being overweight all may contribute to an increased risk of kidney cancer.

RISK FACTORS

Although we do not know all the causes of kidney cancer, the following factors can also increase the risk of developing this disease:

* long-term dialysis, a process in which a machine filters the blood of a person without functioning kidneys

* exposure to asbestos, such as occupational exposure

* exposure to cadmium, a metal that can increase the cancer-causing effect of smoking

* a family history of kidney cancer

* von Hippel-Lindau disease, a syndrome caused by a genetic mutation that leads to multiple tumors in the kidney, often at an early age

* tuberous sclerosis, a disease characterized by several bumps on the skin, seizures, mental retardation, and cysts in the kidneys, liver, and pancreas

SYMPTOMS

Kidney cancer usually shows no symptoms in the early stages. It is generally not suspected until the patient begins to experience symptoms, and at this point the tumor may have grown fairly large.

As the cancer progresses, symptoms may include some of the following:

* Abdominal mass or lump
* Blood in the urine (hematuria)
* Fever
* High blood pressure (hypertension)
* Pain in the side (flank) or lower back not associated with injury
* Persistent fatigue
* Rapid, unexplained weight loss
* Swelling (edema) in the legs and ankles

DIAGNOSIS

Blood tests :
1) CBC
3) Creatinine
3) Calcium

Imaging tests:

1)Ultrasound

2)CT Scan/MRI



STAGING



TREATMENT

Surgery is the standard treatment for RCC. There are several surgical options, depending on the stage of the disease and the overall health of the patient.

Partial Nephrectomy: Kidney-Sparing Surgery

Kidney-sparing (or nephron-sparing) surgery is the term used to describe the procedure in which a kidney tumor is removed, leaving a margin of normal kidney tissue in order to preserve the function of the remaining kidney. Studies have demonstrated that partial nephrectomy yields comparable results to complete nephrectomy in patients with small tumors (less than 4 centimeters), while maintaining functioning kidney tissue.

Radical Nephrectomy

In some situations, the entire kidney needs to be removed. Tumors that require complete nephrectomy tend to be larger in size and to have advanced locally, though sometimes they have spread to another part of the body. This procedure can be done by the open or laparoscopic approach. Because we are able to offer all possible modes of treatment, we can tailor the approach to each individual patient.

The advanced Minimally Invasive Surgery in Mindanao

The establishment of the state-of-the art center of Minimally Invasive Surgery (MIS) in Mindanao intensifies the evolution of open surgery.

The evolution of open surgery paves way to fewer invasions of human body. However, specialists can still generate quality result at a more precise manner.

The MIS employs video cameras and lens system to provide anatomic visualization using the laparoscopic/endoscopic instruments for diagnostic/ therapeutic intervention

The MIS center of DMSF Hospital has the following sections: General Surgery, Urology, Colorectal, Gastroenterology, Gyne, Orthopedic, ENT, Thoracic and Bronchoscopy.

The movers behind this revolution are trained locally and internationally.

The DMSF Hospital like any other hospitals worldwide joins in the innovation of surgical practice wherein less tissue trauma, scars and greater recovery of tissue at a more painstaking effort.

Patients can expect a more quality of alternate open surgeries at an affordable and less invasive delivery of minimally invasive surgery yet the culture of trust and utmost care is strongly practiced.

from DMSF Hospital website: http://www.dmsfhospital.com/

That Same Old Feeling

Last June 20, I had a procedure at DMSF Hospital. My patient had an obstructing 1.8 cm ureteral stone on the left noted on ultrasound and his creatinine was already elevated. However, it was not seen on the plain KUB xray. Good, since the option of dissolving the stone through medication would work for this patient meaning that I dont have to open him up. He was not a regular patient since he was diabetic, hypertensive and in heart failure! Not to mention, he is the father of a grade school classmate, brother of one of my mom's amigas and a fellow Batangueno-Davaoeno. Usually, I don't give in to this kind of pressure but honestly, I felt quite uneasy but still focused. He was cleared for surgery and it was the first time that I did a surgery with the cardiologist requesting that the cardiovascular anesthesiologist be the one to induce anesthesia. I had no qualms regarding that since it was all for patient safety, and I know that he will be in good hands. I did a cystoscopy, retrograde pyelography which showed a radiolucent 1.5 cm, partially obstructing proximal ureteral stone. Luckily, I was able to bypass the stone and insert a double J stent. When I talked to the family after the procedure, I could see their relief after knowing I that I didn't have to do an open procedure. I, too, was relieved because as much as possible, opening him up was last on my list. God was on my side that day!

My patient had a follow up check up a week (June 27) after I put in the stent, His creatinine went down to 1.3 mg/dL from the elevated 2.9 mg/dL preoperatively. I could feel his happiness with the outcome of the procedure. I received endless words of gratitude which made me feel good. He returned to work a few days after he was discharged from the hospital. His co-workers were curious about what procedure was done and how was it done. He even told me: "Doc, don't worry, people will start coming here, I told them to see you if they have any problems with regards to your specialty."
Thanks! Instant advertisement for me.

Its different when I was still in training since most of the patients that I handled had a purely doctor-patient relationship. I have this nice and light feeling everytime I my patients and relatives express their gratitude especially after a successful surgery.

I had the same nice and light feeling since I was able to do good to someone who is not only a patient but also is considered a friend of the family.

Conked Out...

RENAL FAILURE

Acute Renal Failure

Acute renal failure (ARF) is a condition of abrupt deterioration in renal function as evidenced by rising blood urea nitrogen (BUN) and creatinine levels. It is usually associated with decreased urine output. Approximately occur in the surgical setting and early recognition can minimize the extent of renal injury. It is classified under 3 categories: prerenal, postrenal and intrarenal.



Prerenal azotemia is caused by the direct result of inadequate renal blood flow. If the cause for the poor blood flow can be reversed then the problem can be resolved. However, prolonged low flow states can produce ischemic kidney injury.

Causes of Prerenal azotemia:

1) Volume depletion – hemorrhage, dehydration
2) Low cardiac output – congestive heart failure, cardiogenic shock)
3) Renal artery (stenosis, occlusion, vasoconstriction)
4) Systemic vasodilatation (sepsis, anaphylaxis, overdose)

Postrenal azotemia is caused by obstruction to urine flow. Pressures in the renal collecting system and tubules rise with obstruction causing renal injury if the obstruction is not relieved.

Causes of urinary obstruction:

1) Bladder outlet – enlarged prostate, urethral stricture, bladder stones, foreign body, tumor, blood clot)
2) Ureter – stones, tumors, stricture, stenosis

Intrarenal

Acute parenchymal renal failure is the result of damage to the renal tubules brought about by inflammation, injury from substances toxic to the kidney (nephrotoxic) and decreased blood flow.

Causes of intrarenal failure

1) Acute tubular necrosis (ATN) – 3 phases: 1) onset 2) oliguric 3) postoliguric. The oliguric period (urine output less than 500cc/day) typically lasts for 10-14 days but may be as brief as 2 days or as long as 6-8 weeks. A non-oliguric ATN can occur when it is secondary to nephrotoxic injury for ex from certain drugs or substances.

Causes of ATN

a) Ischemic injury – hypotension, cardiogenic or septic shock
b) Nephrotoxins – aminoglycosides, anesthetic agents, iodinated contrast media, NSAIDS
c) Hemoglobinuria (hemoglobin in the urine) or myoglobinuria (muscle cells in the urine)

2) Acute glomelular nephritis (AGN)

3) Acute interstititial nephritis (AIN)

The work up of a patient with sudden elevation of BUN and creatinine, with or without decreased urine output requires a prompt, systematic approach to exclude any reversible pathophysiologic states and remove any potentially nephrotoxic agents. Prerenal and postrenal causes must be excluded before diagnosing intrinsic renal disease.

CHRONIC RENAL FAILURE

Chronic renal failure (CRF) is caused by a spectrum of diseases resulting in progressive irreversible loss of functioning nephrons ultimately leading to end stage renal disease (ESRD) requiring dialysis or transplantation. The most common causes include:

1) Diabetes mellitus
2) Hypertension
3) Primary and secondary glomerular disease
4) Hereditary renal disease
5) Obstructive uropathy
6) Chronic infection
7) Interstitial nephritis

A wide variety of systemic symptoms are seen and there is a multisystem involvement making management difficult. Symptoms include:

1) Electrolyte imbalance –decreased phosphates, increased potassium
2) Gastrointestinal – nausea, vomiting, anorexia
3) Hematologic –anemia, platelet dysfunction
4) Neurologic –neuropathy, encephalopathy
5) Cardiovascular – increased severity of atherosclerosis, prolonged hypertension
6) Endocrine – abnormal bone metabolism, glucose intolerance
7) Sexual dysfunction

The general management of patients with CRF centers on slowing the progression of functional renal deterioration. There is no effective treatment for most glomerulopathies. Any reversible or controllable factors must be addressed. Once the glomerular filtration rate deteriorates to levels that produce symptoms of ESRD, then dialysis or transplantation becomes the only option

A Different World

Fresh from my urology training at National Kidney and Transplant Institute, I arrived in Davao City on the last week of January 2008. After complying with the requirements, I started private practice sometime mid February. Quite a struggle, I was out of touch with my medical and non-medical circle of friends, only a handful knew that I was back. Thanks to supportive colleagues and friends, I was able to inch my way slowly into the world of private practice. No one said that its gonna be a walk in the park. Especially if there are people who make you make things harder for you. I had a difficult time adjusting to this slow pace since I trained in a high volume institution wherein surgeries are done day in and day out.
The tide has changed, when I arrived in NKTI, I asked myself if I was ready for the fast pace life in the capital, now I found myself asking me again if I was ready to go back to the laid back lifestyle in Davao. After staying in Manila for the past 4 yrs, I was accustomed to the pace and lifestyle there, especially in the workplace.
In my line of work, efficiency is of the essence, so I hate it so much if there are problems caused by inefficiency of the staff. I also am systematic in things that I do especially with my surgeries. I get upset if there would be delays because of poor preparation of supplies and/or instruments. Well, I guess that I have to extend my patience more since most people here are not used to the usual "toxic" that is considered a way of life in other places. Call me strict or toxic, but I have a systematic and efficient way of doing things so that no effort is wasted (Toxic- a hospital slang used for busy; strict person. During training, the toxic persons were the residents and fellows especially the seniors. Why? Its something that cant be explained in words but could be understood by people who were once residents and fellows.)
I'm in a different world right now, a place where I'll be in the years to come. No one said that it's gonna be easy, but I know that it's gonna be worth it.

MY Workplaces

DAVAO MEDICAL SCHOOL FOUNDATION HOSPITAL, BAJADA, DAVAO CITY


RIVERA MEDICAL CENTER, INC, PANABO CITY

NEW GROWTHS

A neoplasm is an abnormal or new growth of tissues. This may be benign, which means that there is an abnormal growth pattern and on the other hand, malignant which is characterized by an uncontrolled cell division with the ability of these cells to invade other tissues, either by direct growth into nearby tissue (invasion) or by spread of cells to other sites (metastasis).




Tumors may arise from most of the organs of the genito-urinary tract namely:

*kidneys
*ureters
*bladder
*adrenal glands
*penis
*testis
*prostate




Any cancer, for that matter, warrants the appropriate and immediate attention for the benefit of every patient. The earlier the cancer is dectected, the better is the success rate of cure and survival of the patient.
Urologists recommend annual check-ups especially for those with family histories of cancer.