Diagnosis and Treatment of Urological Tumors

Bladder cancers: These are tumors that arise from the mucosa cells lining the inner surface of the bladder. More than half of bladder cancers in men are related to smoking. Considering that the rate of heavy smokers in our country is much higher than in developed countries, it is clear that the frequency of bladder tumors is also high. Chemical substances that are not normally present in the urine of smokers are excreted. Substances that can cause cancer cause tumor formation through chemical irritation over the years. In addition to the fact that tumors seen in the bladder occur in more than one focus, there are also formations in the initial stage that are not yet visible to the naked eye. 70% of tumors are at the base of the bladder, where urine waits the most due to the effect of gravity.


It usually occurs with bleeding in the urine (hematuria). While there may be visible bleeding with or without clots, blood in the urine during routine checks or urine tests performed for other reasons may also be the first symptom.


Bladder Tumors Are Divided into Two According to Their Stages
  • Superficial Tumors
  • Infiltrating Tumors


Superficial tumors are cauliflower-like tumors that are attached to the bladder wall with a thin stalk. They are often found in more than one focus. With closed surgery, they are removed by cutting the stem from the bladder wall and some solid tissue underneath. Superficial bladder tumors do not progress outside the bladder and do not spread to the lymph nodes. However, superficial tumors frequently recur within the bladder. The reason for this is the presence of structures in formation that are not yet visible to the naked eye when the tumors are cut out. These formations are tried to be treated with medications that are left into the bladder through a urinary catheter and kept for a few hours after the closed surgery. In cases where intravesical drug administration and postoperative treatment are not performed, recurrence is observed in more than 50% of cases with tumors in more than one focus. For these reasons, controls are more important than treatment in controlling the disease. After treatment, checks should be made at 3-month intervals during the first year. Checks must be made through endoscopy and observation of the inside of the bladder. Recurrent tumors are superficial like the first tumor and are treated with the same methods. However, a group of tumors may change behavior and gain infiltrating properties as they relapse, and this rate does not exceed 20%.



In tumors that have advanced to the bladder wall, the standard treatment is to remove the bladder, prostate and testicular glands along with most of the lymph nodes in the pelvis. (Radical Cystectomy) Although it means organ loss and disability for patients, it is lifesaving in appropriate cases. The results of methods such as chemotherapy and radiotherapy that protect the bladder are not good.



In addition, after these procedures, the operation to remove the bladder may become technically very difficult or impossible.



Despite the removal of the bladder, in appropriate cases, it may be possible for the patient to urinate normally with the help of a bladder made from the intestine. In inappropriate cases, the urinary tubes are collected in a bag with a mouth made on the abdominal wall. These patients can continue their daily lives with normal clothing. They can enter social environments. Male patients can continue their sexual life. With the development of surgical techniques and the experience of surgeons, the long operation time has decreased to acceptable levels and complication rates have decreased considerably.



Prostate Cancer is One of the Three Most Common Cancers in Men

The urinary tract passes through the middle of the prostate. While benign prostate enlargement develops from the tissue surrounding the urinary pipe, in the majority of cases (70-80%), it starts from the outer parts of the prostate gland, just below the sheath surrounding it. Therefore, it does not cause urination symptoms. However, in advanced stages, it causes urination symptoms, during which time it has mostly spread to distant organs and there is no possibility of healing. Therefore, after the age of 50, patients must undergo prostate control, including PSA measurement, once a year. In cases with a familial predisposition, the age can be reduced to 40 and control intervals can be held more frequently. PSA began to be used in the early 1980s. Before now, 70-80% of prostate cancers were diagnosed with distant organ spread when first diagnosed. Today, this ratio has reversed. In the majority of cases diagnosed at an early stage, 10-year survival rates with surgical treatment have reached 80-90%.




  • It is one of the top three most common cancers in men.
  • It accounts for 32% of all cancers.
  • It is rarely seen under the age of forty. It increases in a geometric sequence over the decades.
  • While the rate of prostate cancer (not clinically significant – found incidentally) is found at 40% at autopsy at the age of fifty, this rate is 75% at the age of seventy-five.
  • The majority of cases are latent (without clinical significance).
  • Prostate cancer occurs in one in eight American men over the age of fifty.
  • It ranks second among cancer deaths.
  • The lives of patients with latent prostate cancer are not affected by this condition; they die due to another reason such as heart attack or brain hemorrhage.

It is more common in western developed countries due to environmental and nutritional habits. This is thought to be related to high consumption of fat, animal fat and red meat. Indeed, its incidence is low in Far-Eastern countries where plant foods low in fat are consumed. The incidence of prostate cancer increases exponentially in those who migrate to the USA from the Far East due to exposure to environmental factors. 2-3 years old living in the USA. It occurs in Japanese immigrants at the same rate as American whites. This is 10 times more than those living in Japan.



There is information about infections causing prostate cancer.



Men whose first-degree relatives have prostate cancer are approximately three times more likely to develop prostate cancer than the normal population. We can call this familial predisposition.



Genetic prostate cancer usually occurs at an early age. It constitutes 43% of tumors and 9% of prostate cancers under the age of 55.
It is thought that normal prostate cells turn into cancer cells with the stimulation of male hormones. It is not clear why it occurs in some men. There are findings that clearly show the hormonal effect.


Prostate cancer does not occur in men with hormonal diseases in which the blood level of the male hormone (testosterone) is low.
In patients with painful prostate cancer that has spread to the bones, removing the male hormone in the blood by removing both testicles (castration) causes dramatic improvement in pain.



There is no relationship between benign prostate enlargement and prostate cancer formation. Benign prostate enlargement does not turn into prostate cancer by waiting. The two diseases are independent phenomena that begin in separate parts of the prostate. Patients who have open or closed surgery due to benign prostatic hyperplasia have the same risk of developing prostate cancer as patients who have not had surgery. Because in these surgeries, the areas of the prostate gland where cancer develops are not removed.


Development and Stages

Clinically significant prostate cancers are those that reach a volume of 0.2-0.5 cc.



Tumors that remain within the prostate capsule are early stage tumors. With treatment, it is possible to get rid of the disease completely. Tumors that extend beyond the capsule and tumors that have spread to other organs may have a poor prognosis.
Diagnosing prostate cancers is usually due to the following reasons.


  • Accidental tumor discovery during open or closed surgery performed for benign prostate enlargement. It is indicated as a result of the pathology of the removed tissue.
  • Feeling a nodule during digital rectal examination during prostate control.
  • High Prostate Specific Antigen (PSA) level.
  • Symptoms of an enlarged tumorous prostate or bone spread.


Today, in developed societies, men over the age of 50 need to have their prostate checked. Due to the high sensitivity of PSA, more than half of prostate cancers are diagnosed at an early stage.


What is Prostate Specific Antigen (PSA)? How is it used in diagnosis?

It is a serine protease in glycoprotein structure produced in benign and malignant cells of the prostate. It is largely incorporated into the semen and, in normal physiology, helps the semen dissolve after it is ejaculated.


It increases in prostate cancer. Benign growths and prostate inflammations also cause PSA to rise. For this reason, in cases with high PSA levels, if there are no rectal examination findings, even if there are no signs of prostate inflammation, antibiotics that can pass into the prostate should be given for 2-3 weeks before the biopsy, and then PSA measurement should be repeated.



The normal value of PSA measured in blood in young adults is 0-4 ng/ml. At values between 4-10 ng/ml, the probability of prostate cancer is around 25%. PSA elevations in this range may more often be due to benign prostate enlargement or inflammation. In cases whose PSA level does not decrease despite the use of antibiotics, bipsy accompanied by Transrectal Ultrasonography (TRUS) is indicated.


  • A number of parameters have been developed using PSA in order to reduce the number of unnecessary biopsies. Age-appropriate PSA
  • PSA level increases with age
  • 40-49 years 0-2.5 ng/ml
  • 50-59 years 0-3.5
  • 60-69 years 0-4.5
  • At the age of 70-79, the upper limit increases to 6.5 ng/ly

More prostate cancer is detected in younger men with lower PSA than in older men PSA Density1 g of benign prostate tissue increases PSA by 0.12 ng/ml. Therefore, in cases with large-volume benign prostate, the indication for biopsy with high PSA should be determined more carefully.


PSA Rise Rate

An increase of more than 0.75 ng/ml in PSA measurements made in the same laboratory in a year should raise suspicion of Prostate Cancer. According to PSA increase rate and prostate volume, PSA is suggestive but not decisive.


Free PSA/total PSA Ratio

Free PSA is a measurable fraction of PSA and is increased especially in benign prostatic hyperplasia. Therefore, the free PSA/total PSA ratio is important. A ratio greater than 0.20 indicates benign growth.


Serum PSA level is very useful in determining the stage of the disease. If the PSA level of patients diagnosed with prostate cancer in the biopsy is below 15 ng/ml, it is not necessary to have a CT or MRI to investigate lymph node enlargement or a bone scan to investigate bone spread.


Transrectal Ultrasonography (TRUS) and Prostate Needle Biopsy

It is performed in the presence of high PSA and/or suspicious digital rectal examination to make a diagnosis. It should not be forgotten that the findings on digital rectal examination are normal in more than half of the early stage tumors. The procedure can be performed under local anesthesia. If preventive antibiotics are started at least 48 hours before the procedure, blood thinners should be discontinued 5-7 days before.


If there is a nodule observed with TRUS, a biopsy should be taken from the nodule and/or from 8-12 quadrants.


Pathology (Biopsy Result)

Prostate cancer is Adeno cancer. In other words, the cells are arranged to form a gland. The more the organization of the glands is disrupted as the cells acquire a tumoral structure, the more aggressive the tumor is. This is expressed by the Gleason grading system. Tumors are rated from 1 to 10. 0-4 is expressed as good, 4-7 as moderate, and 7-10 as advanced. More than one grade is often found together in prostate cancer. Gleason score is reported with the two most dominant of these (4+3, 7+8 etc.).



Questions such as whether the tumor has passed the prostate capsule or not and whether it has spread to the adjacent testicles are related to local staging. Digital rectal examination findings and transrectal ultrasonography images can be helpful in this regard. Endorectal magnetic resonance (MRI) imaging can be performed in high-risk patient groups where the available parameters are limited in making a decision.


Problems such as jumping to the lymph nodes or spreading to the bones may need to be clarified. These involvements are extremely rare in cases where the total PSA level is below 15 ng/ml. These tests are not performed in standard evaluation, but tests may be requested in cases where final treatment preference will be made.

  • Early stage Prostate Cancers

For those with well-treated organ-confined cancer, 10-year disease-free survival rates vary between 70-85%. The same rate is around 75% in cases with minimal local spread outside the organ.


Treatment options at this stage are radical prostatectomy and radiotherapy. Today, radical prostatectomy is used as the first choice in cases whose general condition is suitable for surgery and whose life expectancy is 10 years or more. Survival rates are higher than with radiation therapy.


There are types of radiotherapy performed by irradiating from outside the body and placing a radioactive seed into the prostate.

  • Radical Prostatectomy

It is the complete removal of the prostate along with the urinary tract and testicles passing through it. The urinary tract is reconnected to the bladder and its continuity is ensured. It can be performed by open surgery and robotic surgery. In the long run, it may cause two important problems.


The incidence of complete urinary incontinence is 3%. The incidence of stress incontinence (with standing up, coughing, straining) has been reported to be around 15-20%. Urinary incontinence is related to the experience and skill of the surgeon rather than the method in which it is performed.


Erectile Dysfunction (Impotence) We can say that the nerves that provide erection are anatomically close enough to the side surfaces of the prostate sheath to be attached.


If these are cut during the operation, erection problems occur. In cases where there is no possibility of spread outside the prostate capsule, these nerves can be preserved and the patient’s sexual function can be maintained. In cases where impotence develops after surgery, the patient’s sexual life can be continued by placing penile prostheses (happiness stick).