15th July 2024

Renal, Bladder and Prostate Malignancy

Whilst a large part of the management of renal tract malignancies is surgical, there are aspects which it is important to be aware of for MRCP.

Renal malignancy

Around half of all renal cancers are incidental findings on imaging, a virtue of being asymptomatic. Renal cell carcinoma (RCC) accounts for the majority of renal malignancies. It is an adenocarcinoma arising from the tubular epithelium. There is a classical triad of pain, haematuria and a palpable mass which is seen in less than 10%. Pain occurs due to capsular stretching, whilst haematuria occurs on invasion of the collecting system. Scrotal varices on the left more than the right is also a classical sign. Clear cell renal cell carcinoma is the most common cause of primary renal tumours.

Diagnosis is often made with USS, followed by CT and/or MRI. PET can be used to detect occult metastases. Definitive diagnosis is made using CT-guided biopsy most commonly.

Radical surgery is often curative and is the aim of treatment in the majority of cases, unless widespread metastasis has occurred. Nephrectomy can be radical or partial. Immunotherapy and chemotherapy also play a role, however this is dependent on the type of tumour present.

Bladder malignancy

Bladder cancers are predominantly transitional cell cancers (TCCs) originating from the urothelium. Such cancers can, in fact, originate anywhere from the renal pelvis to the urethra. Squamous cell cancers are less common in the UK and the Western world, often occurring secondary to schistosomiasis infection.

The most common presenting complaint is painless haematuria, and around 15% of patients presenting with macroscopic haematuria will have bladder cancer. Patients may also have symptoms we often associate with prostatism, such as frequency urgency, nocturia and dysuria.

Cystoscopy is the mainstay of diagnosis, allowing visualisation of lesions and biopsy. Further imaging, such as CT or USS, can demonstrate obstruction and hydronephrosis, as well as allow staging.

The nature of TCCs means they often grow as papillary tumours, projecting into the bladder lumen initially. They are also often multifocal, around a third are synchronous at presentation. The majority are low grade at diagnosis, not invading muscle and therefore have a good prognosis.

Management is often surgical, with transurethral resection with or without intravesical immunotherapy bacille Calmette – Guérin (BCG).

Prostate malignancy

Whilst prostate cancer is perceived to be something men die with rather than of, it remains a common cause of cancer death in the UK. Most are adenocarcinomas arising from the prostatic urethral urothelium. Local invasion results in spread to the bladder, neck and ejaculatory ducts and seminal vesicles.  Patients may present with no symptoms at all but a positive prostate specific antigen (PSA), or may have symptoms of localised disease such as urinary hesitancy, frequency and urgency. Localised disease has a good prognosis, with 10-year survival >90%. Treatment options include surgery in the form of prostatectomy, brachytherapy, radiotherapy, hormone-based therapy or watchful waiting. Questions on benign prostatic hyperplasia may also fall under this category.

References

• Steddon S, Ashman N, Chesser A, Cunningham J. Oxford Handbook of Nephrology and hypertension (2ⁿᵈ ed.). Oxford (UK): Oxford University Press; 2014
• National Institute for Health Care Excellence. Bladder cancer: diagnosis and management. London: NICE; 2019. (NICE Guideline No. 2). Available from: www.nice.org.uk/guidance/ng02
• National Institute for Health Care Excellence. Suspected cancer: recognition and referral. London: NICE; 2019. (NICE Guideline No. 12). Available from: www.nice.org.uk/guidance/ng12
• National Institute for Health Care Prostate cancer: diagnosis and management. London: NICE; 2019. (NICE Guideline No. 131). Available from: www.nice.org.uk/guidance/ng131