Urologic Oncology

Uro-oncology is a field of specialization that combines the surgical skill of the department of urology with the cancer-focused principles of oncology and manages the diagnosis, staging, and treatment processes of malignant tumors arising in the kidneys, prostate, bladder, testicles, and adrenal glands. This discipline aims to control cancer types in both the urinary system and the male reproductive organs through surgical and medical methods. Serving in a broad field ranging from early diagnosis to technological interventions, this branch provides a tumor-focused recovery process while preserving the patient’s general health and functional quality of life. It is considered one of the most competent areas of specialization in the diagnosis, surgical treatment, and follow-up of urinary tract and reproductive system cancers.

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What Is Uro-Oncology and Which Organs Does This Medical Branch Deal With?

Uro-oncology is essentially a subspecialty of the main branch of urology that combines the surgical techniques of urology with the principles of oncology, namely cancer science. We can compare the human body to a complex and magnificent plumbing system. This system has cleaning filters, transport pipes, and storage areas. The diagnosis, determination of the stage, treatment with the most appropriate method, and long-term follow-up of malignant cellular changes, namely tumors, that may arise in the parts of this urinary and reproductive system fall within the area of expertise of this discipline. The approach to patients is never determined by the decision of a single doctor, but through a collective judgment in councils where radiologists, pathologists, and medical oncology specialists come together.

The main body structures this branch deals with concern cancers of the following organs:

• Kidneys
• Ureters
• Bladder
• Urethra
• Prostate
• Testicles
• Penis
• Adrenal glands

What Are the Most Commonly Treated Types of Cancer in the Field of Uro-Oncology?

The structure and cell type of every organ in our body, and therefore the characteristics of the diseases arising from these cells, are completely different from one another. A condition that progresses very slowly and silently in one organ may move much faster in another organ. Therefore, each disease must be approached with a completely personalized strategy appropriate to its own nature. The aim is not only to eliminate the disease but also to manage the process by causing the least possible harm to the person’s normal life, functions, and quality of life.

The diseases most frequently encountered in this field are as follows:

• Prostate cancer
• Bladder cancer
• Kidney cancer
• Testicular cancer
• Penile cancer
• Adrenal cancer
• Ureteral cancer

How Does Prostate Cancer Develop and Why Does It Progress Silently?

The prostate is a walnut-sized gland located immediately below the urinary bladder, through which the urinary tract passes, and is a very important part of the male reproductive system. Its main function is to contribute to the production of the fluid that nourishes and protects sperm. As age advances, certain changes may occur in this gland at the cellular level. Although prostate cancer is one of the most common types of cancer among men worldwide, it has a rather interesting character. It often grows in an extremely insidious and slow manner for years without causing any symptoms.

The main reason for this is generally related to where the tumor begins in the prostate. Malignant cells mostly begin to develop in the parts of the prostate gland close to the outer capsule. The urinary tract passes directly through the center of this gland. Therefore, a tumor growing in the outer parts does not cause complaints such as difficulty urinating, split urinary stream, or frequently getting up to use the toilet at night until it becomes large enough to press on the urinary tract. Urinary problems experienced by men as they age generally result from benign enlargement of the prostate. Precisely because of this silent nature, regular check-ups after a certain age are vitally important even in the absence of any complaints.

Which Tests Are Used to Detect Prostate Cancer Early?

The silent progression of the disease has made it necessary to develop special methods to detect it. At this point, the best-known and first-used method is a blood test. A special protein produced by prostate cells and released into the blood is measured. However, a very important detail must be emphasized here. A high level of this value in the blood does not directly and definitively mean cancer. This protein is specific to the prostate, not specific to cancer. In other words, this value may also rise when the prostate is under stress for any reason, enlarges, or becomes inflamed. We can compare this situation to a smoke detector; the alarm sounding indicates that something is wrong, but it does not always mean there is a major fire, sometimes only food may have burned in the kitchen.

Some conditions that cause the PSA level in the blood to rise are as follows:

• Prostate cancer
• Benign prostate enlargement
• Prostate inflammation
• Urinary tract infection
• Insertion of a urinary catheter
• Prostate biopsy
• Regular or prolonged cycling

If the value in the blood test is found suspicious or unusual hardness is felt during a digital examination, more advanced imaging and tissue sampling procedures are performed to clarify the situation.

Why Are Imaging (mpMRI) and Smart Biopsy (Prostate Fusion Biopsy) a Revolution in the Diagnosis of Prostate Cancer?

In the past, when prostate cancer was suspected, tissue samples were routinely taken from certain areas of the prostate under ultrasound guidance, previously by digital guidance and later with the help of ultrasound. However, although these methods aimed to obtain samples regularly, the success of the targeted mapped sampling was low. This method could sometimes cause a small but important tumor focus to be missed between the needles, meaning that the test could come back clear even though the patient had the disease. However, the incredible advances in imaging technologies today have completely changed this process. The internal structure of the prostate can now be seen more clearly and potentially problematic areas can be noticed with advanced MRI devices, commonly called MRI scanners, using special imaging techniques without relying solely on the PSA test.

If a risky area is detected in the MRI images, these images are transferred to the ultrasound device with special software. During the biopsy procedure, the patient’s MRI map and live ultrasound image are superimposed. You can compare this system to navigation devices in automobiles. The destination address, the tumor, is marked on the map, and the system guides the doctor directly to that target with high precision. In this way, incomplete sampling from the patient is prevented, the margin of error is minimized, and the success rate of detecting small tumor foci is increased.

What Is Bladder Cancer and How Is Its Most Important First Symptom Noticed?

The bladder, namely the urinary bladder, is a flexible and muscular organ where urine filtered by the kidneys is stored until it is expelled from the body. The inner surface of this organ is covered with a protective membrane layer against the composition of urine. Harmful chemicals entering our body circulate in the blood, are filtered by the kidneys, and reach the bladder through the urine. If a person smokes heavily or is exposed to industrial chemicals, these harmful substances remain in contact with the bladder wall within the urine. Years of this exposure disrupt the structure of the cells inside the bladder and create the basis for their malignant proliferation.

The most critical and most important first symptom of this disease is blood in the urine. However, this bleeding is generally painless. Since people do not feel pain, burning, or discomfort, they may sometimes dismiss this condition as being caused by a chill or fatigue. However, visible redness in the urine, tea-colored darkness, or the passage of clots should always be considered an alarming situation and requires a detailed examination without delay.

How Is the Minimally Invasive Surgical Method (TUR-BT) Used to Remove Bladder Cancer Performed?

When the presence of a tumor in the bladder is confirmed, a very delicate procedure performed under anesthesia is used both to establish the definitive diagnosis of the disease and to remove that mass from there. No incision is made in the abdominal area during this procedure. A thin special instrument with a high-resolution illuminated camera at its tip is inserted through the natural urinary tract. The inside of the bladder can be comfortably viewed on the screen with high magnification.

Tumors generally seen on the bladder wall as structures resembling sea plants or cauliflower are cut and removed from the bladder muscle tissue using electrical current or laser, thanks to a special energy system at the tip of this instrument. These removed pieces are sent to the pathology laboratory for examination to determine what type of cellular structure they have and how deeply the cancer has progressed into the bladder wall. The course of all treatments the patient will receive in the following years is shaped entirely according to the report that will come from this laboratory.

Which Medications Are Administered Into the Bladder to Prevent Bladder Cancer From Recurring?

If the removed tumor has remained only in the innermost thin shiny layer of the bladder, the epithelial layer, meaning that it has not progressed into the deeper muscle tissues like the roots of a tree, this is extremely good news. However, bladder cancer has a tendency by nature to recur even after it has been removed, either in the same place, in another corner of the bladder, or even at any point along the pathway extending from inside the kidney through which urine passes to the outside of the body. To minimize this risk, certain liquid drug treatments are administered at regular intervals into the bladders of patients with a high probability of recurrence or progression.

One of the most interesting and successful methods in medical history is a vaccine that we all know in some way. The vaccine, which consists of an attenuated bacterium developed against tuberculosis, is administered into the bladder with the help of a thin catheter. This treatment is called intravesical BCG instillation. After the treatment is administered, the patient is asked to hold the urine for one or two hours if possible. The aim here is not to give the patient tuberculosis, but to activate an alarm in the body by creating a regional, local immune response in the bladder wall thanks to the weakened bacteria in the vaccine. The soldiers in the body’s defense system rapidly rush to the bladder, and while fighting the bacteria there, they also detect and destroy any cancer cells that may have been overlooked or have newly begun to form.

The periods during which the treatment is administered are generally as follows:

• The initial six-week treatment when bladder healing is completed after surgery (instillation treatment)
• Camera examinations of the bladder every three months and booster doses if there is no recurrence of the disease (maintenance treatment; at least one year)
• After a period of time, depending on the patient’s treatment duration and the severity of the disease, camera examinations of the bladder and booster dose treatments every six months (maintenance treatment)
• These follow-up periods and treatments administered into the bladder are applied for at least 1 year and at most 3 years
• Camera examinations of the bladder are performed at six-month intervals for at least two years
• After four years of follow-up, annual follow-ups are started for camera examinations of the bladder

How Is Artificial Bladder Surgery Performed in Advanced-Stage Bladder Cancers?

If the disease has already invaded the deep muscle layers of the bladder at the time it is first diagnosed or stubbornly resists the drug treatments administered into the bladder and recurs at dangerous levels, keeping that organ in the body now puts the patient’s life at risk. In this case, to minimize the risk of the disease spreading to other organs, it may be necessary to surgically remove the entire bladder, the surrounding lymph nodes, and the prostate in men, while in women the uterus, ovaries, and part of the vagina may also need to be removed.

After the bladder is removed, a new drainage system must be established so that urine continuing to come from the kidneys can be expelled from the body. For this purpose, a small section is taken from the patient’s own small intestine. In suitable patients, this intestinal segment is shaped into a spherical artificial bladder and connected to the normal urinary tract. In this way, the patient can continue to urinate through the normal route without using any external bag. If the patient is not suitable for this when anatomical structure and other factors are taken into consideration, the intestine is brought to the abdominal wall and the urine is collected in a special, odorless, transparent bag attached to the outside of the abdomen. Both methods are successful, life-saving solutions to which the person adapts over time. Since this is a serious and important stage of the disease, patients may need to receive chemotherapy before surgery, called neoadjuvant treatment, or after surgery, called adjuvant treatment.

How Is Kidney Cancer Usually Detected Incidentally and How Does the Disease Progress?

Our kidneys are incredibly hardworking organs that filter our blood many times every day, remove waste substances from the body, balance our blood pressure, and even produce hormones that help blood production. However, cancerous processes beginning in the internal tissues of this organ unfortunately do not produce any signal for a long time. Most patients are completely unaware that they have a tumor in their kidney. This is because kidney tumors do not cause pain and usually continue to grow silently until they reach very advanced sizes and cause bleeding into the urinary tract.

Today, a very large proportion of kidney cancers are detected completely by chance. A person may go to the hospital due to gallbladder pain, indigestion, stomach discomfort, or merely for a general health screening, and after imaging of the abdominal region such as ultrasound, tomography, or MRI, the radiologist notices an unexpected mass on the kidney. This situation is actually a great opportunity because the disease is caught at an early stage before spreading elsewhere. Kidney cancers are generally resistant to drug or radiation treatment. Surgery is usually the most effective treatment option for masses detected in the kidney. In rare cases, a biopsy may also be performed to distinguish these masses from benign ones. However, the absence of cancer cells in the masses on biopsy does not mean that these masses are not cancer. Therefore, biopsy is often not recommended.

How Is Only the Tumor Removed Instead of the Entire Organ in Kidney Surgeries?

In previous years, even if there was a small mass in the kidney, the entire organ was surgically removed. A person can live a very healthy and long life with a single kidney. However, scientific studies have proven how valuable it is to preserve as much of the patient’s own kidney tissue as possible in order to protect cardiovascular health in later years, prevent high blood pressure, and avoid the need for dialysis.

Therefore, today, especially in kidney tumors below a certain size, it is preferred to remove only the cancerous part, just like carving out the rotten part of an apple. The remaining healthy kidney tissue is carefully repaired and left in place. This organ-preserving surgery both eliminates the cancer and safeguards the patient’s future general health capacity. Using the device called a robot while performing these procedures facilitates both the success and performance of the operation. However, the procedure may also be performed laparoscopically or through an open approach.

For Whom Are Non-Surgical Methods Suitable in Uro-Oncology Treatments?

Of course, not every patient’s physical resistance, age, and accompanying diseases may be at a level that can tolerate major surgery. In very elderly patients, those with serious heart or lung diseases, and patients for whom anesthesia carries a life-threatening risk, non-surgical alternative methods without incisions are used to control the tumor.

The options offered to suitable patients are as follows:

• Cryotherapy
• Radiofrequency ablation
• Active surveillance

In cryotherapy, the mass is entered from outside with thin needles and the cancer cells are killed by freezing. In the radiofrequency method, the mass is destroyed by burning it with high heat. These methods may even be performed under local anesthesia and may not exhaust the patient. However, the failure rates of these methods also increase as the masses grow. If the masses are below a size such as 3 cm, there is a low possibility that they may be benign, and such masses may be closely monitored in high-risk patients.

Why Does Testicular Cancer Threaten Young Men and What Is the Treatment Success Like?

Although old age always comes to mind when cancer is mentioned, testicular cancer is a complete exception. This disease is mostly seen in young men between the ages of 15 and 35, during the most active period of their lives. It is generally noticed as a painless and hard swelling felt on the testicle while bathing. It is extremely important that these individuals, most of whom are young, do not neglect this condition and do not hesitate to consult a doctor.

Although it psychologically frightens a young man greatly, the medical aspect of the issue is extremely important. Testicular cancer is one of the types of cancer with the highest cure rates in the medical world. Even if the disease has spread to other parts of the body, the lungs, or the lymph nodes, thanks to advanced surgical methods and the chemotherapy drugs subsequently administered, a large proportion of patients can regain their health, return to their normal lives, and continue their plans to have children.

What Advantages Do Robotic Surgery Systems Such as Da Vinci Provide to the Patient and the Doctor in Uro-Oncology Surgeries?

One of the most fascinating points reached by medical technology today is robotic surgery. However, a common misconception must be corrected here; there is no independent robot that decides and performs the surgery on its own. The robot is a tremendous tool that can contribute incredibly to the surgeon’s eyes, hands, and abilities. The surgeon sits at a special console immediately next to the patient and, through a control placed on the fingers, manages the more precise and more mobile arms belonging to the system, which resemble laparoscopic devices advanced into the body through the patient’s abdomen, as well as the camera system that provides a sharper and closer view.

The unique advantages offered by this system are as follows:

• Three-dimensional depth perception
• High-resolution magnification
• Minimization of the natural tremor in the human hand
• Much greater range of movement than the human wrist
• Less blood loss
• Faster recovery process

Especially in surgery of organs such as the prostate, which are located very deep in the pelvis in a dark and narrow area, the benefit provided by this system is invaluable. Very critical hair-thin nerve and vascular networks responsible for sexual functions, erection, and urinary continence pass immediately next to the prostate. Thanks to the high-resolution camera and precisely moving arms of the robotic system, the tumor can be carefully removed from the body while the maximum preservation of this nerve and vascular network and important nearby structures is aimed for. Patients get back on their feet much faster after surgery and regain their normal functions much sooner.

Which Advanced Screening Methods Are Used to Detect the Spread of Uro-Oncological Diseases in the Body?

Whether the cancer has remained only in the organ where it began or has entered the blood or lymphatic pathways and traveled to the bones or other organs forms the heart of the treatment plan. Sometimes conventional X-rays, tomography scans, or MRI scans may be insufficient to show these small spreads, namely metastases.

At exactly this stage, the newest diagnostic methods of nuclear medicine, especially PET scans, come into play. In the case of prostate cancer, very safe and mildly radioactive substances prepared in the laboratory and programmed to bind to a special protein found on the surface of tumor cells are administered intravenously to the patient. These intelligent substances entering the body circulate throughout the whole body like a guided missile and attach wherever there is a prostate cancer cell. In the resulting image, the cancerous areas light up like a bulb glowing in the dark. In this way, a more detailed analysis of the spread of the disease in the body is supported, allowing the creation of a targeted treatment strategy. This imaging is called PSMA PET. Similarly, there are different PET tomography methods used in other types of cancer. Among these, the other PET method used in uro-oncology is FDG PET.

Why Are Patients Followed for Life in Uro-Oncology and What Is “Active Surveillance”?

After the treatment process is completed and surgeries or medications are finished, the process is never considered completely over. Cancer is a chronic condition by nature. Therefore, patients are not left to their fate; regular follow-up schedules are created that continue for years, become less frequent over time, but are never abandoned. The patient’s condition is continuously monitored through blood tests, ultrasounds, or camera-assisted imaging. These regular follow-ups provide the opportunity to detect the disease at an early stage in the event of a possible recurrence and intervene more effectively from a medical perspective.

On the other hand, every cancer diagnosis does not necessarily require immediate surgery or radiation treatment. Especially in elderly patients, when prostate cancer is detected at a very early stage, with a very indolent cellular structure and a growth rate almost at a standstill, an “active surveillance” strategy may be adopted to avoid unnecessarily exhausting the patient. In this approach, the patient is not operated on but is followed very closely, almost under a magnifying glass, with regular tests. If the slightest sign of increased aggressiveness in the disease is detected, immediate intervention is performed. In this way, the patient’s quality of life is preserved for years. A similar situation may also be recommended in prostate cancer patients, even if the patient is young and physically strong, when the cancer is very low risk, in order to protect the patient from potentially serious side effects of treatment.

What Should Uro-Oncology Patients Pay Attention to in Their Lifestyle During and After the Treatment Process?

Of course, treatments applied only by doctors are not sufficient; how the patient takes care of their own body is one of the most important factors directly affecting treatment success and recovery speed. Receiving a cancer diagnosis does not mean stopping life; on the contrary, it should be seen as a turning point for taking better care of the body, showing compassion toward it, and acquiring healthy habits. Keeping the immune system strong both makes it easier to fight with the current treatment and helps prevent problems that may arise in the future.

The basic lifestyle changes that should be considered during this process are actually those required for a healthy life:

• Completely quitting smoking and tobacco products
• Drinking at least two and a half liters of water per day
• Avoiding processed foods
• Following a Mediterranean-style diet rich in fresh vegetables and fruits
• Taking light-paced walks at least three days a week
• Losing excess weight
• Paying attention to sleep patterns

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