INTRODUCTION Cancer is a major public health problem worldwide and is the second leading cause of death globally, and was responsible for 8.8 million deaths in 2015. Globally, nearly 1 in 6 deaths is 1due to cancer . Urological cancers are one of the most common type of cancers in the world. In Indonesia, the morbidity and mortality rates are mostly happened in the middle and lower socioeconomic population. Urological cancer is a disease with multifactor causes that formed over a long period of time and progressed through different stages2,3 According to Globocan 2012, prostate, bladder and kidney cancer are among 20 most common cancers in both sexes in Indonesia. They ranked sixth, twelfth and eight-tenth 3,4respectively Some of our Colleagues have already studied the prole and characteristic of urology cancer in Indonesia like studies which had already done by Zulkar Y et al in 2010, Wahidin et 3,5,6al in 2012, Umbas et al in 2015. , and also from the other nations, Japan Hideyuki Akaza in 2015, China Cheng Pang et 8,12,35al in 2016, Taiwan Chi-Feng Hung et al in 2016. Therefore, in this study we would like to describe the prole of urological cancer based on our medical record data in our institution. METHODS We conduct this study in Haji Adam Malik General Hospital in Medan. Data were collected retrospectively from the medical records of all the patients with urologic cancer in 2013-2017 (5 years). The patients whose data were collected are patients with prostate cancer, kidney tumor, bladder cancer, testicular tumor, penile cancer, and adrenal tumor. We classify the data based on year when patient was admitted and organ that were exposed by cancer. We collected age, gender, pathological examination, diagnosis, type of treatment the patient would have. RESULT From the collected data we found 446 urologic cancer cases from 2013-2017 in Haji Adam Malik General Hospital Medan. From the data we found that from 446 cases, 364 are male patients (81.6%), followed by woman with 82 patients (18,3%). For the target organ statistic, the data showed that prostate cancer is the highest cancer incidence across the last 5 years with 167 cases (37,4%), followed by bladder cancer with 133 cases (29.9%) in second place, and penile cancer with 72 cases (16.1%) in third place. The lowest cancer incidence in this study is adrenal cancer with 1 case from 2013-2017 (0.1%), followed by renal 43 cases (9.6%) and testicular 30 cases (6.7%). Table 1. Characteristic table DISCUSSION Cancer incidence raised annually up to 8% within the last decade whereas the cancer morbidity was raised from 3.4% in 1980 to 5.7% in 2007 and it became the seventh leading reason 5for death in Indonesia . According to Report of National Basic Health Research these raising trends may be thanks to many factors cherish exposure to matter of carcinogen, chronic 7infection and longer lifetime expectancy . Unhealthy diet and fewer physical activity result in 19% overall fatness in the UROLOGIC CANCER IN ADAM MALIK GENERAL HOSPITAL Original Research Paper Frendy Wihono* Urology Department Of General Surgery, H. Adam Malik Hospital, Medan, Indonesia *Corresponding Author X 51GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Oncology INTRODUCTION:Urological cancers are one of the most common type of cancers worldwide. We would like to describe the prole of urological cancer in Indonesia. MATERIALS AND METHODS:Data collected retrospectively from in 2013 – 2017 in Haji Adam Malik General Hospital, with prostate cancer, kidney tumor, bladder cancer, testicular tumor, penile cancer, and adrenal tumor. We classify the data based on the year, age, gender, pathological examination, diagnosis, treatment. RESULTS:A total of 446 urologic cancer cases included (364 males (81.6%) and 82 females (18,3%)). Prostate cancer is the highest cancer incidence (167 cases (37,4%)), bladder cancer 133 cases (29.9%), and penile cancer 72 cases (16.1%). The lowest incidence is adrenal cancer 1 case (0.1%), renal 43 cases (9.6%) and testicular 30 cases (6.7%). CONCLUSION:Indonesian urologists, other healthcare providers, government and non-government organizations must collaborate to promote health education to minimize the incidences of urologic cancer in Medan. ABSTRACT KEYWORDS : Urologic Cancer, Prostate Cancer, Bladder Cancer, Penile Cancer, Adrenal Cancer VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Ginanda Putra Siregar Urology Department Of General Surgery, H. Adam Malik Hospital, Medan, Indonesia Syah Mirsya Warli Urology Department of General Surgery, H. Adam Malik Hospital, Medan, Indonesia Variable (n =446) N (%) Age 59 (±16.907) Sex Ÿ Man 364 (81.6%) Ÿ Woman 82 (18.3%) Organ Ÿ Prostate 167 (37.4%) Ÿ Bladder 133 (29.9%) Ÿ Penile 72 (16.1%) Ÿ Renal 43 (9.6%) Ÿ Testicular 30 (6.7%) Ÿ Adrenal 1 (0.2%) 52 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS population older than fteen years old, that are risk factors for malignant diseases. Therefore, in this article we would like to highlight these urologic cancers based on our institution. PROSTATE CANCER Prostate cancer is the second leading cause of cancer-related death in men in the western world, second to lung cancer. Although there is a noticable difference in the incidence rates 13,17,18in Asian and Western country . However, cancer in Asia is expected to dramatically increase and cause burden to 38human development index in Asia . Growth of the prostate gland is initially dependent on androgen and the tumor marker to diagnose prostate cancer is known as prostate- 13,18specic antigen or PSA . Many of treatment that can be utilize in prostate, such as; bilateral adrenalectomy and androgen deprivation therapy, and some still an ongoing research, that includes; abiraterone acetate pluse prednisone chemotherapy, and enza lu tamide usage be fore 14,16chemotherapy. In Indonesia itself the incidence of Prostate cancer compared with the reports from western countries was relatively low, 4according to Ferlay et al (2013) . However, based on report from akaza, et al (2013), prostate cancer patients in Indonesia increased within the last decade and it becomes the third 9commonest cancer in men . IAU guideline suggests performing a digital rectal examination (DRE) and prostate specic antigen (PSA) measurement in men older than 50 years, or 40 years in patients with family history of prostate 11cancer, who came with lower urinary tract symptoms (LUTS) . A recent survey of the Indonesian urologists reported that DRE was done in all patients with LUTS and in 83% of patients with 10elevated PSA . In Jakarta and Surabaya study proposed a PSA cutoff of 8 ng/ml and 10 ng/ml. In our study we have found that prostate cancer in the highest urologic cancer cases with 167 cases (37.4%), with PSA cutoff was 4 ng/ml, 56.6 % was positive prostate cancer. According to IAU guidelines, the treatment option depends on risk factors and patient's age; however, many factors such as co-morbidity, compliance, patient's residence and preference are also considered. In our region, radical treatment by radical prostatectomy (RP) was no been considered because of the refusal from the patient, androgen deprivated therapy (ADT) was the most options. ADT that we perform in our institution was total androgen blockage (53 cases, 31.7%) and sub-capsular orchiectomy bilateral (114 cases, 68.2%). BLADDER CANCER Bladder cancer (BC) is one of the common cancers of both 4sexes in Indonesia . Bladder cancer is an international public health problem that commonly occurs in developing country. BC need to be taken seriously in developing country due to lower survival rate in developing country than those from the 37,39USA . As it was reported by Umbas et al (2007), The incidence increased ~15% per year in the last decade with Transitional cell carcinoma (TCC) as the most histological type (78.8%), followed by Squamous cell carcinoma (SCC) 20(10.2%), adenocarcinoma (8.6%) and sarcoma (2.4%) . Most of the patients with SCC type had concomitant bladder stone at diagnosis (37.1%) or history of bladder stone operation 20performed between 1 and 25 years . In our study we found that bladder cancer is the second most common urologic cancer (133 cases) in Haji Adam Malik General Hospital from 2013- 2017 in Medan. Compared to China as one of the largest countries in Asia with the highest population on Earth, bladder cancer was one of the most common urologic mali 21,28gnancies . For BC diagnosis, we screened all patients with hematuria 23,24using urine cytology . As a rule, an underlying ultrasound examination will be performed. A further radiologic examination, in examples iv contrast abdominal Ct-scan, was performed to assess the tumor invasion, regional lymph node 25,26and metastasis site . In China, cystoscopy can be used in terms of diagnosing, giving follow up, and giving a prognosis 22to the patient, according to Na et al . According to Supit et al (2011), our guideline in Indonesia, we performed cystoscopy and transurethral resection of bladder tumor (TURBT) as the gold standard for BC diagnostic and denitive treatment in 27non-muscle-invasive bladder cancer (NMIBC) . Early intravesical chemotherapy installation, for the most part with Mitomycin-C, will be given inside 24 h after TURBT when all of the tumors are effectively expelled and there is no suspicious of bladder puncturing. In our institution 3 NMIBC have done Mitomycin-C instillation for 8 times and for 3 years follow-up 1 patient has recurrent BC, has done re-TURBT. Table 2. Clinicopathological characteristics of bladder cancer patients in Medan MIBC, muscle-invasive bladder cancer; NMIBC, non-muscle- invasive bladder cancer. A report of 133 BC treated from 2013-2017, heterogeneous treatment was summarized in table 2. In common, the issue of treatment refusal signicantly hinders cancer treatment in Indonesia. The underlying cause is not only due to socioeconomic and nancial issues, but also due to the lack of knowledge. Table 3. Treatment options between NMIBC and MIBC PENILE CANCER Penile cancer is urologic cancer affecting about one in 100,000 men worldwide in a year, thus penile cancer classied as one 40,41of the so-called 'rare malignancies' . It's prevalence highest in developing country such as; Thailand and lead into high 45,48morbidity and mortality . Study from National Taiwan 19University Hospital there were 71 cases within 20 years . It is estimated that at least 40% of penile cancers cases are 43attributable to human papillomavirus (HPV) . In our institution penile cancer was the third most cases of urologic cancer, 72 cases within 5 years. On the other hand, there are 283 new cases of penile cancer in brazil ranging from 2006- 2006 that predominantly affecting; low income, living in the north or northeast side of the country, white, and 44uncircumcised patients . In Uganda, penile cancer are more 46rarely to be nd than prostate cancer . Numbers of cases in our region was affected by culture and religion, that has no circumcision, lack of education and knowledge. According to Larke et al, childhood/adolescent circumcision elicit a strong 42protective effect from an invasive penile cancer . Is is due to phimosis that associated with risk of balanitis that can lead 147into penile cancer, removing the foreskin can reduce it . From 72 cases, almost al l came with advanced stage, chemotherapy and total penectomy was done (see table 4). VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Characteristics Number of patients (%) Muscle-invasion Ÿ NMIBC (Stage 0, 1) Ÿ MIBC (Stage II, III, IV) 3 (2.25%) 130 (97,7%) Treatments NMIBC (%) MIBC (%) Radical Cystectomy - 20 (15%) Chemoradiation - 11 (8.2%) EBRT - 7 (5.2%) Intravesical Mitomycin C with TURBT 3 (2.2%) - TURBT only 24 (18%) Patient refusal of treatment - 68 (51.1%) Table 4. Treatment option in penile cancer KIDNEY CANCER In our Study, kidney Cancer is in fourth place 43 (9,6%) as the highest urologic cancer behind prostate, bladder, and penile cancer. According to Ferlay et al (2012), In Indonesia, the overall incidence of kidney cancer is estimated to be 2.4–3 cases/100 000 population. This is an increase from an earlier estimate, which calculated the overall incidence to be 1.4–1.8 4cases/ 100 000 population. Due to lack of follow-up data, Hamiseno, et al., (2011) could not estimate the survival rate of 30our kidney cancer patients . Another research which specically looked for RCC cases in Cipto Mangunkusumo Hospital from 1995 to 2009 found 99 cases, which is 33% of all kidney cancer cases. That study also reveals an increase in the hospital incidence of 1.5- to 2-fold for every 5 years period. Metastatic disease on the rst presentation was found in 37% 30of all RCC cases . There are quite a signicant number of squamous cell and transitional cell carcinoma (TCC) of the 6,29kidney caused by kidney stones . The essential treatment of kidney malignancy cases incorporates careful resection of the inuenced kidney. For the most part, the treatment was done as open radical nephrectomy, with just a couple of focuses doing it 34laparoscopically . In addition, nephroctomy also alleviates 31,32the response rate of chemotherapy in metastasized RCC . In our institution we have done 43 nephrectomy several cases done in laparoscopy. Partial nephrectomy is rarely performed because the tumor stage at presentation is mostly T2 or more. Just two institutions ('Cipto Mangunkusumo' and 'Hasan Sadikin' Hospital) are doing laparoscopic partial nephrectomy. According to Naito et al, the median survival time of RCC patient that already metastasized was 21.4 33months . CONCLUSION There are increasing incidences of urologic cancer in Medan, especially prostate, bladder, penile, and kidney cancer. Nevertheless, treatment refusal is still common and advanced stage is the common incidences, due to patient ignorance. As a result, it is important for the Indonesian urologists especially in Medan, other healthcare providers, government and non- government organization to work together in community health education to minimize these problems. From this data our institution can complete the national data for urologic cancer in Indonesia. REFERENCES 1. Jeanne Held-Warmkessel, MSN, RN, AOCN, ACNS-BC. Chapter 1: Introduction to Genitourinary Cancers. Genitourinary Cancers. Site-Specic Cancer Series. Oncology Nursing Society. 2011 2. Josh Gottlieb, BS, Cory Higley, BS, MPH, Roman Sosnowski, MD, PhD, et al. Smoking-related Genitourinary Cancers: A Global Call to Action in Smoking Cessation. Vol 18 No. 4. 2016. Reviews in Urology 3. Rainy Umbas, Ferry Safriadi, Chaidir A Mochtar, et al. Urologic Cancer in Indonesia. 2015. Japanese Joural of Clinical Oncology, 2015, 45(8) 708-712. 4. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11 [Internet]. Lyon, France: Internat ional Agency for Research on Cancer, 2013. http://globocan.iarc.fr 5. Wahidin M, Noviani R, Hermawan S, Andriani V, Ardian A, Djarir H. Population-based cancer registration in Indonesia. Asian Pacic J Cancer Prev 2012;13:1709–10. 6. Zulkar Y, Umbas R, Mochtar CA, Santoso RB, Hamid AR. Renal pelvis and ureter carcinoma in Jakarta: characteristic and risk factors. Indones J Cancer 2010;4:55–60 7. Report of National Basic Health Research (RISKESDAS) 2007. Indonesia: The National Institute of Health Research and Development, Ministry of Health, Republic of Indonesia; 2008. http://labdata.litbang.depkes.go.id/menu- download/menu-download laporan (25 January 2015, date last accessed). 8. Hideyuki Akaza. Urologic cancer in Japan: role of Japan at the Frontier of Issue in Asia. Japanese Journal of Clinical Oncology, 2016, 46(1) 23-30. 9. Akaza H, Hinotsu S, Cooperberg MR, et al. Sixth joint meeting of J-CaP and CaPSURE—a multinational perspective on prostate cancer management and patient outcomes. Jpn J Clin Oncol 2013;43:56–66. 10. Umbas R, Hardjowijoto S, Mochtar CA, et al. Guidelines on Prostate Cancer Management of the Indonesian Urological Association. Jakarta: Indonesian Urological Association, 2011. ISBN: 978-979-25-4288-2 (in Indonesian). 11. Monoarfa RA, Hamid AR, Mochtar AC, Umbas R. Perspective of the Indonesian urologists in prostate cancer diagnosis. Indones J Cancer 2012; 6:97–104 (in Indonesian). 12. Chi-Feung Hung, Cheng-Kuang Yang, and Yen-Chuan Ou. Urologic cancer in Taiwan. Japanese Journal of Clinical Oncology, 2016, 46(7) 605-609. 13. Katsogiannou M, Ziouziou H, Karaki S, Andrieu C, Henry de Villeneuve M, Rocchi P. The hallmarks of castration-resistant prostate cancers. Cancer Treat Rev 2015 May 9. doi: 10.1016/j.ctrv.2015.05.003. [Epub ahead of print]. 14. Ryan CJ, Smith MR, Fizazi K, et al. Abiraterone acetate plus prednisone versus placebo plus prednisone in chemotherapy-naive men with metastatic castration-resistant prostate cancer (COU-AA-302): nal overall survival analysis of a randomised, double-blind, placebo-controlled phase 3 study. Lancet Oncol 2015;16:152–60. 15. Beer TM, Armstrong AJ, Rathkopf DE, et al. Enzalutamide in metastatic prostate cancer before chemotherapy. N Engl J Med 2014;371:424–33. 16. Huggins C, Scott WW. Bilateral adrenalectomy in prostatic cancer: clinical features and urinary excretion of 17-ketosteroids and estrogen. Ann Surg 1945;122:1031–41. 17. GLOBOCAN 2012 v2.0, Cancer incidence and mortality worldwide: IARC. http://globocan.iarc.fr (May 2018, date last accessed). 18. Akaza H. Prostate cancer chemoprevention by soy isoavones: role of intestinal bacteria as the “second human genome”. Cancer Sci 2012;103:969–75. 19. Taiwan Cancer Registry Annual Report, 2012. Department of Health and Welfare T, 2015. 20. Umbas R. Bladder cancer: 10 years experiences from two tertiary care hospitals in Indonesia. Indones J Surgery 2007;35:17–22. 21. ChenW, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer in China, 2011. Chin J Cancer Res 2015;27:2–12. 22. Na YQ, Ye ZQ, Sun YH, Sun G editors. Guidelines on Urology in China. 2014 ed. Beijing: People’s Medical Publishing House 2014. 23. Arif MI, Santoso A, Djatisoesanto W, Notosoehardjo ISE, Joewarini E, Widodo JP. Detection of transitional cell carcinoma of the bladder with NMP test and urine sitology. Indones J Urol 2007;14:1–4 (in Indonesian). 24. Tiera H, Umbas R. Rapid urinary bladder cancer antigen test for the detection of transitional cell carcinoma of the bladder in Indonesian population (a preliminary study). Indones J Cancer 2013;7:41–6 (in Indonesian). 25. Aschorijanto A, Djatisoesanto W, Soebadi DM, Hermantha C, Soemarno T,Widodo JP. Comparison on staging accuracy in bladder cancer between MRI, trans-abdominal Ultrasound, and TUR-BT in Soetomo Hospital, Surabaya. Indones J Urol 2006;13:1–4 (in Indonesian). 26. Umbas R, Hardjowijoto S, Mochtar CA, et al. Guidelines on Urothelial Bladder Cancer of the Indonesian Urological Association. Indonesian Urological Association, 2014. ISBN: 978-602-18283-2-8 (in Indonesian). 27. Supit W, Mochtar CA, Sugiono M, Umbas R. Survival of patients with transitional cell carcinoma of the urinary bladder in Indonesia: a single institution review. Asian Pac J Cancer Prev 2011;12:549–53. 28. ChenW, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer in China, 2011. Chin J Cancer Res 2015;27:2–12. 29. Li M, He Z, Gao J, Sun Y, Li C, Huang Y, et al. Analysis of clinical characteristics of renal cell carcinoma in multi-centers. Chin J Urol 2010;31:77–80; (in Chinese). 30. Hamiseno D, Mochtar CA, Umbas R. Current systemic therapy in metastatic renal cell carcinoma. Indones J Cancer 2011;5:105–12. 31. Kinouchi T, Saiki S, Maeda O, Kuroda M, Usami M, Kotake T. Treatment of advanced renal cell carcinoma with a combination of human lymphoidblastoid interferon-alpha and cimetidine. J Urol 1997;157:1604–7. 32. Akaza H, Tsukamoto T, Onishi T, Miki T, Kinouchi T, Naito S. A low-dose combination therapy of interleukin-2 and interferon-alpha is effective for lung metastasis of renal cell carcinoma; a multicenter open study. Int J Clin Oncol 2006;11:434–40. 33. Naito S, Yamamoto N, Takayama T, et al. Prognosis of Japanese metastatic renal cell carcinoma patients in the cytokine era: a cooperative group report of 1463 patients. Eur Urol 2010;57:317–25. 34. Umbas R, Hardjowijoto S, Safriadi F, et al. Guidelines on Renal Malignant Tumor of the Indonesian Urological Association. Jakarta: Indonesian Urological Association, 2012. ISBN: 978-979-25-4289-9 (in Indonesian). 35. Cheng Pang, Youan Guan, Hongbo Li, et al. Urologic Cancer in China. Japanese Journal of Clinical Oncology, 2016, 46(6) 497-501. 36. La Vecchia C, Bosetti C, Lucchini F, Bertuccio P, Negri E, Boyle P, et al. Cancer mortality in Europe, 2000-2004, and an overview of trends since 1975. Ann Oncol 2010;21:1323–60. 37. Sankaranarayanan R, Swaminathan R, Black R (1996). Global variations in cancer survival. Cancer, 78, 2461-4. 38. Pakzad R, Mohammadian-Hafshejani A, Ghoncheh M, et al (2015b). The incidence and mortality of prostate cancer and its relationship with development in Asia. Prostate Int, 3, 135-40. 39. Mahdavifar N, Ghoncheh M, Pakzad R, et al (2016). Epidemiology, Incidence and Mortality of Bladder Cancer and their Relationship with the Development Index in the World. Asian Pac J Cancer Prev, 17, 381-6. 40. Eslick GD. What is a rare cancer? Hematol Oncol Clin North Am. 2012 Dec;26(6): 1137–41. 41. Greenlee RT, Goodman MT, Lynch CF, Platz CE, Havener LA, Howe HL. The occurrence of rare cancers in U.S. adults, 1995–2004. Public Health Rep. 125(1):28–43. 42. Larke NL, Thomas SL, dos Santos Silva I, Weiss HA. Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control. 2011;22(8): 1097–110. 43. Hernandez BY, Barnholtz-Sloan J, German RR, Giuliano A, Goodman MT, King JB, et al. Burden of invasive squamous cell carcinoma of the penis in the United States, 1998-2003. Cancer. 2008;113(November):2883–91 X 53GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Treatment Number of patients (%) Penectomy 35 (48.6%) Chemotherapy 12 (16.6%) Refusal of treatment 25 (34.7%) 44. Favorito LA, Nardi AC, Ronalsa M, Zequi SC, Sampaio FJB, Glina S. Epidemiologic study on penile cancer in Brazil. Int Braz J Urol. 2008 Sep- Oct;34(5):587–93. 45. Vatanasapt V, Sriamporn S, Martin N, Sriplung H, Chindavijak K, Sontipong S, et al. Cancer incidence in Thailand, 1988–1991.Cancer Epidemiol Biomarkers Prev. 1995 Jul-Aug;4(5):475–83. 46. Wabinga HR, Parkin DM, Wabwire-Mangen F, Nambooze S. Trends in cancer incidence in Kyadondo County, Uganda, 1960–1997. Br J Cancer. 2000;82(9): 1585–92. 47. Morris BJ. The strong protective effect of circumcision against cancer of the penis. Adv Urol. 2011;2011:812368. doi: 10.1155/2011/812368. Epub 2011 May 22. 48. Bleeker MC, Heideman DA, Snijders PJ, et al. Penile cancer: epidemiology, pathogenesis and prevention. World J Urol 2009; 27:141-50. 54 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra