Trends in genitourinary tumors

ABSTRACT

Objectives:

To analyze the trends, histopathological characteristics, and demographic distribution of genitourinary (GU) tumors at a major academic center in Jeddah, Saudi Arabia, over a 16-year period (2007–2023).

Methods:

A retrospective review of electronic medical records was conducted, including all histologically confirmed cases of GU tumors. Data on patient demographics, tumor type, and histopathological findings were extracted and analyzed using descriptive and inferential statistical methods.

Results:

A total of 1,791 GU tumor cases were identified. Bladder cancer was the most prevalent (42%), followed by prostate cancer (21%) and renal cell carcinoma (21%). Testicular and ureteral tumors were less common, with scrotal and penile malignancies being rare (<1%). The mean age at diagnosis varied significantly, with prostate and bladder cancers occurring predominantly in older patients, while testicular tumors were diagnosed at a younger age. A significant rise in kidney and bladder cancer diagnoses was observed, potentially linked to improved screening and environmental factors.

Conclusion:

This study provides valuable insights into the epidemiological trends of GU tumors in Saudi Arabia, emphasizing the need for early detection and targeted screening. Further research is needed to explore contributing factors and optimize treatment approaches.

Genitourinary tumors (GU) encompass a diverse group of malignancies affecting the urinary and reproductive systems, including bladder, prostate, renal, ureteral, and testicular cancers. The significance of studying trends in these tumors lies in their distinct epidemiological characteristics, variations in clinical presentation, and treatment outcomes, which can inform healthcare strategies and improve patient management. The management and outcomes of GU tumors have been a topic of significant interest in the field of oncology. Over the past decade and a half, substantial advancements in diagnostic and therapeutic approaches have influenced the landscape of GU oncology, necessitating a comprehensive examination of these trends within an academic center setting. These tumors represent a significant burden of disease worldwide, with varying incidence rates across different regions. In Saudi Arabia, the epidemiology of GU tumors has not been extensively studied, particularly in the context of tertiary centers. This study aims to fill this gap by analyzing the trends and characteristics of GU tumors at an academic hospital in Jeddah over a 16-year period (2007-2023), providing valuable insights into the evolving patterns of these malignancies. By elucidating these trends, this research not only contributes to the existing body of knowledge but also underscores the importance of continuous monitoring and adaptation of clinical practices to enhance patient outcomes in the management of GU tumors.^1,2

In addition to the collaborative efforts of multidisciplinary teams, understanding the epidemiological disparities among different demographic groups is crucial in addressing GU tumors effectively. For instance, studies have shown that African American men face significant barriers to screening and early detection of prostate cancer, which contributes to higher mortality rates within this population.³ Furthermore, as treatment modalities evolve, there is a pressing need for targeted educational initiatives aimed at these high-risk groups to enhance awareness and promote timely intervention. By integrating timely and culturally sensitive approaches into healthcare strategies, we can not only improve access to care but also tailor interventions that resonate with specific communities, ultimately leading to better outcomes in the management of GU tumors.⁴

Methods

On 1st of September, 2024, we conducted a retrospective review of medical records from an academic hospital in Jeddah, Saudi Arabia, covering the period from 2007 to 2023. Variables analyzed included patient demographics, clinical presentation, histopathologic findings, and treatment modalities. The study included patients diagnosed with GU tumors (including kidney, bladder, prostate, ureter, testis, scrotum, and penis cancers) between 2007 and 2023, provided they had complete medical records with demographic data, histopathological findings, and treatment details. Patients of all ages and genders were included. Cases were excluded if medical records were incomplete or missing, if the diagnosis of GU tumors was not confirmed histologically, or if patients had non-malignant or benign GU conditions.

Descriptive statistics were used to summarize the data, including frequencies, percentages, means, and standard deviations for continuous variables. Categorical variables were presented as proportions. To compare the mean age at diagnosis across different tumor types, ANOVA and Kruskal-Wallis tests were performed. Trends in tumor incidence over time were analyzed using linear regression models. All statistical analyses were conducted using SPSS version 25, with a significance level set at p<0.05. The study was approved by ethical committee, and patient confidentiality was maintained throughout the research process.

Results

The dataset includes GU tumors diagnosed at an academic hospital between 2007 and 2023, covering 7 tumor locations: kidney, bladder, prostate, ureter, testis, scrotum, and penis. A total of 1,791 cases were analyzed. The most common tumor type was bladder cancer, accounting for 42% of cases (749/1,791), with urothelial cell carcinoma being the predominant histologic type. Prostate cancer was the second most frequent, representing 21% of cases (385/1,791), with acinar adenocarcinoma as the most common histologic subtype. Renal cell carcinoma (RCC) cases were fewer than previously reported, comprising 385 specimens (21%), with clear cell RCC being the most common histologic subtype, followed by papillary and chromophobe RCC histologic subtypes. Ureteral tumors accounted for 11% of cases (193/1,791), while testicular tumors made up 4% (68/1,791), predominantly seminoma germ cell tumors. Rare tumors, including scrotal and penile cancers, collectively accounted for less than 1% of cases (11/1,791).

The mean age at diagnosis varied significantly among tumor types (ANOVA: p<1.69×10−147 p<1.69 \times 10^{-147}p<1.69×10−147, Kruskal-Wallis: p<2.83×10−102 p<2.83 \times 10^{-102}p<2.83×10−102). Prostate cancer patients had the highest mean age (75 years) and bladder cancers (70 years), while testicular tumors were diagnosed at the youngest age (34 years). Kidney tumors had a mean diagnostic age of 47.9 years, while ureteral tumors were diagnosed at 63.8 years (Table 1 and Figure 1). Males were more commonly affected, particularly in bladder cancers.

Table 1.

- Demographic and clinical characteristics of GU tumors (2007-2023).

Tumor site	n (%)	Mean Age (Years)±SD	95% Confidence Interval for mean age
Kidney	385 (21.5)	47.9±10.2	46.8 - 49.0
Bladder	749 (41.8)	70.6±9.5	69.9 - 71.3
Prostate	385 (21.5)	75.4±8.2	74.5 - 76.3
Ureter	193 (10.8)	63.8±11.7	62.1 - 65.5
Testis	68 (3.8)	34.1±6.1	32.6 - 35.6
Scrotum	7 (0.4)	55.6±7.8	49.1 - 62.1
Penis	4 (0.2)	50.5±9.3	40.2 - 60.8

GU: Genitourinary

Figure 1.

- Mean Age at diagnosis by genitourinary tumor type (2007–2023). One-way ANOVA analysis revealed highly significant differences in mean age across tumor types (p<1.69×10^-¹⁴⁷). Testicular tumors were diagnosed at significantly younger ages compared to all other tumor types, while prostate and bladder cancers occurred at significantly older ages. Brackets and corresponding p-values (p<0.001) denote statistically significant differences between tumor types based on post-hoc pairwise comparisons.

The most frequently reported presenting symptom was hematuria, particularly in bladder, kidney, and ureteral tumors. Flank pain was common in renal tumors, whereas testicular masses were a typical finding in testicular cancer. Surgical resection remained the primary treatment modality, especially for kidney, prostate, and testicular cancers, while bladder and ureteral tumors often required additional therapies.

Analysis of diagnosis trends over time showed a notable increase in kidney and bladder tumors, peaking around 2018-2019. To quantify these observed trends, we performed linear regression analyses for each tumor type over the 16-year study period (2007-2023).

For kidney tumors, linear regression analysis revealed a significant increasing trend with a slope coefficient of 2.14 cases per year (95% CI: 1.48-2.80, p<0.001, R²=0.73), indicating a consistent rise in incidence over the study period. Similarly, bladder cancer cases demonstrated a significant upward trend with a slope coefficient of 3.27 cases per year (95% CI: 2.46-4.08, p<0.001, R²=0.81).

Prostate cancer cases showed a modest but statistically significant increase (slope coefficient=0.92 cases per year, 95% CI: 0.31-1.53, p=0.006, R²=0.41). In contrast, ureteral tumors (slope coefficient=0.32, 95% CI: -0.14-0.78, p=0.16, R²=0.13) and testicular tumors (slope coefficient=0.15, 95% CI: -0.12-0.42, p=0.26, R²=0.08) displayed fluctuating patterns without statistically significant trends. The incidence rates for kidney and bladder cancers, calculated per 100,000 hospital admissions, increased from 9.8 and 18.5 in 2007 to 22.3 and 39.2 in 2023, respectively, representing 127.6% and 111.9% increases over the 16-year period (Figure 2).

Figure 2.

- The line chart illustrates the annual number of cases for each tumor type from 2007 to 2023.

Discussion

The increasing incidence of multiple primary malignancies within the GU system raises important considerations for clinical practice and patient management. The interplay between genetic predispositions, environmental factors, and lifestyle choices may contribute to this alarming trend, necessitating a deeper understanding of their etiology. As healthcare professionals continue to refine diagnostic techniques and therapeutic interventions, it becomes crucial to consider these complexities in developing tailored treatment plans that address not only the individual tumor but also the potential for concurrent malignancies. This holistic approach is essential for improving long-term outcomes and enhancing the quality of life for patients navigating the challenges posed by GU cancers. Understanding the multifaceted nature of these cancers will enable clinicians to implement more effective surveillance protocols, ultimately leading to earlier detection and intervention for patients at risk.

Recent studies indicate that synchronous and metachronous tumors are becoming more prevalent, with significant implications for treatment strategies and prognosis. For instance, a significant increase in the incidence of prostate and kidney cancers among the Saudi population.⁵ Specifically, prostate cancer incidence rates have been documented to rise from 0.2 to 1.4 per 100,000 individuals, showcasing a concerning trend in malignancy rates.⁶ Additionally, late presentations of GU cancers at the time of diagnosis have been reported, highlighting the need for improved early detection strategies.⁵

Health-related quality of life issues are prevalent among cancer patients, with older demographics and those undergoing chemotherapy experiencing more significant challenges.⁷ Similar to our renal malignancies collection, Alasker et al⁸ found 72.4% of patients have clear cell RCC. However, they reported that papillary RCC in their cohort exhibited lower survival rates compared to clear cell RCC and chromophobe RCC which is in contrary to other studies which reported that clear cell RCC have poor survival outcome compared to papillary and chromophobe RCC. These findings underscoring the variability in prognosis based on tumor subtype.^8-11

Alkhateeb et al¹² recorded an observation similar to the trend we documented. Over the past 2 decades, there has been an observable increase in kidney cancer cases.¹² In both our study and Alkhateeb et al. study, the predominant histologic subtype is clear cell RCC followed by papillary and chromophobe RCCs.¹² However, the mean age of diagnosis of kidney cancer in our cohort is 47.9 years which is 10 years younger than the reported mean age of diagnosis in Alkhateeb et al. study.¹² El-Siddig et al¹³ reported that urothelial cell carcinoma is the most common histologic type of bladder cancer like our cohort. However, the mean age of diagnosis for bladder cancer is 62.6 years,¹³ nearly a decade younger than our cohort. These findings potentially reflecting differences in risk factor exposure or diagnostic practices and underscore the need for additional studies to clarify evolving risk profiles in Saudi Arabia.

From global point of view, previous studies have examined the epidemiologic trends and clinical characteristics of GU tumors. Schafer et al¹⁴ revealed significant disparities in GU cancer incidence and mortality across different demographic groups in the United States. Men have notably higher incidence and mortality rates for bladder and kidney cancers compared to women, while African American men face the highest rates of prostate cancer death among all racial groups. Additionally, the incidence of kidney and testicular cancers has been rising across all racial and ethnic populations, with advanced-stage prostate cancer also showing an increasing trend in recent years. The study suggests that disparities in access to healthcare, along with variations in risk factors such as smoking and obesity, may contribute to these trends, emphasizing the need for targeted public health interventions and improved access to early detection and treatment.¹⁴

In Saudi Arabia, the management of GU tumors has evolved significantly over the past decade, marked by the adoption of minimally invasive surgical techniques and novel therapies. For renal cell carcinoma (RCC), Alkhateeb et al¹² reported a significant increase in the percentage of nephron-sparing surgeries, such as partial nephrectomies, in the recent years that align with global trends toward the use of minimally invasive surgical techniques and preserving renal function.¹² Similarly, a retrospective review by Junejo et al¹⁵ assessed the trends in the surgical management of renal cell carcinoma, highlighting the increased use of nephron-sparing techniques and minimally invasive procedures over time. Also, Elaimy et al¹⁶ reported on the changing landscape of prostate cancer treatment globally, with a shift towards more conservative management strategies, such as active surveillance for patients with low risk disease, in recent years. Immunotherapy, particularly checkpoint inhibitors like nivolumab, has been integrated into advanced bladder cancer regimens, reflecting guidelines from recent clinical trials.¹⁷ These advancements highlight the importance of adopting innovative therapies while ensuring equitable access across socioeconomic groups.

The significant upward trends in kidney and bladder cancer incidence demonstrated through regression analyses (p<0.001 for both) aligns with global patterns and may reflect multiple factors, including improved diagnostic techniques, increased exposure to environmental risk factors, and changes in lifestyle practices. One of the most important modifiable risk factors for bladder cancer is smoking, with up to 60% of patients affected with bladder cancer being smokers, with increased risk in a dose-dependent manner. Also, occupational exposure to aromatic amines and polycyclic aromatic hydrocarbons has been associated with an increased risk for bladder cancer.¹⁸ For kidney cancer, a body mass index (BMI) ≥30, likely contributes to RCC risk as adiposity promotes insulin resistance, increases insulin-like growth factors-1 (IGF1) which triggers transduction pathways such as phosphatidylinositol 3-kinase/ protein kinase B(PI3K/AKT) and Hypoxia-inducible factor 1-alpha (HIF1-A).^19,20 The doubling of incidence rates for these cancers over the 16-year study period emphasizes the growing burden of urological malignancies in our population and highlights the urgent need for enhanced screening protocols and public health initiatives targeting smoking cessation, enhancing occupational safety, and metabolic health are needed to address these trends. Future studies should further investigate the underlying causes of these trends, including potential genetic, environmental, and lifestyle factors specific to the Saudi population.

The rising incidence of GU tumors has prompted a renewed focus on the importance of early detection and preventive strategies, particularly in high-risk populations. Understanding demographic factors such as age, sex, and geographic distribution can aid in developing targeted screening programs that may significantly improve outcomes.²¹ For instance, prostate cancer screenings are increasingly recommended for men over 50 or those with a family history,²² while bladder cancer risk factors necessitate vigilance among smokers and individuals exposed to certain chemicals.¹⁸ For prostate cancer, US Preventive Services Task Force recommends periodic PSA testing for men aged 55-69 with average risk.²³ High-risk bladder cancer groups (e.g., smokers, industrial workers) could benefit from annual urinalysis and cytology starting at age 50. For renal cancer, abdominal imaging in smokers, hypertensive, or obese individuals, may improve early detection.⁹ Additional studies are required to establish a national screening program tailored to the Saudi population needs. Expanding the Saudi Cancer Registry to track screening adherence and outcomes will ensure resources align with demographic needs and enhancing the cost-effectiveness of these initiatives.

Additionally, advancements in molecular diagnostics hold promise for identifying genetic markers associated with predisposition to these malignancies, potentially allowing for personalized surveillance protocols tailored to individual patient profiles. Such proactive measures could mitigate the burden of advanced disease and enhance survival rates across diverse patient demographics by fostering early detection and intervention strategies that are more aligned with the specific risks faced by different populations. Such tailored approaches not only improve the effectiveness of screenings but also empower patients with knowledge about their health, encouraging them to engage actively in preventive measures and treatment decisions.

In conclusion, this study provides valuable insights into the trends and characteristics of GU tumors in an academic hospital in Jeddah, Saudi Arabia. The high prevalence of RCC and increasing trends of bladder cancer highlights the need for targeted screening and treatment strategies. Early detection and multidisciplinary management are crucial for improving patient outcomes. Further research is needed to explore the underlying factors contributing to the observed trends and to optimize treatment approaches for GU tumors in the region.