Urology Division

Introduction
In the Urology Division, all of the urogenital malignant diseases (kidney cancer, urotherial cancer, prostate cancer, and testicular germ cell tumors) are diagnosed and treated by radical surgery, irradiation, sometimes in combination with chemotherapy. We also provide palliative care during the terminal stage of the disease.

Routine Activities
The urology team consists of five staff doctors, including the director of the hospital, one chief resident and three residents. In addition, working together with medical oncologists, multi-disciplinary treatments for advanced disease including metastatic kidney cancer, hormone refractory prostate cancer and metastatic germ cell tumor, are performed. Daily morning round starts at 7:30 a.m. Clinical conference to discuss inpatients is held on Monday evening. Clinico-pathological conference and urological consensus meeting are held on alternativeWednes-day.
Major urological malignant diseases are treated according to the following strategies:
(1) Renal cell carcinoma. M0: partial or radical nephrectomy. M1: immunotherapy with IFN-a or IL-II with or without palliative nephrectomy.
(2) Bladder cancer. Carcinoma in situ: BCG instillation therapy. Ta, T1: transurethral resection of bladder cancer (TUR-Bt), often combined with preoperative or postoperative BCG instillation. T2, T3: radical cystectomy with or without neoadjuvant chemo-therapy by a combination of MTX + VBL + ADR + CDDP. In some limited T2N0M0 cases, bladder-preserving therapy is adopted. T4, N(+): systemic chemotherapy, radiation; sometimes urinary diversion alone.
(3) Prostate cancer. T1a,b,c and T2a,2b with clinically insignificant cancer: various options, such as watchful waiting, radical prostatectomy, radiation, and hormonal therapy, are explained to the patients. A final treatment plan is decided upon after sufficient discussion with the patient. T2, T3N0M0: radical prostatectomy or radiation therapy combined with neoadjuvant endocrine therapy. N(+), M1: endocrine therapy and radiation.
(4) Testicular germ cell tumor (GCT). Stage I: careful watching irrespective of pathological element. Stage II or higher stages: EP (etoposide + CDDP) chemo-therapy is the first line. The residual tumor is resected in nonseminomatous cases. In seminoma cases, careful watching or radiation rather than surgery is preferred. Patients having a large tumor burden are treated with a combination of ultra-high-dose chemotherapy with autologous peripheral blood stem cell transplantation (PBSCT).

Research Activities
We are constantly seeking improved treatments for urological malignant tumors.
1. Renal cell carcinoma: We have established a more precise preoperative diagnosis by using a combination of various imaging modalities, such as CT scanning, ultrasonography, and MRI. The next study is aimed at the establishment of diagnosis criteria for atypical renal cell carcinoma and miscellaneous tumors with relatively low incidence.
2. Bladder cancer: We are re-estimating the effectiveness of neoadjuvant / adjuvant M-VAC therapy for T2,3N0M0 bladder cancer. To establish more precise criteria concerning bladder sparing treatment for T2,T3N0M0 bladder cancer, pathological factors have been analyzed. Intestinal neobladder formation after cystectomy is the main mode of urinary tract reconstruction after cystectomy. The neobladder is evaluated continuously, in terms of function and physiology. Indications for selecting appropriate patients for this mode of surgery were established by analyzing the risk factors for synchronous anterior urethral involvement of bladder cancer. Patients having CIS in the prostatic urethra should be treated with simultaneous urethrectomy at the time of cystectomy for bladder cancer because they are at high risk for anterior urethral cancer.
3. Prostate cancer: A more sophisticated prostate biopsy system was established by analyzing the efficacy and reliability of the classical sextant biopsy. Patients with small, well-differentiated adeno-carcinoma are defined as "insignificant cases" Various treatment options, including watchful waiting (W/W), are explained to these patients. The clinical meaning of W/W will be evaluated after a sufficient follow-up period. For patients with locally invasive cancer, radical prostatectomy or external beam radiation combined with neoadjuvant endocrine therapy are the treatment options. The efficacy and final outcome of these treatment options were analyzed. For the patients treated by conformal radiotherapy, the indication of adjuvant continuous or intermittent hormone therapy is being analyzed.
4. Testicular germ cell tumor: Advanced and/or refractory cases are treated with high-dose systemic chemotherapy supported by PBSCT. A comprehensive treatment strategy was designed, and its efficacy and clinical significance is being evaluated.

Clinical Trials
We are involved in ongoing protocol studies as follows:
1. A pilot study of dendritic cell-based immunotherapy for metastatic hormone- refractory prostate cancer;
2. A pilot study of allogenic peripheral blood stem cell transplantation for metastatic renal cell carcinoma; 3. A pilot study of maintenance M-VAC (CDDP, MTX, TPH-ADM, VBL) administered every 2 months for metastatic bladder or renal pelvic cancer; and 4. Phase III randomized prospective study for T3-4N0M0 prostate cancer with/without adjuvant endocrine therapy.

H. FUJIMOTO

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