Recent Advances in the Management of Genitourinary Neoplasms

The varying stage presentations and evolutions of kidney, bladder, prostate and testis neoplasms have motivated the philosophy of multidisciplinary management. Surgery, irradiation, chemotherapy and immunotherapy, individually and in various combinations, constitute the principal basis of treatment strategies but modifications and innovations provide a continuously changing arena for laboratory and clinical investigations. Impressive technological advances have permitted progressive insights into molecular, cell and immunobiology and cyto-genetics, exposing new targets for diagnostic and therapeutic strategies which may ultimately provide the basis for more rational and less empiric therapeutic choices. General advances relative to anesthesia, antibiotics and preand postoperative care continue to reduce the mortality and morbidity of the surgical patient. Improvements in treatment planning, radiation therapy equipment, and new methods of irradiation are altering radiation therapy. New concepts in chemotherapy and the availability of granulocyte colony-stimulating factors are impacting on chemotherapy. Advances in immunobiology have provided a progressively more rational basis for immunotherapy. Quality of life issues are being increasingly addressed. This brief summary will necessarily focus on some of the more important recent advances in management, recognizing that it is impossible to cover all areas of potential progress and that an unquantified proportion of such putative advances may not survive the tests of time and experience. Kidney Cancer Surgery remains the keystone of treatment of renal cancer with radical nephrectomy the standard treatment for local or locoregional renal cancers but with consideration of partial nephrectomy in selected cases. Irradiation has only focal and generally palliative indications. The presence of the MDR-1 gene in proximal tubular cells and derived renal cancers provides a potential explanation for at least some of the resistance to chemotherapy exhibited by renal cancers and suggests potential strategies for more effective drug treatment. The earlier recognition of renal cancer made possible by modern imaging techniques raises questions regarding screening and regarding the management of small (3 cm) renal masses. Interferons, interleukin 2 and lymphokine-activated killer cells have advanced the immunotherapy of patients with advanced renal cancer. Monoclonal antibodies have contributed insights into renal embryogenesis and morphogenesis and continue to be investigated for potential uses in diagnosis and therapy. Bladder Cancer Endoscopic treatment variously coupled with some form of intravesical therapy or prophylaxis is the keystone of management of superficial bladder tumors. BCG appears to be the most effective