The Transition of Urological Practice for Forty Years in Juntendo University

I enrolled in the Juntendo University Urological Course in 1982 and worked at Juntendo for 40 years until I retired in 2022. The transition of Urology had been slow until recent years. In the last 20-30 years, Urological practice has made significant progress. I will look back on the 40 years of Juntendo University and describe it in this article. In particular, the transition and breakthrough in the diagnosis and treatment of prostate cancer were remarkable. This point will be described mainly based on the experience at Juntendo Nerima Hospital.


The Transition of Urology for forty years
The prostate cancer practice has undergone significant changes over the last 40 years.Forty years ago, when I was still a new physician, surgical castration was the first operation for a new urologist.At that time, surgical castration was the only surgery for prostate cancer and was the mainstay of hormone therapy for prostate cancer.Currently, robot-assisted radical prostatectomy (RARP, Figure 3) has become a main surgical procedure that is widely performed not only in Western countries but also in Japan.Hormone therapy for prostate cancer has also started to use new AR target drugs (Abiraterone, Enzalutamide, Apalutamide, and Darolutamide) as well as surgical castration and medical castration.In addition, anticancer drugs such as Docetaxel and Cabazitaxel have been used, and radiation therapy for bone metastases such as Ra-223 has also been administered.
Prostate biopsy has also changed significantly.In the 1980s, when induration of prostate cancer was palpable, prostate biopsy was performed using a TruCut needle (Figure 4) under a finger guidance.In recent years, puncture needles have also advanced, allowing us to use superior products (Figure 5).PSA measurement became possible by Wang et al. 1) in 1979, Holm et al. 2) performed a transrectal ultrasound-guided prostate biopsy (TRUS-B) in 1981.
In Japan, in 1963, Hiroki Watanabe of the Department of Urology, Kyoto Prefectural University of Analysis of prostate cancer localization toward improved diagnostic accuracy of transperineal prostate biopsy 3) .Delineating the precise localization of prostate cancer is important in improving the diagnostic accuracy of prostate biopsy.In Juntendo University Nerima Hospital, initial 12core or repeat 16-core biopsies were performed using a transrectal ultrasound guided transperineal prostate biopsy method.We step-sectioned prostates from radical prostatectomy specimens at 5-mm intervals from the urethra to the urinary bladder and designated five regions: the (1) Apex, (2) Apex-Mid, (3) Mid, (4) Mid-Base, and (5) Base.We then mapped prostate cancer localization on eight zones around the urethra for each of those regions.Prostate cancer was detected in 93 cases of 121 cases (76.9%) in the Apex, in 115 cases (95.0%) in the Apex-Mid, in 101 cases (83.5%) in the Mid, in 71 cases (58.7%) in the Mid-Base, and in 23 cases (19.0%) in the Base.In 99.2% of all cases, prostate cancers were detected from the Apex to Mid regions.For this reason, transperineal prostate biopsies have routinely been prioritized in the Apex, Apex-Mid, and Mid regions, while the Base region of the prostate was considered to be of lesser importance.Our analyses of prostate cancer localization revealed a higher rate of cancer in the posterior portion of the Apex, antero-medial and postero-medial portion of the Apex-Mid and antero-medial and postero-lateral portion of the Mid.The transperineal prostate biopsies in our institute performed had a sensitivity of 70.9%, a specificity of 96.6%, a positive predictive value (PPV) of 92.2% and a negative predictive value (NPV) of 85.5% (Figure 7, 8, Table 1, 2).

Conclusions
The concordance of prostate cancer between prostatectomy specimens and biopsies is comparatively favorable.According to our study, the diagnostic accuracy of transperineal prostate biopsy    can be improved in our institute by including the anterior portion of the Apex-Mid and Mid regions in the 12-core biopsy or 16-core biopsy, such that a 4-core biopsy of the anterior portion is included.
During my 40 years at Juntendo University, I served three chief professors and two directors (Figure 9).Thanks to these doctors, I was able to carry out a very fulfilling and happy medical practice.We would like to express our sincere gratitude to all the bosses and staff who have been involved in reaching retirement age.

Figure 9
Figure 9 Three chief professors and two directors who were my mentors

Table 1
Prostate cancer localization in the Apex, Apex-Mid, Mid, Mid-Base, and Base out of the 121 cases Region No. of cases of prostate cancer positive (%)