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Taratkin M, Singla N, Babaevskaya D, Androsov A, Shariat SF, Fajkovic H, Baniel J, Enikeev D. A Review of How Lasers Are Used in UTUC Surgery: Can the Choice of Laser Affect Outcomes? Cancers (Basel) 2023; 15:cancers15061874. [PMID: 36980763 PMCID: PMC10047311 DOI: 10.3390/cancers15061874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is a relatively rare disease with an aggressive phenotype compared to urothelial carcinoma in the bladder. In recent years, kidney-sparing surgery (KSS) and, in particular, endoscopic surgery have become the procedure of choice among urologists where the treatment of localized UTUC is concerned. Endoscopy tends to result in satisfactory oncological disease control while lowering morbidity and minimizing complications amongst the appropriately selected cohort of patients. While endoscopic surgery for UTUC might appear to be standardized, it, in fact, differs considerably depending on the source of energy used for resection/ablation. There has been little reliable data up to now on which laser energy source is the most superior. The goal of this review is, therefore, to outline the results of endoscopic UTUC treatment using different lasers and to analyze how these laser-tissue interactions may affect the surgery. We start by pointing out that the data remains insufficient when trying to determine which laser is the most effective in the endoscopic management of UTUC. The ever-growing number of indications for minimally invasive treatment and the increasing number of centers using laser surgery will, hopefully, lead to novel randomized controlled trials that compare the performance characteristics of the lasers as well as the effects of UTUC on patients.
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Affiliation(s)
- Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Nirmish Singla
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Diana Babaevskaya
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Alexander Androsov
- Institute for Clinical Medicine, Sechenov University, 119021 Moscow, Russia
| | - Shahrokh F Shariat
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
- Department of Urology, Medical University of Vienna, 1030 Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Urology, University of Texas Southwestern, Dallas, TX 75390, USA
- Division of Urology, Department of Special Surgery, Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman 19328, Jordan
- Department of Urology, Second Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic
| | - Harun Fajkovic
- Department of Urology, Medical University of Vienna, 1030 Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, 3100 Vienna, Austria
| | - Jack Baniel
- Division of Urology, Rabin Medical Center, Petach Tikva 4920232, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
- Department of Urology, Medical University of Vienna, 1030 Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, 3100 Vienna, Austria
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Chien AL, Chua KJ, Doppalapudi SK, Ghodoussipour S. The role of endoscopic management and adjuvant topical therapy for upper tract urothelial cancer. FRONTIERS IN UROLOGY 2022; 2:916259. [PMID: 38855025 PMCID: PMC11160966 DOI: 10.3389/fruro.2022.916259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Upper tract urothelial carcinoma (UTUC) has traditionally been managed with radical nephroureterectomy, and while this approach remains the gold standard for high-risk disease, endoscopic, kidney-sparing management has increasingly been adopted for low-risk disease as it preserves kidney function without compromising oncologic outcomes. Ureteroscopy and percutaneous renal access not only provide diagnoses by tumor visualization and biopsy, but also enable treatment with electrocautery or laser ablation. Several modalities exist for laser ablative treatments including thulium:YAG, neodymium:YAG, holmium:YAG, and combinations of the preceding. Furthermore, due to high recurrence rates after endoscopic management, adjuvant intracavitary instillation of various agents such as mitomycin C and bacillus Calmette-Guerin have been used given benefits seen in non-muscle invasive urothelial bladder cancer. Other formulations also being studied include gemcitabine, anthracyclines, and immunotherapies. More recently, Jelmyto, a mitomycin reverse thermal gel, has been developed to allow for adequate drug delivery time and potency since urine flow could otherwise dilute and washout topical therapy. In this article, the authors review techniques, indications, best practices, and areas of current investigation in endoscopic management and adjuvant topical therapy for UTUC.
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Affiliation(s)
- Austin L. Chien
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Kevin J. Chua
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Sai Krishnaraya Doppalapudi
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
- Division of Urology, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Phillips CK, Landman J. Lasers in the upper urinary tract for non-stone disease. World J Urol 2007; 25:249-56. [PMID: 17562052 DOI: 10.1007/s00345-007-0179-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 05/03/2007] [Indexed: 10/23/2022] Open
Abstract
Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.
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Affiliation(s)
- Courtney K Phillips
- Department of Urology, Columbia University School of Medicine, 161 Fort Washington Avenue, Room 1111, New York, NY 10032, USA
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Abstract
Technological advances have increased the applicability of endoscopic treatment for upper-tract transitional-cell carcinoma (TCC). Percutaneous and ureteroscopic tumor resection have become reasonable treatment options for patients with anatomically or functionally solitary kidneys, bilateral upper-tract tumors, significant renal insufficiency, or comorbid disease that would preclude standard open surgery. This approach also is being used increasingly on those with a normal contralateral kidney in whom nephroureterectomy and en bloc removal of the ipsilateral ureteral orifice and surrounding bladder cuff is considered the standard therapy. This paper reviews the current role of ureteroscopic management of upper-tract TCC.
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Affiliation(s)
- Khai-Linh V Ho
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA
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Shiraishi K, Eguchi S, Mohri J, Kamiryo Y. Role of ureteroscopic biopsy in the management of upper urinary tract malignancy. Int J Urol 2004; 10:627-30. [PMID: 14633064 DOI: 10.1046/j.1442-2042.2003.00721.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The aim of the study presented here was to examine the accuracy of ureteroscopic biopsy in the diagnosis of upper urinary tract transitional cell carcinoma (TCC) and whether nephron-sparing management (holmium YAG laser, transurethral resection or partial ureterectomy) is possible or not based on pathological diagnosis. METHODS Forty consecutive patients underwent ureteroscopic biopsy with the use of 3-Fr cold cup forceps. Pathological diagnosis of the biopsy sample and grade or stage of surgically resected tumors were compared. In patients with grade 1 or 2 TCC diagnosed by ureteroscopic biopsy, the disease-free and survival rates determined whether nephron-sparing management was performed or not. RESULTS There were no major complications associated with ureteroscopic biopsy. The pathological grading of the biopsy specimen was almost the same as that of the surgically resected specimen. Eighty five percent of grade 2 or 3 TCC showed muscle invasive disease. There were no significant differences in the disease-free and survival rates between the nephroureterectomy and the nephron-sparing management groups, except for grade 3 or pT3 tumors. CONCLUSION Ureteroscopic biopsy is safe and accurate if sufficient tissue sample is obtained. Ureteroscopic biopsy should be performed in patients who require nephron-sparing management. Nephroureterectomy can be avoided if the tumor is confirmed as low-grade.
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Affiliation(s)
- Koji Shiraishi
- Department of Urology, Saiseikai Shimonoseki General Hospital, 3-4-1 Kifune-cho, Shimonoseki, Yamaguchi, Japan.
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Abstract
The expanding experience with endoscopic techniques for treating upper tract urothelial malignancy demonstrates its safety and efficacy in carefully selected patients. Diagnostic accuracy can be enhanced, and pathologic confirmation of tumor grade and stage is possible. In carefully selected patients who have low-grade and low-stage disease, the results of endourologic management have been encouraging. Patients with an anatomic or functionally solitary kidney, bilateral disease, or significant renal insufficiency can often be considered candidates for endoscopic treatment as the first line of therapy. In the setting of low-grade, low-stage disease in a patient with a normal contralateral kidney, the role of endourologic management remains controversial. Adjuvant topical therapy with mitomycin C or BCG seems to be safe and well tolerated after endoscopic management of upper tract TCC.
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Affiliation(s)
- John S Lam
- Department of Urology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, Irving Pavilion, 11th Floor, New York, NY 10032, USA
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Matsuoka K, Lida S, Tomiyasu K, Inoue M, Noda S. Transurethral endoscopic treatment of upper urinary tract tumors using a holmium:YAG laser. Lasers Surg Med 2003; 32:336-40. [PMID: 12766954 DOI: 10.1002/lsm.10184] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The feasibility of treating upper urinary tract tumors with a holmium:YAG (Ho:YAG) laser in transurethral endoscopy was examined. STUDY DESIGN/MATERIALS AND METHODS Thirty-three treatments were performed on 30 patients with renal pelvic and ureteral carcinomas. After vaporization and coagulation eliminated the tumors, the surrounding mucosa was fully coagulated. Postoperative follow-up consisted of urinary cytology once a month, cystoscopy every 3 months, excretory pyelography every 6 months, and uretero-pyeloscopy every 6-12 months. RESULTS The recurrence rate after the first treatment was 86% in the imperative indication group. The tumor-free rate (median follow-up, 37 months) in the imperative indication group was 57%. In the elective indication group, those values were 20 and 95% (median follow-up, 33 months), respectively. CONCLUSIONS Transurethral endoscopic treatment of upper urinary tract tumors using Ho:YAG laser can be a useful method on limited cases identified into specific treatments groups combined with a strict follow-up.
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Affiliation(s)
- Kei Matsuoka
- Department of Urology, Kurume University School of Medicine, Kurume City 8300011, Japan.
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Assimos DG, Hall MC, Martin JH. Ureteroscopic management of patients with upper tract transitional cell carcinoma. Urol Clin North Am 2000; 27:751-60. [PMID: 11098772 DOI: 10.1016/s0094-0143(05)70123-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Endoscopic therapy for the management of upper urinary tract TCC is mainly indicated for patients with an anatomically or functionally solitary kidney, renal insufficiency, bilateral tumors, or severe medical comorbidity. It may be a reasonable alternative to distal ureterectomy with bladder-cuff resection in individuals with low-grade superficial distal ureteral tumors. Although use of this approach has been suggested for treating standard patients with low-grade, low-stage collecting system tumors, this recommendation should not be embraced until more supporting evidence is generated. The efficacy of adjuvant therapy for the prevention of recurrent or progressive disease needs to be defined. If current adjuvant strategies prove ineffective, alternative ones will need to be developed. It is anticipated that advancements in endoscopic technology will facilitate the performance of this type of surgery in the future.
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Affiliation(s)
- D G Assimos
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
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Affiliation(s)
- A Borkowski
- University Clinic of Urology, Warsaw, Poland
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10
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Abstract
Neodymium:YAG and holmium:YAG lasers were used to remove intraluminal sutures from three patients. In two, the suture was in the bladder and had served as a nidus for stone formation. In the other, the suture was in the ureter. An in vitro study showed that the Nd:YAG laser could divide all types of suture readily, whereas the Ho:YAG laser could divide all materials except Gortex. These cases illustrate another application for lasers.
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Affiliation(s)
- D H Bagley
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Grafstein LA, Selman SH. Thermal lasers in urologic oncology. JOURNAL OF CLINICAL LASER MEDICINE & SURGERY 1998; 16:49-54. [PMID: 9728131 DOI: 10.1089/clm.1998.16.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Urology is a surgical specialty that relies heavily on the endoscopic approach for diagnosis and treatment of disease. Electrosurgical instruments have been the standard vehicle for endoscopic tumor ablation. Over the last 30 years a number of investigators have explored the use of the medical laser as either an alternative or an adjunct to standard electrosurgical techniques. The development of small caliber flexible and rigid endoscopic application. In addition, the potential for very limited and precise distribution of laser energy in targeted tissue is clinically appealing for endoscopic applications. In this article, we review the use of thermal laser in urologic oncology.
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Affiliation(s)
- L A Grafstein
- Department of Urology, Medical College of Ohio, Toledo, USA
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Bagley DH. Ureteroscopic laser treatment of upper urinary tract tumors. JOURNAL OF CLINICAL LASER MEDICINE & SURGERY 1998; 16:55-9. [PMID: 9728132 DOI: 10.1089/clm.1998.16.55] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To summarize the present status of ureteroscopic laser treatment of upper urinary tract tumors. SUMMARY AND BACKGROUND DATA Small diameter rigid and flexible ureteroscopes can provide convenient access to the upper urinary tract. The small diameter of the instruments and the working channels are ideally suited for the placement of laser fibers as an intraluminal ablative technique. METHODS The authors reviewed the literature and their own experience with laser treatment of upper tract tumors for the description of instruments, techniques, and the results achieved. RESULTS At least 12 reports have presented the results after using lasers for treating upper tract tumors. The Nd:YAG laser has been used in most series but more recently, the holmium:YAG laser has become available. Each laser has particular advantages and each can be delivered along the same low water content quartz fibers. Less scarring with stricture formation has been reported after use of the laser versus electrofulguration. Among the series reported, local recurrences occurred in 33% of patients with renal pelvic tumors or ureteral tumors. In the authors' experience, the holmium:YAG laser was most frequently used and the combination of holmium and Nd:YAG was nearly as common. The Nd:YAG was used alone in less than 10% of patients. CONCLUSIONS The ureteroscopic treatment of upper tract transitional cell carcinoma is a reasonable alternative to surgical removal in many patients. It provides a major advantage in patients with specific indications for conservative therapy and may be a reasonable elective therapy in others with small, low grade, tumors. The holmium laser alone or in combination with the Nd:YAG laser has become our primary mode of therapy.
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Affiliation(s)
- D H Bagley
- Department of Urology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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13
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Abstract
Advances in ureteroscopic techniques have made it possible to treat many upper-tract tumors conservatively. Such treatment has demonstrated acceptable survival and renal preservation in high-risk patients, particularly those with a solitary kidney, bilateral tumors, poor renal function, or prohibitive operative risk. It is also preferred in patients with grade I TCC, particularly when located in the distal ureter. For patients with regionally extensive upper-tract urothelial neoplasms, use of endourologic techniques should be considered to control hemorrhage, relieve obstruction, and preserve as much functioning renal tissue as possible. Success with small, solitary, low-grade tumors allows the application of this technique to patients with a normal contralateral kidney on an elective basis. Adjuvant BCG or mitomycin C therapy appears to be safe, but confirmation of any benefits awaits the results of larger trials. Benign neoplasms can occur in the upper urinary tract and should be distinguished from TCC, thus avoiding more radical treatment for a benign lesion. Endoscopic surveillance should be maintained because recurrences can develop without radiographic evidence.
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Affiliation(s)
- E R Tawfiek
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Wong AK, Lupu AN, Shanberg AM. Laser ablation of renal pelvic transitional cell carcinoma in a solitary kidney: a 9-year follow-up. Urology 1996; 48:298-300. [PMID: 8753746 DOI: 10.1016/s0090-4295(96)00173-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser ablation of upper-tract urothelial tumors has been well documented in the urologic literature. However, the standard treatment of choice remains radical nephroureterectomy with excision of a cuff of the bladder for most patients. We report on a patient with recurrent superficial transitional cell carcinoma of the renal pelvis in a solitary kidney treated with Nd:YAG laser with a 9-year follow-up.
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Affiliation(s)
- A K Wong
- Division of Urology, UCI Medical Center, Orange 92668, USA
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