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Hanna P, Zabell J, Konety B, Warlick C. Perioperative complications and oncological outcomes of open versus robotic-assisted radical cystectomy: a propensity score-matched study. World J Urol 2024; 42:220. [PMID: 38587653 DOI: 10.1007/s00345-024-04907-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/24/2024] [Indexed: 04/09/2024] Open
Abstract
PURPOSE To conduct a comparative effectiveness analysis between robot-assisted radical cystectomy (RARC) and open approach (ORC). MATERIALS AND METHODS A retrospective cohort study was conducted involving all patients undergoing radical cystectomy and urinary diversion for invasive bladder cancer at our institution from 2010 to 2018. Of a total 296 patients, we matched ORC and RARC cases based on age, BMI, Charlson comorbidity index, pathological TN staging of the tumor, prior radiotherapy, and type of diversion. The perioperative complications and oncological outcomes were compared. RESULTS Eighty-nine patients were matched in the ORC and RARC groups. The median operative time was longer in RARC group (430 min) than that of ORC group (372 min) (p = 0.03); however, the median estimated blood loss (EBL) was significantly lower in RARC group (500 ml) than that of ORC (700 ml) (p < 0.0001). The median length of hospital stay (LOS) was significantly reduced in the RARC group (7 days) compared to the ORC group (8 days) (p = 0.02). There were no significant differences between both groups in 30- and 90-day postoperative complications (p = 0.3 and p = 0.2, respectively). A total of 68 deaths (38.2%) were observed, of which 36 (40.4%) were in ORC group while 32 (36%) were in RARC group (p = 0.5). The results were comparable in both groups regarding 5-year survival rate and cancer-specific survival (p = 0.3 and p = 0.1, respectively). CONCLUSION RARC showed better perioperative outcomes in the form of less EBL and shortened LOS compared to ORC group. However, both RARC and ORC provide similar postoperative oncologic control, in terms of similar positive surgical margins, cancer-specific rates, and 5-year survival rates.
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Affiliation(s)
- Peter Hanna
- Department of Urology, University of Minnesota, Minneapolis, MN, USA.
- Department of Urology, Aswan University, Aswan, Egypt.
| | - Joseph Zabell
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
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2
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Kawada T, Yanagisawa T, Rajwa P, Motlagh RS, Mostafaei H, Quhal F, Laukhtina E, Pallauf M, König F, Pradere B, Araki M, Nasu Y, Shariat SF. The Prognostic Value of Tumor Infiltrating Lymphocytes After Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis. Clin Genitourin Cancer 2024; 22:535-543.e4. [PMID: 38336572 DOI: 10.1016/j.clgc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND We aimed to assess the prognostic value of tumor infiltrating lymphocytes (TILs) in patients with bladder cancer (BC) after radical cystectomy (RC). MATERIALS AND METHODS We searched Pubmed, Web of Science and Scopus in April 2022 to identify studies assessing the prognostic value of TILs, including a subset of lymphocytes (eg, CD3, CD8, FOXP3), after RC. The endpoints were overall survival and recurrent free survival. Subgroup analyses were performed based on the evaluation method for TILs (ie, CD3, CD8, FOXP3, HE staining). RESULTS Overall, 9 studies comprising 1413 patients were included in this meta-analysis. The meta-analysis revealed that elevated expressions of TILs were significantly associated with favorable OS (pooled hazard ratio [HR]: 0.65, 95% confidence interval [CI]: 0.51-0.83) and RFS (pooled HR: 0.48, 95% CI: 0.35-0.64). In subgroup analyses, high CD8+ TILs were also associated with favorable OS (HR: 0.51, 95% CI: 0.33-0.80) and RFS (pooled HR: 0.53, 95% CI: 0.36-0.76). Among 3 studies comprising 146 patients, high intratumoral TILs were significantly associated with favorable OS (pooled HR: 0.34, 95% CI: 0.19-0.60). CONCLUSION TILs are useful prognostic markers in patients treated with RC for BC. Although the prognostic value of TILs is varied, depending on the subset and infiltration site, CD8+ TILs and intratumoral TILs are associated with oncologic outcomes. Further studies are warranted to explicate the predictive value of TILs on the response to perioperative systemic therapy to help clinical decision-making in patients with BC.
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Affiliation(s)
- Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Daneshjoo Blvd, Tehran, Iran
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maximilian Pallauf
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Paracelsus Medical University Salzburg, University Hospital Salzburg, Salzburg, Austria
| | - Frederik König
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Pradere
- Department of Urology, La Croix Du Sud Hospital, Quint-Fonsegrives, France
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yasutomo Nasu
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan; Department of Urology, University of Texas Southwestern, Dallas, Texas, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prag, Czech Republic; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Research Center for Evidence Medicine, Urology Department Tabriz University of Medical Sciences, Tabriz, Iran.
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3
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Davidson T, Sjödahl R, Aldman Å, Lennmarken C, Kammerlind AS, Theodorsson E. Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes. Scand J Surg 2024; 113:13-20. [PMID: 37555486 DOI: 10.1177/14574969231186283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
BACKGROUND AND AIM The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations. METHODS A narrative review was carried out. RESULTS When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs. CONCLUSIONS Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.
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Affiliation(s)
- Thomas Davidson
- Department of Health, Medicine and Caring Sciences, Linköping University, SE 58183, Linkoping Sweden
| | - Rune Sjödahl
- Division of Surgery and Clinical Experimental Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Åke Aldman
- Department of Surgery, Region Kalmar län, Kalmar, Sweden
| | - Claes Lennmarken
- Department for Medical Quality, Region Östergötland, Linkoping, Sweden
| | - Ann-Sofi Kammerlind
- Futurum, Jönköping, Sweden Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Elvar Theodorsson
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
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4
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Aminoltejari K, Hird AE, Klaassen Z, Satkunasivam R, Kulkarni GS, Luckenbaugh AN, Laviana AA, Wallis CJD, Clark R. Robotic Versus Open Cystectomy for Bladder Cancer: Synthesizing the Data from Current Systematic Reviews and Meta-Analyses. Ann Surg Oncol 2023; 30:2976-2987. [PMID: 36774434 DOI: 10.1245/s10434-022-12692-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/10/2022] [Indexed: 02/13/2023]
Abstract
This is a summary of existing systematic reviews comparing robotic assisted radical cystectomy (RARC) with open radical cystectomy (ORC). Our aim was to compare operative approaches with respect to perioperative, postoperative, oncologic, and health-related quality of life (QOL) outcomes. We performed a systematic review of MEDLINE, Medline-in-Process and Medline Epubs Ahead of Print, and the Cochrane Library on 22 February 2022. We included reviews of adult patients with bladder cancer undergoing RARC or ORC for muscle invasive or high-risk non-muscle invasive bladder cancer. Nonrandomized studies were excluded to minimize confounding and selection bias. The GRADE approach was used to determine the confidence in estimates. We assessed the quality of identified systematic reviews using AMSTAR 2 checklist. Six well-conducted, systematic reviews and meta-analyses were included. RARC was consistently associated with lower estimated blood loss (EBL) and transfusion rates, and longer operative time. There was inconsistent evidence for the impact of RARC on hospital length of stay (LOS). There was no significant difference in overall complication rate or major complication rate, or oncologic outcomes between groups. Comparison of QOL outcomes between studies was limited by statistical and methodological heterogeneity. RARC is associated with improvement in EBL and transfusion risk. There does not appear to be differences in oncologic outcomes or complications between approaches. Prospective studies are needed to assess the impact of diversion type, technique, and recovery pathways on patient outcomes and to assess the impact of operative approach on cost and patient-reported QOL.
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Affiliation(s)
- Khatereh Aminoltejari
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Amanda E Hird
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Zachary Klaassen
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Raj Satkunasivam
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Girish S Kulkarni
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Amy N Luckenbaugh
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Aaron A Laviana
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Christopher J D Wallis
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Roderick Clark
- Urologic Oncology, Mount Sinai Hospital, University of Toronto, 60 Murray St, Toronto, ON, M5T 3L9, Canada.
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Zahid A, Ayyan M, Farooq M, Cheema HA, Shahid A, Naeem F, Ilyas MA, Sohail S. Robotic surgery in comparison to the open and laparoscopic approaches in the field of urology: a systematic review. J Robot Surg 2023; 17:11-29. [PMID: 35526260 DOI: 10.1007/s11701-022-01416-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
Abstract
To establish the feasibility of robotic surgical procedures in urology in terms of the applications, merits, and demerits as well as the postoperative and oncological outcomes while comparing it with the conventional approaches. A systematic search of electronic databases was performed to identify Randomized Controlled Trials and Cohort studies on Robot-Assisted urological surgical procedures in comparison with the conventional methods. The quality assessment of included studies was performed using the Newcastle-Ottawa Scale and the revised Cochrane "Risk of Bias" tool. A qualitative narrative synthesis of the data extracted from the studies was performed and presented in tabulated form. After screening, 39 studies were included in our review (7 Randomized Controlled Trials and 32 Cohort studies). Robot-Assisted Prostatectomy appears to be associated with lower estimated blood loss and shorter length of hospital stay. For Robot-Assisted Cystectomy, the results suggest longer operative time and fewer complications. Robot-Assisted Radical Nephrectomy was found to be associated with fewer perioperative complications and longer mean operative time while Robot-Assisted Partial Nephrectomy was associated with less positive surgical margins and reduced need for postoperative analgesia. The mean operative time was longer while the length of stay was shorter for the robotic approach in inguinal lymphadenectomy and ureteral reimplantation. The feasibility of Robot-Assisted surgery varied for different outcome measures as well as for different procedures. Some common advantages were a shorter length of stay, lesser blood loss, and fewer complications while the drawbacks included longer operative time.Study protocol PROSPERO database (Registration Number: CRD42021256623).
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Affiliation(s)
- Afra Zahid
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Muhammad Ayyan
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan.
| | - Minaam Farooq
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Huzaifa Ahmad Cheema
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Abia Shahid
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Faiza Naeem
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | | | - Shehreen Sohail
- Department of Life Sciences, University of Central Punjab, Lahore, Pakistan
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6
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Grauer R, Wiklund NP. Update on robotic cystectomy. Curr Opin Urol 2021; 31:537-541. [PMID: 34506337 DOI: 10.1097/mou.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This article aims to discuss recently published (2019-2021) studies on robot-assisted radical cystectomy (RARC) with attention to evidence comparing intracorporeal (ICUD) and extracorporeal urinary diversion (ECUD) in terms of intraoperative and perioperative metrics. RECENT FINDINGS RARC produces equivalent oncological outcomes compared to open radical cystectomy (ORC). The benefits of RARC are most pronounced perioperatively. ICUD has been increasingly used at centers of excellence as it reduces intestinal exposure, which may incrementally minimize morbidity compared to ECUD or ORC. As the learning curve for ICUD diversion has flattened, retrospective analyses have emerged that suggest this technique may hold benefit over both ORC and RARC with ECUD, though current data is conflicting, and a randomized controlled study is forthcoming. SUMMARY ORC is the current 'gold standard' management for muscle-invasive bladder cancer. Based on the premise of the minimization of perioperative morbidity, the development of RARC, most recently with ICUD, seeks to improve patient outcomes. Despite a protracted learning curve, many expert bladder cancer centers have adopted an intracorporeal approach. As more centers adopt, refine, and climb the learning curve for ICUD, a clearer insight of its effect on morbidity will be revealed-informing further adoption of the technique.
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Affiliation(s)
- Ralph Grauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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7
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Katayama S, Mori K, Pradere B, Mostafaei H, Schuettfort VM, Quhal F, Motlagh RS, Laukhtina E, Moschini M, Grossmann NC, Nasu Y, Shariat SF, Fajkovic H. Intracorporeal versus extracorporeal urinary diversion in robot-assisted radical cystectomy: a systematic review and meta-analysis. Int J Clin Oncol 2021; 26:1587-1599. [PMID: 34146185 PMCID: PMC8364906 DOI: 10.1007/s10147-021-01972-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/13/2021] [Indexed: 12/29/2022]
Abstract
This
systematic review and meta-analysis aimed to assess and compare the perioperative and oncological outcomes of intracorporeal (ICUD) and extracorporeal (ECUD) urinary diversion following robot-assisted radical cystectomy (RARC). A systematic literature search of articles was performed in PubMed®, Web of Science®, and Scopus® databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. We included studies that compared patients who underwent RARC with ICUD to those with ECUD. Twelve studies including 3067 patients met the eligibility criteria. There were no significant differences between ICUD and ECUD in overall and major complications, regardless of the period (short-term [≤ 30 days] or mid-term [> 30 days]). Subgroup analyses demonstrated that ICUD performed by high-volume centers exhibited a significantly reduced risk of major complications (short-term: OR 0.57, 95% CI 0.37–0.86, p = 0.008, mid-term: OR 0.66, 95% CI 0.46–0.94, p = 0.02). Patients who underwent ICUD had lower estimated blood loss (MD -102.3 ml, 95% CI − 132.8 to − 71.8, p < 0.00001), less likely to receive blood transfusion rates (OR 0.36, 95% CI 0.20–0.62, p = 0.00003); and these findings were consistent in subgroup analyses by low-volume centers (MD-121.6 ml, 95% CI − 160.9 to − 82.3, p < 0.00001 and OR 0.36, 95% CI 0.20–0.62, p = 0.00003, respectively). ICUD had a higher lymph node yield (MD 3.68, 95% CI 0.80–6.56, p = 0.01). Patients receiving ICUD provided comparable complications, superior perioperative outcomes, and similar oncological outcomes compared with ECUD. Centralization of patients may contribute to a reduction of postoperative complications, while maintaining the advantages.
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Affiliation(s)
- Satoshi Katayama
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Urology, University Hospital of Tours, Tours, France
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Victor M Schuettfort
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Marco Moschini
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Nico C Grossmann
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Yasutomo Nasu
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Department of Urology, Weill Cornell Medical College, New York, NY, USA.,Department of Urology, University of Texas Southwestern, Dallas, TX, USA.,Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.,Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Harun Fajkovic
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria. .,Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.
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8
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Iwata T, Kobayashi Y, Maruyama Y, Kawada T, Sadahira T, Oiwa Y, Katayama S, Nishimura S, Takamoto A, Sako T, Wada K, Edamura K, Araki M, Watanabe M, Watanabe T, Nasu Y. Comparison of intracorporeal versus extracorporeal urinary diversion after robot-assisted radical cystectomy at a medium-sized facility. Int J Clin Oncol 2021; 26:1714-1721. [PMID: 34089095 DOI: 10.1007/s10147-021-01957-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study is to compare the perioperative outcomes and learning curves between intracorporeal and extracorporeal urinary diversion at our medium-sized institution. METHODS Between January 2018 and September 2020, a single surgeon at our institution performed 46 consecutive robot-assisted radical cystectomies with ileal conduit. We compared the perioperative outcomes between patients who underwent intracorporeal versus extracorporeal urinary diversion. We also investigated learning curves for the first and last 10 patients in each group. RESULTS The extracorporeal group had shorter overall operative time (P = 0.003) and urinary diversion time (P < 0.0001) than the intracorporeal group. The intracorporeal group had shorter length of hospital stay (P = 0.02). There was no difference in complication and readmission rates. The extracorporeal group demonstrated no difference between the first and last 10 patients for overall operative time or time for cystectomy, lymph node dissection, or urinary diversion. However, the intracorporeal group had shorter urinary diversion time for the last 10 patients compared with the first 10 patients. The first 10 patients in the extracorporeal group had shorter overall operative time than the first 10 in the intracorporeal group, but there was no difference for the last 10 patients. CONCLUSIONS Intracorporeal urinary diversion requires longer overall operative time than extracorporeal diversion for the first 10 patients, due to longer urinary diversion time. However, there is no difference in overall operative time for the last 10 patients. The benefit of intracorporeal over extracorporeal urinary diversion was not confirmed at our medium-sized institution.
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Affiliation(s)
- Takehiro Iwata
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Yasuyuki Kobayashi
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan.
| | - Yuki Maruyama
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Tatsushi Kawada
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Takuya Sadahira
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Yuko Oiwa
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Satoshi Katayama
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
- Department of Urology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Shingo Nishimura
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Atsushi Takamoto
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Tomoko Sako
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Koichiro Wada
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Kohei Edamura
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Motoo Araki
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Masami Watanabe
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Toyohiko Watanabe
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
| | - Yasutomo Nasu
- Department of Urology, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho, Kita-ku, Okayama-City, Okayama, 700-8558, Japan
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Zennami K, Sumitomo M, Takahara K, Nukaya T, Takenaka M, Fukaya K, Ichino M, Fukami N, Sasaki H, Kusaka M, Shiroki R. Intra-corporeal robot-assisted versus open radical cystectomy: a propensity score-matched analysis comparing perioperative and long-term survival outcomes and recurrence patterns. Int J Clin Oncol 2021; 26:1514-1523. [PMID: 34009486 DOI: 10.1007/s10147-021-01939-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To compare perioperative and long-term oncological outcomes and recurrence patterns between robot-assisted radical cystectomy with intra-corporeal urinary diversion (iRARC) and open radical cystectomy (ORC). METHODS We retrospectively analyzed 177 bladder cancer patients who received iRARC or ORC at Fujita Health University between 2008 and 2020. Our primary endpoint was long-term oncological outcomes. As a secondary endpoint, we examined perioperative outcomes, complications, and recurrence patterns. These outcome measures were compared between the propensity score (PS)-matched cohorts. RESULTS PS-matched analysis resulted in 60 matched pairs from iRARC and ORC groups. The iRARC cohort was associated with significantly longer operative time (p = 0.02), lower estimated blood loss (p < 0.001), lower blood transfusion rate (p < 0.001), shorter length of hospital stay (p < 0.001), fewer overall complications (p = 0.03), and lower rate of postoperative ileus (p = 0.02). There was no statistically significant difference between iRARC and ORC in 5-year RFS (p = 0.46), CSS (p = 0.63), and OS (p = 0.71). RFS and CSS were also comparable, even in locally advanced (≥ cT3) disease. Multivariate analysis identified lymphovascular invasion as a robust predictor of RFS, CSS, and OS. The number of recurrence was similar between the groups, while extra-pelvic lymph nodes were more frequent in iRARC than that in ORC (22.7% vs. 7.7%). CONCLUSIONS iRARC has favorable perioperative outcomes, fewer complications, and comparable long-term survival outcomes, including locally advanced (≥ cT3) disease, compared to that in ORC. Our results need to be validated in prospective randomized clinical trials.
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Affiliation(s)
- Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Takuhisa Nukaya
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Masashi Takenaka
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kosuke Fukaya
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Manabu Ichino
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Naohiko Fukami
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Hitomi Sasaki
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
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Nayak B, Garg H, Goel R, Singh P, Nayyar R, Kumar R, Seth A. Contemporary Outcomes of Open Radical Cystectomy: a 5-Year Experience from a Tertiary Care Center. Indian J Surg Oncol 2021; 12:86-93. [PMID: 33814837 DOI: 10.1007/s13193-020-01226-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/15/2020] [Indexed: 11/25/2022] Open
Abstract
To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4 min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5 ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.
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Affiliation(s)
- Brusabhanu Nayak
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Harshit Garg
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Ritesh Goel
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Prabhjot Singh
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Rishi Nayyar
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Rajeev Kumar
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
| | - Amlesh Seth
- Department of Urology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, India
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11
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Cai Z, Li H, Hu J, Qiu D, Yi Z, Chen J, Zu X. Intracorporeal versus extracorporeal urinary diversion after robot-assisted radical cystectomy: a pooled analysis. Gland Surg 2021; 10:706-720. [PMID: 33708553 DOI: 10.21037/gs-20-740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background To compare intracorporeal urinary diversion (ICUD) with extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC) for surgery safety, postoperative recovery, complication, and prognosis. Methods We performed a literature search on PubMed, Embase, Medline and the Cochrane Library based on all randomized controlled trials (RCTs) and observational comparative studies related to study topics published before July 14th, 2020. Then systematic review and meta-analysis was performed. Results 13 retrospective studies containing 4,755 patients were identified. In terms of surgery safety, with similar operative time, ICUD group showed less estimated blood loss (EBL) (P<0.0001) and lower blood transfusion rate (P=0.006). In terms of postoperative recovery, with similar hospital stay, ICUD group showed earlier recovery on flatus (P<0.001) and oral intake (P<0001). In aspect of complications, there were no significant differences between ICUD and ECUD groups, except for gastrointestinal system complications. ICUD group had lower gastrointestinal complications rate than ECUD group (P=0.002). In aspect of prognosis outcomes, with similar mortality, ICUD group had lower recurrence rate than ECUD group (P=0.004). Conclusions Based on the current evidence, ICUD procedure is excellence in surgery safety, postoperative recovery, complications, and prognosis. However, the observational studies reduced the level of evidence, larger randomized trials are needed to confirm these findings.
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Affiliation(s)
- Zhiyong Cai
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Huihuang Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Jiao Hu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Dongxu Qiu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenglin Yi
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Jinbo Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiongbing Zu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
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12
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Yee CH, Yuen-Chun J, Chan ESY. Current evidence for robotic surgery in radical cystectomy. Turk J Urol 2020; 47:S1-S8. [PMID: 32976090 DOI: 10.5152/tud.2020.20355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022]
Abstract
Robotic-assisted radical cystectomy (RARC) has been gaining momentum as an alternative to its conventional open radical cystectomy (ORC) for the management of invasive bladder cancer. Although RARC, in general, demonstrated less blood loss and shorter hospital stay than ORC, whether there is any significant difference in the overall complication rate still requires further investigation. Thus, both RARC and ORC share a similar oncology outcome, with comparable positive surgical margin rates, disease-free survival, and overall survival. Techniques of intracorporeal urinary diversion (ICUD) have not yet been standardized. ICUD may result in a lower risk of ureteroileal anastomotic stricture than extracorporeal urinary diversion (ECUD). However, ECUD is still a valid and commonly practiced option according to the available data. In general, RARC has been demonstrated to provide promising results. Long-term data and functional outcome after RARC and ICUD are needed to further validate the role of RARC in the management of bladder cancer.
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Affiliation(s)
- Chi Hang Yee
- Department of Surgery, S.H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong
| | - Jeremy Yuen-Chun
- Department of Surgery, S.H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong
| | - Eddie Shu-Yin Chan
- Department of Surgery, S.H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong
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13
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Xie W, Bi J, Wei Q, Han P, Song D, Shi L, Ye D, Shen Y, Gou X, He W, Wang S, Liu Z, Fan J, Wu K, Chen Z, Zhou X, Kong C, Liu Y, Liu C, Xu A, Jin B, Fu G, Xue W, Chen H, Pan T, Tu Z, Lin T, Huang J. Survival after radical cystectomy for bladder cancer: Multicenter comparison between minimally invasive and open approaches. Asian J Urol 2020; 7:291-300. [PMID: 32742929 PMCID: PMC7385523 DOI: 10.1016/j.ajur.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/01/2020] [Accepted: 04/26/2020] [Indexed: 02/08/2023] Open
Abstract
Objective To investigate oncological outcomes in patients with bladder cancer who underwent minimally invasive radical cystectomy (MIRC) or open radical cystectomy (ORC). Methods We identified patients with bladder cancer who underwent radical cystectomy (RC) in 13 centers of the Chinese Bladder Cancer Consortium (CBCC). Perioperative outcomes were compared between MIRC and ORC. The influence of surgical approaches on overall survival (OS) and cancer-specific survival (CSS) in the entire study group and subgroups classified according to pathologic stage or lymph node (LN) status was assessed with the log-rank test. Multivariable Cox proportional hazard models were used to evaluate the association among OS, CSS and risk factors of interest. Results Of 2 098 patients who underwent RC, 1 243 patients underwent MIRC (1 087 laparoscopic RC and 156 robotic-assisted RC, respectively), while 855 patients underwent ORC. No significant differences were noted in positive surgical margin rate and 90-day postoperative mortality rate. MIRC was associated with less estimated blood loss, more LN yield, higher rate of neobladder diversion, longer operative time, and longer length of hospital stay. There was no significant difference in OS and CSS according to surgical approaches (p=0.653, and 0.816, respectively). Subgroup analysis revealed that OS and CSS were not significantly different regardless of the status of extravesical involvement or LN involvement. Multivariable Cox regression analyses showed that the surgical approach was not a significant predictor of OS and CSS. Conclusions Our study showed that MIRC was comparable to conventional ORC in terms of OS and CSS.
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Affiliation(s)
- Weibin Xie
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junming Bi
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qiang Wei
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Han
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Dongkui Song
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Shi
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dingwei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yijun Shen
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xin Gou
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weiyang He
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shaogang Wang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zheng Liu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhai Fan
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Kaijie Wu
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiwen Chen
- Department of Urology, First Affiliated Hospital of Army Medical University, Urology Institute of People Liberation Army, Chongqing, China
| | - Xiaozhou Zhou
- Department of Urology, First Affiliated Hospital of Army Medical University, Urology Institute of People Liberation Army, Chongqing, China
| | - Chuize Kong
- Department of Urology, The First Hospital of China Medical University, Shenyang, China
| | - Yang Liu
- Department of Urology, The First Hospital of China Medical University, Shenyang, China
| | - Chunxiao Liu
- Department of Urology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Abai Xu
- Department of Urology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Baiye Jin
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guanghou Fu
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haige Chen
- Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tiejun Pan
- Department of Urology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, China
| | - Zhong Tu
- Department of Urology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, China
| | - Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian Huang
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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