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Kim D, You D, Jeong IG, Hong JH, Ahn H, Hong B. Kidney sparing surgery in upper tract urothelial carcinoma: paradigm change in surgical treatment for ureter cancer. J Cancer Res Clin Oncol 2023; 149:13717-13725. [PMID: 37522922 DOI: 10.1007/s00432-023-05207-x] [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: 05/24/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To extend the indications of kidney-sparing surgery (KSS) for ureter cancer by comparing the oncological outcomes between patients with upper tract urothelial carcinoma (UTUC) who underwent radical nephroureterectomy (RNU) or KSS. METHODS We retrospectively reviewed 708 patients with UTUC who underwent RNU (N = 646) or KSS (N = 62) between 2011 and 2019 to analyze the oncologic outcomes and prognostic factors. Subgroup analyses were performed for patients with unifocal ureteral urothelial carcinoma (UC). RESULTS No significant difference was observed in the overall survival (OS) or cancer-specific survival (CSS) between RNU and KSS (distal ureterectomy with reimplantation (N = 33), ureterectomy with ileal ureter (N = 14), ureteroscopic tumor resection (N = 10), and ureterectomy with ureteroureterostomy (N = 5)). Among 269 (38.0%) patients with unifocal ureteral UC, 219 and 50 patients underwent RNU and KSS, respectively. OS and CSS were not significantly different between these two groups. Pathologic stage was a significant risk factor in multivariate analysis (hazard ratio = 2.621; p = 0.000). Among 646 RNU patients, 219 (33.9%) had unifocal ureteral UC, 40 (18.3%) with low-grade tumors. Among these, 13 (5.9%) patients with unifocal, low-grade and small (< 2 cm) tumors received nephroureterectomy. CONCLUSION Kidney-sparing surgery should be regarded as an important alternative to RNU for patients with unifocal ureteral UC thought to have noninvasive disease to preserve renal function and reduce overtreatment.
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Affiliation(s)
- Dongsu Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 43 Gil 88, Olympic-Road, Songpa-Gu, 05505, Seoul, Republic of Korea
| | - Dalsan You
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 43 Gil 88, Olympic-Road, Songpa-Gu, 05505, Seoul, Republic of Korea
| | - In Gab Jeong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 43 Gil 88, Olympic-Road, Songpa-Gu, 05505, Seoul, Republic of Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 43 Gil 88, Olympic-Road, Songpa-Gu, 05505, Seoul, Republic of Korea
| | - Hanjong Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 43 Gil 88, Olympic-Road, Songpa-Gu, 05505, Seoul, Republic of Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 43 Gil 88, Olympic-Road, Songpa-Gu, 05505, Seoul, Republic of Korea.
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Wang Z, Shi H, Xu Y, Fang Y, Song J, Jiang W, Xia D, Wu Z, Wang L. Intravesical Therapy for Upper Urinary Tract Urothelial Carcinoma: A Comprehensive Review. Cancers (Basel) 2023; 15:5020. [PMID: 37894387 PMCID: PMC10605447 DOI: 10.3390/cancers15205020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) poses unique challenges in diagnosis and treatment. This comprehensive review focuses on prophylactic intravesical therapy for UTUC, summarizing key aspects of intravesical therapy in various clinical scenarios, including concurrent with or following radical nephroureterectomy, kidney-sparing surgery, ureteroscopy-guided biopsy. The incidence of intravesical recurrence in UTUC after surgical treatment is significant, necessitating effective preventive measures. Intravesical therapy plays a vital role in reducing the risk of bladder recurrence following UTUC surgery. Tailoring timing, drug selection, dosage, and frequency is vital in optimizing treatment outcomes and reducing intravesical recurrence risk in UTUC. This review provides a comprehensive summary of the history, clinical trials, guideline recommendations, and clinical applications of intravesical therapy for UTUC. It also discusses the future directions based on current clinical needs and ongoing trials. Future directions entail optimizing dosage, treatment duration, and drug selection, as well as exploring novel agents and combination therapies. Intravesical therapy holds tremendous potential in improving outcomes for UTUC patients and reducing the risk of bladder recurrence. Although advancements have been made in UTUC treatment research, further refinements are necessary to enhance efficacy and safety.
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Affiliation(s)
- Zheng Wang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Haoqing Shi
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Yifan Xu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Yu Fang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Jiaao Song
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Wentao Jiang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Demeng Xia
- Department of Pharmacy, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China;
| | - Zhenjie Wu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
| | - Linhui Wang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China; (Z.W.); (H.S.); (Y.X.); (Y.F.); (J.S.); (W.J.)
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Yoshida T, Ohe C, Nakamoto T, Kinoshita H. Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma. Int J Urol 2023; 30:634-647. [PMID: 37294007 DOI: 10.1111/iju.15208] [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: 02/25/2023] [Accepted: 05/09/2023] [Indexed: 06/10/2023]
Abstract
Current guidelines recommend endoscopic management (EM) for patients with low-risk upper urinary tract urothelial carcinoma, as well as those with an imperative indication. However, regardless of the tumor risk, radical nephroureterectomy is still mainly performed worldwide despite the benefits of EM, such as renal function maintenance, no hemodialysis requirement, and treatment cost reduction. This might be explained by the association of EM with a high risk of local recurrence and progression. Furthermore, the need for rigorous patient selection and close surveillance following EM may be relevant. Nevertheless, recent developments in diagnostic modalities, pathological evaluation, surgical devices and techniques, and intracavitary regimens have been reported, which may contribute to improved risk stratification and treatments with superior oncological outcomes. In this review, considering recent advances in endourology and oncology, we propose novel treatment strategies for optimal EM.
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Affiliation(s)
- Takashi Yoshida
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
- Corporate Sponsored Research Programs for Multicellular Interactions in Cancer, Kansai Medical University, Osaka, Japan
| | - Chisato Ohe
- Corporate Sponsored Research Programs for Multicellular Interactions in Cancer, Kansai Medical University, Osaka, Japan
- Department of Pathology, Kansai Medical University, Osaka, Japan
| | - Takahiro Nakamoto
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
- Department of Pathology, Kansai Medical University, Osaka, Japan
| | - Hidefumi Kinoshita
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
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Laukhtina E, Kawada T, Quhal F, Yanagisawa T, Rajwa P, von Deimling M, Pallauf M, Bianchi A, Majdoub M, Enikeev D, Fajkovic H, Teoh JYC, Rouprêt M, Gontero P, Shariat SF. Oncologic and Safety Outcomes for Retrograde and Antegrade Endoscopic Surgeries for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis. Eur Urol Focus 2022; 9:258-263. [PMID: 36428210 DOI: 10.1016/j.euf.2022.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/02/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022]
Abstract
The aim of this study was to identify and summarize available data on oncologic and safety outcomes for retrograde versus antegrade endoscopic surgery in patients with upper tract urothelial carcinoma (UTUC). We systematically searched studies reporting on endoscopic surgery in patients with UTUC. The primary outcome of interest was oncologic control, including bladder and upper urinary tract recurrences. The secondary outcomes were any-grade and major complications. Twenty studies comprising 1091 patients were included in our analysis. The pooled bladder recurrence rate was 35% (95% confidence interval [CI] 28.0-42.3%; I2 = 48%) after retrograde endoscopic surgery and 17.7% (95% CI 6.5-32.1%; I2 = 29%) after antegrade endoscopic surgery. The pooled upper urinary tract recurrence rate was 56.4% (95% CI 41.2-70.9; I2 = 93%) after retrograde endoscopic surgery and 36.2% (95% CI 25.5-47.6%; I2 = 57%) after antegrade endoscopic surgery. The pooled complication rate was 12.5% (95% CI 0.8-32.8%; I2 = 94%) for any-grade complications and 6.6% (95% CI 0.1-19.1%; I2 = 89%) for major complications in the retrograde endoscopic cohort. In summary, our analyses suggest promising oncologic benefits of antegrade kidney-sparing surgery in terms of bladder and upper urinary tract recurrence rates in UTUC. Retrograde endoscopic surgery is a safe procedure with a minimal risk of complications and acceptable oncologic outcomes. Research should address the hypothesis that endoscopic antegrade surgery can be a safe and effective alternative for well-selected patients. PATIENT SUMMARY: One of the surgical options for treatment of cancer of the upper urinary tract is removal of the tumor through a small telescope called an endoscope. The endoscope can be inserted via the urethra (called a retrograde approach) or through a small incision in the skin (antegrade approach). Our review shows that the antegrade approach seems to provide acceptable cancer control rates. Further research could help to identify the role for endoscope surgery in cancer of the upper urinary tract.
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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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Nandurkar R, Basto M, Sengupta S. Nephron-sparing surgery for the management of upper tract urothelial carcinoma: an outline of surgical technique and review of outcomes. Transl Androl Urol 2020; 9:3160-3167. [PMID: 33457288 PMCID: PMC7807310 DOI: 10.21037/tau.2019.11.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Upper tract urothelial carcinoma (UTUC) often occurs in elderly patients with multiple co-morbidities including renal impairment. As such, nephron sparing surgery (NSS) often needs to be considered. This article reviews the available NSS techniques for UTUC, including ureteroscopy, percutaneous approaches and segmental ureterectomy. PubMed and OvidMEDLINE reviews of available case series from the last 10 years demonstrated that recurrence was highly variable between studies and occurred in 19–90.5% of ureteroscopic cases, 29–98% of percutaneous resections and in 10.2–31.4% of patients who underwent segmental ureterectomy. The small number of included studies and variable follow up periods made comparison between techniques difficult. NSS is a necessary alternative for patients with significant comorbidities or renal impairment who cannot undergo radical nephro-ureterectomy. However, there is significant variation in oncological outcomes, with an increased risk of progression or death from cancer—salvage by radical surgery may sometimes be required.
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Affiliation(s)
- Ruchira Nandurkar
- Eastern Health Clinical School, Monash University, Clayton, Victoria, Australia
| | - Marnique Basto
- Department of Urology, Eastern Health, Melbourne, Victoria, Australia
| | - Shomik Sengupta
- Eastern Health Clinical School, Monash University, Clayton, Victoria, Australia.,Department of Urology, Eastern Health, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
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Chiu AW. Recent advances in oncological endourology. Asian J Urol 2016; 3:113-114. [PMID: 29264176 PMCID: PMC5730829 DOI: 10.1016/j.ajur.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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