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Liu K, Zhao H, Chen X, Nicoletti R, Vasdev N, Chiu PKF, Ng CF, Kawada T, Laukhtina E, Mori K, Yanagisawa T, D'Andrea D, von Deimling M, Albisinni S, Krajewski W, Pradere B, Soria F, Moschini M, Enikeev D, Shariat S, Kamat A, Giannarini G, Teoh JYC. A Territory-wide Study Investigating the Dose and Efficacy of Different Bacillus Calmette-Guérin Strains in Patients with Intermediate- and High-risk Non-muscle-invasive Bladder Cancer. Eur Urol Oncol 2024; 7:438-446. [PMID: 37827948 DOI: 10.1016/j.euo.2023.09.014] [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: 08/02/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Current European Association of Urology (EAU) guidelines support adjuvant intravesical Bacillus Calmette-Guérin (BCG) treatment after Transurethral Resection of Bladder Tumor (TURB) for intermediate- or high-risk Non-Muscle-Invasive Bladder Cancer (NMIBC) patients, aiming to reduce the risk of tumor recurrence. The quality of data, however, does not allow definitive conclusions on whether different strains and dosages of BCG have different efficacies on long-term survival outcomes. OBJECTIVE To evaluate the long-term survival outcomes of different strains and dosages of BCG in patients with NMIBC. DESIGN, SETTING, AND PARTICIPANTS All NMIBC patients treated with intravesical BCG therapy from 2001 to 2020 were identified using a territory-wide database in Hong Kong. INTERVENTION BCG strains and dosages (Connaught strain 81 mg, Connaught strain 27 mg, Tokyo strain 80 mg, and Danish strain 30 mg) were retrieved from medical records. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Overall Survival (OS), Cancer-Specific Survival (CSS), Recurrence-Free Survival (RFS), and Progression-Free Survival (PFS) were analyzed using the Kaplan-Meier method. A multivariable Cox regression analysis was used to adjust potential confounding factors, and to estimate Hazard Ratio (HR) and 95% confidence interval (CI) of different BCG strains. A further subgroup analysis on adequate versus inadequate BCG treatment was performed. RESULTS AND LIMITATIONS A total of 2602 NMIBC patients treated with intravesical BCG were identified. Among them, 1291 (49.6%) received Connaught strain 81 mg, 199 (7.6%) received Connaught strain 27 mg, 1014 (39.0%) received Tokyo strain, and 98 (3.8%) received Danish strain. The median follow-up was 11.0 years. No statistically significant differences in OS, CSS, RFS, and PFS were detected among the different groups. At the multivariable analysis, the Connaught strain 27 mg group was inferior to the Connaught strain 81 mg group in terms of OS (HR: 1.26, 95% CI: 1.05-1.51), CSS (HR: 1.69, 95% CI: 1.08-2.66), and PFS (HR: 1.86, 95% CI: 1.20-2.88). Adequate BCG treatment was associated with improved OS (HR: 0.82, 95% CI: 0.73-0.92), CSS (HR: 0.64, 95% CI: 0.47-0.86), RFS (HR: 0.80, 95% CI: 0.70-0.92), and PFS (HR: 0.52, 95% CI: 0.39-0.68). Among patients treated with adequate BCG, at the multivariable analysis the Connaught strain 27 mg group showed worse results than the Connaught strain 81 mg group in terms of CSS (HR: 1.93, 95% CI: 1.07-3.51). Compared with the Connaught strain 81 mg group, both Tokyo and Danish strains had similar survival outcomes in the whole cohort and the adequate BCG treatment subgroup. CONCLUSIONS Our findings suggest that adequate BCG remains the most important factor in optimizing survival outcomes in patients with intermediate- and high-risk NMIBC. No significant differences in survival outcomes were observed between full-dose Connaught, Tokyo, and Danish strains. Reduced-dose Connaught strain was associated with the worst survival outcomes. PATIENT SUMMARY We evaluated the efficacy of different strains and dosages of bacillus Calmette-Guérin (BCG) in patients with intermediate- or high-risk non-muscle-invasive bladder cancer in the past two decades in Hong Kong. We conclude no significant differences in long-term survival outcomes in terms of full-dose Connaught, Tokyo, and Danish strains, while reduced-dose Connaught strain was inferior to the full-dose group. Adequate BCG treatment benefits long-term survival.
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Affiliation(s)
- Kang Liu
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Hongda Zhao
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xuan Chen
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Rossella Nicoletti
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China; Department of Experimental and Clinical Biomedical Science, University of Florence, Florence, Italy
| | - Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Peter Ka-Fung Chiu
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi-Fai Ng
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Tatsushi Kawada
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Yanagisawa
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Markus von Deimling
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Albisinni
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, Wrocław, Poland
| | - Benjamin Pradere
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - Francesco Soria
- AOU Città della Salute e della Scienza di Torino, Torino School of Medicine, Torino, Italy
| | - Marco Moschini
- Department of Urology, San Raffaele Hospital and Scientific Institute, Milan, Italy
| | - Dmitry Enikeev
- Department of Urology, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Rabin Medical Center, Petah Tikva, Israel and Medical University of Vienna, Austria
| | - Shahrokh Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Hourani Center of Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Ashish Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Gianluca Giannarini
- Unit of Urology, Santa Maria della Misericordia Academic Medical Center, Udine, Italy
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.
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Bourlotos G, Baigent W, Hong M, Plagakis S, Grundy L. BCG induced lower urinary tract symptoms during treatment for NMIBC-Mechanisms and management strategies. Front Neurosci 2024; 17:1327053. [PMID: 38260019 PMCID: PMC10800852 DOI: 10.3389/fnins.2023.1327053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) accounts for ~70-75% of total bladder cancer tumors and requires effective early intervention to avert progression. The cornerstone of high-risk NMIBC treatment involves trans-urethral resection of the tumor followed by intravesical Bacillus Calmette-Guerin (BCG) immunotherapy. However, BCG therapy is commonly accompanied by significant lower urinary tract symptoms (LUTS) including urinary urgency, urinary frequency, dysuria, and pelvic pain which can undermine treatment adherence and clinical outcomes. Despite this burden, the mechanisms underlying the development of BCG-induced LUTS have yet to be characterized. This review provides a unique perspective on the mechanisms thought to be responsible for the development of BCG-induced LUTS by focussing on the sensory nerves responsible for bladder sensory transduction. This review focuses on how the physiological response to BCG, including inflammation, urothelial permeability, and direct interactions between BCG and sensory nerves could drive bladder afferent sensitization leading to the development of LUTS. Additionally, this review provides an up-to-date summary of the latest clinical data exploring interventions to relieve BCG-induced LUTS, including therapeutic targeting of bladder contractions, inflammation, increased bladder permeability, and direct inhibition of bladder sensory signaling. Addressing the clinical burden of BCG-induced LUTS holds significant potential to enhance patient quality of life, treatment compliance, and overall outcomes in NMIBC management. However, the lack of knowledge on the pathophysiological mechanisms that drive BCG-induced LUTS has limited the development of novel and efficacious therapeutic options. Further research is urgently required to unravel the mechanisms that drive BCG-induced LUTS.
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Affiliation(s)
- Georgia Bourlotos
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - William Baigent
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - Matthew Hong
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
- Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Sophie Plagakis
- Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Luke Grundy
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
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Hannouneh ZA, Hijazi A, Alsaleem AA, Hami S, Kheyrbek N, Tanous F, Khaddour K, Abbas A, Alshehabi Z. Novel immunotherapeutic options for BCG-unresponsive high-risk non-muscle-invasive bladder cancer. Cancer Med 2023; 12:21944-21968. [PMID: 38037752 PMCID: PMC10757155 DOI: 10.1002/cam4.6768] [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: 09/23/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND High-risk non-muscle-invasive bladder cancer (HR-NMIBC) presents a challenge to many physicians due to its ability to resist Bacillus Calmette-Guérin (BCG) intravesical therapy and the substantial rate of progression into muscle-invasive bladder cancer (MIBC). Patients who are BCG-unresponsive have worse prognosis and thus require further management including radical cystectomy (RC), which significantly impacts quality of life. Moreover, the ongoing worldwide shortage of BCG warrants the need for policies that prioritize drug use and utilize alternative treatment strategies. Hence, there is a significant unmet need for bladder preserving therapy in this subset of patients. METHODS To address this issue, we searched the relevant literature in PUBMED for articles published from 2019 through May of 2023 using appropriate keywords. All clinical trials of patients with HR-NMIBC treated with immune-related agents were retrieved from clinicaltrials.gov. FINDINGS AND FUTURE PERSPECTIVES Exploratory treatments for BCG-Unresponsive HR-NMIBC included immune checkpoint inhibitors (ICI), oncolytic viral therapy, cytokine agonists, and other immunomodulators targeting TLR, EpCaM, FGFR, MetAP2, and IDO1. Some combination therapies have been found to work synergistically and are preferred therapeutically over monotherapy. Three drugs-pembrolizumab, valrubicin, and most recently, nadofaragene firadenovec-vncg-have been FDA approved for the treatment of BCG-unresponsive NMIBC in patients who are ineligible for or decline RC. However, all explored treatment options tend to postpone RC rather than provide long-term disease control. Additional combination strategies need to be studied to enhance the effects of immunotherapy. Despite the challenges faced in finding effective therapies, many potential treatments are currently under investigation. Addressing the landscape of biomarkers, mechanisms of progression, BCG resistance, and trial design challenges in HR-NMIBC is essential for the discovery of new targets and the development of effective treatments.
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Affiliation(s)
- Zein Alabdin Hannouneh
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Amjad Hijazi
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Alaa Aldeen Alsaleem
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Siwan Hami
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Nina Kheyrbek
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
- Faculty of MedicineTishreen UniversityLattakiaSyrian Arab Republic
| | - Fadi Tanous
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
- Faculty of MedicineAl‐Baath UniversityHomsSyrian Arab Republic
| | - Karam Khaddour
- Department of Medical OncologyDana‐Farber Cancer Institute, Harvard Medical SchoolBostonMassachusettsUSA
| | - Abdulfattah Abbas
- Professor of Nephrology, Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
| | - Zuheir Alshehabi
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
- Department of PathologyTishreen University HospitalLattakiaSyrian Arab Republic
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Shafique MA, Haseeb A, Siddiq MA, Mussarat A, Rangwala HS, Mustafa MS. Current and Emerging Treatments for Urothelial Carcinoma: A Focus on Enfortumab Vedotin. Cancer Manag Res 2023; 15:699-706. [PMID: 37485038 PMCID: PMC10362867 DOI: 10.2147/cmar.s418009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/17/2023] [Indexed: 07/25/2023] Open
Abstract
Urothelial carcinoma is a common malignancy that affects the urinary system, with bladder cancer being the most prevalent form. Although the management of early-stage disease has seen significant improvements, the treatment of locally advanced and metastatic urothelial carcinoma remains challenging. Over the past decade, there has been an explosion in the number of therapies available for the treatment of advanced disease, with immune checkpoint inhibitors and antibody-drug conjugates leading the way. Enfortumab vedotin is an antibody-drug conjugate that targets Nectin-4, a protein that is overexpressed in urothelial carcinoma cells. In clinical trials, it has shown promising outcomes for the treatment of advanced urothelial carcinoma that has progressed after chemotherapy or immunotherapy. The US Food and Drug Administration has granted expedited approval for enfortumab vedotin in the treatment of advanced urothelial carcinoma. This review provides an overview of the current and emerging treatments for urothelial carcinoma, with a particular focus on enfortumab vedotin. We discuss the mechanisms of action, clinical efficacy, safety, and ongoing research of enfortumab vedotin, along with the current landscape of other approved therapies and promising agents in development. The aim of this review is to provide a comprehensive and up-to-date summary of the available treatment options for urothelial carcinoma, including their limitations and future prospects.
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Affiliation(s)
| | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | | | - Abdullah Mussarat
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
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Gao L, Ren R, Shen J, Hou J, Ning J, Feng Y, Wang M, Wu L, Sun Y, Wang H, Wang D, Cao J. Values of OAS gene family in the expression signature, immune cell infiltration and prognosis of human bladder cancer. BMC Cancer 2022; 22:1016. [PMID: 36162993 PMCID: PMC9510761 DOI: 10.1186/s12885-022-10102-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/15/2022] [Indexed: 12/24/2022] Open
Abstract
Background Bladder cancer (BLCA) is one of the most common genitourinary malignancies in the world, but its pathogenic genes have not been fully identified and the treatment outcomes are still unsatisfactory. Although the members of 2', 5'-oligoadenylate synthetase (OAS) gene family are known involved in some tumorous biological processes, the roles of the OAS gene family in BLCA are still undetermined. Methods By combining vast bioinformatic datasets analyses of BLCA and the experimental verification on clinical BLCA specimen, we identified the expressions and biological functions of OAS gene family members in BLCA with comparison to normal bladder tissues. Results The expression levels of OAS gene family members were higher in BLCA than in normal bladder tissues. The expression levels of most OAS genes had correlations with genomic mutation and methylation, and with the infiltration levels of CD4 + T cells, CD8 + T cells, neutrophils, and dendritic cells in the microenvironment of BLCA. In addition, high expressions of OAS1, OAS2, OAS3, and OASL predicted better overall survival in BLCA patients. Conclusions The highly expressed OAS genes in BLCA can reflect immune cells infiltration in the tumor microenvironment and predict the better overall survival of BLCA, and thus may be considered as a signature of BLCA. The study provides new insights into the diagnosis, treatment, and prognosis of BLCA. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10102-8.
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Affiliation(s)
- Lijuan Gao
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Ruimin Ren
- Department of Urology, Shanxi Bethune Hospital (Third Hospital of Shanxi Medical University), Taiyuan, 030032, China
| | - Jing Shen
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Jiayi Hou
- Department of Clinical Laboratory, Shanxi Provincial Academy of Traditional Chinese Medicine, Taiyuan, 030012, China
| | - Junya Ning
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Yanlin Feng
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Meiyue Wang
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Lifei Wu
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China
| | - Yaojun Sun
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Huang Wang
- Department of Urology, Shanxi Bethune Hospital (Third Hospital of Shanxi Medical University), Taiyuan, 030032, China
| | - Deping Wang
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China. .,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China.
| | - Jimin Cao
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China. .,Department of Physiology, Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China.
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Arora A, Bakshi G, Pal M, Addla S, Waigankar S, Prakash G. Tailoring the dose of Moscow strain of intravesical bacillus Calmette-Guérin for Indian patients: A plea for urgent action. Indian J Urol 2022; 38:165-169. [PMID: 35983125 PMCID: PMC9380456 DOI: 10.4103/iju.iju_69_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Amandeep Arora
- Department of Uro-Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ganesh Bakshi
- Department of Uro-Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mahendra Pal
- Department of Uro-Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sanjai Addla
- Department of Uro-Oncology, Apollo Cancer Institutes, Apollo Health City, Hyderabad, Telangana, India
| | - Santosh Waigankar
- Department of Uro-Oncology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
| | - Gagan Prakash
- Department of Uro-Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India,
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