1
|
Chen Y, Xu C, Mou Z, Hu Y, Yang C, Hu J, Chen X, Luo J, Zou L, Jiang H. Endoscopic Cryoablation Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. Eur Urol Oncol 2024:S2588-9311(24)00104-4. [PMID: 38693018 DOI: 10.1016/j.euo.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/25/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Cryoablation is a traditional antitumor therapy with good prospects for development. The efficacy of endoscopic management as a kidney-sparing surgery for high-risk upper tract urothelial carcinoma (UTUC) remains controversial. Our aim was to evaluate the impact of endoscopic cryoablation (ECA) versus radical nephroureterectomy (RNU) on survival outcomes, renal function, and complications. METHODS We retrospectively analyzed data for 116 patients with newly diagnosed high-risk UTUC who underwent either ECA (n = 13) or RNU (n = 103) from March 25, 2019 to December 8, 2021. Propensity score matching (1:4) using the nearest neighbor method was performed before analysis. The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS), intravesical recurrence-free survival (RFS), the change in renal function, and treatment-emergent adverse events (TEAEs). KEY FINDINGS AND LIMITATIONS At median follow-up of 28.2 mo for the ECA group and 27.6 mo for the RNU group, 2-yr OS (82% vs 84%), PFS (73% vs 71%), and intravesical RFS (81% vs 83%) rates after matching did not significantly differ. A decline in renal function was observed after RNU, but not after ECA. Five (41.7%) patients in the ECA group reported six TEAEs, and 17 patients (35.4%) in the RNU group reported 20 TEAEs. CONCLUSIONS AND CLINICAL IMPLICATIONS In comparison to RNU, ECA for UTUC resulted in noninferior oncological outcomes and superior preservation of renal function. PATIENT SUMMARY Our study suggests that a treatment called endoscopic cryoablation for high-risk cancer in the upper urinary tract can help in preserving kidney function, with similar survival outcomes to those after more extensive surgery. This option can be considered for selected patients with a strong preference for kidney preservation.
Collapse
Affiliation(s)
- Yiling Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Chenyang Xu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Zezhong Mou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Yun Hu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Chen Yang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Jinzhong Hu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Xinan Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics and Social Medicine, School of Public Health, Fudan University, Shanghai, China.
| | - Lujia Zou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China.
| | - Haowen Jiang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China; National Clinical Research Center for Aging and Medicine, Fudan University, Shanghai, China.
| |
Collapse
|
2
|
Xu K, Li J, Liu Y, Jiao D, Han X. Percutaneous Nephroureteral Stent Placement and Antegrade Forceps Biopsy of Ureteral Obstruction. J Vasc Interv Radiol 2024; 35:404-408. [PMID: 37939999 DOI: 10.1016/j.jvir.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 09/24/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023] Open
Abstract
PURPOSE To evaluate the feasibility of percutaneous transluminal ureteral biopsy (PTUB) combined with percutaneous nephroureteral stent placement for ureteral obstruction under fluoroscopy. MATERIALS AND METHODS From September 2011 to July 2021, 37 patients (27 men and 10 women; median age, 65.0 years) who experienced ureteroscopic biopsy failure or refused or were unable to undergo ureteroscopic biopsy underwent PTUB for ureteral obstruction during nephroureteral stent placement under fluoroscopic guidance. Data on technical success, early adverse events, and radiation dose were collected. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy (OA) of PTUB were analyzed. RESULTS The technical success of PTUB was 89.2%, with a mean irradiation dose of 76.9 mGy·cm2 ± 12.2. A total of 67.6% (25/37) of the cases were correctly diagnosed with malignancy, whereas 8 cases were confirmed to be true negatives. There were 4 false negatives and no false positives. PTUB had a sensitivity, specificity, PPV, NPV, and OA of 86.2% (25/29), 100% (8/8), 100% (25/25), 66.7% (8/12), and 89.2% (33/37), respectively. Eleven patients (29.7%) experienced Grade 1 adverse events (transient aggravated hematuria). CONCLUSIONS PTUB appears to be a safe and effective alternative to ureteroscopic biopsy for ureteral obstruction.
Collapse
Affiliation(s)
- Kaihao Xu
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Li
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yiming Liu
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dechao Jiao
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Xinwei Han
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
3
|
Bernabei M, Fabbri N, Romeo D, Paiolo E, Bandi M, Simone M. Conservative management of an early abdominal complication during a Tullio percutaneous endoscopic excision of renal pelvis urothelial carcinoma: A case report. World J Clin Urol 2024; 13:1-6. [DOI: 10.5410/wjcu.v13.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/28/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Upper tract urothelial carcinoma (UTUC) representing only a small fraction of all urothelial tumors. It predominantly affects the renal pelvis in men, often coexisting with bladder carcinoma. UTUC displays a more aggressive genetic profile compared to bladder neoplasms, with the majority of patients presenting with advanced disease. Histologically, about a quarter of UTUC cases exhibit high-grade subtypes, associated with a worse prognosis. Tobacco use and past exposure to aromatic amines are significant risk factors for UTUC. Imaging modalities such as Uro-computed tomography and magnetic resonance imaging play crucial roles in diagnosis. Ureterorenoscopy is vital for direct visualization and biopsy sampling, but its limited sampling capacity presents challenges in determining tumor depth and staging. Traditionally, nephroureterectomy with bladder cuff excision has been the gold-standard treatment for UTUC. Endoscopic conservative treatment has recently emerged as a viable option for selected patients, offering comparable oncological outcomes to radical surgery. Percutaneous access is also feasible for larger intrarenal tumors.
CASE SUMMARY We present a case of an 84-year-old woman who underwent percutaneous endoscopic excision of a renal pelvis neoplasm using the Tullio laser. Despite successful tumor removal, the patient experienced a postoperative complication with abdominal fluid leakage. Conservative management effectively resolved the complication. Given the patient's age and refusal for radical surgery, the conservative approach proved to be a valid therapeutic choice.
CONCLUSION Overall, UTUC remains a diagnostic and therapeutic challenge due to its rarity. However, advances in endoscopic and percutaneous techniques provide valuable alternatives for selected patients, warranting further exploration in this evolving field.
Collapse
Affiliation(s)
| | - Nicolò Fabbri
- Department of Surgery, University of Ferrara, Azienda USL of Ferrara, Azienda USL of Ferrara, Ferrara 44100, Ferrara, Italy
| | - Danila Romeo
- Local Health Agency of Ferrara, Ferrara 44100, Italy
| | - Elisa Paiolo
- Department of Urology, Azienda USL di Ferrara, Ferrara 44100, Italy
| | - Martina Bandi
- Department of Urology, Azienda USL di Ferrara, Ferrara 44100, Italy
| | - Maurizio Simone
- Department of Urology, Azienda USL di Ferrara, Ferrara 44100, Italy
| |
Collapse
|
4
|
Hu H, Lai S, Wang M, Tang X, Lai CH, Xu K, Xu T, Hu H. Effect of subsequent bladder cancer on survival in upper tract urothelial carcinoma patients post-radical nephroureterectomy: a systematic review and meta-analysis. BMC Urol 2023; 23:212. [PMID: 38129811 PMCID: PMC10734187 DOI: 10.1186/s12894-023-01387-3] [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: 06/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Radical nephroureterectomy (RNU) is the primary treatment strategy for upper tract urothelial carcinoma (UTUC). However, the intravesical recurrence occurs in 20-50% of all patients. The specific effect of subsequent bladder cancer (SBCa) on survival remains unclear. Therefore, we investigated the effect of SBCa following RNU in patients with UTUC. METHODS PubMed, EMBASE, and Cochrane Library were exhaustively searched for studies comparing oncological outcomes between SBCa and without SBCa. Standard cumulative analyses using hazard ratios (HR) with 95% confidence intervals (CI) were performed using Review Manager (version 5.3). RESULTS Five studies involving 2057 patients were selected according to the predefined eligibility criteria. Meta-analysis of cancer-specific survival (CSS) and overall survival (OS) revealed no significant differences between the SBCa and non-SBCa groups. However, subgroup analysis of pT0-3N0M0 patients suggested that people with SBCa had worse CSS (HR = 5.13, 95%CI 2.39-10.98, p < 0.0001) and OS (HR = 4.00, 95%CI 2.19-7.31, p < 0.00001). CONCLUSIONS SBCa appears to be associated with worse OS in patients with early stage UTUC. However, caution must be taken before recommendations are made because this interpretation is based on very few clinical studies and a small sample size. Research sharing more detailed surgical site descriptions, as well as enhanced outcome data collection and improved reporting, is required to further investigate these nuances.
Collapse
Affiliation(s)
- Haopu Hu
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Shicong Lai
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Mingrui Wang
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Xinwei Tang
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Chin-Hui Lai
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Kexin Xu
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Tao Xu
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Hao Hu
- Department of Urology, Peking University People's Hospital, Beijing, China.
| |
Collapse
|
5
|
Luo Z, Jiao B, Huang T, Zhao H, He W, Bo Y, Ding Z, Zhang G. Development and external validation of a novel nomogram to predict intravesical recurrence after radical nephroureterectomy: a multicenter study. J Cancer Res Clin Oncol 2023; 149:11223-11231. [PMID: 37355502 DOI: 10.1007/s00432-023-05016-2] [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: 05/23/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE This study aimed to establish and validate nomograms to predict the probability of intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper urinary tract epithelial carcinoma (UTUC). METHODS Clinical data of 528 patients with UTUC after RNU were collected from two medical centers between 2009 and 2020. We used the least absolute shrinkage and selection operator (LASSO) regression to select variables for multivariable Cox regression analysis in the training cohort and included independent risk factors into nomogram models predicting IVR-free survival (IVRFS). Another center was applied as the external cohort to validate the predictive accuracy and discriminative ability of the nomogram by performing area under the receiver operating curve (AUC), consistency index (C-index), and calibration curve. RESULTS History of bladder cancer, tumor size, preoperative urine cytology, postoperative instillation, Ki-67, and platelet-to-lymphocyte ratio (PLR) were identified as independent risk factors for IVR. The prognosis model including these predictors demonstrated excellent discriminatory performance in both the training cohort (C-index, 0.814) and external validation cohort (C-index, 0.748). The calibration plots of the nomogram revealed good consistency in both cohorts. Finally, patients could be classified into two risk groups based on scores obtained from the nomogram, with significant differences in IVRFS. CONCLUSION Our study provided a reliable nomogram for predicting the probability of IVR in patients with UTUC after RNU. Risk stratification based on this model may assist urologists make optimal clinical decisions on the management of UTUC.
Collapse
Affiliation(s)
- Zhenkai Luo
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, No. 9 Dongdan Santiao, Dongcheng District, Beijing, 100730, China
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Nanli, Panjiayuan, Chaoyang District, Beijing, 100021, China
| | - Binbin Jiao
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Tao Huang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, No. 300. Guangzhou Road, Nanjing, 210029, China
| | - Hang Zhao
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, 270 Dong an Road, Xuhui District, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong an Road, Xuhui District, Shanghai, 200032, China
| | - Weifeng He
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yuxuan Bo
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Zhenshan Ding
- Department of Urology, China-Japan Friendship Hospital, Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
| | - Guan Zhang
- Department of Urology, China-Japan Friendship Hospital, Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
| |
Collapse
|
6
|
Woldu SL, Labbate C, Murray KS, Rose K, Sexton W, Tachibana I, Kaimakliotis H, Jacob J, Dickstein R, Linehan J, Nieder A, Bjurlin MA, Humphreys M, Ghodoussipour S, Quek ML, O'Donnell M, Eisner BH, Feldman AS, Matin SF, Lotan Y. Early experience with UGN-101 for the treatment of upper tract urothelial cancer - A multicenter evaluation of practice patterns and outcomes. Urol Oncol 2023; 41:147.e15-147.e21. [PMID: 36424224 DOI: 10.1016/j.urolonc.2022.10.029] [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: 07/11/2022] [Revised: 09/28/2022] [Accepted: 10/30/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND UGN-101 is a novel delivery system for intracavitary treatment of upper tract urothelial cancer (UTUC). UGN-101 was approved based on a pivotal trial for small volume residual low-grade UTUC. Our aim was to report our experience with UGN-101 in a more heterogenous and real-world setting. METHODS We performed a retrospective review of all UGN-101 cases from 15 institutions with a focus on practice patterns, efficacy, and adverse effects. We include UGN-101 utilization in both the chemoablative and adjuvant setting. RESULTS There were a total 136 renal units treated from 132 patients. The majority of cases were biopsy proven low-grade UTUC. Practice patterns varied considerably - the most common administration technique was antegrade instillation via a percutaneous nephrostomy. When utilized in the adjuvant setting, 69% of patients were disease free at the time of their first endoscopic evaluation, while in the chemoablative setting, 37% were endoscopically clear on the first evaluation (P < 0.001). Complete response was higher in patients with smaller tumor size prior to UGN-101 induction; low volume (<1 cm) residual disease was associated with a 70% complete response, similar to disease free rate at first endoscopic evaluation when UGN-101 was used in the adjuvant setting. The use of maintenance doses of UGN-101 was reported in 27% of cases. The overall incidence of new onset, clinically significant ureteral stenosis was 23%. CONCLUSIONS This study represents the largest review of patients treated with UGN-101 and can serve as a basis of ongoing hypotheses regarding treatment with UGN-101 for UTUC.
Collapse
Affiliation(s)
| | - Craig Labbate
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | - Joseph Jacob
- State University of New York Upstate Medical Center, Syracuse, NY
| | - Rian Dickstein
- University of Maryland Medical Center, Baltimore, MD; Chesapeake Urology, Baltimore, MD
| | | | | | - Marc A Bjurlin
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | | | | | | | | | | | | | - Surena F Matin
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, TX.
| |
Collapse
|
7
|
Gao J, Liu J, Liu J, Lin S, Ding D. Survival and risk factors among upper tract urothelial carcinoma patients after radical nephroureterectomy in Northeast China. Front Oncol 2022; 12:1012292. [PMID: 36387197 PMCID: PMC9648663 DOI: 10.3389/fonc.2022.1012292] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/10/2022] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE The study objective was to investigate the prognostic risk factors related to overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and metastasis-free survival (MFS) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Patients were then divided into different risk groups (based on their number of prognostic risk factors), and specific postoperative treatment plans were formulated for patients in different risk groups. METHODS We retrospectively analyzed the data of 401 patients with UTUC who underwent RNU between 2010 and 2020. Univariate and multivariate Cox regression analyses were used to evaluate the associations of clinicopathological variables with prognosis among UTUC patients. Kaplan-Meier survival analysis of patients in different risk groups (based on their number of prognostic risk factors) was conducted. RESULTS Multivariate Cox regression analysis showed that sex (being male), LVI, pT stage (>pT2), and lack of postoperative intravesical instillation were independent risk predictors of shorter OS, CSS, RFS, and MFS (all P<0.05). Laparoscopic RNU was also associated with shorter OS, CSS, and MFS, but not with shorter RFS (P=0.068). After risk stratification, the 5-year OS, CSS, RFS, and MFS in the high-risk group were 42.3%, 46.4%, 41%, and 46%, respectively. CONCLUSIONS Sex (being male), LVI, pT stage (>pT2), and intravesical instillation were independent predictors of OS, CSS, RFS, and MFS for UTUC. All were risk factors, except for intravesical instillation, which was a protective factor. Additionally, laparoscopic RNU was an independent risk factor for OS, CSS, and MFS. Patients in the high-risk group may benefit greatly from adjuvant or neoadjuvant chemotherapy.
Collapse
Affiliation(s)
- Jianing Gao
- Department of Urology Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jingya Liu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jianyu Liu
- Department of Respiratory Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Shiyan Lin
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Dexin Ding
- Department of Urology Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| |
Collapse
|
8
|
He Y, Gao W, Ying W, Feng N, Wang Y, Jiang P, Gong Y, Li X. A Novel Preoperative Prediction Model Based on Deep Learning to Predict Neoplasm T Staging and Grading in Patients with Upper Tract Urothelial Carcinoma. J Clin Med 2022; 11:jcm11195815. [PMID: 36233682 PMCID: PMC9571440 DOI: 10.3390/jcm11195815] [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: 07/15/2022] [Revised: 09/01/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives: To create a novel preoperative prediction model based on a deep learning algorithm to predict neoplasm T staging and grading in patients with upper tract urothelial carcinoma (UTUC). Methods: We performed a retrospective cohort study of patients diagnosed with UTUC between 2001 and 2012 at our institution. Five deep learning algorithms (CGRU, BiGRU, CNN-BiGRU, CBiLSTM, and CNN-BiLSTM) were used to develop a preoperative prediction model for neoplasm T staging and grading. The Matthews correlation coefficient (MMC) and the receiver-operating characteristic curve with the area under the curve (AUC) were used to evaluate the performance of each prediction model. Results: The clinical data of a total of 884 patients with pathologically confirmed UTUC were collected. The T-staging prediction model based on CNN-BiGRU achieved the best performance, and the MMC and AUC were 0.598 (0.592–0.604) and 0.760 (0.755–0.765), respectively. The grading prediction model [1973 World Health Organization (WHO) grading system] based on CNN-BiGRU achieved the best performance, and the MMC and AUC were 0.612 (0.609–0.615) and 0.804 (0.801–0.807), respectively. The grading prediction model [2004 WHO grading system] based on BiGRU achieved the best performance, and the MMC and AUC were 0.621 (0.616–0.626) and 0.824 (0.819–0.829), respectively. Conclusions: We developed an accurate UTUC preoperative prediction model to predict neoplasm T staging and grading based on deep learning algorithms, which will help urologists to make appropriate treatment decisions in the early stage.
Collapse
Affiliation(s)
- Yuhui He
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Wenzhi Gao
- Department of Urology, Peking University First Hospital, Beijing 100034, China
- Department of Urology, The Third Hospital of Hebei Medical University, Shijiazhuang 050052, China
| | - Wenwei Ying
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Ninghan Feng
- Department of Urology, The Second People’s Hospital of Wuxi, Wuxi 214002, China
| | - Yang Wang
- Department of Urology, The Second People’s Hospital of Wuxi, Wuxi 214002, China
| | - Peng Jiang
- Department of Urology, The Second People’s Hospital of Wuxi, Wuxi 214002, China
| | - Yanqing Gong
- Department of Urology, Peking University First Hospital, Beijing 100034, China
- Correspondence: (Y.G.); (X.L.)
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Beijing 100034, China
- Correspondence: (Y.G.); (X.L.)
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Photodynamic diagnostic ureteroscopy using the VISERA ELITE video system for diagnosis of upper-urinary tract urothelial carcinoma: a prospective cohort pilot study. BMC Urol 2021; 21:45. [PMID: 33765999 PMCID: PMC7995577 DOI: 10.1186/s12894-021-00819-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background The advantages of photodynamic diagnostic technology using 5-aminolevulinic acid (ALA-PDD) have been established. The aim of this prospective cohort study was to evaluate the usefulness of ALA-PDD to diagnose upper tract urothelial carcinoma (UT-UC) using the Olympus VISERA ELITE video system. Methods We carried out a prospective, interventional, non-randomized, non-contrast and open label cohort pilot study that involved patients who underwent ureterorenoscopy (URS) to detect UT-UC. 5-aminolevulinic acid hydrochloride was orally administered before URS. The observational results and pathological diagnosis with ALA-PDD and traditional white light methods were compared, and the proportion of positive subjects and specimens were calculated. Results A total of 20 patients were enrolled and one patient who had multiple bladder tumors did not undergo URS. Fifteen of 19 patients were pathologically diagnosed with UT-UC and of these 11 (73.3%) were ALA-PDD positive. Fourteen of 19 patients were ALA-PDD positive and of these 11 were pathologically diagnosed with UC. For the 92 biopsy specimens that were malignant or benign, the sensitivity for both traditional white light observation and ALA-PDD was the same at 62.5%, whereas the specificities were 73.1% and 67.3%, respectively. Of the 38 specimens that were randomly biopsied without any abnormality under examination by both white light and ALA-PDD, 11 specimens (28.9%) from 5 patients were diagnosed with high grade UC. In contrast, four specimens from 4 patients, which were negative in traditional white light observation but positive in ALA-PDD, were diagnosed with carcinoma in situ (CIS). Conclusions Our results suggest that ALA-PDD using VISERA ELITE is not sufficiently applicable for UT-UC. Nevertheless, it might be better particularly for CIS than white light and superior results would be obtained using VISERA ELITE II video system. Trial registration: The present clinical study was approved by the Okayama University Institutional Review Board prior to study initiation (Application no.: RIN 1803–002) and was registered with the UMIN Clinical Trials Registry (UMIN-CTR), Japan (Accession no.: UMIN000031205).
Collapse
|
11
|
Marcq G, Foerster B, Abufaraj M, Matin SF, Azizi M, Gupta M, Li WM, Seisen T, Clinton T, Xylinas E, Mir MC, Schweitzer D, Mari A, Kimura S, Bandini M, Mathieu R, Ku JH, Guruli G, Grabbert M, Czech AK, Muilwijk T, Pycha A, D'Andrea D, Petros FG, Spiess PE, Bivalacqua T, Wu WJ, Rouprêt M, Krabbe LM, Hendricksen K, Egawa S, Briganti A, Moschini M, Graffeille V, Autorino R, John P, Heidenreich A, Chlosta P, Joniau S, Soria F, Pierorazio PM, Shariat SF, Kassouf W. Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study. Eur Urol Focus 2021; 8:491-497. [PMID: 33773965 DOI: 10.1016/j.euf.2021.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories. OBJECTIVE To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points. RESULTS AND LIMITATIONS A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU). CONCLUSIONS Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design. PATIENT SUMMARY We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.
Collapse
Affiliation(s)
- Gautier Marcq
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada; Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France
| | - Beat Foerster
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Surena F Matin
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Mounsif Azizi
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Department of Surgery, Division of Urology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Canada
| | - Mohit Gupta
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wei-Ming Li
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Thomas Seisen
- Urology, GRC 5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Timothy Clinton
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Paris Descartes University, Paris, France
| | - M Carmen Mir
- Instituto Valenciano de Oncologia Foundation, Valencia, Spain
| | - Donald Schweitzer
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Shoji Kimura
- Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Marco Bandini
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Romain Mathieu
- Department of Urology, University of Rennes, Rennes, France
| | - Ja H Ku
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Georgi Guruli
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Markus Grabbert
- Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany
| | - Anna K Czech
- Department of Urology, Jagiellonian University Medical College, Krakow, Poland
| | - Tim Muilwijk
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Armin Pycha
- Department of Urology, Provincial Hospital of Bozen, Bozen, Italy; Medical School, Sigmund Freud University, Vienna, Austria
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Firas G Petros
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA; Department of Urology and Kidney Transplant, The University of Toledo Medical Center and Eleanor N. Dana Cancer Center, Toledo, OH, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Trinity Bivalacqua
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wen-Jeng Wu
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Morgan Rouprêt
- Urology, GRC 5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Laura-Maria Krabbe
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University Hospital Muenster, Muenster, Germany
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Shin Egawa
- Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Moschini
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Riccardo Autorino
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Patricia John
- Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University Medical College, Krakow, Poland
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Francesco Soria
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Surgical Sciences, University of Torino School of Medicine, Turin, Italy
| | - Phillip M Pierorazio
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada.
| |
Collapse
|
12
|
Maruyama Y, Araki M, Wada K, Yoshinaga K, Mitsui Y, Sadahira T, Nishimura S, Edamura K, Kobayashi Y, Watanabe M, Watanabe T, Monga M, Nasu Y, Kumon H. Long-term ureteroscopic management of upper tract urothelial carcinoma: 28-year single-centre experience. Jpn J Clin Oncol 2021; 51:130-137. [PMID: 32715306 DOI: 10.1093/jjco/hyaa132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/06/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Long-term survival outcomes of patients who undergo endoscopic management of non-invasive upper tract urothelial carcinoma remain uncertain. The longest mean follow-up period in previous studies was 6.1 years. This study reports the long-term outcomes of patients with upper tract urothelial carcinoma who underwent ureteroscopic ablation at a single institution over a 28-year period. METHODS We identified all patients who underwent ureteroscopic management of upper tract urothelial carcinoma as their primary treatment at our institution between January 1991 and April 2011. Survival outcomes, including overall survival, cancer-specific survival, upper-tract recurrence-free survival and renal unit survival, were estimated using Kaplan-Meier methodology. RESULTS A total of 15 patients underwent endoscopic management, with a mean age at diagnosis of 66 years. All patients underwent ureteroscopy, and biopsy-confirmed pathology was obtained. Median (range; mean) follow-up was 11.7 (2.3-20.9, 11.9) years. Upper tract recurrence occurred in 87% (n = 13) of patients. Twenty percent (n = 3) of patients proceeded to nephroureterectomy. The estimated cancer-specific survival rate was 93% at 5, 10, 15 and 20 years. Estimated overall survival rates were 86, 80, 54 and 20% at 5, 10, 15 and 20 years. Only one patient experienced cancer-specific mortality. The estimated mean and median overall survival times were 14.5 and 16.6 years, respectively. The estimated mean cancer-specific survival time was not reached. CONCLUSIONS Although upper tract recurrence is common, endoscopic management of non-invasive upper tract urothelial carcinoma provides a 90% cancer-specific survival rate at 20 years in selected patients.
Collapse
Affiliation(s)
- Yuki Maruyama
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Koichiro Wada
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Kasumi Yoshinaga
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yosuke Mitsui
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Takuya Sadahira
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shingo Nishimura
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Kohei Edamura
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasuyuki Kobayashi
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masami Watanabe
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Toyohiko Watanabe
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Manoj Monga
- Department of Urology, The Cleveland Clinic, Cleveland, OH, USA
| | - Yasutomo Nasu
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hiromi Kumon
- Innovation Center Okayama for Nanobio-Targeted Therapy, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.,Niimi University, 1263-2, Niimi, Okayama, 718-8585, Japan
| |
Collapse
|
13
|
[Upper urinary tract urothelial cell carcinoma]. Urologe A 2020; 59:1265-1274. [PMID: 32936335 DOI: 10.1007/s00120-020-01323-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Upper urinary tract urothelial cell carcinoma (UTUC) is a rare entity. The incidence in Germany is approximately 2/100,000 with a ratio between women and men of 1:2.5. Most clinical signs are nonspecific, which is why early diagnosis is rarely successful. Computed tomography urography in combination with diagnostic ureterorenoscopy is currently the gold standard in the diagnostics of UTUC. Regarding surgical treatment, radical nephroureterectomy (RNU) with resection of a bladder cuff remains the method of choice, although the radical approach is developing towards laparoscopic/robotic or endourological procedures with preservation of kidney tissue. Due to the high recurrence rate (22-47%) of urothelial carcinoma inside the bladder, close follow-up after RNU is mandatory.
Collapse
|
14
|
Organ-sparing procedures in GU cancer: part 3-organ-sparing procedures in urothelial cancer of upper tract, bladder and urethra. Int Urol Nephrol 2019; 51:1903-1911. [PMID: 31352580 DOI: 10.1007/s11255-019-02232-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The impact of radical surgery for urothelial carcinoma is significant on patient's quality of life. Organ-sparing surgery (OSS) can provide comparable oncological outcomes and with improved quality of life. In this review, we summarize the indications, techniques and outcomes of OSS for these tumors. METHODS PubMed® was searched for relevant articles. Keywords used were: for upper tract urothelial carcinoma (UTUC): endoscopic, ureteroscopic/percutaneous management, laser ablation; for urothelial bladder cancer: bladder preservation, trimodal therapy, muscle invasive bladder cancer (MIBC); for urethral cancer: urethra/penile-sparing, urethral carcinoma. RESULTS Kidney-sparing surgery is an option in patients with low-risk UTUC with better renal function preservation and comparable oncological control to radical nephroureterectomy. In select patients with MIBC, trimodal therapy has better quality of life and comparable oncological control to radical cystectomy. In distal male urethral cancer, penile conserving surgery is feasible and offers acceptable survival outcomes. In female urethral cancer, organ preservation can be achieved, in addition to OSS, through radiation. CONCLUSIONS In the appropriately selected patient, OSS in upper tract, bladder and urethral carcinoma has comparable oncological outcomes to radical surgery and with the additional benefit of improved quality of life.
Collapse
|
15
|
Abstract
A select group of patients with upper tract urothelial carcinoma (UTUC) may meet indications for endoscopic management. Strategies for disease management are provided, based on a comprehensive review of the data using PubMed and Medline databases and marrying this with our experience with endoscopic management of UTUC. Endoscopic management of UTUC via retrograde or antegrade approaches is a viable treatment option for appropriately selected patients with low-risk UTUC, including those with low-grade, low-volume, and solitary tumors. However, recurrence risk limits these procedures to compliant patients under a vigilant surveillance program. Efficacious adjuvant therapies are needed to reduce local recurrences.
Collapse
Affiliation(s)
- Firas G Petros
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Roger Li
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Surena F Matin
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| |
Collapse
|