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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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Farrow JM, Kern SQ, Gryzinski GM, Sundaram CP. Nephron-sparing management of upper tract urothelial carcinoma. Investig Clin Urol 2021; 62:389-398. [PMID: 34190434 PMCID: PMC8246013 DOI: 10.4111/icu.20210113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/12/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022] Open
Abstract
Urothelial carcinoma of the upper urinary tract is uncommon and presents unique challenges for diagnosis and management. Nephroureterectomy has been the preferred management option, but it is associated with significant morbidity. Nephron-sparing treatments are a valuable alternative and provide similar efficacy in select cases. A PubMed literature review was performed in English language publications using the following search terms: urothelial carcinoma, upper tract, nephron-sparing, intraluminal and systemic therapy. Contemporary papers published within the last 10 years were primarily included. Where encountered, systematic reviews and meta-analyses were given priority, as were randomized controlled trials for newer treatments. Core guidelines were referenced and citations reviewed for inclusion. A summary of epidemiological data, clinical diagnosis, staging, and treatments focusing on nephron-sparing approaches to upper tract urothelial carcinoma (UTUC) are outlined. Nephron-sparing management strategies are viable options to consider in patients with favorable features of UTUC. Adjunctive therapies are being investigated but the data remains mixed. Protocol variability and dosage differences limit statistical interpretation. New mechanisms to improve treatment dwell times in the upper tracts are being designed with promising preliminary results. Studies investigating systemic therapies are ongoing but implications for nephron-sparing management are uncertain. Nephron-sparing management is an acceptable treatment modality best suited for favorable disease. More work is needed to determine if intraluminal and/or systemic therapies can further optimize treatment outcomes beyond resection alone.
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Affiliation(s)
- Jason M Farrow
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Sean Q Kern
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gustavo M Gryzinski
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandru P Sundaram
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
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Bozzini G, Gastaldi C, Besana U, Calori A, Casellato S, Parma P, Pastore A, Macchi A, Breda A, Gozen A, Skolarikos A, Herrmann T, Scoffone C, Eissa A, Sighinolfi MC, Rocco B, Buizza C, Liatsikos E. Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study. Minerva Urol Nephrol 2020; 73:114-121. [PMID: 32026668 DOI: 10.23736/s2724-6051.20.03689-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Radical nephroureterectomy (RNU) is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC); however, patients presenting with small low-grade UTUC have been treated by flexible ureteroscopic laser ablation with good outcomes. Different types of laser have been discussed in the literature including Holmium and Neodymium lasers. We aimed to assess the safety and efficacy of Thulium laser (Tm:YAG) in the ureteroscopic ablation of UTUC. METHODS A retrospective observational multicentre study of patients diagnosed with papillary UTUC between January 2015 and December 2016 was carried out. All patients underwent ureteroscopic biopsy of the UTUC followed by Tm:YAG ablation. Based on the histopathological grade of the tumor, patients were counseled to undergo either RNU (high- grade tumors) or conservative management and follow-up (low-grade tumor). RESULTS RNU was performed in 31 patients, while the remaining 47 patients (undergone Tm:YAG ablation only) were followed up for a mean of 11.7 months with only 19.2% of patients showing upper tract recurrence and no patients showed postoperative ureteral strictures. Limitations include the short follow-up and retrospective nature of the study. CONCLUSIONS On the short term, thulium Laser ablation of UTUC is safe and feasible especially in low-grade UTUC.
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Affiliation(s)
- Giorgio Bozzini
- ESUT (European section for UroTechnology), Arnehm, the Netherlands - .,Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy -
| | | | - Umberto Besana
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Alberto Calori
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Stefano Casellato
- Department of Urology, Istituti Clinici Zucchi, Monza, Monza-Brianza, Italy
| | - Paolo Parma
- Department of Urology, Poma Hospital, Mantua, Italy
| | | | - Alberto Macchi
- Department of Urology, IRCCS Istituto Nazionale Tumori Foundation, Milan, Italy
| | - Alberto Breda
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, Puigvert Foundation, Barcelona, Spain
| | - Ali Gozen
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, University of Heidelberg, Heilbronn, Germany
| | - Andreas Skolarikos
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, Athens Univerity, Athens, Greece
| | - Thomas Herrmann
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, Spital Thurgau AG, Kantonspital Frauenfeld, Frauenfeld, Switzerland
| | - Cesare Scoffone
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, Cottolengo Hospital, Turin, Italy
| | - Ahmed Eissa
- Department of Urology, Baggiovara Hospital, Modena, Italy.,Department of Urology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Bernardo Rocco
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, Baggiovara Hospital, Modena, Italy
| | - Carlo Buizza
- Department of Urology, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Evangelos Liatsikos
- ESUT (European section for UroTechnology), Arnehm, the Netherlands.,Department of Urology, University of Patras, Patras, Greece
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Diagnosis, management, and follow-up of upper tract urothelial carcinoma: an interdisciplinary collaboration between urology and radiology. Abdom Radiol (NY) 2019; 44:3893-3905. [PMID: 31701194 DOI: 10.1007/s00261-019-02293-9] [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] [Indexed: 01/19/2023]
Abstract
Upper tract urothelial carcinoma (UTUC) is a common and lethal malignancy. Patients diagnosed with this illness often face invasive workups, morbid therapies, and prolonged post-operative surveillance. UTUC represents approximately 5-10% of urothelial malignancies in the United States and affect 4600-7800 new patients annually. Various environmental exposures as well as smoking have been implicated in the development of UTUC. The diagnosis and workup of UTUC relies on heavily on imaging studies, a close working relationship between Urologists and Radiologists, and invasive procedures such as ureteroscopy. Treatments range from renal-sparing endoscopic surgery to radical extirpative surgery depending on the specific clinical situation. Follow-up is crucial as UTUC has a high recurrence rate. Here we review the epidemiology, diagnosis, management strategies, and follow-up of UTUC from an interdisciplinary perspective.
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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.
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Kaler KS, Cooper V, O'Leary M, Valley ZA, Lee TK, Patel RM, Landman J, Clayman RV. Laser Endoscopic X-Ray-Guided Intrarenal Tract: Comparison Among Renal Access Modalities in the Porcine Kidney. J Endourol 2019; 33:719-724. [PMID: 31184211 DOI: 10.1089/end.2019.0234] [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: 11/12/2022] Open
Abstract
Introduction and Objectives: Laser endoscopic X-ray-guided intrarenal tract (LEXIT) is a recently described holmium laser retrograde access technique for creating percutaneous access during a percutaneous nephrolithotomy. We compared bleeding, ease of access, and the time to achieve access for each of the following three modalities: LEXIT, retrograde Lawson puncture wire, and antegrade 18-gauge nephrostomy needle access in the porcine kidney. Methods: Eight pigs underwent an average of five nephrostomy accesses per kidney under simultaneous laparoscopic vision at 5 mm Hg insufflation pressure. Data collected included: access time (seconds), bleeding intensity (scale: 1 [no bleeding] - 10 [severe bleeding]), bleeding duration (seconds), accuracy of caliceal entry, and surgeon comfort with the technique (scale: 1 [very easy] - 10 [very difficult]). Results: A total of 64 nephrostomy accesses were obtained. The speed of nephrostomy access with LEXIT was significantly faster than the nephrostomy needle and Lawson wire (p < 0.001). Bleeding intensity (p = 0.002) and severity (p = 0.001) were lower with the Lawson puncture wire, followed by LEXIT and then by the nephrostomy needle. LEXIT was rated as easier in acquiring access within the upper pole (p = 0.003) and interpolar calices (p < 0.001). Histopathology demonstrated no difference in parenchymal damage between LEXIT and nephrostomy needle (p = 0.18); however, LEXIT was associated with significantly increased peri-tract thermal injury, although within a narrow focus of 1.6 mm (p < 0.01). Conclusion: Among the three renal access techniques, LEXIT provided the fastest access times and greatest ease of access specifically for upper pole and interpolar calices. Also, bleeding with LEXIT was significantly less compared with the standard antegrade nephrostomy needle access. Histopathological analysis demonstrated that the holmium laser resulted in focal thermal tissue effects similar in range to the blunt tissue trauma caused by the 18-gauge nephrostomy needle.
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Affiliation(s)
- Kamaljot S Kaler
- Department of Urology, University of California, Irvine, California
- Department of Surgery, Section of Urology, University of Calgary, Calgary, Canada
| | - Vinay Cooper
- Department of Urology, University of California, Irvine, California
| | - Mitchell O'Leary
- Department of Urology, University of California, Irvine, California
| | - Zachary A Valley
- Department of Urology, University of California, Irvine, California
| | - Thomas K Lee
- Department of Urology, University of California, Irvine, California
| | - Roshan M Patel
- Department of Urology, University of California, Irvine, California
| | - Jaime Landman
- Department of Urology, University of California, Irvine, California
| | - Ralph V Clayman
- Department of Urology, University of California, Irvine, California
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Emiliani E, Talso M, Haddad M, Pouliquen C, Derman J, Côté JF, Doizi S, Millán F, Berthe L, Audouin M, Traxer O. The True Ablation Effect of Holmium YAG Laser on Soft Tissue. J Endourol 2018; 32:230-235. [DOI: 10.1089/end.2017.0835] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Esteban Emiliani
- Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, F-75020 Paris, France
- Fundación Puigvert, Department of Urology, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Michele Talso
- Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, F-75020 Paris, France
- Ospedale Policlinico di Milano-Universita' degli Studi di Milano, Milan, Italy
| | - Mattieu Haddad
- Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Christelle Pouliquen
- Sorbonne Université, Department of Pathology, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Jonathan Derman
- Sorbonne Université, Department of Pathology, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Jean-François Côté
- Sorbonne Université, Department of Pathology, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Steeve Doizi
- Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Felix Millán
- Fundación Puigvert, Department of Urology, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Laurent Berthe
- Process and Engineering in Mechanics and Materials Laboratory (PIMM), UMR CNRS/ENSAM, Paris VI, France
| | - Marie Audouin
- Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Olivier Traxer
- Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, F-75020 Paris, France
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