1
|
Asimakopoulos AD, Kochergin M, Klöcker C, Gakis G. The Role of Local Agents for the Treatment of Localized Upper Tract Urothelial Carcinoma: A Review of the Current Evidence. Bladder Cancer 2023; 9:15-27. [PMID: 38994483 PMCID: PMC11181742 DOI: 10.3233/blc-220093] [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: 09/21/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Abstract
Kidney-sparing surgery (KSS) for upper urinary tract urothelial carcinoma (UTUC) is a promising alternative to radical nephroureterectomy, especially for low-risk cases. However, due to the established risk of ipsilateral UTUC recurrence caused by the implantation of floating neoplastic cells after endoscopic resection, adjuvant endocavitary (endoureteral) instillations have been proposed. Instillation therapy may be also used as primary treatment for UTUC. The two most studied drugs that have been evaluated in both the adjuvant and primary setting of endocavitary instillation are mitomycin C and Bacillus Calmette-Guerin. The current paper provides an overview of the endocavitary treatments for UTUC, focusing on methods of administration, novel formulations, oncologic outcomes (in terms of endocavitary recurrence and progression), as well as on complications. In particular, the role of UGN-101 as a primary chemoablative treatment of primary noninvasive, endoscopically unresectable, low-grade, UTUC has been analysed. The drug achieved a complete response rate of 58% after the induction cycle, with a durable response independently of the maintenance cycle. The cumulative experience on the role of UUT instillation therapy appears encouraging; however, no definitive conclusions can be drawn about its therapeutic benefit. Given the current state of the art, any decision to administer adjuvant endoureteral therapy for UTUC should be carefully weighed against the potential adverse events. Nevertheless, newer investigations that improve visualization during ureteroscopy, genomic characterization, novel drugs and innovative strategies of improved drug delivery are under evaluation. The landscape of KSS for the treatment of the UTUC is evolving and seems promising.
Collapse
Affiliation(s)
| | - Maxim Kochergin
- Department of Urology and Neurourology, BG Unfallkrankenhaus Berlin, Berlin, Germany
| | - Christian Klöcker
- Department of Urology and Pediatric Urology, University Hospital of Würzburg, Würzburg, Germany
| | - Georgios Gakis
- Department of Urology, University Hospital of Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| |
Collapse
|
2
|
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.
Collapse
|
3
|
Ng Chieng Hin J, Hettiarachchilage D, Gravestock P, Rai B, Somani BK, Veeratterapillay R. Role of Ureteroscopy in Treatment of Upper Tract Urothelial Carcinoma. Curr Urol Rep 2021; 22:49. [PMID: 34622345 PMCID: PMC8497313 DOI: 10.1007/s11934-021-01065-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Upper tract urothelial carcinoma (UTUC) is uncommon accounting for less than 10% of all urothelial tumours. Ureteroscopic management (URS) is the first line treatment for low-risk disease and has been increasingly utilised due to technological advances and increasing surgical experience. This review looks at patient outcomes relating to URS, emerging technologies and the role of adjuvant intracavitary therapy in the management of UTUC. RECENT FINDINGS URS has firmly established itself in the management algorithm for UTUC, and a good body of evidence supports its use for low-risk disease, wherein oncological outcomes are comparable to traditional nephroureterectomy (RNU). Larger tumours can now be managed using URS with a lower morbidity than radical surgery, though with higher associated local recurrence rate and risk of progression to RNU, and as a result, patient selection and close surveillance remains key. There is limited evidence for adjuvant intracavitary therapy (Mitomycin C or BCG) in UTUC although the development of novel polymers and biodegradable stents may improve drug delivery to the upper urinary tract. URS has a clearly defined role in low-risk UTUC, and its use in larger tumours appears to be appropriate in a selected cohort of patients. The efficacy of adjuvant intracavitary therapy is as of yet undetermined, though developments in delivery techniques are promising. Likewise further developments of laser technology are anticipated to further expand the role of URS.
Collapse
Affiliation(s)
| | | | | | - Bhavan Rai
- Department of Urology, Freeman Hospital, Newcastle, UK
| | - Bhaskar K Somani
- Department of Urology, University Hospital Southamptom, Southamptom, UK.
| | | |
Collapse
|
4
|
Abstract
While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.
Collapse
Affiliation(s)
- John J Knoedler
- Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
5
|
Metcalf M, Pierorazio PM. Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma. Transl Androl Urol 2020; 9:1831-1840. [PMID: 32944547 PMCID: PMC7475682 DOI: 10.21037/tau.2019.11.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Though radical nephroureterectomy remains the gold standard treatment for high grade or invasive disease in upper tract urothelial cancer (UTUC), kidney-sparing surgery has become preferred for low risk disease, in order to minimize morbidity and preserve renal function. Many methods exist for endoscopic management, whether via an antegrade percutaneous or retrograde ureteroscopic approach, including electroresection, laser ablation, and fulguration. There has been an increase in use of adjuvant intracavitary therapy, predominantly using mitomycin and bacillus Calmette-Guerin (BCG), to reduce recurrence after primary endoscopic management for noninvasive tumors, although efficacy remains questionable. Intraluminal BCG has additionally been used for primary treatment of CIS in the upper tract, with around 50% success. Newer investigations include use of narrow band imaging or photodynamic diagnosis with ureteroscopy to improve visualization during diagnosis and treatment. Genomic characterization may improve selection for kidney-sparing surgery as well as identify actionable mutations for systemic therapy. The evolution in adjuvant management has seen strategies to increase the dwell time and the urothelial contact of intraluminal agents. Lastly, chemoablation using a hydrogel for sustained effect of mitomycin is under investigation with promising early results. Continued expansion of the armamentarium available and better identification and characterization of tumors ideal for organ-sparing treatment will further improve kidney preservation in UTUC.
Collapse
Affiliation(s)
- Meredith Metcalf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
6
|
Endocavitary treatment for upper tract urothelial carcinoma: A meta-analysis of the current literature. Urol Oncol 2019; 37:430-436. [DOI: 10.1016/j.urolonc.2019.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/28/2019] [Accepted: 02/10/2019] [Indexed: 12/12/2022]
|
7
|
Huang GL, Luo HL, Chiang PH. Does preoperative percutaneous nephrostomy insertion worsen upper-tract urothelial cancer oncological outcome? A retrospective single center study. BMC Urol 2019; 19:50. [PMID: 31174519 PMCID: PMC6555991 DOI: 10.1186/s12894-019-0482-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/29/2019] [Indexed: 11/13/2022] Open
Abstract
Background Physicians doubt percutaneous nephrostomy (PCN) insertion on cancer related hydronephrosis patients causes tumor seeding and worse cancer control. In this article, we attempted to determine if preoperative PCN alters cancer control in upper tract urothelial cancer (UTUC) patients. Methods Retrospective analysis of UTUC patients in a single center from 2005 to 2015. Exclusion criteria included lymph node metastasis, and patients underwent perioperative adjuvant chemotherapy or radiotherapy. There were 664 patients in this analysis, with clinico-pathological data being collected retrospectively for Cox-regression statistical analysis. Outcomes were measured by local recurrence, distant metastasis and cancer-specific death with Kaplan-Meier curves. Results There were respectively 25 and 639 UTUC cancers in the preoperative PCN and non-PCN insertion groups with mean follow-up duration of 37.9 and 48.6 months, respectively. The preoperative PCN group consisted of 17 patients (68%) with tumor located in the ureter, while the PCN-negative group included 236 patients (36%) with tumor located in the ureter being statistically significant. These two groups were comparable in gender, age, follow-up duration, tumor stage, and pathological features of the UTUC. As for the cancer control in the PCN group, 4(16%), 1(4%) and 1(4%) had local recurrence, distant metastasis and cancer-specific death respectively; in the non-PCN group, 101(15.8%), 96(15%) and 72(11.2%) exhibited local recurrence, distant metastasis and cancer-specific death respectively. Statistical analysis showed no difference in oncologic outcomes between these two groups.(p = 0.804, 0.201 and 0.254). Conclusions Preoperative percutaneous nephrostomy on upper-tract urothelial cancer poses little risk on tumor seeding and could be considered as part of treatment strategy if renal function preservation is needed.
Collapse
Affiliation(s)
- Guan-Lin Huang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung, Taiwan
| | - Hao-Lun Luo
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung, Taiwan
| | - Po-Hui Chiang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, Niaosung, Kaohsiung, Taiwan.
| |
Collapse
|
8
|
Knoedler JJ, Raman JD. Intracavitary therapies for upper tract urothelial carcinoma. Expert Rev Clin Pharmacol 2018; 11:487-493. [PMID: 29634361 DOI: 10.1080/17512433.2018.1461560] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION While radical nephroureterectomy remains the gold-standard for upper tract urothelial carcinoma (UTUC), there is a growing push for organ-sparing therapy in low-risk disease. Herein we review the use of intracavitary topical therapy for treatment of UTUC. Areas covered: A PubMed search was performed for studies pertaining to upper tract urothelial carcinoma, with 236 articles reviewed, and distilled for content pertinent to intracavitary therapy for UTUC. Topics discussed include agents used for management of UTUC, most commonly BCG, as well as techniques for administration. Additionally, we review the evidence for curative treatment for Cis versus adjuvant therapy for Ta/T1 disease. Finally, we discuss emerging technologies to improve agent delivery and efficacy in the upper tract. Expert commentary: No significant advances have occurred in topical management of UTUC in the past 2 decades. However, advances in diagnostic techniques such as modern ureteroscopes, and improved diagnostic imaging at the time of ureteroscopy may help improve our patient selection. Additional advances in topical therapy focused on increasing the duration of contact between agent delivered and the upper tract urothelium offer hope that a new leap forward in topical therapy is on the horizon.
Collapse
Affiliation(s)
- John J Knoedler
- a Department of Surgery, Division of Urology , Penn State Hershey Surgical Specialties , Hershey , PA , USA
| | - Jay D Raman
- a Department of Surgery, Division of Urology , Penn State Hershey Surgical Specialties , Hershey , PA , USA
| |
Collapse
|
9
|
Re: Impact of Diagnostic Ureteroscopy on Intravesical Recurrence in Patients Undergoing Radical Nephroureterectomy for Upper Tract Urothelial Cancer: A Systematic Review and Meta-Analysis. J Urol 2018; 199:889-890. [PMID: 29642354 DOI: 10.1016/j.juro.2018.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/20/2022]
|
10
|
Raman JD, Park R. Endoscopic management of upper-tract urothelial carcinoma. Expert Rev Anticancer Ther 2017; 17:545-554. [DOI: 10.1080/14737140.2017.1326823] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
11
|
Abstract
PURPOSE OF REVIEW This study aims to make the reader be aware of recent trends regarding the endoscopic management of upper tract urothelial carcinoma (UTUC) via review of the urologic literature over the past 5 years. Given the rare incidence of this disease, and the lack of level 1 evidence, systematic reviews and meta-analyses were also evaluated. Studies of importance are also considered and outlined in the annotated reference section. RECENT FINDINGS The PubMed database was queried using the following medical subject headings (MeSH terms): "carcinoma, transitional cell," "ureter," "ureteral neoplasms," "kidney pelvis," "endoscopy," "laser therapy," "ureteroscopy," "urologic surgical procedures," and "ureteroscopes." MeSH terms were linked together in varying combinations and limited to human studies in English. Given the relatively rare nature of upper tract urothelial carcinoma (UTUC), level 1 evidence regarding the efficacy of endoscopic treatment does not exist, even after 30+ years of experience. Rather, the literature available mostly is in the form of single institutional retrospective series consisting of relatively small numbers of patients with short to intermediate follow-up. Only within the last 3 years have published series with larger numbers of patients and mean follow-up over 5 years been made available. Even with these more robust experiences, comparisons among series are difficult given variable treatment and follow-up approaches. Most endoscopically managed UTUC will locally recur, especially with longer follow-up. Renal preservation rate is high, however, approaching 80% with follow-up well over 3 years. Patients with high-grade disease often fare poorly regardless of treatment modality. As such, endoscopic management for high-grade urothelial carcinoma should only be used in exceptional circumstances (i.e., in those patients medically unfit for NU or those with solitary kidneys wishing to avoid the morbidity of dialysis). No level 1 evidence exists for the routine use of intraluminal adjuvant therapy for UTUC (i.e., BCG and Mitomycin C) and multiple retrospective observational series claim there is no overt benefit. The recent formation of multiple international groups with interest in UTUC may eventually lead to the production of level 1 studies regarding optimal treatment; however, uniformity in treatment approach will likely still offer challenges.
Collapse
|
12
|
Mandalapu RS, Remzi M, de Reijke TM, Margulis V, Palou J, Kapoor A, Yossepowitch O, Coleman J, Traxer O, Anderson JK, Catto J, de la Rosette J, O'Brien T, Zlotta A, Matin SF. Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma. World J Urol 2017; 35:355-365. [PMID: 27233780 PMCID: PMC5554604 DOI: 10.1007/s00345-016-1859-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/17/2016] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group. METHODS The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report. RESULTS There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy. CONCLUSIONS Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC.
Collapse
Affiliation(s)
| | | | | | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - J Palou
- Fundacio Puigvert, Barcelona, Spain
| | - A Kapoor
- McMaster University, Hamilton, ON, Canada
| | | | - Jonathan Coleman
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Olivier Traxer
- Hôpital Tenon, Université Pierre et Marie Curie Paris 6, Paris, France
| | - J Kyle Anderson
- University of Minnesota Medical Center, Minneapolis, MN, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | | | | | | | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1373, Houston, TX, 77030, USA.
| |
Collapse
|
13
|
Pan S, Smith AD, Motamedinia P. Minimally Invasive Therapy for Upper Tract Urothelial Cell Cancer. J Endourol 2017; 31:238-245. [PMID: 28117602 DOI: 10.1089/end.2016.0475] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Minimally invasive therapy for upper tract urothelial cell cancer has assumed an important role in the management of this relatively uncommon genitourinary malignancy. In this review, current standards for patient selection, surgical approach, as well as overall outcomes will be discussed. Moreover, the use of intraluminal agents in upper tract disease is examined along with its efficacy and associated complications.
Collapse
Affiliation(s)
- Shu Pan
- 1 Yale University School of Medicine , New Haven, Connecticut
| | - Arthur D Smith
- 2 Smith Institute for Urology, Northwell-Hofstra University , New Hyde Park, New York
| | | |
Collapse
|
14
|
Abstract
A 58-year-old female presented with renal colic and was found to have renal transitional cell carcinoma at the time of percutaneous surgery. She developed percutaneous tract seeding that clinically presented as subcutaneous skin nodules. After local treatment with surgical excision and radiation treatment, the patient developed retroperitoneal recurrence 5 years later. Percutaneous tract seeding is rare. There is no general consensus on prevention of tract seeding during percutaneous resection of renal urothelial tumors. Various recommendations from the literature are discussed.
Collapse
|
15
|
Fiuk JV, Schwartz BF. Upper tract urothelial carcinoma: Paradigm shift towards nephron sparing management. World J Nephrol 2016; 5:158-165. [PMID: 26981440 PMCID: PMC4777787 DOI: 10.5527/wjn.v5.i2.158] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/10/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is relatively rare compared to urothelial carcinoma of the lower tract, comprising only 5%-10% of all urothelial cancers. Although both entities share histologic properties, UTUC tends to be more invasive at diagnosis and portend a worse prognosis, with a 5 year overall mortality of 23%. To date, the gold standard management of UTUC has been radical nephroureterectomy (RNU), with nephron sparing techniques reserved for solitary kidneys or cases where the patient could not tolerate radical surgery. Limited data from these series, as well as select series where nephron-sparing endoscopic management has been offered to a broader patient base, suggest that minimally invasive, nephron sparing techniques can offer comparable oncologic and survival outcomes to RNU in appropriately selected patients. We review the current literature on the topic and discuss long term outcomes and sequelae of the gold standard treatment, RNU. We also discuss the oncologic outcomes of minimally invasive, endoscopic management of UTUC. Our goal is to provide the reader a comprehensive overview of the current state of the field in order to inform and guide their treatment decisions.
Collapse
|
16
|
Risk-adapted strategy for the kidney-sparing management of upper tract tumours. Nat Rev Urol 2015; 12:155-66. [DOI: 10.1038/nrurol.2015.24] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
17
|
Pignot G, Colin P, Rouprêt M, Traxer O. Traitement conservateur des tumeurs de la voie excrétrices supérieure : revue de littérature systématique pour le rapport scientifique annuel de l’Association française d’urologie. Prog Urol 2014; 24:1011-20. [DOI: 10.1016/j.purol.2014.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 07/17/2014] [Indexed: 01/11/2023]
|
18
|
Bachir BG, Kassouf W. Efficacy of instillations with chemotherapy or immunotherapy following endoscopic resection for upper tract urothelial carcinoma. Expert Rev Anticancer Ther 2014; 12:63-75. [DOI: 10.1586/era.11.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
19
|
Kapoor A, Allard CB, Black P, Kassouf W, Morash C, Rendon R. Canadian guidelines for postoperative surveillance of upper urinary tract urothelial carcinoma. Can Urol Assoc J 2013; 7:306-11. [PMID: 24319507 DOI: 10.5489/cuaj.1578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON
| | | | | | | | | | | |
Collapse
|
20
|
Aboumarzouk OM, Somani B, Ahmad S, Nabi G, Townell N, Kata SG. Mitomycin C instillation following ureterorenoscopic laser ablation of upper urinary tract carcinoma. Urol Ann 2013; 5:184-9. [PMID: 24049383 PMCID: PMC3764901 DOI: 10.4103/0974-7796.115746] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 05/22/2012] [Indexed: 11/29/2022] Open
Abstract
Introduction: Instillation of Mitomycin C (MMC) should prevent implantation of cancer cells released during endoscopic treatment and prevent recurrences as seen in carcinoma of the bladder. Aim: To develop and evaluate a protocol for a single dose MMC instillation following Holmium: YAG laser ablation of upper urinary tract transitional cell carcinoma (UUT-TCC). Setting and Design: A single institute prospective study. Materials and Methods: MMC instillations protocol was designed and offered to patients between August 2005 and April 2011. Following tumor ablation, MMC was instilled into upper urinary tract (UUT) over 40 minutes. All the patients were regularly followed up. Results: Twenty UUT units (19 patients) were managed for UUT-TCCs using our MMC protocol. Two UUT units had G1pTa tumors, 14 had G2pTa, 2 had G3pTa, and 2 had G3pT1. At a mean follow-up of 24 months (range 1-72 months), 13/20 (65%) of the UUT units remained cancer-free, 3 (15%) UUT units developed stricture and were treated with endoscopic dilatation, only 1 (5%) of these developed long-term complications. None of the patients developed postoperative renal impairment or systemic side-effects. Conclusions: Using a set standard protocol, MMC can safely be instilled into the UUT after TCC ablation with minimal complications or side effects, good preservation of renal function, and with a low recurrences rate comparable to the literature.
Collapse
Affiliation(s)
- Omar M Aboumarzouk
- Wales Deanery, Department Urology, Cardiff, UK and Islamic University of Gaza, College of Medicine, Gaza, Palestine
| | | | | | | | | | | |
Collapse
|
21
|
Park BH, Jeon SS. Endoscopic management of upper urinary tract urothelial carcinoma. Korean J Urol 2013; 54:426-32. [PMID: 23878683 PMCID: PMC3715704 DOI: 10.4111/kju.2013.54.7.426] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 05/27/2013] [Indexed: 11/18/2022] Open
Abstract
Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.
Collapse
Affiliation(s)
- Bong Hee Park
- Department of Urology, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | | |
Collapse
|
22
|
|
23
|
Maurice MJ, Madi R, Chuang DY, Abouassaly R. Retrograde chemoinfusion of the upper tract: standardizing the delivery of topical adjuvant therapy. J Endourol 2012; 27:540-4. [PMID: 23253199 DOI: 10.1089/end.2012.0608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Upper tract urothelial carcinoma has a high recurrence rate after endoscopic treatment. Immediate postoperative topical chemotherapy may reduce recurrences, as in bladder cancer. A reliable delivery method to the upper tract does not exist. We propose a new infusion pump technology for the delivery of topical chemotherapeutic agents to the upper tract. With the patient under general anesthesia, contrast is infused into the upper collecting system using a standard infusion pump. An optimal infusion rate is determined based on fluoroscopic filling of the upper collecting system and transduced intrapelvic pressures. Using this rate, the infusion is repeated postoperatively with the chemotherapeutic agent. We report one case of successful execution to demonstrate proof of concept. We are the first to describe retrograde upper tract chemotherapeutic irrigation with an intravenous pump. This technique may facilitate and standardize the delivery of intracavitary chemotherapy. Further investigation to determine whether it translates into improved safety and/or efficacy is warranted.
Collapse
Affiliation(s)
- Matthew J Maurice
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | | | | | | |
Collapse
|
24
|
Results and outcomes after endoscopic treatment of upper urinary tract carcinoma: the Austrian experience. World J Urol 2012; 31:37-44. [PMID: 23014836 DOI: 10.1007/s00345-012-0948-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 09/07/2012] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Through evolution in technology, endoscopic treatment has gained popularity for the treatment of upper tract urothelial carcinoma (ENDO-UTUC). METHODS A total of 20 patients with ENDO-UTUC were compared to 178 treated by radical nephroureterectomy (RNU) for a pTa-1 UTUC, and a systematic review was performed. RESULTS Mean age for ENDO-UTUC was 71.9 ± 16.0 years, and tumor features were favorable (90 % papillary, 14 low grade, 11 pTa). All ENDO-UTUC were performed ureteroscopically. Mean follow-up was 20.4 ± 30 months. The 5-year overall survival (OS) rate was 45 %. Local (LR) and bladder recurrence (BR) was 25 and 15 %. Time to definitive treatment was longer, ASA higher, LR rates higher, OS lower for ENDO-UTUC (all p < 0.001), but no difference was recorded for BR (p = 0.056) and cancer-specific survival (CSS) (p = 0.364). Postoperative kidney function (KF) was better in the ENDO-UTUC (p = 0.048), though preoperative KF showed no difference. The maximal level of evidence was 3b, patients were highly selected, numbers of patients were low, and ASA scores high. OS was rather low and CSS high. LR rate was high (61 %) and BR rate moderate (39 %) for ureteroscopic and 36 and 28 %, respectively, for percutaneous approach. CONCLUSIONS LR for ENDO-UTUC is high. In high-grade UTUC, oncological outcome is worse. RNU is associated with a significant loss of KF, but LR is rare. ENDO-UTUC is reserved for selected cases if elective. In imperative cases, it has to be balanced between KF, morbidity of the procedure, risk of operation and tumor control. ENDO-UTUC is not necessarily underused in Austria, because of lack in evidence, but 41 % of all RNU were performed in pTa/pTis/pT1 lesions.
Collapse
|
25
|
Adamis S, Varkarakis J. Minimally invasive approach in the management of upper- urinary-tract tumours. ACTA ACUST UNITED AC 2012; 45:381-7. [PMID: 22070534 DOI: 10.3109/00365599.2011.590999] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Nephroureterectomy with bladder cuff excision has been the gold standard treatment for upper tract transitional cell carcinoma (UTTCC) for more than 60 years. However, endoscopic treatment of urothelial tumours of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. MATERIAL AND METHODS A review in the English language of the Medline and Pub Med databases was performed using the keywords upper urinary tract transitional cell carcinoma and endoscopic management. There was a particular emphasis on treatment outcomes from published series. RESULTS Endoscopic treatment of UTTCC alone for high-grade tumours is not advised owing to high rates of both local recurrence and disease progression, while many authors do not recommend primary endoscopic management of UTTCC in elective situations if pathological analysis and tumour grade cannot be obtained. CONCLUSION Endourological management of UTTCC has become an accepted treatment option in highly selected patients, provided long-term close surveillance to detect and treat recurrences is ensured.
Collapse
Affiliation(s)
- Stefanos Adamis
- 2nd Department of Urology, University of Athens, Medical School, Sismanoglion Hospital, Athens, Greece.
| | | |
Collapse
|
26
|
Cutress ML, Stewart GD, Zakikhani P, Phipps S, Thomas BG, Tolley DA. Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int 2012; 110:614-28. [DOI: 10.1111/j.1464-410x.2012.11068.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
27
|
Forster JA, Palit V, Browning AJ, Biyani CS. Endoscopic management of upper tract transitional cell carcinoma. Indian J Urol 2011; 26:177-82. [PMID: 20877592 PMCID: PMC2938538 DOI: 10.4103/0970-1591.65382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The “gold standard” management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.
Collapse
Affiliation(s)
- James A Forster
- Department of Urology, Castle Hill Hospital, Hull and East Yorkshire NHS Trust, Cottingham, East Yorkshire HU16 5JQ, UK
| | | | | | | |
Collapse
|
28
|
Bird VG, Kanagarajah P. Surgical management of upper tract urothelial carcinoma. Indian J Urol 2011; 27:2-9. [PMID: 21716884 PMCID: PMC3114582 DOI: 10.4103/0970-1591.78400] [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] [Indexed: 11/15/2022] Open
Abstract
Upper tract urothelial cell carcinoma accounts for 5% of all urothelial tumors. Compared to lower urinary tract tumors, upper tract urothelial carcinoma is diagnosed more frequently at advanced stages. Open radical nephroureterectomy remains the gold standard treatment option for upper tract tumors. However, with the advancement of minimally invasive techniques and the benefits of these procedures regarding perioperative morbidity, cosmesis, and earlier convalescence, these options have shown promise in managing the patients with upper tract urothelial carcinoma. Despite the perioperative advantages, concerns exist on the oncological safety after minimally invasive surgery. In this article, we provide a comprehensive overview of the surgical management of upper tract urothelial carcinoma.
Collapse
Affiliation(s)
- Vincent G Bird
- Department of Urology, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | | |
Collapse
|
29
|
Irwin BH, Berger AK, Brandina R, Stein R, Desai MM. Complex percutaneous resections for upper-tract urothelial carcinoma. J Endourol 2010; 24:367-70. [PMID: 20218882 DOI: 10.1089/end.2009.0181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Percutaneous endoscopic resection is a viable treatment option for upper-tract urothelial carcinoma (UC) in selected patients. We present our experience with patients who underwent percutaneous resections for complex urothelial tumors. PATIENTS AND METHODS Patients who were undergoing percutaneous treatment for UC were identified within a prospectively maintained database at a single institution. Charts were reviewed to identify complex patients (n = 16) who met the following criteria: (a) tumor size >2.5 cm (n = 8), (b) preoperative creatinine level >3.0 mg/dL (n = 3), or (c) anatomic variant (cystectomy/urinary diversion [n = 2]; autotransplanted kidney [n = 1]; ipsilateral partial nephrectomy [n = 1]; distal ureterectomy [n = 1]). Demographic, operative, and oncologic data were captured. Recurrence-free, cancer-specific, and overall survivals were calculated and compared with a control group of noncomplex cases (n = 23). RESULTS No difference was found in mean age (69.7 +/- 10.8 years vs 69.8 +/- 11.2 years), complication rate (6.3% vs 7.1%), or change in creatinine level (1.53 mg/dL to 1.51 mg/dL vs 1.88 mg/dL to 1.57 mg/dL) between noncomplex and complex cases. The incidences of high-grade tumors (55% vs 71%), invasive tumors (15% vs 20%), solitary kidney (82% vs 92%), contralateral nephroureterectomy (52% vs 60%), and history of bladder cancers (47% vs 38%) were similar between the two groups. Median follow-up was 36 months. No difference was seen in cancer-specific survival (P = 0.98) or recurrence-free survival (P = 0.39). An improved trend in overall survival (P = 0.20) was seen in the noncomplex patients when compared with the complex group. CONCLUSIONS These findings suggest that patients with large tumors, poor renal function, and significant anatomic variations may be well served by endoscopic treatment for upper-tract UC when indicated.
Collapse
Affiliation(s)
- Brian H Irwin
- Steven B. Streem Center for Endourology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | | | | | |
Collapse
|
30
|
Cai G, Liu X, Wu B. Treatment of upper urinary tract urothelial carcinoma. Surg Oncol 2009; 20:43-55. [PMID: 19854042 DOI: 10.1016/j.suronc.2009.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 09/28/2009] [Accepted: 10/02/2009] [Indexed: 11/28/2022]
Abstract
Upper urinary tract urothelial carcinoma (UUTUC) is relatively rare, occurring in only 5% of all urothelial cancers. It has not been as extensively studied and reviewed as carcinoma of the bladder. UUTUC has a propensity for multifocality, local recurrence, and development of metastases, which argues for an aggressive treatment approach. Open radical nephroureterectomy (ORNU) with removal of an ipsilateral bladder cuff still remains the gold standard treatment for patients with UUTUC and a normal contralateral kidney, which, however, is being challenged by minimally invasive approaches, such as endoscopic and laparoscopic approaches. They are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper-tract carcinoma in situ. Chemotherapy and radiotherapy also show some improvement in recurrence rates, but there have been no randomized, prospective trials. Gene and molecular-targeted therapy is expected. Several controversies remain in our management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of immunotherapy, chemotherapy, radiotherapy and genetics and molecular markers in UUTUC. Aims of this paper are to critically review the treatment of UUTUC.
Collapse
Affiliation(s)
- Guiyang Cai
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China
| | | | | |
Collapse
|
31
|
Kaufman DS, McDougal WS, Harisinghani MG, Wu CL. Case records of the Massachusetts General Hospital. Case 30-2009. A 77-year-old man with recurrent transitional-cell carcinoma of the ureter. N Engl J Med 2009; 361:1292-9. [PMID: 19776411 DOI: 10.1056/nejmcpc0900642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Donald S Kaufman
- Hematology-Oncology Division, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, USA
| | | | | | | |
Collapse
|
32
|
Azémar MD, Comperat E, Richard F, Cussenot O, Rouprêt M. Bladder recurrence after surgery for upper urinary tract urothelial cell carcinoma: frequency, risk factors, and surveillance. Urol Oncol 2009; 29:130-6. [PMID: 19762256 DOI: 10.1016/j.urolonc.2009.06.003] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 06/10/2009] [Accepted: 06/11/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To highlight the main risk factors for metachronous bladder recurrence after treatment of an upper urinary tract urothelial cell carcinomas (UUT-UCCs) based on the recent literature. MATERIALS AND METHODS Data on urothelial malignancies after UUT-UCCs management in the literature were searched using MEDLINE and by matching the following key words: urinary tract cancer; bladder carcinomas, urothelial carcinomas, upper urinary tract, renal pelvis, ureter prognosis, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, cystectomy, nephroureterectomy, minimally invasive surgery, recurrence, and survival. RESULTS No evidence level 1 information from prospective randomized trials was available. A range of 15% to 50% of patients with a UUT-UCC will subsequently develop a metachronous bladder UCC. Intraluminal tumor seeding and pan-urothelial field change effect have both been proposed to explain intravesical recurrences. In most cases, bladder cancer arises in the first 2 years after UUT-UCC management. However the risk is lifelong and repeat episodes are common. The identification of variables that allow accurate risk stratification of UUT-UCC patients with regards to future bladder relapse is disappointing. No factors have been identified to date that can reliably predict bladder recurrences. A history of bladder cancer prior to UUT-UCC management and upper tract tumor multifocality are the only frequently reported clinical risk factors among current literature. CONCLUSION Prior histories of bladder cancer and upper tract tumor multifocality are the most frequently reported risk factors for bladder tumors following UUT-UCCs. Surveillance regimen is based on cystoscopy and on urinary cytology for at least 5 years.
Collapse
Affiliation(s)
- Marie-Dominique Azémar
- Department of Urology, Pitié-Salpêtrière and Tenon Hospitals, GHU Est, AP-HP, Faculté de Médecine Pierre et Marie Curie, University Paris VI, Paris, France
| | | | | | | | | |
Collapse
|
33
|
|
34
|
Rastinehad AR, Smith AD. Bacillus Calmette-Guérin for upper tract urothelial cancer: is there a role? J Endourol 2009; 23:563-8. [PMID: 19335155 DOI: 10.1089/end.2008.0164] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Since the first reported case of using adjuvant topical immunotherapy utilizing bacillus Calmette-Guérin (BCG) was published by Herr and associates, several institutions have utilized numerous agents for topical infusion therapies (BCG, Mitomycin, Epirubicin, Thiotepa or combination therapy of BCG/INF) as adjuncts in the treatment of upper tract papillary transitional cell carcinoma. A comprehensive review of the current data in the treatment of upper tract transitional cell carcinoma (Ta/T1 disease) with adjuvant BCG therapy was completed. Currently, the efficacy of adjuvant BCG therapy was not demonstrated.
Collapse
Affiliation(s)
- Ardeshir R Rastinehad
- Department of Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York 11040, USA.
| | | |
Collapse
|
35
|
Lasers in percutaneous renal procedures. World J Urol 2009; 28:135-42. [PMID: 19488759 DOI: 10.1007/s00345-009-0423-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2009] [Accepted: 05/10/2009] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Since the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed. MATERIALS AND METHODS Pubmed was searched for citations since 1966. The following terms were used: "lasers", "calculi", "endopyelotomy", and "transitional cell carcinoma". RESULTS Due to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma. CONCLUSIONS Holmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma.
Collapse
|
36
|
[Primary upper urinary tract tumors and subsequent location in the bladder]. Prog Urol 2009; 19:583-8. [PMID: 19800544 DOI: 10.1016/j.purol.2009.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 03/30/2009] [Indexed: 11/20/2022]
Abstract
The urothelium is the epithelium that lines the upper and lower urinary tract. Over 95% of urothelial carcinomas are derived from urothelium. They can be located in the lower tract (bladder, urethra) or upper tract (pyelocaliceal cavities, ureter). Urothelial carcinomas are the fourth most common tumours after prostate (or breast) cancer, lung cancer and colorectal cancer. On one hand, bladder tumours account for 90-95% of urothelial carcinomas. It is the most common malignancy of the urinary tract and the second most common malignancy of the urogenital tract after prostate cancer. It accounts for 5-10% of all cancers diagnosed each year in Europe. On the other hand, upper urinary tract urothelial cell carcinomas (UUT-UCC) are scarce and account for only 5-10% of urothelial carcinomas. Recurrence in the bladder after primary UUT-UCC occurs in 15-50% of UUT-UCC. Differences in treatment modalities of the primary UUT-UCC do not play a key role in the subsequent appearance of a bladder recurrence. However, others factors have been described such as stage and location in the upper tract of the primary tumour or upper tract tumour multifocality. Previous history of bladder tumour is also associated with the risk that another tumour arises in the bladder subsequently. However, it becomes difficult to distinguish between natural history of bladder tumour and evolution of UUT-UCC in these cases. In most cases, bladder cancer occurs in the first two years after UUT-UCC management. Surveillance protocol is based on cystoscopy and on urinary cytology during at least every three months for two years. Current surveillance regimen have a low level of evidence considering the paucity of UUT-UCC.
Collapse
|
37
|
Are we underutilizing minimally invasive approaches for upper tract urothelial carcinoma? Urol Oncol 2009; 27:75-80. [PMID: 19111803 DOI: 10.1016/j.urolonc.2008.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Accepted: 04/02/2008] [Indexed: 11/21/2022]
Abstract
Endoscopy should be considered a first-line treatment for technically resectable low grade/stage upper tract urothelial carcinoma, even in the presence of a normal contralateral kidney. Endoscopy also should be considered an alternative to nephroureterectomy and end stage renal disease in patients with a solitary kidney or other imperative indications for nephron sparing, even in the presence of high-risk upper tract urothelial carcinoma. In both cases, however, endoscopic management is acceptable only if the patient and the urologist accept the rigorous surveillance regimens and the frequent need for repeated treatments.
Collapse
|
38
|
Endoscopic management of upper tract urothelial carcinoma. Adv Urol 2009:620604. [PMID: 19132098 PMCID: PMC2613442 DOI: 10.1155/2009/620604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 11/03/2008] [Indexed: 11/30/2022] Open
Abstract
Nephroureterectomy is currently the gold standard for management
of upper urinary tract urothelial carcinoma despite it results. This review article
in the loss of a renal unit. The ultimate aim of endoscopic
management of this condition is cancer control whilst preserving
renal function and the integrity of the urinary tract. Endoscopic
treatments of upper tract TCC include the antegrade percutaneous
and retrograde ureteroscopic approaches. This review article
summarizes the endoscopic management of upper tract urothelial
carcinoma, surveillance of the disease after endoscopic management
and adjuvant therapy. The main message regarding endoscopic
management of upper tract urothelial cancer is that patients must
be carefully selected. Patient selection is based on tumour size,
grade, and multifocality. Single low-grade tumours, less than 1.5
cm in size, generally have a good outcome with endoscopic treatment
provided that they have regular ureteroscopic surveillance.
Ureteroscopic treatment of high-grade tumours is essentially
palliative. It is essential that patients are motivated and
compliant as lifetime follow-up is necessary. However, until
large randomized trials with long-term follow-up are performed,
endoscopic management cannot be considered a standard treatment
and should be limited to poor performance status patients.
Collapse
|
39
|
A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy? Urology 2008; 73:27-31. [PMID: 18929398 DOI: 10.1016/j.urology.2008.06.026] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Revised: 05/12/2008] [Accepted: 06/01/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine whether there is an oncologic benefit of adjuvant bacillus Calmette Guérin (BCG) after resection of upper tract transitional cell carcinoma (UTTCC). METHODS A total of 133 renal units (RU) treated by percutaneous resection for UTTCC between 1985 and 2005 were retrospectively analyzed. Forty-four RU were excluded because of carcinoma in situ, high grade/stage, metastatic disease present at initial presentation, and/or the patient could tolerate loss of RU. Eighty-nine RU treated primarily by percutaneous resection were then analyzed. Fifty RU received adjuvant BCG therapy 2 weeks after endoscopic management for a total of 6 courses. Recurrence was defined as a positive biopsy result after the third-look nephroscopy. Progression of disease was assessed at time of recurrence and defined as an increase in grade/stage of disease. RESULTS Mean age (+/- SD) of 89 RU was 70.9 +/- 11.1 years. Overall follow-up was 61.1 + 54.8 months. Grade distribution was 56.2% (50 of 89) and 43.8% (39 of 89) for low- and high-grade disease, respectively. There was no statistical difference with regard to tumor grade or stage between treated and nontreated groups (P > .05). Recurrence, time to recurrence, and progression of disease among RU treated with BCG were subselected by grade and compared with the corresponding nontreated group. Statistical significance between any of the treated and nontreated groups was not demonstrated (P > .05). CONCLUSIONS Our data demonstrate that there is no overall oncologic benefit in the administration of adjuvant BCG with regard to disease recurrence, interval to recurrence, and progression of disease in the treatment of UTTCC.
Collapse
|
40
|
Box GN, Lehman DS, Landman J, Clayman RV. Minimally Invasive Management of Upper Tract Malignancies: Renal Cell and Transitional Cell Carcinoma. Urol Clin North Am 2008; 35:365-83, vii. [DOI: 10.1016/j.ucl.2008.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
41
|
[Endosopic organ-sparing treatment of urothelial tumors of the upper urinary tract: indications and results]. Urologe A 2008; 47:830, 832-7. [PMID: 18560800 DOI: 10.1007/s00120-008-1714-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In addition to radical nephrourterectomy with removal of the bladder cuff, which is still the gold standard in the therapy of urothelial tumors of the upper urinary tract, various percutaneous and transurethral endoscopic methods are now well established for organ-sparing therapies due to technical improvements in endoscopy. Although these were originally only used with selective indications, if radical nephrourterectomy were not coupled with an unreasonable postoperative morbidity (e.g. dialysis-dependence after removal of a tumor-carrying single kidney), organ-sparing therapy attempts are increasingly more recommended, even by extended indications. Analysis of the current literature shows that organ-sparing is strived for, especially with small (<1.5 cm) solitary urothelial tumors with low grade malignancy and without muscle invading growth. Although tumor-specific survival with 69-100% is comparable to nephrourterectomy, organ-sparing treatment appears more inclined to tumor recurrence (relapse rate 23-90%). These data must, however, be interpreted with caution because they originate from retrospective single center studies with low patient numbers, very different patient collectives and mostly relatively short follow-up time periods. Prospective randomized multicenter studies with large patient collectives and long follow-up times are not yet available. After organ-sparing therapy of urothelial tumors of the upper urinary tract, it is important to have life-long follow-up with imaging and endoscopy, in order to initiate an early second therapy in the case of a relapse.
Collapse
|
42
|
Thompson RH, Krambeck AE, Lohse CM, Elliott DS, Patterson DE, Blute ML. Elective endoscopic management of transitional cell carcinoma first diagnosed in the upper urinary tract. BJU Int 2008; 102:1107-10. [PMID: 18522631 DOI: 10.1111/j.1464-410x.2008.07766.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report our experience using ureteroscopic or percutaneous management of upper urinary tract (UUT) transitional cell carcinoma (TCC) in patients with no history of bladder TCC. PATIENTS AND METHODS Between 1983 and 2004 we identified 22 patients who underwent endoscopic management of TCC first diagnosed in the UUT and in the setting of a normal contralateral kidney. We performed a retrospective chart review and conducted outcome analyses. RESULTS The median (range) age at diagnosis was 64 (37-86) years and the median tumour size was 0.8 (0.3-2.6) cm. The tumour grade was 1, 2, or diagnosed as visual low grade in two (9%), seven (32%), and 13 (59%) patients, respectively; no patient had grade 3 TCC at diagnosis. Tumour stage was Ta or visual Ta in all patients. The median follow-up was 4.9 (0.4-17) years during which 11 (50%) patients developed 21 UUT recurrences and 10 (45%) patients developed bladder TCC. At last follow-up, seven (32%) patients required a nephroureterectomy for recurrent TCC and two (9%) patients died from TCC. Among 13 patients with a diagnosis based on visual inspection only, three recurred with grade 3 invasive TCC during follow-up. No patient with pathological confirmation of low-grade/stage TCC recurred with high-grade or invasive TCC. CONCLUSIONS Recurrence is common after endoscopic management of UUT-TCC, underscoring the need for strict surveillance. Patients diagnosed visually, without adequate tissue for pathological examination, can recur with high-grade invasive TCC. No patient with pathological confirmation of low-grade TCC developed progressive disease during follow-up.
Collapse
Affiliation(s)
- R Houston Thompson
- Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
43
|
Tan LB, Chen KT, Guo HR. Clinical and epidemiological features of patients with genitourinary tract tumour in a blackfoot disease endemic area of Taiwan. BJU Int 2008; 102:48-54. [PMID: 18445081 DOI: 10.1111/j.1464-410x.2008.07565.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the clinical and epidemiological characteristics of patients with genitourinary (GU) tract transitional cell carcinoma (TCC) in an endemic area of blackfoot disease (BFD), the arsenic-exposed group, to compare them with characteristics among other non-BFD endemic areas (unexposed group). PATIENTS AND METHODS In all, 474 patients with pathologically diagnosed GU-TCC were enrolled in the study. All follow-up data were prospectively collected and entered into a database throughout the study period. Statistical analysis was used to determine the association between clinical variables and prognosis, and multivariate regression models were used to assess the association between arseniasis and mortality from GU-TCC. RESULTS There were no significant differences between the groups in age, sex, tumour stage and grade. However, the exposed group had a significantly higher proportion of females. The overall 5-year survival rate of patients with upper urinary tract (UUT) TCC was 49%, and the two groups had similar 5-year survival rates. The overall 5-year survival rate of patients with urinary bladder (UB) TCC was 68.3%, and there was a statistically significant difference in survival between the groups, with a 5-year survival rate of 58.7% for the exposed and 72.4% for the unexposed group. For patients with early-stage (pTa and pT1) UB cancers, the death rate was five times higher in exposed patients with tumour progression and recurrence after transurethral resection of bladder tumour than in the unexposed group. CONCLUSIONS There was a significantly higher mortality rate for UB-TCC among exposed patients in the area endemic for arseniasis than in those from other non-endemic areas. The arsenic content of artesian-well water might contribute to the increased ratio of female patients with GU-TCC and the unusually high incidence of UUT-TCC in the BFD endemic area in Taiwan.
Collapse
Affiliation(s)
- Lia-Beng Tan
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | | |
Collapse
|
44
|
Endoscopic Management of Upper Tract Transitional Cell Carcinoma in Patients with Normal Contralateral Kidneys. Urology 2008; 71:713-7. [DOI: 10.1016/j.urology.2007.11.018] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 10/18/2007] [Accepted: 11/08/2007] [Indexed: 11/21/2022]
|
45
|
Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors. Eur Urol 2008; 53:720-31. [PMID: 18207315 DOI: 10.1016/j.eururo.2008.01.006] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Accepted: 01/04/2008] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Open radical nephroureterectomy (O-RNU) has been the gold standard for the treatment of upper urinary tract urothelial carcinoma (UUT-UC) for decades. With the advances in laparoscopic techniques and endourologic procedures, this concept has been increasingly challenged. Oncologic outcome prediction is mainly based on stage and grade. With progress in medical treatment, adjuvant therapies may gain importance in the future. This review assesses the values of the variety of available treatments as well as prognostic factors that may become relevant regarding patient selection for future adjuvant treatment trials. METHODS We performed a systematic literature research using MEDLINE with emphasis on open surgical, laparoscopic, and endourologic (ureteroscopic or percutaneous) techniques and prognostic contents. RESULTS Overall, no evidence level 1 information from prospective randomised trials is available for treatment of UUT-UC. Laparoscopic radical nephroureterectomy (L-RNU) is increasingly challenging open surgery. Currently, L-RNU should be reserved for low-stage, low-grade tumours. Ureteroscopy and percutaneous nephron-sparing techniques show favourable survival data but high local recurrence rates. Regarding prognosis, estimation of outcome still relies mainly on stage and grade because no additional parameters have been introduced in a routine clinical setting. CONCLUSIONS O-RNU still represents the gold standard for the treatment of UUT-UC. The laparoscopic approach is not yet standard of care and should be reserved for low-stage, low-grade tumours. Endourologic nephron-sparing treatments are still experimental in elective indications due to high local recurrence rates. For prognosis, no parameters in addition to stage and grade have been standardised.
Collapse
|
46
|
Sanderson KM, Rouprêt M. Upper urinary tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: an update on the risk factors, surveillance regimens and treatments. BJU Int 2007; 100:11-6. [PMID: 17428248 DOI: 10.1111/j.1464-410x.2007.06841.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Urothelial carcinoma is characterized by multiple, multifocal recurrences throughout the genitourinary tract; approximately 3% of patients treated by radical cystectomy (RC) for invasive transitional cell carcinoma (TCC) of the bladder will subsequently develop a subsequent TCC in the upper urinary tract (UUT) urothelium. Metachronous upper UUT tumours (mUUT-TCC) typically occur as a late oncological event (>3 years after RC). The vast majority of mUUT-TCCs are detected only after the progression to tumour-related symptoms, e.g. haematuria, flank pain or pyelonephritis, despite strict adherence to surveillance protocols. Failure of imaging and cytology to detect most asymptomatic tumours has led to questions about the need for routine UUT surveillance. Some authors have advocated a more tailored approach to surveillance after RC, targeting high-risk patients and with limiting imaging in those patients at lowest risk of developing a subsequent UUT-TCC. mUUT-TCCs are most common in patients with TCC in the ureter or urethra, and with organ-confined bladder cancer. Although the prognosis is generally poor, long-term survival can be achieved in a subset of patients after radical nephroureterectomy (NU). Minimally invasive techniques, e.g. ureteroscopic and percutaneous resection, have been proposed as renal-sparing alternatives to radical surgery for patients with low-stage and -grade de novo UUT-TCC. However, oncological control of renal-sparing therapies in those with high-risk mUUT-TCC remains largely unconfirmed. Until oncological outcomes equivalent to the standard, radical NU, are reported in patients after RC, conservative treatment strategies should be avoided.
Collapse
Affiliation(s)
- Kristin M Sanderson
- Urologic Oncology, Department of Urology, Keck School of Medicine, University of Southern California, USC/Norris Cancer Center, Los Angeles, CA, USA
| | | |
Collapse
|
47
|
Gilligan T, Dreicer R. The atypical urothelial cancer patient: management of bladder cancers of non-transitional cell histology and cancers of the ureters and renal pelvis. Semin Oncol 2007; 34:145-53. [PMID: 17382798 DOI: 10.1053/j.seminoncol.2006.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Non-transitional cell neoplasms of the bladder and upper tract transitional cell carcinomas (ureter and renal pelvis) represent only a small fraction of urothelial carcinomas. Clinicians faced with the rare case are always confronted with management dilemmas complicated by the scarcity of published experience to guide decisions. The current review brings together the best of the limited published data in an attempt to provide some reasonable context to help in the management of these difficult neoplasms.
Collapse
Affiliation(s)
- Timothy Gilligan
- Department of Solid Tumor Oncology, Taussig Cancer Center, and Glickman Urologic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | | |
Collapse
|
48
|
Argyropoulos AN, Tolley DA. Upper urinary tract transitional cell carcinoma: current treatment overview of minimally invasive approaches. BJU Int 2007; 99:982-7. [PMID: 17437430 DOI: 10.1111/j.1464-410x.2007.06870.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
49
|
Steffens J, Humke U, Alloussi S, Ziegler M, Siemer S. Partial nephrectomy and autotransplantation with pyelovesicostomy for renal urothelial carcinoma in solitary kidneys: a clinical update. BJU Int 2007; 99:1020-3. [PMID: 17309555 DOI: 10.1111/j.1464-410x.2007.06753.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the indications and outcomes after partial nephrectomy and renal autotransplantation for urothelial cancer in solitary kidneys, with special attention to the ease of endoscopic tumour control after pyelovesicostomy. PATIENTS AND METHODS In all, 978 records of three institutions were reviewed for patients undergoing partial nephrectomy between January 1990 and December 2000. Ex vivo organ-preserving surgery was used in selected patients with a solitary kidney and localized pelvic or calyceal tumour. Autotransplantation was established using a pyelovesicostomy. The follow-up included ultrasonography, pelvi-cystoscopy, urine cytology, computed tomography, renal functional evaluation and video-urodynamics. The study included four patients aged 52-56 years, with a follow-up of 6-14 years. RESULTS The histopathological status was pT1G2R0 in two and pT1G1R0 in the other two patients. One of them had an additional papilloma in the upper ureter. All patients entered a protocol of mitomycin/bacille Calmette-Guérin instillation therapy after surgery. The patients are currently alive with no recurrences. There is stable kidney function despite vesico-renal reflux, and normal bladder function with no subvesical obstruction. CONCLUSIONS Partial nephrectomy and renal autotransplantation for renal urothelial cancer in solitary kidneys is feasible, but should only be used in the rarest cases, and for the most selective indications. Dialysis and renal replacement can be avoided. Pyelovesicostomy allows effective chemotherapy instillation therapy, and easy and secure urothelial cancer control of the upper urinary tract.
Collapse
Affiliation(s)
- Joachim Steffens
- Department of Urology, St Antonius Hospital, Eschweiler, and University of Saarland, Hombérg/Saar, Germany.
| | | | | | | | | |
Collapse
|
50
|
Abstract
Radical surgery that is intended to cure cancer disease tends to cause some damage to the operated organ and the quality of life of the patient. It is now a worldwide trend to preserve the function and minimize the operative damage to the patient, without compromising the oncological outcome. In urologic cancers, nephron-sparing surgery for kidney tumors, and nerve-sparing procedures in radical cystectomy and radical prostatectomy for retaining potency are now more frequently used for providing better quality of life after surgery. New constructive surgeries such as neobladder formation and nerve graft techniques after complete removal of the cavernous nerve have been developed for recovering the lost function.
Collapse
Affiliation(s)
- Kenichi Tobisu
- Urology Division, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, 411-8777, Shizuoka, Japan.
| |
Collapse
|