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Shah M, Blest F, Blackmur J, Laird A, Dawson S, Aning J. Malignant upper urinary tract obstruction in cancer patients: A systematic review. BJUI COMPASS 2024; 5:405-416. [PMID: 38751956 PMCID: PMC11090775 DOI: 10.1002/bco2.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/05/2024] [Accepted: 02/04/2024] [Indexed: 05/18/2024] Open
Abstract
Objective To systematically summarise the current clinical evidence for de novo malignant upper urinary tract obstruction treatment with a focus on standards of reporting, patient outcomes and future research needs. Methods This review protocol was published via PROSPERO (CRD42022341588). OVID MEDLINE (R), EMBASE, Cochrane Central Register of Controlled Trials-CENTRAL were searched up to June 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Prospective and retrospective studies were included. Results Of 941 articles identified, 82 with 8796 patients were eligible for inclusion.Most studies in the published literature are retrospective and investigate heterogenous malignancies. Percutaneous nephrostomy and ureteric stenting are the most studied interventions. Few studies describe the outcomes from no intervention or investigate patient perspectives. Overall reported median survival after intervention was around 11.7 months. A lack of standardised reporting of outcomes was evident. Conclusions Malignant upper urinary tract obstruction is an important clinical condition affecting patients globally. Overall survival after intervention appears poor however the current evidence base has significant limitations due to studies of low methodological quality and the lack of a standardised framework for reporting outcomes.We have provided a pragmatic framework for future studies based on the review to ensure a uniform methodology is utilised moving forward.
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Affiliation(s)
| | | | - James Blackmur
- Department of UrologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Early Cancer InstituteUniversity of CambridgeCambridgeUK
| | - Alexander Laird
- Department of Urology, Western General HospitalEdinburghUK
- Institute of Genetics and CancerThe University of EdinburghEdinburghUK
| | | | - Jonathan Aning
- Bristol Urological Institute, Southmead HospitalNorth Bristol TrustBristolUK
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
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Tsauo J, Shin JH, Kim GH, Chu HH. A Silicone-Covered Self-Expanding Metal Stent with Anti-migration Features for Treating Malignant Ureteral Obstruction. Cardiovasc Intervent Radiol 2022; 45:1503-1511. [PMID: 35676542 DOI: 10.1007/s00270-022-03174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the effectiveness and safety of the Urexel stent for treating malignant ureteral obstruction (MUO). MATERIALS AND METHODS This retrospective study included 129 patients (mean age: 57.9 ± 11.8 years; men: n = 64, 49.6%; ureteral units [UUs]: N = 175) who underwent Urexel stent placement to treat MUO between March 2013 and April 2021. The Urexel stent is a fully covered self-expanding metal stent. To reduce stent migration, the proximal end of the stent has an additional layer of stent mesh and is flared mildly. RESULTS Eighty-three patients (64.3%) had unilateral MUO (right side: n = 47, 36.4%; left side: n = 36, 27.9%), and 46 patients (35.7%) had bilateral MUO. Successful Urexel stent placement after successful guidewire passage of the obstructed ureteral segment was achieved in 172 UUs, rendering a technical success rate of 98.3%. Stent malfunction occurred in 37 UUs (21.4%) during follow-up, including tumor overgrowth (n = 29), tumor ingrowth (n = 3), stent migration (n = 3), and stent collapse (n = 2). A total of 120 patients (93.0%) died during a median follow-up of 4.1 months (range: 0.2 - 33.5). The median survival of the patients was 4.4 months (interquartile range [IQR] 2.0 - 8.8). The median malfunction-free survival of the patients was 3.6 months (IQR: 1.6 - 7.9). Fifteen grade 3 or higher complications occurred in 14 patients (10.9%), including flank pain (n = 10), gross hematuria (n = 4), and dysuria (n = 1). CONCLUSION Urexel stent placement may be effective and safe for treating MUO.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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3
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Cui H, Zhang K, Gao C, Kang Y, Jiang H. Design and characterization of a novel braided biodegradable
double‐J
ureteral stent. POLYM ADVAN TECHNOL 2022. [DOI: 10.1002/pat.5706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Haipo Cui
- Shanghai Institute for Minimally Invasive Therapy University of Shanghai for Science and Technology Shanghai People's Republic of China
| | - Kui Zhang
- Shanghai Institute for Minimally Invasive Therapy University of Shanghai for Science and Technology Shanghai People's Republic of China
| | - Chenguang Gao
- Shanghai Key Laboratory of Interventional Medical Devices & Equipment, and Research & Engineering Academy of MicroPort Medical Group Co., Ltd Shanghai People's Republic of China
| | - Yahong Kang
- Shanghai Key Laboratory of Interventional Medical Devices & Equipment, and Research & Engineering Academy of MicroPort Medical Group Co., Ltd Shanghai People's Republic of China
| | - Hongyan Jiang
- Shanghai Key Laboratory of Interventional Medical Devices & Equipment, and Research & Engineering Academy of MicroPort Medical Group Co., Ltd Shanghai People's Republic of China
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Janssen P, Tailly T. New Stent Technologies. Urol Clin North Am 2021; 49:185-196. [PMID: 34776051 DOI: 10.1016/j.ucl.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Ureteral stents are an indispensable part of any (endo-) urologic practice. Despite the widely demonstrated advantages of stents, they also carry a considerable risk of side effects and complications, such as urinary symptoms, pain, hematuria, decreased quality of life, stent-related infection, and encrustation. Multiple pathways in preventing or mitigating these side effects and complications and improving stent efficacy have been and are being investigated, including stent architecture and design, biomaterials, and coatings. This article provides an update on currently researched and available stents as well as future perspectives.
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Affiliation(s)
- Pieter Janssen
- Department of Urology, University Hospital Ghent, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Thomas Tailly
- Department of Urology, University Hospital Ghent, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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5
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Chen C, Kim SW, Shin JH, Chu HH, Li HL. Technical Notes on Fluoroscopy-Guided Removal of Metallic Ureteral Stents. J Vasc Interv Radiol 2021; 32:1615-1622. [PMID: 34391931 DOI: 10.1016/j.jvir.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 11/28/2022] Open
Abstract
This manuscript describes various techniques for fluoroscopy-guided removal of metallic ureteral stents. Fifteen patients underwent 17 fluoroscopy-guided removal procedures of 22 metallic ureteral stents. The simple or modified snare or retrieval hook technique was primarily used for antegrade access, whereas the loop snare technique was primarily used for retrograde access. Overall 64.7% of the stents were removed using the initial retrieval technique, and 82.4% were removed using an adjunct technique. Procedure-related complications included hematuria in 41.2% of cases and resolved spontaneously in all patients. Fluoroscopy-guided removal of metallic ureteral stents is safe and effective.
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Affiliation(s)
- Chengshi Chen
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Sung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China; Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea.
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Hai-Liang Li
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
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Comparison of a covered metallic ureteral stent and a double-J stent for malignant ureteral obstruction in advanced gastric cancer. Clin Radiol 2021; 76:519-525. [PMID: 33736879 DOI: 10.1016/j.crad.2021.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 02/11/2021] [Indexed: 11/24/2022]
Abstract
AIM To compare the patency and safety of covered metallic stents (CMS) and the double-J stent (DJS) for treating malignant ureteral obstruction (MUO) in advanced gastric cancer (AGC). MATERIALS AND METHODS Between 2016 and 2018, the medical records of 61 patients (84 ureters; CMS, 39 patients, 54 ureters; DJS, 22 patients, 30 ureters) with MUO caused by AGC were reviewed retrospectively. The Kaplan-Meier method and log-rank test were used to evaluate differences of primary or assisted primary patency between groups. Cox regression was conducted separately for early (within 7 days) and late (after 7 days) primary patency. RESULTS Technical success of CMS placement was 100% (54/54) and 96.8% (29/30) for DJS (p=0.357). The cumulative stent patency rates at 1, 3, 6, and 12 months were 77%, 74%, 70%, and 70%, in the CMS group and 72%, 60%, 53%, and 26%, in the DJS group. Apart from the period within 7 days (p=0.784), primary patency was consistently higher in the CMS group when compared to the DJS group over the entire follow-up period (p=0.034). Assisted primary patency was consistently higher in the CMS group than in the DJS group over the entire follow-up period (p=0.001). The CMS group was more likely to have complications than the DJS group (48.1% versus 16.7%, p=0.004). Complications were minor, self-limiting events such as haematuria/haematoma. CONCLUSION CMS had better late patency and assisted primary patency than DJS. Procedure-related minor complications more frequently occurred with CMS.
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Cao C, Kim JW, Shin JH, Li M, Hong B, Kim YH, Chu HH. Temporary Covered Metallic Ureteral Stent Placement for Ureteral Strictures following Kidney Transplantation: Experience in 8 Patients. J Vasc Interv Radiol 2020; 31:1795-1800. [PMID: 32962854 DOI: 10.1016/j.jvir.2020.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 11/28/2022] Open
Abstract
This brief report presents 8 patients with silicone-covered metallic stent placement for ureteral strictures refractory to double-J stent placement, following kidney transplantation. Stent removal was successfully performed in 7 patients via antegrade (n = 4) or retrograde (n = 3) access 6 weeks to 6 months after stenting for elective removal (6-month interval, n = 3), urothelial hyperplasia (n = 2), or stent migration (n = 2), and their mean primary ureteral patency after stent removal was 15.4 months (range, 2-27 months). Hematuria (n = 2) and pain (n = 3) occurred, but resolved within 1 week. One stent was removed during reconstructive surgery. During follow-up of mean 22.6 months after stent removal, ureteral strictures recurred in 2 patients.
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Affiliation(s)
- Chuanwu Cao
- Department of Radiology, The Tenth People's Hospital, Shanghai, China
| | - Jong-Woo Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olymphic-ro 43 gil 88, Songpa-Gu, Seoul 138-735, Korea
| | - Ji Hoon Shin
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olymphic-ro 43 gil 88, Songpa-Gu, Seoul 138-735, Korea.
| | - Maoqian Li
- Department of Radiology, The Tenth People's Hospital, Shanghai, China
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Olymphic-ro 43 gil 88, Songpa-Gu, Seoul 138-735, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olymphic-ro 43 gil 88, Songpa-Gu, Seoul 138-735, Korea
| | - Hee Ho Chu
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olymphic-ro 43 gil 88, Songpa-Gu, Seoul 138-735, Korea
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Stenting Using the Rendezvous Technique for Postoperative Ureteral Complications in Cancer Patients. Cardiovasc Intervent Radiol 2020; 43:1486-1491. [PMID: 32533310 DOI: 10.1007/s00270-020-02546-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE This study aimed to retrospectively evaluate the safety and efficacy of ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients. MATERIALS AND METHODS From January 2005 to April 2015, 19 patients (2 men and 17 women; median age, 59; range, 42-79 years old) with unilateral ureteral lesions (ureteral leakages in 6, strictures in 4, and both in 9) underwent ureteral stent placement using the rendezvous technique. Percutaneous nephrostomy was performed, and stent placement was attempted via antegrade and retrograde approaches. The technical success, procedure-related complications, and clinical success were retrospectively analyzed. RESULTS The median follow-up period was 29.8 months (range, 0.3-116.5 months). The ureteral stent placement was successful in 17 out of 19 patients (89.5%). Double J ureteral stent was used in 6 patients, and straight catheter as an internal-external nephro-ureteral stent was used in 11 patients. The rendezvous technique was used in the retroperitoneal space and urinary tract in 6 and 11 patients, respectively. No major complications related to the rendezvous technique occurred. Finally, 4 patients achieved stent-free condition (21.1%), and periodic stent exchange was continued in 9 (47.4%). However, permanent external drainage and surgical reconstruction were needed in 4 (21.1%) and 2 (10.5%) patients, respectively. The final clinical success rate was 68.4% (13 out of 19 patients). CONCLUSION Ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients is safe and may be alternative to permanent external drainage and invasive surgical reconstruction. LEVEL OF EVIDENCE Level 4, Case series.
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Choe YH. Characteristics of Recent Articles Published in the Korean Journal of Radiology Based on the Citation Frequency. Korean J Radiol 2020; 21:1284. [PMID: 33236548 PMCID: PMC7689137 DOI: 10.3348/kjr.2020.1322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yeon Hyeon Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- HVSI Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Turgut B, Bayraktar AM, Bakdık S, Hamarat MB, Öncü F, Gönen M, Tolu I. Placement of double-J stent in patients with malignant ureteral obstruction: antegrade or retrograde approach? Clin Radiol 2019; 74:976.e11-976.e17. [PMID: 31506172 DOI: 10.1016/j.crad.2019.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/14/2019] [Indexed: 12/30/2022]
Abstract
AIM To determine whether antegrade or retrograde methods should be preferred for double-J stent placement in patients with malignant ureteral obstruction (MUO). MATERIAL AND METHODS The medical records of patients treated for MUO in the Urology and Interventional Radiology Clinic, Konya Training and Research Hospital, were reviewed retrospectively. Patients with benign aetiology were excluded from the study. Reports of the procedures, ultrasonography findings, computed tomography (CT), angiography, and pyelography images and the follow-up records of patients with MUO were assessed. A total of 111 patients and 114 ureteral stenting treatments were included in the study; 63 (55.3%) were operated on using the antegrade ureteral stenting (AUS) method, whereas 51 (44.7%) were operated on using the retrograde ureteral stenting (RUS), method, and the characteristics of these groups were evaluated. The presence of hydroureteronephrosis and ureteral tortuosity were determined. RESULTS Overall success rates were found to be 95.2% using the AUS method and 47.1% using the RUS method. The technical success of the antegrade method was significantly higher in patients with or without tortuosity (respectively: p=0.005, Z shape p=0.001, pigtail shape p=0.035″). The technical success of the antegrade method was significantly higher in patients with hydroureteronephrosis (p=0.001). CONCLUSION The AUS technique should be the first choice for double-J stent placement in patients with MUO.
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Affiliation(s)
- B Turgut
- Department of Radiology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey.
| | - A M Bayraktar
- Department of Urology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - S Bakdık
- Department of Radiology, University of Necmettin Erbakan Training and Research Hospital, Konya, Turkey
| | - M B Hamarat
- Department of Urology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - F Öncü
- Department of Radiology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - M Gönen
- Department of Urology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - I Tolu
- Department of Radiology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
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Chen Y, Liu CY, Zhang ZH, Xu PC, Chen DG, Fan XH, Ma JC, Xu YP. Malignant ureteral obstruction: experience and comparative analysis of metallic versus ordinary polymer ureteral stents. World J Surg Oncol 2019; 17:74. [PMID: 31039812 PMCID: PMC6492337 DOI: 10.1186/s12957-019-1608-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To study the outcome and experience of using metallic stents in treating patients with malignant ureteral obstruction (MUO). METHODS Seventy-six patients with MUO were assigned to the metallic stent group (MSG) or the ordinary polymer stent group (OPSG) according to the different materials. The success rate of the operation, duration of operation, patency rate serum creatinine values ,postoperative complications and QOL scores were compared between the two groups. RESULTS In the OPSG and MSG, the success rates of the operation were 95.5% and 96.9%, respectively, and the durations of the operation were 20.6 ± 2.2 min and 50.9 ± 10.3 min (P < 0.01), respectively. There was no significant difference between the groups in serum creatinine values at 3 days after the operation (P > 0.05); however, the creatinine values at 3 days after the operation decreased significantly compared with those before the operation (P < 0.01). In the OPSG, there was no significant difference in creatinine values between 3 days and 6 months after operation, while the creatinine values 1 year after operation were increased significantly compared to those at 3 days after the operation (P < 0.05). In the MSG, there was no significant difference among creatinine values at different intervals (P > 0.05). The total rate of post-procedural complication was lower in the MSG than that in the OPSG(P < 0.05). There was no significant difference in the QOL score between the two groups before the operation (P > 0.05); however, the QOL scores at 6 months and 1 year after the operation were higher in the MSG than that in the OPSG(P < 0.05). In the MSG, there was no significant difference in the QOL score between preoperation and 6 months after surgery. Similarly, there was also no difference in the QOL score between 6 months after surgery and 1 year after surgery(P > 0.05). On the contrary, the differences of QOL score in the OPSG group were much significant between disparate time intervals (P < 0.05). CONCLUSIONS For patients with MUO who require long-term retention of the stent, metallic stents with longer indwelling time are superior to ordinary polymeric stents.
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Affiliation(s)
- Yue Chen
- Department of Urology, The Second Hospital of Tianjin Medical University, No.23, Pingjiang Road, Hexi Disctrict, Tianjin, 300211 China
| | - Cheng-yi Liu
- Department of Urology, The Second Hospital of Tianjin Medical University, No.23, Pingjiang Road, Hexi Disctrict, Tianjin, 300211 China
| | - Zhi-hong Zhang
- Department of Urology, The Second Hospital of Tianjin Medical University, No.23, Pingjiang Road, Hexi Disctrict, Tianjin, 300211 China
| | - Peng-cheng Xu
- Department of Urology, Lu’an Affiliated Hospital of Anhui Medical University, Lu’an, 237000 Anhui China
| | - De-gang Chen
- Department of Urology, Lu’an Affiliated Hospital of Anhui Medical University, Lu’an, 237000 Anhui China
| | - Xin-huan Fan
- Department of Urology, Lu’an Affiliated Hospital of Anhui Medical University, Lu’an, 237000 Anhui China
| | - Ji-ci Ma
- Department of Urology, Lu’an Affiliated Hospital of Anhui Medical University, Lu’an, 237000 Anhui China
| | - Yi-peng Xu
- Institute of Urology, Zhejiang Cancer Hospital, Hangzhou, 310000 ZheJiang China
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Choe YH. A Glimpse on Trends and Characteristics of Recent Articles Published in the Korean Journal of Radiology. Korean J Radiol 2019; 20:1555-1561. [PMID: 31854145 PMCID: PMC6923209 DOI: 10.3348/kjr.2019.0928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Yeon Hyeon Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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