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Pathak RA, Hemal AK. Management of the distal ureter and bladder cuff at the time of nephroureterectomy: an overview of open, laparoscopic, and robotic approaches. Transl Androl Urol 2024; 13:109-115. [PMID: 38404548 PMCID: PMC10891381 DOI: 10.21037/tau-23-197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024] Open
Abstract
Radical nephroureterectomy remains the gold standard treatment for high-risk upper tract urothelial carcinoma. The procedure is subdivided into six main steps: nephrectomy, ureterectomy, bladder cuff excision, cystorrhaphy, template-based lymph node dissection, and perioperative instillation of chemotherapy. Crucial in performing radical nephroureterectomy is successful management of the distal ureter and bladder cuff. Improper, inadequate, or incomplete bladder cuff excision can lead to worse oncologic outcomes and inferior cancer-specific survival. Throughout the years, open, laparoscopic, endoscopic, and robotic approaches have all been reported in performing bladder cuff excision during radical nephroureterectomy. The procedure can be accomplished via an extravesical, intravesical or transvesical manner. Each approach has distinct advantages and disadvantages. The robotic approach offers inherent advantages including improved dexterity, range of motion, and visualization. Critical to choosing an approach, however, is surgeon experience and comfort level. To date, no data suggests superiority of one approach over another. Sound oncologic principles must be adhered to when performing radical nephroureterectomy and include (I) adequate bladder cuff excision, (II) lymphadenectomy, (III) no complications and (IV) negative surgical margins, and (V) perioperative instillation of chemotherapeutic agent. Herein, we describe the various approaches in performing a bladder cuff excision and provide technical commentary supporting the advantages and disadvantages of each technique.
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Affiliation(s)
- Ram A. Pathak
- Department of Urology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ashok K. Hemal
- Department of Urology, Wake Forest University, Winston-Salem, NC, USA
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2
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Gallioli A, Baboudjian M, Diana P, Moschini M, Xylinas E, Del Giudice F, Laukhtina E, Soria F, Mari A, Subiela JD, Rouy M, Territo A, Basile G, Palou J, Pradere B, Breda A. Perioperative and oncological outcomes of distal ureter management during nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis. Minerva Urol Nephrol 2023; 75:672-682. [PMID: 38126282 DOI: 10.23736/s2724-6051.23.05448-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The best approach of the bladder cuff (i.e., transvesical, extravesical, endoscopic) during radical nephroureterectomy (RNU) remains an unsolved question. The aim of this review is to compare the oncological and perioperative outcomes among three different approaches of the distal ureter during RNU. EVIDENCE ACQUISITION A literature search was conducted through June 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The primary outcome was bladder recurrence-free survival and secondary outcomes included: perioperative outcomes, metastasis-free survival, and cancer-specific survival. EVIDENCE SYNTHESIS A total of 19 non-randomized studies comprising 6581 patients met our inclusion criteria. The risk of bladder recurrence, metastasis and cancer-related death did not differ significantly between each approach (all P>0.05). In subgroup analysis excluding patients with history of bladder cancer, the risk of bladder recurrence remained similar between each approach (all P>0.05). There was no significant difference in terms of operative time, estimated blood loss, length of hospital stay, and postoperative complications between each approach (all P>0.05). The main limitation is the retrospective design of 18/19 included studies. CONCLUSIONS The present systematic review and meta-analysis highlights the lack of high-level evidence on distal ureter management during RNU. On the basis of the available data, the present review supports the equivalence of different techniques of bladder cuff excision during RNU. The extravesical approach seems non-inferior to the transvesical approach in terms of oncological and perioperative outcomes.
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Affiliation(s)
- Andrea Gallioli
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Michael Baboudjian
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
- Department of Urology, APHM, North Academic Hospital, Marseille, France
- Department of Urology, APHM, La Conception Hospital, Marseille, France
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - Pietro Diana
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Marco Moschini
- Department of Urology, Urological Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital Paris Descartes University, Paris, France
| | - Francesco Del Giudice
- Department of Maternal Infant and Urologic Sciences, Sapienza University, Umberto I Polyclinic Hospital, Rome, Italy
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Francesco Soria
- Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, Turin, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | - Angelo Territo
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Giuseppe Basile
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain -
- Department of Urology, Urological Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - Joan Palou
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Benjamin Pradere
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alberto Breda
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
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Oshina T, Taguchi S, Miyakawa J, Akiyama Y, Sato Y, Kawai T, Fukuhara H, Nakagawa T, Kume H. Clinicopathological features and oncological outcomes of urothelial carcinoma involving the ureterovesical junction. Jpn J Clin Oncol 2022; 52:65-72. [PMID: 34510192 DOI: 10.1093/jjco/hyab143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The ureterovesical junction is the boundary between the urinary bladder and upper urinary tract. Because treatment strategies for bladder cancer and upper tract urothelial carcinoma are entirely different, urothelial carcinoma involving the ureterovesical junction requires special attention. Nevertheless, studies focusing on the disease are lacking. METHODS We reviewed consecutive patients with urothelial carcinoma treated via either transurethral resection of bladder tumor (n = 2791) or radical nephroureterectomy (n = 292) between 2000 and 2020 and identified those with bladder cancer involving the ureteral orifice (n = 64) and those with upper tract urothelial carcinoma involving the intramural ureter (≤2 cm) (n = 41). After excluding overlapping cases (n = 24), 80 patients with urothelial carcinoma involving the ureterovesical junction were analyzed. RESULTS The initial symptoms or reasons for diagnosing urothelial carcinoma involving the ureterovesical junction were hematuria (n = 30), hydronephrosis (n = 21), follow-up examinations for prior urothelial carcinoma (n = 13), screening examinations (n = 7), frequent urination (n = 6) and unknown causes (n = 3). During a median follow-up period of 42 months, 18 patients died of urothelial carcinoma. The definitive surgical treatments for urothelial carcinoma involving the ureterovesical junction were transurethral resection of bladder tumor alone (n = 26), radical nephroureterectomy (n = 41) and radical cystectomy (n = 13), with different treatments having different cancer-specific survivals. Multivariate analyses identified T stage (≥T2) as an independent predictor of shorter cancer-specific survival. CONCLUSIONS Given the positional property of urothelial carcinoma involving the ureterovesical junction, the profiles of patients with the disease were highly heterogeneous. Further optimization of treatment strategies for urothelial carcinoma involving the ureterovesical junction is urgently warranted for better clinical outcomes.
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Affiliation(s)
- Takahiro Oshina
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Taguchi
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jimpei Miyakawa
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiyuki Akiyama
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yusuke Sato
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taketo Kawai
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Fukuhara
- Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tohru Nakagawa
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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4
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Chung JH, Song W, Kang M, Jeon HG, Jeong BC, Seo SI, Jeon SS, Lee HM, Sung HH. Conditional Intravesical Recurrence-Free Survival Rate After Radical Nephroureterectomy With Bladder Cuff Excision for Upper Tract Urothelial Carcinoma. Front Oncol 2021; 11:730114. [PMID: 34692504 PMCID: PMC8529179 DOI: 10.3389/fonc.2021.730114] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/16/2021] [Indexed: 11/28/2022] Open
Abstract
Background To evaluate the conditional intravesical recurrence (IVR)–free (IVRF) survival rate in patients with upper tract urothelial carcinoma (UTUC) who had no history of bladder cancer and no concomitant bladder cancer. Hence, we aimed to analyze a relatively large number of patients with UTUC who underwent radical nephroureterectomy with bladder cuff excision (RNUx). Methods We retrospectively analyzed the data of 1,095 patients with UTUC who underwent RNUx. Their baseline characteristics, bladder tumor history, and UTUC features were analyzed to evaluate oncological outcomes. To determine the factors affecting IVR, surgical modality, use of preoperative ureteroscopy, TNM stage, and pathological outcomes were evaluated. Multivariable Cox regression analyses were performed to evaluate the factors affecting IVR. Conditional IVRF survival rate was analyzed using Kaplan–Meier curves. Results Among the 1,095 patients, 462 patients developed IVR, and the mean time to the development of IVR was 13.08 ± 0.84 months after RNUx. A total of 30.74% of patients with IVR and 15.32% of those without IVR had a history of bladder cancer (p < 0.001). Multivariable analysis showed that a history of bladder cancer, multifocal tumors, use of preoperative ureteroscopy, extravesical bladder cuffing method, lymph node involvement, positive surgical margins, and use of adjuvant chemotherapy were determined to be risk factors for IVR. The conditional IVRF rate was 74.0% at 12 months after RNUx, 87.1% at 24 months after RNUx, 93.6% at 36 months after RNUx, and 97.3% at 60 months after RNUx. The median IVRF survival period was 133.00 months for all patients. In patients with IVRF at 24 months after RNUx, only ureteroscopy was an independent risk factor for IVR [hazard ratio (HR) 1.945, p = 0.040]. In patients with IVRF at ≥36 months, there was no significant factor affecting IVR. Conclusions Active IVR assessment is required until 36 months after RNUx. In addition, patient education and regular screening tests, such as urine analysis and cytology, are required for patients with IVRF for ≥36 months.
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Affiliation(s)
- Jae Hoon Chung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wan Song
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Minyong Kang
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hwang Gyun Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Hwan Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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5
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König F, Shariat SF, Karakiewicz PI, Mun DH, Rink M, Pradere B. Quality indicators for the management of high-risk upper tract urothelial carcinoma requiring radical nephroureterectomy. Curr Opin Urol 2021; 31:291-296. [PMID: 33973537 DOI: 10.1097/mou.0000000000000895] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article was to identify quality indicators for an optimized management of high-risk upper tract urothelial carcinoma (UTUC) requiring radical nephroureterectomy (RNU). RECENT FINDINGS RNU with bladder cuff resection is the standard treatment of high-risk UTUC. For the bladder cuff resection, two main approaches are accepted: transvesical and extravesical. Lymph node dissection following a dedicated template should be performed in all high-risk patients undergoing RNU as it improves tumour staging and possibly survival. Postoperative bladder instillation of single-dose chemotherapy should be administered after RNU to decrease the risk of intravesical tumour recurrence. Perioperative systemic chemotherapy should always be considered for advanced cancers. Although level-1 evidence is available for adjuvant platinum-based chemotherapy, neoadjuvant regimens are still being evaluated. SUMMARY Optimal management of high-risk UTUC requires evidence-based reproducible quality indicators in order to allow guidance and frameworks for clinical practices. Adherence to quality indicators allows for the measurement and comparison of outcomes that are likely to improve prognosis. Based on the literature, we found four evidence-based accepted quality indicators that are easily implementable to improve the management of high-risk UTUC patients treated with RNU: adequate management of the distal ureter/ bladder cuff, template-based lymph node dissection, single-shot postoperative intravesical chemotherapy, and perioperative systemic treatment.
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Affiliation(s)
- Frederik König
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, New York
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada
| | - Dong-Ho Mun
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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6
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Ryoo H, Kim J, Kim T, Kang M, Jeon HG, Jeong BC, Seo SI, Jeon SS, Lee HM, Sung HH. Effects of Complete Bladder Cuff Removal on Oncological Outcomes Following Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. Cancer Res Treat 2020; 53:795-802. [PMID: 33421984 PMCID: PMC8291174 DOI: 10.4143/crt.2020.919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/25/2020] [Indexed: 01/19/2023] Open
Abstract
Purpose This study aimed to evaluate the effects of bladder cuff method on oncological outcomes in patients who underwent radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. Materials and Methods The records of 1,095 patients treated with RNU performed at our hospital between 1994 and 2018 were retrospectively reviewed; 856 patients with no bladder tumor history were enrolled in the present study. The management of bladder cuff was divided into two categories: extravesical ligation (EL) or transvesical resection (TR). Survival was analyzed using the Kaplan-Meier method and Cox regression analyses were performed to determine which factors were associated with intravesical recurrence (IVR)–free survival (IVRFS), cancer-specific survival (CSS), and overall survival (OS). Results The mean patient age was 64.8 years and the median follow-up was 37.7 months. Among the 865 patients, 477 (55.7%) underwent the TR and 379 (44.3%) the EL. Significantly higher IVRFS (p=0.001) and OS (p=0.013) were observed in the TR group. In multivariable analysis, IVR, CSS, and OS were independently associated with the EL. Among 379 patients treated with the EL, eight underwent remnant ureterectomy. Based on radical cystectomy–free survival, significant difference was not observed between the two groups. However, significantly higher IVRFS was observed in the TR group when the tumor was located in the renal pelvis. Conclusion Intramural complete excision of the distal ureter during RNU should be the gold standard approach compared with EL for the management of distal ureter in terms of oncological outcomes.
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Affiliation(s)
- Hyunsoo Ryoo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jungyu Kim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taejin Kim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minyong Kang
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hwang Gyun Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Hwan Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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7
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Hoe V, Yao HH, Crozier J, Kanagarajah A, Florescu G, Kearsley J, Dundee P, O'Connell HE, Lawrentschuk N, Agarwal DK. Long-term oncological outcomes of the Agarwal loop-ligation technique for management of the distal ureter during laparoscopic radical nephroureterectomy. BJU Int 2020; 128:112-121. [PMID: 33305469 DOI: 10.1111/bju.15321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the Agarwal loop-ligation technique for the management of the distal ureter during laparoscopic radical nephroureterectomy (LRNU) for upper tract urothelial carcinoma (UTUC) and report on long-term oncological outcomes. PATIENTS AND METHODS In the Agarwal loop-ligation technique, the distal ureteric stump is controlled using endoscopic Endoloop® or PolyLoop® ligation to ensure en bloc excision of the bladder cuff and prevent spillage of upper tract urine into the perivesical space. A retrospective review of the medical records of 76 patients who underwent the Agarwal loop-ligation technique for UTUC at participating centres from July 2004 to December 2017 was performed. Data collected included demographics, perioperative, and long-term oncological outcomes. Survival was calculated using Kaplan-Meier survival analyses. RESULTS AND LIMITATIONS A total of 76 patients were included. The median age was 71.5 years and median operative time was 4.3 h. The intramural ureter and bladder cuff were completely excised in all patients. Distal surgical margins were clear in all, with only two patients found to have tumour extending to the circumferential surgical margin. There were no cases of perivesical recurrence or port-site metastasis. The 5-year bladder, local, and contralateral recurrence-free survival was 59.6%, 89.0% and 93.5%, respectively. Metastasis-free survival at 5-years was 73.5%. The 5-year overall survival and cancer-specific survival rates were 70.3% and 84.7%, respectively. CONCLUSIONS We have described the Agarwal loop-ligation technique for the management of the distal ureter in LRNU. This technique complies with oncological principles outlined in the European Association of Urology guidelines, which minimises tumour spillage. Long-term oncological outcomes are satisfactory, with no cases of perivesical recurrence detected in this series.
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Affiliation(s)
- Venetia Hoe
- Department of Urology, Western Health, Melbourne, Vic., Australia.,University of Melbourne, Parkville, Vic., Australia
| | - Henry H Yao
- Department of Urology, Western Health, Melbourne, Vic., Australia
| | - Jack Crozier
- Department of Urology, Western Health, Melbourne, Vic., Australia
| | - Abbie Kanagarajah
- Department of Urology, Western Health, Melbourne, Vic., Australia.,University of Melbourne, Parkville, Vic., Australia
| | - Grace Florescu
- Department of Urology, The Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Jamie Kearsley
- Department of Urology, The Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Philip Dundee
- Department of Urology, The Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Helen E O'Connell
- Department of Urology, Western Health, Melbourne, Vic., Australia.,University of Melbourne, Parkville, Vic., Australia
| | - Nathan Lawrentschuk
- University of Melbourne, Parkville, Vic., Australia.,Department of Urology, The Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Dinesh K Agarwal
- Department of Urology, Western Health, Melbourne, Vic., Australia.,Department of Urology, The Royal Melbourne Hospital, Melbourne, Vic., Australia
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8
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Barton GJ, Tan WP, Inman BA. The nephroureterectomy: a review of technique and current controversies. Transl Androl Urol 2020; 9:3168-3190. [PMID: 33457289 PMCID: PMC7807352 DOI: 10.21037/tau.2019.12.07] [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: 12/03/2022] Open
Abstract
The nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.
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Affiliation(s)
- Gregory J Barton
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Wei Phin Tan
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Brant A Inman
- Division of Urology, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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9
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Lai SC, Wu PJ, Liu JY, Seery S, Liu SJ, Long XB, Liu M, Wang JY. Oncological impact of different distal ureter managements during radical nephroureterectomy for primary upper urinary tract urothelial carcinoma. World J Clin Cases 2020; 8:5104-5115. [PMID: 33269247 PMCID: PMC7674733 DOI: 10.12998/wjcc.v8.i21.5104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The current standard surgical treatment for non-metastatic upper urinary tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU) with bladder cuff excision (BCE). Typically, BCE techniques are classified in one of the following three categories: An open technique described as intrasvesical incision of the bladder cuff, a transurethral incision of the bladder cuff (TUBC), and an extravesical incision of the bladder cuff (EVBC) method. Even though each of these management techniques are widely used, there is no consensus about which surgical intervention is superior, with the best oncologic outcomes.
AIM To investigate the oncological outcomes of three BCE methods during RNU for primary UTUC patients.
METHODS We retrospectively analyzed the data of 248 primary UTUC patients, who underwent RNU with BCE between January 2004 to December 2018. Patients were analyzed according to each BCE method. Data extracted included patient demographics, perioperative parameters, and oncological outcomes. Statistical analyses were performed using chi-square and log-rank tests. The Cox proportional hazards regression model was utilized to identify independent predictors. P < 0.05 was considered statistically significant.
RESULTS Of the 248 participants, 39.9% (n = 99) underwent intrasvesical incision of the bladder cuff, 38.7% (n = 96) EVBC, and 21.4% (n = 53) TUBC. At a median follow-up of 44.2 mo, bladder recurrence developed in 17.2%, 12.5%, and 13.2% of the cases, respectively. Cancer-specific deaths occurred in 11.1%, 5.2%, and 7.5% of patients, respectively. Kaplan-Meier survival curves with a log-rank test highlighted no significant differences in intravesical recurrence-free survival, cancer-specific survival, and overall survival among these approaches with P values of 0.987, 0.825, and 0.497, respectively. Multivariate analysis showed that the lower ureter location appears to have inferior intravesical recurrence-free survival (P = 0.042). However, cancer-specific survival and overall survival were independently influenced by tumor stage (hazard ratio [HR] = 8.439; 95% confidence interval: 2.424-29.377; P = 0.001) and lymph node status (HR = 14.343; 95%CI: 5.176-39.745; P < 0.001).
CONCLUSION All three techniques had comparable outcomes; although, EVBC and TUBC are minimally invasive. While based upon rather limited data, these findings will support urologists in blending experience with evidence to inform patient choices. However, larger, rigorously designed, multicenter studies with long term outcomes are still required.
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Affiliation(s)
- Shi-Cong Lai
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Peng-Jie Wu
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jian-Yong Liu
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Samuel Seery
- School of Humanities and Social Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Sheng-Jie Liu
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xing-Bo Long
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ming Liu
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jian-Ye Wang
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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Kwon SY, Ko YH, Song PH, Kim BH, Kim BS, Kim TH. The Remaining Ipsilateral Ureteral Orifice Provokes Intravesical Tumor Recurrence After Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multicenter Study With a Mid-Term Follow-Up. Urology 2020; 145:166-171. [DOI: 10.1016/j.urology.2020.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
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11
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Braun AE, Srivastava A, Maffucci F, Kutikov A. Controversies in management of the bladder cuff at nephroureterectomy. Transl Androl Urol 2020; 9:1868-1880. [PMID: 32944551 PMCID: PMC7475677 DOI: 10.21037/tau.2020.01.17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Upper tract urothelial carcinoma (UTUC) accounts for roughly 5% of urothelial carcinomas. Historically, the gold standard for high-risk or bulky low-risk UTUC was an open radical nephroureterectomy with formal bladder cuff excision (BCE). The development of novel endoscopic, laparoscopic, and robotic techniques has transformed this operation, yet no level I evidence exists at present that demonstrates the superiority of one strategy over another. While new approaches to nephroureterectomy in the last decade have shifted the management paradigm to decrease the morbidity of surgery, controversy continues to surround the approach to the distal ureter and bladder cuff. Debate continues within the urologic community over which surgical approach is best when managing UTUC and how various approaches impact clinical outcomes such as intravesical recurrence, recurrence-free survival (RFS) and disease-specific mortality (DSM). When focusing on the existing treatment algorithm, key metrics of quality include (I) removal of the entire specimen en bloc, (II) minimizing the risk of tumor and urine spillage, (III) R0 resection, and (IV) water-tight closure allowing for early use of prophylactic intravesical chemotherapy. In the absence of robust evidence demonstrating a single superior approach, the urologic surgeon should base decisions on technical comfort and each patient's particular clinical circumstance.
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Affiliation(s)
- Avery E Braun
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Abhishek Srivastava
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Fenizia Maffucci
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
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Whiting D, Sriprasad S. Management of the Distal Ureter in Radical Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma. J Laparoendosc Adv Surg Tech A 2020; 31:610-620. [PMID: 32716832 DOI: 10.1089/lap.2020.0420] [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: 11/13/2022] Open
Abstract
Introduction: Management of the distal ureter during laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC) is controversial. The aim of this review was to determine whether this affects oncological outcomes. Methods: A literature review was conducted searching MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials in June 2019. Studies reporting outcomes of LNU in UTUC using either open, laparoscopic, or endoscopic approaches to excise the distal ureter were identified. All eligible studies underwent critical appraisal and were excluded if not of sufficient quality. Cumulative analysis of the results was performed. Results: Nine studies with a total of 383 patients (168 open, 159 laparoscopic, and 56 endoscopic excision of distal ureter) were eligible for inclusion. Study design and outcome reporting were variable between studies. Mean age of patients was comparable (67.7 years versus 65.0 years versus 66.6 years). Mean follow-up duration was comparable between open and laparoscopic groups (46.2 months versus 45.5 months) but reduced in the endoscopic group (33.4 months). The open group had a higher proportion of high grade/G3 tumors and pT2-4 tumors when compared to the laparoscopic and endoscopic groups (P < .001 and P = .002). The open group had a higher rate of intravesical recurrence and the laparoscopic group had a higher rate of distant metastases (P < .001). Conclusion: This review has identified differences in oncological outcomes between different techniques of managing the distal ureter in LNU for UTUC. However, the poor reporting of potentially confounding factors does not enable any one technique to be recommended as superior and requires further research.
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Affiliation(s)
- Danielle Whiting
- Department of Urology, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, United Kingdom
| | - Seshadri Sriprasad
- Department of Urology, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, United Kingdom
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13
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Pathak RA, Hemal AK. Fate of residual ureteral stump in patients undergoing robot-assisted radical nephroureterectomy for high-risk upper tract urothelial carcinoma. Transl Androl Urol 2020; 9:856-862. [PMID: 32420200 PMCID: PMC7214963 DOI: 10.21037/tau.2019.09.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Management of the distal ureter in radical nephroureterectomy and bladder cuff excision (RNUBCE) is paramount, directly influencing oncologic outcomes. Herein, we analyze the natural history of patients who have undergone robotic radical nephroureterectomy without formal bladder cuff excision and retained ureteral stump and compare this cohort with patients undergoing formal RNUBCE for high-risk upper tract urothelial carcinoma (UTUC). Methods From February 2008 to October 2018, all patients who underwent robotic RNUBCE by multiple surgeons in a single institution for high-risk UTUC were reviewed. Preoperative, perioperative, and postoperative variables were investigated. Overall survival, cancer specific survival, local recurrence-free survival, distant recurrence-free survival, and bladder recurrence-free survival were compared between the two cohorts. Further management treatments were explored for patients with retained ureteral stump. Follow-up consisted of abdominopelvic/chest imaging and cystoscopy at regular intervals. Results A total of 105 patients underwent robotic RNU during the above time period. Of patients with documented 6-month follow-up, approximately 6.6% of patients had retained ureteral stump. Median follow-up for the entire cohort was 31.5 months with a range of 6 to 114.2 months. Factors that precluded formal BCE were densely, fibrotic reaction near the ureterovesical junction due to prior vascular or pelvic surgery in 5 patients, severe pyonephrosis and continued anesthetic risk in one patient, and surgeon choice (patient co-morbidities) in another patient. Three patients died with metastatic disease and one patient succumbed to cardiovascular compromise. Two additional patients developed local recurrence only at the level of the ureteral stump, with one patient undergoing eventual distal excision, contralateral RNUBCE and radical cystectomy. Conclusions In these cases, responsibilities assumed by the surgeon demand the utmost in judgement and skill; however, at times, circumstances prevail such as patient factors and nature/biology of the disease. These factors may prevent adequate excision the complete ureter, ureterovesical junction, and bladder cuff at the time of RNU. In this robotic cohort of patients undergoing RNUBCE for UTUC, not excising the most distal part of the ureter directly translates to inferior oncologic outcomes. Complete ureteral excision with bladder cuff should be performed where possible as this is an integral part of the radical nephroureterectomy. Also, if feasible, adjunctive chemotherapy/immunotherapy treatments should be considered.
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Affiliation(s)
- Ram A Pathak
- Wake Forest University Baptist Medical Center, 1 Medical Center BLVD, Winston-Salem, NC 27157, USA
| | - Ashok K Hemal
- Wake Forest University Baptist Medical Center, 1 Medical Center BLVD, Winston-Salem, NC 27157, USA
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Assessing the impact of different distal ureter management techniques during radical nephroureterectomy for primary upper urinary tract urothelial carcinoma on oncological outcomes: A systematic review and meta-analysis. Int J Surg 2020; 75:165-173. [PMID: 31978650 DOI: 10.1016/j.ijsu.2020.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the oncological outcomes of several distal ureter management techniques in patients administered with radical nephroureterectomy (RNU) for primary upper urinary tract urothelial carcinoma (UTUC). METHODS A systematic search of PubMed, EMBASE, and the Cochrane Library was conducted to identify studies comparing outcomes following RNU under various surgical methods for bladder cuff management. Standard cumulative analyses of hazard ratios (HRs) with 95% confidence intervals (CIs) were performed using Review Manager (5.3). RESULTS Nine studies involving 4683 patients were selected based upon eligibility criteria. Meta-analysis of cancer-specific survival (CSS) and overall survival (OS) revealed no significant differences among intravesical incision of the bladder cuff (IVBC), extravesical incision of the bladder cuff (EVBC) and transurethral incision of the bladder cuff (TUBC) techniques. However, the IVBC technique appeared to have better recurrence-free survival (RFS) (HR = 1.37, p < 0.01) and intravesical recurrence-free survival (IRFS) (HR = 1.45, p < 0.01) compared with non-IVBC methods, including both TUBC and EVBC. When studies involving patients with bladder tumour history were excluded, the pooled statistic appeared to confirm that IVBC was associated with improved IRFS (HR = 1.25, p = 0.03) compared with EVBC and TUBC. No significant difference was found between the EVBC and TUBC groups (HR = 1.81, p = 0.32). CONCLUSIONS The findings suggest that IVBC is associated with improved oncologic outcomes and that it may be recommended for distal ureter management. However, caution must be taken because this recommendation is based upon a very limited number of clinical studies. Further research with enhanced outcome data collection and improved reporting is required to confirm these findings.
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15
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Lee SM, McKay A, Grimes N, Umez-Eronini N, Aboumarzouk OM. Distal Ureter Management During Nephroureterectomy: Evidence from a Systematic Review and Cumulative Analysis. J Endourol 2019; 33:263-273. [PMID: 30793934 DOI: 10.1089/end.2018.0819] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Standard of care in upper tract urothelial cancer is nephroureterectomy with bladder cuff excision (BCE). However, alternative techniques such as transurethral incision/resection have been used to simplify distal ureterectomy. The optimum strategy is unclear, and current guidelines do not specify a gold standard technique. The objective of this study was to perform a systematic review of the literature, to compare BCE and transurethral distal ureter methods. MATERIALS AND METHODS A Cochrane and PRISMA-guided systematic literature search was conducted on English language articles from January 2000 to present, reporting on centers' experience with either BCE or transurethral distal ureterectomy. A cumulative meta-analysis comparison between the two procedures was performed. Primary outcome was intravesical recurrence. Secondary outcomes were local/distant recurrence, surgical margins, and disease-specific mortality (DSM). Groups were compared using chi-square analysis. RESULTS In total, 66 studies were included after excluding 1795. BCE and transurethral groups contained 6130 and 1183 patients, respectively. Mean/median age ranged from 57.5 to 75.2 years, and follow-up from 6.1 to 78 months. Level of evidence was low, with high risk of bias and small sample size (<100 patients) in 41 (62%) and 52 (79%) studies, respectively. Baseline cancer demographic analysis identified significantly higher rates of high grade, advanced stage, node-positive and carcinoma in situ disease in the BCE group. However, intravesical recurrence (23.6% vs 28.7%, p = 0.0002) and local/distant recurrence (17.9% vs 21.6%, p = 0.02) were significantly lower than the transurethral group. No difference was seen regarding surgical margins (3.1% vs 2.4%, p = 0.27) or DSM (16.8% vs 14.3%, p = 0.06). CONCLUSIONS No prospective, randomized comparisons exist for distal ureterectomy at nephroureterectomy. In this analysis, patients undergoing BCE had more advanced disease burden compared with the transurethral group. Despite this, the BCE group had statistically lower intravesical and local/distant recurrence. Further prospective research should be encouraged to identify gold standard ureter management.
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Affiliation(s)
- Su-Min Lee
- 1 Bristol Urological Institute, Southmead Hospital, Bristol, United Kingdom
| | - Alistair McKay
- 2 Glasgow Urological Research Unit, Department of Urology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Nathan Grimes
- 2 Glasgow Urological Research Unit, Department of Urology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Nkem Umez-Eronini
- 2 Glasgow Urological Research Unit, Department of Urology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Omar M Aboumarzouk
- 2 Glasgow Urological Research Unit, Department of Urology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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16
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Kao YL, Lin YC, Ou CH, Yang WH. How safe could open extravesical bladder cuff resection guarantee complete removal of ipsilateral ureteral orifice? UROLOGICAL SCIENCE 2019. [DOI: 10.4103/uros.uros_40_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Baldissera Aradas JV, Rodríguez Villamil L, Fernández-Pello Montes S, Gil Ugarteburu R, Mosquera Madera J. Laparoscopic nephroureterectomy with laser endoscopic transuretral disinsertion in lateral decubitus: progressive adaptation to retroperitoneocopic approach. Actas Urol Esp 2018; 42:649-658. [PMID: 29576194 DOI: 10.1016/j.acuro.2018.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The ureteral disinsertion with bladder cuff technique continues to evolve. We present the endoscopic laser transurethral technique combined with a transperitoneal and retroperitoneal laparoscopic approach in lateral decubitus, without patient repositioning, for treating urothelial carcinomas of the upper urinary tract. MATERIALS AND METHODS We present 3 laparoscopic nephroureterectomies: 1 transperitoneal and 2 retroperitoneal. Disinsertion was performed in lateral decubitus using a flexible cystoscope and a 365-μm holmium laser fiber. The endoscopic technique was progressively adapted to 3-port and single-port retroperitoneoscopic approaches. Before laparoscopic handling of the kidney, ureter was clamped below the tumour. The endoscopic technique was then started. Both approaches were simultaneously employed. RESULTS Nephroureterectomies were achieved performing en bloc endoscopic disinsertion of the bladder cuff and ensuring a closed system comparable to open technique. The second case required reconversion due to technical problems and extension of the surgical time. No relapses were diagnosed during follow-up. CONCLUSION Results are comparable to open surgery, technique ensured compliance to oncology principles, enabled disinsertion in lateral decubitus and avoid patient repositioning saving surgical time. The results reflect the benefits of minimally invasive surgery in all cases.
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Affiliation(s)
| | - L Rodríguez Villamil
- Servicio de Urología, Hospital Universitario de Cabueñes, Gijón, Asturias, España
| | | | - R Gil Ugarteburu
- Servicio de Urología, Hospital Universitario de Cabueñes, Gijón, Asturias, España
| | - J Mosquera Madera
- Servicio de Urología, Hospital Universitario de Cabueñes, Gijón, Asturias, España
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Aragón Chamizo J, Herranz Amo F, Hernández Fernández C, González Enguita C. Prognostic factors for vesical relapse in patients with upper urothelium tumours treated with surgery. Actas Urol Esp 2017; 41:571-576. [PMID: 28258788 DOI: 10.1016/j.acuro.2017.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify the prognostic factors for vesical relapse in patients with tumours of the upper urothelium treated with surgery. MATERIAL AND METHODS We conducted a retrospective analysis of patients with tumours of the upper urothelium who underwent surgery between 1999 and 2011 at our centre (139 patients). We collected demographic, clinical, diagnostic and pathological variables, as well as the treatment, complications and progression. A descriptive analysis was performed using the chi-squared test for categorical variables and the ANOVA test for continuous variables. We also performed a univariate and multivariate analysis using the Cox proportional hazards model. Statistical significance was considered when P<.05. All calculations were performed with SPSS Statistics version 21. RESULTS During the follow-up, 26.6% of the patients (37 cases) showed vesical relapse. Some 19.6% of the patients with no history of bladder tumours showed a bladder tumour relapse compared with 48.6% of the patients with a history of bladder tumours (P<.001). In the multivariate analysis, only the presence of bladder tumours prior to or concomitant with the upper urinary tract tumour diagnosis was identified as an independent predictor of bladder tumour relapse (P=.007). CONCLUSION In our series, only the presence of a prior or synchronous bladder tumour behaved as an independent predictor of bladder tumour relapse in patients with tumours of the upper urothelium treated with surgery.
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Affiliation(s)
- J Aragón Chamizo
- Hospital General Universitario Gregorio Marañón, Madrid, España; Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
| | - F Herranz Amo
- Hospital General Universitario Gregorio Marañón, Madrid, España
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Oncological outcomes of laparoscopic nephroureterectomy with pluck method for distal ureter resection. UROLOGICAL SCIENCE 2017. [DOI: 10.1016/j.urols.2016.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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20
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Yoo ES, Ha YS, Lee JN, Kim BS, Kim BW, Byun SS, Choi YD, Kang HW, Yun SJ, Kim WJ, Kim JH, Kwon TG. Can lymphovascular invasion replace the prognostic value of lymph node involvement in patients with upper tract urothelial carcinoma after radical nephroureterectomy? Can Urol Assoc J 2017; 10:E229-E236. [PMID: 28255413 DOI: 10.5489/cuaj.3557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to evaluate whether lymphovascular invasion (LVI) can replace lymph node (LN) involvement as a prognostic marker in patients who do not undergo lymph node dissection (LND) during surgery in patients with upper tract urothelial carcinoma (UTUC). METHODS A total of 505 patients who underwent radical nephroureterectomy (RNU) were recruited from four academic centres and divided into four groups: node negative (N0, Group 1); node positive (N+, Group 2); no LND without LVI (NxLVI-, Group 3); and no LND with LVI (NxLVI+, Group 4). RESULTS Patients in Group 2 had larger tumours, a higher incidence of left-sided involvement, more aggressive T stage and grade, and a higher positive surgical margin rate than patients in other groups. Pathological features (T stage and grade) were poorer in Group 4 than in Groups 1 and 3. Compared to other groups, Group 2 had the worst prognostic outcomes regarding locoregional/distant metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). LVI and LN status in Group 4 was not associated with MFS in multivariate analysis. Among Nx diseases, LVI was not an independent predictor of MFS or CCS. The small number of cases in Groups 2 and 4 is a major limitation of this study. CONCLUSIONS Clinical outcomes according to LVI did not correlate with those outcomes predicted by LN involvement in patients with UTUC. Therefore, LVI may not be used as a substitute for nodal status in patients who do not undergo LND at the time of surgery.
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Affiliation(s)
- Eun Sang Yoo
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yun-Sok Ha
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Nyung Lee
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bum Soo Kim
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bup Wan Kim
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Deuk Choi
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Won Kang
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Seok-Joong Yun
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Wun-Jae Kim
- Department of Urology, College of Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Jeong Hyun Kim
- Department of Urology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Tae Gyun Kwon
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
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Mbeutcha A, Mathieu R, Rouprêt M, Gust KM, Briganti A, Karakiewicz PI, Shariat SF. Predictive models and prognostic factors for upper tract urothelial carcinoma: a comprehensive review of the literature. Transl Androl Urol 2016; 5:720-734. [PMID: 27785429 PMCID: PMC5071205 DOI: 10.21037/tau.2016.09.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In the context of customized patient care for upper tract urothelial carcinoma (UTUC), decision-making could be facilitated by risk assessment and prediction tools. The aim of this study was to provide a critical overview of existing predictive models and to review emerging promising prognostic factors for UTUC. A literature search of articles published in English from January 2000 to June 2016 was performed using PubMed. Studies on risk group stratification models and predictive tools in UTUC were selected, together with studies on predictive factors and biomarkers associated with advanced-stage UTUC and oncological outcomes after surgery. Various predictive tools have been described for advanced-stage UTUC assessment, disease recurrence and cancer-specific survival (CSS). Most of these models are based on well-established prognostic factors such as tumor stage, grade and lymph node (LN) metastasis, but some also integrate newly described prognostic factors and biomarkers. These new prediction tools seem to reach a high level of accuracy, but they lack external validation and decision-making analysis. The combinations of patient-, pathology- and surgery-related factors together with novel biomarkers have led to promising predictive tools for oncological outcomes in UTUC. However, external validation of these predictive models is a prerequisite before their introduction into daily practice. New models predicting response to therapy are urgently needed to allow accurate and safe individualized management in this heterogeneous disease.
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Affiliation(s)
- Aurélie Mbeutcha
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; ; Department of Urology, University of Nice Sophia-Antipolis, Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Morgan Rouprêt
- Department of Urology, Pitié-Salpêtrière, APHP, University Paris VI, Paris, France
| | - Kilian M Gust
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Alberto Briganti
- Unit of Urology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Ospedale S. Raffaele, Milan, Italy
| | | | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; ; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; ; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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Prognostic factors and predictive tools for upper tract urothelial carcinoma: a systematic review. World J Urol 2016; 35:337-353. [DOI: 10.1007/s00345-016-1826-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 04/04/2016] [Indexed: 01/12/2023] Open
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23
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Mathieu R, Bensalah K, Lucca I, Mbeutcha A, Rouprêt M, Shariat SF. Upper urinary tract disease: what we know today and unmet needs. Transl Androl Urol 2016; 4:261-72. [PMID: 26816829 PMCID: PMC4708228 DOI: 10.3978/j.issn.2223-4683.2015.05.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Upper tract urothelial carcinoma (UTUC) is a rare and poorly investigated disease. Intense collaborative efforts have increased our knowledge and improved the management of the disease. The objective of this review was to discuss recent advances and unmet needs in UTUC. Methods A non-systematic Medline/PubMed literature search was performed on UTUC using the terms “upper tract urothelial carcinoma” with different combinations of keywords. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Results UTUC is a disease with specific epidemiologic and risk factors different to urothelial carcinoma of the bladder (UCB). Similarly to UCB, smoking increases the risk of UTUC and worsens its prognosis, whereas aristolochic acid (AA) exposure and mismatch repair genes abnormality are UTUC specific risk factors. A growing understanding of biological pathways involved in the tumorigenesis of UTUC has led to the identification of promising prognostic/predictive biomarkers. Risk stratification of UTUC is difficult due to limitations in staging and grading. Modern imaging and endoscopy have improved clinical decision-making, and allowed kidney-sparing management and surveillance in favorable-risk tumors. In high-risk tumors, radical nephroureterectomy (RNU) remains the standard. Complete removal of the intramural ureter is necessary with inferiority of endoscopic management. Post-RNU intravesical instillation has been shown to decrease bladder cancer recurrence rates. While the role of neoadjuvant cisplatin based combination chemotherapy and lymphadenectomy are not clearly established, the body of evidence suggests a survival benefit to these. There is currently no evidence for adjuvant chemotherapy (AC) in UTUC. Conclusions Despite growing interest and understanding of UTUC, its management remains challenging, requiring further high quality multicenter collaborations. Accurate risk estimation is necessary to avoid unnecessary RNUs while advances in technology are still required for optimal kidney-sparing approaches.
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Affiliation(s)
- Romain Mathieu
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Karim Bensalah
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Ilaria Lucca
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Aurélie Mbeutcha
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Morgan Rouprêt
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Shahrokh F Shariat
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
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Mateu L, Huguet J, Carrión A, García-Cruz E, Izquierdo L, Musquera M, Ribal M, Alcaraz A. Predictors, pathological characteristics and outcomes of bladder recurrences following nephroureterectomy. Actas Urol Esp 2015; 39:488-93. [PMID: 25881516 DOI: 10.1016/j.acuro.2015.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To analyze the predictors for bladder recurrence (BR) after nephroureterectomy (NU) for upper urinary tract tumors (UUTT), as well as its pathological characteristics, outcomes and impact on survival. MATERIAL AND METHODS Retrospective study of 117 patients who underwent laparoscopic nephroureterectomy by UUTT between 2007-2012 at our center. The potential predictors for BR were analyzed using Cox regression; Kaplan-Meier curves were employed to study survival. RESULTS The sample was composed of 85 men (73%) and 32 women (27%), with a mean age of 70 years. After a mean follow-up of 26 months, 23 patients presented BR (19.6%). In the multivariate analysis, sex (p=.003; HR [female], 3.8) and the location of the UUTT in the distal ureter (p=.002; HR, 4.8) were independent predictors for BR. The median time to BR was 8 months. Fifteen patients presented a nonmuscle-invasive BR (65.2%), and 8 presented a muscle-invasive BR (34.8%). All BRs, except for 2, appeared during the first 2 years. Five cases with nonmuscle-invasive BR presented a new BR. Six patients with muscle-invasive BR died before it could be determined whether cause of death was the BR or an UUTT relapse. The onset of BR showed no repercussion on the survival of patients with UUTT. CONCLUSIONS Sex (female) and the location of the UUTT (distal ureter) are predictors for BR after NU. Patients with these characteristics might benefit from adjuvant intravesical treatment and closer monitoring. The onset for RV has no impact on the survival of patients with UUTT.
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