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Pellegrino F, Martini A, Falagario UG, Rautiola J, Russo A, Mertens LS, Di Gianfrancesco L, Bravi CA, Vollemaere J, Abdeen M, Moschini M, Mendrek M, Kjøbli E, Buse S, Wijburg C, Touzani A, Ploussard G, Antonelli A, Schwenk L, Ebbing J, Vasdev N, Froelicher G, John H, Canda AE, Balbay MD, Stoll M, Edeling S, Berquin C, Van Praet C, Leyh-Bannurah SR, Siemer S, Stoeckle M, Mottrie A, D'Hondt F, Crestani A, Porreca A, Briganti A, Montorsi F, van der Poel H, Dacaestecker K, Gaston R, Hosseini A, Wiklund NP. How can we reduce morbidity after robot-assisted radical cystectomy with intracorporeal neobladder? A report on postoperative complications by the European Association of Urology Robotic Urology Section Scientific Working Group. BJU Int 2024. [PMID: 38511350 DOI: 10.1111/bju.16283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Affiliation(s)
- Francesco Pellegrino
- Division of Oncology/Unit of Urology, URI, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Urology, Karolinska University Hospital, Solna, Sweden
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - Alberto Martini
- Department of Molecular Medicine and Surgery, Karolinska institute, Stockholm, Sweden
| | - Ugo Giovanni Falagario
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
- Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - Juhana Rautiola
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - Antonio Russo
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Laura S Mertens
- Oncological Urology, IRCCS Veneto Institute of Oncology, Padua, Italy
| | | | - Carlo Andrea Bravi
- Orsi Academy, Ghent, Belgium
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK
- Department of Urology and Pediatric Urology, Saarland University, Homburg/Saar, Germany
| | - Jonathan Vollemaere
- Department of Urology, Urologic Oncology and Robot-assisted Surgery, St. Antonius Hospital, Gronau, Germany
| | - Muhammad Abdeen
- Department of Urology, Urologic Oncology and Robot-assisted Surgery, St. Antonius Hospital, Gronau, Germany
| | - Marco Moschini
- Division of Oncology/Unit of Urology, URI, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - Mikolaj Mendrek
- Department of Urology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eirik Kjøbli
- Department of Urology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Stephan Buse
- Department of Urology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Carl Wijburg
- Department of Urology, International Center of Oncology, Casablanca, Morocco
| | - Alae Touzani
- Department of Urology, University of Verona, Verona, Italy
- Department of Molecular Medicine and Surgery, Karolinska institute, Stockholm, Sweden
| | - Guillaume Ploussard
- Department of Molecular Medicine and Surgery, Karolinska institute, Stockholm, Sweden
| | | | - Laura Schwenk
- Department of Urology, Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK
| | - Jan Ebbing
- Department of Urology, Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK
| | - Nikhil Vasdev
- Department of Urology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Gabriel Froelicher
- Department of Urology, Koç University School of Medicine, Istanbul, Turkey
| | - Hubert John
- Department of Urology, Koç University School of Medicine, Istanbul, Turkey
| | - Abdullah Erdem Canda
- RMK AIMES (Rahmi M. Koç Academy of Interventional Medicine, Education and Simulation), Istanbul, Turkey
- Department of Urology, American Hospital, Istanbul, Turkey
| | - Mevlana Derya Balbay
- Department of Urology, Vinzenz Hospital, Hannover, Germany
- RMK AIMES (Rahmi M. Koç Academy of Interventional Medicine, Education and Simulation), Istanbul, Turkey
| | - Marcel Stoll
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | | | - Camille Berquin
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Charles Van Praet
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Stefan Siemer
- Department of Urology, Urologic Oncology and Robot-assisted Surgery, St. Antonius Hospital, Gronau, Germany
| | - Michael Stoeckle
- Department of Urology, Urologic Oncology and Robot-assisted Surgery, St. Antonius Hospital, Gronau, Germany
| | - Alexander Mottrie
- Orsi Academy, Ghent, Belgium
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Frederiek D'Hondt
- Orsi Academy, Ghent, Belgium
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Alberto Briganti
- Division of Oncology/Unit of Urology, URI, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, URI, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - Hendrik van der Poel
- Oncological Urology, IRCCS Veneto Institute of Oncology, Padua, Italy
- Department of Urology, AZ Maria Middelares Hospital, Ghent, Belgium
| | - Karel Dacaestecker
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Gaston
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Abolfazl Hosseini
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - N Peter Wiklund
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
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Martini A, Falagario UG, Russo A, Mertens LS, Di Gianfrancesco L, Bravi CA, Vollemaere J, Abdeen M, Mendrek M, Kjøbli E, Buse S, Wijburg C, Touzani A, Ploussard G, Antonelli A, Schwenk L, Ebbing J, Vasdev N, Froelicher G, John H, Canda AE, Balbay MD, Stoll M, Edeling S, Witt JH, Leyh-Bannurah SR, Siemer S, Stoeckle M, Mottrie A, D'Hondt F, Crestani A, Porreca A, van der Poel H, Decaestecker K, Gaston R, Peter Wiklund N, Hosseini A. Robot-assisted Radical Cystectomy with Orthotopic Neobladder Reconstruction: Techniques and Functional Outcomes in Males. Eur Urol 2023; 84:484-490. [PMID: 37117109 DOI: 10.1016/j.eururo.2023.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/25/2023] [Accepted: 04/03/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction. OBJECTIVE To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes. DESIGN, SETTING, AND PARTICIPANTS We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer. SURGICAL PROCEDURE The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article. MEASUREMENTS The outcomes measured were UC and EF at 12 mo. RESULTS AND LIMITATIONS A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p < 0.02) were inversely associated with EF. CONCLUSIONS RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities. PATIENT SUMMARY We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery.
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Affiliation(s)
- Alberto Martini
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | - Ugo Giovanni Falagario
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy; Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - Antonio Russo
- Department of Urology, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - Laura S Mertens
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Carlo Andrea Bravi
- Department of Urology, OLV Hospital, Aalst, Belgium; Orsi Academy, Ghent, Belgium
| | - Jonathan Vollemaere
- Department of Urology and Pediatric Urology, Saarland University, Homburg/Saar, Germany
| | - Muhammad Abdeen
- Department of Urology and Pediatric Urology, Saarland University, Homburg/Saar, Germany
| | - Mikolaj Mendrek
- Department of Urology, Pediatric Urology and Urologic Oncology, St. Antonius Hospital Gronau, Gronau, Germany
| | - Eirik Kjøbli
- Department of Urology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stephan Buse
- Department of Urology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Carl Wijburg
- Department of Urology Rijnstate Hospital, Arnhem, The Netherlands
| | - Alae Touzani
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France; Department of Urology, International Center of Oncology, Casablanca, Morocco
| | | | | | - Laura Schwenk
- Department of Urology, University Hospital Basel, Basel, Switzerland
| | - Jan Ebbing
- Department of Urology, University Hospital Basel, Basel, Switzerland
| | - Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
| | - Gabriel Froelicher
- Department of Urology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Hubert John
- Department of Urology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | | | - Marcel Stoll
- Department of Urology, Vinzenz Hospital, Hannover, Germany
| | | | - Jorn H Witt
- Department of Urology, Pediatric Urology and Urologic Oncology, St. Antonius Hospital Gronau, Gronau, Germany
| | - Sami-Ramzi Leyh-Bannurah
- Department of Urology, Pediatric Urology and Urologic Oncology, St. Antonius Hospital Gronau, Gronau, Germany
| | - Stefan Siemer
- Department of Urology and Pediatric Urology, Saarland University, Homburg/Saar, Germany
| | - Michael Stoeckle
- Department of Urology and Pediatric Urology, Saarland University, Homburg/Saar, Germany
| | - Alexander Mottrie
- Department of Urology, OLV Hospital, Aalst, Belgium; Orsi Academy, Ghent, Belgium
| | - Frederiek D'Hondt
- Department of Urology, OLV Hospital, Aalst, Belgium; Orsi Academy, Ghent, Belgium
| | | | - Angelo Porreca
- Oncological Urology, IRCCS Veneto Institute of Oncology, Padua, Italy
| | - Hendrik van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Karel Decaestecker
- Department of Urology, AZ Maria Middelares Hospital, Ghent, Belgium; Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Richard Gaston
- Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - N Peter Wiklund
- Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Solna, Sweden.
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Grauer R, Wiklund NP. Update on robotic cystectomy. Curr Opin Urol 2021; 31:537-541. [PMID: 34506337 DOI: 10.1097/mou.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This article aims to discuss recently published (2019-2021) studies on robot-assisted radical cystectomy (RARC) with attention to evidence comparing intracorporeal (ICUD) and extracorporeal urinary diversion (ECUD) in terms of intraoperative and perioperative metrics. RECENT FINDINGS RARC produces equivalent oncological outcomes compared to open radical cystectomy (ORC). The benefits of RARC are most pronounced perioperatively. ICUD has been increasingly used at centers of excellence as it reduces intestinal exposure, which may incrementally minimize morbidity compared to ECUD or ORC. As the learning curve for ICUD diversion has flattened, retrospective analyses have emerged that suggest this technique may hold benefit over both ORC and RARC with ECUD, though current data is conflicting, and a randomized controlled study is forthcoming. SUMMARY ORC is the current 'gold standard' management for muscle-invasive bladder cancer. Based on the premise of the minimization of perioperative morbidity, the development of RARC, most recently with ICUD, seeks to improve patient outcomes. Despite a protracted learning curve, many expert bladder cancer centers have adopted an intracorporeal approach. As more centers adopt, refine, and climb the learning curve for ICUD, a clearer insight of its effect on morbidity will be revealed-informing further adoption of the technique.
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Affiliation(s)
- Ralph Grauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Sehmbi AS, Sridhar AN, Sahadevan K, Rai BP, Nwangwu P, Mohammed A, Freeman A, Mottrie A, Olsson MJ, Wiklund NP, Nathan MS, Briggs TP, Kelly JD, Rajan P. Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: a single surgeon cohort study. Journal of Clinical Urology 2021. [DOI: 10.1177/2051415820938176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Technical skills in robot-assisted radical prostatectomy (RARP) are not mandated by the Intercollegiate Surgical Curriculum Programme. The European Association of Urology Robotic Urology Section (ERUS) developed a structured curriculum; however, surgeons’ outcomes data from subsequent independent practice are limited. We describe the initial post-ERUS curriculum RARP outcomes for a United Kingdom (UK)-based surgeon. Patients and methods: This was a prospective single surgeon cohort study of 272 patients who underwent RARP between February 2016 and October 2019 in a high-volume UK centre and who were followed up at approximately 3 and 12 months. Positive surgical margins (PSMs), and 3- and 12-month continence rates were obtained and used to generate learning curves, with point of plateau estimated from logarithmic trendlines. Results: Overall (⩾3 mm) PSM rate for pT2 was 14.9% (5.4%) and pT3 was 22.6% (3.2%). Where data were available, 70.5% (of n=251) and 95.5% (of n=154) patients achieved social continence (0–1 pads) at 3 and 12 months, respectively. PSM and 3-month social continence rates plateaued at ~175 and ~100 cases, respectively. Conclusion: Following completion of the ERUS RARP curriculum, early oncological and functional outcomes consistent with published standards are rapidly achievable in independent practice. These data exemplify the potential value of a standardised RARP training curriculum to mitigate possible compromises in outcomes. Level of evidence: IV
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Affiliation(s)
- Arjan S Sehmbi
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Cancer Research UK Barts Centre, Queen Mary University of London, UK
| | - Ashwin N Sridhar
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | | | - Bhavan P Rai
- Department of Urology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Pamela Nwangwu
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Anna Mohammed
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, UK
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium
- Division of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Mats J Olsson
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Icahn School of Medicine at Mount Sinai Health System, New York, USA
| | - M Senthil Nathan
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - Timothy P Briggs
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
| | - John D Kelly
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
- Division of Surgery and Interventional Sciences, University College London, UK
| | - Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Cancer Research UK Barts Centre, Queen Mary University of London, UK
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, UK
- Department of Urology, Barts Health NHS Trust, London, UK
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Martini A, Sfakianos JP, Renström-Koskela L, Mortezavi A, Falagario UG, Egevad L, Hosseini A, Mehrazin R, Galsky MD, Steineck G, Wiklund NP. The natural history of untreated muscle-invasive bladder cancer. BJU Int 2019; 125:270-275. [PMID: 31310696 DOI: 10.1111/bju.14872] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVE To describe the natural history of untreated muscle-invasive bladder cancer (MIBC) and compare the oncological outcomes of treated and untreated patients. PATIENTS AND METHODS We utilised a database encompassing all patients with newly diagnosed bladder cancer in Stockholm, Sweden between 1995 and 1996. The median follow-up for survivors was 14.4 years. Overall, 538 patients were diagnosed with bladder cancer of whom 126 had clinically localised MIBC. Patients were divided into two groups: those who received radical cystectomy or radiation therapy, and those who did not receive any form of treatment. Multivariable Cox or competing-risks regressions were adopted to predict metastasis, overall survival (OS), and cancer-specific mortality (CSM), when appropriate. Analyses were adjusted for age at diagnosis, sex, tumour stage, clinical N stage, and treatment. RESULTS In all, 64 (51%) patients did not receive any definitive local treatment. In the untreated group, the median (interquartile range) age at diagnosis was 79 (63-83) vs 69 (63-74) years in the treated group (P < 0.001). Overall, 109 patients died during follow-up. At 6 months after diagnosis, 38% of the untreated patients had developed metastatic disease and 41% had CSM. The 5-year OS rate for untreated and treated patients was 5% (95% confidence interval [CI] 1, 12%) vs 48% (95% CI 36, 60%), respectively. Patients not receiving any treatment had a 5-year cumulative incidence of CSM of 86% (95% CI 75, 94%) vs 48% (95% CI 36, 60%) for treated patients. Untreated patients had a higher risk of progression to metastatic disease (hazard ratio [HR] 2.40, 95% CI 1.28, 4.51; P = 0.006), death from any cause (HR 2.63, 95% CI 1.65, 4.19; P < 0.001) and CSM (subdistribution HR 2.02, 95% CI 1.24, 3.30; P = 0.004). CONCLUSIONS Untreated patients with MIBC are at very high risk of near-term CSM. These findings may help balance the risks vs benefits of integrating curative intent therapy particularly in older patients with MIBC.
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Affiliation(s)
- Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lotta Renström-Koskela
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Ashkan Mortezavi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ugo G Falagario
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lars Egevad
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Abolfazal Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew D Galsky
- Division of Hematology and Oncology, Department of Medicine, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gunnar Steineck
- Sahlgrenska Academy Clinical Sciences, University of Göteborg, Gothenburg, Sweden
| | - N Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
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Martini A, Jia R, Ferket BS, Waingankar N, Plimack ER, Crabb SJ, Harshman LC, Yu EY, Powles T, Rosenberg JE, Pal SK, Vaishampayan UN, Necchi A, Wiklund NP, Mehrazin R, Mazumdar M, Sfakianos JP, Galsky MD. Tumor downstaging as an intermediate endpoint to assess the activity of neoadjuvant systemic therapy in patients with muscle-invasive bladder cancer. Cancer 2019; 125:3155-3163. [PMID: 31150110 DOI: 10.1002/cncr.32169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/23/2019] [Accepted: 02/24/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Achieving a pathologic complete response (pCR) with neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC) has been associated with improved overall survival (OS). This study was aimed at evaluating the impact of pathologic downstaging (pDS; ie, a pT stage at least 1 stage lower than the pre-NAC cT stage) on the OS of patients with MIBC treated with NAC. METHODS The Retrospective International Study of Cancers of the Urothelial Tract (RISC) and the National Cancer Database (NCDB) were queried for cT2-4N0M0 patients treated with NAC. A multivariable Cox model including either pDS or pCR was generated. A nested model was built to evaluate the added value of pDS (excluding patients achieving a pCR) to a model including pCR alone. C indices were computed to assess discrimination. NCDB was used for validation. The treatment effect of NAC versus cystectomy alone in achieving pDS was estimated through an inverse probability-weighted regression adjustment. RESULTS Overall, 189 and 2010 patients from the RISC and NCDB cohorts, respectively, were included; pDS and pCR were achieved by 33% and 35% and by 20% and 15% in RISC and NCDB, respectively. In both data sets, pDS and pCR were associated with better OS and C indices. Adding pDS excluding pCR to the model with pCR fit the data better (likelihood ratio, P = .019 for RISC and P < .001 for NCDB), and it yielded better discrimination (incremental C index, 4.2 for RISC and 1.6 for NCDB). The treatment effect of NAC in achieving pDS was 2.07-fold (P < .001) in comparison with cystectomy alone. CONCLUSIONS A decrease of at least 1 stage from the cT stage to the pT stage is associated with improved OS in patients with MIBC treated with NAC.
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Affiliation(s)
- Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel Jia
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bart S Ferket
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Simon J Crabb
- University of Southampton, Southampton, United Kingdom
| | | | - Evan Y Yu
- University of Washington, Seattle, Washington
| | - Thomas Powles
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | | | - Sumanta K Pal
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | - N Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew D Galsky
- Division of Hematology and Oncology, Department of Medicine, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract
INTRODUCTION The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP). EVIDENCE ACQUISITION We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines. EVIDENCE SYNTHESIS A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken. CONCLUSIONS A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden - .,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece -
| | | | - Nikolaos Grivas
- Department of Urology, G. Hatzikosta General Hospital, Ioannina, Greece.,Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital Amsterdam, Amsterdam, The Netherlands
| | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital Amsterdam, Amsterdam, The Netherlands
| | - N Peter Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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8
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Rajan P, Hagman A, Sooriakumaran P, Nyberg T, Wallerstedt A, Adding C, Akre O, Carlsson S, Hosseini A, Olsson M, Egevad L, Wiklund F, Steineck G, Wiklund NP. Oncologic Outcomes After Robot-assisted Radical Prostatectomy: A Large European Single-centre Cohort with Median 10-Year Follow-up. Eur Urol Focus 2018; 4:351-359. [PMID: 28753802 DOI: 10.1016/j.euf.2016.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa) treatment has been widely adopted with limited evidence for long-term (>5 yr) oncologic efficacy. OBJECTIVE To evaluate long-term oncologic outcomes following RARP. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 885 patients who underwent RARP as monotherapy for PCa between 2002 and 2006 in a single European centre and followed up until 2016. INTERVENTION RARP as monotherapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Biochemical recurrence (BCR)-free survival (BCRFS), salvage therapy (ST)-free survival (STFS), prostate cancer-specific survival (CSS), and overall survival (OS) were estimated using the Kaplan-Meier method, and event-time distributions were compared using the log-rank test. Variables predictive of BCR and ST were identified using Cox proportional hazards models. RESULTS AND LIMITATIONS We identified 167 BCRs, 110 STs, 16 PCa-related deaths, and 51 deaths from other/unknown causes. BCRFS, STFS, CSS, and OS rates were 81.8%, 87.5%, 98.5%, and 93.0%, respectively, at median follow-up of 10.5 yr. On multivariable analysis, the strongest independent predictors of both BCR and ST were preoperative Gleason score, pathological T stage, positive surgical margins (PSMs), and preoperative prostate-specific antigen. PSM >3mm/multifocal but not ≤3mm independently affected the risk of both BCR and ST. Study limitations include a lack of centralised histopathologic reporting, lymph node and post-operative tumour volume data in a historical cohort, and patient-reported outcomes. CONCLUSIONS RARP appears to confer effective long-term oncologic efficacy. The risk of BCR or ST is unaffected by ≤3mm PSM, but further follow-up is required to determine any impact on CSS. PATIENT SUMMARY Robot-assisted surgery for prostate cancer is effective 10 yr after treatment. Very small (<3mm) amounts of cancer at the cut edge of the prostate do not appear to impact on recurrence risk and the need for additional treatment, but it is not yet known whether this affects the risk of death from prostate cancer.
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Affiliation(s)
- Prabhakar Rajan
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Barts Cancer Institute, Centre for Molecular Oncology, Queen Mary University of London, London, UK; Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Anna Hagman
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Prasanna Sooriakumaran
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Urology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tommy Nyberg
- Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden; Department of Oncology-Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Wallerstedt
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Christofer Adding
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Akre
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Carlsson
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Olsson
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Egevad
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Wiklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Steineck
- Department of Oncology-Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden.
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9
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Tyritzis SI, Wiklund NP. Is the open cystectomy era over? An update on the available evidence. Int J Urol 2017; 25:187-195. [PMID: 29178344 DOI: 10.1111/iju.13497] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/18/2017] [Indexed: 12/24/2022]
Abstract
In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is being made to standardize complication reporting and videos of the procedure are readily available, it is inevitable and justified that like everything novel, robot-assisted radical cystectomy should be scrutinized against the gold standard, open radical cystectomy. The present comparison is focused on several parameters: oncological, functional and complication outcomes, and direct and indirect costs. Meta-analysis and prospective randomized trials comparing robot-assisted radical cystectomy versus open radical cystectomy have been published, showing an oncological equivalence and in some cases an advantage of robot-assisted radical cystectomy in terms of postoperative morbidity. In the present review, we attempt to update the available knowledge on this debate and discuss the limitations of the current evidence that prevent us from drawing safe conclusions.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - N Peter Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Rajan P, Sooriakumaran P, Nyberg T, Akre O, Carlsson S, Egevad L, Steineck G, Wiklund NP. Effect of Comorbidity on Prostate Cancer-Specific Mortality: A Prospective Observational Study. J Clin Oncol 2017; 35:3566-3574. [PMID: 28930493 PMCID: PMC5662843 DOI: 10.1200/jco.2016.70.7794] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Purpose To determine the effect of comorbidity on prostate cancer (PCa)-specific mortality across treatment types. Patients and Methods These are the results of a population-based observational study in Sweden from 1998 to 2012 of 118,543 men who were diagnosed with PCa with a median follow-up of 8.3 years (interquartile range, 5.2 to 11.5 years) until death from PCa or other causes. Patients were categorized by patient characteristics (marital status, educational level) and tumor characteristics (serum prostate-specific antigen, tumor grade and clinical stage) and by treatment type (radical prostatectomy, radical radiotherapy, androgen deprivation therapy, and watchful waiting). Data were stratified by Charlson comorbidity index (0, 1, 2, or ≥ 3). Mortality from PCa and other causes and after stabilized inverse probability weighting adjustments for clinical patient and tumor characteristics and treatment type was determined. Kaplan-Meier estimates and Cox proportional hazards regression models were used to calculate hazard ratios. Results In the complete unadjusted data set, we observed an effect of increased comorbidity on PCa-specific and other-cause mortality. After adjustments for patient and tumor characteristics, the effect of comorbidity on PCa-specific mortality was lost but maintained for other-cause mortality. After additional adjustment for treatment type, we again failed to observe an effect for comorbidity on PCa-specific mortality, although it was maintained for other-cause mortality. Conclusion This large observational study suggests that comorbidity affects other cause-mortality but not PCa-specific- mortality after accounting for patient and tumor characteristics and treatment type. Regardless of radical treatment type (radical prostatectomy or radical radiotherapy), increasing comorbidity does not seem to significantly affect the risk of dying from PCa. Consequently, differences in oncologic outcomes that were observed in population-based comparative effectiveness studies of PCa treatments may not be a result of the varying distribution of comorbidity among treatment groups.
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Affiliation(s)
- Prabhakar Rajan
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - Prasanna Sooriakumaran
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Nyberg
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Akre
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Carlsson
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Egevad
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Steineck
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
| | - N. Peter Wiklund
- Prabhakar Rajan, Queen Mary University of London; Prabhakar Rajan and Prasanna Sooriakumaran, University College London Hospitals National Health Service Foundation Trust; Prabhakar Rajan, Barts Health National Health Service Trust, London; Prasanna Sooriakumaran, University of Oxford, Oxford; Tommy Nyberg, University of Cambridge, Cambridge, United Kingdom; Tommy Nyberg, Olof Akre, Stefan Carlsson, Lars Egevad, Gunnar Steineck, and N. Peter Wiklund, Karolinska Institutet; and Olof Akre, Stefan Carlsson, and Lars Egevad, Karolinska University Hospital, Stockholm, Sweden
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11
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Guan NN, Svennersten K, de Verdier PJ, Wiklund NP, Gustafsson LE. Prostaglandin D 2 effects and DP 1 /DP 2 receptor distribution in guinea pig urinary bladder out-flow region. J Cell Mol Med 2016; 21:234-243. [PMID: 27664012 PMCID: PMC5264142 DOI: 10.1111/jcmm.12959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 07/21/2016] [Indexed: 12/23/2022] Open
Abstract
The proximal urethra and urinary bladder trigone play important roles in continence. We have previously shown that PGD2 is released from guinea pig bladder urothelium/suburothelium and can inhibit detrusor contractile responses. We presently wished to investigate PGD2 actions in guinea pig out‐flow region and the distribution of DP1/DP2 receptors. The effects of PGD2 on urothelium‐intact trigone and proximal urethra contractility were studied in organ bath experiments. Expression of DP1/DP2 receptor proteins was analysed by western blot. Immunohistochemistry was used to identify distribution of DP1/DP2 receptors. PGD2 in a dose‐dependent manner inhibited trigone contractions induced by electrical field stimulation (EFS) and inhibited spontaneous contractions of the proximal urethra. PGD2 was equally (trigone) or slightly less potent (urethra) compared with PGE2. Expression of DP1 and DP2 receptors was found in male guinea pig bladder trigone, neck and proximal urethra. In the trigone and proximal urethra, DP1 receptors were found on the membrane of smooth muscle cells and weak immunoreactivty was observed in the urothelium. DP2 receptors were distributed more widespread, weakly and evenly in the urothelium and smooth muscles. Inhibitory effects by PGD2 on motor activity of guinea pig trigone and proximal urethra are consistent with finding DP1 and DP2 receptors located in the urothelium and smooth muscle cells of the trigone and proximal urethra, and PGD2 may therefore be a modulator of the bladder out‐flow region, possibly having a function in regulation of micturition and a role in overactive bladder syndrome.
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Affiliation(s)
- Na N Guan
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Karl Svennersten
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Petra J de Verdier
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lars E Gustafsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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12
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Ryk C, de Verdier P, Montgomery E, Peter Wiklund N, Wiklund F, Grönberg H. Polymorphisms In The Nitric-Oxide Synthase 2 Gene And Prostate Cancer Pathogenesis. Redox Biol 2015; 5:419. [PMID: 28162285 DOI: 10.1016/j.redox.2015.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Nitric-oxide synthase (NOS)-polymorphisms influence the cellular amount of NO, and are associated with disease-risk in many disorders. We investigated 145 SNP-polymorphisms and a (CCTTT)n-microsatellite in the NOS2-gene in 3161 prostate-cancer patients and 2149 controls from a Swedish population-based GWAS-study. AIM To analyze possible associations between NOS2-polymorphisms, prostate cancer, and prostate cancer pathogenesis. METHODS Two groups were analyzed, those with advanced tumours (Gleason≥6), and those with tumours of mixed Gleason-statues. Affymetrix 5.0-chip (SNP-polymorphisms), DNA Fragment-analysis and Sequencing ((CCTTT)n-microsatellite) were used for genotyping. Genotypes were combined with information on tumour stage, Gleason, PSA, metastases and cancer-specific death, using clinical follow-up. RESULTS We divided the (CCTTT)n-alleles into short (S, n≤10), intermediate (M, n=11-12) and long (L, n≥13). Patients homozygous for longer repeats (LL) had decreased risk of highly aggressive (Gleason ≥7;PSA>20;T3+) tumours (OR:0.40;CI:0.14-1.08;p=0.071), but, once ill they showed a threefold increased risk of dying in prostate cancer (HR:3.31;CI:0.85-12.85;p=0.084), compared to SS-homozygotes. The SNP-alleles that co-varied with the (CCTTT)l-allele also had lower risk of aggressive tumours, as well as, once ill, a 2-4 times higher risk of dying (p=0.009). Also the proportion of patients with lymph node metastases increased with length of the (CCTTT)n-alleles of the patients (SS<SM<SL<MM<ML <LL)(trend analysis; p=0.033). CONCLUSIONS Nitric oxide can induce proliferation as well as apoptosis depending on cellular context. Our results suggest that NOS2 polymorphisms may influence the risk of aggressive prostate cancer and that these polymorphisms could have an impact on disease pathogenesis, possibly by affecting intracellular nitric oxide levels.
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Affiliation(s)
- Charlotta Ryk
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Petra de Verdier
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Emmie Montgomery
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Grönberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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13
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Ryk C, Koskela LR, Thiel T, Wiklund NP, Steineck G, Schumacher MC, de Verdier PJ. Outcome after BCG treatment for urinary bladder cancer may be influenced by polymorphisms in the NOS2 and NOS3 genes. Redox Biol 2015; 6:272-277. [PMID: 26298202 PMCID: PMC4556773 DOI: 10.1016/j.redox.2015.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/04/2015] [Accepted: 08/09/2015] [Indexed: 11/05/2022] Open
Abstract
Purpose Bacillus Calmette-Guérin (BCG)-treatment is an established treatment for bladder cancer, but its mechanisms of action are not fully understood. High-risk non-muscle invasive bladder-cancer (NMIBC)-patients failing to respond to BCG-treatment have worse prognosis than those undergoing immediate radical cystectomy and identification of patients at risk for BCG-failure is of high priority. Several studies indicate a role for nitric oxide (NO) in the cytotoxic effect that BCG exerts on bladder cancer cells. In this study we investigated whether NO-synthase (NOS)-gene polymorphisms, NOS2-promoter microsatellite (CCTTT)n, and the NOS3-polymorphisms-786T>C (rs2070744) and Glu298Asp (rs1799983), can serve as possible molecular markers for outcome after BCG-treatment for NMIBC. Materials and methods All NMIBC-patients from a well-characterized population based cohort were analyzed (n=88). Polymorphism data were combined with information from 15-years of clinical follow-up. The effect of BCG-treatment on cancer-specific death (CSD), recurrence and progression in patients with varying NOS-genotypes were studied using Cox proportional hazard-models and log rank tests. Results BCG-treatment resulted in significantly better survival in patients without (Log rank: p=0.006; HR: 0.12, p=0.048), but not in patients with a long version ((CCTTT)n ≧13 repeats) of the NOS2-promoter microsatellite. The NOS3-rs2070744(TT) and rs1799983(GG)-genotypes showed decreased risk for CSD (Log rank(TT): p=0.001; Log rank(GG): p=0.010, HR(GG): 0.16, p=0.030) and progression (Log rank(TT): p<0.001, HR(TT): 0.05, p=0.005; Log rank(GG): p<0.001, HR(GG): 0.10, p=0.003) after BCG-therapy compared to the other genotypes. There was also a reduction in recurrence in BCG-treated patients that was mostly genotype independent. Analysis of combined genotypes identified a subgroup of 30% of the BCG-treated patients that did not benefit from BCG-treatment. Conclusions Our results suggest that the investigated polymorphisms influence patient response to BCG-treatment and thus may serve as possible markers for identification of BCG-failures. 30% of BCG treated bladder cancer (NMIBC)-patients do not respond to BCG-treatment. We need to identify BCG failures before the BCG-treatment is given. Altered NOS2 and NOS3 gene activity may be associated with BCG treatment outcome. NOS-polymorphisms are possible BCG-failure biomarkers in bladder cancer patients.
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Affiliation(s)
- Charlotta Ryk
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden; Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | - Lotta Renström Koskela
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden; Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Tomas Thiel
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden; Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - N Peter Wiklund
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden; Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Gunnar Steineck
- Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institutet, 171 76 Stockholm, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology, Onkologiskt centrum, Sahlgrenska University Hospital, 413 45 Göteborg, Sweden
| | - Martin C Schumacher
- Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Petra J de Verdier
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden; Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden
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14
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Svennersten K, Hallén-Grufman K, de Verdier PJ, Wiklund NP, Poljakovic M. Localization of P2X receptor subtypes 2, 3 and 7 in human urinary bladder. BMC Urol 2015; 15:81. [PMID: 26253104 PMCID: PMC4529706 DOI: 10.1186/s12894-015-0075-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 07/28/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Voiding dysfunctions are a common problem that has a severe negative impact on the quality of life. Today there is a need for new drug targets for these conditions. The role of ATP receptors in bladder physiology has been studied for some time, primarily in animal models. The aim of this work is to investigate the localization of the ATP receptors P2X2, P2X3 and P2X7 and their colocalization with vimentin and actin in the human urinary bladder. METHODS Immunohistochemical analysis was conducted on full-thickness bladder tissues from fundus and trigonum collected from 15 patients undergoing open radical cystectomy due to chronic cystitis, bladder cancer or locally advanced prostate cancer. Colocalization analyses were performed between the three different P2X subtypes and the structural proteins vimentin and actin. Specimens were examined using epifluorescence microscopy and correlation coefficients were calculated for each costaining as well as the mean distance from the laminin positive basal side of the urothelium to the vimentin positive cells located in the suburothelium. RESULTS P2X2 was expressed in vimentin positive cells located in the suburothelium. Less distinct labelling of P2X2 was also observed in actin positive smooth muscle cells and in the urothelium. P2X3 was expressed in vimentin positive cells surrounding the smooth muscle, and in vimentin positive cells located in the suburothelium. Weaker P2X3 labelling was seen in the urothelium. P2X7 was expressed in the smooth muscle cells and the urothelium. In the suburothelium, cells double positive for P2X2 and vimentin where located closer to the urothelium while cells double positive for P2X3 and vimentin where located further from the urothelium. CONCLUSION The results from this study demonstrate that there is a significant difference in the expression of the purinergic P2X2, P2X3 and P2X7 receptors in the different histological layers of the human urinary bladder.
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Affiliation(s)
- Karl Svennersten
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
| | - Katarina Hallén-Grufman
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
| | - Petra J de Verdier
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - N Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
| | - Mirjana Poljakovic
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
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15
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Guan NN, Svennersten K, de Verdier PJ, Wiklund NP, Gustafsson LE. Receptors involved in the modulation of guinea pig urinary bladder motility by prostaglandin D2. Br J Pharmacol 2015; 172:4024-37. [PMID: 25917171 DOI: 10.1111/bph.13174] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND PURPOSE We have described a urothelium-dependent release of PGD2 -like activity which had inhibitory effects on the motility of guinea pig urinary bladder. Here, we have pharmacologically characterized the receptors involved and localized the sites of PGD2 formation and of its receptors. EXPERIMENTAL APPROACH In the presence of selective DP and TP receptor antagonists alone or combined, PGD2 was applied to urothelium-denuded diclofenac-treated urinary bladder strips mounted in organ baths. Antibodies against PGD2 synthase and DP1 receptors were used with Western blots and for histochemistry. KEY RESULTS PGD2 inhibited nerve stimulation -induced contractions in strips of guinea pig urinary bladder with estimated pIC50 of 7.55 ± 0.15 (n = 13), an effect blocked by the DP1 receptor antagonist BW-A868C. After blockade of DP1 receptors, PGD2 enhanced the contractions, an effect abolished by the TP receptor antagonist SQ-29548. Histochemistry revealed strong immunoreactivity for PGD synthase in the urothelium/suburothelium with strongest reaction in the suburothelium. Immunoreactive DP1 receptors were found in the smooth muscle of the bladder wall with a dominant localization to smooth muscle membranes. CONCLUSIONS AND IMPLICATIONS In guinea pig urinary bladder, the main effect of PGD2 is an inhibitory action via DP1 receptors localized to the smooth muscle, but an excitatory effect via TP receptors can also be evoked. The urothelium with its suburothelium might signal to the smooth muscle which is rich in PGD2 receptors of the DP1 type. The results are important for our understanding of regulation of bladder motility.
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Affiliation(s)
- Na N Guan
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Karl Svennersten
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Petra J de Verdier
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lars E Gustafsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Wallerstedt A, Tyritzis SI, Thorsteinsdottir T, Carlsson S, Stranne J, Gustafsson O, Hugosson J, Bjartell A, Wilderäng U, Wiklund NP, Steineck G, Haglind E. Short-term Results after Robot-assisted Laparoscopic Radical Prostatectomy Compared to Open Radical Prostatectomy. Eur Urol 2015; 67:660-70. [DOI: 10.1016/j.eururo.2014.09.036] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
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Collins JW, Sooriakumaran P, Sanchez-Salas R, Ahonen R, Nyberg T, Wiklund NP, Hosseini A. Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience. Indian J Urol 2014; 30:307-13. [PMID: 25097318 PMCID: PMC4120219 DOI: 10.4103/0970-1591.134251] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Introduction: The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation. Materials and Methods: Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates. Results: The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women. Conclusions: Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.
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Affiliation(s)
- Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - P Sooriakumaran
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden ; Department of Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - R Sanchez-Salas
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - R Ahonen
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - T Nyberg
- Department of Oncology and Pathology, Section of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - N P Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - A Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
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Guan NN, Thor A, Hallén K, Wiklund NP, Gustafsson LE. Cascade bioassay evidence for the existence of urothelium-derived inhibitory factor in Guinea pig urinary bladder. PLoS One 2014; 9:e103932. [PMID: 25084114 PMCID: PMC4118989 DOI: 10.1371/journal.pone.0103932] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 07/08/2014] [Indexed: 11/20/2022] Open
Abstract
Our aim was to investigate whether guinea pig urothelium-derived bioactivities compatible with the existence of urothelium-derived inhibitory factor could be demonstrated by in vitro serial bioassay and whether purinergic P1 receptor agonists, nitric oxide, nitrite or prostaglandins might explain observed activities. In a cascade superfusion system, urothelium-denuded guinea pig ureters were used as bioassay tissues, recording their spontaneous rhythmic contractions in presence of scopolamine. Urothelium-intact or -denuded guinea pig urinary bladders were used as donor tissues, stimulated by intermittent application of carbachol before or during the nitric oxide synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME), the adenosine/P1 nucleoside receptor antagonist 8-(p-sulfophenyl)theophylline (8-PST) or the cyclo-oxygenase inhibitor diclofenac infused to bath donor and bioassay tissues. The spontaneous contractions of bioassay ureters were unaltered by application of carbachol 1-5 µM in the presence of scopolamine 5-30 µM. When carbachol was applied over the urothelium-denuded bladder, the assay ureter contraction rate was unaltered. Introducing carbachol over the everted urothelium-intact bladder significantly inhibited the contraction frequency of the assay ureter, suggesting the transfer of an inhibitory activity from the bladder to the assay ureter. The transmissible inhibitory activity was not markedly antagonized by L-NAME, 8-PST or diclofenac, while L-NAME nearly abolished nitrite release from the urothelium-intact bladder preparations. We suggest that urothelium-derived inhibitory factor is a transmissible entity over a significant distance as demonstrated in this novel cascade superfusion assay and seems less likely to be nitric oxide, nitrite, an adenosine receptor agonist or subject to inhibition by administration of a cyclo-oxygenase inhibitor.
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Affiliation(s)
- Na N. Guan
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Thor
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Hallén
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - N. Peter Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lars E. Gustafsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Thiel T, Ryk C, Chatzakos V, Hallén Grufman K, Bavand-Chobot N, Flygare J, Wiklund NP, de Verdier PJ. Secondary stimulation from Bacillus Calmette-Guérin induced macrophages induce nitric oxide independent cell-death in bladder cancer cells. Cancer Lett 2014; 348:119-25. [PMID: 24657658 DOI: 10.1016/j.canlet.2014.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 02/25/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
Abstract
The anti-tumour mechanisms following Bacillus Calmette-Guérin (BCG) treatment of bladder-cancer remain largely unknown. Previous studies have shown involvement of nitric-oxide (NO) formation in the BCG-mediated effect. We analyzed the effects of macrophage secreted factors (MSFs) from BCG-stimulated RAW264.7 cells on the bladder-cancer cell line MBT2. Direct treatment with BCG did not induce NO in MBT2-cells whereas supernatant from BCG-stimulated macrophages increased NOS2 mRNA and protein expression, NO concentrations and cell-death. Blocking NO-synthesis with the NOS-inhibitor L-NAME did not affect levels of cell-death suggesting cytotoxic pathways involving other signalling molecules than NO. Several such candidate genes were identified in a microarray.
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Affiliation(s)
- Tomas Thiel
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Charlotta Ryk
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Vicky Chatzakos
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institutet and Karolinska University Hospital Huddinge, Stockholm, Sweden; Stockholm University, Department of Genetics, Microbiology and Toxicology, Stockholm, Sweden
| | - Katarina Hallén Grufman
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Nasrin Bavand-Chobot
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Flygare
- Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institutet and Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - N Peter Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Petra J de Verdier
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden; Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Affiliation(s)
- Justin W. Collins
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
- St. Peter's Hospital; Chertsey
| | - Prasanna Sooriakumaran
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
- Surgical Intervention Trials Unit; Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - N. Peter Wiklund
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
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Abstract
We performed a systematic literature review to assess the current status of a totally intracorporeal robot-assisted radical cystectomy (RARC) approach. The current 'gold standard' for radical cystectomy remains open radical cystectomy. RARC has lagged behind robot-assisted prostatectomy in terms of adoption and perceived patient benefit, but there are indications that this is now changing. There have been several recently published large series of RARC, both with extracorporeal and with intracorporeal urinary diversions. The present review focuses on the totally intracorporeal approach. Radical cystectomy is complex surgery with several important outcome measures, including oncological and functional outcomes, complication rates, patient recovery and cost implications. We aim to answer the question of whether there are advantages to a totally intracorporeal robotic approach or whether we are simply making an already complex procedure more challenging with an associated increase in complication rates. We review the current status of both oncological and functional outcomes of totally intracorporeal RARC compared with standard RARC with extraperitoneal urinary diversion and with open radical cystectomy, and assess the associated short- and long-term complication rates. We also review aspects in training and research that have affected the uptake of RARC. Additionally we evaluate how current technology is contributing to the future development of this surgical technique.
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Abstract
In the USA, the incidence of bladder cancer is three-times higher in men than in women and it is the fourth most common cancer in men after prostate, lung and colorectal cancer. Muscle-invasive urothelial urinary bladder cancer has a very high mortality rate. This is regardless of intensive therapeutic efforts such as radical surgery in combination with oncological treatment options. The development of treatments with better outcomes regarding disease-specific survival and treatment-inflicted morbidity is likely to occur over the next few years. The significance of meta-analyses on the effect of neoadjuvant chemotherapy, the development of sentinel node dissection and the impact of the introduction of robot-assisted surgery on the possibility of performing minimally invasive surgery in advanced bladder cancer patients is discussed.
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Affiliation(s)
- Amir Sherif
- Karolinska University Hospital, Department of Urology, 171 76 Stockholm, Sweden.
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Collins JW, Tyritzis S, Nyberg T, Schumacher M, Laurin O, Khazaeli D, Adding C, Jonsson MN, Hosseini A, Wiklund NP. Robot-assisted radical cystectomy: description of an evolved approach to radical cystectomy. Eur Urol 2013; 64:654-63. [PMID: 23769588 DOI: 10.1016/j.eururo.2013.05.020] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 05/05/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery. OBJECTIVE We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ-preserving approaches in men and women. DESIGN, SETTING, AND PARTICIPANTS Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC. SURGICAL PROCEDURE We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ-preserving approaches. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis. RESULTS AND LIMITATIONS RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37-84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤ pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0-57). Twenty percent of patients had lymph node-positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3-107). We recorded a total of 70 early complications (0-30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥ 3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥ 3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr. CONCLUSIONS Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.
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Mogorovich A, Nilsson AE, Tyritzis SI, Carlsson S, Jonsson M, Haendler L, Nyberg T, Steineck G, Wiklund NP. Radical prostatectomy, sparing of the seminal vesicles, and painful orgasm. J Sex Med 2013; 10:1417-23. [PMID: 23421911 DOI: 10.1111/jsm.12086] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health. AIM This study aims to investigate the prevalence of PO and to identify potential risk factors. MAIN OUTCOME MEASURES A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire. METHODS Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency. RESULTS The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7-4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)-sparing approach (RR 2.33, 95% CI 1.0-5.3, P = 0.045) and age <60 years were significantly related to the presence of PO (95% CI 0.5-0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO. CONCLUSIONS We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population.
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Affiliation(s)
- Andrea Mogorovich
- Department of Surgery, Section of Urology, University of Pisa, Pisa, Italy
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Tyritzis SI, Hosseini A, Jonsson M, Adding C, Nilsson A, Wiklund NP. Robot-Assisted Intracorporeal Formation of the Ileal Neobladder. J Endourol 2012; 26:1570-5. [DOI: 10.1089/end.2012.0424] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stavros I. Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Abolfazl Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Jonsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Christofer Adding
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Nilsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - N. Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
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Wallerstedt A, Carlsson S, Steineck G, Thorsteinsdottir T, Hugosson J, Stranne J, Wilderäng U, Haglind E, Wiklund NP. Patient and tumour-related factors for prediction of urinary incontinence after radical prostatectomy. Scand J Urol 2012; 47:272-81. [DOI: 10.3109/00365599.2012.733410] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Koskela LR, Poljakovic M, Ehrén I, Wiklund NP, de Verdier PJ. Localization and expression of inducible nitric oxide synthase in patients after BCG treatment for bladder cancer. Nitric Oxide 2012; 27:185-91. [PMID: 22819699 DOI: 10.1016/j.niox.2012.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 06/25/2012] [Accepted: 07/10/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Lotta Renström Koskela
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
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Hosseini A, Ploumidis A, Adding C, Wiklund NP. Radical surgery for treatment of primary localized bladder amyloidosis: Could prostate-sparing robot-assisted cystectomy with intracorporeal urinary diversion be an option? Scand J Urol 2012; 47:72-5. [DOI: 10.3109/00365599.2012.693539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ploumidis A, Sooriakumaran P, Philippou P, Wiklund NP. Robotic-assisted laparoscopic vesiculectomy for lower urinary tract obstruction by a large seminal vesicle cyst. Int J Surg Case Rep 2012; 3:375-8. [PMID: 22613183 DOI: 10.1016/j.ijscr.2012.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 04/18/2012] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Seminal vesicle (SV) cysts are rare, benign lesions. Most of them are congenital in origin and are usually diagnosed incidentally due to extensive imaging. When symptomatic, surgical excision is recommended. PRESENTATION OF CASE We describe the case of a 17.2cm seminal vesicle cyst removed using a transperitoneal, robotic-assisted laparoscopic approach in a 45-year old male with lower urinary tract symptoms and no other genitourinary abnormality. DISCUSSION Laparoscopic excision of seminal vesicle cysts is a minimal invasive alternative to the open technique with single-center studies reporting high success rates. With the advent of the robotic platform, urologists have shifted to this approach especially for confined anatomical spaces such as the pelvis. To our knowledge this is the largest seminal vesicle cyst described in the literature that has been managed by minimally invasive surgery. CONCLUSION With the advantage of combined 3D vision and wristed instrumentation, excision of large seminal vesicle cysts by robotic assisted laparoscopic approach is feasible, safe and regarded as a natural continuity of conventional laparoscopy. Previous experience in Robotic assisted laparoscopic prostatectomy (RALP) especially in the posterior dissection technique is recommended.
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Affiliation(s)
- Achilles Ploumidis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
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Wallerstedt A, Carlsson S, Nilsson AE, Johansson E, Nyberg T, Steineck G, Wiklund NP. Pad use and patient reported bother from urinary leakage after radical prostatectomy. J Urol 2011; 187:196-200. [PMID: 22099992 DOI: 10.1016/j.juro.2011.09.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE To better understand clinically significant definitions of urinary incontinence we investigated the relationship between urinary leakage and patient reported bother from urinary leakage. MATERIALS AND METHODS A consecutive series of 1,411 men who underwent radical prostatectomy at Karolinska University Hospital, Stockholm, Sweden, from 2002 to 2006 were invited to complete a study specific questionnaire with questions on pad status, urinary leakage and bother from urinary leakage. RESULTS Questionnaires were received from 1,179 men with a followup of greater than 1 year (median 2.2). Results showed that even a small amount of urinary leakage resulted in a high risk of urinary bother. Of 775 survivors 46 (6%) reporting 0 pads indicated moderate or much bother compared to 38 of 123 (31%) who reported using a security pad. When comparing the 2 groups, the risk of bother from urinary leakage was more than 5 times higher in the safety pad vs the 0 pad group (RR 5.2, 95% CI 3.5-7.7). As the number of pads increased, we noted a higher bother risk. Cross-tabulation of pad use and urinary leakage revealed wide variation in pad requirements despite the same answer to urinary leakage questions. CONCLUSIONS If the definition of continence is based on pad use, for example safety pads, a certain number of men who report moderate or much bother from urinary leakage will be defined as continent. Our results also show that for each stated rate of urinary leakage men prove to have a major variation in the pad requirement.
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Affiliation(s)
- Anna Wallerstedt
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
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Abstract
OBJECTIVE • The aim of this report is to describe our surgical technique of robotic assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion in patients with urinary bladder cancer. PATIENTS AND METHODS • A total of 45 patients (7 women and 38 men) with high-grade and/or muscle-invasive urothelial cancer of the bladder underwent RARC and intracorporeal urinary diversion at our department. • Orthotopic ileal neobladder was performed in 36 patients and ileal conduit was performed in 9 patients. RESULT • Except in two patients that operation was converted to open surgery during the reconstruction of the orthotopic neobladder, the procedure was performed totally intracorporeal. • The operations time, estimated blood loss and length for hospital stay were decreased over the time. CONCLUSION • RARC with totally intracorporeal urinary diversion is feasible.
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Affiliation(s)
- Abolfazl Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.
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Jonsson MN, Adding LC, Hosseini A, Schumacher MC, Volz D, Nilsson A, Carlsson S, Wiklund NP. Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder. Eur Urol 2011; 60:1066-73. [PMID: 21852033 DOI: 10.1016/j.eururo.2011.07.035] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/08/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Robot-assisted radical cystectomy (RARC) may reduce morbidity after cystectomy. Descriptions of the surgical techniques of RARC with intracorporeal orthotopic neobladder or ileal conduit are sparse and oncologic and functional outcome data have not been reported. OBJECTIVE We present our technique with RARC and intracorporeal urinary diversion (neobladder or ileal conduit) and present oncologic and functional outcomes, as well as complication rates. DESIGN, SETTING, AND PARTICIPANTS Single-hospital institution case-series from 2004 to 2009 including 45 selected patients (38 male, 7 female) with high-grade and/or muscle-invasive urothelial cancer of the bladder. SURGICAL PROCEDURE We performed RARC; pelvic lymph node dissection using three different templates; and a totally intracorporeal urinary diversion, either orthotopic neobladder (n=36) or ileal conduit (n=9). MEASUREMENTS Perioperative variables, pathology data, early and late complication rates, urinary continence, potency, and cancer-specific survival were evaluated as outcome measures. RESULTS AND LIMITATIONS Median patient age, operative time, estimated blood loss, and lymph node yield were 62 yr (range: 37-79), 477 min (range: 325-760), 550 ml (range: 200-2200), and 19 (range: 10-52), respectively. Nine patients were diagnosed with positive lymph nodes. Surgical margins were clear in all but one patient. Early complications occurred in 18 patients (40%). Median postoperative stay was 9 d (range: 4-78), and median postoperative follow-up time was 25 mo. Four patients died due to metastatic disease. The study is limited by a relative small sample size and no comparative group. CONCLUSIONS RARC with totally intracorporeal urinary diversion is technically feasible with good intermediate-term oncologic results. This is a nonrandomised study including a limited number of patients with a restricted follow-up time, however, and so precautions must be considered when interpreting the outcomes.
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Affiliation(s)
- Martin N Jonsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
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Affiliation(s)
- N Peter Wiklund
- Department of Molecular Medicine and surgery section of Urology, Karolinska Institutet, Stockholm, Sweden
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Nilsson AE, Carlsson S, Johansson E, Jonsson MN, Adding C, Nyberg T, Steineck G, Wiklund NP. Orgasm-associated urinary incontinence and sexual life after radical prostatectomy. J Sex Med 2011; 8:2632-9. [PMID: 21699660 DOI: 10.1111/j.1743-6109.2011.02347.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Involuntary release of urine during sexual climax, orgasm-associated urinary incontinence, occurs frequently after radical prostatectomy. We know little about its prevalence and its effect on sexual satisfaction. AIM To determine the prevalence of orgasm-associated incontinence after radical prostatectomy and its effect on sexual satisfaction. METHODS Consecutive series, follow-up at one point in calendar time of men having undergone radical prostatectomy (open surgery or robot-assisted laparoscopic surgery) at Karolinska University Hospital, Stockholm, Sweden, 2002-2006. Of the 1,411 eligible men, 1,288 (91%) men completed a study-specific questionnaire. MAIN OUTCOME MEASURE Prevalence rate of orgasm-associated incontinence. RESULTS Of the 1,288 men providing information, 691 were sexually active. Altogether, 268 men reported orgasm-associated urinary incontinence, of whom 230 (86%) were otherwise continent. When comparing them with the 422 not reporting the symptom but being sexually active, we found a prevalence ratio (with 95% confidence interval) of 1.5 (1.2-1.8) for not being able to satisfy the partner, 2.1 (1.1-3.5) for avoiding sexual activity because of fear of failing, 1.5 (1.1-2.1) for low orgasmic satisfaction, and 1.4 (1.2-1.7) for having sexual intercourse infrequently. Prevalence ratios increase in prostate-cancer survivors with a higher frequency of orgasm-associated urinary incontinence. CONCLUSION We found orgasm-associated urinary incontinence to occur among a fifth of prostate cancer survivors having undergone radical prostatectomy, most of whom are continent when not engaged in sexual activity. The symptom was associated with several aspects of sexual life.
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Affiliation(s)
- Andreas E Nilsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.
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Ryk C, Wiklund NP, Nyberg T, De Verdier PJ. Ser608Leu polymorphisms in the nitric oxide synthase-2 gene may influence urinary bladder cancer pathogenesis. ACTA ACUST UNITED AC 2011; 45:319-25. [PMID: 21612325 DOI: 10.3109/00365599.2011.584901] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to analyse whether the exonic Ser608Leu (rs2297518) polymorphism in nitric oxide synthase-2 (NOS2) influences urinarybladder cancer risk and pathogenesis. MATERIAL AND METHODS Genotyping of 359 bladder cancer patients from a population-based cohort and 164 population controls was carried out by allelic discrimination and sequencing. Genotypes were combined with information on tumour stage, grade, stage progression and cancer-specific death, from a 5-year clinical follow-up. RESULTS For the Ser608Leu polymorphism, TT homozygotes had three-fold higher odds for bladder cancer (p = 0.081), but once ill, a lower risk for stage progression (p = 0.031) and a better prognosis. CONCLUSIONS The data indicate that the Tallele of the NOS2 Ser608Leu polymorphism is an initial risk factor for developing urinary bladder cancer. Among bladder cancer patients, however, individuals who are TT homozygous have a lower risk of developing muscle-invasive disease and a higher cancer-specific survival. Depending on the cellular context, nitric oxide can induce proliferation as well as apoptosis. The results from this and previous studies suggest that NOS2 polymorphisms may influence both the risk of contracting bladder cancer and the aggressiveness of the disease.
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Affiliation(s)
- Charlotta Ryk
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Nilsson AE, Schumacher MC, Johansson E, Carlsson S, Stranne J, Nyberg T, Wiklund NP, Steineck G. Age at surgery, educational level and long-term urinary incontinence after radical prostatectomy. BJU Int 2011; 108:1572-7. [DOI: 10.1111/j.1464-410x.2011.10231.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Jonsson MN, Mahmood M, Askerud T, Hellborg H, Ramel S, Wiklund NP, Kjellman M, Ahlberg G. ProMIS™ can serve as a da Vinci® simulator--a construct validity study. J Endourol 2010; 25:345-50. [PMID: 21114413 DOI: 10.1089/end.2010.0220] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE The purpose of this study was to investigate if the ProMIS™ simulator could serve as a training platform for the da Vinci® surgical system and if this constellation could prove construct validity. MATERIALS AND METHODS The da Vinci system was connected to the ProMIS simulator, which registered objective data concerning how the surgeon performed in the box environment related to time, path, and smoothness. Five experienced robotic surgeons passed four different surgical tasks with progressive difficulty. A novice group-constituted of 13 consultants and 6 residents, none of them with any previous experience in the da Vinci system-passed the same tasks and the data were compared with the results from the expert group. RESULTS A statistically significant difference between experts and novices was demonstrated in all tasks concerning time and smoothness. For the parameter path, significant difference was only noted in the more complex tasks. CONCLUSIONS Our study showed that ProMis could differentiate between experienced robotic surgeons and novices, thereby proving construct validity. Smoothness appeared to be the most sensitive objective parameter in our study. Tasks with high complexity are recommended when designing the program for robotic training.
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Affiliation(s)
- Martin N Jonsson
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Thulin H, Kreicbergs U, Onelöv E, Ahlstrand C, Carringer M, Holmäng S, Ljungberg B, Malmström PU, Robinsson D, Wijkström H, Wiklund NP, Steineck G, Henningsohn L. Defecation disturbances after cystectomy for urinary bladder cancer. BJU Int 2010; 108:196-203. [PMID: 21050359 DOI: 10.1111/j.1464-410x.2010.09815.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE • To describe and compare long-term defecation disturbances in patients who had undergone a cystectomy due to urinary bladder cancer with non-continent urostomies, continent reservoirs and orthotopic neobladder urinary diversions. PATIENTS AND METHODS • During their follow-up we attempted to contact all men and women aged 30-80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. • During a qualitative phase we identified defecation disturbances as a distressful symptom and included this item in a study-specific questionnaire together with free-hand comments. The patients completed the questionnaire at home. • Outcome variables were dichotomized and the results are presented as relative risks with 95% confidence interval. RESULTS • The questionnaire was returned from 452 (92%) of 491 identified patients. Up to 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). • A sense of decreased straining capacity was reported by 20% of the men and women with non-continent urostomy and 14% and 8% of those with continent reservoirs and orthotopic neobladders, respectively. CONCLUSIONS • Of the cystectomized individuals 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). • Those wanting to improve the situation for bladder cancer survivors may consider communicating before surgery the possibility of stool-emptying problems, and asking about them after surgery.
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Affiliation(s)
- Helena Thulin
- Division of Clinical Cancer Epidemiology, Department of Oncology and Pathology, Karolinska Institutet, Karolinska University Hospital-Huddinge, Stockholm, Sweden.
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Ryk C, Steineck G, Wiklund NP, Nyberg T, de Verdier PJ. The (CCTTT)n microsatellite polymorphism in the nitric oxide synthase 2 gene may influence bladder cancer pathogenesis. J Urol 2010; 184:2150-7. [PMID: 20850837 DOI: 10.1016/j.juro.2010.06.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Indexed: 01/22/2023]
Abstract
PURPOSE We analyzed whether the NOS2 promoter microsatellite (CCTTT)n polymorphism influences bladder cancer pathogenesis. MATERIALS AND METHODS We genotyped 359 patients with bladder cancer in a population based cohort and 164 population controls by DNA fragment analysis and sequencing. Genotypes were combined with information on tumor stage, grade and stage, grade progression and cancer specific death. Clinical followup was 5 years. RESULTS We divided (CCTTT)n alleles into short-10 or fewer, intermediate-11 or 12 and long-13 or greater repeats. Patients homozygous for 13 or longer (CCTTT)n repeats were at decreased odds ratio for bladder cancer (p = 0.010). However, after illness developed they were at 3-fold increased hazard ratio for stage progression (p = 0.062) and 4-fold increased hazard ratio for death from bladder cancer (p = 0.056). We discovered what is to our knowledge a previously undescribed polymorphism at position 23105343 (C/T). There was no difference in frequency between bladder cancer cases and population controls for this polymorphism. No associations were found between tumor stage, grade or stage and grade progression. However, patients with bladder cancer with the heterozygous CT genotype were at 3-fold increased hazard ratio of death from cancer (p = 0.011). CONCLUSIONS Nitric oxide can induce proliferation or apoptosis depending on the cellular context. Results suggest that the (CCTTT)n NOS2 microsatellite may influence bladder cancer risk and aggressiveness. This polymorphism may have an impact on disease pathogenesis, possibly by affecting intracellular nitric oxide levels.
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Affiliation(s)
- Charlotta Ryk
- Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Abstract
OBJECTIVE Beta-tubulin isotype III is a microtubule component associated with resistance to chemotherapy and poor outcome in various cancers. This study aimed to investigate its expression in prostate cancer and its role as a prognostic factor in this setting. MATERIAL AND METHODS A tissue microarray was constructed of 289 prostate cancers from radical prostatectomy specimens with a median follow-up of 48.9 months. Slides were immunostained for β-tubulin III. The intensity and extent of immunoreactivity and their product [immunoreactivity product (IRP)] were evaluated. RESULTS Tubulin III was expressed in the cytoplasm of prostate cancer cells but not in benign glands. Only 11.6% of cancers were positive for tubulin III. Among low-grade (Gleason score 5-6) and high-grade (Gleason score 7-10) cancers, 6.0% and 16.6% were positive, respectively (p = 0.006). β-Tubulin III expression was more often seen in high-stage disease and more often in metastases (62.5%) than in primary lesions (11.6%) (p < 0.001). The intensity, extent and IRP of tubulin III all predicted biochemical recurrence in univariate Cox analysis (p = 0.02, p = 0.048 and p = 0.012, respectively). IRP was an independent predictor of prognosis when adjusted for serum prostate-specific antigen in a multivariate Cox analysis (p = 0.005), but not when the Gleason score was added to the model (p = 0.17). CONCLUSION β-Tubulin III predicts biochemical recurrence after radical prostatectomy in a subset of patients. Its practical utility is limited by the low number of cases positive for this biomarker.
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Affiliation(s)
- Lars Egevad
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
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Abstract
Nitrite has been implicated in carcinogenesis, especially under acidic conditions such as in the stomach or in urine, where it forms nitrosating species that can react with secondary amines to form nitrosamines. Recent studies have shown that nitrite and acid form a variety of other nitrogen oxides in vivo including nitric oxide-a compound with documented antitumor activity. Here we tested the effects of nitrite on bladder tumor cells incubated in mildly acidified urine. Nitrite (50 microM) inhibited thymidine incorporation in human T24 bladder cancer cells. This inhibition required slight acidification (pH 5.5-6), and no effect of nitrite could be observed at pH 7. Nitrite effects were further augmented in the presence of ascorbic acid, whereas ascorbic acid alone had no effect. The effects were paralleled by formation of nitric oxide gas. We here demonstrate an inhibitory effect of nitrite on cancer cell replication at concentrations and acidity commonly found in urine and gastric juice. The inhibitory effect is likely caused by nitric oxide and possibly other reactive nitrogen oxides formed from acidified nitrite.
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Thorstenson A, Schumacher MC, Wiklund NP, Jonsson MN, Larsson P, Wijkström H, Onelöv E, Steineck G, De Verdier PJ. Diagnostic random bladder biopsies: reflections from a population-based cohort of 538 patients. ACTA ACUST UNITED AC 2010; 44:11-9. [PMID: 19958071 DOI: 10.3109/00365590903419020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess whether diagnostic random bladder biopsies and the detection of concomitant carcinoma in situ (CIS) have an impact on the frequency of intravesical bacille Calmette-Guérin (BCG) instillations or radical cystectomy; and whether this affects the cancer-specific survival in patients with pTaG3 or pT1G1-G3 transitional cell carcinoma of the urinary bladder. MATERIAL AND METHODS A population-based cohort of 538 patients with newly diagnosed bladder cancer was prospectively registered in the Stockholm County during 1995 and 1996 and followed for more than 5 years. RESULTS Random biopsies were recommended in all patients but the decision to take biopsies was made by the treating urologist and hence performed in 326 out of 538 patients (61%), which revealed concomitant CIS in 47 patients(14%). Sixty out of 103 (58%) patients with pTaG3 or pT1G1-G3 tumours, in whom random biopsies were performed, received intravesical BCG compared with five out of 22 patients (23%) where random biopsies were not taken (p = 0.004). Moreover, 23 out of 103 patients (22%) with pTaG3 or pT1G1-G3 tumours in whom random biopsies were performed underwent radical cystectomy compared with none out of 22 patients (0%) without random biopsies (p = 0.013). The Cox proportional hazard ratio for death due to bladder cancer in patients with pTaG3 or pT1G1-G3 tumours among patients not having versus having undergone random biopsies was 2.5 (95% confidence interval 1.1-5.6). CONCLUSION Patients diagnosed in Stockholm in 1995 or 1996 with pTaG3 or pT1G1-G3 bladder tumours having undergone random bladder biopsies more frequently underwent BCG treatment and radical cystectomy and had higher cancer-specific survival than patients who did not undergo random biopsies.
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Affiliation(s)
- Andreas Thorstenson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska University Hospital, Stockholm, Sweden
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Ryk C, Steineck G, Wiklund NP, Nyberg T, de Verdier P. 964 POLYMORPHISMS IN NITRIC-OXIDE SYNTHASE 2 INFLUENCE URINARY-BLADDER CANCER PATHOGENESIS. J Urol 2010. [DOI: 10.1016/j.juro.2010.02.1911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Thulin H, Steineck G, Kreicbergs U, Onelöv E, Ahlstrand C, Carringer M, Holmäng S, Ljungberg B, Malmström PU, Robinsson D, Wijkström H, Wiklund NP, Henningsohn L. Hygiene and urinary tract infections after cystectomy in 452 Swedish survivors of bladder cancer. BJU Int 2010; 105:1107-17. [DOI: 10.1111/j.1464-410x.2009.08909.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The pathophysiology of cluster headache (CH) is only partly understood. Nitric oxide (NO), a potent vasodilator, has been suggested to be involved, and increased plasma levels of nitrite, a stable product on NO degradation, have been identified in the active period and in remission. The aim of our study was to investigate the role of NO in CH by measuring its oxidation products, nitrite and nitrate, in the cerebrospinal fluid (CSF), a biological compartment closer to the supposed focus of the disorder. We collected CSF from 14 episodic CH patients. Lumbar puncture (LP) was performed at two occasions: in active period between headache attacks, and in remission, not earlier than three weeks after the last CH attack. Eleven healthy volunteers served as controls. To estimate NO production, we determined the levels of NO-oxidation end products (NOx), that is, the sum of nitrite and nitrate, by using capillary electrophoresis. CH patients in the active period had significantly increased NOx levels (mean 9.3, 95% confidence interval [CI] 8.5-10.1) compared with those in remission (mean 7.6, 95% CI 6.9-8.2; p < 001) and control subjects (mean 6.2, 95% CI 4.9-7.5; p < 0.001). CH patients also had statistically significant enhanced NOx levels in remission compared with those of control subjects (p = 0.034). CSF was also analysed with regard to inflammatory parameters and protein content. CSF showed signs of pleocytosis or oligoclonal bands or albumin increase in 43% of CH patients although these results were not conclusive. We suggest that CH patients have a generally raised NO tonus, both in the active period and in remission. We interpret these results as indications of a basal hyperfunction of the L-arginine-NO pathway, possibly as an expression of inflammatory activity, and sensitization of pain pathways. This is the first study analysing NOx in CSF in CH, and the results support NO involvement in the pathogenesis of CH.
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Schumacher MC, Holmäng S, Davidsson T, Friedrich B, Pedersen J, Wiklund NP. Transurethral Resection of Non–Muscle-Invasive Bladder Transitional Cell Cancers With or Without 5-Aminolevulinic Acid Under Visible and Fluorescent Light: Results of a Prospective, Randomised, Multicentre Study. Eur Urol 2010; 57:293-9. [DOI: 10.1016/j.eururo.2009.10.030] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 10/27/2009] [Indexed: 10/20/2022]
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Thorstenson A, O'connor RC, Ahonen R, Jonsson MN, Wijkström H, Akre O, Hosseini A, Wiklund NP, Henningsohn L. Clinical outcome following prostatic capsule- and seminal-sparing cystectomy for bladder cancer in 25 men. ACTA ACUST UNITED AC 2009; 43:127-32. [DOI: 10.1080/00365590802571751] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - R. Corey O'connor
- Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Riitta Ahonen
- Department of Molecular Medicine and Surgery, Section of Urology
| | | | | | - Olof Akre
- Division of Urology, CLINTEC
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - N. Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology
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Abstract
OBJECTIVE The last decade has witnessed an increasing trend towards minimally invasive management of prostate cancer, including laparoscopic and, more recently, robot-assisted laparoscopic prostatectomy. Several different laparoscopic approaches have been continuously developed during the last 5 years and it is still unclear which technique yields the best outcome. We present our current technique of robot-assisted laparoscopic radical prostatectomy. MATERIAL AND METHODS The technique described has evolved during the course of >400 robotic prostatectomies performed by the robotic team since the robot-assisted laparoscopic radical prostatectomy program was introduced at Karolinska University Hospital in January 2002. SURGICAL PROCEDURE Our procedure comprises several modifications of previously reported ones, and we utilize fewer robotic instruments to reduce costs. An extended posterior dissection is performed to aid in the bladder neck-sparing dissection. In nerve-sparing procedures the vesicles are divided to avoid damage to the erectile nerves. In order to preserve the apical anatomy the dorsal venous complex is incised sharply and is first over-sewn after the apical dissection is completed. CONCLUSIONS Our technique enables a more fluent dissection than previously described robotic techniques. Minimizing changes of instruments and the camera not only cuts costs but also reduces inefficient operating maneuvers, such as switching between 30 degrees and 0 degrees lenses during the procedure. We present a technique which in our hands has achieved excellent functional and oncological results.
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Affiliation(s)
- Andreas E Nilsson
- Department of Urology, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden.
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Stranne J, Nilsson AE, Carlsson S, Johansson E, Onelöv E, Wiklund NP, Steineck G. ROBOT ASSISTED RADICAL PROSTATECTOMY HALVES THE RISK OF POST-OPERATIVE INGUINAL HERNIA FORMATION AS COMPARED TO OPEN RADICAL RETROPUBIC PROSTATECTOMY. J Urol 2009. [DOI: 10.1016/s0022-5347(09)62112-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jonsson M, Schumacher MC, Hosseini A, Thorstenson A, Haendler L, Nilsson AE, Carlsson S, Wiklund NP. ROBOT-ASSISTED RADICAL CYSTECTOMY WITH TOTALLY INTRACORPOREAL URINARY DIVERSION IN PATIENTS WITH TRANSITIONAL CELL CARCINOMA OF THE BLADDER. J Urol 2009. [DOI: 10.1016/s0022-5347(09)60810-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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