Novel laser therapies and new technologies in the endoscopic management of upper tract urothelial carcinoma: a narrative review

Background and Objective

Upper tract urothelial carcinoma (UTUC) is a rare disease. The gold standard treatment is radical nephroureterectomy (RNU). Endoscopic management of UTUC has emerged as an alternative therapy that aims to preserve kidney function while providing effective oncologic control. Over the years, this has become an increasingly important alternative to RNU for treating UTUC in patients with localized disease. Advancements in lasers and endoscopic technology have continued to expand the applications of endoscopic nephron-sparing treatment. This review aims to provide an overview of the available lasers and ureteroscopic technologies used in treating UTUC with a focus on their clinical applications and outcomes.

Methods

A comprehensive literature review was completed using PubMed to create this narrative mini review. Publications from peer-reviewed journals written in English between 1987 to 2022 were evaluated by the authors for inclusion.

Key Content and Findings

Improvements in ureteroscopic technology have led to improved visualization and tumor detection. Laser ablation using different laser energies including the holmium/yttrium-aluminum-garnet, neodymium/YAG, and thulium/YAG has demonstrated promising oncologic outcomes. However, accurate staging and risk-stratification remain limitations to the role of laser ablation for the treatment of UTUC. This review also highlights appropriate patient selection as a critical component of successful endoscopic management.

Conclusions

The continued evolution of endoscopic management will rely on the development of new technologies to improve risk stratification and oncologic outcomes. Overall, this review provides insights into the available laser therapies and ureteroscopic technologies for the endoscopic management of UTUC.

Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis

OBJECTIVE

To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices.

PATIENTS AND METHODS

Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ² tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation.

RESULTS

The median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001).

CONCLUSION

In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.

Wide Variation in Opioid Prescribing After Urological Surgery in Tertiary Care Centers

OBJECTIVE

To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery.

PATIENTS AND METHODS

We identified 11,829 patients who underwent 21 urological surgical procedures at 3 associated facilities from January 1, 2015, through December 31, 2016. After converting opioids to oral morphine equivalents (OMEs), prescribing patterns were compared within and across procedures. Subgroup analysis for opioid-naive patients (those without a history of long-term opioid use) was performed. Statistical analysis was utilized to evaluate variations based on demographic and perioperative/postoperative variables.

RESULTS

Of the 11,829 patients, 9229 (78.0%) were prescribed an opioid at discharge, and the median (interquartile range [IQR]) OME prescribed was 188 (150-225). The remaining 9253 patients (78.2%) were considered opioid naive. Striking variation in prescribing patterns was observed within and across surgical procedures. For instance, IQR ranges of 150 or greater were observed for open cystectomy (median, 300; IQR, 210-375], open radical nephrectomy (median, 300; IQR, 225-375), retroperitoneal node dissection (median, 300; IQR, 225-375), hand-assisted laparoscopic nephrectomy (median, 225; IQR, 150-300), and penile prosthesis (median, 225; IQR, 150-315). On multivariate analysis, younger age, cancer diagnosis, and inpatient hospitalization were associated with higher likelihood of receiving a highest-quartile OME prescription for opioid naive patients. Thirty-day refill rates varied from 1.6% to 25.9%. Interestingly, refill rates were higher in patients receiving more opioids at discharge.

CONCLUSION

The United States is facing an opioid epidemic, and physicians must take action. In this study, we found considerable variation in opioid prescribing patterns within and across surgical procedures. These data provide support for the development of standardized opioid prescribing guidelines for postoperative analgesia.

Hand problems among endourologists

BACKGROUND AND PURPOSE

Endourology has evolved rapidly for the management of both benign and malignant disease of the upper urinary tract. Limited data exist, however, on the occupational hazards posed by complex endourologic procedures. The aim of this study was to determine the prevalence and possible causes of hand problems among endourologists who routinely perform flexible ureteroscopy compared with controls.

MATERIALS AND METHODS

An online computer survey targeted members of the Endourological Society and psychiatrists in academic and community settings. A total of 600 endourologists and 578 psychiatrists were contacted by e-mail. Invited physicians were queried regarding their practice settings and symptoms of hand pain, neuropathy, and/or discomfort.

RESULTS

Survey responses were obtained from 122 (20.3%) endourologists and 74 (12.8%) psychiatrists. Of endourologists, 61% were in an academic setting and 70% devoted their practice to endourology. Endourologists were in practice for a mean 13 years, performing 4.5 ureteroscopic cases per week with a mean operative time of 50 minutes. Hand/wrist problems were reported by 39 (32%) endourologists compared with 14 (19%) psychiatrists (P=0.0486, relative risk [RR]=1.69). Surgeons who preferred counterintuitive ureteroscope deflection were significantly more likely to have problems (56%) compared with intuitive users (27%) (RR 2.07, P=0.0139) or those with no preference (26%) (RR 2.15, P=0.0451). Overall, most respondents (85%) with hand/wrist problems needed either medical or surgical intervention.

CONCLUSIONS

Hand and wrist problems are very common among endourologists. Future studies are needed to develop more ergonomic platforms and thereby reduce the endourologist's exposure to these occupational hazards.

What is the cost of maintaining a kidney in upper-tract transitional-cell carcinoma? An objective analysis of cost and survival

BACKGROUND AND PURPOSE

For many years, the gold standard in upper urinary tract transitional-cell carcinoma (UT-TCC) management has been nephroureterectomy with excision of the bladder cuff. Advances in endourologic instrumentation have allowed urologists to manage this malignancy. The feasibility and success of conservative measures for UT-TCC have been widely published, but there has not been an objective cost analysis performed to date. Our goal was to examine the direct costs of renal-sparing conservative measures v nephroureterectomy and subsequent chronic kidney disease (CKD) or end-stage renal disease (ESRD). Secondary analysis includes a discussion of survival and quality-of-life issues for both treatment cohorts.

PATIENTS AND METHODS

Retrospective review of a cohort of patients treated at our institution with renal-sparing ureteroscopic management of UT-TCC who were followed for a minimum of 2 years. The costs per case were based on equipment, anesthesia, surgeon fees, pathologic evaluation fees, and hospital stay. ESRD and CKD costs were estimated based on published reports.

RESULTS

From 1996 to 2006, 254 patients were evaluated and treated for UT-TCC at our institution. A cohort of 57 patients was examined who had a minimum follow-up period of 2 years. Renal preservation in our series approached 81%, with cancer-specific survival of 94.7%. Assuming a worst-case scenario of a solitary kidney with recurrences at each follow-up for 5 years v nephroureterectomy and dialysis for the same period, an estimated $252,272 U.S. dollars would be saved. This savings would cover the expenses of five cadaveric renal transplantations.

CONCLUSIONS

Conservative endoscopic management of UT-TCC in our experience should be the gold standard management for low-grade and superficial-stage disease. From a cost perspective, renal-sparing UT-TCC management is effective in reducing ESRD health care expenses.

Simple aspiration technique to address voiding dysfunction associated with transurethral injection of dextranomer/hyaluronic acid copolymer

Dextranomer/hyaluronic acid copolymer (Zuidex) is currently under Food and Drug Administration investigation for use as a transurethral bulking agent to treat female stress urinary incontinence secondary to intrinsic sphincter deficiency. Urethral obstruction is a recognized complication of bulking agents. We describe an aspiration method to address iatrogenic voiding dysfunction resulting from this therapy.

Review of vitamin E and selenium in the prevention of prostate cancer: implications of the selenium and vitamin E chemoprevention trial

The National Cancer Institute in cooperation with the Southwest Oncology Group has begun one of the largest prostate cancer prevention studies to date, the Selenium and Vitamin E Chemoprevention Trial (SELECT). The purpose of this article is to review the evidence and discuss the individual antioxidant compounds under study. The authors comprehensively reviewed the peer-reviewed literature on the chemoprevention of prostate cancer with emphasis on the antioxidants vitamin E and selenium. The credible leads for the primary prevention of prostate cancer using selenium and vitamin E have emerged as secondary findings from randomized controlled trials with corroborative evidence from observational and in vitro studies. Selenium and vitamin E are widely available compounds that are safe if taken in moderation, with relatively few adverse effects. The evidence in support of the antioxidants in the primary prevention of prostate cancer is promising, and the next step in definitively answering the question has been addressed by the investigators of SELECT. The SELECT study will define the role of the antioxidants selenium and vitamin E in the prevention of prostate cancer; complete data from the study will be available in 12 years.

Trospium chloride: A quaternary amine with unique pharmacologic properties

The mainstay of pharmacologic treatment of overactive bladder is anticholinergic therapy. Cholinergic blockade is efficacious in decreasing the symptoms of urgency, frequency, and urge incontinence, but also is associated with undesirable side effects such as dry mouth, blurred vision, constipation, and central nervous system side effects. The property of anticholinergic agents that has been associated with increased efficacy and tolerability is receptor specificity. The safety of anticholinergic agents has been associated with the pharmacokinetics, metabolism, protein binding, and ability to penetrate the blood brain barrier. Trospium chloride, available in Europe for more than 20 years and under review by the US Food and Drug Administration for the treatment of overactive bladder, is a quaternary amine that is minimally metabolized, not highly protein-bound, and theoretically should not cross the blood brain barrier. Some of the characteristics of this unique anticholinergic agent are reviewed in this article and the relative contributions of these factors are discussed.