Partial nephrectomy, thermal ablation and active surveillance are acceptable options for T1 stage renal tumor management. Currently, we lack sufficient information to make an accurate comparison of ...thermal ablation with active surveillance. The study objectives were to compare thermal ablation with active surveillance indirectly using partial nephrectomy as a reference.
We performed a systematic literature search using two databases (Scopus and Medline). The detailed search strategy is available at Prospero, CRD42021290055. The primary outcome was cancer-specific survival. Secondary outcomes included overall survival and metastasis-free survival.
The final sample comprised 33 articles. They included the ones that compare: partial nephrectomy to ablation (29 studies), partial nephrectomy to active surveillance (2 studies), and partial nephrectomy vs. active surveillance vs. ablation (2 articles). We assessed 3-year and 5-year cancer-specific survival, and 3-, 5- and 7-year overall survival. The surface under the cumulative ranking curve (SUCRA) treatment benefit ranking was: cancer-specific survival - 48.6% for thermal ablation and 1.6% for active surveillance (5-year follow-up); overall survival - 52% for thermal ablation and 0.6% for active surveillance (7-year follow-up). The results demonstrated a significantly higher 3-year cancer-specific survival (RR 1.55, P=0.02) and 3- and 7-year follow-up overall survival (RR 1.85, P=0.03) in thermal ablation compared to active surveillance. At 5-year follow-up, cancer-specific survival and overall survival were in favor of thermal ablation while no statistically significant difference was reported.
Thermal ablation offers a significantly higher cancer-specific survival and overall survival at mid-term follow-up in the management of T1 renal tumors compared to active surveillance. However, it is necessary to conduct further prospective randomized studies to validate the data.
Introduction
The Thulium fiber laser (TFL) is a new device that in contrast to the other solid-state YAG-based lasers takes a different approach to pulse formation allowing for two different modes: ...in the QCW (quasi-continuous wave) function, TFL is convenient for soft tissue surgery and in the SP (Superpulsed) mode it is highly effective in lithotripsy. Thus, unlike the other thulium lasers (Tm : YAG), TFL can be used in a wide range of surgical procedures.
Materials and Methods
We conducted a systematic search in 3 databases: Medline, Scopus and Cochrane library. All original articles (both preclinical and clinical) on TFL application in soft tissue surgery were included in data analysis.
Results
In terms of its cutting properties, QCW TFL is not inferior to the other thulium lasers, and in fact allows for decreased carbonization (due to lower heat production) compared to continuous lasers (e.g. Tm : YAG). It has been used successfully in endoscopic enucleation of the prostate (EEP) and in en bloc resection of bladder tumors (ERBT). The efficacy and safety of this laser is comparable to TURP and simple prostatectomy, but the recovery period is shorter and the learning curve is slightly superior to other endoscopic procedures. There are no significant differences between TFL and Ho : YAG in terms of efficacy and safety during EEP. Unfortunately, there are no clinical studies that analyse the efficacy and safety of SP TFL in EEP or ERBT.
Conclusion
TFL is a safe and effective tool for BPH surgery. In terms of parameters, it is in no way inferior to Tm : YAG or Ho : YAG during EEP. However, TFL surpasses these lasers in terms of usability and serviceability. These advantages are likely to render it more popular over time.
Current European Association of Urology (EAU) guidelines support adjuvant intravesical Bacillus Calmette-Guérin (BCG) treatment after Transurethral Resection of Bladder Tumor (TURB) for intermediate- ...or high-risk Non-Muscle-Invasive Bladder Cancer (NMIBC) patients, aiming to reduce the risk of tumor recurrence. The quality of data, however, does not allow definitive conclusions on whether different strains and dosages of BCG have different efficacies on long-term survival outcomes.
To evaluate the long-term survival outcomes of different strains and dosages of BCG in patients with NMIBC.
All NMIBC patients treated with intravesical BCG therapy from 2001 to 2020 were identified using a territory-wide database in Hong Kong.
BCG strains and dosages (Connaught strain 81 mg, Connaught strain 27 mg, Tokyo strain 80 mg, and Danish strain 30 mg) were retrieved from medical records.
Overall Survival (OS), Cancer-Specific Survival (CSS), Recurrence-Free Survival (RFS), and Progression-Free Survival (PFS) were analyzed using the Kaplan-Meier method. A multivariable Cox regression analysis was used to adjust potential confounding factors, and to estimate Hazard Ratio (HR) and 95% confidence interval (CI) of different BCG strains. A further subgroup analysis on adequate versus inadequate BCG treatment was performed.
A total of 2602 NMIBC patients treated with intravesical BCG were identified. Among them, 1291 (49.6%) received Connaught strain 81 mg, 199 (7.6%) received Connaught strain 27 mg, 1014 (39.0%) received Tokyo strain, and 98 (3.8%) received Danish strain. The median follow-up was 11.0 years. No statistically significant differences in OS, CSS, RFS, and PFS were detected among the different groups. At the multivariable analysis, the Connaught strain 27 mg group was inferior to the Connaught strain 81 mg group in terms of OS (HR: 1.26, 95% CI: 1.05-1.51), CSS (HR: 1.69, 95% CI: 1.08-2.66), and PFS (HR: 1.86, 95% CI: 1.20-2.88). Adequate BCG treatment was associated with improved OS (HR: 0.82, 95% CI: 0.73-0.92), CSS (HR: 0.64, 95% CI: 0.47-0.86), RFS (HR: 0.80, 95% CI: 0.70-0.92), and PFS (HR: 0.52, 95% CI: 0.39-0.68). Among patients treated with adequate BCG, at the multivariable analysis the Connaught strain 27 mg group showed worse results than the Connaught strain 81 mg group in terms of CSS (HR: 1.93, 95% CI: 1.07-3.51). Compared with the Connaught strain 81 mg group, both Tokyo and Danish strains had similar survival outcomes in the whole cohort and the adequate BCG treatment subgroup.
Our findings suggest that adequate BCG remains the most important factor in optimizing survival outcomes in patients with intermediate- and high-risk NMIBC. No significant differences in survival outcomes were observed between full-dose Connaught, Tokyo, and Danish strains. Reduced-dose Connaught strain was associated with the worst survival outcomes.
We evaluated the efficacy of different strains and dosages of bacillus Calmette-Guérin (BCG) in patients with intermediate- or high-risk non-muscle-invasive bladder cancer in the past two decades in Hong Kong. We conclude no significant differences in long-term survival outcomes in terms of full-dose Connaught, Tokyo, and Danish strains, while reduced-dose Connaught strain was inferior to the full-dose group. Adequate BCG treatment benefits long-term survival.
•The uPA system was overexpressed in approximately 80% in NMIBC.•The uPA system was associated with tumor grade and tumor size in NMIBC.•The uPA system was associated with disease recurrence and ...progression in NMIBC.
To assess the role of the urokinase plasminogen activator (uPA) system as a prognostic biomarker in patients with nonmuscle invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB) with or without adjuvant intravesical therapy.
We stained TURB tissue from 827 NMIBC patients with uPA, its receptor (uPAR) and its inhibitor (PAI-1). The status of these markers was categorized as normal vs. overexpressed using the cutoffs of 30% for uPA, 50% for uPAR, and 30% for PAI-1. Multivariable Cox regression analyses were performed to evaluate the prognostic value of these markers.
uPA was overexpressed in 37.7% of patients, uPAR in 44.7% and PAI-1 in 44.6%. Overexpression of these markers was associated with high tumor grade. Within a median follow-up was 60 months (interquartile range: 22–109), uPA (hazard ratio HR: 1.40; P = 0.006), uPAR (HR: 1.70; P < 0.001), PAI-1 (HR: 1.35; P = 0.014), and the combination of all 3 markers (HR: 3.38; P < 0.001) were associated with recurrence-free survival (RFS); uPA (HR: 1.68; P = 0.035) and the combination of all 3 markers (HR: 8.79; P = 0.005) were associated with progression-free survival (PFS). The addition of the uPA system to a base model improved the discrimination by 1.3% for RFS and 2.1% for PFS. In subgroup analyses, uPA (HR: 2.19; P = 0.018) was associated with PFS in T1G3 patients and its addition to a base model improved the discrimination by 2.5%. uPA (HR: 1.44; P = 0.019), uPAR (HR: 1.54; P = 0.006), PAI-1 (HR: 1.46; P = 0.013) and the combination of all 3 markers (HR: 3.48; P < 0.001) were associated with RFS in TaG1-2 patients and their addition to a base model improved the discrimination by 2.1%.
uPA, uPAR, and PAI-1 are overexpressed in one-third to half of patients with NMIBC. Their overexpression is an independent prognosticator of RFS and PFS which improved the predictive accuracy of current clinicopathological characteristics. Biomarkers that capture the biological and clinical behavior of individual tumors may help personalize clinical decision-making in patients with NMIBC.
Among various clinicopathologic factors used to identify low-risk upper tract urothelial carcinoma (UTUC), tumor grade and stage are of utmost importance. The clinical value added by inclusion of ...other risk factors remains unproven.
To assess the performance of a tumor grade- and stage-based (GS) model to identify patients with UTUC for whom kidney-sparing surgery (KSS) could be attempted.
In this international study, we reviewed the medical records of 1240 patients with UTUC who underwent radical nephroureterectomy. Complete data needed for risk stratification according to the European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) guidelines were available for 560 patients.
Univariable and multivariable logistic regression analyses were performed to determine if risk factors were associated with the presence of localized UTUC. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the GS, EAU, and NCCN models in predicting pathologic stage were calculated.
Overall, 198 patients (35%) had clinically low-grade, noninvasive tumors, and 283 (51%) had ≤pT1disease. On multivariable analyses, none of the EAU and NCCN risk factors were associated with the presence of non–muscle-invasive UTUC among patients with low-grade and low-stage UTUC. The GS model exhibited the highest accuracy, sensitivity, and negative predictive value among all three models. According to the GS, EAU, and NCCN models, the proportion of patients eligible for KSS was 35%, 6%, and 4%, respectively. Decision curve analysis revealed that the net benefit of the three models was similar within the clinically reasonable range of probability thresholds.
The GS model showed favorable predictive accuracy and identified a greater number of KSS-eligible patients than the EAU and NCCN models. A decision-making algorithm that weighs the benefits of avoiding unnecessary kidney loss against the risk of undertreatment in case of advanced carcinoma is necessary for individualized treatment for UTUC patients.
We assessed the ability of three models to predict low-grade, low-stage disease in patients with cancer of the upper urinary tract. No risk factors other than grade assessed on biopsy and stage assessed from scans were associated with better prediction of localized cancer. A model based on grade and stage may help to identify patients who could benefit from kidney-sparing treatment of their cancer.
Refinement of the current indications for treatment of low-risk upper tract urothelial carcinoma is mandatory. Despite not being perfect, a tumor grade- and stage-based model sets a framework for establishing weighted sequential selection for kidney-sparing surgery.
Measurement of circulation tumour DNA may help in identifying patients who are unlikely to respond to systemic therapy and could serve as a monitoring biomarker during systemic therapy for patients ...with urothelial carcinoma.
We summarise the available data for and assess the prognostic value of circulating tumour DNA (ctDNA) in patients treated with systemic therapy for urothelial carcinoma (UC). Studies were deemed eligible if they reported on oncologic outcomes for patients with UC treated with systemic therapy according to the baseline ctDNA profile (before starting systemic therapy) and/or changes over the course of therapy. Five studies met the eligibility criteria. We found a strong association between high baseline ctDNA levels and worse disease-free survival (DFS; hazard ratio HR 3.53, 95% confidence interval CI 2.58–4.84) and overall survival (OS; HR 2.99, 95% CI 2.17–4.13). Patients with a decline in ctDNA level after immunotherapy had better DFS (HR 0.25, 95% CI 0.13–0.49) and OS (HR 0.10, 95% CI 0.03–0.42) in comparison to patients without a ctDNA decline. Conversely, an increase in ctDNA levels after immunotherapy was associated with worse survival outcomes. Patients with UC who exhibited a decrease in ctDNA levels during systemic therapy had better survival outcomes compared to those with stable or increasing ctDNA levels.
Measurement of tumour DNA in blood may help in identifying patients with cancer of the urinary tract who are unlikely to respond to chemotherapy or immunotherapy. This could serve as a biomarker for monitoring cancer treatment.
The objective of this study is assess the outcomes of whole-gland ablation (high-intensity focused ultrasound (HIFU), cryotherapy and brachytherapy) and active surveillance (AS) in patients with ...low-risk prostate cancer (PCa).
This prospective non-randomised study included 155 patients with low-risk PCa managed with either ablative therapy or AS. Follow-up included mpMRI, biopsies, prostate-specific antigen (PSA), quality of life and complications for up to 24 months. The primary endpoint was cancer progression. The secondary endpoint was the impact of each treatment on the quality of life.
Mean total preoperative PSA was 8.8 ±1.5 ng/ml. Of 155 patients, 125 received treatment: 45 - HIFU; 45 - cryoablation; 35 - brachytherapy. Thirty were under AS. Mean nadir PSA levels were 0.64 ±0.55 ng/ml for HIFU, 0.53 ±0.38 ng/ml for cryoablation and 0.48 ±0.34 ng/ml for brachytherapy. In the AS group, mean PSA was 9.9 ±3.8 ng/ml. Biochemical relapse-free survival rates at 24 months were 81.8% for HIFU, 85% for cryoablation, 93.9% for brachytherapy and 93.3% for AS. In only one HIFU patient relapse was not confirmed on biopsy. Increased anxiety was found in up to 6.7% after treatment and in 36.7% of patients undergoing AS. The Kaplan-Meier analysis revealed no statistical differences between the techniques.
Whole-gland ablative therapy can be considered a viable treatment modality for carefully selected patients with low-risk PCa who are reluctant to select AS due to anxiety.
The article summarizes the findings of Russian and international studies of the genetic aspects of polygenic urolithiasis associated with impairment of calcium metabolism. The article analyzes the ...genetic risk factors of polygenic nephrolithiasis that show significant association with the disease in case-control studies and Genome-Wide Association Studies (16 genes). We described the gene functions involved in concrement formation in polygenic nephrolithiasis. The modern molecular and genetic technologies (DNA microarray, high-throughput DNA sequencing, etc.) enable identification of the genetic predisposition to a specific disease, realization of the individualized treatment of the patient, and carrying out timely preventive measures among the proband’s relatives.
Prostate cancer is the most common cancer amongst men, and one of its treatments in the localized stage is radical prostatectomy (RP). This technique achieves a high success rate regarding ...oncological results, but one of its main drawbacks are sexual disorders, especially erectile dysfunction, ranging from 14-90% of the cases. Therefore, surgery advancements in the last decade have been focused on minimizing the impact on patient’s functioning. Now is time for a step forward in the recovery of functional outcomes after RP. Bioengineering solutions such as stem-cell therapy and tissue engineering hold great opportunities for the treatment of all tissues and organs dysfunctions, which may help in neuroprotection and neuro-regeneration. Specifically, the use of Dehydrated human amnion/chorion membrane (dHACM) allografts and chitosan membranes (ChiMe) aims at reconstructing damaged neurovascular plexuses of the urogenital system to support erectile function recovery. Some research is being done on this topic, and promising results are emerging.
Based on the currently available literature, we have proposed an algorithm to guide the decision-making process to help identify and treat urethral recurrence (UR) after radical cystectomy. Given the ...lack of evidence on how to deal with UR and surveil patients at risk for UR, this study may invigorate research in this area of unmet need.
Surveillance of the urethra and management of urethral recurrence (UR) after radical cystectomy (RC) is an area with poor evidence.
We aimed to summarize the available evidence and provide clinicians with practical recommendations on how to prevent and manage UR after RC for bladder cancer.
The MEDLINE and EMBASE databases were searched during September 2021 for studies evaluating UR after RC. The primary endpoint was oncologic outcomes for patients who experienced UR depending on different surveillance and management approaches.
Forty-three studies were included in the quantitative synthesis. According to the currently available literature, a tight-knitted surveillance protocol should be implemented for males treated with RC and nonorthotopic neobladder diversion as well as patients with prostatic involvement, tumor multifocality, bladder neck involvement, and concomitant carcinoma in situ. A survival benefit of a prophylactic urethrectomy has been reported only in patients at very high risk for UR based on clinical factors. Surveillance protocols were highly heterogeneous and poorly documented among included studies. Patients whose UR was diagnosed based on clinical symptoms had a poor prognosis. Only limited data were available on the comparative effectiveness of watchful waiting after RC versus clinical symptom screening as part of a follow-up strategy. However, the use of regular cytology and/or urethroscopy seems useful in select patients at high risk for UR. Despite limited data on the optimal management of UR, urethra-sparing approaches (transurethral resection of UR) seem to be an option for Ta (only) recurrences; a salvage urethrectomy with or without chemotherapy should be the standard for all others.
Based on the currently available literature, we have proposed an algorithm to guide the decision-making process to help identify and treat UR after RC. Given the lack of evidence on how to deal with UR and surveil patients at risk for UR, this study may invigorate research in this area of unmet need.
Early diagnosis and tailored management of urethral recurrence could help improve oncologic outcomes in these patients.
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