ABSTRACT
INTRODUCTION: The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group. METHODS: The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report. RESULTS: There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy. CONCLUSIONS: Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC.
Subject(s)
Antineoplastic Agents/therapeutic use , Carcinoma in Situ/therapy , Carcinoma, Transitional Cell/therapy , Kidney Neoplasms/therapy , Kidney Pelvis/surgery , Ureteral Neoplasms/therapy , Administration, Intravesical , Administration, Topical , Carcinoma in Situ/diagnostic imaging , Carcinoma in Situ/pathology , Carcinoma, Transitional Cell/diagnostic imaging , Carcinoma, Transitional Cell/pathology , Combined Modality Therapy , Cystoscopy , Disease-Free Survival , Humans , Kidney Neoplasms/diagnostic imaging , Kidney Neoplasms/pathology , Kidney Pelvis/diagnostic imaging , Kidney Pelvis/pathology , Lymph Node Excision , Minimally Invasive Surgical Procedures , Nephrectomy , Nephrostomy, Percutaneous , Organ Sparing Treatments , Practice Guidelines as Topic , Risk Assessment , Societies, Medical , Tomography, X-Ray Computed , Ureter/surgery , Ureteral Neoplasms/diagnostic imaging , Ureteral Neoplasms/pathology , Ureteroscopy , Urologic Surgical Procedures , UrologyABSTRACT
With more than 60% of radical prostatectomies being performed robotically, robotic-assisted laparoscopic prostatectomy (RALP) has largely replaced the open and laparoscopic approaches and has become the standard of care surgical treatment option for localized prostate cancer in the United States. Accomplishing negative surgical margins while preserving functional outcomes of sexual function and continence play a significant role in determining the success of surgical intervention, particularly since the advent of nerve-sparing (NS) robotic prostatectomy. Recent evidence suggests that NS surgery improves continence in addition to sexual function. In this review, we describe the neuroanatomical concepts and recent developments in the NS technique of RALP with a view to improving the "trifecta" outcomes.
ABSTRACT
Radical nephroureterectomy with en bloc bladder cuff excision and regional lymphadenectomy is the gold standard for the management of high-grade and high-risk upper tract urothelial carcinomas. There are a few prospective randomized controlled studies in this uncommon and often aggressive disease to support level-1 management guidelines. However, recent developments in imaging, minimally invasive techniques, lymphatic dissemination, and bladder cancer prevention raise the hope for improved risk stratification and treatments without compromising, and hopefully improving, oncological outcomes. Multimodality approaches in terms of neoadjuvant, adjuvant topical, and systemic chemotherapeutic regimens are promising, with 2 prospective trials either open or in development.