RESUMEN
PURPOSE: To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. METHODS: A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10-12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to "Stop at the point they anticipate ureteral damage, and they would not proceed in real life". RESULTS: Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48-3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05-7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53-10.74). CONCLUSION: The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons' tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.
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Uréter , Uréter/lesiones , Humanos , Procedimientos Quirúrgicos Urológicos/métodos , CirujanosRESUMEN
OBJECTIVES: To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS. MATERIALS AND METHODS: After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided. RESULTS: A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications. CONCLUSION: The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.
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Cálculos Renales , Litotricia , Uréter , Urolitiasis , Humanos , Cálculos Renales/cirugía , Ureteroscopía/métodos , Urolitiasis/cirugía , Litotricia/métodos , Resultado del TratamientoRESUMEN
PURPOSE: The prognosis of upper urinary tract urothelial carcinoma (UTUC) is associated with tumour grade (G) and stage. Despite preoperative risk stratification and radical treatment, recurrence and progression are common. Thus, prognostic and monitoring biomarkers are needed. This feasibility study aimed to investigate if targeted analyses on circulating tumour DNA (ctDNA) in plasma could identify tumour-specific gene variants, and thus have potential for further evaluation as a biomarker in UTUC. METHODS: Nine UTUC patients with genetically characterised tumours were included in this prospective pilot study. Two tumour-specific variants were chosen for targeted analyses with multiplex droplet digital PCR on cell-free DNA (cfDNA) from plasma at diagnosis or from recurrence. RESULTS: Of six patients with diagnostic plasma samples, ctDNA was detected in four with G2 or G3 tumours and tumours > 300m2 in size. Three of these patients progressed in their disease and the fourth had the largest G3 tumour at sampling. In contrast, the two patients with undetectable ctDNA in diagnostic plasma had a G1 tumour and G3 carcinoma in situ (CIS), respectively. The patient with G3 CIS had detectable ctDNA later during follow-up and progressed thereafter with aggressive intravesical recurrence and CT-scan-verified CIS progression in the upper urinary tract. In three patients with small recurrent G1 or G2 tumours, none had detectable ctDNA in plasma and all were progression free. CONCLUSION: Our early findings demonstrate that ctDNA in plasma can be detected by targeted analysis in patients with UTUC. However, further studies are needed to determine its role as a potential biomarker.
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Carcinoma de Células Transicionales , ADN Tumoral Circulante , Neoplasias de la Vejiga Urinaria , Humanos , Neoplasias de la Vejiga Urinaria/patología , Carcinoma de Células Transicionales/diagnóstico , Carcinoma de Células Transicionales/genética , Carcinoma de Células Transicionales/cirugía , Proyectos Piloto , Estudios Prospectivos , Pronóstico , Biomarcadores , Biomarcadores de Tumor/genética , Recurrencia Local de Neoplasia/patologíaRESUMEN
PURPOSE: To map current literature and provide an overview of upcoming future diagnostic and prognostic methods for upper tract urothelial carcinoma (UTUC), including translational medical science. METHODS: A scoping review approach was applied to search the literature. Based on the published literature, and the experts own experience and opinions consensus was reached through discussions at the meeting Consultation on UTUC II in Stockholm, September 2022. RESULTS: The gene mutational profile of UTUC correlates with stage, grade, prognosis, and response to different therapeutic strategies. Analysis of pathway proteins downstream of known pathogenic mutations might be an alternative approach. Liquid biopsies of cell-free DNA may detect UTUC with a higher sensitivity and specificity than urinary cytology. Extracellular vesicles from tumour cells can be detected in urine and may be used to identify the location of the urothelial carcinoma in the urinary tract. 3D microscopy of UTUC samples may add information in the analysis of tumour stage. Chemokines and chemokine receptors were linked to overall survival and responsiveness to neoadjuvant chemotherapy in muscle-invasive bladder cancer, which is potentially also of interest in UTUC. CONCLUSION: Current diagnostic methods for UTUC have shortcomings, especially concerning prognostication, which is important for personalized treatment decisions. There are several upcoming methods that may be of interest for UTUC. Most have been studied for urothelial carcinoma of the bladder, and it is important to keep in mind that UTUC is a different entity and not all methods are adaptable or applicable to UTUC.
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Carcinoma de Células Transicionales , Neoplasias Renales , Neoplasias Ureterales , Neoplasias de la Vejiga Urinaria , Humanos , Carcinoma de Células Transicionales/diagnóstico , Carcinoma de Células Transicionales/genética , Carcinoma de Células Transicionales/patología , Neoplasias de la Vejiga Urinaria/diagnóstico , Neoplasias de la Vejiga Urinaria/genética , Pronóstico , Neoplasias Renales/diagnóstico , Neoplasias Renales/genética , Neoplasias Renales/patología , Neoplasias Ureterales/patologíaRESUMEN
PURPOSE: To summarise the current knowledge regarding diagnostics, prognostication and follow-up in upper tract urothelial carcinoma (UTUC). METHODS: A scoping review combined with expert opinion was applied to provide an overview of the current research field. Based on the published literature and the experts' own experience and opinions, consensus was reached through presentations and discussions at the meeting Consultation on UTUC II in Stockholm 2022. RESULTS: The strongest prognostic factors in UTUC are tumour grade and stage. They are correlated, and grade is used for indirect staging. The diagnostic examinations should include multiphase computed tomography urography (CTU) with corticomedullary phase, and urethrocystoscopy with cytology. If there is no clear diagnosis for clinical decision-making, ureterorenoscopy (URS) with focal cytology and biopsies should be performed. Both WHO classification systems (1973/1999 and 2004/2016) should be used. Novel biomarker tests are not yet widespread nor recommended for the detection of UTUC. Long-term, regular follow-up, including URS in patients who have had organ-sparing treatment, is important to check for tumour recurrences, intravesical recurrences, metastases and progression of the tumour. CONCLUSION: Proper diagnostics with correct grading of UTUC are necessary for appropriate treatment decisions. The diagnostics should include CTU with corticomedullary phase, urine or bladder cytology, URS with focal barbotage cytology, and biopsies when needed for proper diagnosis and risk stratification. Regular, long-term follow-ups are fundamental, due to the high rate of recurrence and risk of progression.
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Carcinoma de Células Transicionales , Neoplasias Renales , Neoplasias Ureterales , Neoplasias de la Vejiga Urinaria , Humanos , Carcinoma de Células Transicionales/patología , Neoplasias de la Vejiga Urinaria/diagnóstico , Neoplasias Renales/patología , Estudios de Seguimiento , Neoplasias Ureterales/patología , Recurrencia Local de Neoplasia/diagnósticoRESUMEN
OBJECTIVES: To investigate gene alterations as diagnostic and prognostic markers in upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: Patients with UTUC who underwent nephroureterectomy between 2005 and 2012 were followed until November 2020. DNA was extracted from paraffin-embedded tumour tissue. Next-generation sequencing using a 388-gene panel was performed. First a blinded analysis using principal component analysis and hierarchical clustering was used to search for patterns of mutations. Then a comparative analysis using analysis of variance (ANOVA) was used to search for mutations enriched in groups of various grades, stages, and survival. In addition, careful manual annotation was used to identify pathogenic mutations over-represented in tumours of high grade/stage and/or poor survival. RESULTS: A total of 39 patients were included. All tumour stages and grades were represented in the cohort. The median follow-up was 10.6 years. In all, 11 patients died from UTUC during the follow-up. Tumour mutational burden showed a statistically significant correlation with stage, grade, and stage + grade. Grade 1, Grade 2, and Grade 3 tumours had different mutational patterns. Patients who died from UTUC had pathogenic mutations in specific genes e.g. tumour protein p53 (TP53) and HRas proto-oncogene, GTPase (HRAS). Patients with Ta Grade 1 tumours with a known pathogenic fibroblast growth factor receptor 3 (FGFR3) mutation did not die from UTUC. CONCLUSION: The genetic analysis was highly concordant with histopathological features and added prognostic information in some cases. Thus, results from genomic profiling may contribute to the choice of treatment and follow-up regimens in the future.
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Carcinoma de Células Transicionales , Neoplasias Renales , Neoplasias Ureterales , Neoplasias de la Vejiga Urinaria , Carcinoma de Células Transicionales/diagnóstico , Carcinoma de Células Transicionales/genética , Genómica/métodos , Humanos , Riñón/anomalías , Neoplasias Renales/diagnóstico , Neoplasias Renales/genética , Neoplasias Renales/patología , Nefroureterectomía , Pronóstico , Neoplasias Ureterales/patología , Neoplasias de la Vejiga Urinaria/genética , Anomalías UrogenitalesRESUMEN
PURPOSE: To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). METHODS: A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled "Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy" held in Copenhagen, Denmark, in September 2019. RESULTS: New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). CONCLUSION: Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.
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Cálculos Renales/terapia , Litotricia , Nefrolitotomía Percutánea , Terapia Combinada , Humanos , Resultado del TratamientoRESUMEN
PURPOSE: To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety. METHODS: A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark. RESULTS AND CONCLUSIONS: Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.
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Cálculos Renales/terapia , Litotricia/métodos , Ureteroscopía , Terapia Combinada , Humanos , Litotripsia por LáserRESUMEN
PURPOSE: To investigate whether volumetric imaging of tumor vasculature can be used to phenotypically characterize advanced upper tract urothelial carcinoma, and if this technique can distinguish aggressive invasive tumors from non-aggressive superficial ones. METHODS: In a pilot study, two TaG1 and two T3G3 formalin-fixed paraffin-embedded (FFPE) tumor samples were examined using the DIPCO pipeline (Tanaka et al. in Nature Biomed Eng 1(10):796-806. https://doi.org/10.1038/s41551-017-0139-0 , 2017). Briefly, punch biopsies of FFPE tumors were deparaffinized, cleared, immunolabeled with the vessel marker CD34 and imaged with a light-sheet microscope. Thereafter, the three-dimensional (3D) vasculature of the tumors was analyzed and characterized using a specialized image processing software. RESULTS: We found that T3G3 tumors had increased CD34 density kurtosis and skewness compared to TaG1 tumors. This suggests that analysis of the 3D vasculature can distinguish between high-grade invasive and low-grade superficial tumors. CONCLUSIONS: Volumetric imaging of tumor samples may represent novel methodology that can complement conventional histopathology. Volumetric imaging enabled us to differentiate between invasive and non-invasive upper tract urothelial carcinoma. The method is of particular interest in diagnostic work-up of patients with upper tract urothelial carcinoma as previous findings indicate that volumetric imaging of vascular patterns could be used to differentiate superficial and invasive urothelial carcinoma, irrespective of if the tumor sample was deep or superficial. However, further and more extensive studies are required before this method can be applied clinically.
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Carcinoma de Células Transicionales/diagnóstico por imagen , Carcinoma de Células Transicionales/patología , Imagenología Tridimensional , Neoplasias Renales/diagnóstico por imagen , Neoplasias Renales/patología , Neoplasias Ureterales/diagnóstico por imagen , Neoplasias Ureterales/patología , Carcinoma de Células Transicionales/irrigación sanguínea , Humanos , Neoplasias Renales/irrigación sanguínea , Estadificación de Neoplasias , Proyectos Piloto , Carga Tumoral , Neoplasias Ureterales/irrigación sanguíneaRESUMEN
PURPOSE: The aim of this prospective study was to identify the tumour characteristics that are associated with invasiveness and those that are relevant for disease-specific survival (DSS) in upper tract urothelial carcinoma, UTUC. METHODS: From a prospective consecutive cohort of patients with suspicion of UTUC, those who were diagnosed with UTUC using URS prior to rNU between 2005 and 2012 were included. Tumour characteristics were analysed for prediction of invasiveness and association with DSS. Stages were categorised as superficial (pTa-1 and CIS only) or invasive (≥ pT2). Tumours were graded according to WHO 1999 classification. DSS was analysed regarding possible association with stage, grade, size, multifocality, location, ploidy and rate of proliferation. Associations were tested using Fisher's exact test, Pearson Chi-square or Cox's regression. Kaplan-Meier survival curves were constructed. RESULTS: Forty-five consecutive patients were included, and 43 of them were included in the final analyses because their rNU specimens were available for reassessment. The only tumour characteristics that were significantly associated with stage were tumour grade (P < 0.001), DNA ploidy (P = 0.045) and rate of proliferation (P = 0.004). No association with stage was noted for size, multifocality or location. Grade, stage and rate of proliferation were associated with DSS. CONCLUSIONS: Grade, DNA ploidy and S-phase fraction were the only tumour characteristics associated with stage in our study. However, DNA ploidy was not associated with DSS. The prognostic factors that we identified were tumour grade, stage, and S-phase fraction.
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Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Valor Predictivo de las Pruebas , Estudios Prospectivos , Tasa de SupervivenciaRESUMEN
PURPOSE: To provide an overview of treatment modalities for management of upper tract urothelial carcinoma (UTUC). METHODS: In accordance with the standards for a scoping review, data presentation and discussion at the Consultation on UTUC in Stockholm, 6-7 September 2018, consensus was reached on the latest and most important treatment recommendations for UTUC. Using Pubmed, Web of Science, and Embase, publications were selected based on quality, clinical relevance, and level of evidence. RESULTS: Kidney-sparing surgery should be attempted for low-grade UTUC. Radical nephroureterectomy with bladder cuff excision is first option for high-grade disease. Post-operative bladder instillation of chemotherapy should be offered after RNU to reduce intravesical recurrence rate. Identification of tumor grade and stage is crucial when selecting treatment. Ureteroscopic management of low-grade and non-invasive UTUC achieves disease-free survival similar to that offered by radical nephroureterectomy but seems to be a risk factor for intravesical recurrence. Lymphadenectomy appears important for high-risk disease, although the therapeutic benefit needs further validation. There is little evidence supporting use of Bacillus Calmette-Guérin (BCG) and mitomycin C as monotherapy and adjuvant treatment in UTUC. A randomized clinical trial has indicated that platin-based chemotherapy for invasive UTUC improves disease-free survival, suggesting that adjuvant chemotherapy should be considered standard care for ≥ T2 N0-3M0 disease. CONCLUSIONS: Risk stratification assessment is feasible and mandatory in UTUC. Identification of tumor grade and stage is essential for optimal treatment selection. Kidney-sparing surgery should be offered in low-risk disease, whereas radical nephroureterectomy and adjuvant chemotherapy should be considered in high-risk disease.
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Carcinoma de Células Transicionales/terapia , Neoplasias Renales/terapia , Neoplasias Ureterales/terapia , Antineoplásicos/uso terapéutico , Humanos , Nefrectomía/métodos , Guías de Práctica Clínica como Asunto , Suecia , Uréter/cirugíaRESUMEN
PURPOSE: To summarize current knowledge on upper urinary tract carcinoma (UTUC) regarding risk stratification, long-term results, and follow-up. METHODS: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC, September 2018, Stockholm. RESULTS: To optimize oncological outcome considering both cancer-specific survival (CSS) and overall survival (OS), it is essential to identify pre- and postoperative prognostic factors. In low-risk UTUC, kidney-sparing surgery (KSS) and radical nephroureterectomy (RNU) offer equivalent CSS, whereas RNU may result in poorer OS due to nephron loss. For more aggressive tumours, undergrading can lead to insufficient treatment. The strongest prognostic factors are tumour stage and grade. Determining grade is best achieved by ureterorenoscopy (URS) with focal samples, biopsy and cytology. Staging is more difficult but can be indirectly achieved by multiphase computed tomography urography (CTU) or tumour grade determined by cytology and histopathology. Patients treated with KSS should be monitored closely with regular follow-ups (URS and CTU). CONCLUSION: KSS should be offered in low-risk UTUC when feasible, whereas RNU is the treatment of choice in organ-confined high-risk UTUC. Intravesical recurrence (IVR) is common after RNU, but a single postoperative dose of mitomycin instillation decreases IVR. Endourological management has high local and bladder recurrence rates; however, its effect on CSS or overall survival OS is unclear. RNU is associated with significant risk of chronic kidney disease. Careful selection of patients and risk stratification are mandatory, and patients should be followed according to strict protocols.
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Carcinoma de Células Transicionales/diagnóstico , Neoplasias Renales/diagnóstico , Medición de Riesgo , Neoplasias Ureterales/diagnóstico , Estudios de Seguimiento , Humanos , Guías de Práctica Clínica como Asunto , Suecia , Factores de TiempoRESUMEN
PURPOSE: To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers. METHODS: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018. RESULTS: Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice. CONCLUSIONS: Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.
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Carcinoma de Células Transicionales/diagnóstico , Neoplasias Renales/diagnóstico , Neoplasias Ureterales/diagnóstico , Biopsia , Técnicas de Diagnóstico Urológico , Humanos , Guías de Práctica Clínica como Asunto , Pronóstico , Factores de Riesgo , Suecia , UreteroscopíaRESUMEN
OBJECTIVE: To investigate diagnostic accuracy of multiphase computed tomography urography (MCTU) and visual assessment at ureterorenoscopy (URS) for detection of upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: Consecutive patients referred to our tertiary care centre were included in a prospective study covering the period 2005 to 2012. The patients underwent initial imaging and URS with focal samples taken. Cytopathological results served as reference standard. RESULTS: We investigated 174 renal units (RUs; renal pelvis and adjacent ureter) in 148 patients. UTUC was found in 104 RUs. MCTU had an accuracy of 0.74, sensitivity of 0.89, specificity of 0.51, positive predictive value of 0.73, and negative predictive value of 0.75; corresponding values for URS were 0.84, 0.84, 0.85, 0.89, and 0.78, respectively. MCTU had significantly higher sensitivity and accuracy compared with other imaging techniques (P<0.05). Compared with MCTU, URS had similar sensitivity but significantly greater specificity and accuracy. CONCLUSION: Both MCTU and URS are important tools in the diagnostic evaluation of UTUC although neither of those techniques achieves 100% accuracy. MCTU should be chosen as the radiographical method if there are no contraindications and URS should always be combined with focal cytology and biopsies of suspicious lesions. To enhance diagnostic precision both MCTU and URS with focal samples should be included in the diagnostic procedure. The present results add impact to current diagnostic guidelines.
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Carcinoma de Células Transicionales/diagnóstico por imagen , Neoplasias Renales/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Neoplasias Ureterales/diagnóstico por imagen , Ureteroscopía , Urografía/métodos , Anciano , Femenino , Humanos , Masculino , Estudios Prospectivos , Reproducibilidad de los ResultadosAsunto(s)
Cálculos Renales/terapia , Litotricia , Congresos como Asunto , Humanos , Litotricia/métodosAsunto(s)
Carcinoma de Células Transicionales/cirugía , Neoplasias Renales/cirugía , Neoplasias Ureterales/cirugía , Carcinoma de Células Transicionales/diagnóstico , Carcinoma de Células Transicionales/patología , Europa (Continente) , Humanos , Neoplasias Renales/diagnóstico , Neoplasias Renales/patología , Clasificación del Tumor , Estadificación de Neoplasias , Medición de Riesgo , Neoplasias Ureterales/diagnóstico , Neoplasias Ureterales/patologíaRESUMEN
PURPOSE: The use of a ureteral access sheath (UAS) during flexible retrograde intrarenal surgery (RIRS) has become increasingly popular. Our aim was to evaluate the accessibility of a new UAS device, allowing the transformation of the working guidewire into a safety guidewire. METHODS: A prospective, multicenter study was conducted between January and February 2010 in six European tertiary reference centers. Patients needing flexible RIRS were eligible to participate in the study. In all cases, insertion of the Re-Trace™ (12/14Fr, Coloplast, Denmark) was attempted at the beginning of the procedure. Insertion success was defined as placement of the UAS in the lumbar ureter with successful disengagement of the working guidewire, which turned into a safety guidewire. Influence of gender and pre-stenting status was analyzed by univariate analysis. RESULTS: 137 UASs were used in 75 male and 62 female patients. 25.5% of ureters were pre-stented: men were 2.17 more often pre-stented than women. The overall Re-Trace™ insertion rate was 82.5%. Success rate was not significantly different between men and women (77.3 vs. 88.7%, respectively, p = 0.11). Pre-stenting status did not significantly influence the success rate (p = 0.31). When analyzing the combined influence of pre-stenting status and gender, the worst success rates seemed to be obtained in men without pre-stenting, but no significant differences were found between groups. CONCLUSIONS: Re-Trace™ UAS showed good overall insertion rates. This evaluation validated the new concept of guidewire disengagement: A single wire automatically switches from working to safety role.
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Diseño de Equipo , Equipos y Suministros , Uréter/cirugía , Ureteroscopía/instrumentación , Ureteroscopía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Stents , Resultado del Tratamiento , Obstrucción Ureteral/cirugía , Neoplasias Urológicas/cirugíaRESUMEN
Upper tract urothelial carcinoma (UTUC) is a rare form of urothelial cancer with a high incidence of recurrence and a low survival rate. Almost two-thirds of UTUCs are invasive at the time of diagnosis; therefore, improving diagnostic methods is key to increasing survival rates. Histopathological analysis of UTUC is essential for diagnosis and typically requires endoscopy biopsy, tissue sectioning, and labeling. However, endoscopy biopsies are minute, and it is challenging to cut into thin sections for conventional histopathology; this complicates diagnosis. Here, we used volumetric 3-dimensional (3D) imaging to explore the inner landscape of clinical UTUC biopsies, without sectioning, revealing that 3D analysis of phosphorylated ribosomal protein S6 (pS6) could predict tumor grade and prognosis with improved accuracy. By visualizing the tumor vasculature, we discovered that pS6+ cells were localized near blood vessels at significantly higher levels in high-grade tumors than in low-grade tumors. Furthermore, the clustering of pS6+ cells was associated with shorter relapse-free survival. Our results demonstrate that 3D volume imaging of the structural niches of pS6 cells deep inside the UTUC samples improved diagnostic yield, grading, and prognosis prediction.