Long-term survival after female pelvic organ-sparing radical cystectomy versus standard radical cystectomy: a multi-institutional propensity score-matched analysis.

BACKGROUND: The application of pelvic organ preserving-radical cystectomy (POPRC) in female patients with bladder cancer has attracted more and more attention in recent years. In the current study, the authors aim to compare the long-term oncological outcomes of POPRC versus standard radical cystectomy (SRC) in a large multicenter retrospective cohort. PATIENTS AND METHODS: Data on female patients with bladder cancer who underwent POPRC or SRC in January 2006 and April 2018 were included from three Chinese urological centers. The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival and recurrence-free survival. To decrease the effect of unmeasured confounders associated with treatment selection, 1:1 propensity score matching was performed. RESULTS: Among the 273 enrolled patients, 158 underwent POPRC (57.9%), and 115 underwent SRC (42.1%). The median follow-up time was 38.6 (15.9-62.5) months. After propensity score matching, each cohort included 99 matched patients. The OS ( P =0.940), cancer-specific survival ( P =0.957), and recurrence-free survival ( P =0.476) did not differ significantly from the two matched cohorts. Subgroup analysis confirmed that the OS was similar between the patients treated with POPRC and SRC across all subgroups examined (all P > 0.05). In multivariable analysis, the surgical method (SRC vs. POPRC) was not an independent risk factor for OS (Hazard ratio 0.874, 95% CI 0.592-1.290; P =0.498). CONCLUSIONS: The results showed that no significant difference in long-term survival was determined between female patients undergoing SRC and those undergoing POPRC.

De novo upper tract urothelial carcinoma after renal transplantation: a single-center experience in China.

BACKGROUND: Long-term prognosis and risk factors of de novo upper tract urothelial carcinoma after renal transplantation were rarely studied. Thus, the aim of this study was to investigate the clinical features, risk factors, and long-term prognosis of de novo upper tract urothelial carcinoma after renal transplantation, especially the impact of aristolochic acid on tumor, using a large sample. METHODS: 106 patients were enrolled in retrospective study. The endpoints included overall survival, cancer-specific survival, bladder or contralateral upper tract recurrence-free survival. Patients were grouped according to aristolochic acid exposure. Survival analysis was performed using Kaplan-Meier curve. Log-rank test was used to compare the difference. Multivariable cox regression was conducted to evaluate the prognostic significance. RESULTS: Median time from transplantation to development of upper tract urothelial carcinoma was 91.5 months. Cancer-specific survival rate at 1, 5, 10 years was 89.2%, 73.2%, 61.6%. Tumor staging (≥ T2), lymph node status (N +) were independent risk factors for cancer-specific death. Contralateral upper tract recurrence-free survival rate at 1, 3, 5 years was 80.4%, 68.5%, 50.9%. Aristolochic acid exposure was independent risk factor for contralateral upper tract recurrence. The patients exposed to aristolochic acid had more multifocal tumors and higher incidence of contralateral upper tract recurrence. CONCLUSION: Both higher tumor staging and positive lymph node status were associated with a worse cancer-specific survival in patients with post-transplant de novo upper tract urothelial carcinoma, which highlighted the importance of early diagnosis. Aristolochic acid was associated with multifocality of tumors and higher incidence of contralateral upper tract recurrence. Thus, prophylactic contralateral resection was suggested for post-transplant upper tract urothelial carcinoma, especially for patients with aristolochic acid exposure.

Etiology, characteristics and management of ureteric injury: experience from a nationwide study.

Background: To investigate the common etiologies, characteristics, and management of ureteric injury. Methods: A nationwide study was performed in 38 medical centers from Mar 2017 to Mar 2019. The data of patients with ureteric injury were retrospectively collected. Results: Overall, 294 patients were included in this study. Ten cases (3.4%) were due to abdominal injuries, and 284 cases (96.6%) were due to iatrogenic injuries, including 48.6% from urological procedures, 41.9% from gynecological procedures, 6.3% from general surgery, and 3.2% from other treatments. Most urological injuries (79.7%) were caused by endourological procedures. Injury occurred in the distal ureter in 178 cases (60.5%), the mid-ureter in 31 cases (10.5%), and the proximal ureter in 85 cases (28.9%). Only 51 patients (17.3%) were diagnosed immediately during primary surgery. Immediate ureter reconstruction was performed in 30 patients (58.8%), while delayed urinary diversion was performed in 148 patients (60.9%) in the delayed diagnosis group. The side and the location of the injury were different between the urological and nonurological injury groups (P<0.001). Ureteric injuries were diagnosed timelier in the urological group than in the nonurological group (P=0.037). Conclusions: Iatrogenic injury was the most common cause of ureteric injury. The majority of iatrogenic injuries were caused by urological procedures and were primarily due to aggressive endourological techniques. Depending on the condition of the patient, the time of diagnosis, and the location and length of the ureteric injury, different management strategies should be applied.

A laparoscopic vascular blocking forceps used for renal carcinoma combined with tumor thrombus

ABSTRACT Objectives: To discuss the feasibility and efficacy of a laparoscopic vessel blocking forceps in laparoscopic inferior vena cava (IVC) thrombectomy (1-3). Materials and methods: The patient was secured in a left lateral decubitus position. The surgical field was built with 4-trocar. The laparoscopic vessel blocking forceps was used to block the IVC partially. With the help of the forceps, we completed a retroperitoneal laparoscopic radical nephrectomy and IVC thrombectomy. Results: The patient was a 73-year-old female. The tumor was located on the right side. Based on the preoperative radiology examination, the tumor thrombus extended from the right renal vein into the IVC, and the cephalic extent of tumor thrombus was 1.6cm above the renal vein. The preoperative stage was T3b, and the Mayo grade of the tumor thrombus was grade I. The operation was successfully completed without conversion to open surgery. The operation time was 159 minutes, and the estimated blood loss was about 50ml. No blood transfusion was needed. The postoperative hospital stay was 10 days. No operation related complication was observed. Postoperative pathology showed diffusely poor differentiated carcinoma, and the pathological stage was T3bN0. Conclusion: The laparoscopic vascular blocking forceps can clamp vessels without damaging the vessels. Vascular blocking forceps is suitable for laparoscopic surgical field. We recommend such a vascular blocking forceps for laparoscopic thrombectomy in patients with renal carcinoma and Mayo grade 0-I tumor thrombus. It may be used to clamp other blood vessels temporarily or control bleeding during laparoscopy in the future.

Etiology and Ureteral Reconstruction Strategy for Iatrogenic Ureteral Injuries: A Retrospective Single-Center Experience.

OBJECTIVE: To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center. METHODS: Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded. RESULTS: Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries. CONCLUSIONS: Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury.

Experience managing distal ureteral strictures with Boari flap-psoas hitch and comparison of open and laparoscopic procedures.

BACKGROUND: To summarize our experience with the Boari flap-psoas hitch and compare the indications, perioperative data and outcomes between open and laparoscopic procedures. METHODS: This study retrospectively reviewed 35 patients with complex distal ureteral stricture between January 2015 and April 2019. All patients were treated with Boari flap-psoas hitch by either an open or a laparoscopic procedure. Selection criteria were based on the etiology, comorbidities, medical history, and patient preference. RESULTS: All surgeries were performed successfully. The median operation time was 201 min (range, 120 to 300 min), and the median estimated blood loss was 50 mL (range, 20 to 400 mL). The median postoperative hospitalization was 9 days (range, 3 to 46 days). Nineteen patients were treated by the open procedure, and 16 were treated by the transperitoneal laparoscopic procedure. The surgical indication of open surgery was broader than that for laparoscopic surgery. For patients experiencing iatrogenic injury and ureterovesical reimplantation failure, no significant differences in sex, laterality, operative time, ASA score or postoperative hospitalization stay were observed between the two groups. The median estimated blood loss was lower in the laparoscopic group than in the open group (P=0.047). Patients in the open group had more surgical complications than patients in the laparoscopic group (P=0.049). The postoperative follow-up showed the radiological resolution of hydronephrosis in 33 patients. CONCLUSIONS: With the appropriate surgical considerations, Boari flap-psoas hitch is a valid method to bridge distal ureteral defects. For select patients, laparoscopic surgery had advantages being a minimal invasive surgery with less estimated blood loss and fewer surgical complications.

Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review.

Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.

Urothelial Carcinoma Detection Based on Copy Number Profiles of Urinary Cell-Free DNA by Shallow Whole-Genome Sequencing.

BACKGROUND: Current noninvasive assays for urothelial carcinoma (UC) lack clinical sensitivity and specificity. Given the utility of plasma cell-free DNA (cfDNA) biomarkers, the development of urinary cfDNA biomarkers may improve the diagnostic sensitivity. METHODS: We assessed copy number alterations (CNAs) by shallow genome-wide sequencing of urinary cfDNA in 95 cancer-free individuals and 65 patients with UC, 58 with kidney cancer, and 45 with prostate cancer. We used a support vector machine to develop a diagnostic classifier based on CNA profiles to detect UC (UCdetector). The model was further validated in an independent cohort (52 patients). Genome sequencing data of tumor specimens from 90 upper tract urothelial cancers (UTUCs) and CNA data for 410 urothelial carcinomas of bladder (UCBs) from The Cancer Genome Atlas were used to validate the classifier. Genome sequencing data for urine sediment from 32 patients with UC were compared with cfDNA. To monitor the treatment efficacy, we collected cfDNA from 7 posttreatment patients. RESULTS: Urinary cfDNA was a more sensitive alternative to urinary sediment. The UCdetector could detect UC at a median clinical sensitivity of 86.5% and specificity of 94.7%. UCdetector performed well in an independent validation data set. Notably, the CNA features selected by UCdetector were specific markers for both UTUC and UCB. Moreover, CNA changes in cfDNA were consistent with the treatment effects. Meanwhile, the same strategy could localize genitourinary cancers to tissue of origin in 70.1% of patients. CONCLUSIONS: Our findings underscore the potential utility of urinary cfDNA CNA profiles as a basis for noninvasive UC detection and surveillance.

Technical considerations and outcomes for ileal ureter replacement: a retrospective study in China.

BACKGROUND: Ileal ureter replacement is an alternative treatment for various length ureter defects. We present our experience and outcome of ileal ureter replacement in China. METHODS: We retrospectively collected data of patients who underwent ileal ureter replacement between January 2010 and January 2015. We reviewed the medical history, indications for surgery, operative data, perioperative data, and outcomes. Besides, follow-up data included symptom, urine routine test, serum creatinine, serum electrolyte status, and radiographic test. RESULTS: There were 23 patients who underwent ileal ureter replacement by the same surgeon. Twenty patients were performed unilateral ileal ureter replacement, two patients underwent a combination of ileal ureter replacement and Boari flap-psoas hitch, and one received bilateral ileal ureter replacement. Among these patients, the main cause leading to surgical treatment was iatrogenic injuries (n = 15), especially urinary surgery procedure (n = 11). The median follow-up time was 45 months. There were 6 early complications and 6 late complications after operation. Only one patient suffered from small bowel-related complication and was cured by conservative treatment. Only the patient who underwent bilateral ileal ureter replacement had metabolic acidosis. And 22 patients (95.7%) had a good renal function. CONCLUSIONS: Ileal ureter replacement is an efficacious and safe procedure for the therapy of long ureteral defects. With appropriate technical considerations, the complication rate may decrease.

Laparoscopic Radical Cystectomy With Extracorporeal Neobladder: Our Initial Experience.

OBJECTIVE: To illustrate our technique to construct the Institute of Urology Peking University (IUPU) orthotopic ileal bladder and present our initial experience. METHODS: From August 2017 to April 2018, 12 patients with bladder cancer underwent radical cystectomy (RC), pelvic lymph node dissection and extracorporeal construction of an IUPU neobladder (IUPUB) by an experienced surgeon. We present the demographic, clinicopathologic, perioperative, and follow-up data. We also describe our step-by-step surgical technique for the IUPUB in this article. RESULTS: Laparoscopic RC with an extracorporeal IUPUB was successfully accomplished in 11 patients, and 1 patient was converted to open RC with an IUPUB. The median total operative time and median time spent suturing the pouch were 248 minutes and 23 minutes, respectively. The median estimated blood loss was 150 mL. The median time to recovery of bowel function (tolerance of a liquid diet) was 3½ days. The urinary catheter was removed on post-operative day 21 in 10 patients. The ureteral stents and stoma catheter were removed on day 7 after cystography. At a median followup of 7½ months, 2 patients had early complications (<30 days), and no major complications (grade ≥ 3) occurred. The follow-up outcomes were satisfactory. The limitations included the small sample size and short-term outcomes. CONCLUSION: Our technique of constructing the IUPUB is feasible and safe. The operative time and early complication rates are acceptable.

Head-to-Head Comparison of Modified Laparoscopic Pyeloplasty and Robot-Assisted Pyeloplasty for Ureteropelvic Junction Obstruction in China.

OBJECTIVE: To compare the outcomes of modified laparoscopic pyeloplasty (LP) and robot-assisted pyeloplasty (RLP) for ureteropelvic junction obstruction (UPJO) in China patients. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who underwent modified LP and RLP using a transperitoneal laparoscopic approach at 2 different medical institutions between October 2009 and November 2017. RESULTS: Seventy-six patients underwent modified LP and 140 patients underwent RLP. No open conversion occurred. The mean operative time of RLP was shorter than that of modified LP (p = 0.042). For UPJO concomitant with renal calculi, there was no difference in operative time between 2 groups (p = 0.656). With RLP, the operative time for UPJO concomitant with horseshoe was shorter (p = 0.011). In terms of complication rate, there was no significant difference between 2 groups (p = 0.596). The postoperative hospital stay for modified LP was shorter than that for RLP (p < 0.05). The mean follow-up time for modified LP and RLP was 31.79 months and 10.85 months respectively (p < 0.05). The success rate was 96.05 and 97.86% for modified LP and RLP, respectively (p = 0.736). CONCLUSIONS: Modified LP and RLP are safe and efficient treatment for UPJO with similar success rates.