Prognostic Factors and Oncological Outcomes after Radical Nephroureterctomy for Upper Tract Urothelial Carcinoma: Review of Contemporary Multi-Center Series

Upper tract urothelial cancers (UTUC) are uncommon and the information guiding their management used to be driven from small single center studies. Multi-center international collaborations should provide clinicians with best management practices as well as prognostic factors guiding treatment decisions and outcomes. We reviewed literature from the largest multicenter collaborations for radical nephroureterctomy (RNU) performed for management of UTUC. Our review included over 50 recent manuscripts from 2009-2012 that were published from multi-center UTUC collaboration groups. Our review aims to determine of the prognostic factors predicting oncological outcomes after RNU and to provide insights about possible maximization of cure with utilization of multimodal treatment approaches. Application of approaches comprising RNU including lymphadenectomy and systemic chemotherapy;particularly in neoadjuvant settings;might have implications on improvement of oncological outcomes in high risk patients.

Heterogeneity and renal mass biopsy:a review of its role and reliability

Increased abdominal imaging has led to an increase in the detection of the incidental small renal mass(SRM). With increasing recognition that the malignant potential of SRMs is heterogeneous, ranging from benign(15%-20%) to aggressive(20%), enthusiasm for more conservative management strategies in the elderly and infirmed, such as active surveillance(AS), have grown considerably. As the management of the SRM evolves to incorporate ablative techniques and AS for low risk disease, the role of renal mass biopsy(RMB) to help guide individualized therapy is evolving. Historically, the role of RMB was limited to the evaluation of suspected metastatic disease, renal abscess, or lymphoma. However, in the contemporary era, the role of biopsy has grown, most notably to identify patients who harbor benign lesions and for whom treatment, particularly the elderly or frail, may be avoided. When performing a RMB to guide initial clinical decision making for small, localized tumors, the most relevant questions are often relegated to proof of malignancy and documentation(if possible) of grade. However, significant intratumoral heterogeneity has been identified in clear cell renal cell carcinoma(ccRCC) that may lead to an underestimation of the genetic complexity of a tumor when single-biopsy procedures are used. Heterogeneous genomic landscapes and branched parallel evolution of ccRCCs with spatially separated subclones creates an illusion of clonal dominance when assessed by single biopsies and raises important questions regarding how tumors can be optimally sampled and whether future evolutionary tumor branches might be predictable and ultimately targetable. This work raises profound questions concerning the genetic landscape of cancer and how tumor heterogeneity may affect, and possibly confound, targeted diagnostic and therapeutic interventions. In this review, we discuss the current role of RMB, the implications of tumor heterogeneity on diagnostic accuracy, and highlight promising future directions.

Potential benefit of lymph node dissection during radical nephrectomy for kidney cancer:A review and critical analysis of current literature

Objective:The role of lymph node dissection(LND)is still controversial in patients with renal cell carcinoma undergoing surgery.We aimed to provide a comprehensive review of the literature about the effect of LND on survival,prognosis,surgical outcomes,as well as patient selection and available LND templates.Methods:Recent literature(from January 2011 to December 2021)was assessed through PubMed and MEDLINE databases.A narrative review of most relevant articles was provided.Results:The frequencies in which LNDs are being carried out are decreasing due to an increase in minimally invasive and nephron sparing surgery.Moreover,randomized clinical trials and meta-analyses failed to show any survival advantage of LND versus no LND.However,retrospective studies suggest a survival benefit of LND in high-risk patients(bulky tumors,T3-4 stage,and cN1 patients).Moreover,extended LND might provide important staging information,which could be of interest for adjuvant treatment planning.Conclusion:No level 1 evidence of any survival advantage deriving from LND is currently available in literature.Thus,the role of LND is limited to staging purposes.However,low grade evidence suggests a possible role of LND in high-risk patients.Randomized clinical trials are warranted to corroborate these findings.

Current strategies to diagnose and manage positive surgical margins and local recurrence after partial nephrectomy

Objective:No standard strategy for diagnosis and management of positive surgical margin(PSM)and local recurrence after partial nephrectomy(PN)are reported in literature.This review aims to provide an overview of the current strategies and further perspectives on this patient setting.Methods:A non-systematic review of the literature was completed.The research included the most updated articles(about the last 10 years).Results:Techniques for diagnosing PSMs during PN include intraoperative frozen section,imprinting cytology,and other specific tools.No clear evidence is reported about these methods.Regarding PSM management,active surveillance with a combination of imaging and laboratory evaluation is the first option line followed by surgery.Regarding local recurrence management,surgery is the primary curative approach when possible but it may be technically difficult due to anatomy resultant from previous PN.In this scenario,thermal ablation(TA)may have the potential to circumvent these limitations representing a less invasive alternative.Salvage surgery represents a valid option;six studies analyzed the outcomes of nephrectomy on local recurrence after PN with three of these focused on robotic approach.Overall,complication rates of salvage surgery are higher compared to TA but ablation presents a higher recurrence rate up to 25%of cases that can often be managed with repeat ablation.Conclusion:Controversy still exists surrounding the best strategy for management and diagnosis of patients with PSMs or local recurrence after PN.Active surveillance is likely to be the optimal first-line management option for most patients with PSMs.Ablation and salvage surgery both represent valid options in patients with local recurrence after PN.Conversely,salvage PN and radical nephrectomy have fewer recurrences but are associated with a higher complication rate compared to TA.In this scenario,robotic surgery plays an important role in improving salvage PN and radical nephrectomy outcomes.

Pain management strategies in penile implantation

The opioid epidemic continues to be a serious public health concern.Many have pointed to prescription drug misuse as a nidus for patients to become addicted to opioids and as such,urologists and other surgical subspecialists must critically define optimal pain management for the various procedures performed within their respective disciplines.Controlling pain following penile prosthesis implantation remains a unique challenge for urologists,given the increased pain patients commonly experience in the postoperative setting.Although most of the existing urological literature focuses on interventions performed in the operating room,there are many studies that examine the role of preoperative adjunctive pain medicine in diminishing postoperative narcotic requirements.There are relatively few studies looking at postoperative strategies for managing pain in prosthetic surgery with follow-up past the immediate hospitalization.This review assess the various strategies employed for managing pain following penile implantation through the lens of the current state of the opioid crisis,thus examining how urologists can responsibly treat pain without contributing to the growing threat of opioid addiction.