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A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors
Savio Domenico Pandolfo, Clara Cerrato, Zhenjie Wu, Antonio Franco, Francesco Del Giudice, Alessandro Sciarra, Paolo Verze, Giuseppe Lucarelli, Ciro Imbimbo, Sisto Perdonà, Edward E. Cherullo, Francesco Porpiglia, Ithaar H. Derweesh, Riccardo Autorino
Asian Journal of Urology    2023, 10 (4): 390-406.   DOI: 10.1016/j.ajur.2023.06.001
Abstract   HTML PDF (1105KB)  

Objective: Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors.

Methods: A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes.

Results: After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.

Conclusion: Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

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Robotic approach with neoadjuvant chemotherapy in adult Wilms’ tumor: A feasibility study report and a systematic review of the literature
Simone Sforza,Valeria Emma Palmieri,Maria Rosaria Raspollini,Giandomenico Roviello,Alberto Mantovani,Umberto Basso,Maria Carmen Affinita,Alberto D’Angelo,Lorenzo Antonuzzo,Marco Carini,Andrea Minervini,Lorenzo Masieri
Asian Journal of Urology    2023, 10 (2): 128-136.   DOI: 10.1016/j.ajur.2021.10.004
Abstract   HTML PDF (5333KB)  

Objective: The incidence of Wilms’ tumor (WT) among adult individuals accounts for less than 1% of kidney cancer cases, with a prognosis usually less favorable when compared to younger individuals and an overall survival rate of 70% for the adult patients versus 90% for the pediatric cases. The diagnosis and treatment of WT are complex in the preoperative setting; neoadjuvant chemotherapy (NAC) or robotic surgery has rarely been described. This study aimed to review the literature of robotic surgery in WT and report the first adult WT management using both NAC and robotic strategy.
Methods: We reported a case of WT managed in a multidisciplinary setting. Furthermore, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations, a systematic review of the literature until August 2020 of WT treated with a robotic approach was carried out.
Results: A 33-year-old female had a diagnosis of WT. She was scheduled to NAC, and according to the clinical and radiological response to a robotic radical nephrectomy with aortic lymph nodes dissection, she was managed with no intraoperative rupture, a favorable surgical outcome, and a follow-up of 25 months, which did not show any recurrence. The systematic review identified a total number of 230 cases of minimally invasive surgery reported in the literature for WT. Of these, approximately 15 patients were carried out using robotic surgery in adolescents while none in adults. Moreover, NAC has not been administered before minimally invasive surgery in adults up until now.
Conclusion: WT is a rare condition in adults with only a few cases treated with either NAC or minimally invasive approach so far. The advantage of NAC followed by the robotic approach could lead to favorable outcomes in this complex scenario. Notwithstanding, additional cases of adult WT need to be identified and investigated to improve the oncological outcome.

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The application of indocyanine green in guiding prostate cancer treatment
Donghua Xie,Di Gu,Ming Lei,Cong Cai,Wen Zhong,Defeng Qi,Wenqi Wu,Guohua Zeng,Yongda Liu
Asian Journal of Urology    2023, 10 (1): 1-8.   DOI: 10.1016/j.ajur.2021.07.004
Abstract   HTML PDF (463KB)  

Objective: Indocyanine green (ICG) with near-infrared fluorescence absorption is approved by the United States Food and Drug Administration for clinical applications in angiography, blood flow evaluation, and liver function assessment. It has strong optical absorption in the near-infrared region, where light can penetrate deepest into biological tissue. We sought to review its value in guiding prostate cancer treatment.

Methods: All related literature at PubMed from January 2000 to December 2020 were reviewed.

Results: Multiple preclinical studies have demonstrated the usefulness of ICG in identifying prostate cancer by using different engineering techniques. Clinical studies have demonstrated the usefulness of ICG in guiding sentinel node dissection during radical prostatectomy, and possible better preservation of neurovascular bundle by identifying landmark prostatic arteries. New techniques such as adding fluorescein in additional to ICG were tested in a limited number of patients with encouraging result. In addition, the use of the ICG was shown to be safe. Even though there are encouraging results, it does not carry sufficient sensitivity and specificity in replacing extended pelvic lymph node dissection during radical prostatectomy.

Conclusion: Multiple preclinical and clinical studies have shown the usefulness of ICG in identifying and guiding treatment for prostate cancer. Larger randomized prospective studies are warranted to further test its usefulness and find new modified approaches.

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A review of regenerative therapies as penile rehabilitation in men following primary prostate cancer treatment: Evidence for erectile restoration and cavernous nerve regeneration
Eric Chung
Asian Journal of Urology    2022, 9 (3): 287-293.   DOI: 10.1016/j.ajur.2021.11.005
Abstract   HTML PDF (334KB)  

Objective: The following article explores our evolving understandings of the role of regenerative technology as an effective penile rehabilitation tool in men with erectile dysfunction (ED) in the setting of prostate cancer (PCa) treatment and PCa survivorship.
Methods: This narrative clinical review paper summarizes what is currently known about various modalities of regenerative therapy in restoring spontaneous erectile function (EF) in men following PCa treatment with an emphasis on penile rehabilitation strategies.
Results: Conventional medical therapy often does not reverse underlying endothelial dysfunction or promote neuro-vasculogenesis to preserve penile health in men with ED. Over the past decade, there has been considerable interest in the role of regenerative therapy to restore endothelial dysfunction and ED without future dependency on medical therapy. Regenerative therapy can be classified into cellular-based (immunomodulators, stem cells, and platelet-rich plasma), biomaterials (nerve graft transfer), and device-related technology (low-intensity shockwave). Although published literature shows early promise in the role of regenerative technology for ED, there is a paucity of high-quality clinical trials in the setting of penile rehabilitation and PCa survivorship to support their use as standard care and be adopted in clinical guidelines.
Conclusion: While the use of regenerative technology to restore EF is exciting and highly innovative, considerable limitations remain regarding actual clinical translation and the need for longer-term efficacy and safety data as well as governmental regulation on clinical framework and more robust clinical studies before they can be accepted as standard of care to restore EF in men following PCa treatment.

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An overview of benign prostatic hyperplasia and its appreciation in Greco-Arab (Unani) system of medicine
Shabir Ahmad Bhat,Shameem Ahmad Rather,Naquibul Islam
Asian Journal of Urology    2022, 9 (2): 109-118.   DOI: 10.1016/j.ajur.2021.05.008
Abstract   HTML PDF (1013KB)  

Objective: Conventional treatments for benign prostatic hyperplasia (BPH) like 5alpha-reductase inhibitors and invasive surgery are associated with some obvious side effects. Conversely, evidence, though limited, has shown that alternative medicines are safer and have potential to improve the lower urinary tract symptoms (LUTS) and quality of life in addition to improving sexual dysfunction in patients with BPH. The current article aimed to include an overview of BPH, different ways of its management, and particularly its appreciation in Greco-Arab (Unani) system of medicine, one of the alternative medicinal systems.

Methods: PubMed, Scopus, ScienceDirect, Web of Sciences, Google Scholar databases and classical texts of Greco-Arab medicine were searched for data collection.

Results: In Unani system of medicine, BPH, traced under the headings of Waram unuq al-mathana (bladder neck swelling) and Insidad majra-i-mathana (bladder outlet obstruction), has been managed for centuries with herbal medicines yet demanding a comprehensive scientific validation. Among the herbs, Cucurbita pepo, Tribulus terrestris, Urtica dioica, and Linum usitatissimum are worth mentioning.

Conclusion: For achieving the goal of LUTS-free ageing men, and safer and cost-effective future management of BPH, Unani herbal medicine could hopefully prove beneficial.

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Blood and urine biomarkers in prostate cancer: Are we ready for reflex testing in men with an elevated prostate-specific antigen?
Edward K. Chang,Adam J. Gadzinski,Yaw A. Nyame
Asian Journal of Urology    2021, 8 (4): 343-353.   DOI: 10.1016/j.ajur.2021.06.003
Abstract   HTML PDF (415KB)  

Objective: There is no consensus on the role of biomarkers in determining the utility of prostate biopsy in men with elevated prostate-specific antigen (PSA). There are numerous biomarkers such as prostate health index, 4Kscore, prostate cancer antigen 3, ExoDX, SelectMDx, and Mi-Prostate Score that may be useful in this decision-making process. However, it is unclear whether any of these tests are accurate and cost-effective enough to warrant being a widespread reflex test following an elevated PSA. Our goal was to report on the clinical utility of these blood and urine biomarkers in prostate cancer screening.
Methods: We performed a systematic review of studies published between January 2000 and October 2020 to report the available parameters and cost-effectiveness of the aforementioned diagnostic tests. We focus on the negative predictive value, the area under the curve, and the decision curve analysis in comparing reflexive tests due to their relevance in evaluating diagnostic screening tests.
Results: Overall, the biomarkers are roughly equivalent in predictive accuracy. Each test has additional clinical utility to the current diagnostic standard of care, but the added benefit is not substantial to justify using the test reflexively after an elevated PSA.
Conclusions: Our findings suggest these biomarkers should not be used in binary fashion and should be understood in the context of pre-existing risk predictors, patient's ethnicity, cost of the test, patient life-expectancy, and patient goals. There are more recent diagnostic tools such as multi-parametric magnetic resonance imaging, polygenic single-nucleotide panels, IsoPSA, and miR Sentinel tests that are promising in the realm of prostate cancer screening and need to be investigated further to be considered a consensus reflexive test in the setting of prostate cancer screening.

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Future perspective of focal therapy for localized prostate cancer
Luke P. O’Connor,Shayann Ramedani,Michael Daneshvar,Arvin K. George,Andre Luis Abreu,Giovanni E. Cacciamani,Amir H. Lebastchi
Asian Journal of Urology    2021, 8 (4): 354-361.   DOI: 10.1016/j.ajur.2021.04.011
Abstract   HTML PDF (363KB)  

Objective: To summarize the recent literature discussing focal therapy for localized prostate cancer.
Methods: A thorough literature review was performed using PubMed to identify recent studies involving focal therapy for the treatment of localized prostate cancer.
Results: In an effort to decrease the morbidity associated with prostate cancer treatment, many urologists are turning to focal therapy as an alternative treatment option. With this approach, the cancer bearing portion of the prostate is targeted while leaving the benign tissue untouched. Multiparametric magnetic resonance imaging remains the gold standard for visualization during focal therapy, but new imaging modalities such as prostate specific membrane antigen/positron emission tomography and contrast enhanced ultrasound are being investigated. Furthermore, several biomarkers, such as prostate cancer antigen 3 and prostate health index, are used in conjunction with imaging to improve risk stratification prior to focal therapy. Lastly, there are several novel technologies such as nanoparticles and transurethral devices that are under investigation for use in focal therapy.
Conclusion: Focal therapy is proving to be a promising option for the treatment of localized prostate cancer. However, further study is needed to determine the true efficacy of these exciting new technologies.

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Biomarkers in renal cell carcinoma: Are we there yet?
Shuchi Gulati,Nicholas J. Vogelzang
Asian Journal of Urology    2021, 8 (4): 362-375.   DOI: 10.1016/j.ajur.2021.05.013
Abstract   HTML PDF (810KB)  

Management of kidney cancer has undergone a paradigm shift with the approval of new therapies over the last two decades. Although these drugs have improved clinical outcomes in patients with kidney cancer, there are still a large number of patients who do not show objective responses. A multitude of investigators, including those for The Cancer Genome Atlas have biologically characterized and sub-classified kidney cancer. However, we have not been able to identify molecular targets to effectively treat patients with kidney cancer. As we familiarize ourselves with newer drugs for patients with kidney cancer, it is important to understand that these drugs may not work in every patient and instead may expose patients to unnecessary toxic effects along with burdening society with the financial impact. As we head toward the era of “precision medicine”, validated biomarkers are being utilized to guide treatment choices and help identify pathways of resistance in other tumor types. The current review aims at evaluating the progress made so far in this realm for patients with kidney cancer.

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Molecular markers of systemic therapy response in urothelial carcinoma
Francesco Claps,Maria Carmen Mir,Homayoun Zargar
Asian Journal of Urology    2021, 8 (4): 376-390.   DOI: 10.1016/j.ajur.2021.05.001
Abstract   HTML PDF (484KB)  

Identification of reliable molecular biomarkers that can complement clinical practice represents a fascinating challenge in any cancer field. Urothelial carcinoma is a very heterogeneous disease and responses to systemic therapies, and outcomes after radical cystectomy are difficult to predict. Advances in molecular biology such as next generation sequencing and whole genome or transcriptomic analysis provide promising platforms to achieve a full understanding of the biology behind the disease and can identify emerging predictive biomarkers. Moreover, the ability to categorize patients' risk of recurrence after curative treatment, or even predict benefit from a conventional or targeted therapies, represents a compelling challenge that may reshape both selection for tailored treatment and disease monitoring. Progress has been made but currently no molecular biomarkers are used in the clinical setting to predict response to systemic agents in either neoadjuvant or adjuvant settings highlighting a relevant unmet need. Here, we aim to present the emerging role of molecular biomarkers in predicting response to systemic agents in urothelial carcinoma.

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The emerging role of somatic tumor sequencing in the treatment of urothelial cancer
Lexiaochuan Wen,Cameron J. Britton,Rohan Garje,Benjamin W. Darbro,Vignesh T. Packiam
Asian Journal of Urology    2021, 8 (4): 391-399.   DOI: 10.1016/j.ajur.2021.06.005
Abstract   HTML PDF (364KB)  

The development of rapid genome sequencing has greatly enhanced our understanding of the molecular biology underlying many malignancies. Whole exome sequencing has highlighted the individualistic nature of malignancies on a patient-to-patient basis and begun to revolutionize therapeutic approaches. In recent years, whole genome sequencing of urothelial malignancies has identified a host of somatic mutations which contribute to growth, progression, and metastasis of urothelial carcinoma of the bladder and upper tract urothelial carcinoma. As genetic sequencing continues, additional targets will be identified, allowing development of novel therapeutic agents targeting cancer on a molecular level, with the goal of delivering highly individualized care based on the underlying mutational profile of the patient's malignancy. In this review, we aim to discuss known genetic alterations of urothelial malignancy and the implications these mutations carry in terms of prognostication and development of targeted therapeutic agents. We will focus on RNA-expression profiling and genomic DNA profiling, with a focus on comprehensive whole exome and whole genome sequencing relative to selected urothelial carcinoma-associated genes and circulating tumor DNA analysis.

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CN 31-2124/R
ISSN 2214-3882 (Print)
ISSN 2214-3890 (Online)
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