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Rahman KMM, Giram P, Foster BA, You Y. Photodynamic Therapy for Bladder Cancers, A Focused Review †. Photochem Photobiol 2023; 99:420-436. [PMID: 36138552 PMCID: PMC10421568 DOI: 10.1111/php.13726] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/18/2022] [Indexed: 02/02/2023]
Abstract
Bladder cancer is the first cancer for which PDT was clinically approved in 1993. Unfortunately, it was unsuccessful due to side effects like bladder contraction. Here, we summarized the recent progress of PDT for bladder cancers, focusing on photosensitizers and formulations. General strategies to minimize side effects are intravesical administration of photosensitizers, use of targeting strategies for photosensitizers and better control of light. Non-muscle invasive bladder cancers are more suitable for PDT than muscle invasive and metastatic bladder cancers. In 2010, the FDA approved blue light cystoscopy, using PpIX fluorescence, for photodynamic diagnosis of non-muscle invasive bladder cancer. PpIX produced from HAL was also used in PDT but was not successful due to low therapeutic efficacy. To enhance the efficacy of PpIX-PDT, we have been working on combining it with singlet oxygen-activatable prodrugs. The use of these prodrugs increases the therapeutic efficacy of the PpIX-PDT. It also improves tumor selectivity of the prodrugs due to the preferential formation of PpIX in cancer cells resulting in decreased off-target toxicity. Future challenges include improving prodrugs and light delivery across the bladder barrier to deeper tumor tissue and generating an effective therapeutic response in an In vivo setting without causing collateral damage to bladder function.
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Affiliation(s)
- Kazi Md Mahabubur Rahman
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| | - Prabhanjan Giram
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| | - Barbara A. Foster
- Department of Pharmacology & Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Youngjae You
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
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En Bloc Resection of Bladder Tumours: Ready for Clinical Use? Eur Urol Oncol 2022; 5:449-450. [DOI: 10.1016/j.euo.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/20/2022]
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Lamy L, Thomas J, Leroux A, Bisson JF, Myren K, Godal A, Stensrud G, Bezdetnaya L. Antitumor Effect and Induced Immune Response Following Exposure of Hexaminolevulinate and Blue Light in Combination with Checkpoint Inhibitor in an Orthotopic Model of Rat Bladder Cancer. Biomedicines 2022; 10:biomedicines10030548. [PMID: 35327351 PMCID: PMC8945090 DOI: 10.3390/biomedicines10030548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/11/2022] [Accepted: 02/22/2022] [Indexed: 01/01/2023] Open
Abstract
Previous studies have found that use of hexaminolevulinate (HAL) and blue light cystoscopy (BLC) during treatment of bladder cancer had a positive impact on overall survival after later cystectomy, indicating a potential treatment effect beyond improved diagnostic accuracy. The aim of our study was to determine whether HAL and BL mimicking clinically relevant doses in an orthotopic rat model could have therapeutic effect by inducing modulation of a tumor-specific immune response. We also assessed whether administration with a checkpoint inhibitor could potentiate any effects observed. Rats were subjected to HAL BL alone and in combination with anti-PD-L1 and assessed for anti-tumor effects and effects on immune markers. Positive anti-tumor effect was observed in 63% and 31% of rats after, respectively, 12 and 30 days after the procedure, together with a localization effect of CD3+ and CD8+ cells after 30 days. Anti-tumor effect at 30 days increases from 31% up to 38% when combined with intravesical anti-PD-L1. In conclusion, our study demonstrated treatment effects with indications of systemic immune activation at diagnostic doses of HAL and blue light. The observed treatment effect seemed to be enhanced when used in combination with intravesically administrated immune checkpoint inhibitor.
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Affiliation(s)
- Laureline Lamy
- Centre de Recherche en Automatique de Nancy, Centre National de la Recherche Scientifique, UMR 7039, Université de Lorraine, Campus Sciences, Boulevard des Aiguillette, 54506 Vandoeuvre-lès-Nancy, France;
- Research Department, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - Jacques Thomas
- Service de Biopathologie, Institut de Cancérologie de Lorraine, 54506 Vandoeuvre-Lès-Nancy, France; (J.T.); (A.L.)
| | - Agnès Leroux
- Service de Biopathologie, Institut de Cancérologie de Lorraine, 54506 Vandoeuvre-Lès-Nancy, France; (J.T.); (A.L.)
| | | | - Kari Myren
- Photocure ASA, Hoffsveien 4, 0275 Oslo, Norway; (K.M.); (A.G.); (G.S.)
| | - Aslak Godal
- Photocure ASA, Hoffsveien 4, 0275 Oslo, Norway; (K.M.); (A.G.); (G.S.)
| | - Gry Stensrud
- Photocure ASA, Hoffsveien 4, 0275 Oslo, Norway; (K.M.); (A.G.); (G.S.)
| | - Lina Bezdetnaya
- Centre de Recherche en Automatique de Nancy, Centre National de la Recherche Scientifique, UMR 7039, Université de Lorraine, Campus Sciences, Boulevard des Aiguillette, 54506 Vandoeuvre-lès-Nancy, France;
- Research Department, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
- Correspondence:
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Mulawkar PM, Sharma G, Tamhankar A, Shah U, Raheem R. Role of Macroscopic Image Enhancement in Diagnosis of Non-Muscle-Invasive Bladder Cancer: An Analytical Review. Front Surg 2022; 9:762027. [PMID: 35265660 PMCID: PMC8898829 DOI: 10.3389/fsurg.2022.762027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022] Open
Abstract
Early diagnosis of non-muscle-invasive bladder cancer (NMIBC) is of paramount importance to prevent morbidity and mortality due to bladder cancer. Although white light imaging (WLI) cystoscopy has long been considered the gold standard in the diagnosis of bladder cancer, it can miss lesions in a substantial percentage of patients and is very likely to miss carcinoma in situ and dysplasia. Tumor margin detection by WLI can be inaccurate. Moreover, WLI could, sometimes, be inadequate in distinguishing inflammation and malignancy. To improve the diagnostic efficacy of cystoscopy, various optical image enhancement modalities have been studied. These image enhancement modalities have been classified as macroscopic, microscopic, or molecular. Photodynamic diagnosis (PDD), narrow band imaging (NBI), and Storz image 1 S enhancement (formerly known as SPIES) are macroscopic image enhancement modalities. A relevant search was performed for literature describing macroscopic image enhancement modalities like PDD, NBI, and image 1 S enhancement. The advantages, limitations, and usefulness of each of these in the diagnosis of bladder cancer were studied. Photodynamic diagnosis requires intravesical instillation of a photosensitizing agent and a special blue light cystoscope system. PDD has been shown to be more sensitive than WLI in the detection of bladder cancer. It is superior to WLI in the detection of flat lesions. Bladder tumor resection (TURBT) by PDD results in more complete resection and reduced recurrence rates. PDD-guided TURBT may have some role in reducing the risk of progression. Narrow band imaging provides increased contrast between normal and abnormal tissues based on neovascularization, thereby augmenting WLI. NBI requires a special light source. There is no need for intravesical contrast instillation. NBI is superior to WLI in the detection of bladder cancer. The addition of NBI to WLI improves the detection of flat lesions like carcinoma in situ. NBI is not useful in predicting invasive tumors or grades of tumors. NBI-directed TURBT reduces recurrence rates and recurrence free survival. But its efficacy in retarding progression is unproven. Image 1 S-enhancement utilizes software-based image enhancement modes without the need for a special light source or intravesical contrast instillation. This system provides high-quality images and identifies additional abnormal-looking areas. Another advantage of this system is simultaneous side-by-side visualization of WLI and enhanced image, providing WLI images as the control for comparison. As with PDD, S-enhancement produces a lower rate of a missed bladder cancer diagnosis. The system significantly improves the diagnosis of NMIBC. The sensitivity and negative predictive value of image 1 S enhancement increase with the increase in cancer grade. A negative test by S-enhancement effectively rules out NMIBC. All the image enhancement modalities have proven their utility in improving detection and short-term cancer control. But none of these modalities have proven their utility in delaying progression, or in long-term cancer control. Cancer progression and long-term control are governed by the biological nature of cancer cells. Early detection by optical enhancement may not be of utility in this regard. Well-designed studies are needed to establish the efficacy of these modalities in the evaluation of patients with bladder cancer. The last word, in this regard, is yet to be written.
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Affiliation(s)
- Prashant Motiram Mulawkar
- Department of Urology, Tirthankar Superspeciality Hospital, Akola, India
- Tutor in Urology, University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Prashant Motiram Mulawkar
| | | | | | - Utsav Shah
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Rickaz Raheem
- Milton Keynes University Hospital, Eaglestone, United Kingdom
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Maisch P, Koziarz A, Vajgrt J, Narayan V, Kim MH, Dahm P. Blue versus white light for transurethral resection of non-muscle invasive bladder cancer. Cochrane Database Syst Rev 2021; 12:CD013776. [PMID: 34850382 PMCID: PMC8632646 DOI: 10.1002/14651858.cd013776.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Disease recurrence and progression remain major challenges in the treatment of non-muscle invasive bladder cancer (NMIBC). Blue light-enhanced transurethral resection of bladder cancer (TURBT) is an approach to improve staging and achieve a complete resection of NMIBC. OBJECTIVES To assess the effects of blue light-enhanced TURBT compared to white light-based TURBT in the treatment of NMIBC. SEARCH METHODS We searched several medical literature databases, including the Cochrane Library, MEDLINE, and Embase, as well as trial registers, including ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We performed a comprehensive search with no restrictions on language of publication or publication status until March 2021. SELECTION CRITERIA We included randomized controlled trials using blue light versus white light TURBT. Included participants had a high level of suspicion based on imaging or 'visible diagnosis' for primary urothelial carcinoma of the bladder or recurrent urothelial carcinoma of the bladder upon cytoscopy. We excluded studies in which blue light was used in a surveillance setting. DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and risk of bias assessment. Our primary outcomes were time to disease recurrence, time to disease progression, and serious surgical complications. Secondary outcomes were time to death from bladder cancer, any adverse events, and non-serious complications. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS We included 16 randomized controlled trials involving a total of 4325 participants in the review. The studies compared blue light versus white light TURBT for treatment of NMIBC. Primary outcomes Blue light TURBT may reduce the risk of disease recurrence over time (hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.54 to 0.81; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 48 (66 fewer to 27 fewer), 109 (152 fewer to 59 fewer), and 147 (211 fewer to 76 fewer) fewer recurrences per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT may also reduce the risk of disease progression over time (HR 0.65, 95% CI 0.50 to 0.84; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate-, and high-risk NMIBC, this corresponded to 1 (1 fewer to 0 fewer), 17 (25 fewer to 8 fewer), and 56 (81 fewer to 25 fewer) fewer progressions per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT may have little or no effect on serious surgical complications (risk ratio (RR) 0.54, 95% CI 0.14 to 2.14; low-certainty evidence). This corresponded to 10 fewer (19 fewer to 25 more) surgical complications per 1000 participants with blue light TURBT. Secondary outcomes Blue light TURBT may have little or no effect on the risk of death from bladder cancer over time (HR 0.55, 95% CI 0.19 to 1.61; low-certainty evidence). This corresponded to 22 deaths per 1000 participants with white light TURBT and 10 fewer (17 fewer to 13 more) deaths per 1000 participants with blue light TURBT. We are very uncertain how blue light TURBT affects the outcome adverse events of any grade (RR 1.09, 95% CI 0.88 to 1.33; low-certainty evidence). No analysis was possible for the outcome non-serious surgical complications, as it was not reported by any of the included studies. AUTHORS' CONCLUSIONS Blue light-enhanced TURBT for the treatment of non-muscle invasive bladder cancer compared to white light-based TURBT may reduce the risk of disease recurrence and disease progression over time depending on baseline risk. There may be little or no effect on serious surgical complications. The certainty of evidence for our findings was low, meaning that future studies are likely change to the reported estimates of effect. Frequent issues that led to downgrading of the certainty of the evidence were study limitations, inconsistency, and imprecision.
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Affiliation(s)
- Philipp Maisch
- Department of Urology, University of Ulm, Ulm, Germany
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Alex Koziarz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jon Vajgrt
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Vikram Narayan
- Department of Urology, Emory University, Atlanta, Georgia, USA
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
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de la Rosette J, Martov A, Hurle R, Favre G, Mamoulakis C, Castanheira de Oliveira M, Stenzl A, Linares-Espinós E, Trelles Guzmán CR, Gravas S, Knoll T, Boz MY, Herrmann T, Laguna P. Conventional white light imaging-assisted transurethral resection of bladder tumour (TURBT) versus IMAGE1S-assisted TURBT in non-muscle-invasive bladder cancer patients: trial protocol and 18 months results. World J Urol 2021; 40:727-738. [PMID: 34741631 DOI: 10.1007/s00345-021-03866-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/16/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE White light (WL) is the traditional imaging modality for transurethral resection of bladder tumour (TURBT). IMAGE1S is a likely addition. We compare 18-mo recurrence rates following TURBT using IMAGE1S versus WL guidance. METHODS Twelve international centers conducted a single-blinded randomized controlled trial. Patients with primary and recurrent non-muscle-invasive bladder cancer (NMIBC) were randomly assigned 1:1 to TURBT guided by IMAGE1S or WL. Eighteen-month recurrence rates and subanalysis for primary/recurrent and risk groups were planned and compared by chi-square tests and survival analyses. RESULTS 689 patients were randomized for WL-assisted (n = 354) or IMAGE1S-assisted (n = 335) TURBT. Of these, 64.7% had a primary tumor, 35.3% a recurrent tumor, and 4.8%, 69.2% and 26.0% a low-, intermediate-, and high-risk tumor, respectively. Overall, 60 and 65 patients, respectively, completed 18-mo follow-up, with recurrence rates of 31.0% and 25.4%, respectively (p = 0.199). In patients with primary, low-/intermediate-risk tumors, recurrence rates at 18-mo were significantly higher in the WL group compared with the IMAGE1S group (31.9% and 22.3%, respectively: p 0.035). Frequency and severity of adverse events were comparable in both treatment groups. Immediate and adjuvant intravesical instillation therapy did not differ between the groups. Potential limitations included lack of uniformity of surgical resection, central pathology review, and missing data. CONCLUSION There was not difference in the overall recurrence rates between IMAGE1S and WL assistance 18-mo after TURBT in patients with NMIBC. However, IMAGE1S-assisted TURBT considerably reduced the likelihood of disease recurrence in primary, low/intermediate risk patients. REGISTRATION ClinicalTrials.gov Identifier NCT02252549 (30-09-2014).
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Affiliation(s)
- Jean de la Rosette
- Department of Urology, Istanbul Medipol Mega University Hospital, Istanbul, Turkey.
| | - Alexey Martov
- Department of Urology, Pletnew Moscow City Hospital, Moscow, Russia
| | - Rodolfo Hurle
- Department of Urology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gabriel Favre
- Department of Urology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Charalampos Mamoulakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Medical School, Heraklion, Crete, Greece
| | | | - Arnulf Stenzl
- Department of Urology, University of Tuebingen Medical Center, Tuebingen, Germany
| | | | | | - Stavros Gravas
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Medical School, University of Cyprus, Nicosia, Cyprus
| | - Thomas Knoll
- Department of Urology, Klinikum Sindelfingen-Boblingen, Germany
| | - Mustafa Yucel Boz
- Department of Urology, Istanbul Medipol Mega University Hospital, Istanbul, Turkey
| | - Thomas Herrmann
- Department of Urology, Spital Thurgau, AG, Switzerland
- Department of Urology, Hannover Medical School (MHH), Hannover, Germany
| | - Pilar Laguna
- Department of Urology, Istanbul Medipol Mega University Hospital, Istanbul, Turkey
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In vitro evaluation of cytotoxic properties of 5-Aminolevulinic acid (5-ALA) on bladder cancer cells. Photodiagnosis Photodyn Ther 2020; 30:101714. [PMID: 32165337 DOI: 10.1016/j.pdpdt.2020.101714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/28/2020] [Accepted: 03/06/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION 5-Aminolevulinic (5-ALA) may be used as a photo diagnostic agent in bladder cancer. The aim of this study was to investigate the cytotoxic effect of 5-ALA on bladder cancer cells. MATERIALS AND METHODS T24 cells treated with various concentrations of mitomycin (MC), 5-ALA and an MC/5-ALA mixture were evaluated to determine the role of 5-ALA on MC cytotoxicity. Cell cycle analysis was conducted, and apoptosis was analyzed by flow cytometry. Caspase 3 enzyme and reactive oxygen species were measured. RESULTS Our initial studies exploring the impact of combination therapy on cell viability demonstrated improved cytotoxic effects on T24 and RT cells with relatively low doses of 5-ALA/MC in conjunction with MC alone. Indicated no significant difference between the IC50 of MC and MC/5-ALA in T24 cells, while IC50 value was decreased by 25 % in RT4 cells in 5-ALA/MC in comparing with MC alone. However, examination of cell cycle phase arrests by flow cytometry revealed significant PreG1 apoptosis and cell growth arrest in G2/M in T24 cells treated with the MC/5-ALA mixture compared with MC treatment. In addition, caspase 3 enzyme was increased by 1.15-fold in T24 cells treated with MC/5-ALA in comparison with MC alone. CONCLUSION These results suggest that 5-ALA might possess anti-cancer properties and is not only a photo diagnostic element.
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Gakis G. Management of Muscle-invasive Bladder Cancer in the 2020s: Challenges and Perspectives. Eur Urol Focus 2020; 6:632-638. [PMID: 31987763 DOI: 10.1016/j.euf.2020.01.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 12/16/2022]
Abstract
Despite an increased use of neoadjuvant and adjuvant chemotherapy, the long-term survival rates after radical cystectomy or trimodal therapy (TMT) for muscle-invasive bladder cancer (MIBC) remain basically unchanged for decades. Detection and effective treatment of micrometastatic disease are still a clinical dilemma. Assessment of circulating tumor DNA in combination with improved imaging modalities may improve the prediction of micrometastatic disease. Different genetic subtypes of MIBC show varying degrees of chemosensitivity. Further progress needs to be made in order to develop a common molecular classifier that can be used easily for daily clinical decision making. With the advent on immuno-oncology, bladder-sparing protocols are on the rise as an alternative to surgery. The extent of transurethral bladder tumor resection has a marked impact on the response rates to TMT and neoadjuvant chemotherapy. This review focuses on strategies regarding how to integrate surgery, radiotherapy, and molecular-based systemic treatment for improved oncological outcomes of patients with MIBC. PATIENT SUMMARY: Effective treatment of micrometastatic disease is the key to improved oncological outcomes in muscle-invasive bladder cancer and requires a multidisciplinary approach.
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Affiliation(s)
- Georgios Gakis
- Department of Urology and Pediatric Urology, Julius Maximillians University, Würzburg, Germany.
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[Cost-effectiveness analysis of blue light cystoscopy with hexylaminolevulinate in transurethral resection of the bladder]. Urologe A 2019; 58:34-40. [PMID: 29637215 DOI: 10.1007/s00120-018-0624-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Photodynamic diagnosis using the optical imaging agent hexaminolevulinate (HAL, Hexvix®, Ipsen Pharma GmbH, Ettlingen, Germany) as an adjunct to white light cystoscopy (WLC) during the initial transurethral resection of bladder tumours (TURB) improves the detection rate of bladder cancer and leads to fewer recurrences. OBJECTIVES A cost-effectiveness analysis was carried out in order to calculate the consequences for the German healthcare system. METHODS We combined a short-term decision tree and a Markov model to evaluate outcomes over a long period of time. The alternatives investigated were HAL-assisted blue light cystoscopy (BLC) as adjunct to WLC (HAL + BLC/WLC) compared with WLC alone in patients undergoing TURB. RESULTS HAL + BLC/WLC compared to WLC alone was associated with 0.07 incremental quality-adjusted life years (QALYs) and cost savings of 537 € per patient. CONCLUSION HAL + BLC/WLC compared with WLC alone resulted in both cost savings and improved patient outcome rendering it the "dominant" strategy.
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Novel endoscopic visualization techniques for bladder cancer detection: a review of the contemporary literature. Curr Opin Urol 2019; 28:214-218. [PMID: 29045251 DOI: 10.1097/mou.0000000000000459] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW To describe the principles of photodynamic diagnosis (PDD), narrow-band imaging (NBI) and Storz Professional Image Enhancement System (SPIES) techniques for the endoscopic management of nonmuscle-invasive bladder cancer (BCa) and to report their impact on clinical practice. RECENT FINDINGS PDD is associated with an increased sensitivity for detecting BCa specifically carcinoma in situ (CIS). Moreover, PDD has been shown to lower recurrence rate in comparison with white-light cystoscopy. The impact on progression-free survival is still unclear yet. NBI and, more recently, SPIES are two novel imaging techniques that do not require preoperative instillation of photosensitizing agents. NBI seems to be associated with lower recurrence rates. Nevertheless, further trials are necessary to confirm these results, in particular in high-risk lesions and CIS. Randomized clinical trials addressing the clinical impact of SPIES are ongoing. SUMMARY Novel endoscopic imaging techniques are useful diagnostic tools for evaluating BCa during cystoscopic diagnostic surveillance as well as during transurethral resection of the bladder. Although the standard of care remains white-light cystoscopy, these techniques provide higher sensitivity in detecting BCa especially CIS. The continued evidence also suggests that this increased detection leads to lower recurrence rates. The impact on progression and the cost-efficacy as well as selection remains to be refined.
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Renninger M, Fahmy O, Schubert T, Schmid MA, Hassan F, Stenzl A, Gakis G. The prognostic impact of hexaminolevulinate-based bladder tumor resection in patients with primary non-muscle invasive bladder cancer treated with radical cystectomy. World J Urol 2019; 38:397-406. [PMID: 31030231 DOI: 10.1007/s00345-019-02780-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/20/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To investigate whether hexaminolevulinate-based (HAL) bladder tumor resection (TURBT) impacts on outcomes of patients with primary non-muscle-invasive bladder cancer (NMIBC) who were eventually treated with radical cystectomy (RC). METHODS A total of 131 consecutive patients exhibiting NMIBC at primary diagnosis were retrospectively investigated whether they had undergone any HAL-guided TURBT prior to RC. Uni- and multivariable analyses were used to evaluate the impact of HAL-TURBT on cancer-specific (CSS) and overall survival (OS). The median follow-up was 38 months (IQR 13-56). RESULTS Of the 131 patients, 69 (52.7%) were managed with HAL- and 62 (47.3%) with white light (WL)-TURBT only prior to RC. HAL-TURBT was associated with a higher number of TURBTs prior to RC (p = 0.002) and administration of intravesical chemotherapy (p = 0.043). A trend towards a higher rate of tumor-associated immune cell infiltrates in RC specimens (p = 0.07) and a lower utilization rate of post-operative systemic chemotherapy (p = 0.10) was noted for patients who were treated with HAL-TURBT. The 5-year CSS/OS was 90.9%/74.5% for the HAL-group and 73.8%/55.8% for the WL-group (p = 0.042/0.038). In multivariable analysis, lymph node tumor involvement (p = 0.007), positive surgical margins (p = 0.001) and performance of WL-TURBT only (p = 0.040) were independent predictors for cancer-specific death. CONCLUSIONS The present data suggest that the resection of NMIBC under HAL exerts a beneficial impact on outcomes of patients who will need to undergo RC during their course of disease. This finding may be due to improved risk stratification as the resection under HAL may allow more patients to be treated timely and adequately.
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Affiliation(s)
- Markus Renninger
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany
| | - Omar Fahmy
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany.,Department of Urology, University Putra Malaysia (UPM), Selangor, Malaysia
| | - Tina Schubert
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany.,Department of Urology and Pediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Oberduerrbacher Strasse 6, 97080, Würzburg, Germany
| | - Manuel Alexander Schmid
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany
| | - Fahmy Hassan
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany.,Department of Urology and Pediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Oberduerrbacher Strasse 6, 97080, Würzburg, Germany
| | - Arnulf Stenzl
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany
| | - Georgios Gakis
- Department of Urology, University Hospital of Tübingen, Eberhard-Karls University, Tübingen, Germany. .,Department of Urology and Pediatric Urology, University Hospital of Würzburg, Julius-Maximillians University, Oberduerrbacher Strasse 6, 97080, Würzburg, Germany.
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Chiong E, Zang Z, Wu Q. Blue-light cystoscopy and narrow-band imaging in bladder cancer management. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_133_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
PURPOSE OF REVIEW Endoscopy coupled with targeted resections represents a cornerstone in the diagnosis, staging, and treatment of patients with bladder cancer. Direct visualization can be challenging and imprecise due to patient-, tumor-, and surgeon-specific factors. We will review contemporary endoscopic technologies and techniques used to improve our ability to safely identify and resect malignant lesions in patients with bladder cancer. RECENT FINDINGS Enhanced endoscopic imaging technology may improve detection rates for bladder cancer throughout the upper and lower urinary tract, which may lead to improvements in recurrence and progression rates for non-muscle invasive bladder cancer (NMIBC). New techniques including narrow-band imaging (NBI), photodynamic diagnosis (PDD), Storz Professional Image Enhancement System (SPIES), optical coherence tomography (OCT), and others have shown benefit and may further improve our ability to detect and stage bladder tumors. Enhanced endoscopy technologies have already demonstrated value in improving the sensitivity of bladder cancer detection and early results suggest they may improve short- and long-term oncologic outcomes.
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Stenzl A. Editorial Comment. J Urol 2018; 199:1165. [PMID: 29458033 DOI: 10.1016/j.juro.2017.11.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Arnulf Stenzl
- Department of Urology, Eberhard-Karls-University, Tuebingen, Germany
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Lyseng-Williamson KA. Hexaminolevulinate: a profile of its use with blue-light cystoscopy in the diagnosis of bladder cancer. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0436-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Schubert T, Rausch S, Fahmy O, Gakis G, Stenzl A. Optical improvements in the diagnosis of bladder cancer: implications for clinical practice. Ther Adv Urol 2017; 9:251-260. [PMID: 29662543 DOI: 10.1177/1756287217720401] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/22/2017] [Indexed: 12/20/2022] Open
Abstract
Background For over 100 years white-light cystoscopy has remained the gold-standard technique for the detection of bladder cancer (BCa). Some limitations in the detection of flat lesions (CIS), the differentiation between inflammation and malignancy, the inaccurate determination of the tumor margin status as well as the tumor depth, have led to a variety of technological improvements. The aim of this review is to evaluate the impact of these improvements in the diagnosis of BCa and their effectiveness in clinical practice. Methods A systematic literature search was conducted according to the PRISMA statement to identify studies reporting on imaging modalities in the diagnosis of NMIBC between 2000 and 2017. A two-stage selection process was utilized to determine eligible studies. A total of 74 studies were considered for final analysis. Results Optical imaging technologies have emerged as an adjunct to white-light cystoscopy and can be classified according to their scope as macroscopic, microscopic and molecular. Macroscopic techniques including photodynamic diagnosis (PDD), narrow-band imaging (NBI) and the Storz Professional Image Enhancement System (IMAGE1 S, formerly known as SPIES) are similar to white-light cystoscopy, but are superior in the detection of bladder tumors by means of contrast enhancement. Especially the detection rate of very mute lesions in the bladder mucosa (CIS) could be significantly increased by the use of these methods. Microscopic imaging techniques like confocal laser endomicroscopy and optical coherence tomography permit a real-time high-resolution assessment of the bladder mucosa at a cellular and sub-cellular level with spatial resolutions similar to histology, enabling the surgeon to perform an 'optical biopsy'. Molecular techniques are based on the combination of optical imaging technologies with fluorescence labeling of cancer-specific molecular agents like antibodies. This labeling is intended to favor an optical distinction between benign and malignant tissue. Conclusions Optical improvements of the standard white-light cystoscopy have proven their benefit in the detection of BCa and have found their way into clinical practice. Especially the combination of macroscopic and microscopic techniques may improve diagnostic accuracy. Nevertheless, HAL-PDD guided cystoscopy is the only approach approved for routine use in the diagnosis of BCa by most urological associations in the EU and USA to date.
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Affiliation(s)
- Tina Schubert
- Department of Urology, University Hospital Tübingen, Tübingen, Germany
| | - Steffen Rausch
- Department of Urology, University Hospital Tübingen, Tübingen, Germany
| | - Omar Fahmy
- Department of Urology, University Putra Malaysia (UPM), Selangor, Malaysia
| | - Georgios Gakis
- Department of Urology, University Hospital Tübingen, Tübingen, Germany
| | - Arnulf Stenzl
- Department of Urology, University Hospital Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
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Optimised photodynamic diagnosis for transurethral resection of the bladder (TURB) in German clinical practice: results of the noninterventional study OPTIC III. World J Urol 2016; 35:737-744. [PMID: 27578233 PMCID: PMC5397437 DOI: 10.1007/s00345-016-1925-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/13/2016] [Indexed: 11/04/2022] Open
Abstract
Purpose White light cystoscopy (WLC) is the standard procedure for visualising non-muscle invasive bladder cancer (NMIBC). However, WLC can fail to detect all cancerous lesions, and outcomes with transurethral resection of the bladder differ between institutions, controlled trials, and possibly between trials and routine application. This noninterventional study assessed the benefit of hexaminolevulinate blue light cystoscopy (HALC; Hexvix®, Ipsen Pharma GmbH, Germany) plus WLC versus WLC alone in routine use. Methods From May 2013 to April 2014, 403 patients with suspected NMIBC were screened from 30 German centres to perform an unprecedented detailed assessment of the additional detection of cancer lesions with HALC versus WLC alone. Results Among the histological results for 929 biopsy samples, 94.3 % were obtained from suspected cancerous lesions under either WLC or HALC: 59.5 % were carcinoma tissue and 40.5 % were non-cancerous tissue. Of all cancer lesions, 62.2 % were staged as Ta, 20.1 % as T1, 9.3 % as T2, 7.3 % as carcinoma in situ (CIS), and 1.2 % were unknown. Additional cancer lesions (+6.8 %) and CIS lesions (+25 %, p < 0.0001) were detected by HALC plus WLC versus WLC alone. In 10.0 % of patients, ≥1 additional positive lesion was detected with HALC, and 2.2 % of NMIBC patients would have been missed with WLC alone. No adverse events were observed. Conclusions The results of this study demonstrate that HALC significantly improves the detection of NMIBC versus WLC alone in routine clinical practice in Germany. While this benefit is statistically significant across all types of NMIBC, it seems most relevant in CIS.
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Gakis G, Fahmy O. Systematic Review and Meta-Analysis on the Impact of Hexaminolevulinate- Versus White-Light Guided Transurethral Bladder Tumor Resection on Progression in Non-Muscle Invasive Bladder Cancer. Bladder Cancer 2016; 2:293-300. [PMID: 27500197 PMCID: PMC4969683 DOI: 10.3233/blc-160060] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Although there is evidence that hexaminolevulinate (HAL)-based transurethral bladder tumor resection (TURBT) improves the detection of Ta-T1 non-muscle-invasive bladder cancer (NMIBC) as well as carcinoma in situ there is uncertainty about its beneficial effects on progression. Material and Methods: A systematic literature search was conducted according to the PRISMA statement to identify studies reporting on HAL- vs. white-light (WL-) based TUR-BT in non-muscle invasive bladder cancer between 2000 and 2016. A two-stage selection process was utilized to determine eligible studies. Of a total of 294 studies, 5 (4 randomized and one retrospective) were considered for final analysis. The primary objective was the rate of progression. Results: The median follow-up for patients treated with HAL- and WL-TURBT was 27.6 (1–55.1) and 28.9 (1–53) months, respectively. Of a total of 1301 patients, 644 underwent HAL- and 657 WL-based TURBT. Progression was reported in 44 of 644 patients (6.8%) with HAL- and 70 of 657 patients (10.7%) with WL-TURBT, respectively (median odds ratio: 1.64, 1.10–2.45 for HAL vs. WL; p = 0.01). Data on progression-free survival was reported in a single study with a trend towards improved survival for patients treated with HAL-TURBT (p = 0.05). Conclusions: In this meta-analysis the rate of progression was significantly lower in patients treated with HAL- vs. WL-based TURBT. These results support the initiation of randomized trials on HAL with progression as primary endpoint.
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Affiliation(s)
- Georgios Gakis
- Department of Urology, University Hospital Tübingen , Tübingen, Germany
| | - Omar Fahmy
- Department of Urology, University Putra Malaysia (UPM) , Selangor, Malaysia
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May M, Fritsche HM, Vetterlein MW, Bastian PJ, Gierth M, Nuhn P, Aziz A, Fisch M, Stief CG, Hohenfellner M, Wirth MP, Novotny V, Hakenberg OW, Noldus J, Gilfrich C, Bolenz C, Burger M, Brookman-May SD. Impact of photodynamic diagnosis-assisted transurethral resection of bladder tumors on the prognostic outcome after radical cystectomy: results from PROMETRICS 2011. World J Urol 2016; 35:245-250. [DOI: 10.1007/s00345-016-1877-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/06/2016] [Indexed: 12/24/2022] Open
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Kamat AM, Cookson M, Witjes JA, Stenzl A, Grossman HB. The Impact of Blue Light Cystoscopy with Hexaminolevulinate (HAL) on Progression of Bladder Cancer - A New Analysis. Bladder Cancer 2016; 2:273-278. [PMID: 27376146 PMCID: PMC4927917 DOI: 10.3233/blc-160048] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The International Bladder Cancer Group (IBCG) recently proposed a new definition of disease progression in non-muscle invasive bladder cancer (NMIBC), including change in T-stage, change to T2 or higher or change from low to high grade. Objective: To establish whether blue light cystoscopy with hexaminolevulinate (HAL) impacts the rate of progression and time to progression using the revised definition. Methods: An earlier long-term follow-up of a controlled Phase III study reported outcomes following blue light cystoscopy with HAL (255 patients) or white light (WL) cystoscopy (261 patients) in NMIBC patients. The data was re-analysed according to the new definition. Results: In the original analysis, after 4.5 years (median), eight HAL and 16 WL patients were deemed to have progressed (transition from NMIBC to muscle invasive bladder cancer, (T2-4)). According to the new definition, additional patients in both groups were found to have progressed: 31 (12.2%) HAL vs 46 (17.6%) WL (p = 0.085) with four (1.6%) HAL and 11 (4.2%) WL patients progressing from Ta to CIS. Time to progression was longer in the HAL group (p = 0.05). Conclusions: Applying the new IBCG definition there was a trend towards a lower rate of progression in HAL patients, particularly in those progressing from Ta to CIS. Time to progression was significantly prolonged. This suggests that patients should receive blue light cystoscopy with HAL rather than WL at resection. Adoption of the new definition could allow more patients at risk of progression to be treated appropriately earlier.
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Affiliation(s)
- Ashish M Kamat
- Department of Urology, University of Texas M D Anderson Cancer Center , Houston, TX, USA
| | - Michael Cookson
- Department of Urology, University of Oklahoma , Oklahoma City, OK, USA
| | - J Alfred Witjes
- Radboud University , Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Arnulf Stenzl
- Department of Urology, University Hospital , Tübingen (AS), Germany
| | - H Barton Grossman
- Department of Urology, University of Texas M D Anderson Cancer Center , Houston, TX, USA
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Editorial Comment. J Urol 2016; 195:892. [DOI: 10.1016/j.juro.2015.10.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Dansk V, Malmström PU, Bläckberg M, Malmenäs M. Hexaminolevulinate hydrochloride blue-light flexible cystoscopy in the detection and follow-up of nonmuscle-invasive bladder cancer: cost consequences during outpatient surveillance in Sweden. Future Oncol 2016; 12:1025-38. [PMID: 26975197 DOI: 10.2217/fon-2015-0021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM This study explored the cost consequences of introducing hexaminolevulinate hydrochloride-guided blue-light flexible cystoscopy (HAL BLFC) as an adjunct to white-light flexible cystoscopy compared with white-light flexible cystoscopy alone, for the detection and management of nonmuscle invasive bladder cancer in Sweden. METHODS The model evaluated 231 patients in the outpatient setting after successful initial transurethral resection of the bladder tumor. RESULTS HAL BLFC introduction across all risk groups resulted in minimal budget impact (+1.6% total cost/5 years, or 189 Swedish Krona [SEK] per patient/year), and translated to cost savings in intermediate- and high-risk groups from year 2. CONCLUSION HAL BLFC allowed more outpatient treatment with improved recurrence detection and reduced transurethral resection of the bladder tumors, cystectomies, bed days and operating room time, with minimal cost impact across all risk groups, demonstrating the economic benefits of introducing HAL.
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Affiliation(s)
- Viktor Dansk
- HERON™ Commercialization, PAREXEL, Stockholm, Sweden
| | - Per-Uno Malmström
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Mats Bläckberg
- Department of Urology & Surgery, Helsingborg Hospital, Helsingborg, Sweden
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Fluorescence guided resection (FGR): A primer for oncology. Photodiagnosis Photodyn Ther 2016; 13:73-80. [DOI: 10.1016/j.pdpdt.2015.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 01/27/2023]
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Lotan Y. Promises and challenges of fluorescence cystoscopy. Urol Oncol 2015; 33:261-4. [DOI: 10.1016/j.urolonc.2015.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
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Aziz A, Gierth M, Rink M, Schmid M, Chun FK, Dahlem R, Roghmann F, Palisaar RJ, Noldus J, Ellinger J, Müller SC, Pycha A, Martini T, Bolenz C, Moritz R, Herrmann E, Keck B, Wullich B, Mayr R, Fritsche HM, Burger M, Bastian PJ, Seitz C, Brookman-May S, Xylinas E, Shariat SF, Fisch M, May M. Optimizing outcome reporting after radical cystectomy for organ-confined urothelial carcinoma of the bladder using oncological trifecta and pentafecta. World J Urol 2015; 33:1945-50. [DOI: 10.1007/s00345-015-1572-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022] Open
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