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Sasahara T, Yanagisawa T, Sugaya S, Hisakane A, Sakanaka K, Hara S, Otsuka T, Takamizawa S, Yata Y, Takahashi Y, Takiguchi Y, Mori K, Tsuzuki S, Kimura S, Miki J, Kimura T. Prognostic factors for overall survival in clinical node-positive patients with upper tract urothelial carcinoma. Int J Urol 2024; 31:386-393. [PMID: 38169105 DOI: 10.1111/iju.15380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND There is sparse evidence regarding optimal management and prognosticators for oncologic outcomes in patients with clinical node-positive (cN+) upper tract urothelial carcinoma (UTUC). METHODS We retrospectively analyzed the data from 105 UTUC patients with cN1-2M0 between June 2010 and June 2022 at multiple institutions affiliated with our university. At the time of diagnosis, all patients received standard-of-care treatment including radical nephroureterectomy (RNU), chemotherapy, and/or palliative care. We employed a Cox regression model to analyze the prognostic importance of various factors on overall survival (OS). RESULTS Of 105 patients, 54 (51%) underwent RNU, while 51 (49%) did not. RNU was likely to be selected in patients with younger and higher G8 score, resulting in better median OS in patients who underwent RNU than in those who did not (42 months vs. 15 months, p < 0.001). Multivariable analysis among the entire cohort revealed that low G8 score (≤14) (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.08-3.99), elevated pretreatment C-reactive protein (CRP) (HR: 3.35, 95%CI: 1.63-6.90), and failure to perform RNU (HR: 2.16, 95%CI: 1.06-4.42) were independent prognostic factors for worse OS. In the subgroup analyses of cohorts who did not undergo RNU, elevated pretreatment CRP was the only independent prognostic factor for worse OS in cN+ UTUC patients. CONCLUSIONS RNU seems to be a reasonable treatment option in cN+ UTUC patients where applicable. Elevated pretreatment CRP appears to be a reliable prognosticator of worse OS and may be helpful in optimizing candidate selection for intensified treatment in this setting.
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Affiliation(s)
- Taishiro Sasahara
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
- Department of Urology, Machida Municipal Hospital, Tokyo, Japan
| | - Takafumi Yanagisawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shingo Sugaya
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
- Department of Urology, Machida Municipal Hospital, Tokyo, Japan
| | - Akira Hisakane
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Keigo Sakanaka
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shuhei Hara
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Otsuka
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shigeaki Takamizawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuji Yata
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Takahashi
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Takiguchi
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Tsuzuki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shoji Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
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Fletcher SA, Pallauf M, Watts EK, Lombardo KA, Campbell JA, Rezaee ME, Rouprêt M, Boorjian SA, Potretzke AM, Roshandel MR, Ploussard G, Djaladat H, Ghoreifi A, Mari A, Campi R, Khene ZE, Raman JD, Kikuchi E, Rink M, Abdollah F, Boormans JL, Fujita K, D'Andrea D, Soria F, Breda A, Hoffman-Censits J, McConkey DJ, Shariat SF, Pradere B, Singla N. Oncologic Outcomes in Patients with Residual Upper Tract Urothelial Carcinoma Following Neoadjuvant Chemotherapy. Eur Urol Oncol 2024:S2588-9311(24)00035-X. [PMID: 38262800 DOI: 10.1016/j.euo.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/21/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Growing evidence supports the use of neoadjuvant chemotherapy (NAC) for upper tract urothelial carcinoma (UTUC). However, the implications of residual UTUC at radical nephroureterectomy (RNU) after NAC are not well characterized. Our objective was to compare oncologic outcomes for pathologic risk-matched patients who underwent RNU for UTUC who either received NAC or were chemotherapy-naïve. METHODS We retrospectively identified 1993 patients (including 112 NAC recipients) who underwent RNU for nonmetastatic, high-grade UTUC between 1985 and 2022 in a large, international, multicenter cohort. We divided the cohort into low-risk and high-risk groups defined according to pathologic findings of muscle invasion and lymph node involvement at RNU. Recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) estimates were calculated using the Kaplan-Meier method. Multivariable analyses were performed to determine clinical and demographic factors associated with these outcomes. KEY FINDINGS AND LIMITATIONS Among patients with low-risk pathology at RNU, RFS, OS, and CSS were similar between the NAC and chemotherapy-naïve groups. Among patients with high-risk pathology at RNU, the NAC group had poorer RFS (hazard ratio [HR] 3.07, 95% confidence interval [CI] 2.10-4.48), OS (HR 2.06, 95% CI 1.33-3.20), and CSS (subdistribution HR 2.54, 95% CI 1.37-4.69) in comparison to the pathologic risk-matched, chemotherapy-naïve group. Limitations include the lack of centralized pathologic review. CONCLUSIONS AND CLINICAL IMPLICATIONS Patients with residual invasive disease at RNU after NAC represent a uniquely high-risk population with respect to oncologic outcomes. There is a critical need to determine an optimal adjuvant approach for these patients. PATIENT SUMMARY We studied a large, international group of patients with cancer of the upper urinary tract who underwent surgery either with or without receiving chemotherapy beforehand. We identified a high-risk subgroup of patients with residual aggressive cancer after chemotherapy and surgery who should be prioritized for clinical trials and drug development.
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Affiliation(s)
- Sean A Fletcher
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maximilian Pallauf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Urology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Emelia K Watts
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Kara A Lombardo
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jack A Campbell
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael E Rezaee
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Sorbonne University, Department of Urology, Pitie-Salpetriere Hospital, AP-HP, Paris, France
| | | | | | - M Reza Roshandel
- Department of Urology, Mayo Clinic, Rochester, MN, USA; Department of Urology, Westchester County Medical Center, Valhalla, NY, USA
| | | | - Hooman Djaladat
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Alireza Ghoreifi
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Andrea Mari
- Department of Urology, Careggi Hospital, Florence, Italy
| | - Riccardo Campi
- Department of Urology, Careggi Hospital, Florence, Italy
| | | | - Jay D Raman
- Department of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Eiji Kikuchi
- Department of Urology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Firas Abdollah
- Department of Urology, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Joost L Boormans
- Department of Urology, Erasmus University Medical Center Rotterdam, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kazutoshi Fujita
- Department of Urology, Kindai University Faculty of Medicine, Osaka, Japan
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Alberto Breda
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Jean Hoffman-Censits
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - David J McConkey
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Benjamin Pradere
- Department of Urology, La Croix du Sud Hôpital, Quint Fonsegrives, France
| | - Nirmish Singla
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA.
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Calleris G, Rouprêt M, Seisen T, Bendjeddou L, Chevallier T, Masson-Lecomte A, Thibault C, Neuzillet Y, Audenet F, Xylinas E, Houédé N. Design and rationale of a single-arm phase II study of neoadjuvant Durvalumab and Gemcitabine associated with Cisplatin or Carboplatin for upper urinary tract urothelial cancer: the iNDUCT trial (NCT04617756). World J Urol 2023; 41:3413-3420. [PMID: 37698632 DOI: 10.1007/s00345-023-04596-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/23/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Upper urinary tract urothelial carcinoma (UTUC) is often locally advanced at initial diagnosis and is associated with high recurrence and mortality rates after radical nephroureterectomy (RNU). Adjuvant platinum-based chemotherapy has shown a recurrence-free survival benefit in a randomised phase III trial, while neoadjuvant treatment seems promising in retrospective series. On the contrary, little is known about the role of perioperative immunotherapy and its combination with chemotherapy for UTUC patients, although initial positive results have been published for muscle-invasive bladder cancer. STUDY DESIGN AND ENDPOINTS Against this backdrop, we are running a multi-centre single-arm phase 2 trial of neoadjuvant Durvalumab, a monoclonal antibody targeting programmed cell death ligand 1, combined with Gemcitabine and Cisplatin or Carboplatin for high-risk UTUC patients. The primary outcome is pathological complete response rate at RNU. Secondary endpoints include the partial pathological response rate, safety, as well as disease-free and overall survival. A biomarker analysis is also planned. PATIENTS AND INTERVENTIONS Included patients must have a good performance status and harbour a non-metastatic UTUC, considered at high risk of progression, defined as either biopsy-proven high-grade disease or invasive features at imaging with or, more recently, without high-grade cytology at the multidisciplinary team discretion, as specified in the latest amendment. Enrolled patients receive 3 cycles of neoadjuvant immuno-chemotherapy before RNU, and the standard of care thereafter. The trial is registered as NCT04617756 and is supervised by an independent data monitoring committee.
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Affiliation(s)
- Giorgio Calleris
- GRC 5 Predictive Onco-Urology Research Group and Urology Department, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, 75013, Paris, France
- Department of Surgical Sciences, Urology, University of Turin, Turin, Italy
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Urology Research Group and Urology Department, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, 75013, Paris, France.
| | - Thomas Seisen
- GRC 5 Predictive Onco-Urology Research Group and Urology Department, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, 75013, Paris, France
| | - Lyamin Bendjeddou
- Research and Innovation Department, Nimes University Hospital, 30029, Nimes, France
| | - Thierry Chevallier
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM), Nimes University Hospital, 30029, Nimes, France
- UMR 1302, Institute Desbrest of Epidemiology and Public Health, INSERM, Univ. Montpellier, Montpellier, France
| | - Alexandra Masson-Lecomte
- Department of Urology, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, 75010, Paris, France
| | - Constance Thibault
- Department of Medical Oncology, Assistance Publique-Hôpitaux de Paris, Hopital Européen Georges Pompidou, Paris, France
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, Paris Saclay University, Suresnes, France
| | - François Audenet
- Department of Urology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Evanguelos Xylinas
- Service d'Urologie, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Nadine Houédé
- Gard Cancer Institute, Nimes University Hospital, University of Montpellier, 30029, Nimes, France
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Dłubak A, Karwacki J, Logoń K, Tomecka P, Brawańska K, Krajewski W, Szydełko T, Małkiewicz B. Lymph Node Dissection in Upper Tract Urothelial Carcinoma: Current Status and Future Perspectives. Curr Oncol Rep 2023; 25:1327-1344. [PMID: 37801187 PMCID: PMC10640513 DOI: 10.1007/s11912-023-01460-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW This narrative review aims to evaluate the role of lymph node dissection (LND) in upper tract urothelial carcinoma (UTUC) and its implications for staging and management outcomes, as well as future perspectives. RECENT FINDINGS Multiple studies have demonstrated the limitations of conventional imaging techniques in accurately localizing lymph node metastasis (LNM) in UTUC. While 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18FDG-PET/CT) shows promise for preoperative LNM detection, its specificity is low. Alternative methods such as choline PET/CT and sentinel lymph node detection are under consideration but require further investigation. Additionally, various preoperative factors associated with LNM hold potential for predicting nodal involvement, thereby improving nodal staging and oncologic outcomes of LND. Several surgical approaches, including segmental ureterectomy and robot-assisted nephroureterectomy, provide a possibility for LND, while minimizing morbidity. LND remains the primary nodal staging tool for UTUC, but its therapeutic benefit is still uncertain. Advances in imaging techniques and preoperative risk assessment show promise in improving LNM detection. Further research and multi-center studies are needed to comprehensively assess the advantages and limitations of LND in UTUC, as well as the long-term outcomes of alternative staging and treatment strategies.
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Affiliation(s)
- Andrzej Dłubak
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Jakub Karwacki
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Katarzyna Logoń
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Paulina Tomecka
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Kinga Brawańska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland.
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Bobjer J, Gerdtsson A, Abrahamsson J, Baseckas G, Bergkvist M, Bläckberg M, Brändstedt J, Jancke G, Hagberg O, Kollberg P, Lundström KJ, Löfgren A, Nyberg M, Rian Mårtensson L, Saemundsson Y, Ståhl E, Sörenby A, Warnolf Å, Liedberg F. Location of Retroperitoneal Lymph Node Metastases in Upper Tract Urothelial Carcinoma: Results from a Prospective Lymph Node Mapping Study. EUR UROL SUPPL 2023; 57:37-44. [PMID: 38020529 PMCID: PMC10658412 DOI: 10.1016/j.euros.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background There is limited information on the distribution of retroperitoneal lymph node metastases (LNMs) in upper tract urothelial carcinoma (UTUC). Objective To investigate the location of LNMs in UTUC of the renal pelvis or proximal ureter and short-term complications after radical nephroureterectomy (RNU) with lymph node dissection (LND). Design setting and participants This was a prospective Nordic multicenter study (four university hospitals, two county hospitals). Patients with clinically suspected locally advanced UTUC (stage >T1) and/or clinical lymph node-positive (cN+) disease were invited to participate. Participants underwent RNU and fractionated retroperitoneal LND using predefined side-specific templates. Outcome measurements and statistical analysis The location of LNMs in the LND specimen and retroperitoneal lymph node recurrences during follow-up was recorded. Postoperative complications within 90 d of surgery were ascertained from patient charts. Descriptive statistics were used. Results and limitations LNMs were present in the LND specimen in 23/100 patients, and nine of 100 patients experienced a retroperitoneal recurrence. Distribution per side revealed LNMs in the LND specimen in 11/38 (29%) patients with right-sided tumors, for whom the anatomically larger, right-sided template was used, in comparison to 12/62 (19%) patients with left-sided tumors, for whom a more limited template was used. High-grade complications (Clavien grade ≥3) within 90 d of surgery were registered for 13/100 patients. The study is limited in size and not powered to assess survival estimates. Conclusions The suggested templates that we prospectively applied for right-sided and left-sided LND in patients with advanced UTUC included the majority of LNMs. High-grade complications directly related to the LND part of the surgery were limited. Patient summary This study describes the location of lymph node metastases in patients with cancer in the upper urinary tract who underwent surgery to remove the affected kidney and ureter. The results show that most metastases occur within the template maps for lymph node surgery that we investigated, and that this surgery can be performed with few severe complications.
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Affiliation(s)
- Johannes Bobjer
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Axel Gerdtsson
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Johan Abrahamsson
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | | | - Mats Bergkvist
- Pelvic Cancer Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Bläckberg
- Department of Urology, Helsingborg County Hospital, Helsingborg, Sweden
| | - Johan Brändstedt
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Georg Jancke
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Oskar Hagberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Petter Kollberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Karl-Johan Lundström
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
- Department of Urology, Östersund County Hospital, Östersund, Sweden
| | - Annica Löfgren
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Martin Nyberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | | | - Ymir Saemundsson
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Elin Ståhl
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Anne Sörenby
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Åsa Warnolf
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology Skåne University Hospital, Malmö, Sweden
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