Management of primary upper urinary tract carcinoma in situ diagnosed by ureteroscopic biopsy: Is bacillus Calmette-Guerin an alternative to nephroureterectomy? | Actas Urológicas Españolas (English Edition)

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "221" "paginaFinal" => "228" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Territo, S. Fontanet, I. Meneghetti, A. Gallioli, F. Sanguedolce, Ó. Rodriguez-Faba, J.M Gaya, J. Palou, J. Huguet, A. Breda" "autores" => array:10 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Territo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] 1 => array:4 [ "nombre" => "S." "apellidos" => "Fontanet" "email" => array:1 [ 0 => "sofia.fontanet@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] 1 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Meneghetti" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Gallioli" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Sanguedolce" ] 5 => array:2 [ "nombre" => "Ó." 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"apellidos" => "Breda" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo del carcinoma in situ de tramo urinario superior diagnosticado por biopsia ureteroscópica: ¿es el bacilo de Calmette-Guérin una alternativa a la nefroureterectomía?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2563 "Ancho" => 3091 "Tamanyo" => 305196 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Kaplan-Meyer tables for Cancer-specific survival (A), Recurrence-free survival (B), Progression-free survival (C) and overall survival (D)." ] ] ] "textoCompleto" => "IntroductionUpper tract urothelial carcinoma (UTUC) accounts for 5% of urothelial carcinomas and, among this group of tumors, upper urinary tract CIS (UT-CIS) is a rare disease (<3%)<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. Concomitant UT-CIS is reported to be present in 11%–36% of patients with UTUC<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and we know that primary UT-CIS is less frequent than concomitant UT-CIS<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. Although carcinoma in situ (CIS) of the bladder and UT-CIS present a similar histopathological aspect, differences in behavior have been identified: bladder CIS progresses in approximately 50% of patients without treatment, whereas progression rate of UT-CIS with topical therapy is around 5–10%<a class="elsevierStyleCrossRef" href="#bib0020">4</a>. CIS displays great sensitivity to immunomodulators, and bacillus Calmette-Guérin (BCG) represents the first-line treatment for bladder CIS with a response rate greater than 60%<a class="elsevierStyleCrossRefs" href="#bib0025">5–8</a>; it means that BCG could be an option in UT-CIS.The diagnosis of UT-CIS remains a challenge. In most published studies, patients received a diagnosis of UT-CIS by means of positive voided urine cytology, with negative biopsies of the bladder and prostatic urethra, no findings on the upper urinary tract imaging study, and/or positive cytology in selective ipsilateral urine samples<a class="elsevierStyleCrossRefs" href="#bib0015">3,8–17</a>. This means that in these studies the diagnosis of UT-CIS was made without histological confirmation.Although radical nephroureterectomy (RNU) remains the gold standard therapy for UT-CIS, BCG therapy has been widely used in imperative and elective cases. The initial rate of response to BCG in UT-CIS has been reported to be 63%–100% and its use is almost entirely safe<a class="elsevierStyleCrossRef" href="#bib0070">14</a>. Up to now, instillation of BCG has been proposed with promising results, but data are limited to small series of retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0040">8–18</a>.In the present study, we assessed the long-term efficacy of BCG instillation in patients who received a histological diagnosis of primary UT-CIS. Oncological outcomes were compared in patients treated with BCG and treated by RNU.Materials and methodsA retrospective chart review was performed identifying patients with primary UT-CIS diagnosed between January 1990 and December 2018. The study was approved by our institutional ethical committee previously to its development.All patients were preoperatively evaluated by imaging studies as computed tomography urography or intravenous urography. Cystoscopy with randomized bladder biopsies was performed in order to rule out bladder CIS and most patients underwent a selective ureteral barbotage. Diagnosis of UT-CIS was determined by random biopsies or biopsies of suspected areas performed at ureteroscopy (URS). The distal and mid ureter was explored with a semirigid ureteroscope and sampled using a 5-Fr biopsy forceps, while a flexible ureteroscope with 3-Fr forceps was used to explore and biopsy the upper ureter and pyelocaliceal system. In the 90s and 2000s semirigid ureteroscope was used to biopsy the entire ureter and renal pelvis.When UT-CIS was diagnosed, BCG instillation was offered in imperative cases and in patients unwilling or unfit to undergo a surgical approach.The following data were collected: age at diagnosis, gender, history of previous bladder tumor, renal function at diagnosis, ASA score, voiding and selective urinary cytology, imaging study, tumor laterality, multifocality, location, treatment, BCG instillation method, post-BCG URS, recurrence or progression, recurrence treatment, perioperative renal function, complications according to the Clavien-Dindo system<a class="elsevierStyleCrossRef" href="#bib0090">18</a>, and follow-up time.RNU was performed using either an open or a laparoscopic approach. It included en bloc removal of the kidney, the ureter, including the distal portion with the ipsilateral ureteral orifice.When distal ureterectomy was carried out, an extravesical approach was chosen and ureteral reimplantation was then performed according to the Politano-Leadbetter technique<a class="elsevierStyleCrossRef" href="#bib0095">19</a>.Patients treated with immunotherapy received BCG instillation by retrograde catheterization using a double J (D-J) 6-Fr ureteral stent, single J (S-J), or by antegrade administration using an 8-Fr percutaneous nephrostomy tube. In cases in which a D-J was used, BCG (81mg ImmuCyst BCG) dissolved in 50ml 0.9% sodium chloride was instilled into the bladder using a urethral catheter and BCG solution was kept in place for at least 2h. When using the nephrostomy tube or single-J technique, a perfusion was placed 20cm above the kidney of the patient and the instillation speed was 1ml per minute to avoid intrarenal tension. BCG solution was infused once weekly for a 6-week period as one course.In the BCG group, complete response was defined on the basis of negative imaging study results, negative URS biopsies at 2 months post-BCG, and absence of disease recurrence during follow-up.Persistent disease was defined as the presence of positive URS biopsies at 2 months after BCG. Recurrence was defined as the diagnosis of UT-CIS or UTUC during the follow-up. Disease progression was defined as local invasive disease or the appearance of metastasis.Later follow-up of patients who had undergone RNU and distal ureterectomy was carried out in accordance with European Association of Urology Guidelines<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. Patients who had received BCG instillations underwent a more stringent follow-up.Due to the small number of cases of distal ureterectomy we did not include these subgroups in the survival analyses.All statistical analyses were performed using SPSS version 22.0 software (IBM Corp., Armonk, NY, USA). Continuous variables were described using the median and interquartile range. The Kruskal-Wallis H test was used for comparison of quantitative variables. Cancer-specific survival (CSS), recurrence-free survival (RFS), progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan-Meier plots and log-rank tests. Statistical significance was defined as p<0.05.ResultsA total of 28 patients [29 renal units (RUs)] with primary UT-CIS were included in the study.Sixteen patients (57.1%) (17 RUs) received BCG as primary treatment. BCG instillation was selected as the initial treatment for the following reasons: reduced performance status<a class="elsevierStyleCrossRef" href="#bib0020">4</a>, patient’s own choice<a class="elsevierStyleCrossRef" href="#bib0020">4</a>, history of bladder CIS that responded successfully to BCG<a class="elsevierStyleCrossRef" href="#bib0020">4</a>, solitary functioning kidney<a class="elsevierStyleCrossRef" href="#bib0015">3</a>, and bilateral disease<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. In the BCG group, age at diagnosis was higher, ASA score of III–IV was more frequent, and follow-up time was shorter (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The method of administration of BCG was nephrostomy tube, S-J, and D-J in four, five, and seven patients respectively (patient with bilateral disease was treated with bilateral double J). (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) A complete response was detected in ten (58.8%) RUs while recurrence or persistence of disease was observed in seven (41.2%), with a mean recurrence time of 12 months.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Treatment for recurrence was RNU in five RUs (three pTis and two pT3) and two cases did not receive further surgical treatment or immunotherapy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Eight (27.6%) RUs underwent RNU, all with pTis at the pathology report. An open approach was used in six cases and laparoscopic in two. Median pre- and postoperative renal function was 81.5ml/min/1.73 m2 (IQR 58–85) and 57.5ml/min/1.73 m2 (IQR 39–71), respectively (p=0.05).). In four (50%) patients a contralateral recurrence was detected at a median time of 21 months. Those patients with recurrence were treated with distal ureterectomy<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and BCG instillation<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.Four (13.8%) RUs underwent distal ureterectomy for distal unifocal CIS. One patient developed ipsilateral recurrence and was successfully treated with BCG; another died because of disease progression.Three patients (17.6%) who received BCG experienced fever as an adverse event and one required antituberculostatic treatment. One patient treated with RNU complained of low abdominal pain after catheter removal due to urinary leakage at the suture site of the bladder cuff. No complications related to diagnostic ureteroscopic biopsies were reported.No significant differences were observed between the RNU and BCG subgroups in relation to CSS (p=0.776), RFS (p=0.841), PFS (p=0.451), or OS (p=0.701) at 5 years after treatment (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The 5-year CSS, RFS, PFS, and OS in the RNU and BCG subgroups were 74% versus 78%, 50% versus 56%, 75% versus 88%, and 42% versus 78%, respectively.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>DiscussionBCG instillations for UT-CIS have traditionally been reserved for imperative cases and its use in elective cases remains controversial. Moreover, previously only one other study has included biopsy proof of UT-CIS as a diagnostic criterion in the entire cohort of investigated patients<a class="elsevierStyleCrossRef" href="#bib0100">20</a>.We evaluated 29 RUs with a histological diagnosis of UT-CIS. A total of 17 RUs received BCG treatment, with a complete response in ten cases (58.8%) and recurrence in seven (41.2%). Salvage RNU after BCG persistence or recurrence was effective in four out of five patients. In eight (28.6%) patients RNU was performed, and four of these patients developed a contralateral recurrence during follow-up.Although UT-CIS is a rare disease, many articles on this topic have addressed BCG treatment as an alternative to RNU, the accepted gold standard. In most of these studies, the diagnosis of UT-CIS was made on the basis of positive results of bladder or selective ureteral cytology<a class="elsevierStyleCrossRefs" href="#bib0015">3,8,10–17</a>. One of the strengths of our study is that all of our patients had a histological diagnosis of UT-CIS and also repeated ureteral biopsies 2 months after BCG treatment. Authors against biopsies claim that they are not useful because it is difficult to obtain adequate multiple samples from the UUT<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> and also because the sensitivity of voided urinary cytology and selective ureteral urine collection is high<a class="elsevierStyleCrossRef" href="#bib0115">23</a>. We think that it is not difficult to obtain biopsies from the ureter with a semirigid ureteroscope and 5-Fr forceps, but we agree that it could be more difficult to biopsy the pelvis and calyces with a flexible ureteroscope and 3-Fr forceps. A recent review recommended histological diagnosis by brushing or forceps coupled with selective washings<a class="elsevierStyleCrossRef" href="#bib0020">4</a>.Redrow et al. analyzed the outcomes of ten series of UT-CIS treated with BCG. A total of 139 RUs were included. With a median follow-up between 13.5 and 58 months, the rate of response to BCG treatment was 64%–100% and the rate of recurrence, 8%–50%<a class="elsevierStyleCrossRef" href="#bib0020">4</a>.Some authors have compared BCG with RNU in UT-CIS patients. In their retrospective study on patients with UT-CIS, Horiguchi et al. treated 20 patients with RNU and 38 patients with BCG. They did not report statistically significant differences between the two groups in relation to CSS (RNU 100% vs BCG 89%, p=0.39) at 5-year follow-up<a class="elsevierStyleCrossRef" href="#bib0075">15</a>. Kojima et al. similarly found no statistically significant differences with respect to CSS (RNU 80% vs BCG 91%, p=0.62) in the two groups of patients treated with RNU (n=6) and BCG (n=11)<a class="elsevierStyleCrossRef" href="#bib0060">12</a>.In our study, a comparison of the subgroup of patients who underwent RNU with the subgroup who underwent BCG revealed no statistically significant differences in relation to CSS, RFS, PFS, or OS. This means that BCG could be the first option to treat patients with UT-CIS; it achieves a high complete response rate and in the case of recurrence, salvage RNU is usually curative<a class="elsevierStyleCrossRef" href="#bib0070">14</a>.Follow-up after BCG treatment must be strict, sometimes flat lesions are undetectable on tomography until they progress to thickening of the UUT, and in these instances stage is usually high<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. Five out of seven recurrences after BCG were treated with RNU (three pTis and two pT3).We agree with other authors that, with a strict follow-up, BCG can be used in patients with imperative and also elective indications<a class="elsevierStyleCrossRefs" href="#bib0020">4,14</a>. In our series only half of the patients who received BCG had strict imperative indications.There is however controversy over the best method of administering BCG. A recent animal study found surface area staining by dye administered via an open-ended ureteral catheter to be significantly superior to nephrostomy, and both methods were better than reflux with indwelling double pigtail<a class="elsevierStyleCrossRef" href="#bib0020">4</a>. Studer et al. considered that the anterograde route is preferable for the administration of BCG as it is safer in optimizing contact of the agent with the urothelium<a class="elsevierStyleCrossRef" href="#bib0040">8</a>. It is to be noted that there is a potential risk of seeding neoplastic cells along the nephrostomy track, but this eventuality has a very low incidence, with only a small number of cases reported in literature<a class="elsevierStyleCrossRefs" href="#bib0120">24,25</a>.In our cohort, only those patients with concomitant bladder-cis or with UT-cis location at distal ureter were selected for retrograde BCG instillation with D-J. In agreement with Korkes et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>, the D-J was positioned 2 weeks before the first instillation in order to favor vesicoureteral reflux and therefore contact of the substance with the urothelium of the entire UUT.There was a marked statistically significant difference (p=0.007) in age at the time of diagnosis between the treatment categories. As this was a non-randomized study, a less invasive approach was chosen in patients who had a more advanced age at the time of diagnosis, bearing in mind that the majority would also have had a worse performance status. Similarly, we started treating patients conservatively with BCG for primary CIS in 1991, but most patients treated with BCG were from the period between 2014 and 2018; hence the duration of follow-up was significantly shorter (p=0.02) than for patients treated surgically.As expected, the decrease in renal function in the subgroup of patients who underwent RNU was statistically significant (p=0.05). The choice of a conservative treatment is in fact aimed at the preservation of renal function and takes into account the potential for urothelial disease to occur later on the contralateral site.Two patients who had received BCG instillation suffered fever (>38.5°C) and both were treated with appropriate antimicrobial therapy. Another patient required intensive care management and received tuberculostatic treatment because of genitourinary tuberculosis. Most patients received BCG treatment as outpatients, so we only reported the complications that required medical treatment and hospitalization. This is why we did not report, for example, transient fever without infection or irritative voiding cystitis-like symptoms, even though such symptoms are frequent in this group of patients<a class="elsevierStyleCrossRef" href="#bib0135">27</a>.Horiguchi et al. reported that 35 (92.1%) out of 38 patients who received BCG treatment had complications of any grade while two (5.3%) experienced adverse events of grade≥III. The most common complication was cystitis (76%), followed by fever (50%) and hematuria (39%)<a class="elsevierStyleCrossRef" href="#bib0075">15</a>.Other authors<a class="elsevierStyleCrossRefs" href="#bib0060">12–15,16,28,29</a> have reported pericarditis, bladder contraction, urethral stenosis, Escherichia coli septicemia, BCG dissemination, and death from interstitial pneumonia in correlation with hypersensitivity or disseminated BCG infection. These results indicated that while BCG treatment is not usually associated with significant complications, adverse events can be critical, especially when they are related to poor functioning of the infusion system.Our study presented the usual bias inherent to a retrospective design. In fact, the choice of treatment and BCG instillation mode in this heterogeneous cohort of patients was at the discretion of the uro-oncologic committee and was therefore not made in a randomized manner. The shorter follow-up for BCG instillations cases could also distort the data pertinent to the oncological outcomes.Moreover, due to the small number of cases, we reported but did not analyze differences between BCG formulations, instillations, regimens or dose.ConclusionOur results confirm that BCG treatment for UT-CIS is effective. BCG could be the first treatment option in patients with UT-CIS because it yields good rates of complete response and in the case of recurrence, a salvage RNU is usually curative. Histological confirmation of UT-CIS should be mandatory before any treatment. On the other hand, loss of kidney function and multifocal disease are drawbacks of RNU.Authors' contributionsStudy design: Huguet JData collection: Fontanet SManuscript writing: Territo A, Fontanet S, Meneghetti I, Sanguedolce F, Huguet J.Manuscript editing: Territo A, Meneghetti I, Gallioli A, Gaya JM, Palou J, Breda A.FundingThe authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.Conflict of interestsThe authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1901444" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1644477" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1901445" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1644476" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Authors' contributions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-08-23" "fechaAceptado" => "2022-10-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1644477" "palabras" => array:4 [ 0 => "Carcinoma in situ" 1 => "Urinary upper tract" 2 => "Bacillus Calmette-Guérin" 3 => "Radical nephroureterectomy[" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1644476" "palabras" => array:4 [ 0 => "Carcinoma in situ" 1 => "Tramo urinario superior" 2 => "Bacilo de Calmette-Guérin" 3 => "Nefroureterectomía radical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundRadical nephroureterectomy (RNU) represents the gold standard treatment for upper tract urothelial carcinoma (UTUC); however, attempts have been made to treat upper urinary tract CIS (UT-CIS) conservatively. The aim of this study was to compare the outcome of patients with primary UT-CIS treated in our center by means of RNU vs. bacillus Calmette-Guérin (BCG) instillations. MethodsThis retrospective study included patients with diagnosis of primary UT-CIS between 1990 and 2018. All patients had histological confirmation of UT-CIS in the absence of other concomitant UTUC. Histological confirmation was obtained by ureteroscopy with multiple biopsies. Patients were treated with BCG instillations, RNU or distal ureterectomy. Clinicopathological features and outcomes were compared between RNU and BCG groups. ResultsA total of 28 patients and 29 renal units (RUs) were included. Sixteen (57.1%) patients (17 RUs) received BCG. BCG was administered via nephrostomy tube in 4 patients, with a single-J ureteral stent in 5, and using a Double-J stent in 7. Complete response and persistence or recurrence were detected in ten (58.8%) and seven (41.2%) RUs treated with BCG, respectively. Eight (27.6%) RUs underwent RNU, and 4 (13.8%) Rus distal ureterectomy. No differences were found in recurrence-free survival (p=0.841) and cancer-specific survival (p=0.77) between the RNU and BCG groups. ConclusionsAlthough RNU remains the gold standard treatment for UT-CIS, our results confirm that BCG instillations are also effective. Histological confirmation of UT-CIS is mandatory before any treatment." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa nefroureterectomía radical (NFU) es el tratamiento estándar del carcinoma de tramo urinario superior (TUS). No obstante, desde 1985 se ha introducido el tratamiento conservador en el manejo del carcinoma in situ en TUS (cisTUS). El objetivo de este estudio fue comparar la evolución oncológica de los pacientes con cisTUS tratados en nuestro centro con NFU vs instilaciones de bacillus Calmette-Guérin (BCG). MétodosSe trata de un estudio retrospectivo de pacientes con diagnóstico de cisTUS primario entre 1990−2018. Todos los pacientes presentaban diagnóstico histológico de cisTUS con ausencia de otro carcinoma de TUS concomitante. La confirmación histológica se obtuvo mediante ureteroscopia con múltiples biopsias. Los pacientes fueron tratados mediante NFU, ureterectomía distal o instilaciones de BCG. Los datos clinicopatológicos y la evolución oncológica fue comparada entre los grupos NFU y BCG. ResultadosSe incluyeron un total de 28 pacientes, 29 unidades renales (UR). Dieciséis (57,1%) pacientes (17 UR) recibieron BCG. Las instilaciones fueron administradas por nefrostomía en 4 pacientes, uni-J en 5 y doble J en 7. La respuesta completa y la persistencia o recurrencia fueron detectados en diez (58,8%) y siete (41,2) UR tratadas con BCG. Ocho UR (27,6%) fueron tratadas con NFU, con una recurrencia contralateral detectada en 4 casos (50%). Finalmente, 4 UR con cisTUS (13,8%) fueron tratados con ureterectomía distal. No se detectaron diferencias en supervivencia libre de recurrencia (p=0,841) y supervivencia cáncer específica (p=0,77) entre los grupos de NFU y BCG. ConclusionesAunque la nefroureterectomía radical representa el tratamiento estándar para el CIS de tramo urinario superior, nuestros resultados confirman que las instilaciones con BCG también son efectivas. La confirmación histológica de cisTUS debería realizarse previamente a la decisión terapéutica." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "These authors worked equally in writing the manuscript." "identificador" => "fn0005" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2563 "Ancho" => 3091 "Tamanyo" => 305196 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Kaplan-Meyer tables for Cancer-specific survival (A), Recurrence-free survival (B), Progression-free survival (C) and overall survival (D)." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 936 "Ancho" => 2508 "Tamanyo" => 143150 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Oncological outcomes by treatment groups. DU: distal ureterectomy BGC: Bacille Calmette-Guérin." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LEGEND: BCG=Bacille Calmette-Guérin; RNU=Radical nephroureterectomy; IQR=interquartile rang; ASA=American Society of Anesthesiologist." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient’s Characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total<a class="elsevierStyleCrossRef" href="#bib0120">[24]</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BCG<a class="elsevierStyleCrossRef" href="#bib0080">[16]</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RNU<a class="elsevierStyleCrossRef" href="#bib0040">[8]</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.289 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age at diagnosis in years (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Body mass index (median, IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (21.4−27.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.3 (22–82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (23–28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.926 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous history of bladder cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.129 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Voided urine cytology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.117 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Missing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Selective urinary cytology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Missing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laterality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.657 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Disease location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distal ureter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mid ureter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proximal ureter/pelvis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Missing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multifocality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.362 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multifocal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ASA score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I–II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III–IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Missing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative renal function (ml/min/1.73 m2) (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.382 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up time in months: median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (30−56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (22−55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 (50−91) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.020 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3176804.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics in the BCG and RNU groups." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration technique \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total<a class="elsevierStyleCrossRef" href="#bib0085">[17]</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recurrences <a class="elsevierStyleCrossRef" href="#bib0035">[7]</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single-J stent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (29.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (40%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Double-J stent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (47.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (37.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous nephrostomy tube \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (23.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (50%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3176805.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Techniques of administration for BCG instillations and related recurrences in our cohort of patients." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of upper tract urothelial carcinoma in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Fernandez Aparicio" 1 => "J.A. Galan Llopis" 2 => "R. Cansino Alcaide" 3 => "D. Pérez Fentes" 4 => "M. Cepeda Delgado" 5 => "J.L. Alvarez-Ossorio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2020.03.007" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2020" "volumen" => "44" "paginaInicial" => "512" "paginaFinal" => "518" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32622540" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European Association of Urology guidelines on upper urinary tract urothelial carcinoma: 2017 update" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Rouprêt" 1 => "M. Babjuk" 2 => "E. Compérat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2017.07.036" "Revista" => array:7 [ "tituloSerie" => "Eur Urol" "fecha" => "2018" "volumen" => "73" "paginaInicial" => "111" "paginaFinal" => "122" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28867446" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022510X12005710" "estado" => "S300" "issn" => "0022510X" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biological behavior and long-term outcomes of carcinoma in situ in upper urinary tract managed by radical nephroureterectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Inamoto" 1 => "H. Matsuyama" 2 => "N. Ibuki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.juro.2017.10.019" "Revista" => array:6 [ "tituloSerie" => "J Urol" "fecha" => "2018" "volumen" => "199" "paginaInicial" => "933" "paginaFinal" => "939" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29037861" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Upper urinary tract carcinoma in situ: Current knowledge, future direction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G.P. Redrow" 1 => "C.C. 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Management of primary upper urinary tract carcinoma in situ diagnosed by ureteroscopic biopsy: Is bacillus Calmette-Guerin an alternative to nephroureterectomy?

Manejo del carcinoma in situ de tramo urinario superior diagnosticado por biopsia ureteroscópica: ¿es el bacilo de Calmette-Guérin una alternativa a la nefroureterectomía?

A. Territo1, S. Fontanet

,1, I. Meneghetti, A. Gallioli, F. Sanguedolce, Ó. Rodriguez-Faba, J.M Gaya, J. Palou, J. Huguet, A. Breda

Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain

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differences in behavior have been identified&#58; bladder CIS progresses in approximately 50&#37; of patients without treatment&#44; whereas progression rate of UT-CIS with topical therapy is around 5&#8211;10&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; CIS displays great sensitivity to immunomodulators&#44; and bacillus Calmette-Gu&#233;rin &#40;BCG&#41; represents the first-line treatment for bladder CIS with a response rate greater than 60&#37;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a>&#59; it means that BCG could be an option in UT-CIS&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis of UT-CIS remains a challenge&#46; In most published studies&#44; patients received a diagnosis of UT-CIS by means of positive voided urine cytology&#44; with negative biopsies of the bladder and prostatic urethra&#44; no findings on the upper urinary tract imaging study&#44; and&#47;or positive cytology in selective ipsilateral urine samples<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8&#8211;17</span></a>&#46; This means that in these studies the diagnosis of UT-CIS was made without histological confirmation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although radical nephroureterectomy &#40;RNU&#41; remains the gold standard therapy for UT-CIS&#44; BCG therapy has been widely used in imperative and elective cases&#46; The initial rate of response to BCG in UT-CIS has been reported to be 63&#37;&#8211;100&#37; and its use is almost entirely safe<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; Up to now&#44; instillation of BCG has been proposed with promising results&#44; but data are limited to small series of retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;18</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the present study&#44; we assessed the long-term efficacy of BCG instillation in patients who received a histological diagnosis of primary UT-CIS&#46; Oncological outcomes were compared in patients treated with BCG and treated by RNU&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A retrospective chart review was performed identifying patients with primary UT-CIS diagnosed between January 1990 and December 2018&#46; The study was approved by our institutional ethical committee previously to its development&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All patients were preoperatively evaluated by imaging studies as computed tomography urography or intravenous urography&#46; Cystoscopy with randomized bladder biopsies was performed in order to rule out bladder CIS and most patients underwent a selective ureteral barbotage&#46; Diagnosis of UT-CIS was determined by random biopsies or biopsies of suspected areas performed at ureteroscopy &#40;URS&#41;&#46; The distal and mid ureter was explored with a semirigid ureteroscope and sampled using a 5-Fr biopsy forceps&#44; while a flexible ureteroscope with 3-Fr forceps was used to explore and biopsy the upper ureter and pyelocaliceal system&#46; In the 90s and 2000s semirigid ureteroscope was used to biopsy the entire ureter and renal pelvis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">When UT-CIS was diagnosed&#44; BCG instillation was offered in imperative cases and in patients unwilling or unfit to undergo a surgical approach&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following data were collected&#58; age at diagnosis&#44; gender&#44; history of previous bladder tumor&#44; renal function at diagnosis&#44; ASA score&#44; voiding and selective urinary cytology&#44; imaging study&#44; tumor laterality&#44; multifocality&#44; location&#44; treatment&#44; BCG instillation method&#44; post-BCG URS&#44; recurrence or progression&#44; recurrence treatment&#44; perioperative renal function&#44; complications according to the Clavien-Dindo system<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#44; and follow-up time&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">RNU was performed using either an open or a laparoscopic approach&#46; It included en bloc removal of the kidney&#44; the ureter&#44; including the distal portion with the ipsilateral ureteral orifice&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">When distal ureterectomy was carried out&#44; an extravesical approach was chosen and ureteral reimplantation was then performed according to the Politano-Leadbetter technique<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients treated with immunotherapy received BCG instillation by retrograde catheterization using a double J &#40;D-J&#41; 6-Fr ureteral stent&#44; single J &#40;S-J&#41;&#44; or by antegrade administration using an 8-Fr percutaneous nephrostomy tube&#46; In cases in which a D-J was used&#44; BCG &#40;81<span class="elsevierStyleHsp" style=""></span>mg ImmuCyst BCG&#41; dissolved in 50<span class="elsevierStyleHsp" style=""></span>ml 0&#46;9&#37; sodium chloride was instilled into the bladder using a urethral catheter and BCG solution was kept in place for at least 2<span class="elsevierStyleHsp" style=""></span>h&#46; When using the nephrostomy tube or single-J technique&#44; a perfusion was placed 20<span class="elsevierStyleHsp" style=""></span>cm above the kidney of the patient and the instillation speed was 1<span class="elsevierStyleHsp" style=""></span>ml per minute to avoid intrarenal tension&#46; BCG solution was infused once weekly for a 6-week period as one course&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the BCG group&#44; complete response was defined on the basis of negative imaging study results&#44; negative URS biopsies at 2 months post-BCG&#44; and absence of disease recurrence during follow-up&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Persistent disease was defined as the presence of positive URS biopsies at 2 months after BCG&#46; Recurrence was defined as the diagnosis of UT-CIS or UTUC during the follow-up&#46; Disease progression was defined as local invasive disease or the appearance of metastasis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Later follow-up of patients who had undergone RNU and distal ureterectomy was carried out in accordance with European Association of Urology Guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Patients who had received BCG instillations underwent a more stringent follow-up&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Due to the small number of cases of distal ureterectomy we did not include these subgroups in the survival analyses&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">All statistical analyses were performed using SPSS version 22&#46;0 software &#40;IBM Corp&#46;&#44; Armonk&#44; NY&#44; USA&#41;&#46; Continuous variables were described using the median and interquartile range&#46; The Kruskal-Wallis H test was used for comparison of quantitative variables&#46; Cancer-specific survival &#40;CSS&#41;&#44; recurrence-free survival &#40;RFS&#41;&#44; progression-free survival &#40;PFS&#41;&#44; and overall survival &#40;OS&#41; were estimated using Kaplan-Meier plots and log-rank tests&#46; Statistical significance was defined as <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 28 patients &#91;29 renal units &#40;RUs&#41;&#93; with primary UT-CIS were included in the study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Sixteen patients &#40;57&#46;1&#37;&#41; &#40;17 RUs&#41; received BCG as primary treatment&#46; BCG instillation was selected as the initial treatment for the following reasons&#58; reduced performance status<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; patient&#8217;s own choice<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; history of bladder CIS that responded successfully to BCG<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; solitary functioning kidney<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#44; and bilateral disease<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; In the BCG group&#44; age at diagnosis was higher&#44; ASA score of III&#8211;IV was more frequent&#44; and follow-up time was shorter &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The method of administration of BCG was nephrostomy tube&#44; S-J&#44; and D-J in four&#44; five&#44; and seven patients respectively &#40;patient with bilateral disease was treated with bilateral double J&#41;&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; A complete response was detected in ten &#40;58&#46;8&#37;&#41; RUs while recurrence or persistence of disease was observed in seven &#40;41&#46;2&#37;&#41;&#44; with a mean recurrence time of 12 months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Treatment for recurrence was RNU in five RUs &#40;three pTis and two pT3&#41; and two cases did not receive further surgical treatment or immunotherapy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Eight &#40;27&#46;6&#37;&#41; RUs underwent RNU&#44; all with pTis at the pathology report&#46; An open approach was used in six cases and laparoscopic in two&#46; Median pre- and postoperative renal function was 81&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span> &#40;IQR 58&#8211;85&#41; and 57&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span> &#40;IQR 39&#8211;71&#41;&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;&#41;&#46; In four &#40;50&#37;&#41; patients a contralateral recurrence was detected at a median time of 21 months&#46; Those patients with recurrence were treated with distal ureterectomy<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and BCG instillation<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Four &#40;13&#46;8&#37;&#41; RUs underwent distal ureterectomy for distal unifocal CIS&#46; One patient developed ipsilateral recurrence and was successfully treated with BCG&#59; another died because of disease progression&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Three patients &#40;17&#46;6&#37;&#41; who received BCG experienced fever as an adverse event and one required antituberculostatic treatment&#46; One patient treated with RNU complained of low abdominal pain after catheter removal due to urinary leakage at the suture site of the bladder cuff&#46; No complications related to diagnostic ureteroscopic biopsies were reported&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">No significant differences were observed between the RNU and BCG subgroups in relation to CSS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;776&#41;&#44; RFS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;841&#41;&#44; PFS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;451&#41;&#44; or OS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;701&#41; at 5 years after treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The 5-year CSS&#44; RFS&#44; PFS&#44; and OS in the RNU and BCG subgroups were 74&#37; versus 78&#37;&#44; 50&#37; versus 56&#37;&#44; 75&#37; versus 88&#37;&#44; and 42&#37; versus 78&#37;&#44; respectively&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">BCG instillations for UT-CIS have traditionally been reserved for imperative cases and its use in elective cases remains controversial&#46; Moreover&#44; previously only one other study has included biopsy proof of UT-CIS as a diagnostic criterion in the entire cohort of investigated patients<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We evaluated 29 RUs with a histological diagnosis of UT-CIS&#46; A total of 17 RUs received BCG treatment&#44; with a complete response in ten cases &#40;58&#46;8&#37;&#41; and recurrence in seven &#40;41&#46;2&#37;&#41;&#46; Salvage RNU after BCG persistence or recurrence was effective in four out of five patients&#46; In eight &#40;28&#46;6&#37;&#41; patients RNU was performed&#44; and four of these patients developed a contralateral recurrence during follow-up&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although UT-CIS is a rare disease&#44; many articles on this topic have addressed BCG treatment as an alternative to RNU&#44; the accepted gold standard&#46; In most of these studies&#44; the diagnosis of UT-CIS was made on the basis of positive results of bladder or selective ureteral cytology<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8&#44;10&#8211;17</span></a>&#46; One of the strengths of our study is that all of our patients had a histological diagnosis of UT-CIS and also repeated ureteral biopsies 2 months after BCG treatment&#46; Authors against biopsies claim that they are not useful because it is difficult to obtain adequate multiple samples from the UUT<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> and also because the sensitivity of voided urinary cytology and selective ureteral urine collection is high<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; We think that it is not difficult to obtain biopsies from the ureter with a semirigid ureteroscope and 5-Fr forceps&#44; but we agree that it could be more difficult to biopsy the pelvis and calyces with a flexible ureteroscope and 3-Fr forceps&#46; A recent review recommended histological diagnosis by brushing or forceps coupled with selective washings<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Redrow et al&#46; analyzed the outcomes of ten series of UT-CIS treated with BCG&#46; A total of 139 RUs were included&#46; With a median follow-up between 13&#46;5 and 58 months&#44; the rate of response to BCG treatment was 64&#37;&#8211;100&#37; and the rate of recurrence&#44; 8&#37;&#8211;50&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Some authors have compared BCG with RNU in UT-CIS patients&#46; In their retrospective study on patients with UT-CIS&#44; Horiguchi et al&#46; treated 20 patients with RNU and 38 patients with BCG&#46; They did not report statistically significant differences between the two groups in relation to CSS &#40;RNU 100&#37; vs BCG 89&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;39&#41; at 5-year follow-up<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Kojima et al&#46; similarly found no statistically significant differences with respect to CSS &#40;RNU 80&#37; vs BCG 91&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;62&#41; in the two groups of patients treated with RNU &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; and BCG &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In our study&#44; a comparison of the subgroup of patients who underwent RNU with the subgroup who underwent BCG revealed no statistically significant differences in relation to CSS&#44; RFS&#44; PFS&#44; or OS&#46; This means that BCG could be the first option to treat patients with UT-CIS&#59; it achieves a high complete response rate and in the case of recurrence&#44; salvage RNU is usually curative<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Follow-up after BCG treatment must be strict&#44; sometimes flat lesions are undetectable on tomography until they progress to thickening of the UUT&#44; and in these instances stage is usually high<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Five out of seven recurrences after BCG were treated with RNU &#40;three pTis and two pT3&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">We agree with other authors that&#44; with a strict follow-up&#44; BCG can be used in patients with imperative and also elective indications<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;14</span></a>&#46; In our series only half of the patients who received BCG had strict imperative indications&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">There is however controversy over the best method of administering BCG&#46; A recent animal study found surface area staining by dye administered via an open-ended ureteral catheter to be significantly superior to nephrostomy&#44; and both methods were better than reflux with indwelling double pigtail<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Studer et al&#46; considered that the anterograde route is preferable for the administration of BCG as it is safer in optimizing contact of the agent with the urothelium<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; It is to be noted that there is a potential risk of seeding neoplastic cells along the nephrostomy track&#44; but this eventuality has a very low incidence&#44; with only a small number of cases reported in literature<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our cohort&#44; only those patients with concomitant bladder-cis or with UT-cis location at distal ureter were selected for retrograde BCG instillation with D-J&#46; In agreement with Korkes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#44; the D-J was positioned 2 weeks before the first instillation in order to favor vesicoureteral reflux and therefore contact of the substance with the urothelium of the entire UUT&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">There was a marked statistically significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41; in age at the time of diagnosis between the treatment categories&#46; As this was a non-randomized study&#44; a less invasive approach was chosen in patients who had a more advanced age at the time of diagnosis&#44; bearing in mind that the majority would also have had a worse performance status&#46; Similarly&#44; we started treating patients conservatively with BCG for primary CIS in 1991&#44; but most patients treated with BCG were from the period between 2014 and 2018&#59; hence the duration of follow-up was significantly shorter &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; than for patients treated surgically&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As expected&#44; the decrease in renal function in the subgroup of patients who underwent RNU was statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The choice of a conservative treatment is in fact aimed at the preservation of renal function and takes into account the potential for urothelial disease to occur later on the contralateral site&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Two patients who had received BCG instillation suffered fever &#40;&#62;38&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; and both were treated with appropriate antimicrobial therapy&#46; Another patient required intensive care management and received tuberculostatic treatment because of genitourinary tuberculosis&#46; Most patients received BCG treatment as outpatients&#44; so we only reported the complications that required medical treatment and hospitalization&#46; This is why we did not report&#44; for example&#44; transient fever without infection or irritative voiding cystitis-like symptoms&#44; even though such symptoms are frequent in this group of patients<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Horiguchi et al&#46; reported that 35 &#40;92&#46;1&#37;&#41; out of 38 patients who received BCG treatment had complications of any grade while two &#40;5&#46;3&#37;&#41; experienced adverse events of grade<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>III&#46; The most common complication was cystitis &#40;76&#37;&#41;&#44; followed by fever &#40;50&#37;&#41; and hematuria &#40;39&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Other authors<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15&#44;16&#44;28&#44;29</span></a> have reported pericarditis&#44; bladder contraction&#44; urethral stenosis&#44; <span class="elsevierStyleItalic">Escherichia coli</span> septicemia&#44; BCG dissemination&#44; and death from interstitial pneumonia in correlation with hypersensitivity or disseminated BCG infection&#46; These results indicated that while BCG treatment is not usually associated with significant complications&#44; adverse events can be critical&#44; especially when they are related to poor functioning of the infusion system&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Our study presented the usual bias inherent to a retrospective design&#46; In fact&#44; the choice of treatment and BCG instillation mode in this heterogeneous cohort of patients was at the discretion of the uro-oncologic committee and was therefore not made in a randomized manner&#46; The shorter follow-up for BCG instillations cases could also distort the data pertinent to the oncological outcomes&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Moreover&#44; due to the small number of cases&#44; we reported but did not analyze differences between BCG formulations&#44; instillations&#44; regimens or dose&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0205" class="elsevierStylePara elsevierViewall">Our results confirm that BCG treatment for UT-CIS is effective&#46; BCG could be the first treatment option in patients with UT-CIS because it yields good rates of complete response and in the case of recurrence&#44; a salvage RNU is usually curative&#46; Histological confirmation of UT-CIS should be mandatory before any treatment&#46; On the other hand&#44; loss of kidney function and multifocal disease are drawbacks of RNU&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authors&#39; contributions</span><p id="par0210" class="elsevierStylePara elsevierViewall">Study design&#58; Huguet J</p><p id="par0215" class="elsevierStylePara elsevierViewall">Data collection&#58; Fontanet S</p><p id="par0220" class="elsevierStylePara elsevierViewall">Manuscript writing&#58; Territo A&#44; Fontanet S&#44; Meneghetti I&#44; Sanguedolce F&#44; Huguet J&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Manuscript editing&#58; Territo A&#44; Meneghetti I&#44; Gallioli A&#44; Gaya JM&#44; Palou J&#44; Breda A&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript&#46;</p></span></span>"
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          "titulo" => "Conflict of interests"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2022-08-23"
    "fechaAceptado" => "2022-10-20"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Carcinoma in situ"
            1 => "Urinary upper tract"
            2 => "Bacillus Calmette-Gu&#233;rin"
            3 => "Radical nephroureterectomy&#91;"
          ]
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          "palabras" => array:4 [
            0 => "Carcinoma <span class="elsevierStyleItalic">in situ</span>"
            1 => "Tramo urinario superior"
            2 => "Bacilo de Calmette-Gu&#233;rin"
            3 => "Nefroureterectom&#237;a radical"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Radical nephroureterectomy &#40;RNU&#41; represents the gold standard treatment for upper tract urothelial carcinoma &#40;UTUC&#41;&#59; however&#44; attempts have been made to treat upper urinary tract CIS &#40;UT-CIS&#41; conservatively&#46; The aim of this study was to compare the outcome of patients with primary UT-CIS treated in our center by means of RNU vs&#46; bacillus Calmette-Gu&#233;rin &#40;BCG&#41; instillations&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">This retrospective study included patients with diagnosis of primary UT-CIS between 1990 and 2018&#46; All patients had histological confirmation of UT-CIS in the absence of other concomitant UTUC&#46; Histological confirmation was obtained by ureteroscopy with multiple biopsies&#46; Patients were treated with BCG instillations&#44; RNU or distal ureterectomy&#46; Clinicopathological features and outcomes were compared between RNU and BCG groups&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A total of 28 patients and 29 renal units &#40;RUs&#41; were included&#46; Sixteen &#40;57&#46;1&#37;&#41; patients &#40;17 RUs&#41; received BCG&#46; BCG was administered via nephrostomy tube in 4 patients&#44; with a single-J ureteral stent in 5&#44; and using a Double-J stent in 7&#46; Complete response and persistence or recurrence were detected in ten &#40;58&#46;8&#37;&#41; and seven &#40;41&#46;2&#37;&#41; RUs treated with BCG&#44; respectively&#46; Eight &#40;27&#46;6&#37;&#41; RUs underwent RNU&#44; and 4 &#40;13&#46;8&#37;&#41; Rus distal ureterectomy&#46; No differences were found in recurrence-free survival &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;841&#41; and cancer-specific survival &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;77&#41; between the RNU and BCG groups&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Although RNU remain<span class="elsevierStyleBold">s</span> the gold standard treatment for UT-CIS&#44; our results confirm that BCG instillations are also effective&#46; Histological confirmation of UT-CIS is mandatory before any treatment&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La nefroureterectom&#237;a radical &#40;NFU&#41; es el tratamiento est&#225;ndar del carcinoma de tramo urinario superior &#40;TUS&#41;&#46; No obstante&#44; desde 1985 se ha introducido el tratamiento conservador en el manejo del carcinoma in situ en TUS &#40;cisTUS&#41;&#46; El objetivo de este estudio fue comparar la evoluci&#243;n oncol&#243;gica de los pacientes con cisTUS tratados en nuestro centro con NFU vs instilaciones de bacillus Calmette-Gu&#233;rin &#40;BCG&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio retrospectivo de pacientes con diagn&#243;stico de cisTUS primario entre 1990&#8722;2018&#46; Todos los pacientes presentaban diagn&#243;stico histol&#243;gico de cisTUS con ausencia de otro carcinoma de TUS concomitante&#46; La confirmaci&#243;n histol&#243;gica se obtuvo mediante ureteroscopia con m&#250;ltiples biopsias&#46; Los pacientes fueron tratados mediante NFU&#44; ureterectom&#237;a distal o instilaciones de BCG&#46; Los datos clinicopatol&#243;gicos y la evoluci&#243;n oncol&#243;gica fue comparada entre los grupos NFU y BCG&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron un total de 28 pacientes&#44; 29 unidades renales &#40;UR&#41;&#46; Diecis&#233;is &#40;57&#44;1&#37;&#41; pacientes &#40;17 UR&#41; recibieron BCG&#46; Las instilaciones fueron administradas por nefrostom&#237;a en 4 pacientes&#44; uni-J en 5 y doble J en 7&#46; La respuesta completa y la persistencia o recurrencia fueron detectados en diez &#40;58&#44;8&#37;&#41; y siete &#40;41&#44;2&#41; UR tratadas con BCG&#46; Ocho UR &#40;27&#44;6&#37;&#41; fueron tratadas con NFU&#44; con una recurrencia contralateral detectada en 4 casos &#40;50&#37;&#41;&#46; Finalmente&#44; 4 UR con cisTUS &#40;13&#44;8&#37;&#41; fueron tratados con ureterectom&#237;a distal&#46; No se detectaron diferencias en supervivencia libre de recurrencia &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;841&#41; y supervivencia c&#225;ncer espec&#237;fica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;77&#41; entre los grupos de NFU y BCG&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Aunque la nefroureterectom&#237;a radical representa el tratamiento est&#225;ndar para el CIS de tramo urinario superior&#44; nuestros resultados confirman que las instilaciones con BCG tambi&#233;n son efectivas&#46; La confirmaci&#243;n histol&#243;gica de cisTUS deber&#237;a realizarse previamente a la decisi&#243;n terap&#233;utica&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">These authors worked equally in writing the manuscript&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Kaplan-Meyer tables for Cancer-specific survival &#40;A&#41;&#44; Recurrence-free survival &#40;B&#41;&#44; Progression-free survival &#40;C&#41; and overall survival &#40;D&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Oncological outcomes by treatment groups&#46; DU&#58; distal ureterectomy BGC&#58; Bacille Calmette-Gu&#233;rin&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LEGEND&#58; BCG<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Bacille Calmette-Gu&#233;rin&#59; RNU<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Radical nephroureterectomy&#59; IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>interquartile rang&#59; ASA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>American Society of Anesthesiologist&#46;</p>"
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Age at diagnosis in years &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;007</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">26&#46;3 &#40;22&#8211;82&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Voided urine cytology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;117&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Missing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Selective urinary cytology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Missing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laterality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;657&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disease location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">Multifocality&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Preoperative renal function &#40;ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#41; &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Follow-up time in months&#58; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54 &#40;50&#8722;91&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Single-J stent&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;29&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Double-J stent&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;47&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;37&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Percutaneous nephrostomy tube&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;23&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2022.11.002

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