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At least 901 records · Page 50Linked to original sources
PubMed2001

Selective bladder conservation using transurethral resection, chemotherapy, and radiation: management and consequences of Ta, T1, and Tis recurrence within the retained bladder.

OBJECTIVES: Although radical cystectomy remains the standard of care for invasive bladder cancer in the United States, many groups are exploring the use of trimodality therapy using transurethral resection of the bladder tumor, radiation, and chemotherapy in an attempt to spare patients the need for cystectomy. As transitional cell carcinoma often arises from a urothelial field change, there is concern that the retained bladder is at risk of subsequent superficial (Ta, T1, Tis) tumors, some of which may have lethal potential. This study reports the outcomes of those patients with superficial relapse of transitional cell carcinoma after trimodality therapy. METHODS: One hundred ninety patients were treated using a series of trimodality therapy protocols between 1986 and 1998. All patients received induction chemotherapy and radiation and were selected for bladder preservation on the basis of a cytologic and histologic complete response. One hundred twenty-one patients had a complete response and formed the subjects of this study. RESULTS: With a median follow-up of 6.7 years for patients still alive, 32 experienced a superficial relapse (26%). The median time to this failure was 2.1 years. Sixty percent of the superficial failures were carcinoma in situ (Tis) and 67% arose at the site of the original invasive tumor. The risk of superficial failure was higher among those who had Tis associated with their original muscle-invasive tumor. Twenty-seven of these 32 cases were managed conservatively with transurethral resection and intravesical therapy. The irradiated bladder tolerated this therapy well and only 3 patients required treatment breaks. The 5 and 8-year survival was comparable for those who experienced superficial failure (68% and 54%, respectively) and those who had no failure at all (n = 74, 69% and 61%, respectively). However, a substantially lower chance of being alive with the native bladder owing to the need for late salvage cystectomies (61% versus 34%) was found. Cystectomy became necessary in 31% (10 of 32) either because of additional superficial recurrence (n = 7) or progression to invasive disease (n = 3). CONCLUSIONS: A trimodality approach to transitional cell bladder cancer mandates lifelong cystoscopic surveillance. Although most completely responding patients retain their bladders free from invasive relapse, one quarter will develop superficial disease. This may be managed in the standard fashion with transurethral resection of the bladder tumor and intravesical therapies but carries an additional risk that late cystectomy will be required.

Aged↗
PubMed2001

Treatment of refractory kidney transplant ureteral strictures using balloon cautery endoureterotomy.

OBJECTIVES: To report our long-term clinical results with the use of endoureterotomy in patients undergoing renal transplant with a minimum follow-up of 23 months. METHODS: Six renal transplant patients developed persistent ureteral obstruction demonstrated by elevated serum creatinine levels, renal ultrasound, and antegrade pyelography. Stent placement and balloon dilation were performed as the initial therapy in all patients. Persistent ureteral obstruction was managed with balloon cautery endoureterotomy. Ureteral stents were removed cystoscopically 6 weeks after the procedure. RESULTS: Four men and 2 women, mean age 45 years (range 38 to 54), underwent eight procedures: six by way of an antegrade percutaneous approach and two in an endoscopic retrograde fashion. The sites of ureteral stricture were ureterovesical junction (n = 4), ureteropelvic junction (n = 1), and midureteroureteral (n = 1). Two patients required a second endoureterotomy 3 months after the first attempt. Patients were followed up for a mean of 27 months (range 23 to 34). The mean serum creatinine level for all patients at follow-up was 2.6 mg/dL (range 1.6 to 3.9), including a mean serum creatinine level of 1.8 mg/dL (range 1.6 to 1.9) for nonrejected kidneys and a mean of 3.4 mg/dL (range 2.5 to 3.9) in those found to have concurrent rejection. Overall, five (63%) of eight procedures were successful in 5 (83%) of 6 patients. No intraoperative complications occurred and no blood transfusions were required. CONCLUSIONS: Balloon cautery endoureterotomy was successful in this select group of renal transplant patients with persistent ureteral strictures after initial balloon dilation and stenting failed. This modality proved durable to 27 months of follow-up without significant complications.

Adult↗
PubMed2001

Endourologic reconstruction of post-traumatic obliterated urethral stricture in a young female: a point of technique.

INTRODUCTION: A simple endourologic technique for reconstruction of a post-traumatic obliterated urethra in a young unmarried woman is described as an alternative management to complex open urethral reconstruction. TECHNICAL CONSIDERATIONS: A 20-year-old woman presented with a post-traumatic obliterated urethra after a road traffic accident. The cystogram at 6 weeks did not reveal a bladder neck or urethra. The examination under anesthesia showed just a dimple at the presumed external urethral meatus. Antegrade cystoscopy revealed a complete block just distal to the bladder neck. A puncture was made from the external urethral meatus into the bladder through the bladder neck under antegrade cystoscopic guidance. The tract was dilated up to 18F using fascial dilators over a guidewire. A 16F Foley catheter was placed for 6 weeks. The operative time was 30 minutes, with no intraoperative complications. The catheter was removed at 6 weeks. Urethroscopy showed a normal urethra. She performed self-catheterization for the initial 3 months. A micturating cystourethrogram at 3 months revealed a normal urethra. She was continent and stricture free at follow-up of 16 months. CONCLUSION: This technique is simple and easy, with good results in selected cases of post-traumatic complete obliteration of the urethra with an intact bladder neck in young women.

Accidents, Traffic↗
PubMed2002

Metastatic breast cancer to the bladder: a diagnostic challenge and review of the literature.

Nineteen cases of breast cancer metastatic to the bladder and diagnosed in living patients have been identified in the English literature. Most patients were symptomatic with evidence of disseminated disease at the time of diagnosis. Metastasis usually occurred many years after diagnosis, and the prognosis was poor. The definitive modality for diagnosis in all cases was cystoscopy, which demonstrated an abnormal lesion in the bladder wall that was confirmed on biopsy. In our study, we discuss the case of a patient with breast cancer metastatic to the bladder despite a normal cystoscopic evaluation.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2002

Effect of radical prostatectomy on urethral blood flow.

OBJECTIVES: To study the effect of radical retropubic prostatectomy on urethral microcirculatory blood perfusion and urinary continence. Urinary stress incontinence after radical prostatectomy depends mainly on intrinsic distal sphincter integrity. METHODS: Urethral laser Doppler flowmetry was performed in 37 patients before and in 23 patients after (mean 15 months, range 2 to 23) radical prostatectomy for clinically localized prostate cancer. An endoscopic laser Doppler flow probe with a diameter of 1.8 mm was introduced through the working channel of a cystoscope and gently applied to the urethral mucosa at an intravesical pressure of 30 cm H(2)O. Blood flow was expressed simultaneously as a digital reading on the flowmeter (milliliters blood per minute per 100 gram tissue). The mean arterial blood pressure was monitored noninvasively. The Mann-Whitney U test was used for statistical analysis. RESULTS: Membranous urethral blood flow significantly decreased after radical prostatectomy from 18.8 +/- 7.9 mL/min per 100 gram tissue to 11.9 +/- 7.7 mL/min per 100 gram tissue (P = 0.04). However, the difference in the blood flow did not statistically differentiate continent patients from patients with urinary stress incontinence (P = 0.47). No correlation between urethral microcirculation and mean arterial blood pressure could be detected. CONCLUSIONS: Retropubic radical prostatectomy decreases membranous urethral microcirculation. However, this loss of vascularization does not have a major effect on distal sphincter function and continence after radical prostatectomy.

Humans↗
PubMed2002

Complete laparoscopic ileal cystoplasty.

INTRODUCTION: Laparoscopic enterocystoplasty provides a minimally invasive approach to bladder augmentation in the patient with a neurogenic bladder. In previously published reports, portions of the procedure were performed extracorporeally. We report our technique of complete intracorporeal laparoscopic enterocystoplasty. TECHNICAL CONSIDERATIONS: Important elements of the operation include (a) preoperative evaluation of patient compliance and videourodynamic studies; (b) cystoscopic placement of externalized ureteral stents; (c) transperitoneal placement of five radially dilating trocars; (d) identification of the cecum; (e) proximal mobilization of ileum sufficient for pelvic placement; (f) measurement of ileal length with segment of precut vessel loop; (g) vertical cystotomy after incising peritoneum and entering the space of Retzius; (h) ileal division and side-to-side anastomosis using endoscopic gastrointestinal anastomosis staplers; (i) detubularization and freehand intracorporeal suturing into a U-shaped configuration; (j) fixing ileal patch at the 6 and 11-o'clock positions; (k) completion of ileal-bladder anastomosis in quadrants with running sutures; (l) irrigation of bladder and placement of a closed suction drain in the pelvis; and (m) cystogram 4 weeks postoperatively. CONCLUSIONS: Pure laparoscopic enterocystoplasty is an advanced procedure that is technically feasible and yields excellent results, but has unproven benefits. We perform the entire operation intracorporeally with traditional instruments and do not rely on suturing devices or extracorporeal knots. Additional experience and technological developments may result in routine laparoscopic urinary augmentation and continent diversion.

Anastomosis, Surgical↗
PubMed2002

Leukocyte populations in interstitial cystitis and idiopathic reduced bladder storage.

OBJECTIVES: Mast cells and leukocyte populations in bladder biopsies from women with interstitial cystitis (IC) or idiopathic reduced bladder storage (sensory urgency [SU]) were compared to determine whether any evidence of a common etiology between these conditions could be found. METHODS: Biopsies from 40 patients (9 meeting the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases criteria [IC] and 31 who did not [SU]) and 20 controls (having colposuspension for stress incontinence) were stained with monoclonal antibodies against leukocyte antigens and mast cell tryptase. The median cell counts from 10 high power fields were calculated and compared between cases and controls. The clinical and urodynamic data were also compared. RESULTS: Nocturia (odds ratio 26.7; 95% confidence interval 3.3 to 245.5) and bladder pain (odds ratio 18.5; 95% confidence interval 1.8 to 193.1) were associated with significant odds ratios for disease (IC or SU compared with controls) in logistic regression analysis. Patients with IC were significantly older than those with SU (P = 0.05). Leukocyte populations showed only increased CD20+ cells in patients with IC compared with the others (P = 0.03). CONCLUSIONS: The analysis of the clinical, urodynamic, and cystoscopic data showed no differences between patients with IC and those with SU, except for age. Nocturia or bladder pain discriminated between patients and controls. The lymphocytic infiltrate in SU is similar to that seen in IC but with fewer CD20+ cells. These data support the work of others and may indicate that SU has a common etiology with IC.

Case-Control Studies↗
PubMed2002

Treatment of a complete lower urinary tract obstruction secondary to an expandable foam sealant.

We present a unique case of an iatrogenic complete lower urinary tract obstruction with an expandable foam sealant. A 41-year-old man presented in urinary retention 36 hours after self-injecting his urethra with the foam sealant, which could be palpated throughout his entire urethra. The sealant was removed from the distal urethra in numerous fragments with a hemostat and cystoscopically. A perfect mold of the bladder and prostatic urethra were removed by suprapubic cystotomy. Cystoscopy 2 months later demonstrated a mild bulbar urethral stricture, but normal bladder mucosa. The cystoscopy at 6 months was normal.

Adult↗
PubMed2003

Removal of urinary catheter on postoperative day 3 or 4 after radical retropubic prostatectomy.

OBJECTIVES: To determine the feasibility and safety of removing the urinary catheter on postoperative day (POD) 3 or 4 after radical retropubic prostatectomy (RRP). METHODS: Between January 2001 and August 2001, gravity cystography was performed on POD 3 or 4 after RRP by a single surgeon (H.L.) on 151 men. The urinary catheter was removed on POD 3 or 4 providing no extravasation was evident on cystography. Urinary catheters were replaced over a guidewire placed into the bladder under flexible cystoscopic guidance in cases of acute urinary retention (AUR). Continence was assessed at 3 months after RRP. RESULTS: Of the 151 cystograms performed on POD 3 or 4, 116 (76.8%) revealed no evidence of extravasation. The indwelling catheters were removed in 114 of these cases (98.3%). Twenty-two (19.3%) of the 114 men whose catheters were removed on POD 3 or 4 developed AUR within 48 hours of catheter removal, requiring catheter replacement. Two of these patients required repeated surgery secondary to complications related to AUR. At 3 months after RRP, 75% of the men whose catheters were removed on POD 3 or 4 required no pads or a single pad during a 24-hour interval, and 77.6% reported none or slight bother from incontinence. Of the 37 men whose catheters were removed on POD 7 or later, 1 patient (2.7%) developed AUR, and the catheter was replaced without complications. At 3 months after RRP, 65.7% of men whose catheters were removed on POD 7 or later required no pads or a single pad during a 24-hour interval, and 71.4% reported none or slight bother from incontinence. The incidence of anastomotic stricture in men whose catheters were removed on POD 3 or 4 and POD 7 or later was 12.1% and 22.6%, respectively. CONCLUSIONS: Most men will have a watertight anastomosis on POD 3 or 4 after RRP. Early catheter removal does not have a negative impact on continence or the rate of anastomotic strictures. Because of the high incidence of AUR, requiring replacement of the urinary catheter, and the potential for disruption of the anastomosis or bladder neck reconstruction, we currently recommend delaying catheter removal until POD 7 or later.

Anastomosis, Surgical↗
PubMed2003

Urinary tract infection in men younger than 45 years of age: is there a need for urologic investigation?

OBJECTIVES: To determine in a prospective study whether urinary tract infection (UTI) in men younger than 45 years of age is associated with anomalies of the genitourinary tract that necessitate additional urologic evaluation. UTI in young men is uncommon. In these patients, it is customary to follow the same policy as that for children or older men and to routinely perform urologic investigations. METHODS: Twenty-nine consecutive, otherwise healthy, male patients aged 16 to 45 years (mean 30.5) were hospitalized for a first event of acute UTI. All patients underwent an imaging evaluation, including ultrasonography and intravenous urography. Those with macroscopic hematuria underwent cystoscopy. Uroflowmetry was performed at least 1 month after recovery, and patients with a maximal flow rate of less than 15 mL/s underwent a pressure flow study. RESULTS: Significant urethral stricture was excluded in all patients. Twenty-seven patients (93%) had a postvoid residual urine volume of less than 20 mL, and only two had values of 120 and 200 mL. The imaging and cystoscopic evaluation demonstrated a normal urinary tract in all patients. The maximal urinary flow rate was greater than 15 mL/s in 22 patients (76%) and lower than 15 mL/s in 7 patients (24%). In the latter group, urodynamic investigations, including free flowmetry and/or pressure flow study, revealed normal lower urinary tract function in 6 patients and a bladder outflow obstruction in 1 (3%). CONCLUSIONS: A first event of UTI in men younger than 45 years is usually not associated with significant structural or functional urinary tract abnormalities. Therefore, no radiologic, endoscopic, or urodynamic investigation is required.

Adolescent↗
PubMed2003

Multiple intravesical linear staples identified during surveillance cystoscopy after laparoscopic nephroureterectomy.

Laparoscopic nephroureterectomy has faced technical criticism secondary to the unknown effects of urine-exposed intravesical or intraureteral staples. Although not reported, staples exposed to urine theoretically create a nidus for encrustation and stone formation. We present a case of a 66-year-old man after left laparoscopic ureterectomy for ureteral malignancy. Surveillance cystoscopy at 6 months revealed a nearly complete intravesical titanium staple line without encrustation. Successful transurethral removal of all staples with standard cystoscopic graspers revealed no immediate, or delayed, sequelae.

Aged↗
PubMed1990

Whole bladder photodynamic therapy: critical review of present-day technology and rationale for development of intravesical laser catheter and monitoring system.

Present-day whole bladder photodynamic therapy (WBPDT) is cumbersome and time consuming because cystoscopic and ultrasonic manipulations are necessary to position the light emitter within the bladder. More important, WBPDT is inherently unsafe and often ineffective since neither uniform photoirradiation nor accurate light dosimetry can be achieved with the techniques employed to photoirradiate the bladder wall. The intravesical laser catheter (IVLC) eliminates the need for cystoscopy and ultrasonography because passage of the treatment fiber into the catheter's central lumen automatically positions its light-diffusing tip within the center of the bladder. Use of the IVLC delivery system also assures accurate photoirradiation of the bladder wall since inflation of the catheter's balloon transforms the asymmetric bladder into a sphere of known diameter. The light sensor incorporated in the balloon wall provides a method to monitor light fluence and measure total light dose. When provided the parameters of bladder volume, laser energy output, and desired light dose, the computerized control system calculates treatment time and automatically adjusts the period of photoirradiation to compensate for variations in laser light production, energy losses during transmission, and for variations in light intensity resulting from the integrating sphere effect of the bladder wall. This delivery system also increases the safety of WBPDT since the monitor automatically discontinues treatment if any unsafe situation, with respect to light fluence, develops during photoirradiation.

Administration, Intravesical↗
PubMed1994

The North American experience with the UroLume endoprosthesis as a treatment for benign prostatic hyperplasia: long-term results. The North American UroLume Study Group.

OBJECTIVES: To determine the efficacy and safety of the UroLume endoprosthesis as a treatment for obstructive benign prostatic hyperplasia in healthy men. METHODS: One hundred twenty-six men were enrolled prospectively in a multicenter North American Clinical Trial. Ninety-five men (mean age 68 +/- 7 years) had moderate or severe prostatism, whereas 31 participants (mean age 76 +/- 8 years) were in urinary retention. Voiding function for all patients was assessed prior to stent placement and in follow-up at 1, 3, 6, 12, and 24 months with the Madsen-Iversen symptom questionnaire, peak urinary flow rate, postvoid residual urine volume, and cystoscopic examination. RESULTS: For the nonretention cohort at 24-month follow-up, the results were as follows: (1) total symptom score decreased from 14.3 +/- 0.5 preinsertion to 5.4 +/- 0.5 (p < 0.001); (2) peak urinary flow rate increased from 9.1 +/- 0.5 mL/s preinsertion to 13.1 +/- 0.7 mL/s (p < 0.001); and (3) postvoid residual urine volume decreased from 85 +/- 9 mL to 47 +/- 8 mL (p = 0.02). For the retention group, the total symptom score, peak urinary flow rate, and postvoid residual urine volume at 24 months were 4.1 +/- 0.5, 11.4 +/- 1.0 mL/s and 46 +/- 7 mL, respectively. By 12-month follow-up, most endoprostheses were completely covered with urothelium. Although significant long-term complications were minimal, 17 endoprostheses have been explanted for an overall removal rate of 13%. All devices were removed transurethrally without subsequent sequelae to the external urinary sphincter or urethra. CONCLUSIONS: The long-term results from this North American Clinical Trial suggest that the UroLume endoprosthesis can be an effective and safe treatment for properly selected healthy men with obstructive benign prostatic hyperplasia. Randomized clinical trials comparing this minimally invasive procedure with transurethral resection of the prostate are now underway to document further its efficacy and safety.

Aged↗
PubMed1994

Fluorescence photodetection of neoplastic urothelial lesions following intravesical instillation of 5-aminolevulinic acid.

OBJECTIVES: Tiny papillary tumors and flat urothelial lesions such as dysplasia or carcinoma in situ can easily be missed during routine cystoscopy. Various methods for in vivo detection of fluorescing agents (preferentially localized in malignant tissue) have been developed. Most of them are based on systemically administered synthetic porphyrin compounds and require sensitive detection devices and image processing units for fluorescence visualization. The usefulness of intracellularly accumulated endogenous protoporphyrin IX (PPIX), induced by 5-aminolevulinic acid (ALA), for diagnosis of early bladder cancer and the correlation with cystoscopic, microscopic, and fluorescence findings was investigated. METHODS: ALA was instilled intravesically in 68 patients, followed by fluorescence cystoscopy with violet light from a krypton ion laser that produced fluorescence excitation. There were 299 biopsies obtained from fluorescing and nonfluorescing areas of the bladder. RESULTS: ALA-induced fluorescence could be easily observed with the naked eye during cystoscopy under violet light illumination. All tumor lesions were sharply marked with brightly shining red fluorescence. Correlation of fluorescence and microscopic findings gave a sensitivity of 100% and a specificity of 68.5%. There were 26 malignant or precancerous lesions that were missed during routine cystoscopy but were detected only by ALA-induced fluorescence. CONCLUSIONS: Labeling of urothelial lesions by PPIX fluorescence induced by intravesically instilled ALA seems to be a promising diagnostic procedure for malignant lesions that are difficult to visualize with standard cystoscopy.

Administration, Intravesical↗
PubMed1994

Endoscopic management of bladder calculi following augmentation cystoplasty.

OBJECTIVES: We sought to evaluate the effectiveness and utility of an endoscopic approach to calculi that develop in the bladders of children following augmentation cystoplasty. In addition, we aimed to determine the indications for open vesicolithotomy. METHODS: We reviewed our experience between 1981 and 1993 with 26 children who formed bladder calculi following augmentation cystoplasty. Data were retrieved retrospectively with respect to management approach and outcome. RESULTS: Nineteen cases were managed cystoscopically using simple extraction and/or electrohydraulic lithotripsy; 3 cases required open vesicolithotomy and four calculi passed spontaneously. Complete stone extraction was achieved after a single endoscopic treatment in every case approached in this fashion. Every patient resumed preoperative voiding patterns and there were no infections, strictures, or other complications. Calculi reformed in 4 patients and were successfully managed endoscopically. CONCLUSIONS: An endoscopic approach to bladder calculi is a safe and effective method of managing this increasingly prevalent problem in children following augmentation cystoplasty even in the presence of a reconstructed bladder neck. Open vesicolithotomy should be reserved for the very large stone burden.

Adolescent↗
PubMed1994

Perianastomotic injection of autologous fat at the time of radical retropubic prostatectomy.

OBJECTIVES: The present study represents the first attempt to improve urinary continence following radical prostatectomy (RP) by perianastomotic injection of autologous fat at the time of the surgical procedure. METHODS: A total of 15 consecutive men with clinically localized carcinoma of the prostate underwent nerve-sparing radical retropubic prostatectomy (RRP) with perianastomotic injection of autologous fat. The autologous fat was obtained using a liposuction cannula connected to a power aspirator. The fat was harvested from the adipose tissue immediately adjacent to the lower midline incision. After the pelvic floor musculature was perforated, a total of 30 mL of autologous fat was injected through a 12 gauge angiocatheter under cystoscopic guidance. RESULTS: There were no complications resulting from the harvesting or injection of the autologous fat. All of the patients were evaluated for 6 months. Of the 15 patients, 12 (80%) achieved total urinary control within 6 months. The average time required to achieve total urinary continence was 89 days. None of the patients experienced total or nocturnal incontinence. Of the 3 patients with stress urinary incontinence (SUI), 2 required 2 small pads per day and 1 required 3 pads per day. Only 1 patient reported that the level of bother resulting from the incontinence was severe. CONCLUSIONS: The preliminary experiences with the perianastomotic fat injection at the time of RRP are encouraging. Determining the ultimate safety and effectiveness of this technique requires longer follow-up in expanded series of patients.

Adipose Tissue↗
PubMed1996

Combination transurethral resection, systemic chemotherapy, and pelvic radiotherapy for invasive (T2-T4) bladder cancer unsuitable for cystectomy: a phase I/II Southwestern Oncology Group study.

OBJECTIVES: Primarily to evaluate the toxicity and, secondarily, the tumor response and patient survival associated with a three-phase combined modality treatment plan for patients with invasive transitional cell carcinoma (TCC) of the bladder (T2-T4,NX-N2, MO) who are medically unsuitable for or who refuse cystectomy. METHODS: Eligible patients initially underwent extensive transurethral resection (TUR) of the primary tumor with the attempt to resect disease totally. Subsequently, they received systemic combination chemotherapy consisting of two cycles of methotrexate, cisplatin, and vinblastine (MCV), followed by cystoscopic re-evaluation of the bladder tumor. Patients then received 6480 cGy radiotherapy to the bladder with concurrent systemic cisplatin. Toxicity, primary tumor response, and overall survival were evaluated. RESULTS: Of 34 eligible patients, 27 patients completed the treatment series. Twenty-two received 80% to 100% of the prescribed doses of MCV and only 2 patients experienced grade 4 hematologic toxicities. The most common toxicities were gastrointestinal (23), hematologic (21), and renal (8). The complete response (CR) rate after all treatment phases was 56% (19 of 34), 10 patients achieving a complete tumor resection of visible tumor at the initial TUR of the bladder (TURB); 3, a CR after MCV; and 6, after radiotherapy and concomitant cisplatin. The median overall survival was 21 months with 6 of 34 (18%) alive at 57 months (range, 36 to 75). Complete resection of tumor by TURB was associated with prolonged overall survival. The bladder was the initial site of recurrence in 85% of patients who had achieved a CR status. CONCLUSIONS: This older age patient group tolerated this combined modality therapy with acceptable toxicities, but the overall survival rate was not improved compared with those reported with radiotherapy alone.

Aged↗