Frank, Igor

Tremendous attention and energy have been put toward development of minimally invasive techniques in urology to decrease the morbidity of surgery without compromising outcomes. Urologists have remained on the cutting edge of technology, performing procedures via laparoscopic, robotic, and transurethral approaches in procedures that were formerly only performed with an open approach. As the treatment paradigm shifts toward less invasive procedures, the concept of performing surgery through natural body openings has been recognized. Natural orifice translumenal endoscopic surgery (NOTES) eliminates the need for abdominal incisions, theoretically resulting in decreased pain, faster convalescence, improved cosmesis, and absence of wound infections and hernias. While transvesical NOTES has the potential to develop into a viable technology in the clinical setting, it is still in its infancy. Initial studies have demonstrated the feasibility of transvesical NOTES; however, further work must be dedicated to this subject before its routine application in humans. The purpose of this review is to detail the experimental, cadaveric, and clinical work that has been accomplished with transvesical NOTES, in addition to discussing the advantages and disadvantages, technical obstacles, and potential risks that accompany the use of the bladder as a portal for surgery.

Abstract Purpose: Aberrant expression of T-cell coregulatory molecules has been investigated as a mechanism by which certain cancers may evade host immune surveillance. We evaluated expression of the T-cell coregulators B7-H1, B7-H3, and PD-1 in urothelial cell carcinoma (UCC) of the bladder. Experimental Design: Immunohistochemistry for B7-H1, B7-H3, and PD-1 was done on paraffin-embedded sections from 318 consecutive patients with UCC who underwent radical cystectomy. Expression was correlated with clinicopathologic outcomes and postoperative survival. Results: B7-H3 was widely expressed in UCC, as 222 of 314 (70.7%) tumors showed positive staining. Expression of B7-H3 in UCC was significantly increased compared with adjacent, nontumor urothelium, as a median of 70% of tumor cells expressed B7-H3, compared with 20% of cells in nontumor specimens (P < 0.001). The increase in B7-H3 expression was independent of tumor stage (P = 0.13). Expression of B7-H1 by UCC tumors (P < 0.001) and PD-1 by tumor-infiltrating lymphocytes (P = 0.012) were significantly associated with increased pathologic stage. Patients who had received intravesical bacillus Calmette-Guerin before cystectomy tended to show increased expression of B7-H3 (P = 0.023) and PD-1 (P = 0.071) but were less likely to express B7-H1 (P = 0.027). Moreover, for the subset of patients with organ-confined disease (n = 167), B7-H1 expression independently predicted all-cause mortality after cystectomy (hazard ratio, 3.18; 95% confidence interval, 1.74-5.79; P < 0.001). Conclusions: B7-H3 is highly expressed in UCC across tumor stages, whereas B7-H1 and PD-1 expression are associated with advanced disease. B7-H1 expression predicts mortality after cystectomy for patients with organ-confined tumors. These molecules may represent novel diagnostic or prognostic markers, as well as therapeutic targets, for patients with UCC.