Impact of Ureteroscopy Before Nephroureterectomy for Upper Tract Urothelial Carcinoma on Oncologic Outcomes

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d8575822e227">Objective</h5> <p id="P1">To compare the oncologic outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing nephroureterectomy (NU) with and without prior ureteroscopy (URS). </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d8575822e232">Methods</h5> <p id="P2">We reviewed records of all patients with no prior history of bladder cancer that underwent NU at our institution (n = 201). We compared patients who underwent URS prior to NU to patients who proceeded directly to NU based on imaging alone. After excluding patients undergoing URS with therapeutic intent, we used multivariable Cox proportional hazards models, adjusting for tumor characteristics with cancer specific survival (CSS), intravesical recurrence free survival (IRFS), metastasis free survival (MFS), and overall survival (OS) as endpoints. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d8575822e237">Results</h5> <p id="P3">144 (72%) patients underwent URS prior to NU and 57 (28%) patients proceeded directly to NU. The median follow up time for survivors was 5.4 years from diagnosis. The performance of diagnostic URS prior to NU was significantly associated with IR (HR 2.58; 95% CI 1.47, 4.54; p = 0.001), although it was not associated with CSS, MFS, or OS. The adjusted IRFS probability 3 years after diagnosis is 71% and 42% for patients who did not and did receive URS prior to NU, respectively (adjusted risk difference 30%; 95% CI 13%, 47%). </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d8575822e242">Conclusions</h5> <p id="P4">We did not find evidence that URS adversely impacts disease progression and survival in patients with UTUC. Although patients are at higher risk for IR after NU when they have undergone prior diagnostic URS, their CSS, MFS, and OS are not significantly affected. </p> </div>

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Most cited references 11

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Combining imaging and ureteroscopy variables in a preoperative multivariable model for prediction of muscle-invasive and non-organ confined disease in patients with upper tract urothelial carcinoma.

Ricardo Favaretto, Shahrokh F. Shariat, Caroline Savage … (2012)

To create a preoperative multivariable model to identify patients at risk of muscle-invasive (pT2+) upper tract urothelial carcinoma (UTUC) and/or non-organ confined (pT3+ or N+) UTUC (NOC-UTUC) who potentially could benefit from radical nephroureterectomy (RNU), neoadjuvant chemotherapy and/or an extended lymph node dissection.

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Ureteroscopic and extirpative treatment of upper urinary tract urothelial carcinoma: a 15-year comprehensive review of 160 consecutive patients.

Michael Grasso, Andrew Fishman, Jacob Cohen … (2012)

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UTUC) have historically been treated with radical, extirpative surgery, primarily nephroureterectomy with bladder-cuff excision. In general, there has been growing interest in renal preservation, as evidenced by the broadening application of nephron-sparing surgery for renal parenchymal tumours. Beyond imperative reasons such as tumour in a solitary kidney, bilateral disease, or comorbidities preventing radical surgery, there is a growing role for endoscopic management of upper tract tumours. The aim has been to obtain similar oncological results to those of extirpative surgery, while preserving long-term renal function. Properly selecting patients for these therapies, designing specific treatments based on a complex presentation, and general information with regard to outcomes and risks for patient counselling have been based historically on results from relatively small series without long-term follow-up. This study reflects all patients with UTUC treated by a single tertiary referral surgeon, accrued prospectively over 15 years using the same surgical techniques and treatment algorithms throughout the entire study period, with 10-year survival data. The consecutively accrued nature and size of the study groups, uniformity in treatments, statistical review and long-term follow-up provide baseline oncological data that could help frame future study. • To present long-term oncological outcomes of all patients treated surgically for upper urinary tract urothelial carcinoma (UTUC) over a 15-year period. • All patients (N = 160) treated from January 1996 to August 2011 were prospectively studied and placed into three distinct groups after initial diagnostic ureteroscopy (URS): Group 1: low grade lesions treated with URS (n = 66); Group 2: high grade lesions palliatively treated with URS (n = 16); and Group 3: extirpative surgery (nephroureterectomy [NU]; n = 80). • Statistical analysis was performed using Kaplan-Meier methodology to calculate overall (OS), cancer-specific (CSS) and metastasis-free survival (MFS). • The median patient age at presentation was 73 years, and the mean (range) follow-up time was 38.2 (1-185) months. At initial diagnostic URS, 71 (44.4%) patients presented with high grade and 89 (55.6%) patients presented with low grade disease. • The 2-, 5- and 10-year CSS rates were 98, 87 and 81% for patients with low grade disease, and 97, 87 and 78% for patients treated with URS (Group 1), not significantly different from those patients with low grade disease treated with NU (Group 3), (P = 0.54). • Of the patients treated with URS for low grade disease, 10 (15.2%) progressed to high grade disease at a mean time of 38.5 months. • Patients with high grade disease treated with NU had a 2-, 5-, and 10-year CSS of 70, 53 and 38%, with a MFS of 55, 45 and 35%. • Median survival of patients with high grade disease treated with palliative URS was 29.2 months with a 2-year OS of 54%. • On multivariate analysis only high grade lesion on initial presentation was found to be a significant factor (P < 0.001; hazard ratio = 7.27). • Grade is the most significant predictor of OS and CSS in those with UTUC, regardless of treatment method. • Ureteroscopic and extirpative therapy are acceptable options for those with low grade disease showing excellent long-term CSS. • Extirpative therapy was found to result in relatively poor long-term CSS in patients with high grade disease, underscoring the need for adjuvant or neoadjuvant therapies. © 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.

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Inadequacy of biopsy for diagnosis of upper tract urothelial carcinoma: implications for conservative management.

Armine Smith, Andrew Stephenson, Brian Lane … (2011)

To report changes in grade and stage between initial diagnostic and repeat biopsies or resection for urothelial carcinoma (UTUC) and investigate the consequences for endoscopic management. Ureteroscopic management of upper tract UTUC is an alternative to nephroureterectomy, which is less invasive and preserves renal function. However, concerns about potential understaging, inaccurate grading, incomplete resection, lack of effective tertiary chemoprevention, and need for ureteroscopic surveillance limits it appeal.