Prediction of Intravesical Recurrence After Radical Nephroureterectomy: Development of a Clinical Decision-making Tool

Nephron-sparing management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract is uncommon and presents unique challenges for diagnosis and management. Nephroureterectomy has been the preferred management option, but it is associated with significant morbidity. Nephron-sparing treatments are a valuable alternative and provide similar efficacy in select cases. A PubMed literature review was performed in English language publications using the following search terms: urothelial carcinoma, upper tract, nephron-sparing, intraluminal and systemic therapy. Contemporary papers published within the last 10 years were primarily included. Where encountered, systematic reviews and meta-analyses were given priority, as were randomized controlled trials for newer treatments. Core guidelines were referenced and citations reviewed for inclusion. A summary of epidemiological data, clinical diagnosis, staging, and treatments focusing on nephron-sparing approaches to upper tract urothelial carcinoma (UTUC) are outlined. Nephron-sparing management strategies are viable options to consider in patients with favorable features of UTUC. Adjunctive therapies are being investigated but the data remains mixed. Protocol variability and dosage differences limit statistical interpretation. New mechanisms to improve treatment dwell times in the upper tracts are being designed with promising preliminary results. Studies investigating systemic therapies are ongoing but implications for nephron-sparing management are uncertain. Nephron-sparing management is an acceptable treatment modality best suited for favorable disease. More work is needed to determine if intraluminal and/or systemic therapies can further optimize treatment outcomes beyond resection alone.

The Significance of Preoperative Serum Sodium and Hemoglobin in Outcomes of Upper Tract Urothelial Carcinoma: Multi-Center Analysis Between China and the United States

Purpose

To analyze the effect of preoperative serum sodium and hemoglobin on oncologic outcomes in upper tract urothelial carcinoma (UTUC) based on a multi-center cohort from China and the United States (U.S.).

Methods

We retrospectively reviewed the records of 775 patients with UTUC treated surgically at tertiary care medical facilities in China or the US from 1998 to 2015. We analyzed associations of preoperative serum sodium and hemoglobin with clinicopathological characteristics, overall survival (OS), cancer-specific survival (CSS) and intravesical recurrence free survival (IVRFS).

Results

The US patients had comparatively lower serum sodium and similar hemoglobin at baseline. Preoperative low serum sodium value was associated with tumor multifocality, lymph node metastasis (LNM) and lymphovascular invasion (LVI); preoperative anemia was associated with advanced age, tumor multifocality, high tumor grade and LVI. Preoperative low serum sodium was an independent predictor of worse OS in the entire cohort; preoperative anemia was an independent predictor of worse OS and CSS in the US cohort alone, Chinese cohort alone and the combined cohort. We developed a predictive nomogram for OS which exhibited better prognostic value when it included the values of sodium and anemia, and successfully validated it in different cohorts.

Conclusion

Preoperative low serum sodium and anemia could be informative in predicting worse pathologic and survival outcomes in different UTUC patient ethnic groups.

UroVysion® predicts intravesical recurrence after radical nephroureterectomy for urothelial carcinoma of the upper urinary tract: a prospective study

BACKGROUND

Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UCUUT) is common. One of the mechanisms driving this is the implantation of cancer cells from the UCUUT at the RNUs. Therefore, their detection after RNU can assist in predicting IVR. This study aimed to examine the utility of UroVysion^® as a tool for predicting bladder recurrence after RNU for UCUUT.

METHODS

We prospectively enrolled 65 patients who received RNU for high-grade UCUUT between October 2013 and April 2017.

RESULTS

Of the 65 patients, 54 (83.1%) who had both bladder urine samples available immediately after RNU (0 postoperative days: POD) and 5 days after RNU (5POD) were selected. We performed UroVysion^® and cytology. Twenty-two patients showed IVR with 32 foci. UroVysion^® results at 0POD (26 patients, 48.1%) and/or 5POD (31 patients, 57.4%) were positive in 42 (77.8%) patients. The sensitivity, specificity, positive predictive value, and negative predictive value of UroVysion^® for included cases were measured for both 0POD and 5POD samples; they were determined to be 95.5% (21/22), 34.4% (11/32), 50.0% (21/42), and 91.7% (11/12), respectively. For cytology, these values were 75.0% (15/20), 52.9% (18/34), 48.4% (15/31), and 78.3% (18/23), respectively. Forty-two (64.6%) patients who were UroVysion^®-positive demonstrated IVR. The IVR rate between the group positive for either 0POD or 5POD and that negative for both significantly differed for both UroVysion^® (p = 0.019) and cytology (p = 0.046).

CONCLUSION

Multiple urine tests using UroVysion^® after RNU could be a useful predictor for IVR.

Preoperative Monocyte-to-lymphocyte Ratio Predicts for Intravesical Recurrence in Patients With Urothelial Carcinoma of the Upper Urinary Tract After Radical Nephroureterectomy Without a History of Bladder Cancer

BACKGROUND

This study aimed to investigate the preoperative monocyte-to-lymphocyte ratio (MLR) as a biomarker for intravesical recurrence (IVR) in upper urinary tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU) for the first time.

PATIENTS AND METHODS

This study involved the clinical data of 255 patients with UTUC without a history of bladder cancer who had undergone RNU from March 2004 to February 2019 at an academic institution. The associations between MLR and IVR were assessed with Kaplan-Meier method and Cox regression analysis.

RESULTS

The median follow-up was 43.93 months. Of the 255 patients, 37 developed IVR during the follow-up period. Kaplan-Meier analysis revealed that patients with high MLR (> 0.22) had poor IVR-free survival (P = .001); this prognostic value was in accordance with patients with high grade and more advanced stage UTUC. Cox regression preoperative models showed that ureteral tumor site (hazard ratio [HR], 2.784; P = .005), surgical approach (HR, 2.745; P = .008), and high MLR (HR, 4.085; P < .001) were an independent risk factor for IVR. These factors were used as a signature to establish a prognostic risk model, which revealed significant differences among the 3 subgroups of patients with low, intermediate, and high risk (P < .001).

CONCLUSION

Ureteral tumor site, surgical approach, and preoperative MLR are significant predictors for IVR in patients with UTUC after RNU. MLR may become a useful biomarker to predict IVR in patients with UTUC after RNU.

[Upper urinary tract urothelial cell carcinoma]

Upper urinary tract urothelial cell carcinoma (UTUC) is a rare entity. The incidence in Germany is approximately 2/100,000 with a ratio between women and men of 1:2.5. Most clinical signs are nonspecific, which is why early diagnosis is rarely successful. Computed tomography urography in combination with diagnostic ureterorenoscopy is currently the gold standard in the diagnostics of UTUC. Regarding surgical treatment, radical nephroureterectomy (RNU) with resection of a bladder cuff remains the method of choice, although the radical approach is developing towards laparoscopic/robotic or endourological procedures with preservation of kidney tissue. Due to the high recurrence rate (22-47%) of urothelial carcinoma inside the bladder, close follow-up after RNU is mandatory.

Surgical and oncological outcome after laparoscopic versus open nephroureterectomy for non-metastatic, upper-tract urothelial carcinoma. A single-centre experience

Objectives:

We determined the surgical and oncological outcomes of laparoscopic nephroureterectomy (LNU) in comparison to open nephroureterectomy (ONU) and factors predicting bladder recurrence after nephroureterectomy.

Methods:

We retrospectively reviewed and compared the data of patients who underwent ONU or LNU for non-metastatic, upper-tract urothelial carcinoma from 2000 to 2016. The primary endpoint was to determine bladder cancer recurrence-free survival (BCRFS), cancer-specific survival (CSS), and overall survival (OS). The data were analysed using Student’s t-test, Chi-square test, and Kaplan-Meier curve.

Results:

Total of 50 patients, of which 24 had LNU and 26 had ONU, met the inclusion criteria. Median durations of follow-up were 4.2 and 6.5 years (p=0.1070) in LNU and ONU, respectively. Operative time, blood loss and hospital stay were significantly lower in the LNU group than in the ONU group (p=0.0001, p=0.0001, p=0.0018). Cancer-specific survival rate in the LNU was 75% and ONU was 73.3% (p=0.1902), whereas BCRFS and CSS were not significantly different in both groups (log-rank test; BCRFS: p=0.809 and CSS: p=0.802). Patients who underwent ureteroscopy with biopsy (p=0.001), had multifocality (p=0.001) and previous history of (H/O) bladder cancer (p=0.020) were at significant risk for developing bladder cancer recurrence after nephroureterectomy.

Conclusion:

Laparoscopic nephroureterectomy can benefit patients because of its minimal invasiveness, and oncologic outcomes are comparable to ONU. Preoperative ureteroscopy with biopsy, multifocality and previous H/O bladder cancer might be risk factors for bladder cancer recurrence.

Bladder tumor recurrence after urothelial carcinoma of the upper urinary tract

Upper tract urothelial carcinoma (UTUC) is a relatively uncommon and poorly investigated malignancy, however, bladder recurrence after radical nephroureterectomy (RNU) is a frequent event. In this review, we summarize the current knowledge on risk prediction of bladder tumor recurrence after RNU, including surgical strategies and adjuvant intravesical treatments to reduce the risk of recurrence. Finally, we outline some of the more recent advances in genomics that will likely lead to new prognostic markers and risk stratification tools that may refine UTUC treatment in the future.

Intraoperative prophylactic intravesical chemotherapy to reduce bladder recurrence following radical nephroureterectomy

PURPOSE

Single, postoperative instillation of prophylactic intravesical chemotherapy (pIVC) is effective in reducing bladder cancer recurrences following radical nephroureterectomy (RNU). Despite high level evidence, pIVC is underutilized. Intraoperative pIVC (I-pIVC) may be easier and safer to implement than postoperative pIVC (P-pIVC). We aimed to evaluate the efficacy of I-pIVC during RNU.

MATERIALS AND METHODS

Retrospective analysis of patients undergoing RNU and I-pIVC or postoperative pIVC (P-pVC) with 20 to 40 mg mitomycin-C or 1 to 2 g gemcitabine. Recurrence rates were evaluated using the Kaplan-Meier curves and log rank test. Cox regression was used for univariable and multivariable analysis.

RESULTS

One hundred and thirty-seven patients were included in the final analysis. 81% (111/137) had I-pIVC and 19% (26/137) had P-pIVC. In the I-pIVC group higher rates of HG, muscle invasive disease and gemcitabine use were observed. Overall, 74% (101/137) and 26% (36/137) had mitomycin-C and gemcitabine instillations, respectively. Within 12 months 14% (19/137) of the patients experienced bladder recurrence. Median time to bladder recurrence was 7 months (range 3-27). Twelve months bladder recurrence-free survival rates were 82% for the I-pIVC group, and 72% for the P-pIVC group ((log rank P = 0.365).

CONCLUSIONS

I-pIVC during RNU may reduce bladder recurrence rates. Bladder recurrence rates are comparable to those reported using postoperative instillations. Intraoperative instillations may be easier to implement and may increase usage rates.

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update

CONTEXT

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

OBJECTIVE

To provide an overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC.

CONCLUSIONS

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

PATIENT SUMMARY

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.

A prognostic nomogram for the cancer-specific survival of patients with upper-tract urothelial carcinoma based on the Surveillance, Epidemiology, and End Results Database

Background

The aim of this study was to establish a comprehensive nomogram for the cancer-specific survival (CSS) of patients with upper-tract urothelial carcinoma (UTUC) and compare it with the traditional American Joint Committee on Cancer (AJCC) staging system in order to determine its reliability.

Methods

This study analyzed 9505 patients with UTUC in the Surveillance, Epidemiology, and End Results (SEER) database. R software was used to randomly divided the patients in a 7-to-3 ratio to form a training cohort (n = 6653) and a validation cohort (n = 2852). Multivariable Cox regression was used to identify predictive variables. The new survival model was compared with the AJCC prognosis model using the concordance index (C-index), the area under the time-dependent receiver operating characteristics curve (AUC), the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), calibration plotting, and decision-curve analysis (DCA).

Results

We have established a nomogram for determining the 3-, 5-, and 8-year CSS probabilities of UTUC patients. The nomogram indicates that the AJCC stage has the greatest influence on CSS in UTUC, followed by the age at diagnosis, surgery status, tumor size, radiotherapy status, histological grade, marital status, chemotherapy status, race, and finally sex. The C-index was higher for the nomogram than the AJCC staging system in both the training cohort (0.785 versus 0.747) and the validation cohort (0.779 versus 0.739). Calibration plotting demonstrated that the model has good calibration ability. The AUC, NRI, IDI, and DCA of the nomogram showed that it performs better than the AJCC staging system alone.

Conclusions

This study is the first to establish a comprehensive UTUC nomogram based on the SEER database and evaluate it using a series of indicators. Our novel nomogram can help clinical staff to predict the 3-, 5-, and 8-year CSS probabilities of UTUC patients more accurately than using the AJCC staging system.

A Comparison of Different Prophylactic Intravesical Chemotherapy Regimens for Bladder Cancer Recurrence After Nephroureterectomy for Primary Upper Tract Urothelial Carcinomas: A Retrospective 2-center Study

Prophylactic intravesical chemotherapy can decrease bladder cancer recurrence rate after nephroureterectomy for upper tract urothelial carcinoma. We aimed to compare the effect of different prophylactic intravesical chemotherapy regimens in bladder recurrence-free survival. From 2000 to 2016, a total of 270 patients treated with radical nephroureterectomy at both institutions were enrolled. Patients were divided into 3 groups: multiple-instillation group, single-instillation group, and no-instillation group. Univariable and multivariable analyses with Cox regression methods were performed to calculate hazard ratios for bladder recurrence using clinicopathologic data, including our different instillation strategies. Sixty-three (23.3%) of 270 patients had subsequent intravesical recurrence. Significantly fewer patients in both the instillation groups had a recurrence compared to in the no-instillation group (13.1% vs 25.4% vs 41.5%, P = .001). Furthermore, there was a significant difference between both the instillation groups (P = .016). In different subsets of patients with upper tract urothelial carcinoma, intravesical chemotherapy, either multiple or single instillation, was a protective factor of bladder recurrence in pT2-4 (P = .002) and high grade (P < .0001). Importantly, Kaplan-Meier curves of bladder recurrence-free survival rate were increased observably in multiple-instillation group compared to that in single-instillation group (P = .053 in pT2-4 subgroup; P = .048 in high-grade subgroup, respectively). On multivariable analysis, intravesical chemotherapy (P < .001), especially multiple instillations (hazard ratio 0.230; 95% confidence interval 0.110-0.479), was identified an independent predictor of bladder recurrence-free survival. In conclusion, prophylactic intravesical chemotherapy effectively prevents bladder recurrence after nephroureterectomy, especially with multiple instillations, in patients with invasive upper tract urothelial carcinoma or at high-grade status.

Preoperative sterile pyuria as a prognostic biomarker for intravesical recurrence in upper urinary tract urothelial carcinoma

Purpose

To evaluate if preoperative sterile pyuria can be a prognostic factor for intravesical recurrence (IVR) and overall survival (OS)in patients with upper tract urothelial carcinoma (UTUC) undergoing surgery.

Materials and Methods

We retrospectively reviewed the medical records of patients who were diagnosed with UTUC from October 2003 to December 2016 at Korea University Medical Center. Sterile pyuria was defined as urine containing five or more white blood cells per high-power field in the absence of bacteria in urine culture. We used a stepwise multivariable Cox proportional hazards model to assess the independent effects of the prognostic factors for IVR and OS.

Results

We investigated a total of 176 patients who were diagnosed with UTUC. Among them, 91 (51.7%) patients had preoperative sterile pyuria. There were no significant differences in the baseline characteristics between the pyuria and non-pyuria groups concerning tumor grade, T stage, tumor multiplicity, and recurrence history. However, there was a significant difference in the IVR between the two groups. In the multivariable analysis, preoperative sterile pyuria, diabetes mellitus, high-grade tumor, and lymphovascular invasion were revealed as independent risk factors for IVR, and only lymphovascular invasion was identified as an independent risk factor for OS.

Conclusions

Preoperative sterile pyuria is significantly associated with IVR in patients with UTUC undergoing surgery, but it is not associated with OS. Furthermore, diabetes mellitus, high-grade tumor, and lymphovascular invasion are also independent prognostic factors for these patients.

Impact of AIB1 expression on the prognosis of upper tract urothelial carcinoma after radical nephroureterectomy

BACKGROUND

Amplified in breast cancer 1 (AIB1) is a candidate oncogene in human breast cancer, which has been identified to be amplified and overexpressed in several types of other human cancers. Abnormalities of AIB1 and its clinical/prognostic significance, however, in upper tract urothelial carcinoma (UTUC) remain unclear.

OBJECTIVE

To explore what role AIB1 plays in upper tract urothelial carcinoma.

METHODS

The expression of AIB1 was analyzed using immunohistochemical staining in 133 UTUC patients. Overall, cancer specific and recurrence-free survival rates (OS, CSS, and RFS) were estimated using the Kaplan-Meier method. Multivariable COX regression models containing relevant clinicopathological variables addressed the prediction of postoperative outcome.

RESULTS

High AIB1 expression was observed to be associated with increased hazard ratios for 5-year CSS (80.6% vs. 55.8%, p= 0.008) and OS (78.1% vs. 54.8%, p= 0.006). Multivariable analysis revealed that elevated AIB1 expression was an independent prognostic predictor of OS, CSS and RFS. Additionally, pT, pN and hydronephrosis were independently associated with oncologic outcome of UTUC. Three proposed nomograms were proposed to provide an individualized risk estimate of postoperative outcome in patients with UTUC.

CONCLUSIONS

AIB1 can be used as an independent molecular marker for the prognosis of clinical outcomes of UTUC.

Development and validation of a prognostic nomogram for patients with intravesical recurrence after radical nephroureterectomy for non-metastatic upper tract urothelial carcinoma

PURPOSE

To develop and validate a prognostic nomogram for patients with intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for non-metastatic upper tract urothelial carcinoma (UTUC).

METHODS

The clinical data of 468 patients registered in the surveillance, epidemiology and end results database between 2010 and 2015 were retrospectively analyzed. Multivariate analysis using the Cox proportional hazard model was used to determine independent prognostic factors for the development of a nomogram to predict the 1-, 3-, and 5-year probability of individual cancer-specific survival (CSS). Moreover, the nomogram was internally validated using receiver operating characteristic curves and calibration plots.

RESULTS

Age at IVR > 80 years, UTUC stage ≥ T3, bladder cancer (BC) stage T1, and muscle-invasive BC (stage ≥ T2) were identified as independent risk factors for CSS in patients with IVR after RNU, whereas a time interval of > 24 months between UTUC and BC was an independent protective factor. The 1-, 3-, and 5-year predictive accuracies of our nomogram were 0.74, 0.70, and 0.71, respectively. Additionally, 1-, 3-, and 5-year calibration curves demonstrated perfect agreement between the nomogram-predicted and the actual CSS.

CONCLUSIONS

This study developed and internally validated the first nomogram to date to predict individual prognosis in patients with IVR after RUN for UTUC. This nomogram can be used for patient counseling and for designing clinical trials.

Development and Validation of a Model for Predicting Intravesical Recurrence in Organ-confined Upper Urinary Tract Urothelial Carcinoma Patients after Radical Nephroureterectomy: a Retrospective Study in One Center with Long-term Follow-up

Although radical nephroureterectomy is the standard treatment method for upper urinary tract urothelial carcinoma, it is associated with a high risk of intravesical recurrence. There are no models for predicting IVR after RNU in patients with organ-confined UTUC. Therefore, we developed and validated a model for postoperative prediction of IVR after RNU. The development cohort consisted of 416 patients who underwent RNU with bladder cuff excision at our center between 1 January 2007 and 31 December 2015. Patient clinicopathologic data were recorded. Multivariate Cox proportional hazard ratio regression was used to build a predictive model with regression coefficients, backward step-wise selection was applied, and the likelihood ratio test with Akaike's information criterion was used as the stopping rule. An independent cohort consisting of 152 consecutive patients from 1 January 2016 and 31 December 2017 was used for validation. The performance of this predictive model was assessed with respect to discrimination, calibration, and clinical usefulness. The predictors in this model included tumor stage, tumor diameter, tumor location, and tumor grade. In the validation cohort, the model showed good discrimination, with a concordance index of 0.689 (95% CI, 0.629 to 0.748) and good calibration. Decision curve analysis demonstrated that the model was also clinically useful. This study presents a good model that may facilitate individualized postoperative prediction of IVR after RNU in patients with organ-confined UTUC, and thus, may help improve postoperative strategies and facilitate treatment outcomes.

[French ccAFU guidelines - Update 2018-2020: Upper tract urothelial carcinoma]

INTRODUCTION

To propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search was performed between 2016 and 2018, with regards to the diagnosis, the options of treatment and the follow-up of UTUC, to evaluate the different studies with levels of evidence.

RESULTS

The diagnosis of this rare disease is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low-risk diseases: unifocal tumour, possible complete resection low-grade and lack of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscopy) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended in order to reduce the risk of bladder recurrence. An adjuvant chemotherapy is recommended after RNU in pT2-T4 N0-3 M0 disease.

CONCLUSION

These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment of UTUC.

[Impact of diagnostic ureteroscopy and biopsy on radical nephroureterectomy of upper tract urothelial carcinoma]

OBJECTIVE

To investigate the impact of preoperative diagnostic ureteroscopy and biopsy (UB) on radical nephroureterectomy (RNU) and the prognosis of upper tract urothelial carcinoma (UTUC).

METHODS

The clinical data of UTUC patients receiving RNU between Jan. 2007 and Dec. 2016 were retrospectively collected. The median follow up time was 40 months. The operation time and blood loss of RNU were compared between UB group and non-UB group. Subgroup analyses were conducted according to the time interval between UB and RNU, and surgery methods of lower ureter. The linear regression model was used to adjust for other common factors that impacted operation time.

RESULTS

A total of 163 UTUC patients were included in the final analysis. For the lower ureter, open ureterectomies were performed in 91 patients (55.9%), while retroperitoneal laparoscopic ureterectomies were performed in 72 patients (44.1%). A total of 110 (67.5%) patients received preoperative UB. Compared with non-UB group, the average operation time of UB group was significantly longer [(252.5±79.8) min vs. (221.3±79.8) min, P=0.019], but no difference of blood loss was found (median, 50 mL vs. 50 mL, P=0.143). In subgroup analysis, the average operation time of RNU was significantly prolonged when RNU was performed after 1 week of UB (P=0.023). Meanwhile, the median blood loss of RNU increased significantly when it was done after 2 weeks of UB compared with non-UB group (100 mL vs. 50 mL, P=0.012). UB was also significantly prolonged the operation time of RNU in retroperitoneal laparoscopic ureterectomy group (P=0.012). In multivariable analysis, UB (P=0.049), ≥pT3 (P=0.039), pN+ (P=0.018) and ureterectomy method (P=0.005) were independent risk factors of prolonged operation time. The 3-year cancer specific survival (CSS) rate was 87.2% in our cohort. UB had no significant impact on cancer specific survival (P=0.435).

CONCLUSION

UB was an independent risk factor of prolonged RNU time, but did not significantly influence cancer specific survival of upper tract urothelial carcinoma patients.

Developing a prediction model for disease-free survival from upper urinary tract urothelial carcinoma in the Korean population

Background

In this study, we aimed to propose a validated prediction model for disease‐free survival (DFS) after radical nephroureterectomy (RNU) in a Korean population with upper urinary tract urothelial carcinoma (UTUC).

Methods

We performed a retrospective review of 1561 cases of UTUC who underwent either open RNU (ONU, n = 906) or laparoscopic RNU (LNU, n = 615) from five tertiary Korean institutions between January 2000 and December 2012. Data were used to develop a prediction model using the Cox proportional hazards model. Prognostic factors were selected using the backward variable selection method. The prediction model performance was investigated using Harrell's concordance index (C‐index) and Hosmer‐Lemeshow type 2 statistics. Internal validation was performed using a bootstrap approach, and the National Cancer Center data set (n = 128) was used for external validation.

Results

A best‐fitting prediction model with seven significant factors was developed. The C‐index and two Hosmer‐Lemeshow type statistics of the prediction model were 0.785 (95% CI, 0.755‐0.815), 4.810 (P = 0.8506), and 5.285 (P = 0.8088). The optimism‐corrected estimate through the internal validation was 0.774 (95% CI, 0.744‐0.804) and the optimism‐corrected calibration curve was close to the ideal line with mean absolute error = 0.012. In external validation, the discrimination was 0.657 (95% CI, 0.560‐0.755) and the two calibration statistics were 0.790 (P = 0.9397) and 3.103 (P = 0.5408), respectively.

Conclusion

A validated prediction model based on a large Korean RNU cohort was developed with acceptable performance to estimate DFS in patients with UTUC.

Management of distal ureter and bladder cuff at the time of nephroureterectomy: surgical techniques and predictors of outcome

Open radical nephroureterectomy (NU) with removal of the ureter and bladder cuff is the 'gold standard' in the treatment of high-grade urothelial cancers of the upper urinary tract. A salient issue is the management of the distal ureter and bladder cuff at time of surgery. Which technique confers superior oncologic benefit is of particular interest since this disease process is notoriously plagued with high intravesical recurrence rates. Although open radical NU is the 'gold standard', the maturation of minimally invasive surgery formidably challenges approaches considered 'gold standard'. We thus sought to critically review the literature comparing perioperative and oncologic outcomes in the approaches used to manage the distal ureter and bladder cuff in patients undergoing radical NU.

Single-dose intravesical chemotherapy after nephroureterectomy for upper tract urothelial carcinoma

BACKGROUND

Single-dose, postoperative intravesical chemotherapy reduces the risk of bladder cancer recurrence after transurethral resection of bladder tumours. However, there is limited evidence whether single-dose intravesical chemotherapy is similarly effective at preventing bladder cancer recurrence after nephroureterectomy.

OBJECTIVES

To assess the effects of single-dose intravesical chemotherapy instillation after nephroureterectomy for upper tract urothelial carcinoma.

SEARCH METHODS

We performed a comprehensive literature search using multiple databases (MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to April 15 2019, with no restrictions on language or status of publication.

SELECTION CRITERIA

We included randomised controlled trials in which participants either received or did not receive single-dose intravesical chemotherapy instillation after nephroureterectomy.

DATA COLLECTION AND ANALYSIS

Two review authors screened and independently assessed studies and extracted data from included studies. We performed statistical analyses using a random-effects model. We rated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

The search identified two studies (a multicenter study from Japan and the United Kingdom) with 361 participants.Primary outcomesOur results indicate that single-dose intravesical chemotherapy instillation may reduce the risk of bladder cancer recurrence over time compared to no instillation (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.32 to 0.82, low-certainty evidence). After 12 months follow-up, this would result in 127 fewer bladder cancer recurrences (95% CI: 182 to 44 fewer bladder cancer recurrences) per 1000 participants. We downgraded the certainty of evidence by two levels due to study limitations and imprecision.We found no trials that reported on the outcomes of time to death from upper tract urothelial carcinoma. The effect of single-dose intravesical chemotherapy instillation on serious adverse events is uncertain (risk ratio [RR]: not estimable, 95% CI: not estimable, there were no events, very low-certainty evidence). We downgraded the certainty of evidence by one level due to study limitations and by two levels due to imprecision.Secondary outcomesWe found no trials that reported on the outcomes of time to death from any cause and participants' disease-specific quality of life. The effect of single-dose intravesical chemotherapy instillation on minor adverse events is uncertain (risk ratio [RR]: not estimable, 95% CI: not estimable, there were no events, very low-certainty evidence). We downgraded the certainty of evidence by one level due to study limitations and by two levels due to imprecision.

AUTHORS' CONCLUSIONS

For patients who have undergone nephroureterectomy for upper tract urothelial carcinoma, single-dose intravesical chemotherapy instillation may reduce bladder cancer recurrence after nephroureterectomy. However, we are uncertain as to the risk of serious (and minor) adverse events. We found no evidence for the outcome of time to death from upper tract urothelial carcinoma. We were unable to conduct any of the preplanned subgroup analyses, particularly those based on operative approach, pathologic stage, and method of bladder cuff excision.

Prognostic value of AIB1 and EIF5A2 in intravesical recurrence after surgery for upper tract urothelial carcinoma

Objectives

The aim of this study was to investigate the prognostic effect of amplified in AIB1 and EIF5A2 expression on postoperative intravesical recurrence for upper urinary tract urothelial carcinoma (UTUC) and improve postoperative risk stratification and prediction of intravesical chemotherapy benefit.

Materials and methods

We evaluated immunohistochemical expression of AIB1 and EIF5A2 in 109 UTUC patients to determine the predictive significance in intravesical recurrence. A prognostic model was developed based on univariate and multivariate analyses.

Results

Intravesical recurrence occurred in 18 out of the 109 (16.5%) patients during the follow-up period. Significant associations of high expression of AIB1 and EIF5A2 with shortened bladder recurrence interval (median: 24 months vs 46 months, P=0.021; 28 months vs 39 months, P=0.002) were demonstrated. In different subsets of UTUC patients, high expression of AIB1 was a prognostic indicator in high grade (P=0.006) and pT2–4 (P=0.007), and high expression of EIF5A2 for high grade (P=0.014), pT2–4 (P=0.002) and pN0 (P=0.009). Moreover, in multivariate analysis, AIB1 and EIF5A2 expression (P=0.034 and 0.022, respectively) together with pN stage (P=0.009) provided significant independent predictors for intravesical recurrence after surgery for UTUC. Surgical approach with radical nephroureterectomy (RNU) was an informative factor toward good oncologic outcomes for intravesical recurrence (P=0.056). Based on a prognostic model with these factors, patients with UTUC were classified into the low-risk group and the high-risk group. In a subset analysis, the patients in the high-risk group were found to have a favorable response to intravesical chemotherapy (P=0.047). A nomogram based on the multivariate analysis was developed to predict intravesical recurrence accurately and guide postoperative intravesical instillations. The concordance index (c-index) of this model was 0.806.

Conclusion

High expression of AIB1 and EIF5A2 were independent predictors for intravesical recurrence after RNU and might be able to predict which patients benefit from postoperative intravesical chemotherapy.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la voie excrétrice supérieure French ccAFU guidelines — Update 2018—2020: Upper tract urothelial carcinoma

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.005. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.005. That newer version of the text should be used when citing the article.

Laparoscopic versus open nephroureterectomy for upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of laparoscopic nephroureterectomy (LNU) and open nephroureterectomy (ONU) for the treatment of upper urinary tract urothelial carcinoma (UTUC).

METHODS

PubMed, Embase, and Cochrane databases were selected for systematic review of trials that compared outcomes of LNU and ONU. Meta-analysis was performed using RevMan 5.3 and STATA 13.0 software.

RESULTS

LNU was associated with longer operation time (P < .001), shorter hospital stay (P < .001), less blood loss (P = .006) and lower rate of transfusion (P < .001). The occurrence of complications, including minor (P = .52), major (P = .21) and total complications (P = .19) were similar between LNU and ONU. There was no significant difference in the rate of 5-year recurrence-free survival (P = .90), 5-year cancer-specific survival (P = .12), and 5-year overall survival (P = .11) as well as 2-year RFS (P = .84), 2-year CSS (P = .86), and 2-year OS (P = .25).

CONCLUSION

Our results indicated that LNU is a safe and effective method to treat UTUC. Given the limitations of this study, further multicenter, randomized trials are required to confirm these findings.

Effect of Preoperative Bacteriuria and Pyuria on Intravesical Recurrence in Patients with Upper Tract Urothelial Carcinoma Undergoing Radical Nephroureterectomy

BACKGROUND/AIM

We investigated the effect of bacteriuria and pyuria on intravesical recurrence (IVR) in patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU).

PATIENTS AND METHODS

Preoperative bacteriuria and pyuria were defined as urine containing ≥5 bacteria/high-power field (HPF) and >5 white blood cells/HPF, respectively. Their associations with IVR were evaluated in 97 patients with UTUC undergoing RNU.

RESULTS

Preoperative bacteriuria [n=15 (15%)] was significantly associated with preoperative pyuria [n=42 (43%), p<0.001]. During follow-up (median of 19 months), 45 (46%) patients developed IVR (median IVR-free survival=38 months). On multivariate analysis, preoperative bacteriuria was an independent predictor for reduced risk of IVR (hazard ratio=0.23, p=0.010). The 2-year IVR-free survival of patients with preoperative bacteriuria and pyuria was significantly longer than that of patients without preoperative bacteriuria (83% vs. 54%, p=0.028) and pyuria (69% vs. 50%, p=0.024), respectively.

CONCLUSION

Bacteriuria and pyuria may reduce the risk of IVR in patients with UTUC undergoing RNU.

Surveillance guidelines based on recurrence patterns for upper tract urothelial carcinoma

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) accounts for 5% of all urothelial tumours. Due to its rarity, evidence regarding postoperative surveillance is lacking. The objective of this study was to develop a post-radical nephroureterectomy (RNU) surveillance protocol based on recurrence patterns in a large, multi-institutional cohort of patients.

METHODS

Retrospective clinical and pathological data were collected from 1029 patients undergoing RNU over a 15-year period (1994-2009) at 10 Canadian academic institutions. A multivariable model was used to identify prognostic clinicopathological factors, which were then used to define risk categories. Risk-based surveillance guidelines were proposed based on actual recurrence patterns.

RESULTS

Overall, 555 (49.9%) patients developed recurrence, including 289 (25.9%) in the urothelium and 266 (23.9%) with loco-regional and distant recurrences. Based on multivariable analysis, three risk groups were identified: 1) low-risk patients with pTa-T1, pN0 disease, and no adverse histological features (high tumour grade, lymphovascular invasion [LVI], tumour multifocality); 2) intermediate-risk patients with pTa-T1, pN0 disease with one or more of the adverse histological features; and 3) high-risk patients with a ≥pT2 tumour and/or nodal involvement. Low-, intermediate-, and high-risk patients were free of urothelial recurrence at three years in 72%, 66%, and 63%, respectively, and free of regional/distant recurrence in 93%, 87%, and 62%, respectively. The risks of loco-regional and distant recurrences (p<0.0001) and time to death (p<0.0001) were significantly different between the low-, intermediate-, and high-risk patients.

CONCLUSIONS

Based on recurrence patterns in a large, multicentre patient cohort, we have proposed an evidence-based, risk-adapted post-RNU surveillance protocol.

Reduce bladder cancer recurrence in patients treated for upper urinary tract urothelial carcinoma: The REBACARE-trial

Background

Following radical nephro-ureterectomy for urothelial carcinoma of the upper urinary tract (UUT), the reported bladder recurrence rate of urothelial carcinoma is 22–47%. A single intravesical instillation of chemotherapy within 10 days following nephro-ureterectomy has the potential to decrease the risk of a bladder recurrence significantly. Despite recommendation by the European Association of Urology guideline to administer a single instillation postoperatively, the compliance rate is low because the risk of extravasation of chemotherapy.

Aim

To reduce the risk of bladder cancer recurrence by a single intravesical instillation of Mitomycin immediately (within 3 h) before radical nephro-ureterectomy or partial ureterectomy.

Methods

Adult patients (age ≥ 18 years) with a (suspicion of a) urothelial carcinoma of the UUT undergoing radical nephro-ureterectomy or partial ureterectomy will be eligible and will receive a single intravesical instillation of Mitomycin within 3 h before surgery. In total, 170 patients will be included in this prospective, observational study. Follow-up will be according to current guidelines.

Results

The primary endpoint is the bladder cancer recurrence rate up to two years after surgery. Secondary endpoints are: a) the compliance rate; b) oncological outcome; c) possible side-effects; d) the quality of life; e) the calculation of costs of a single neoadjuvant instillation with Mitomycin and f) molecular characterization of UUT tumors and intravesical recurrences.

Conclusions

A single intravesical instillation of Mitomycin before radical nephro-ureterectomy or partial ureterectomy may reduce the risk of a bladder recurrence in patients treated for UUT urothelial carcinoma and will circumvent the disadvantages of current therapy.

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update

CONTEXT

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

OBJECTIVE

To provide an overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; ureteroscopy; nephroureterectomy; adjuvant treatment; instillation; recurrence; risk factors; and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing number of retrospective articles in UTUC. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification, as well as for radical and conservative treatment; prognostic factors are also discussed. A single postoperative dose of intravesical mitomycin after radical nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumours and two functional kidneys.

CONCLUSIONS

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

PATIENT SUMMARY

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis; appropriate diagnosis and management is most important. We present recommendations based on current evidence for optimal management.

Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a systematic review and meta-analysis

Aim of this study was to analyse the association between the use of diagnostic ureteroscopy (URS) and the development of intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for high-risk upper tract urothelial carcinoma. A systematic review of the published data was performed up to December 2016, using multiple search engines to identify eligible studies. A formal meta-analysis was conducted of studies comparing patients who underwent URS before RNU with those who did not. Hazard ratios (HRs), with their 95% confidence intervals (CIs), from each study were used to calculate pooled HRs. Pooled estimates were calculated using a fixed-effects or random-effects model according to heterogeneity. Statistical analyses were performed using RevMan, version 5. Seven studies were included in the systematic review, but only six of these were deemed fully eligible for meta-analysis. Among the 2 382 patients included in the meta-analysis, 765 underwent diagnostic URS prior to RNU. All examined studies were retrospective, and the majority examined Asian populations. The IVR rate ranged from 39.2% to 60.7% and from 16.7% to 46% in patients with and without prior URS, respectively. In the pooled analysis, a statistically significant association was found between performance of URS prior to RNU and IVR (HR 1.56, 95% CI 1.33-1.88; P < 0.001). There was no heterogeneity in the observed outcomes, according to the I² statistic of 2% (P = 0.40). Within the intrinsic limitations of this type of analysis, these findings suggest a significant association between the use of diagnostic URS and higher risk of developing IVR after RNU. Further research in this area should be encouraged to further investigate the possible causality behind this association and it potential clinical implications.

An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making

OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.

Risk of Intravesical Recurrence After Ureteroscopic Biopsy for Upper Tract Urothelial Carcinoma: Does the Location Matter?

INTRODUCTION

To investigate whether ureteroscopic biopsy (URS-Bx) for upper tract urothelial carcinoma (UTUC) before radical nephroureterectomy affects intravesical recurrence (IVR).

PATIENTS AND METHODS

Of the 515 patients receiving radical nephroureterectomy for UTUC between 1998 and 2012, 387 patients were included for the analysis. URS-Bx was performed in 69 patients (17.8%). Patients were stratified according to tumor location, and the impact of URS-Bx on IVR was evaluated after adjusting for other clinicopathologic variables.

RESULTS

IVR occurred in 163 patients (42.1%). The postoperative 5-year IVR-free survival was not significantly different according to URS-Bx in the overall patient group (54.0% vs 39.3%, p = 0.056). In patients with renal pelvic tumor, IVR-free probability was lower in patients with URS-Bx than in patients without URS-Bx (39.6% vs 62.2%, p = 0.012), although IVR-free survival in patients with ureteral tumor was equivalent (36.7% vs 45.8%, p = 0.946). In multivariate analysis, previous bladder tumors (hazard ratio [HR], 1.65; p = 0.016) were a significant risk factor for IVR in all patients and ureteral tumor location (HR, 1.35; p = 0.071) was associated with IVR, although statistical significance was not achieved. In patients with renal pelvic tumor, URS-Bx HR, 1.98; p = 0.020 was the only risk factor for IVR. However, URS-Bx was not associated with IVR in patients with ureteral tumor, although previous bladder tumor HR, 1.74; p = 0.028 was a risk factor for IVR.

CONCLUSION

URS-Bx is a significant risk factor for IVR in patients with renal pelvic tumor and should be performed after sufficient consideration in these patients if other examinations are uncertain.

[CCAFU french national guidelines 2016-2018 on upper tract tumors]

INTRODUCTION

The purpose was to propose an update of the french guidelines from the national committee CCAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search was performed between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumour, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscope) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduced risk of baldder recurrence. The place of systemic therapy (adjuvant and neoadjuvant chemotherapy) remains to define.

CONCLUSION

These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC. © 2016 Elsevier Masson SAS. All rights reserved.

Predictive models and prognostic factors for upper tract urothelial carcinoma: a comprehensive review of the literature

In the context of customized patient care for upper tract urothelial carcinoma (UTUC), decision-making could be facilitated by risk assessment and prediction tools. The aim of this study was to provide a critical overview of existing predictive models and to review emerging promising prognostic factors for UTUC. A literature search of articles published in English from January 2000 to June 2016 was performed using PubMed. Studies on risk group stratification models and predictive tools in UTUC were selected, together with studies on predictive factors and biomarkers associated with advanced-stage UTUC and oncological outcomes after surgery. Various predictive tools have been described for advanced-stage UTUC assessment, disease recurrence and cancer-specific survival (CSS). Most of these models are based on well-established prognostic factors such as tumor stage, grade and lymph node (LN) metastasis, but some also integrate newly described prognostic factors and biomarkers. These new prediction tools seem to reach a high level of accuracy, but they lack external validation and decision-making analysis. The combinations of patient-, pathology- and surgery-related factors together with novel biomarkers have led to promising predictive tools for oncological outcomes in UTUC. However, external validation of these predictive models is a prerequisite before their introduction into daily practice. New models predicting response to therapy are urgently needed to allow accurate and safe individualized management in this heterogeneous disease.

The neutrophil-to-lymphocyte ratio as a predictor of intravesical recurrence in patients with upper urinary tract urothelial carcinoma treated with radical nephroureterectomy

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with recurrence and poor prognosis in numerous cancer types. The aim of this study was to evaluate the use of the NLR as a biomarker for intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC) for the first time.

METHODS

We retrospectively analyzed the records of 100 patients with UTUC who had undergone RNU between 1999 and 2015 at our institution. The association between the preoperative NLR and IVR were assessed using multivariate models.

RESULTS

Among the 100 patients enrolled in the study, 33 developed IVR during a median follow-up of 34 months. The receiver operating characteristic analysis revealed that the optimum cut-off value for the preoperative NLR was >3.8. A high preoperative NLR (n = 21) was associated with a significantly increased risk of lymph node involvement (p = 0.036) and IVR (p = 0.034) compared with a low preoperative NLR (n = 79). IVR-free survival in patients with a high preoperative NLR was significantly worse than that of patients with a low preoperative NLR (p = 0.018). On multivariate analysis, the preoperative NLR [hazard ratio (HR) 2.49; p = 0.015] and tumor multifocality (HR 2.96; p = 0.024) were independent risk factors predictive of IVR.

CONCLUSION

In our study population of patients with UTUC who had undergone RNU the preoperative NLR was associated with a significantly increased risk of IVR, suggesting that the NRL could be a useful biomarker for predicting IVR.

Long-term oncologic outcomes of laparoscopic nephroureterectomy versus open nephroureterectomy for upper tract urothelial carcinoma: a systematic review and meta-analysis

Background. Several factors have been validated as predictors of disease recurrence in upper tract urothelial carcinoma. However, the oncological outcomes between different surgical approaches (open nephroureterectomy versus laparoscopic nephroureterectomy, ONU vs LNU) remain controversial. Therefore, we performed a meta-analysis to evaluate the oncological outcomes associated with different surgical approaches.

Methods. We conducted an electronic search of the PubMed, Embase, ISI Web of Knowledge and Cochrane Library electronic databases through November 2015, screened the retrieved references, collected and evaluated the relevant information. We extracted and synthesized the corresponding hazard ratios (HRs) and 95% confidence intervals (95% CI) using Stata 13.

Results. Twenty-one observational studies were eligible for inclusion in the meta-analysis. The results of the meta-analysis showed no differences in the intravesical recurrence-free survival (IRFS), unspecified recurrence-free survival (UnRFS) and overall survival (OS) between LNUandONU. However, improvements in the extravesical recurrence free survival (ExRFS) and cancer specific survival (CSS) were observed inLNU. The pooled hazard ratios were 1.05 (95% CI [0.92–1.18]) for IRFS, 0.80 (95% CI [0.64–0.96]) for ExRFS, 1.10 (95% CI [0.93–1.28]) for UnRFS, 0.91 (95% CI [0.66–1.17]) for OS and 0.79 (95% CI [0.68–0.91]) for CSS.

Conclusion. Based on current evidence, LNU could provide equivalent prognostic effects for upper tract urothelial carcinoma, and had better oncological control of ExRFS and CSS compared to ONU. However, considering all eligible studies with the intrinsic bias of retrospective study design, the results should be interpreted with caution. Prospective randomized trials are needed to verify these results.