Gender-related differences in patients with stage I to III upper tract urothelial carcinoma: results from the Surveillance, Epidemiology, and End Results database

Upper tract urothelial carcinoma: Paradigm shift towards nephron sparing management

Upper tract urothelial carcinoma (UTUC) is relatively rare compared to urothelial carcinoma of the lower tract, comprising only 5%-10% of all urothelial cancers. Although both entities share histologic properties, UTUC tends to be more invasive at diagnosis and portend a worse prognosis, with a 5 year overall mortality of 23%. To date, the gold standard management of UTUC has been radical nephroureterectomy (RNU), with nephron sparing techniques reserved for solitary kidneys or cases where the patient could not tolerate radical surgery. Limited data from these series, as well as select series where nephron-sparing endoscopic management has been offered to a broader patient base, suggest that minimally invasive, nephron sparing techniques can offer comparable oncologic and survival outcomes to RNU in appropriately selected patients. We review the current literature on the topic and discuss long term outcomes and sequelae of the gold standard treatment, RNU. We also discuss the oncologic outcomes of minimally invasive, endoscopic management of UTUC. Our goal is to provide the reader a comprehensive overview of the current state of the field in order to inform and guide their treatment decisions.

[Elective organ and function preservation in ureter and renal pelvis tumors]

With the technical innovations of smaller, flexible ureteroscopes, color-filtered imaging, and endoscopic laser technology, organ-preserving treatment for upper urinary tract transitional cell carcinoma has become feasible. While in the past, radical nephroureterectomy was the sole gold standard approach for the treatment of upper urinary tract tumors, the endoscopic approach is no longer restricted to only patients with the imperative indication of kidney preservation. Initial clinical results have demonstrated oncologic efficacy of endoscopic management or segmental ureteral resection. However, careful preoperative risk-assessment and close endoscopic follow-up are mandatory.

Visceral to total obesity ratio and severe hydronephrosis are independently associated with prolonged pneumoperitoneum operative time in patients undergoing laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma

BACKGROUND

Our aim was to evaluate the effect of visceral obesity and impact of severe hydronephrosis on surgical complexity in patients undergoing laparoscopic radical nephroureterectomy (LRNU).

METHODS

From January 2000 to December 2013, 169 patients underwent radical nephroureterectomy at our institution. We retrospectively reviewed the medical records of 70 patients who underwent LRNU. We measured total fat area (TFA) and visceral fat area (VFA) at the level of the umbilicus using computed tomography. We defined accumulated visceral fat distribution as a VFA/TFA ratio ≥0.45. Ipsilateral hydronephrosis was graded from 0 to 4 by two uro-radiologists blinded to the clinical outcomes.

RESULTS

Among the 70 patients, VFA/TFA ratio was ≥0.45 in 40 patients (57.1%) and 28 (40.0%) had severe hydronephrosis (grade 3 or greater). Patients with a VFA/TFA ratio ≥0.45 had significantly longer pneumoperitoneum and total operation times compared to their counterparts (p = 0.047 and p = 0.002, respectively). Patients with severe hydronephrosis had significantly longer pneumoperitoneum and total operative times compared to their counterparts (p = 0.006 and p = 0.002, respectively). Multivariate logistic regression analysis showed that a high VFA/TFA and severe hydronephrosis were independent predictive factors for prolonged pneumoperitoneum (p = 0.048, HR = 2.90; p = 0.015, HR = 3.82, respectively) and total operative times (p < 0.001, HR = 18.7; p = 0.003, HR = 10.7; respectively). Other pre-clinical factors such as age, gender, BMI, clinical stage, tumor size, location, laterality, degree of perinephric stranding, and surgical procedure did not affect the operation times.

CONCLUSION

The present data indicated that the visceral type of adipose accumulation and presence of severe hydronephrosis could provide preoperative information on the degree of technical difficulty associated with LRNU.

Effect of sex on prognosis of urothelial carcinoma: propensity score matching analysis

BACKGROUND

The aim of the present study was to evaluate the effect of differences between the sexes on the prognosis of urothelial carcinoma after adjusting for other factors by using propensity score matching.

PATIENTS AND METHODS

Between 2000 and 2011, 678 consecutive patients who had undergone radical cystectomy or radical nephroureterectomy for urothelial carcinoma were enrolled in this study. Propensity score methodology was used to adjust for selection bias with 10 and 12 perioperative variables for urothelial carcinoma of the bladder (UCB) and upper tract urothelial carcinoma (UTUC). By a 2:1 male-to-female patient matching ratio, we selected 38 and 66 pairs of patients with UCB and UTUC.

RESULTS

The number of male patients was 573 (84.5%), and there were 105 female patients (15.5%). The mean follow-up was 55.5 ± 38.4 months. There were no significant differences in the perioperative variables of age, pathologic T (pT) stage, grade, lymphovascular invasion (LVI), and concomitant carcinoma in situ (CIS) between the sexes. Neither cancer-specific survival (CSS) or overall survival (OS) was associated with sex in a multivariate Cox proportional hazard model. In propensity score matching analysis, female sex was not an independent risk factor for CSS and OS in urothelial carcinoma. In patients with UCB, body mass index (BMI) and pT stage were independently associated with CCS. For the patients with UTUC, age, pT stage, LVI, adjuvant chemotherapy, bladder cuffing, and location were significantly correlated.

CONCLUSION

After adjusting for other risk factors with propensity score matching, female sex may not be an independent risk factor in prognosis for urothelial carcinoma (UC).

Socio-economic deprivation and outcomes following radical nephroureterectomy for clinically localized upper tract transitional cell carcinoma

BACKGROUND

Little is known about the effects of socio-economic deprivation on the oncological outcomes of surgically treated upper tract transitional cell carcinoma.

METHODS

From January 1998 to December 2012, 161 patients underwent nephroureterectomy for upper urinary tract cancer at our tertiary medical centre. We included 124 patients where complete data were available for further analysis. This study also analysed the impact of the reported risk factors such as grade, stage, multifocality in addition to socio-economic deprivation on the long-term oncological outcomes after nephroureterectomy.

RESULTS

One hundred and twenty-four (77 %) patients with complete data for socio-economic status were analysed in this study. The median age of the cohort was 73 years (interquartile range 45-86). There were 20, 18, 17, 40 and 29 patients in different socio-economic categories ranging from 1 to 5, respectively. The median duration of follow-up was 68 months (9-174). A statistically higher grade (p value 0.005) and higher stage (p value 0.0005) disease was seen in patients from less deprived categories on both univariate and multivariate analyses. The cancer-specific mortality and follow-up recurrences, however, did not significantly differ between the different socio-economic categories on multivariate analysis (p value 0.13; 0.6) and on univariate and multivariate analyses. A higher number of patients with multifocal disease and concomitant carcinoma in situ (CIS) had disease recurrences which were statistically significant (p values 0.026 and 0.014, respectively) on multivariate analysis.

CONCLUSIONS

A lower recurrence-free survival was observed in patients with multifocal disease and those with concomitant CIS following nephroureterectomy for clinically localized disease. Long-term follow-up did not show any significant differences in cancer-specific survival between different deprivation categories.

Dysregulation of mammalian target of rapamycin pathway in upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for 5% to 10% of all urothelial carcinomas. Despite many shared features, key clinical and molecular genetic differences between upper tract and bladder urothelial carcinomas are becoming apparent. We have previously demonstrated alterations of mammalian target of rapamycin (mTOR) pathway in bladder carcinoma with a potential impact on biological behavior. In the current study, we evaluated the expression status and prognostic significance of mTOR pathway members in UTUC. Archival formalin-fixed and paraffin-embedded tissues from 99 primary UTUCs were retrieved from one of the authors' institution. Tissue microarrays were constructed with triplicate tumor samples and paired nonneoplastic urothelium. Tissue microarrays were analyzed using immunohistochemistry for mTOR pathway members: PTEN, phos-AKT, phos-mTOR, phos-S6, phos-4EBP1, and related markers p27 and c-MYC; correlation with clinicopathologic parameters and outcome was performed. We found significantly lower expression of PTEN, phos-AKT, phos-mTOR, phos-S6, phos-4EBP1, p27, and c-MYC in UTUC compared with paired benign urothelium (P < .0005). We found a strong positive correlation between PTEN and phos-AKT. Moderate correlation was observed between phos-mTOR and phos-S6, PTEN and p27, phos-AKT and p27, phos-S6 and p27, phos-mTOR and c-MYC, phos-S6 and c-MYC, and p27 and c-MYC. None of the evaluated biomarkers were associated with increased hazard ratios for tumor recurrence or for cancer-specific mortality, when adjusting for relevant clinicopathologic variables. Dysregulation of the mTOR pathway was observed in UTUC compared with normal urothelium, implicating a potential pathogenic role in tumor development. In our cohort, expression of the evaluated biomarkers had no prognostic value.

Predictive factors for worse pathological outcomes of upper tract urothelial carcinoma: experience from a nationwide high-volume centre in China

OBJECTIVES

To analyse the predictive factors for worse pathological outcome (muscle invasive pT2+, non-organ-confined pT3+ or N+ and histological Grade 3) of upper tract urothelial carcinoma (UTUC) in a Chinese population from a nationwide high-volume centre in China.

PATIENTS AND METHODS

Predictors were studied by retrospectively reviewing the clinicopathological data of 729 consecutive patients with UTUC treated in our centre from January 2002 to December 2010. Univariate and multivariate logistic regression analyses were used.

RESULTS

There were more female patients (56.4%) than males and more tumours were located in the ureter (52.7%) than in the pelvis. In multivariate analysis, male gender (hazard ratio [HR] 1.898, P = 0.001), sessile architecture (HR 3.249, P < 0.001), high grade (HR 5.007, P < 0.001), ipsilateral hydronephrosis (HR 4.768, P < 0.001), renal pelvis location (HR 2.620, P < 0.001) and tumour without multifocality (HR 1.639, P = 0.028) were predictive factors for muscle-invasive UTUC. Male gender (HR 2.132, P < 0.001), renal pelvis location (HR 3.466, P < 0.001), tumour without multifocality (HR 2.532, P = 0.001), sessile tumour architecture (HR 3.274, P < 0.001), and high grade (HR 3.019, P < 0.001) were predictive factors for non-organ-confined disease. Chronological old age (HR 1.047, P < 0.001), sessile tumour architecture (HR 25.192, P < 0.001), ipsilateral hydronephrosis (HR 1.689, P = 0.024), and positive urinary cytology (HR 1.997, P = 0.006) were predictive factors for histological Grade 3 UTUC.

CONCLUSIONS

There was a predominance of female patients and ureteric tumours in UTUCs of this Chinese population. Male gender, sessile architecture, tumour location, tumour without multifocality, high histological grade and preoperative ipsilateral hydronephrosis were independent predictive factors for worse pathological outcome of UTUCs.

Endoscopic management of upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.

Age-specific effect of gender on upper tract urothelial carcinoma outcomes

The research is to evaluate the age-specific differential effects of gender on outcomes in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU). Between August 1998 and October 2010, we retrospectively reviewed the data from 285 (67.7%) men and 136 (32.3%) women treated with RNU for UTUC at our two institutions. Kaplan-Meier survival estimates the age-specific effect of gender on cancer-specific survival (CSS). Cox proportional hazards regression analyses were used to address the effect of gender on CSS. No significant sex-related differences were found in age and diagnosis, clinicopathologic features, and treatment (all P values >0.05). Women had a 18.7% increased risk of death from UTUC than men (hazard ratio [HR] 1.187; 95% confidence interval [95% CI] 1.017-1.893; P = 0.021). The survival disadvantage was only present in patients aged 59 years and older (P < 0.001). Conversely, the survival advantage for women was found in women aged 42 to 58 years (P = 0.011) and in the age group <42 years (P = 0.019). On multivariable Cox regression analyses that adjusted for the effects of clinicopathologic features, the female gender was associated with decreased CSS (P = 0.036). In conclusion, the impact of gender on UTUC outcomes after RNU is age-specific. Females who aged 59 years and older experienced worse outcomes than their male counterparts, while women in the age group <42 years and 42-58 years have better outcomes than men. Further research is needed to elucidate the molecular mechanisms underlying the age-specific differential effect of gender on UTUC outcomes.

European guidelines on upper tract urothelial carcinomas: 2013 update

CONTEXT

The European Association of Urology (EAU) guideline group for upper tract urothelial carcinoma (UTUC) has prepared updated guidelines to aid clinicians in assessing the current evidence-based management of UTUC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians in their daily clinical practice.

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations (ie, grade A) due to the rarity of the disease. A number of recent multicentre studies are now available, and there is a growing interest in UTUC in the recent literature. Overall, 135 references have been included here, but most of these studies are still retrospective analyses. The TNM 2009 classification is recommended. Recommendations are given for diagnosis as well as radical and conservative treatment (ie, imperative and elective cases); additionally, prognostic factors are discussed. Recommendations are also provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the management of individual patients according to a current standardised approach. Physicians must take into account the specific clinical characteristics of each individual patient when determining the optimal treatment regimen including tumour location, grade, and stage; renal function; molecular marker status; and medical comorbidities.

Gender-specific effect of smoking on upper tract urothelial carcinoma outcomes

OBJECTIVE

To evaluate the gender-specific differential effects of smoking habits and cumulative smoking exposure on outcomes in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

PATIENTS AND METHODS

A total of 864 consecutive patients, comprising 553 (64%) men and 311 (36%) women, from five international institutions underwent RNU without neoadjuvant chemotherapy. Smoking history included smoking status (current, former or never), quantity of cigarettes per day (CPD), smoking duration in years and years since smoking cessation. Cumulative smoking exposure was categorized as light short-term (≤19 CPD and ≤19.9 years), moderate (all combinations except light short-term and heavy long-term), and heavy long-term (≥20 CPD and ≥20 years). Uni- and multivariable competing risk regression models were used to assess the associations with outcomes.

RESULTS

Overall, 244 (28.2%), 297 (34.4%) and 323 (37.4%) patients were never, former and current smokers, respectively. There were no differences in smoking status, quantity and duration between the genders. In female ever smokers, 30 (9.6%), 121 (38.9%) and 67 (21.5%) were light short-term, moderate and heavy long-term smokers, respectively. Compared with men, female current smokers were more likely to experience disease recurrence in univariable analysis (P = 0.013). In heavy long-term smokers, female gender was significantly associated with disease recurrence (hazard ratio [HR] 1.7; P = 0.03) and cancer-specific mortality (HR 2.0; P = 0.009) in multivariable analysis that adjusted for standard clinico-pathological features. In female patients only, smoking quantity, duration and cumulative exposure were associated with disease recurrence and cancer-specific mortality on multivariable analyses (P ≤ 0.025).

CONCLUSIONS

The impact of smoking on UTUC outcomes after RNU is gender-specific. Females who are current and heavy long-term smokers experience worse outcomes than their male counterparts. Further research is needed to elucidate the molecular mechanisms underlying the gender-specific differential effect of smoking on UTUC outcomes.

The association between gender and outcome of patients with upper tract urothelial cancer

The incidence of upper tract urothelial cancer (UTUC) has gradually increased over the past 30 years. Although most reports have shown that UTUC occurs more frequently in men than in women, women have been found to have a worse prognosis than men. In Taiwan, a high incidence of UTUC has been reported, with an unusual minor predominance of female cases. The purpose of this study was to determine the influence of gender on the outcome of patients with UTUC after nephroureterectomy and bladder cuff excision. From January 1990 to December 2007, 301 patients diagnosed with UTUC were admitted at our institution. A retrospective analysis of the effect of gender on the clinical outcome was performed. We compared the 5-year bladder recurrence-free, progression-free, and disease-specific survival rates. While we did not observe any differences between men and women in bladder recurrence-free, progression-free, or disease-specific survival rates, we found that female patients had a significantly higher percentage of contralateral recurrence than the males (5.9% vs. 0.8%, p = 0.019).

[European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. European Association of Urology Guideline Group for urothelial cell carcinoma of the upper urinary tract]

CONTEXT

The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references.

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.

Upper urinary tract urothelial carcinoma: what have we learned in the last 4 years?

In the last 4 years many studies have been published on the topic of upper urinary tract urothelial carcinoma (UTUC). This is a recent review of the available literature of the last 3 years. A systematic Medline/PubMed search on UTUC including limits for clinical trials and randomized, controlled trials was performed for English-language articles using the keywords 'upper urinary tract carcinoma', 'nephroureterectomy', 'laparoscopic', 'ureteroscopy', 'percutaneous', 'renal pelvis', 'ureter' and their combinations from January 2008 to December 2010. Additional selected reports from 2007 were included. Case reports and non-English literature were excluded. Publications were mostly retrospective, including some large, multicentre studies from the Upper Tract Urothelial Carcinoma Collaboration (UTUCC). The authors of this article are members of the UTUCC. Altogether, 92 original articles dealing with UTUC were identified and summarized. The vast majority of the available literature has a low level of evidence (level IV), although many multicentre studies tried to overcome the problem of low numbers by pooling data. It was concluded that in the last 3 years our knowledge regarding UTUC has increased dramatically, although new study concepts allowing us to increase the level of evidence are needed.

Prognostic factors for upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is a rare disease, which means there are little evidence-based data available to guide clinical decision-making. Although diagnosis and treatment of UTUC have improved significantly over the last 5 years, accurate risk stratification remains a challenge owing to the difficulty of clinical staging. A number of potential prognostic factors have been identified, encompassing clinical characteristics, pathological factors and molecular markers. Tumor stage and lymph node status are the most important predictors of survival in patients with UTUC. Preoperative evaluation for hydronephrosis can identify patients at risk of non-organ-confined disease. In the subgroup of patients with stage ≥pT2 disease, a longer interval between diagnosis and radical nephroureterectomy is associated with a higher risk of disease recurrence and cancer-specific mortality. Extensive tumor necrosis, sessile tumor architecture and lymphovascular invasion are independent predictors of clinical outcomes for patients with UTUC treated with radical nephroureterectomy. The incorporation of such prognosticators into clinical prediction models might help to guide decision-making with regard to timing of surveillance, type of treatment, performance of lymphadenectomy, and consideration of neoadjuvant or adjuvant systemic therapies.

Predictive factors of recurrence and survival of upper tract urothelial carcinomas

OBJECTIVE

UTUCC is a rare tumor, and most reports on prognostic factors come from small single-center series. The objective of this article was to provide an updated overview of current clinical, pathological and biological prognostic factors of UTUC.

METHODS

PubMed was searched for records from 2002 to 2010 using the terms "prognostic factors", "recurrence", "survival", and "upper tract urothelial carcinoma". Among identified citations, papers were selected based on their clinical relevance.

RESULTS

Classical clinical factors that influence UTUC prognosis include age, presence of symptoms, hydronephrosis, and interval from diagnosis. Many biomarkers have shown promises to better appraise the natural course of UTUC although none is currently used in clinical practice. Stage, grade, lymph node metastases, lymphovascular invasion, tumor necrosis, and tumor architecture are strong pathological parameters. RNU is the standard treatment of localized UTUC. Both laparoscopic and open approaches seem to offer similar cancer control. Lymph node dissection increases staging accuracy and might confer a survival benefit.

CONCLUSION

RNU is the standard treatment for most patients with UTUC. Recent multicenter studies confirmed the prognostic value of classical prognostic parameters. Better survival prediction might be obtained with prognostic systems including clinical data and new biomarkers.

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

OBJECTIVE

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.

PATIENTS AND METHODS

We retrospectively analysed data from 324 consecutive patients treated with RNU between 1995 and 2008 at a tertiary cancer centre. Patients with muscle-invasive bladder cancer were excluded, resulting in 274 patients for analysis. Logistic regression models were used to predict pT2+ and NOC-UTUC. Pre-specified predictors included local invasion (i.e. parenchymal, renal sinus fat, or periureteric) on imaging, hydronephrosis on imaging, high-grade tumours on ureteroscopy, and tumour location on ureteroscopy. Predictive accuracy was measured by the area under the curve (AUC).

RESULTS

The median follow-up for patients without disease recurrence or death was 4.2 years. Overall, 49% of the patients had pT2+, and 30% had NOC-UTUC at the time of RNU. In the multivariable analysis, only local invasion on imaging and ureteroscopy high grade were significantly associated with pathological stage. AUC to predict pT2+ and NOC-UTUC were 0.71 and 0.70, respectively.

CONCLUSIONS

We designed a preoperative prediction model for pT2+ and NOC-UTUC, based on readily available imaging and ureteroscopic grade. Further research is needed to determine whether use of this prediction model to select patients for conservative management vs RNU, neoadjuvant chemotherapy, and/or extended lymphadenectomy will improve patient outcomes.

European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update

CONTEXT

The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references.

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.

Gender differences in radical nephroureterectomy for upper tract urothelial carcinoma

PURPOSE

Women have been associated with adverse outcomes after radical cystectomy for lower tract urothelial carcinoma. We evaluated the prognostic value of gender in an international cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively studied 754 patients treated with RNU for UTUC without neoadjuvant chemotherapy at nine centers located in Asia, Canada, and Europe. Univariable and multivariable Cox regression analyses were used to address recurrence-free (RFS) and cancer-specific survival (CSS) estimates. Median follow-up was 40 months (interquartile range: 18-75).

RESULTS

The majority of patients was of men (516, 68.4%). Women were older than men at the time of RNU (median: 69.2 vs. 66.5 years; P = 0.0003). Women were less likely to have high-grade disease, undergo lymph node dissection, and to receive adjuvant chemotherapy. Gender was not associated with pathologic stage, lymph node metastasis, lymphovascular invasion, concomitant CIS, tumor architecture, or tumor necrosis. On univariable Cox regression analyses, there was no association between gender and cancer recurrence (P = 0.76) or cancer-specific mortality (P = 0.30). On multivariable Cox regression analyses that adjusted for the effects of clinicopathologic features, gender was not associated with disease recurrence (P = 0.47) or cancer-specific survival (P = 0.15).

CONCLUSIONS

We found no difference in histopathologic features and outcomes between men and women treated with RNU for UTUC. Nevertheless, epidemiologic and mechanistic molecular studies should be encouraged to design, analyze, and report gender-specific associations to aid in our understanding of gender impact on UTUC incidence, progression, and metastasis.