Chronic kidney disease after nephroureterectomy for upper tract urothelial carcinoma and implications for the administration of perioperative chemotherapy

Perioperative outcomes of laparoscopic radical nephroureterectomy and regional lymphadenectomy in patients with upper urinary tract urothelial carcinoma after neoadjuvant chemotherapy

OBJECTIVES

To determine the effect of neoadjuvant chemotherapy on the surgical outcomes in patients undergoing laparoscopic radical nephroureterectomy (LNUX) for upper urinary tract urothelial carcinoma (UTUC).

METHODS

We performed a retrospective review of all patients with UTUC who had undergone LNUX at our institution from January 2003 to June 2010. We compared the differences in demographic, clinicopathologic, and operative parameters, including the estimated blood loss, duration of surgery, length of postoperative hospitalization, and number of complications, between the patients who had undergone LNUX after neoadjuvant chemotherapy and those who had undergone LNUX without neoadjuvant chemotherapy. Logistic regression analysis was performed to identify the predictors of complications.

RESULTS

We identified 82 patients with UTUC who had undergone LNUX. Of these patients, 26 had received neoadjuvant chemotherapy. The patients who had undergone LNUX after neoadjuvant chemotherapy had a greater body mass index, greater biopsy tumor grade, and longer operative time than those who had undergone LNUX without neoadjuvant chemotherapy. The patients who received neoadjuvant chemotherapy had undergone regional lymphadenectomy more often, with more lymph nodes and lymphoadipose tissue removed, than those who had not received neoadjuvant chemotherapy. Neoadjuvant chemotherapy resulted in a 15% complete remission rate. No differences in the median estimated blood loss, intraoperative transfusion rate, or length of hospitalization between the 2 groups were found. The perioperative complication rates were similar in both groups.

CONCLUSIONS

We found no differences in the surgical outcomes between those patients who had undergone LNUX after neoadjuvant chemotherapy and those who had undergone LNUX without neoadjuvant chemotherapy. Our findings support the use of LNUX for selected patients undergoing neoadjuvant chemotherapy for UTUC.

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.