A systematic review and meta-analysis of oncological and renal function outcomes obtained after segmental ureterectomy versus radical nephroureterectomy for upper tract urothelial carcinoma

Prognostic impact of tumor size in ureteral cancer following segmental ureterectomy

OBJECTIVE

To evaluate the classification and prognostic effects of a 2 cm tumor size in patients with ureteral cancer (UC) undergoing segmental ureterectomy (SU).

PATIENTS AND METHODS

A total of 75 patients with UC who underwent SU in our hospital between April 2013 and April 2023 were included in this study. The study population was grouped based on tumor size, which was defined as the maximum diameter of the pathological specimens, resulting in 30 patients (40.0%) with tumor size <2 cm and 45 patients (60.0%) with tumor size ≥2 cm. The clinicopathological variables, perioperative parameters, and oncological outcomes were compared between the 2 groups. The endpoints were recurrence-free survival (RFS), and cancer-specific survival (CSS).

RESULTS

A tumor ≥2 cm was related to a higher positive rate of urine exfoliative cytology (P = 0.049) and fewer preoperative ureteroscopies (P = 0.033) than tumors <2 cm. After a follow-up of 6.3 to 128.7 months (median 40.2 months), 23 cases (30.7%) experienced recurrence and 11 patients (14.7%) succumbed to UC in the end. Compared to those with tumor size <2 cm, patients with tumor size ≥2 cm experienced more urothelial recurrence (P = 0.032). Kaplan-Meier analysis demonstrated that patients with tumor size ≥2 cm displayed inferior urothelial RFS than those with tumor size <2 cm (P = 0.026). Multivariate Cox analysis identified tumor size ≥2 cm, and pathological stage ≥T2 were significant prognostic factors of poor urothelial RFS (all P < 0.05).

CONCLUSION

Tumor size ≥2 cm was associated with a high rate of urothelial recurrence and served as an independent prognostic factor of adverse urothelial RFS in SU-treated patients with UC. Patients are advised to select surgical treatments for UC following the EAU guidelines.

Long segment ureterectomy with tapered demucosalized ileum replacement of ureter for ureteral cancer: a case report and literature review

Radical nephroureterectomy (RNU) with bladder sleeve resection is currently the gold standard for the treatment of high-risk ureteral cancer. However, in certain special cases, such as bilateral upper tract urothelial carcinoma(UTUC), isolated and chronic kidney disease, and low-risk UTUC, kidney sparing surgery(KSS) may represent a viable alternative, though it remains highly challenging. The current KSS options for ureteral cancer include endoscopic treatment, segmental ureterectomy, total ureterectomy combined with kidney autotransplantation and nephrostomy. These methods are associated with significant disadvantages, such as a high risk of recurrence and vascular-related complications. On the basis of previous studies, we creatively proposed a surgical method of long segment ureterectomy with tapered demucosalized ileum(TDI) replacement of the ureter for ureteral cancer, and successfully performed this operation on a patient with ureteral cancer. The follow-up results showed that this surgical method provides good tumor control while preserving the patient's renal function and improves the inherent defect of the ileal replacement of the ureter, which is a feasible choice for patients with ureteral cancer and kidney preservation.

Robotic distal ureterectomy for high-risk distal ureteral urothelial carcinoma: a retrospective multicenter comparative analysis (ROBUUST 2.0 collaborative group)

BACKGROUND

The role of kidney-sparing surgery in patients with high-risk upper urinary tract urothelial carcinoma is controversial. The present study aimed to assess oncological and functional outcomes of robot-assisted distal ureterectomy in patients with high-risk distal ureteral tumors.

METHODS

The ROBUUST 2.0 multicenter international (2015-2022) dataset was used for this retrospective cohort analysis. High-risk patients with distal ureteral tumors were divided based on type of surgery: robot-assisted distal ureterectomy or robot-assisted nephroureterectomy. A survival analysis was performed for local recurrence-free survival, distant metastasis-free survival, and overall survival. After adjusting for clinical features of the high-risk prognostic group, Cox proportional hazard model was plotted to evaluate significant predictors of time-to-event outcomes.

RESULTS

Overall, 477 patients were retrieved, of which 58 received robot-assisted distal ureterectomy and 419 robot-assisted nephroureterectomy, respectively, with a mean (±SD) follow-up of 29.6 months (±2.6). The two groups were comparable in terms of baseline features. At survival analysis, no significant difference was observed in terms of recurrence-free survival (P=0.6), metastasis-free survival (P=0.5) and overall survival (P=0.7) between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy. At Cox regression analysis, type of surgery was never a significant predictor of worse oncological outcomes. At last follow-up patients undergoing robot-assisted distal ureterectomy had significantly better postoperative renal function.

CONCLUSIONS

Comparable outcomes in terms of recurrence-free survival, metastasis-free survival, and overall survival between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy patients, and better postoperative renal function preservation in the former group were observed. Kidney-sparing surgery should be considered as a potential option for selected patients with high-risk distal ureteral UTUC.

Narrative review of nephron-sparing surgical management of upper tract urothelial carcinoma: is there a role for distal ureterectomy, segmental ureterectomy, and partial nephrectomy

Background and Objective

Upper tract urothelial carcinoma (UTUC) is a relatively rare malignancy and radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is considered as the standard of care for high-risk non-metastatic disease. Loss of the renal unit secondary to RNU, especially in elderly patients, causes significant decline in overall renal function which in turn negatively impacts the overall survival (OS). Such radical surgeries can be spared in a select group of the patients with segmental ureterectomy (SU) or distal ureterectomy to salvage the ipsilateral kidney. In this article, we will review the oncological and renal function outcomes following such procedures. This review excludes endourologic procedures.

Methods

This is a non-systematic review of the published literature focusing on the nephron-sparing surgical alternatives for the management of UTUCs. The following texts were used for literature search: "nephron-sparing surgery", "segmental ureterectomy", "total ureterectomy", "partial nephrectomy", and "ileal ureter". We included the articles indexed in PubMed, written in English language, and published within the last 15 years.

Key Content and Findings

The main argument against the utilization of these procedures is the lack of high quality, level I evidence, which is due to the rarity of this disease and the rates of ipsilateral recurrences. Despite that, the evidence in support of these nephron-sparing surgical alternatives is increasing over time. Published literature including single/multi-centric studies & systematic reviews, suggests comparable oncological outcomes and significantly improved renal function preservation. Lymph node dissection (LND) at the time of nephron-sparing surgical alternatives is largely underutilized. Similarly, the role of neoadjuvant or adjuvant systemic chemotherapy following such procedures is also not established currently.

Conclusions

With comparable oncological outcomes while preserving renal function, the nephron-sparing surgical alternatives to RNU are gaining momentum. These options can be offered to patients with low volume, localized UTUC with imperative indication for renal preservation such as solitary kidney, compromised baseline, and expected significant decline in post-RNU renal function without compromising oncological principles during surgery.

Oncologic outcomes of patients treated with kidney-sparing surgery or radical nephroureterectomy for upper urinary tract urothelial cancer: a population-based study

PURPOSE

Although kidney-sparing surgery (KSS) is a nonminor option for low-risk upper urinary tract urothelial cancer (UTUC), its oncological benefits in high-risk UTUC remain unclear when compared to radical nephroureterectomy (RNU). This study aimed to compare the oncological outcomes of RNU and KSS in patients with UTUC.

METHODS

We searched the SEER database for patients treated for primary non-metastatic UTUC with either RNU or a kidney-sparing approach (segmental ureterectomy (SU) or local tumor excision (LTE)) between 2004 and 2018.

RESULTS

The study included 6,659 patients with primary non-metastatic UTUC treated with surgery; 2,888 (43.4%) and 3,771 (56.6%) patients presented with ureteral and renal pelvicalyceal tumors, respectively. Finally, 5,479 (82.3%) patients underwent RNU, 799 (12.0%) were treated with SU, and 381 (5.7%) patients received LTE. For confounder control, propensity score matching (PSM) of patients treated with SU and RNU was performed to adjust for T stage, grade, age, gender, tumor size, and lymphadenectomy performance. PSM analysis included 694 patients treated with RNU and 694 individuals who underwent SU. In multivariable Cox regression and Kaplan-Meier analyses, we found no difference in either CSS or OS between RNU and SU, even in the subgroup of high-grade and/or muscle-invasive UTUC including pT3-T4 tumors (all p > 0.05).

CONCLUSION

In this population-based study, SU provides equivalent CSS and OS compared to RNU, even in high-risk and locally advanced ureteral cancer. Due to the unavoidable risk of selection bias, further prospective studies are expected to overcome the limitations of this study and support the wider implementation of KSS.

Upper Tract Urothelial Carcinoma: A Narrative Review of Current Surveillance Strategies for Non-Metastatic Disease

Non-metastatic upper urinary tract carcinoma (UTUC) is a comparatively rare condition, typically managed with either kidney-sparing surgery (KSS) or radical nephroureterectomy (RNU). Irrespective of the chosen therapeutic modality, patients with UTUC remain at risk of recurrence in the bladder; in patients treated with KSS, the risk of recurrence is high in the remnant ipsilateral upper tract system but there is a low but existent risk in the contralateral system as well as in the chest and in the abdomen/pelvis. For patients treated with RNU for high-risk UTUC, the risk of recurrence in the chest, abdomen, and pelvis, as well as the contralateral UT, depends on the tumor stage, grade, and nodal status. Hence, implementing a risk-stratified, location-specific follow-up is indicated to ensure timely detection of cancer recurrence. However, there are no data on the type and frequency/schedule of follow-up or on the impact of the recurrence type and site on outcomes; indeed, it is not well known whether imaging-detected asymptomatic recurrences confer a better outcome than recurrences detected due to symptoms/signs. Novel imaging techniques and more precise risk stratification methods based on time-dependent probabilistic events hold significant promise for making a cost-efficient individualized, patient-centered, outcomes-oriented follow-up strategy possible. We show and discuss the follow-up protocols of the major urologic societies.

Modern Kidney-Sparing Management of Upper Tract Urothelial Carcinoma

PURPOSE

To review the latest evidence on the modern techniques and outcomes of kidney-sparing surgeries (KSS) in patients with upper tract urothelial carcinoma (UTUC).

METHODS

A comprehensive literature search on the study topic was conducted before 30 April 2023 using electronic databases including PubMed, MEDLINE, and EMBASE. A narrative overview of the literature was then provided based on the extracted data and a qualitative synthesis of the findings.

RESULTS

KSS is recommended for low- as well as select high-risk UTUCs who are not eligible for radical treatments. Endoscopic ablation is a KSS option that is associated with similar oncological outcomes compared with radical treatments while preserving renal function in well-selected patients. The other option in this setting is distal ureterectomy, which has the advantage of providing a definitive pathological stage and grade. Data from retrospective studies support the superiority of this approach over radical treatment with similar oncological outcomes, albeit in select cases. Novel chemoablation agents have also been studied in the past few years, of which mitomycin gel has received FDA approval for use in low-risk UTUCs.

CONCLUSION

KSSs are acceptable approaches for patients with low- and select high-risk UTUCs, which preserve renal function without compromising the oncological outcomes.

Segmental ureterectomy for high-risk ureteral carcinoma: a preliminary report

BACKGROUND

EAU guidelines strongly recommend kidney sparing surgery (KSS) as the primary treatment option for the low-risk UTUC patients. While there are few reports involving the KSS treated for the high-risk counterparts, especially the ureteral resection.

OBJECTIVE

To evaluate the effectiveness and safety of the segmental ureterectomy (SU) for the patients with high-risk ureteral carcinoma.

MATERIALS AND METHODS

We included 20 patients from May 2017 to December 2021 who underwent segmental ureterectomy (SU) in Henan Provincial People's Hospital. The overall survival (OS) and progression free survival (PFS) were evaluated. Besides, the ECOG scores and postoperative complications were also included.

RESULTS

As of December 2022, the mean OS was 62.1months (95%CI:55.6-68.6months) and the mean PFS was 45.0months (95%CI:35.9-54.1months). The median OS and median PFS were not reached. The 3-year OS rate was 70% and the 3-year PFS rate was 50%. The percentage of Clavien I and II complications was 15%.

CONCLUSION

For the selected patients with high-risk ureteral carcinoma, the efficacy and safety of segmental ureterectomy were satisfactory. But we still need to conduct prospective or randomized study to validate the value of SU in patients with high-risk ureteral carcinoma.

Bladder Recurrence Following Upper Tract Surgery for Urothelial Carcinoma: A Contemporary Review of Risk Factors and Management Strategies

Context

Bladder recurrences have been reported in 22-47% of patients after surgery for upper urinary tract urothelial carcinoma (UTUC). This collaborative review focuses on risk factors for and treatment strategies to reduce bladder recurrences after upper tract surgery for UTUC.

Objective

To review the current evidence on risk factors and treatment strategies for intravesical recurrence (IVR) after upper tract surgery for UTUC.

Evidence acquisition

This collaborative review is based on a literature search of PubMed/Medline, Embase, Cochrane Library, and currently available guidelines on UTUC. Relevant papers on bladder recurrence (etiology, risk factors, and management) after upper tract surgery were selected. Special attention has been paid to (1) the genetic background of bladder recurrences, (2) bladder recurrences after ureterorenoscopy (URS) with or without a biopsy, and (3) postoperative or adjuvant intravesical instillations. The literature search was performed in September 2022.

Evidence synthesis

Recent evidence supports the hypothesis that bladder recurrences after upper tract surgery for UTUC are often clonally related. Clinicopathologic risk factors (patient, tumor, and treatment related) have been identified for bladder recurrences after UTUC diagnosis. Specifically, the use of diagnostic ureteroscopy before radical nephroureterectomy (RNU) is associated with an increased risk of bladder recurrences. Further, a recent retrospective study suggests that performing a biopsy during ureteroscopy may further worsen IVR (no URS: 15.0%; URS without biopsy: 18.4%; URS with biopsy: 21.9%). Meanwhile, a single postoperative instillation of intravesical chemotherapy has been shown to be associated with a reduced bladder recurrence risk after RNU compared with no instillation (hazard ratio 0.51, 95% confidence interval 0.32-0.82). Currently, there are no data on the value of a single postoperative intravesical instillation after ureteroscopy.

Conclusions

Although based on limited retrospective data, performing URS seems to be associated with a higher risk of bladder recurrences. Future studies are warranted to assess the influence of other surgical factors as well as the role of URS biopsy or immediate postoperative intravesical chemotherapy after URS for UTUC.

Patient summary

In this paper, we review recent findings on bladder recurrences after upper tract surgery for upper urinary tract urothelial carcinoma.

Case Report: Step-by-step procedures for total intracorporeal laparoscopic kidney autotransplantation in a patient with distal high-risk upper tract urothelial carcinoma

A 47-year-old man presented to the emergency department with right abdominal pain and a new onset of painless haematuria two weeks earlier. Urine cytology test results suggested urothelial carcinoma. Computed tomography urography (CTU) showed a filling defect in the lower right ureter with right hydronephrosis. Lymphadenopathy and any signs of metastatic disease were absent on CTU. Cystoscopy appeared normal. Creatinine level was also normal before surgery. After the treatment options were discussed, the patient chose to undergo 3D total intracorporeal laparoscopic kidney autotransplantation, bladder cuff excision, and segmental resection of the proximal two-thirds of the ureter based on the membrane anatomy concept. After more than one year of follow-up, the patient was in good health and showed no signs of haematuria. Surveillance cystoscopy and CTU examination showed no evidence of disease recurrence. Therefore, it is reasonable to assume that kidney-sparing surgery may be considered for carefully selected patients with high-grade upper tract urothelial carcinoma.

Robot-assisted ipsilateral partial nephrectomy with distal ureterectomy for synchronous renal and ureteric tumors—a case report

Background

Ipsilateral synchronous renal and ureteric tumor is uncommon. Nephron sparing surgery is the standard for small renal masses. Ureteric tumors can be selectively managed with nephron sparing surgery, especially in renal dysfunction. This case report details the management of double malignancy by nephron sparing surgery with robot-assisted approach.

Case report

A 63-year-old gentleman with diabetes presented with history of intermittent gross hematuria for 2 weeks. He was clinically normal. On evaluation, he had grade 4 renal dysfunction (Se. creatinine 4.5 mg%) with mild proteinuria. Magnetic resonance imaging revealed right renal upper polar Bosniak III lesion and right hydroureteronephrosis due to 2 cm ureteric tumor near the vessel crossing. Renogram showed overall GFR of 22 ml/min with 31% (6 ml/min) contribution from the right side. He underwent robot-assisted right partial nephrectomy with distal ureterectomy and Boari flap ureteric reimplantation. Histopathology revealed margins free T2 clear cell carcinoma (kidney) and high-grade T3 transitional cell carcinoma (ureter). His nadir creatinine at 1 year follow-up was 3.3 mg% and no recurrence on MRI, cystoscopy, and ureteroscopy at 1 year.

Conclusion

Minimally invasive nephron sparing surgery is feasible and reasonable option with satisfactory oncological control even in ipsilateral synchronous renal and ureteric tumors in selected patients with renal dysfunction.

Oncological Outcomes of Distal Ureterectomy for High-Risk Urothelial Carcinoma: A Multicenter Study by The French Bladder Cancer Committee

Simple Summary

Radical nephroureterectomy (RNU) is the standard treatment for high-risk upper tract urothelial carcinoma (UTUC). It implies significant reduction in the renal function, compromising adjuvant chemotherapy administration and leading to risk of end stage renal disease in frail patients. Distal ureterectomy (DU) might be an alternative for tumors of the distal ureter but its indications remain unclear mainly due to concern about potential upper tract recurrences. The objective of our retrospective study was to determine the oncologic outcomes of DU for high-risk UTUC of the pelvic ureter, and to assess factors associated with recurrence in the particular population. We showed that oncological outcomes after DU were similar to those after RNU. Some of the classical prognostic factors after RNU were not identified in this cohort, pinpointing the necessity to consider tumors of the distal ureter as a specific entity.

Abstract

Upper urinary tract urothelial carcinoma (UTUC) is an uncommon disease and its gold-standard treatment is radical nephroureterectomy (RNU). Distal ureterectomy (DU) might be an alternative for tumors of the distal ureter but its indications remain unclear. Here, we aimed to evaluate the oncological outcomes of DU for UTUC of the pelvic ureter. We performed a multicenter retrospective analysis of patients with UTUC who underwent DU. The primary endpoint was 5-year cancer-specific survival (CSS), followed by overall survival (OS), intravesical recurrence-free (IVR) and homolateral urinary tract recurrence-free (HUR) survivals as secondary endpoints. Univariate and multivariate Cox regressions were performed to assess factors associated with outcomes. 155 patients were included, 91% of which were high-risk. 5-year CSS was 84.4%, OS was 71.9%, IVR-free survival was 43.6% and HUR-free survival was 74.4%. Multifocality, high grade and tumor size were the most significant predictors of survival endpoints. Of note, neither hydronephrosis nor pre-operative diagnostic ureteroscopy/JJ stent were associated with any of the endpoints. Perioperative morbidity was minimal. In conclusion, DU stands as a possible alternative to RNU for UTUC of the pelvic ureter. Close monitoring is mandatory due to the high risk of recurrence in the remaining urinary tract.

Nephron-Sparing Approaches in Upper Tract Urothelial Carcinoma: Current and Future Strategies

Upper tract urothelial carcinoma (UTUC) is a relatively rare cancer, and much of the approach to treatment has been derived from strategies employed in treating bladder cancer. Radical nephroureterectomy (RNU) is regarded as the gold standard treatment for UTUC. However, due to potential complications, such as renal function impairment, that can affect oncologic outcomes, the demand for nephron-sparing treatment to effectively treat cancer while preserving renal function has increased. As a result, various treatment methods for low-grade, low-volume UTUC, such as segmental ureterectomy, endoscopic resection, and intraluminal therapy, have been attempted and reported. Although these treatment modalities have exhibited acceptable oncological results, further studies are required. In the future, the introduction of new technologies, such as improved diagnostic and surgical equipment, and new drug delivery systems, could enhance the effectiveness of nephron-sparing strategies in the treatment of UTUC. Additionally, understanding the biological and genetic characteristics of UTUC that distinguish it from those of bladder cancer will also aid in establishing strategies for nephron-sparing.

Characteristics of upper urinary tract urothelial carcinoma in the context of bladder cancer: a narrative review

Urothelial carcinomas (UC) arise from the urothelium that covers the proximal urethra, urinary bladder, and the upper urinary tract. In daily routine and clinical trials UC originating from different locations are often treated and investigated in the same manner. However, differences between the two locations seem to be apparent and may question in handling them as a single oncologic entity. In this review we discuss similarities and differences between bladder and upper urinary tract UC and consider their potential impact on treatment strategies. Despite similarities of UC in the bladder (BC) and the upper urinary tract (UTUC), clinicopathologic and molecular differences may question to generally assemble both as a single tumor entity. Treatment standards for UTUC are often adopted from BC. However, a specific investigation in the former may still be meaningful as shown by the example of adjuvant cisplatin based chemotherapy. In conclusion, future investigations should prioritize the understanding of the tumor biology of both BC and UTUC. This may reveal which UTUC can be treated according to treatment standards of BC and in which cases, a separate approach may be more appropriate.

Contemporary patterns of presentation, diagnostics and management of upper tract urothelial cancer in 101 centres: the Clinical Research Office of the Endourological Society Global upper tract urothelial carcinoma registry

PURPOSE OF REVIEW

To assess patterns of presentation, diagnostics and treatment in patients with upper tract urothelial carcinoma (UTUC), a multicentre registry was launched. Clinical data of UTUC patients were prospectively collected over a 5-year period.

RECENT FINDINGS

Data from 2380 patients were included from 2014 to 2019 (101 centres in 29 countries). Patients were predominantly male (70.5%) and 53.3% were past or present smokers. The majority of patients (58.1%) were evaluated because of symptoms, mainly macroscopic hematuria. Computed tomography (CT) was the most common performed imaging modality (90.5%). A ureteroscopy (URS) was part of the diagnostic process in 1184 (49.7%) patients and 488 (20.5%) patients were treated endoscopically. In total, 1430 patients (60.1%) were treated by a radical nephroureterectomy, 59% without a prior diagnostic URS. Eighty-two patients (3.4%) underwent a segmental resection, 19 patients (0.8%) were treated by a percutaneous tumour resection.

SUMMARY

Our data is in line with the known epidemiologic characteristics of UTUC. CT imaging is the preferred imaging modality as also recommended by guidelines. Diagnostic URS gained a stronger position, however, in almost half of patients a definitive treatment decision was made without complete endoscopic information. Only one-third of patients with UTUC are currently treated with kidney sparing surgery.

[French ccAFU guidelines - update 2020-2022: upper urinary tract urothelial carcinoma]

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 2018 and 2020, 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 tumor, possible complete resection and low grade and absence 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 to reduce risk of bladder recurrence. A systemic 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 for UTUC.

Comparison of oncologic and functional outcomes between radical nephroureterectomy and segmental ureterectomy for upper urinary tract urothelial carcinoma

This study aims to compare oncologic and functional outcomes after radical nephroureterectomy (RNU) and segmental ureterectomy (SU) in patients with upper urinary tract urothelial carcinoma (UTUC). We retrospectively collected data on patients who underwent either RNU or SU of UTUC. Propensity score matching was performed among 394 cases to yield a final cohort of 40 RNU and 40 SU cases. Kaplan-Meier analysis and the log-rank test were used to compare overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), and intravesical recurrence-free survival (IVRFS) between the groups. We also compared the change in postoperative estimated glomerular filtration rate (eGFR). There was no significant difference in terms of CSS, PFS, and IVRFS between the RNU and SU groups, but the RNU group had a better OS than the SU group (p = 0.032). Postoperative eGFR was better preserved in the SU group than in the RNU group (p < 0.001). SU provides comparable CSS, PFS, and IVRFS for patients with UTUC compared to RNU, even in patients with advanced-stage and/or high-grade cancer. Further, SU achieves better preservation of renal function.

Acute kidney injury strongly influences renal function after radical nephroureterectomy for upper tract urothelial carcinoma: A single-centre experience

OBJECTIVE

The aim of our study was to investigate frequency and predictors both of postoperative acute kidney injury (AKI) and renal function decline in a population of consecutive upper tract urothelial carcinoma (UTUC) patients who underwent radical nephroureterectomy (RNU).

MATERIALS AND METHODS

Between October 2014 and February 2020, 93 patients underwent RNU at our Institution. After considered exclusion criteria, 89 patients were selected. Perioperative clinical factors were retrospectively collected. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation. We defined AKI as an increase in serum creatinine by ≥ 0.3 mg/dl or a 1.5-1.9-fold increase in serum creatinine from baseline to I post-operative day (POD). A significant renal function reduction was defined as an eGFR reduction of 40% from baseline at discharge and at last clinical evaluation. Frequency of AKI and eGFR decline was investigated. Association between perioperative clinical factors and AKI and eGFR reduction at discharged and last follow-up was studied using univariate and multivariate models.

RESULTS

AKI was detected at I POD in 45 patients. On multivariate analysis, pre-operative eGFR was an independent predictor of AKI (OR 1.03; p = 0.042). Further, AKI was found to be a significant predictor of eGFR reduction ≥ 40% at discharge at univariate analysis (OR 19.42; p = 0.005) and at multivariate analysis (OR 12.49; p = 0.02). In a multivariate logistic regression model post-operative AKI (OR 5.18; p = 0.033), lack of ipsilateral preoperative hydronephrosis (OR 0.17; p = 0.016), preoperative eGFR (OR 1.04; p = 0.047) and antiplatelet therapy (OR 5.14; p = 0.018) were found to be independent predictors of an eGFR reduction higher than 40% at last clinical evaluation made at a median of 15 (IQR 5-30) months.

CONCLUSIONS

In our cohort, AKI was present in almost 50% of patients after RNU and it was a strong predictor of renal function decline after RNU.

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.

Perioperative complications and adverse sequelae of radical nephroureterectomy

Radical nephroureterectomy (RNU) has long been considered the standard of care for treatment of upper tract urothelial carcinoma (UTUC). Despite providing oncologic control, RNU is associated with measurable morbidity and mortality. High quality data is lacking as a result of low disease incidence and very few randomized studies. In this article we will review preoperative nomograms that assist with patient counseling, summarize current knowledge about perioperative complications, and discuss adverse sequelae that may result after surgery.

Oncologic outcomes of radical nephroureterectomy (RNU)

Radical nephroureterectomy is the mainstay of surgical treatment for upper tract urothelial carcinoma (UTUC), a disease which comprises approximately 5% of urothelial malignancies. Minimally-invasive and nephron-sparing interventions have been explored, although thus far have not shown comparable oncologic outcomes except in a relatively narrow set of patients. Due to the relative rarity of the disease, it has taken decades and multi-disciplinary efforts to sufficiently identify prognostic factors of oncologic outcomes. Despite these efforts, however, oncologic outcomes of nephroureterectomy have remained remarkably stable over the past 30 years. New techniques, such as laparoscopic and robotic surgery, have been applied to this procedure. High level evidence regarding equivalent oncologic outcomes is lacking and open surgery remains the standard of care for high-stage disease, although there is a role for laparoscopic and robotic nephroureterectomy. The importance of bladder cuff removal in improving oncologic outcomes has been broadly accepted, although there is no consensus as to the most oncologically appropriate technique. There does appear to be evidence that endoscopic techniques confer worse oncologic control. The role of lymphadenectomy remains controversial, although there is evidence that increased nodal yield could have oncologic benefit. Given disease heterogeneity and varied technical approaches to the procedure, no consensus standardized template has been identified. There is level 1 evidence for the use of intravesical chemotherapy peri-operatively and that this intervention can improve the risk of intravesical recurrence. Advances in systemic neoadjuvant and adjuvant chemotherapy have yielded promising results and are likely to become standard of care for patients without contraindications. Immunotherapy and targeted biologic agents are also likely to improve the surgical efficacy of radical nephroureterectomy as well. Ultimately, more high level evidence is needed to identify successful surgical and medical approaches to UTUC and multi-institutional collaboration is critical to this progress.

A patient with synchronous bilateral low-grade upper tract urothelial carcinoma who underwent nephroureterectomy and total ureterectomy with ileal ureteric replacement

We present the case of a synchronous bilateral low-grade upper-tract urothelial carcinoma patient who underwent left nephroureterectomy and right total ureterectomy with ileal ureteric replacement resulting in a favorable prognosis. A 66-year-old male presented with bilateral hydronephrosis. Computed tomography revealed left pelvic and right upper-middle ureteral tumors with no lymph node swelling or distant metastasis. The patient underwent a left nephroureterectomy with a bladder cuff, and histopathology revealed a low-grade urothelial carcinoma. Considering the contralateral low-grade nature as revealed in histopathology and the right retrograde ureterography being noninvasive, he underwent a right total ureterectomy with ileal ureteric replacement. Histopathology of the right ureter revealed a low-grade urothelial carcinoma. The patient successfully avoided an anephric status without renal function deterioration for 4 years with a transurethral resection for a recurrent small papillary bladder tumor on 18 months after the total ureterectomy.

Bladder-sparing treatment options in localized muscle-invasive bladder cancer

Introduction: Bladder cancer is the 9th most common cancer in the world and the 4^th and 8th most common cancer diagnosed in men in the United States and United Kingdom respectively. The standard of care for the treatment of MIBC is radical cystectomy. Bladder preserving treatment approaches are emerging for select patients and should be considered strongly in patients who decline a radical cystectomy.Areas covered: In this review we look at the European and American recommended guidelines, the current standard of care, bladder-preserving options in MIBC, trimodal therapy and discuss future developments in the identification of molecular biomarkers that can predict therapeutic outcomes.Expert opinion: We strongly advocate bladder preservation for the right patient with strict criteria for enrolling patients in bladder preservation. The development of a specialized bladder cancer clinic could facilitate the selection of patients to be offered trimodal therapy. We believe that the future of bladder cancer will involve individualized care plans based upon clinical, radiological, endoscopic and molecular assessments.

Organ-sparing procedures in GU cancer: part 3-organ-sparing procedures in urothelial cancer of upper tract, bladder and urethra

PURPOSE

The impact of radical surgery for urothelial carcinoma is significant on patient's quality of life. Organ-sparing surgery (OSS) can provide comparable oncological outcomes and with improved quality of life. In this review, we summarize the indications, techniques and outcomes of OSS for these tumors.

METHODS

PubMed^® was searched for relevant articles. Keywords used were: for upper tract urothelial carcinoma (UTUC): endoscopic, ureteroscopic/percutaneous management, laser ablation; for urothelial bladder cancer: bladder preservation, trimodal therapy, muscle invasive bladder cancer (MIBC); for urethral cancer: urethra/penile-sparing, urethral carcinoma.

RESULTS

Kidney-sparing surgery is an option in patients with low-risk UTUC with better renal function preservation and comparable oncological control to radical nephroureterectomy. In select patients with MIBC, trimodal therapy has better quality of life and comparable oncological control to radical cystectomy. In distal male urethral cancer, penile conserving surgery is feasible and offers acceptable survival outcomes. In female urethral cancer, organ preservation can be achieved, in addition to OSS, through radiation.

CONCLUSIONS

In the appropriately selected patient, OSS in upper tract, bladder and urethral carcinoma has comparable oncological outcomes to radical surgery and with the additional benefit of improved quality of life.

Aristolochic Acid and Immunotherapy for Urothelial Carcinoma: Directions for unmet Needs

Urothelial carcinoma of the bladder (UCB) and upper tracts (UTUC) used to share management with similar principles. However, their genetic and epigenetic differences along with different responses to immunotherapy were recently identified, which are reminiscent of their distinct etiologies. Different from the variety of environmental factors relating to UCB, UTUC is best known for its close relationship with exposure to aristolochic acid (AA). AA is believed to cause its carcinogenicity through forming DNA adducts of deoxyadenosine-aristolactam, as well as A:T → T:A transversions in the TP53 tumor suppressor gene. Since recent findings suggested that cancers with higher somatic mutations are associated with better treatment responses upon immune checkpoint blockade, UTUC and AA-related biomarkers reasonably serve as good candidates, as well as a potential prognostic predictor for the flourishing immunotherapy. This review covers the current state of the literature on the clinical response of UTUC and UCB receiving immunotherapy and points out directions for refinement regarding patient selection.

Consultation on UTUC, Stockholm 2018: aspects of treatment

Purpose

To provide an overview of treatment modalities for management of upper tract urothelial carcinoma (UTUC).

Methods

In accordance with the standards for a scoping review, data presentation and discussion at the Consultation on UTUC in Stockholm, 6–7 September 2018, consensus was reached on the latest and most important treatment recommendations for UTUC. Using Pubmed, Web of Science, and Embase, publications were selected based on quality, clinical relevance, and level of evidence.

Results

Kidney-sparing surgery should be attempted for low-grade UTUC. Radical nephroureterectomy with bladder cuff excision is first option for high-grade disease. Post-operative bladder instillation of chemotherapy should be offered after RNU to reduce intravesical recurrence rate. Identification of tumor grade and stage is crucial when selecting treatment. Ureteroscopic management of low-grade and non-invasive UTUC achieves disease-free survival similar to that offered by radical nephroureterectomy but seems to be a risk factor for intravesical recurrence. Lymphadenectomy appears important for high-risk disease, although the therapeutic benefit needs further validation. There is little evidence supporting use of Bacillus Calmette–Guérin (BCG) and mitomycin C as monotherapy and adjuvant treatment in UTUC. A randomized clinical trial has indicated that platin-based chemotherapy for invasive UTUC improves disease-free survival, suggesting that adjuvant chemotherapy should be considered standard care for ≥ T2 N0–3M0 disease.

Conclusions

Risk stratification assessment is feasible and mandatory in UTUC. Identification of tumor grade and stage is essential for optimal treatment selection. Kidney-sparing surgery should be offered in low-risk disease, whereas radical nephroureterectomy and adjuvant chemotherapy should be considered in high-risk disease.

Formidable Scenarios in Urothelial and Variant Cancers of the Urinary Tract

Diagnostic and therapeutic challenges in the field of bladder and upper tract cancers provide opportunities for multidisciplinary care. Urothelial cancers make up the majority of the histologic subtype of bladder and upper tract cancers. Although the existence of variant histology, nonurothelial cancers, and urethral cancers is rare, these cancers pose a challenging clinical dilemma given the lack of well-defined consensus treatment guidelines. This review focuses on key issues of treatment: cisplatin ineligibility with emphasis on the definition, nuances of chemotherapy and frontline immune checkpoint inhibitor therapy, use of radiation in bladder-preservation strategies, upper tract urothelial cancer management, and highlights of urothelial variants and nonurothelial tumors and management.

Robotic radical nephroureterectomy and segmental ureterectomy for upper tract urothelial carcinoma: a multi-institutional experience

PURPOSE

To report a multi-institutional experience on robotic radical nephroureterectomy (RNU) and segmental ureterectomy (SU) for upper tract urothelial carcinoma (UTUC).

METHODS

Data were prospectively collected from patients with non-metastatic UTUC undergoing robotic SU or RNU at three referral centers between 2015 and 2018. Transperitoneal, single-docking robotic RNU followed established principles. Bladder cuff excision (BCE) was performed with robotic or open approach. Techniques for SU included: ureteral resection and primary uretero-ureterostomy; partial pyelectomy and modified pyeloplasty; ureteral resection with BCE and direct- or psoas hitch-ureteroneocystostomy. We retrospectively evaluated the technical feasibility, and peri-operative and oncologic outcomes after robotic RNU/SU.

RESULTS

81 patients were included. No case required conversion to open surgery. Early major (Clavien-Dindo grade > 2) complications were reported in six (7.4%) patients (two after SU, four after RNU). Three patients experienced late major complications (one after SU, two after RNU). Median ΔeGFR at 3 months was - 1 ml/min/1.73 m² after SU and - 15 ml/min/1.73 m² after RNU. Positive surgical margins were recorded in five patients (one after SU, four after RNU). Median follow-up was 21 months and 22 months in the SU and RNU groups, respectively. Three (20%) patients had ipsilateral upper tract recurrence after SU, while five (7.5%) developed metastases after RNU. No case of port-site metastases or peritoneal carcinomatosis was reported. At last follow-up, 67 (82.7%) patients were alive without evidence of disease.

CONCLUSION

Robotic SU and RNU are technically feasible and achieved promising peri-operative and oncologic outcomes in selected patients with non-metastatic UTUC.

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.

Treatment utilization and overall survival in patients receiving radical nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma: evaluation of updated treatment guidelines

PURPOSE

While radical nephroureterectomy (RNU) is the gold standard treatment for upper tract urothelial carcinoma (UTUC), select patients may benefit from endoscopic treatment (ET). European Association of Urology guidelines recommend ET for patients with low-risk (LR) disease: unifocal, < 2 cm, low-grade lesions without local invasion. To inform the utility of ET, we compare the overall survival (OS) of patients receiving ET and RNU using current and previous guidelines of LR disease.

MATERIALS AND METHODS

Patients with non-metastatic, cT1 or less UTUC diagnosed in 2004-2012 were collected from the National Cancer Database. OS was analyzed with inverse probability of treatment weighted Cox proportional hazard regression. Analyses were conducted for LR disease under updated (size < 2 cm) and previous guidelines (size < 1 cm).

RESULTS

Patients who were older, healthier, and treated at an academic facility had higher odds of receiving ET. In 851 identified patients with LR disease, RNU was associated with increased OS compared with ET (p = 0.006); however, there was no difference between ET and RNU (p = 0.79, n = 202) under the previous guidelines (size < 1 cm). In, otherwise, LR patients, the largest tumor size with no difference between ET and RNU was ≤ 1.5 cm (p = 0.07).

CONCLUSIONS

RNU is associated with improved survival when compared with ET in the management of LR UTUC using current guidelines with a size threshold of < 2 cm. In appropriately selected LR patients, we find no difference between RNU and ET up to a tumor size of ≤ 1.5 cm. However, in the absence of prospective studies, the usage of ET is best left up to clinician discretion.

Therapeutic strategies for upper tract urothelial carcinoma

INTRODUCTION

Many controversies exist regarding the appropriate management of patients with upper tract urothelial carcinoma (UTUC), including staging, surgical management, use of systemic therapy, and prevention of bladder recurrence. Due to the rarity of this condition, high-level evidence is often lacking and in many cases guidelines are extrapolated from existing evidence on urothelial bladder cancer. Areas covered: This review paper summarizes the evidence on proper diagnosis and staging, surgical techniques, prevention of bladder recurrences, the use of local or systemic treatments in both neoadjuvant and adjuvant settings as well as special consideration for hereditary UTUC. Expert commentary: UTUC is a rare malignancy and slow progress is being made in the acquisition of high-quality evidence in this field. Treatments that facilitate preservation of the kidney are being explored such as advanced endoscopic techniques or partial resection of ureteral disease with seemingly acceptable oncological results. Further prospective evidence is needed.

Comparison of Radical Nephroureterectomy and Partial Ureterectomy for the Treatment of Upper Tract Urothelial Carcinoma

This study aimed to compare the oncological and renal outcomes of partial ureterectomy (PU) versus radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). UTUC patients' clinical information was reviewed, and progression-free survival (PFS), overall survival (OS), and kidney function were collected. The mean follow-up period was 59 (6-135) months in the RNU group and 34.5 (5-135) months in the PU group. The mean operation time in the PU group was 141 (64-340) min, which is significantly shorter than the RNU group (P < 0.01). Regarding kidney function at one year or two years after operation, the PU group had significantly improved mean estimated glomerular filtration rate (eGFR) levels and a remarkably decreased constitution of patients with chronic kidney disease (CKD) III or higher group (P < 0.05). There was no significant difference in PFS and OS between the RNU group and the PU group (P > 0.05). Multifactor Cox regression analysis indicated that age and the preoperative CKD stages were independent risk factors for poor kidney functions of UTUC patients. Compared to patients in RNU group, patients in PU have no significant difference in survival time but have shorter operation time, shorter hospital stay, and improved kidney functions.

Risk factors for bladder cancer recurrence survival in patients with upper-tract urothelial carcinoma

PURPOSE

The aim of this work was to investigate the predictive factors for bladder cancer recurrence survival (BCRS) in patients with upper-tract urothelial carcinoma (UTUC).

METHODS

We selected patients with UTUC who underwent segmental ureterectomy (Su) or nephroureterectomy (Nu) from 2004 to 2013 from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with a history of intravesical therapy for bladder cancer and bladder cancer prior to the diagnosis of UTUC were excluded. We used Kaplan-Meier analysis, log-rank tests, and Cox proportional hazards model to compare overall survival, cancer-specific survival, and BCRS.

RESULTS

In a cohort of 1,454 patients, 169 (11.6%) had low-grade tumors and 1,285 (88.4%) had high-grade tumors; 239 (16.4%) underwent Su and 1,215 (83.6%) underwent Nu. We found that T4 grade (hazard ratio [HR] = 6.216; 95% confidence interval [CI], 3.197-12.087) and ureteral tumors (HR = 1.764; 95% CI, 1.173-2.652) were predictors of shorter BCRS, whereas Nu (HR = 0.608; 95% CI, 0.388-0.953) predicted longer BCRS. Five-year BCRS rates were low-grade tumors: 94.1%, high-grade tumors: 85.4% (p = 0.038); plus Su: 82.9%, and Nu: 87.6% (p = 0.016).

CONCLUSIONS

Use of Su should be more selective for high-grade tumors, as it correlates with shorter BCRS. Tumors located in the ureter are associated with shorter BCRS than those located in the renal pelvis.

Segmental Ureterectomy is Acceptable for High-risk Ureteral Carcinoma Comparing to Radical Nephroureterectomy

Purpose: To determine if segmental ureterectomy (SU) could be chosen for wider oncological indications than low-risk ureteral carcinoma, given the difficulties in accurate preoperative risk stratification determination and kidney-sparing needs for successive therapy. Methods: Data from ureteral carcinoma patients who underwent open SU or laparoscopic radical nephroureterectomy (RNU) between 2011 and 2016 were retrospectively reviewed. Kaplan-Meier survival analysis and Cox regression model with patients' baseline characteristics (age, bladder cancer history, hydronephrosis), procedure type, and tumor characteristics (site, size, pathological features) as covariates were used to evaluate oncological outcomes. Life quality parameters including preoperative renal function, Karnofsky performance status, pain score, and surgical complications were set as second endpoints. Results: Sixty-three patients (24 in SU group, 39 in RNU group) who had at least one high-risk factor were enrolled. In the mean follow-up time of 24.67 months, no significant difference was found in recurrence-free survival (66.7% and 69.2%, p = 0.798), overall survival (79.2% and 84.6%, p = 0.453), and cancer-specific survival (83.3% and 89.7%, p = 0.405) between SU and RNU groups. The Cox regression demonstrated that procedure type was not associated with oncological outcomes. Patients in SU group experienced significant mean estimated glomerular filtration rate (eGFR) increase by 4.60 ml/(min·1.73 m²) (p < 0.001). Proportion of patients having poor eGFR also decreased postoperatively in SU group. Mere tendency in physical performance status improvement and serious complications reduction was detected in SU group. Conclusion: SU is acceptable for high-risk ureteral carcinoma comparing to RNU with satisfying tumor control efficacy and advantage in renal function preservation.

Minimally Invasive Therapy for Upper Tract Urothelial Cell Cancer

Minimally invasive therapy for upper tract urothelial cell cancer has assumed an important role in the management of this relatively uncommon genitourinary malignancy. In this review, current standards for patient selection, surgical approach, as well as overall outcomes will be discussed. Moreover, the use of intraluminal agents in upper tract disease is examined along with its efficacy and associated complications.

Upper tract urothelial carcinoma: a different disease entity in terms of management

Upper tract urothelial carcinomas (UTUCs) consist of 5%–10% of all urothelial carcinomas, the rest being urothelial carcinomas of the bladder (UCB). There is increasing evidence to show that UTUC is a distinct disease entity from UCB based on phenotypical and genotypical (genetic and epigenetic) differences. This may account for why the natural history of UTUC is different from that of UCB, with >60% of UTUCs and only 15%–25% of UCB presenting with invasion at diagnosis. Management of UTUC is thus different from UCB in a variety of ways, ranging from surgical management, postoperative instillation therapy, postoperative surveillance and medical management (neoadjuvant and adjuvant chemotherapy). This review paper aims to highlight these differences with an emphasis on the distinct management of UTUC, along with the latest updates.