The extent of lymphadenectomy seems to be associated with better survival in patients with nonmetastatic upper-tract urothelial carcinoma: how many lymph nodes should be removed? Eur Urol. 2009;56:512-518. [PMID: 19559518 DOI: 10.1016/j.eururo.2009.06.004]

Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A Real-World, Retrospective Study

PURPOSE

The aim of this retrospective study was to evaluate the efficacy of adjuvant cisplatin-based chemotherapy in patients with locally advanced upper tract urothelial carcinoma (UTUC), administered following radical nephroureterectomy.

MATERIALS AND METHODS

Patients with UTUC, arising from renal pelvis or ureter, staged pT3/T4 or N+ were treated with adjuvant chemotherapy following surgery. The chemotherapy consisted of gemcitabine 1,000 mg/m2 on days 1 and 8, cisplatin 70 mg/m2 on day 1. Treatment was repeated every 3 weeks for up to 4 cycles. Endpoints included disease-free survival (DFS), metastasis-free survival (MFS), and safety.

RESULTS

Among 89 eligible patients, 85 (95.5%) completed at least 3 cycles of adjuvant chemotherapy. Chemotherapy was well tolerated, the main toxicities being mild-to-moderate gastrointestinal toxic effects and pruritus. With a median follow-up of 37 months, median DFS was 30 months (95% confidence interval, 22 to 39), and the median MFS was not reached. The 3-year DFS and MFS were 44% and 56%, respectively. Multivariate analyses revealed that the main factor associated with DFS and MFS was the lymph node involvement, whereas age, T category, grade, or the primary site of UTUC were not significantly associated with DFS or MFS.

CONCLUSION

Adjuvant cisplatin-based chemotherapy after radical surgery of pT3/T4 or N+ UTUC was feasible and may demonstrate benefits in DFS and MFS. Whether novel agents added to the chemotherapy regimen, as a concurrent combination or maintenance, impacts on survival or reduces the development of metastases remains to be studied.

Lymph Node Dissection in Upper Tract Urothelial Carcinoma: Current Status and Future Perspectives

PURPOSE OF REVIEW

This narrative review aims to evaluate the role of lymph node dissection (LND) in upper tract urothelial carcinoma (UTUC) and its implications for staging and management outcomes, as well as future perspectives.

RECENT FINDINGS

Multiple studies have demonstrated the limitations of conventional imaging techniques in accurately localizing lymph node metastasis (LNM) in UTUC. While 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18FDG-PET/CT) shows promise for preoperative LNM detection, its specificity is low. Alternative methods such as choline PET/CT and sentinel lymph node detection are under consideration but require further investigation. Additionally, various preoperative factors associated with LNM hold potential for predicting nodal involvement, thereby improving nodal staging and oncologic outcomes of LND. Several surgical approaches, including segmental ureterectomy and robot-assisted nephroureterectomy, provide a possibility for LND, while minimizing morbidity. LND remains the primary nodal staging tool for UTUC, but its therapeutic benefit is still uncertain. Advances in imaging techniques and preoperative risk assessment show promise in improving LNM detection. Further research and multi-center studies are needed to comprehensively assess the advantages and limitations of LND in UTUC, as well as the long-term outcomes of alternative staging and treatment strategies.

The Association between Lymph Node Dissection and Survival in Lymph Node-Negative Upper Urinary Tract Urothelial Cancer

The benefit of lymph node dissection (LND) during radical nephroureterectomy (RNU) in lymph node (LN)-negative (cN0/pN0) UTUC remains controversial. We aimed to assess the association between LND and its extent and survival in LN-negative UTUC. The Surveillance, Epidemiology, and End Results database was searched to identify patients with non-metastatic chemotherapy-naïve cN0/pNx or pN0 UTUC who underwent RNU +/- LND between 2004 and 2019. Overall, 4649 patients with cN0/pNx or pN0 UTUC were analyzed, including 909 (19.55%) individuals who had LND. Among them, only in 368 patients (7.92%) was LND extended to at least four LNs, and the remaining 541 patients (11.64%) have had < four LNs removed. In the whole cohort, LND contributed to better cancer-specific survival (CSS) and overall survival (OS). Furthermore, a propensity score-matched analysis adjusted for confounders confirmed that improved CSS and OS was achieved only when ≥ four LNs had been removed, especially in muscle-invasive UTUC. A multivariable analysis further confirmed an association between the extent of LND and CSS. To conclude, adequate LND during RNU was associated with improved OS and CSS in LN-negative UTUC, particularly in muscle-invasive stage. This underscores that a sufficient LN yield is required to reveal a therapeutic benefit in patients undergoing RNU.

First Comparison of Retroperitoneal Versus Transperitoneal Robot-Assisted Nephroureterectomy with Bladder Cuff: A Single Center Study

INTRODUCTION

After recent presentation of the first complete robot-assisted retroperitoneal nephroureterectomy with bladder cuff (RRNU) for patients with upper tract urothelial cancer (UTUC), we aimed to compare this new surgical technique with robot-assisted transperitoneal nephroureterectomy (TRNU) representing the current standard of care.

METHODS

Robot-assisted nephroureterectomies (NUs) were retrospectively analyzed and compared based on two groups: transperitoneal versus retroperitoneal approach. Baseline data were collected for patient demographics, tumor characteristics, intra- (EAUiaiC) and postoperative (Clavien-Dindo) complications, and perioperative variables. Tumor characteristics included grade of malignancy, clinical stage, and surgical margin status. Short-term follow-up data including 30-day readmission rates were collected. Statistical analyses were performed assuming a significant p-value of < 0.05.

RESULTS

The analysis includes perioperative patient data after proven UTUC of 24 TRNU versus 12 RRNU (mean age: 70 versus 71 years; BMI: 25.9 versus 26.1 kg/m²; CCI score ≥ 4: 83% versus 75%; ASA score ≥ 3: 37% vs 33%). Intraoperative (16.4% vs 0%, p = 0.35) and postoperative (25% vs 12.5%, p = 0.64) complications demonstrated no significant discrepancy. Notably, RRNU demonstrated significantly shorter surgery time (p < 0.05) and length of stay (p < 0.05). There was no significant difference in histopathological tumor characteristics, whereas significantly more lymph nodes were removed through RRNU (11.0±3.3 vs. 6.4±5.1, p < 0.05). Finally, no statistical difference was shown in short-term follow-up.

CONCLUSION

We report the first head-to-head comparison between RRNU and TRNU. RRNU proves to be a safe and feasible approach which appears to be non-inferior to TRNU. RRNU expands the spectrum of minimally invasive treatment options, particularly for patients with major previous abdominal surgery.

Clinical Characteristics and Current Status of Treatment for Recurrent Bladder Cancer after Surgeries on Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) is a relatively rare, but highly malignant, disease with an estimated annual incidence of 2 cases per 100,000 people. The main surgical treatment modalities for UTUC are radical nephroureterectomy (RNU) with bladder cuff resection. After surgery, intravesical recurrence (IVR) can occur in up to 47% of patients, and 75% of them present with non-muscle invasive bladder cancer (NMIBC). However, there are few studies focused on the diagnosis and treatment of postoperatively recurrent bladder cancer for patients with previous UTUC history (UTUC-BC), and many of the influencing factors are still controversial. In this article, we performed a narrative review of the recent literature, mainly summarizing the factors influencing postoperative IVR in patients with UTUC and discussing the subsequent prevention, monitoring, and treatment tools for it.

Is Lymph Node Dissection Necessary During Radical Nephroureterectomy for Clinically Node-Negative Upper Tract Urothelial Carcinoma? A Multi-Institutional Study

Purpose

This study aimed to compare the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) without clinical lymph node metastasis (cN0) undergoing lymph node dissection (LND) during radical nephroureterectomy (NU).

Methods

From the updated data of the Taiwan UTUC Collaboration Group, a total of 2726 UTUC patients were identified. We only include patients with ≥ pT2 stage and enrolled 658 patients. The Kaplan–Meier estimator and Cox proportional hazards model were used to analyze overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS) in LND (+) and LND (−) groups.

Results

A total of 658 patients were included and 463 patients without receiving LND and 195 patients receiving LND. From both univariate and multivariate survival analysis, there are no significant difference between LND (+) and LND (-) group in survival rate. In LND (+) group, 18.5% patients have pathological LN metastasis. After analyzing pN+ subgroup, it revealed worse CSS (p = 0.010) and DFS (p &lt; 0.001) compared with pN0 patients.

Conclusions

We found no significant survival benefit related to LND in cN0 stage, ≥ pT2 stage UTUC, irrespective of the number of LNs removed, although pN+ affected cancer prognosis. However, from the result of pN (+) subgroup of LND (+) cohort analysis, it may be reasonable to not perform LND in patients with cT2N0 stage due to low positive predictive value of pN (+). In addition, performing LND may be considered for ureter cancer, which tends to cause lymphatic and hematogenous tumor spreading. Further large prospective studies are needed to validate our findings.

Prospective Clinical Trial of the Oncologic Outcomes and Safety of Extraperitoneal Laparoscopic Extended Retroperitoneal Lymph Node Dissection at Time of Nephroureterectomy for Upper Tract Urothelial Carcinoma

Purpose

To determine the safety and feasibility of extraperitoneal laparoscopic extended lymph node dissection (LND) at the time of extraperitoneal laparoscopic radical nephroureterectomy (RNU).

Materials and Methods

Between May 2018 and March 2019, 39 patients with upper tract urothelial carcinoma (UTUC) received extraperitoneal laparoscopic RNU and concomitant extraperitoneal laparoscopic extended LND. All patients were followed for at least 90 days. Perioperative and pathological data including nodal status and perioperative complications were collected.

Results

Among all 39 patients, 12 patients had pT1, 6 had pT2, 20 had pT3 disease, and 1 had T4 disease. The median (range) lymph node count was 10 (5–22), with 8 patients having pathologically proven lymph node metastasis. The median (range) operating time was 225 (165–430) min, and the median estimated blood loss was 200 (60–800) ml. The median postoperative hemoglobin loss was 1.6 (0–4.2) g/dl. The median (range) postoperative hospital stays were 6 (3–26) days. Overall, 7 patients experienced minor (Clavien Grade I–II) postoperative complications with five patients having Clavien Grade I complications and two patients having Clavien Grade II complications. No major complication (Clavien grade III–IV) occurred. With a median follow-up of 38 months, a total of 8 patients (20.5%) developed local or distant recurrence and no regional LNs where extended LND were performed had recurrence.

Conclusions

The present prospective study demonstrated that extraperitoneal laparoscopic extended LND during extraperitoneal laparoscopic RNU for UTUC is a feasible and safe procedure which provides minimal invasion, rapid recovery, and potentially lower risk of regional LN recurrence. Larger prospective clinical trials with survival endpoints are needed to further determine its potential therapeutic benefits.

Trial Registration

ClinicalTrials.gov identifier NCT 03544437 www.clinicaltrials.gov

Quality indicators for the management of high-risk upper tract urothelial carcinoma requiring radical nephroureterectomy

PURPOSE OF REVIEW

The purpose of this article was to identify quality indicators for an optimized management of high-risk upper tract urothelial carcinoma (UTUC) requiring radical nephroureterectomy (RNU).

RECENT FINDINGS

RNU with bladder cuff resection is the standard treatment of high-risk UTUC. For the bladder cuff resection, two main approaches are accepted: transvesical and extravesical. Lymph node dissection following a dedicated template should be performed in all high-risk patients undergoing RNU as it improves tumour staging and possibly survival. Postoperative bladder instillation of single-dose chemotherapy should be administered after RNU to decrease the risk of intravesical tumour recurrence. Perioperative systemic chemotherapy should always be considered for advanced cancers. Although level-1 evidence is available for adjuvant platinum-based chemotherapy, neoadjuvant regimens are still being evaluated.

SUMMARY

Optimal management of high-risk UTUC requires evidence-based reproducible quality indicators in order to allow guidance and frameworks for clinical practices. Adherence to quality indicators allows for the measurement and comparison of outcomes that are likely to improve prognosis. Based on the literature, we found four evidence-based accepted quality indicators that are easily implementable to improve the management of high-risk UTUC patients treated with RNU: adequate management of the distal ureter/ bladder cuff, template-based lymph node dissection, single-shot postoperative intravesical chemotherapy, and perioperative systemic treatment.

Accuracy and Clinical Utility of a Tumor Grade- and Stage-based Predictive Model in Localized Upper Tract Urothelial Carcinoma

BACKGROUND

Among various clinicopathologic factors used to identify low-risk upper tract urothelial carcinoma (UTUC), tumor grade and stage are of utmost importance. The clinical value added by inclusion of other risk factors remains unproven.

OBJECTIVE

To assess the performance of a tumor grade- and stage-based (GS) model to identify patients with UTUC for whom kidney-sparing surgery (KSS) could be attempted.

DESIGN, SETTING, AND PARTICIPANTS

In this international study, we reviewed the medical records of 1240 patients with UTUC who underwent radical nephroureterectomy. Complete data needed for risk stratification according to the European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) guidelines were available for 560 patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariable and multivariable logistic regression analyses were performed to determine if risk factors were associated with the presence of localized UTUC. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the GS, EAU, and NCCN models in predicting pathologic stage were calculated.

RESULTS AND LIMITATIONS

Overall, 198 patients (35%) had clinically low-grade, noninvasive tumors, and 283 (51%) had ≤pT1disease. On multivariable analyses, none of the EAU and NCCN risk factors were associated with the presence of non-muscle-invasive UTUC among patients with low-grade and low-stage UTUC. The GS model exhibited the highest accuracy, sensitivity, and negative predictive value among all three models. According to the GS, EAU, and NCCN models, the proportion of patients eligible for KSS was 35%, 6%, and 4%, respectively. Decision curve analysis revealed that the net benefit of the three models was similar within the clinically reasonable range of probability thresholds.

CONCLUSIONS

The GS model showed favorable predictive accuracy and identified a greater number of KSS-eligible patients than the EAU and NCCN models. A decision-making algorithm that weighs the benefits of avoiding unnecessary kidney loss against the risk of undertreatment in case of advanced carcinoma is necessary for individualized treatment for UTUC patients.

PATIENT SUMMARY

We assessed the ability of three models to predict low-grade, low-stage disease in patients with cancer of the upper urinary tract. No risk factors other than grade assessed on biopsy and stage assessed from scans were associated with better prediction of localized cancer. A model based on grade and stage may help to identify patients who could benefit from kidney-sparing treatment of their cancer.

Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy

Unlike urothelial carcinoma of the bladder, there is no guideline-based consensus on whether a lymph node dissection (LND) should be performed at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Variable lymphatic drainage based on primary tumor location, lack of prospective trials, and difficulties in developing a risk-adapted approach to LND for UTUC are all challenges to the development of an established approach. The UTUC literature consists of an evidence pool that has historically been limited to single-institution series with heterogenous inclusion criteria for LND and variable LND templates. Areas of controversy exist regarding migration to the great vessel LN beds for mid and distal tumors. A lack of template standardization limits the interpretation of studies relative to one another and a lack of uniformity in reporting templates may lead to inaccuracies in the estimation of lymph node metastasis landing sites. Most clinicians agree that there is a staging benefit to LND for UTUC. Although the data is somewhat heterogenous, it demonstrates a prognostic and staging benefit to LND in higher stages of UTUC. Unlike the staging benefits provided by LND for UTUC, the therapeutic benefits are not as clearly established. Several studies have evaluated differences in cancer-specific survival (CSS) and demonstrated LND to be an independent predictor of CSS when compared to patients not undergoing LND. However, this finding is not consistent across all studies and the literature is again limited by inclusion heterogeneity and inconsistent or lack or template-based resections. LND for UTUC at the time of RNU is a safe and feasible procedure that seems to especially benefit patients with muscle-invasive or locally advanced disease. Prospective, randomized studies with strict inclusion criteria and defined anatomic templates are needed to definitely characterize the role of LND for UTUC.

Supine extraperitoneal laparoscopic nephroureterectomy without patient repositioning

OBJECTIVE

To describe a novel technique allowing laparoscopic nephroureterectomy with bladder cuff excision and lymphadenectomy, in a complete supine position, without patient repositioning.

METHODS

Between January 2016 and October 2018, 20 consecutive patients with upper urinary tract urothelial carcinoma underwent supine extraperitoneal laparoscopic nephroureterectomy. The patients were placed in the complete supine position. A 4-cm pararectal skin incision was made and the extraperitoneal space was developed. We used a unique port placement that permits complete access for nephroureterectomy, bladder cuff excision and concomitant lymphadenectomy. Operative parameters and pathological data were analyzed.

RESULTS

The median age was 70 years (range 49-88 years), the mean operative time was 234 min (range 175-293 min) and the mean estimated blood loss was 67 mL (range 50-200 mL). There were no intraoperative complications, and no patients required transfusion or open conversion. The median number of removed lymph nodes was 10; only one patient had node metastasis. The total operative time and time for nephroureterectomy were significantly longer in the first 10 patients (first group) than in the second 10 patients (second group). Times required for bladder cuff excision and lymphadenectomy did not differ between the two groups.

CONCLUSIONS

Our novel technique, which enables completion of the entire procedure of nephrouretectomy with bladder cuff excision and lymphadenectomy in the supine position without patient repositioning, is safe and minimizes operative time while maintaining oncological efficacy. We believe this approach might become a standard option for patients with upper urinary tract urothelial carcinoma.

The clinicopathological characteristics of muscle-invasive bladder recurrence in upper tract urothelial carcinoma

This study aimed to clarify the clinical characteristics and oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) who developed muscle-invasive bladder cancer (MIBC) after radical nephroureterectomy (RNU). We identified 966 pTa-4N0-2M0 patients with UTUC who underwent RNU and clarified the risk factors for MIBC progression after initial intravesical recurrence (IVR). We also identified 318 patients with primary pT2-4N0-2M0 MIBC to compare the oncological outcomes with those of patients with UTUC who developed or progressed to MIBC. Furthermore, immunohistochemical examination of p53 and FGFR3 expression in tumor specimens was performed to compare UTUC of MIBC origin with primary MIBC. In total, 392 (40.6%) patients developed IVR after RNU and 46 (4.8%) developed MIBC at initial IVR or thereafter. As a result, pT1 stage on the initial IVR specimen, concomitant carcinoma in situ on the initial IVR specimen, and no intravesical adjuvant therapy after IVR were independent factors for MIBC progression. After propensity score matching adjustment, primary UTUC was a favorable indicator for cancer-specific death compared with primary MIBC. Subgroup molecular analysis revealed high FGFR3 expression in non-MIBC and MIBC specimens from primary UTUC, whereas low FGFR3 but high p53 expression was observed in specimens from primary MIBC tissue. In conclusion, our study demonstrated that patients with UTUC who develop MIBC recurrence after RNU exhibited the clinical characteristics of subsequent IVR more than those of primary UTUC. Of note, MIBC subsequent to UTUC may have favorable outcomes, probably due to the different molecular biological background compared with primary MIBC.

Incidence and Survival Rates of Contemporary Patients with Invasive Upper Tract Urothelial Carcinoma

BACKGROUND

Contemporary incidence and mortality rates of upper tract urothelial carcinoma (UTUC) are unavailable.

OBJECTIVE

To describe contemporary UTUC incidence and mortality rates in the USA.

DESIGN, SETTING, AND PARTICIPANTS

Within the Surveillance, Epidemiology and End Results (SEER) database (2004-2016), we identified 13 075 UTUC patients. Of all, 9208 (70.4%) harbored nonmetastatic UTUC and were treated with radical nephroureterectomy versus 1174 (9.0%) who harbored metastatic UTUC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Age-standardized incidence rates per 100 000 person years were calculated. Kaplan-Meier curves and multivariable Cox regression models addressed cancer-specific and overall mortality.

RESULTS AND LIMITATIONS

Overall UTUC age-standardized incidence rates decreased from 1.3 to 1.1 cases per 100 000 person years (average annual percentage change: -1.32%, p = 0.002). Moreover, age-standardized incidence rates decreased for T_1-2N₀M₀ (average annual percentage change: -2.77%, p < 0.001) but increased for T_1-4N_0-2M₁ stage (average annual percentage change: +2.87%, p < 0.01). In nonmetastatic UTUC treated with radical nephroureterectomy, stage, grade, age, and sex (p < 0.001) were independent predictors in multivariable Cox regression models focusing on cancer-specific mortality. In metastatic UTUC, chemotherapy administration, radical nephroureterectomy treatment, and ureteral primary were independent predictors of lower overall mortality in multivariable Cox regression models.

CONCLUSIONS

Although overall incidence of UTUC decreased, the incidence of metastatic UTUC increased over the study period. The majority of nonmetastatic UTUC harbored T₁N₀M₀ stage. However, T₃N₀M₀, T₄N₀M₀, and T_1-4N_1-2M₀ stages, respectively, affected 28.9%, 4.6%, and 10.0% of all incident cases. In metastatic UTUC, both chemotherapy and radical nephroureterectomy use exerted an important protective effect on overall mortality, and ureteral primaries exhibited more favorable survival.

PATIENT SUMMARY

From 2004 to 2016, the incidence of upper tract urothelial carcinoma decreased in the USA. However, more advanced stages are on the rise.

Diagnostic challenges and treatment strategies in the management of upper-tract urothelial carcinoma

Upper-tract urothelial carcinoma (UTUC) is a rare disease, posing many challenges for the treating physician due to the lack of strong evidence-based recommendations. However, novel molecular discoveries and a better understanding of the clinical behavior of the disease lead to a continuous evolution of therapeutic landscape in UTUC. The aim of the review is to provide a comprehensive update of the current diagnostic modalities and treatment strategies in UTUC with a special focus on recent developments and challenges. A comprehensive literature search including relevant articles up to August 2020 was performed using the MEDLINE/PubMed database. Despite several technological improvements, accurate staging and outcome prediction remain major challenges and hamper appropriate risk stratification. Kidney-sparing surgery can be offered in low risk UTUC; however, physician and patient must be aware of the high rate of recurrence and risk of progression due to tumor biology and understaging. The value and efficacy of intracavitary therapy in patients with UTUC remains unclear due to the lack of high-quality data. In high-risk diseases, radical nephroureterectomy with bladder cuff excision and template lymph node dissection is the standard of care. Perioperative systemic chemotherapy is today accepted as a novel standard for advanced cancers. In metastatic or unresectable disease, the therapeutic landscape is rapidly changing due to several novel agents, such as checkpoint inhibitors. While several diagnostic and treatment challenges remain, progress in endoscopic technology and molecular knowledge have ushered a new age in personalized management of UTUC. Novel accurate molecular and imaging biomarkers are, however, still needed to guide decision making as tissue acquisition remains suboptimal. Next generation sequencing and novel agents are promising to rapidly improve patient outcomes.

Lymph node dissection for upper tract urothelial carcinoma: A systematic review

Objective

To perform a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, investigating the role of lymph node dissection (LND) during nephroureterectomy (NU) for upper tract urothelial carcinoma (UTUC); focussing on survival and complication outcomes.

Methods

A comprehensive systematic search was completed using a combination of Medical Subject Headings terms and keywords related to UTUC and LND on multiple databases. Meta-analyses were performed when outcomes were reported under the same definition in two or more studies. Where meta-analysis was not possible, outcomes were reviewed in a narrative manner.

Results

A total of 21 studies were included in the qualitative analysis and 11 cohort studies in the quantitative analysis. Our review did not detect significant improvement in recurrence-free survival (RFS) (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.41–1.92), cancer-specific survival (CSS) (HR 0.89, 95% CI 0.54–1.46) and overall survival (OS) (HR 1.10, 95% CI 0.93–1.30). However, when focussing on studies only including patients with pT2/pT3 UTUC, not performing LND significantly worsened RFS (HR 2.83, 95% CI 1.72–4.66). Reports of removing more than eight lymph nodes may also provide prognostic benefits in pN0 patients. The performance of LND was not associated with a higher rate of postoperative complications (risk ratio 1.06, 95% CI 1.00–1.13).

Conclusion

Overall, LND did not provide additional benefit in RFS, CSS and OS. However, there was a potential benefit in RFS in patients with muscle-invasive and advanced UTUC. LND was also not associated with increased risks of postoperative complications.

Abbreviations: CIS: carcinoma in situ; CSS: cancer-specific survival; HR: hazard ratio; LND: lymph node dissection; NU: nephroureterectomy; OS: overall survival; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RFS: recurrence-free survival; RoB, risk of bias; RR: risk ratio; (UT)UC: (upper tract) urothelial carcinoma

The effectiveness of chemotherapy for patients with pT3N0M0 renal pelvic urothelial carcinomas: An inverse probability of treatment weighting comparison using Surveillance, Epidemiology, and End Results data

Introduction

Unlike the established evidence to use chemotherapy for urothelial carcinoma of the bladder, presently there are insufficient data to inform a recommendation on upper urinary tract urothelial carcinoma treatment. The prognosis for patients with stage T4 and positive lymph nodes is poor; however, primary tumors in the renal pelvis are associated with favorable prognoses compared to those located in the ureter. Our study aimed at investigating the effectiveness of chemotherapy in patients with pT3N0M0 renal pelvic urothelial carcinomas (RPUC) who have relative favorable prognosis.

Methods

Patients with pT3N0M0 tumors who underwent radical nephroureterectomy combined with bladder cuff excision between 2005 and 2014 and registered in the Surveillance, Epidemiology, and End Results database were eligible for inclusion (n = 939). Baseline characteristics between the chemotherapy and observation groups were controlled for with inverse probability of treatment weighting (IPTW)‐adjusted analysis.

Results

After the IPTW‐adjusted analysis, the 5‐year IPTW‐adjusted rates of overall survival (OS) for the chemotherapy and observation groups were 53.1% and 44.9%, respectively. The IPTW‐adjusted Kaplan‐Meier curves suggested that chemotherapy was associated with increased OS compared with observation (P = .028). In the IPTW‐adjusted Cox proportional hazards regression model, chemotherapy was associated with favorable survival benefits compared with observation (hazard ratio [HR] 0.71, 95% CI 0.52‐0.92, P = .031), and this was maintained after bootstrapping (HR 0.72, 95% CI 0.49‐0.93). Chemotherapy had a protective effect on OS benefits, which were found in a majority of the results of the subgroup analysis and were consistent with the main results (all P‐interactions > 0.05).

Conclusion

Chemotherapy may provide significant OS benefits for patients with pT3N0M0 RPUC. The results of our study could strengthen the evidence for using adjuvant chemotherapy in this rare group of patients.

Survival Benefits Based on the Number of Lymph Nodes Removed during Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Systematic Review and Meta-Analysis

The role of lymph node dissection (LND) is still controversial for upper tract urothelial carcinoma (UTUC), and there are no guidelines regarding its use. This study was conducted to find a higher level of evidence for the survival benefits based on the number of LNs removed during radical nephroureterectomy (RNUx) through a systematic review and meta-analysis. We included studies comparing patients who underwent LND during RNUx for UTUC. We searched the major electronic databases (Pubmed, Embase^®, and Scopus^®) and conducted manual searches of the electronically available abstracts of the major international urology cancer meetings [American Society of Clinical Oncology (ASCO), American Urological Association (AUA), and Eropean Association of Urology (EAU)] prior to April 2019 using grouped terms of nephroureterectomy (nephroureterectom*) and lymph node excision (lymphadenectomy; lymph + node*; lymph* + metasta*) with variations in the terms. Study selection, data collection, and risk of bias assessment were performed by two independent authors (A and B). Six retrospective case-control studies included a total of 33,944 patients who underwent RNUx for UTUC, 5071 of whom underwent LND and were finally included in the meta-analysis. The pooled hazard ratio (HR) in these studies revealed that an increased number of LNs removed during RNUx was associated with improved cancer-specific survival (CSS) in patients with UTUC (HR = 0.95, 95% CI: 0.91–0.99; p = 0.07). In addition, increased numbers of LNs removed were associated with improved overall survival (OS) in pN0 patients. However, in pN+ patients, the number of LNs removed showed no survival benefit on CSS, overall survival (OS), or progression-free survival (PFS). Higher numbers of LNs removed during RNUx were associated with improved survival outcomes in patients with UTUC. This study confirmed that LND also has oncological benefits in UTUC patients. Although still a controversial topic, meticulous LND must be considered, and efforts should be made to eliminate as many LNs as possible when administering RNUx for UTUC, especially in patients without clear evidence of LN metastasis.

Pure retroperitoneoscopic extravesical standardized seeable (PRESS) excision of distal ureter and bladder cuff in radical nephroureterectomy: step-by-step technique

BACKGROUND

Concerns have been raised regarding the management of bladder cuff with these minimally invasive approaches. The aim of this study was to describe a modified radical nephroureterectomy (RNU) with pure retroperitoneoscopic extravesical standardized seeable (PRESS) bladder cuff excision (BCE) and to assess its outcomes based on a novel concept of intraoperative "trifecta."

METHODS

Twenty-four patients with upper urinary tract urothelial carcinoma underwent retroperitoneoscopic RNU from August 2017 to August 2019. A modified RNU with PRESS BCE and lymph node dissection (LND) was performed. Descriptive analysis of patients' characteristics, surgical technique, perioperative outcomes, and follow-up data was performed. BCE trifecta was defined as en-bloc excision, mucosa-to-mucosa reliable closure and no urine spillage.

RESULTS

In 23 out of 24 cases (95.8%) the procedure was successfully completed. One patient was converted to open distal ureterectomy with a Gibson incision due to peritoneum rupture during dissection of the distal ureter. BCE trifecta was achieved in 95.7% (22/23) cases of all patients finished with PRESS technique. Median OT was 260 min (IQR: 220-305) with median EBL of 100 mL (IQR: 100-250). Median OT for distal ureterectomy was 52 min (IQR: 40-69). No positive surgical margin occurred. Median postoperative hospital stay was 6 d (IQR: 5-7). Median follow-up time was 7 mo (IQR: 5-17). One patient (4.3%) experienced bladder recurrence and no patient developed distant metastasis or died of the disease.

CONCLUSIONS

Herein, we demonstrate a standardized retroperitoneoscopic RNU technique that is safe and reproducible, enabling the visual confirmation of complete BCE and facilitating LND. BCE trifecta should be a routine goal in minimally invasive RNU. Prospective comparison with the standard open surgical technique is warranted.

The preoperative serum cystatin-C as an independent prognostic factor for survival in upper tract urothelial carcinoma

Cystatin-C (Cys-C) has been reported as a valuable prognostic biomarker in various malignancies. However, its effect on upper tract urothelial carcinoma (UTUC) patients has not been investigated before. Thus, to explore the impact of Cys-C on survival outcomes in patients undergoing radical nephroureterectomy (RNU), a total of 538 patients with UTUC who underwent RNU between 2005 and 2014 in our center (West China Hospital, Chengdu, China) were included in this study. Kaplan–Meier method and Cox regression analyses were performed to assess the relationship between Cys-C and survival outcomes using SPSS version 22.0. The cutoff value of Cys-C was set as 1.4 mg l⁻¹ using the receiver operating characteristic (ROC) curves and Youden index. The mean age of patients included was 66.1 ± 11.1 years, and the median follow-up duration was 38 (interquartile range: 19–56) months. Overall, 162 (30.1%) patients had elevated Cys-C, and they were much older and had worse renal function than those with Cys-C <1.4 mg l⁻¹ (both P < 0.001). Meanwhile, Kaplan–Meier analysis revealed that the group with elevated Cys-C had worse cancer-specific survival (CSS, P = 0.001), disease recurrence-free survival (RFS, P = 0.003), and overall survival (OS, P < 0.001). Multivariable Cox analysis suggested that the elevated Cys-C was identified as an independent prognostic predictor of CSS (hazard ratio [HR]: 1.997, 95% confidential interval [CI]: 1.331–2.996), RFS (HR: 1.429, 95% CI: 1.009–2.023), and OS (HR: 1.989, 95% CI: 1.366–2.896). In conclusion, our result revealed that the elevated preoperative serum Cys-C was significantly associated with worse outcomes in UTUC patients undergoing RNU.

Prognostic role of preoperative De Ritis ratio in upper tract urothelial carcinoma treated with nephroureterectomy

PURPOSE

To validate the predictive and prognostic role of the De Ritis ratio in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy in a large multi-institutional cohort.

MATERIALS AND METHODS

The preoperative De Ritis ratio was assessed in a multi-institutional cohort of 2,492 patients. An altered De Ritis ratio was defined as a ratio >1.35. Logistic regression analyses were performed to assess the association of the De Ritis ratio with advanced disease. The association of the De Ritis ratio with survival outcomes was evaluated using Cox proportional hazards regression models.

RESULTS

An altered De Ritis ratio was observed in 985 (41.5%) patients; it was associated with a more advanced pathological features. In a preoperative model, the De Ritis ratio was an independent predictive factor for the presence of lymph node metastasis and muscle-invasive and nonorgan-confined disease (P < 0.05). Compared to patients with a normal De Ritis ratio, those with an altered De Ritis ratio had worse recurrence free (P <0.0001), cancer specific (P = 0.0003), and overall survival (P = 0.0014) in the Kaplan-Meier analyses. In the multivariable analyses that was adjusted for the effects of standard clinicopathologic features, the De Ritis ratio did not retain its independent prognostic value.

CONCLUSIONS

In UTUC, the preoperative De Ritis ratio is associated with adverse clinicopathologic features and independently predicts features of biologically and clinically aggressive UTUC. Therefore, it might be useful to incorporate the De Ritis ratio into prognostic tools in selecting appropriate treatment strategies.

Lymph node dissection during nephroureterectomy: Establishing the existing evidence based on a review of the literature

Abstract Objective: To determine the role of lymph node dissection (LND) in the treatment of upper tract transitional cell carcinoma (UTTCC), as the role of LND along with nephroureterectomy in treating UTTCC is unclear and several retrospective studies have been published on this topic with conflicting results.

Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials database (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, Google Scholar, and individual urological journals, were searched for all studies investigating the role of LND in the treatment of UTTCC. Of the studies identified, those that met inclusion criteria were included in this review.

Results: In all, 27 studies were included in this review, with 9303 patients who underwent LND. No randomised controlled trials (RCTs) were identified. Tumours were located in the renal pelvis in 62% of patients, in the ureter in 35.5%, and multifocal in 2.3%. In total: 77.1% were LN-negative and 22.9% had LN metastasis. For all patients undergoing LND, the 5-year recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were 27–65.4% and 32.3–95%, respectively. For patients who underwent a LND in accordance with a standardised anatomical template, the 5-year RFS and CSS rates were 84.3–93% and 83.5–94%, respectively.

Conclusion: LND may provide a survival benefit in patients undergoing nephroureterectomy for UTTCC, particularly if following a standardised anatomical template and in those patients with muscle-invasive disease; however, a prospective RCT is required to confirm this.

Abbreviations: CSS: cancer-specific survival; LN(D): lymph node (dissection); MeSH: Medical Subject Headings; OS: overall survival; pT: pathological T stage; RCT: randomised controlled trial; RFS: recurrence-free survival; UTTCC: upper tract TCC

Lymphadenectomy for Upper Tract Urothelial Carcinoma: A Systematic Review

Background: The role of lymphonodal dissection during surgery for a tumor of the urinary tract remains controversial. Objective: To analyze anatomical bases of lymphonodal dissection in tumors of the upper urinary tract and analyze its impact on survival, recurrence, and staging. Acquisition of data: A web-based search for scientific articles using Medline/Pubmed was carried out to identify and analyze articles on the practice and the role of lymphonodal dissection in this indication. Data Synthesis: The lymphatic drainage of the upper urinary tract has rarely been studied and is poorly understood. The lymphonodal metastatic extension is the most common extension in upper urinary tract urothelial carcinoma. Lymphnode invasion is a clear independent poor prognostic factor. Therefore, it seems legitimate to offer an extended lymphonodal dissection to patients undergoing surgery to cure these tumors. When lymphnodes dissection respects clear anatomical principles based on the location of the primary tumor and its extension, it improves both survival and recurrence rates. This result could be secondary to the treatment of subclinical metastatic disease. Conclusion: An extended lymphadenectomy during surgery for upper urinary tract urothelial carcinoma following strict anatomical pattern improves staging with a highly probable therapeutic benefit.

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.

More Extensive Lymph Node Dissection Improves Survival Benefit of Radical Cystectomy in Metastatic Urothelial Carcinoma of the Bladder

BACKGROUND

Radical cystectomy (RC) may occasionally be performed in individuals with metastatic urothelial carcinoma of the bladder (mUCB). However, the role of lymph node dissection (LND) for such cases is unknown. Thus, we tested the effect of RC on cancer-specific mortality (CSM) and overall mortality in mUCB patients and the effect of LND and its extent on CSM.

PATIENTS AND METHODS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2013), we identified patients with mUCB who underwent RC with or without LND or non-RC management. Kaplan-Meier analyses and multivariable Cox regression models (CRMs) were used, after propensity score matching. The number of removed nodes best predicting CSM was identified using cubic splines and then was tested in multivariable CRMs.

RESULTS

Of 2314 patients, 319 (13.8%) underwent RC. After 2:1 propensity score matching, CSM-free survival was 14 versus 8 months (P < .001), and overall mortality-free survival was 12 versus 7 months (P < .001) for, respectively, RC and non-RC patients. In multivariable CRMs, lower CSM (hazard ratio = 0.48; P < .001) and lower overall mortality (hazard ratio = 0.49; P < .001) rates were recorded in RC patients. LND status did not affect CSM-free survival (13 vs. 10 months; P = .1). Cubic splines-derived cutoff of ≥ 13 number of removed nodes showed better CSM-free survival (20 vs. 11 months; P = .02) and reduced CSM in CRMs (hazard ratio = 0.67; P = .02).

CONCLUSION

Our study validates the survival benefit of RC in mUCB and highlights the importance of more extensive LND. These findings may corroborate the hypothesis of potential cytoreductive effect of surgery in the context of metastatic disease.

Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer-Yes, No or Maybe?

While pelvic lymphadenectomy during radical cystectomy for bladder cancer is a well-established standard of care, the same does not hold true for upper tract urothelial carcinoma (UTUC). Indeed, a template-based lymphadenectomy is rarely, if ever, performed in conjunction with radical nephroureterectomy at most centres across the globe. While multiple studies have explored the staging and therapeutic role of lymphadenectomy in cases of UTUC, there remain large gaps in our understanding of the indications, extent and safety of this procedure as an adjunct to nephroureterectomy. This article elucidates the current knowledge on outcomes, benefits and complications of template-based lymphadenectomy during radical nephroureterectomy for UTUC. We also explore the current evidence-based guidelines on this controversial topic.

The prognostic value of preoperative neutrophil-to-lymphocyte ratio in patients with upper tract urothelial carcinoma

BACKGROUND

We evaluated the prognostic impact of the preoperative neutrophil-to-lymphocyte ratio (NLR) in patients with upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy treatment.

METHODS

A total of 717 patients were identified between 2003 and 2016. The cutoff value of NLR was set as 2.5. Kaplan-Meier method and Cox's proportional hazards regression models were utilized to analyze the association between NLR and oncological outcomes.

RESULTS

The median follow-up was 42 months. The results suggested that preoperative elevated NLR was associated with worse pathological features. Also, patients with NLR ≥ 2.5 had worse survival outcomes than those with NLR <2.5 (all P < .001). Multivariate cox analysis revealed that NLR ≥ 2.5 was an independent predictor of worse cancer-specific survival, disease recurrence-free survival, metastasis-free survival and overall survival (HR 1.95, 95%CI: 1.42-2.69, P < .001; HR 1.70, 95%CI: 1.31-2.20, P < .001; HR 1.67, 95%CI: 1.22-2.31, P = .002; and HR 1.88, 95%CI: 1.42-2.50, P < .001; respectively). Notably, NLR was ascertained to be a useful prognostic predictor in patients with high-grade disease, but not in those with low-grade UTUC.

CONCLUSIONS

Preoperative elevated NLR was associated with worse outcomes in patients with UTUC. Subgroup analysis affirmed that NLR was a useful predictor in patients with high-grade disease, but not in those with low-grade UTUC.

Extent of lymph node dissection improves survival in prostate cancer patients treated with radical prostatectomy without lymph node invasion

PURPOSE

To assess the effect of pelvic lymph node dissection (PLND) extent on cancer-specific mortality (CSM) in prostate cancer (PCa) patients without lymph node invasion (LNI) treated with radical prostatectomy (RP).

METHODS

Within the Surveillance, Epidemiology, and End results (SEER) database (2004-2014), we identified patients with D'Amico intermediate- or high-risk characteristics who underwent RP with PLND, without evidence of LNI. First, multivariable logistic regression models tested for predictors of more extensive PLND, defined as removed lymph node count (NRN) ≥75th percentile. Second, Kaplan-Meier analyses and multivariable Cox regression models tested the effect of NRN ≥75th percentile on CSM. Finally, survival analyses were repeated using continuously coded NRN.

RESULTS

In 28 147 RP and PLND patients without LNI, 67.3% versus 32.7% exhibited D'Amico intermediate- or high-risk characteristics. The median NRN was 6 (IQR 3-10), the 75th percentile defined patients with NRN ≥11. Patients with NRN ≥11 had higher rate of cT2/3 stage (29.8 vs 26.1%), GS ≥8 (25.7 vs 22.4%), and respectively more frequently exhibited D'Amico high-risk characteristics (34.6 vs 32.1%). In multivariable logistic regression models predicting the probability of more extensive PLND (NRN ≥11), higher biopsy GS, higher cT stage, higher PSA, more recent year of diagnosis, and younger age at diagnosis represented independent predictors. At 72 months after RP, CSM-free rates were 99.5 versus 98.1% for NRN ≥11 and NRN ≤10, respectively and resulted in a HR of 0.50 (P = 0.01), after adjustment for all covariates. Similarly, continuously coded NRN achieved independent predictor status (HR: 0.955, P = 0.01), where each additional removed lymph node reduced CSM risk by 4.5%.

CONCLUSION

More extensive PLND at RP provides improved staging information and consequently is associated with lower CSM in D'Amico intermediate- and high-risk PCa patients without evidence of LNI. Hence, more extensive PLND should be recommended in such individuals.

Lymphadenectomy for Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Cell Carcinoma

There are currently no reported randomized trials that characterize the staging or therapeutic benefit of performing a lymph node dissection in either bladder cancer or upper tract urothelial carcinoma. Several unanswered questions remain in this domain focused on the indications and patient selection for pelvic lymph node dissection, extent of dissection, its impact on outcome, and potential risks. However, the results of observational studies suggest that the burden of metastasis is high in both diseases when muscle invasive and performing a lymphadenectomy can provide prognostic information and yield therapeutic benefit.

The effect of AB0 and Rhesus blood grouping systems on oncological outcome in patients undergoing radical nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVES

To investigate the effect of AB0 and Rhesus factor expression blood group systems on outcomes of upper tract urothelial carcinoma patients treated with radical nephroureterectomy.

PATIENTS AND METHODS

We analyzed data from 271 patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy at 3 German academic institutions. Cox and logistic regression models assessed the association of AB0 blood group antigen and Rhesus factor expression with tumor biologic features and outcomes, respectively.

RESULTS

In total, 119 patients (43.9%) had blood group antigen A0, 42 patients (15.4%) antigen B0, 15 patients (5.5%) antigen AB, and 95 patients (35.0%) the antigen 00. A total of 231 patients (85.2%) were Rhesus factor positive. The AB0 blood group antigen expression was associated with a higher tumor grade (P = 0.049) and sessile tumor architecture (P = 0.019). Both, AB0 blood group system and Rhesus factor expression, were associated with worse performance status (P = 0.024, and P = 0.003, respectively). In contrast, Rhesus factor expression status was not associated with any clinicopathologic characteristics. Neither the AB0 blood group antigens nor the Rhesus factor was associated with survival.

CONCLUSION

AB0 blood group antigens and Rhesus factor expression are not associated with survival. The association of the AB0 blood group antigens with adverse pathological features warrants further validation.

Effect of Lymphadenectomy During Radical Nephroureterectomy in Locally Advanced Upper Tract Urothelial Carcinoma

BACKGROUND

The role of lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) patients remains controversial. The aim of this study was to evaluate the effect of LND on clinical outcomes during radical nephroureterectomy (RNU) and to determine prognostic factors of survival.

PATIENTS AND METHODS

From 1985 to 2013, 404 patients with UTUC underwent RNU; 5 patients who received neoadjuvant chemotherapy were excluded. Among them, 182 (46%) were pathologically negative for lymph node metastasis (pN0), 177 (44%) were non-LND (pNx), and 40 (10%) were positive for lymph nodes metastasis (pN1/2).

RESULTS

The 5-year disease-free survival (DFS) and cancer-specific survival (CSS) rate were higher in pN0 patients than in pNx patients and in pN1/2 patients. According to multivariate analysis, non-LND was an independent predictive factor of DFS (hazard ratio [HR], 1.91; P = .004) and CSS (HR, 2.28; P = .003). In the subgroup with muscle-invasive UTUC, the 5-year DFS and CSS rates were higher in pN0 patients than in pNx patients. However, there was no statistical difference between pN0 and pNx groups in terms of DFS and CSS in the pT2 cases. DFS and CSS times were significantly prolonged in the pN0 group in the locally advanced UTUC patients (≥pT3).

CONCLUSION

In the ≥pT3 subgroup, the 5-year DFS and CSS were significantly prolonged in the pN0 group, but there were no statistical differences between pN0 and pNx groups in terms of DFS and CSS in the pT2 subgroup. LND for patients with locally advanced UTUC might improve disease prognosis.

Anatomical templates of lymph node dissection for upper tract urothelial carcinoma: a systematic review of the literature

INTRODUCTION

Indications and techniques of lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) are still controversial. Areas covered: In this study, a systematic review of the English-language literature was performed up to 1 July 2016 using the Medline, Scopus, Cochrane Library and Web of Sciences databases to provide a detailed overview of the most commonly dissected surgical templates of LND for UTUC according to laterality and location of the tumor. Overall, sixteen studies were analyzed. Based on the shared experiences in the scientific literature, the LND template typically included: for right-sided tumors of the renal pelvis, upper third and middle third of the ureter, the renal hilar, paracaval, precaval and retrocaval nodes, while for left-sided tumors the renal hilar, paraaortic and preaortic nodes. For tumors of the lower ureter, an extended pelvic LND was performed in most cases; however, the paracaval, paraaortic or presacral nodes were dissected in selected series. Expert commentary: LND is not routinely performed at the time of surgery for UTUC and both indication and extent of LND vary among surgeons and institutions. Future high-quality studies are needed to define the most accurate LND templates and to assess their oncological efficacy and surgical morbidity.

Association between lymph node yield and survival among patients undergoing radical nephroureterectomy for urothelial carcinoma of the upper tract

BACKGROUND

Prior studies examining the value of lymph node (LN) dissection (LND) in patients with urothelial carcinoma of the upper urinary tract (UTUC) have produced conflicting results. The objective of the current study was to assess the relationship between LN yield and survival among patients undergoing radical nephroureterectomy (RNU).

METHODS

The National Cancer Data Base was used to identify patients with non-metastatic UTUC who were treated with RNU between 2004 and 2012. The association between LN yield and overall survival (OS) was assessed using Cox proportional hazards regression, with adjustment for patient, tumor, and facility characteristics.

RESULTS

Of the 14,472 patients, 2926 (20%) underwent LND. The median yield was 2 LNs (interquartile range 1-6 LNs). Among the entire cohort and the LN-negative (pN0) subgroup, a higher LN yield was associated with lower all-cause mortality (multivariable hazard ratio [HR] 0.94 per 5 LNs removed, 95% confidence interval [95% CI] 0.89-1.00 [P = .034] for the entire cohort and HR 0.86, 95% CI 0.79-0.94 [P = .001] for the pN0 subgroup). Among patients with positive LNs (pN+), there was no association noted between LN yield and OS; however, positive and negative LN counts were found to be independent predictors of OS (HR 1.27 per 5 positive LNs, 95% CI 1.16-1.39 [P<.001] and HR 0.90 per 5 negative LNs, 95% CI 0.82-1.00 [P = .049]).

CONCLUSIONS

In this large, contemporary cohort of patients with UTUC, LND was found to be used infrequently despite evidence that a higher LN yield is associated with lower all-cause mortality. Cancer 2017;123:1741-1750. © 2017 American Cancer Society.

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.

Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma

INTRODUCTION

Lymph node dissection (LND) performed during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains controversial and difficult to evaluate. The aim of this study was to investigate whether removal of more lymph nodes during RNU is safe and improves oncologic outcomes.

METHODS

We evaluated 422 patients who underwent RNU with concomitant LND for upper tract urothelial carcinoma between 1976 and 2015, assessing for an association between total nodes removed, recurrence-free survival, and cancer-specific survival using Cox proportional hazards models. We also investigated the relationship between nodal yield and perioperative metrics and intersurgeon variability using linear regression.

RESULTS

In our cohort of 442 patients, 239 developed recurrences and 94 patients died of disease. Median follow-up among survivors was 3.7 years (interquartile range: 1.2, 7.4). The median nodal yield was 9 (interquartile range: 4, 16). Among patients with node-positive disease (pN1), we observed a significant improvement in recurrence-free survival (hazard ratio = 0.84 per 5 nodes removed, P = 0.039) and a nonsignificant improvement in cancer-specific survival with an increase in the nodal yield (hazard ratio = 0.90 per 5 nodes removed, P = 0.2). There was no evidence of an association between node yield and operative time, estimated blood loss, or 30-day complications on multivariable analysis. There was significant heterogeneity among surgeons regarding the extent of LND (P<0.0001).

CONCLUSIONS

We found that a more extensive node dissection may improve oncologic outcomes in a subset of high-risk patients without significantly increasing operative time or serious complications. Additionally, we identified considerable intersurgeon heterogeneity regarding the extent of LND furthering the notion of surgeon variability as a nonstandardized factor.

Current role of lymphadenectomy in the upper tract urothelial carcinoma

Introduction

Lymphadenectomy (LND) has recently attracted considerable interest from urological surgeons, as extended lymphadenectomy might have a role in accurate staging or improving patient survival in those patients with urological malignancies.

Upper tract urothelial carcinoma (UTUC) is a relatively rare neoplasm, accounting for about 5% of all urothelial cancers. Up to 30% of patients with muscle-invasive UTUC have metastasis in the regional lymph nodes (LNs), which represents a well-established poor prognostic factor.

Material and methods

A medline search was conducted to identify original articles and review articles addressing the role of lymphadenectomy LND in UTUC. Keywords included lymphadenectomy, lymph node excision, nephroureterectomy, and upper tract urothelial carcinoma.

Results

LND instead of lymphadenectomy has recently attracted considerable interest from urological surgeons and might have a potential role in improving the oncological outcome in patients with urothelial carcinoma. LND ideally improves disease staging; thereby, we need to find the way to identify the patients who could really benefit from adjuvant systemic theraphy. Template-based LND with Radical Nephroureterectomy (RNU) for high risk disease is gaining support based on accumulating retrospective data and supports its utility as a potentially therapeutic maneuver. RNU is still the gold standard treatment for UTUC, but minimal invasive procedures such as laparoscopic RNU and Robot Assisted Nephroureterectomy (RANU) are becoming more employed in recent years and should be used by expert hands.

Conclusions

Therapeutic benefits of LND and nodal status on disease free survival (DFS) and Cancer Free Survival (CSS) remains controversial. Although most of the data comes from retrospective studies, we encourage performing well designed, prospective, and multicentre studies to clarify this in the coming years.

External validation of the pathological nodal staging score in upper tract urothelial carcinoma: A population-based study

OBJECTIVES

To externally validate our previously developed pathological nodal staging model (pNSS) that allows quantification of the likelihood that a patient with pathologic node-negative status has, indeed, no lymph node metastasis (LNM).

PATIENTS AND METHODS

We analyzed data from 2,768 patients treated with radical nephroureterectomy (RNU) and lymph node dissection (LND) using the Surveillance, Epidemiology, and End Results database from 1988 to 2010. We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed a new pNSS. Then, we compared these findings with those of the initial cohort.

RESULTS

The mean and median numbers of lymph node (LN) removed were 5 and 2, respectively (interquartile range = 5) in the validation cohort, though 66.5% of the patients (n = 1814) were pN0. Similar to the development cohort, the probability of missing a LNM decreased as the number of nodes examined increased in the validation cohort. If only a single node was examined, 35% of patients would be misclassified as pN0 while harboring LNM. Even when 5 nodes were examined, 8% would be misclassified. The probability of having a positive node increased with advancing pathological T stage in both the cohorts. Patients with pT0-Ta-Tis-T1 disease in both cohorts would have more than a 95% chance of a correct pathologic nodal staging with 2 examined nodes. However, if a patient has pT3-T4 disease, more than 12 examined LNs are needed to reach 95% accuracy.

CONCLUSIONS

We confirmed that the number of examined nodes needed for adequate staging depends on pT category. We externally validated our previous pNSS in a population-based database, which could help in the clinical decision-making regarding adjuvant chemotherapy administration.

Changes in oncological outcomes after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma treated in the last two decades: a retrospective analysis based on a multicenter collaborative study

OBJECTIVE

We investigated chronological changes in the outcomes of patients with upper urinary tract urothelial carcinoma treated in the past two decades, during which there was an important change in treatment paradigm.

METHODS

A retrospective review was conducted of 1180 urinary tract urothelial carcinoma patients who underwent radical nephroureterectomy in multicenter collaborative institutions between 1996 and 2015. The patients were divided into four groups according to the year when radical nephroureterectomy was performed, as follows: 1996-2000 (period 1; P1), 2001-05 (P2), 2006-10 (P3) and 2011-15 (P4). Variables including tumor grade, T and N categories, administration of perioperative chemotherapy and treatment outcomes were compared among the four groups.

RESULTS

There were 146 (12%), 312 (27%), 459 (39%) and 263 (22%) patients in the P1, P2, P3 and P4 groups, respectively. The proportion of patients harboring pT2/3 and Grade 3 tumors increased gradually from 42% (P1) to 58% (P4) and from 49% (P1) to 65% (P4), respectively. The 5-year disease-free survival rates were 74%, 74%, 73% and 75%, and the 5-year overall survival rates were 74%, 65%, 67% and 72% for the P1, P2, P3, and P4 groups, respectively. Multivariate analysis with adjustment for possible confounding factors revealed no significant differences in disease-specific survival, overall survival or intravesical recurrence-free survival among the four groups.

CONCLUSIONS

Despite advances in diagnostic instruments, surgery and systemic chemotherapy, the clinical outcome of urinary tract urothelial carcinoma after radical surgery has not significantly improved over the last two decades, and further research is therefore required.

Lymph node yield and tumor location in patients with upper tract urothelial carcinoma undergoing nephroureterectomy affects survival: A U.S. population-based analysis (2004-2012)

PURPOSE

The purpose of the study was to characterize the contemporary trends in lymphadenectomy for the treatment of upper tract urothelial carcinoma in a population-based cohort and to determine if number of lymph nodes removed and tumor location are predictors of cancer-specific survival in patients undergoing nephroureterectomy.

MATERIALS AND METHODS

Individuals with upper tract urothelial carcinoma undergoing nephroureterectomy in the Surveillance, Epidemiology, and End Results program from 2004 to 2012 were identified. Linear regression was used to assess trends in lymphadenectomy. Patients were stratified based on nodal status, quartiles of nodes removed, and tumor location. Kaplan-Meier analysis, log-rank tests, and Cox proportional hazards models were used to compare cancer-specific survival and overall survival among groups.

RESULTS

In the cohort, 25% (721/2,862) of all patients and 27% (566/2,079) of grade 3/4 patients underwent lymphadenectomy. The percentage of patients undergoing lymphadenectomy increased from 20% (60/295) in 2004 to 33% (106/320) in 2012 (P = 0.02). Patients with the highest quartile of lymph nodes removed had improved the 5-year cancer-specific survival of 78% (95% CI: 69%-85%) compared to the second quartile (60%; 95% CI: 51%-67%; P = 0.003) and the third quartile (60%; 95% CI: 51%-68%; P = 0.002) of nodes removed. This trend held for node-negative and node-positive patients. In multivariable modeling, a lower number of lymph nodes dissected (hazard ratio = 0.94, 95% CI: 0.91-0.98) and ureteral tumors (hazard ratio = 1.29, 95% CI: 1.07-1.56) were predictors of worse cancer-specific survival.

CONCLUSIONS

In patients with upper tract urothelial carcinoma undergoing nephroureterectomy, rates of lymphadenectomy have increased from 2004 to 2012 in the United States. In this contemporary cohort, an increase in the number of nodes removed and renal pelvis tumors are associated with improved cancer-specific survival, which highlights the importance of intentional lymph node dissection with adequate lymph node yield in these patients.