Conservative Management of Upper Tract Urothelial Carcinoma in France: A 2004–2011 National Practice Report

Which Patients with Upper Tract Urothelial Carcinoma Can be Safely Treated with Flexible Ureteroscopy with Holmium:YAG Laser Photoablation? Long-Term Results from a High Volume Institution

PURPOSE

We tested the effects of tumor size, distribution and grade on progression-free survival in patients with upper tract urothelial carcinoma treated with flexible ureteroscopy with Ho:YAG laser photoablation.

MATERIALS AND METHODS

Included in analysis were data on 92 consecutive patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation from 2003 to 2015 at a single tertiary care referral center. Stringent followup was offered according to EAU (European Association of Urology) guidelines. Progression during followup was defined by tumor upgrading, distant metastases and/or a relapsing tumor that could not be completely removed with a conservative approach. Kaplan-Meier curves were used to assess the rate of disease progression according to tumor size (1 or less cm vs greater than 1 cm), tumor distribution (unifocal vs multifocal) and tumor grade (low vs high). Cox regression analysis was done to test the impact of clinical and pathological characteristics on the rate of progression-free survival.

RESULTS

At a median followup of 52 months (IQR 27.8-76.4) the progression-free survival rate was 68% vs 72% in patients with a tumor size of 1 or less vs greater than 1 cm (p = 0.9), 72% vs 69% in patients with unifocal vs multifocal lesions (p = 0.6) and 75% vs 52% in patients with a low vs a high grade tumor (p = 0.03). On multivariable Cox regression analysis tumor grade at first treatment was the only independent predictor of disease progression (HR 5.16, 95% CI 1.19-22.26, p = 0.03).

CONCLUSIONS

High tumor grade independently decreased progression-free survival in patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation. Tumor size greater than 1 cm and multifocality did not increase the risk of disease progression in patients treated conservatively with Ho:YAG laser photoablation.

Endoscopic Treatment of Upper Tract Urothelial Carcinoma

PURPOSE OF REVIEW

This study aims to make the reader be aware of recent trends regarding the endoscopic management of upper tract urothelial carcinoma (UTUC) via review of the urologic literature over the past 5 years. Given the rare incidence of this disease, and the lack of level 1 evidence, systematic reviews and meta-analyses were also evaluated. Studies of importance are also considered and outlined in the annotated reference section.

RECENT FINDINGS

The PubMed database was queried using the following medical subject headings (MeSH terms): "carcinoma, transitional cell," "ureter," "ureteral neoplasms," "kidney pelvis," "endoscopy," "laser therapy," "ureteroscopy," "urologic surgical procedures," and "ureteroscopes." MeSH terms were linked together in varying combinations and limited to human studies in English. Given the relatively rare nature of upper tract urothelial carcinoma (UTUC), level 1 evidence regarding the efficacy of endoscopic treatment does not exist, even after 30+ years of experience. Rather, the literature available mostly is in the form of single institutional retrospective series consisting of relatively small numbers of patients with short to intermediate follow-up. Only within the last 3 years have published series with larger numbers of patients and mean follow-up over 5 years been made available. Even with these more robust experiences, comparisons among series are difficult given variable treatment and follow-up approaches. Most endoscopically managed UTUC will locally recur, especially with longer follow-up. Renal preservation rate is high, however, approaching 80% with follow-up well over 3 years. Patients with high-grade disease often fare poorly regardless of treatment modality. As such, endoscopic management for high-grade urothelial carcinoma should only be used in exceptional circumstances (i.e., in those patients medically unfit for NU or those with solitary kidneys wishing to avoid the morbidity of dialysis). No level 1 evidence exists for the routine use of intraluminal adjuvant therapy for UTUC (i.e., BCG and Mitomycin C) and multiple retrospective observational series claim there is no overt benefit. The recent formation of multiple international groups with interest in UTUC may eventually lead to the production of level 1 studies regarding optimal treatment; however, uniformity in treatment approach will likely still offer challenges.

Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel

CONTEXT

There is uncertainty regarding the oncologic effectiveness of kidney-sparing surgery (KSS) compared with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

OBJECTIVE

To systematically review the current literature comparing oncologic outcomes of KSS versus RNU for UTUC.

EVIDENCE ACQUISITION

A computerised bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting comparative oncologic outcomes of KSS versus RNU. Approaches considered for KSS were segmental ureterectomy (SU) and ureteroscopic (URS) or percutaneous (PC) management. Using the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, we identified 22 nonrandomised comparative retrospective studies published between 1999 and 2015 that were eligible for inclusion in this systematic review. A narrative review and risk-of-bias (RoB) assessment were performed using cancer-specific survival (CSS) as the primary end point.

EVIDENCE SYNTHESIS

Seven studies compared KSS overall (n=547) versus RNU (n=1376). Information on the comparison of SU (n=586) versus RNU (n=3692), URS (n=162) versus RNU (n=367), and PC (n=66) versus RNU (n=114) was available in 10, 5, and 2 studies, respectively. No significant difference was found between SU and RNU in terms of CSS or any other oncologic outcomes. Only patients with low-grade and noninvasive tumours experienced similar CSS after URS or PC when compared with RNU, despite an increased risk of local recurrence following endoscopic management of UTUC. The RoB assessment revealed, however, that the analyses were subject to a selection bias favouring KSS.

CONCLUSIONS

Our systematic review suggests similar survival after KSS versus RNU only for low-grade and noninvasive UTUC when using URS or PC. However, selected patients with high-grade and invasive UTUC could safely benefit from SU when feasible. These results should be interpreted with caution due to the risk of selection bias.

PATIENT SUMMARY

We reviewed the studies that compared kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma. We found similar oncologic outcomes for favourable tumours when using ureteroscopic or percutaneous management, whereas indications for segmental ureterectomy could be extended to selected cases of aggressive tumours.

Radical nephroureterectomy versus endoscopic procedures for the treatment of localised upper tract urothelial carcinoma: a meta-analysis and a systematic review of current evidence from comparative studies

The conservative management of upper tract urothelial carcinoma (UTUC) has seen important developments over the last 10 years with advances in endoscopy. Our aim was to compare the available evidence regarding the impact of endoscopic nephron sparing procedures (NSP) and radical nephroureterectomy (RNU) on survival of upper tract urothelial carcinoma (UTUC). A critical review of Pubmed/Medline, Embase and the Cochrane Central Register of Controlled Trials was performed in July 2013 according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. Overall, eight publications were selected for inclusion in this meta-analysis but all of them were retrospective or non-randomised comparative studies. The primary end points were the overall and cancer-specific survivals (OS and CSS) in the two treatment groups. We achieved to pool data on 1002 patients diagnosed with localised UTUC and treated either by endoscopic NSP (n = 322) or by RNU (n = 680). No significant difference was found in terms of OS and CSS between RNU and endoscopic NSP (HR = 1.47 and p = 0.31; HR = 0.96 and p = 0.91, respectively). However, the low level of evidence (3b) and the heterogeneity of the studies limited the quality of the results. In the absence of prospective and randomised studies, the equivalent oncologic control for endoscopic NSP and RNU is not provided by this meta-analysis. Multicentre prospective studies are urgently needed to assess the oncologic outcomes of UTUC with endoscopic management. In the next multicentre studies, the patients should be matched on the basis of the tumour stage (imaging) and grade (biopsy) at diagnosis.