European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update

Impact of dialysis on intravesical recurrence and survival outcomes in upper tract urothelial cancer patients undergoing radical nephroureterectomy

BACKGROUND

Upper tract urothelial carcinoma (UTUC) presents a significant recurrence risk following radical nephroureterectomy (RNU). Patients on dialysis may experience unique clinical trajectories due to uremic states and altered immune responses.

OBJECTIVE

To evaluate the impact of dialysis on intravesical recurrence and survival outcomes in patients with UTUC undergoing RNU, and to identify predictive factors influencing prognosis.

METHODS

A retrospective cohort study analyzed 402 patients with non-metastatic UTUC treated with RNU between 2001 and 2014. Patients were stratified into dialysis (n = 66) and non-dialysis (n = 336) groups. Survival and recurrence outcomes were assessed using Kaplan-Meier and Cox regression analyses.

RESULTS

Dialysis patients were predominantly female, younger, and exhibited less advanced pathological tumor stages. Dialysis was associated with higher intravesical recurrence rates (p = 0.009), which were largely attributable to a history of bladder cancer (42.4% vs. 26.5%; p = 0.009). After adjustment for bladder cancer history, dialysis was not an independent predictor of bladder recurrence-free survival (BRFS). Advanced pT stages (HR: 3.9, p = 0.012) and prior bladder cancer were the primary factors influencing BRFS.

CONCLUSIONS

Dialysis does not independently worsen surgical outcomes or BRFS in UTUC patients post-RNU when accounting for prior bladder cancer. Prognostic models should integrate these findings to enhance individualized surveillance and treatment strategies.

The role of surgical resection of the primary tumor in metastatic upper tract urothelial carcinoma: a systematic review and meta-analysis

PURPOSE OF REVIEW

To evaluate the role of extirpative surgery for the primary tumor in metastatic upper tract urothelial carcinoma (mUTUC).

RECENT FINDINGS

The PubMed, Web of Science, and Cochrane Library were searched on July 2024 to identify relevant studies according to the Preferred Reporting Items for Systematic Review (PRISMA) statement. Studies were eligible for analysis if they compared oncologic outcomes between mUTUC patients who underwent surgical resection of the primary tumor and patients who did not. Cancer-specific survival (CSS) and overall survival (OS) were assessed using multivariate logistic regression analyses. We identified 2686 reports, of which 11 articles comprising 12 833 records were selected for this systematic review. Eight and three studies used Surveillance Epidemiology and End Results (SEER) and National Cancer Database (NCDB) databases, respectively. Surgical resection of the primary tumor was significantly associated with better CSS and OS in patients with mUTUC. Among the 5353 mUTUC patients included in our meta-analysis, radical nephroureterectomy (RNU) was independently associated with better OS with a pooled hazard ratio (HR) of 0.62 [95% confidence interval (CI) 0.54-0.72, P  < 0.05]. Subgroup analyses of studies restricted to mUTUC patients with distant lymph node metastasis ( n  = 1372) revealed RNU to be independently associated with better OS with pooled HR: 0.44 (95% CI 0.28-0.67, P  < 0.05) together with systemic chemotherapy, primary tumor site in the ureter, lower T stage, and no locoregional lymph node involvement.

SUMMARY

Surgical resection of the primary tumor offers oncologic survival benefits in select patients with mUTUC. However, in the absence of data from prospective randomized studies, it is essential to evaluate each patient individually as part of a collaborative multidisciplinary shared decision working with the patient.

Endoscopic ablation versus nephroureterectomy in localized low-grade upper tract urothelial carcinoma: a comparison in terms of cancer-specific and other-cause mortality

PURPOSE

Guidelines recommend endoscopic ablation in select upper urinary tract urothelial carcinoma (UTUC) patients. To test for differences in cancer-specific mortality (CSM) and other-cause mortality (OCM) in localized non-invasive low-grade UTUC with tumor size < 2 cm treated with endoscopic ablation vs. radical nephroureterectomy.

METHODS

Within Surveillance, Epidemiology, and End Results database (2000-2020), we identified UTUC patients treated with either endoscopic ablation or radical nephroureterectomy. After propensity score matching (ratio 1:1), cumulative incidence plots, and competing risks regression models addressed CSM and OCM.

RESULTS

Of 249 included UTUC patients, 66 (27%) were treated with endoscopic ablation vs. 183 (73%) with radical nephroureterectomy. Over the study period, endoscopic ablation use increased from 10 to 45% (p = 0.01). After 1:1 propensity score matching, 66 of 66 (100%) endoscopic ablation and 66 of 183 (36%) radical nephroureterectomy patients were included. Ten-year CSM rates were 15.7% after endoscopic ablation vs. 13.9% after radical nephroureterectomy (p = 0.9). Ten-year OCM rates were 46.3% after endoscopic ablation vs. 57.9% after radical nephroureterectomy (p = 0.5). In multivariable competing risks regression models, CSM (hazard ratio 1.10; p = 0.9) and OCM (hazard ratio 0.83; p = 0.5) did not differ according to use of endoscopic ablation vs. radical nephroureterectomy.

CONCLUSION

Endoscopic ablation of localized non-invasive low-grade UTUC with tumor size < 2 cm results in absence of cancer-control outcome differences relative to radical nephroureterectomy. This observation validates the current guideline recommendations.

Oncological Safety and Diagnostic Yield of Percutaneous Needle-core Biopsies in Upper Tract Urothelial Carcinoma: The UPERCUT Study

BACKGROUND AND OBJECTIVE

A percutaneous biopsy of suspected upper tract urothelial carcinoma (UTUC) is considered contraindicated due to potential safety concerns. This study evaluated the risk of tumor seeding along the needle track following a percutaneous needle-core biopsy for UTUC, along with diagnostic yield and oncological outcomes.

METHODS

We conducted a retrospective multicenter study involving 53 patients who underwent a percutaneous biopsy for upper urinary tract urothelial carcinoma between 2012 and 2022. The primary endpoint was tumor recurrence along the biopsy needle track, assessed through a centralized review of follow-up cross-sectional imaging. The secondary endpoints included biopsy yield, histological concordance in tumor stage and grade compared with final histology in cases of nephroureterectomy, complication rates, and overall oncological outcomes.

KEY FINDINGS AND LIMITATIONS

The cohort consisted of 60% male patients with a mean age of 69 yr. At diagnosis, 32% had metastatic disease. A biopsy was performed due to diagnostic uncertainty regarding renal cell carcinoma or other diseases, distant metastases, or failed endoscopic biopsy. The median follow-up imaging time was 8.3 mo. Tumor track seeding occurred in one case (1.9%) 5 mo after the procedure. Biopsy yield was 94%, with histological concordance rates of 78% for tumor stage and 100% for grade. Complications occurred in 14.8% of cases, including two (3.7%) cases of obstructive pyelonephritis requiring endoscopic management.

CONCLUSIONS AND CLINICAL IMPLICATIONS

A percutaneous biopsy is a useful diagnostic tool for high-grade invasive upper urinary tract urothelial carcinoma, with a low risk of tumor track seeding. It provides critical histological confirmation, facilitating future research on neoadjuvant systemic therapies.

KIF26B promotes bladder cancer progression via activating Wnt/β-catenin signaling in a TRAF2-dependent pathway

In this study, we report that KIF26B is upregulated in bladder cancer and acts as an independent prognostic factor. Knockdown of kif26b blocks the proliferation, metastasis, and cisplatin resistance of bladder cancer cells. Mechanistically, TCF4 potently stimulates kif26b transcription by directly binding to its promoter. KIF26B activates the Wnt/β-catenin signaling pathway through association with TRAF2 and thus promotes the formation of the TCF4/β-catenin complex. KIF26B promotes the protein stability of TRAF2 by facilitating the OTUB2-mediated de-ubiquitination of TRAF2. Importantly, KIF26B promotes the nuclear translocation of TRAF2 through enhancing its association with IPO11, a process that is dependent on the C-terminal domain of β-catenin. Additionally, phosphorylation of tyrosine 78 in TRAF2 is essential for its binding to KIF26B in response to Wnt3a signaling. Furthermore, a KIF26B/TRAF2/PD-L1 axis is identified in bladder cancer, and combined therapy of anti-B7-H3 antibody with kif26b knockdown yields superior anti-tumor effects.

Combined neoadjuvant and adjuvant therapy versus adjuvant therapy in high-risk upper tract urothelial carcinoma: a propensity matched multicenter analysis (ROBUUST 2.0 International Collaborative Group)

INTRODUCTION

The efficacy of combined neoadjuvant and adjuvant therapy (CNAT) in upper tract urothelial carcinoma (UTUC) remains unclear despite its demonstrated potential in bladder urothelial carcinoma. High-risk features- clinical stage ≥ T3, node-positive disease, multifocality, high-grade pathology, hydronephrosis, and large tumor size - are associated with poor prognosis in UTUC. We investigated the oncological outcomes of CNAT versus adjuvant therapy (AT) alone in high-risk UTUC patients.

MATERIALS AND METHODS

We analyzed perioperative data from 2433 patients with UTUC (2015-2023) across 17 centers in the US, Europe, and Asia. Propensity score matching was performed using preoperative clinical T and N stages. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and metastasis-free survival (MFS).

RESULTS

Among 285 high-risk UTUC patients, 76 matched patients (38 CNAT, 38 AT) were analyzed after matching, with a median follow-up of 15 months. CNAT and AT groups had comparable oncological outcomes: 2-year OS (72.9% vs. 71.8%; p = 0.89), CSS (76.7% vs. 75.3%; p = 0.92), RFS (30.1% vs. 39%; p = 0.97), or MFS (45.5% vs. 44.7%; p = 0.91), respectively. Cox regression showed no significant survival benefit of CNAT over AT after adjusting for clinical and pathological factors (HR for OS: 1.06; p = 0.9).

CONCLUSION

In this large multicenter international cohort, our findings suggest that CNAT does not provide a clear advantage over AT alone in patients with high-risk UTUC. Prospective randomized trials are needed to clarify the role of multimodal therapy in UTUC management.

Development and Validation of the UriMee Model: A Methylation-based Diagnostic Tool for Early Diagnosis of Urothelial Carcinoma

BACKGROUND AND OBJECTIVE

Urothelial carcinoma (UC) is a common malignancy that imposes a significant health care burden. Current diagnostic methods are limited by their invasiveness and low sensitivity, particularly for detecting low-grade tumors. Noninvasive, accurate, and reliable diagnostic tests for an early diagnosis of UC are urgently needed.

METHODS

UC-specific DNA methylation biomarkers were identified by combining public datasets from The Cancer Genome Atlas and Gene Expression Omnibus with a cohort from Renji Hospital (n = 50). Using the Least Absolute Shrinkage and Selection Operator regression, we developed a diagnostic model, termed the UriMee model, by selecting key biomarkers from a model cohort (n = 322) and subsequently validating it in an independent cohort (n = 131). The diagnostic performance of the assay was evaluated and compared with that of urine cytology.

KEY FINDINGS AND LIMITATIONS

At 30% threshold probability, the UriMee model demonstrated high sensitivity (92%) and specificity (92%) in distinguishing UC cases, with particularly strong performance in early-stage tumors (83% sensitivity for Ta, 93% for T1, and 100% for Tis). It significantly outperformed urine cytology, offering greater sensitivity (90% vs 25%, p < 0.001) while maintaining comparable specificity. Additionally, the model was highly effective in identifying upper tract urothelial carcinoma (UTUC), achieving sensitivity of 96%. The study's limitations include the necessity for larger multicenter studies and long-term follow-up to validate the findings and assess the test's effectiveness across diverse populations, as well as its utility in monitoring disease progression and recurrence.

CONCLUSIONS

The UriMee test demonstrated high sensitivity and specificity, particularly in detecting early-stage tumors and UTUC, significantly outperforming traditional methods.

Impact of Histological Subtypes/Divergent Differentiation on Clinicopathological and Oncological Outcomes for Patients with Upper Tract Urothelial Carcinoma Treated with Radical Nephroureterectomy: A Comprehensive Updated Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Upper tract urothelial carcinoma (UTUC) is associated with poor survival. Recent studies have evaluated whether the presence of histological subtypes or divergent differentiation (HS/DD) is associated with worse UTUC prognosis. Our aim was to assess the relationship between HS/DD and clinicopathological features and oncological outcomes for patients with UTUC undergoing radical nephroureterectomy (RNU) without investigating causal pathways.

METHODS

A literature search was conducted in September 2024. Patients with UTUC who underwent RNU were included. The main outcomes were differences in clinicopathological features and oncological outcomes between HS/DD and pure urothelial carcinoma (PUC) groups.

KEY FINDINGS AND LIMITATIONS

We included 22 studies involving 14 407 patients in our review. HS/DD was present in 14% of tumours. In comparison to PUC, the HS/DD group had significantly higher rates of ≥pT3 stage, high-grade tumours, lymph node invasion (LNI), lymphovascular invasion (LVI), and receipt of adjuvant chemotherapy. Pooled results revealed that the HS/DD group had significantly worse cancer-specific survival (CSS) (hazard ratio [HR] 1.65, 95% confidence interval CI] 1.39-1.96), overall survival (OS; HR 1.84, 95% CI 1.52-2.22) ,and recurrence-free survival (RFS; HR 1.64, 95% CI 1.43-1.87). Intravesical RFS (IVRFS) and urothelial RFS (URFS) were comparable between the groups.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our findings suggest that UTUC with HS/DD is associated with more advanced/aggressive features, such as higher pathological stage and grade, LNI, and LVI. HS/DD is associated with significantly worse CSS, OS, and RFS, but does not predict worse IVRFS or URFS. Therefore, HS/DD detection should prompt extensive treatment and closer follow-up. To improve the quality of recommendations and patient care, well-designed studies with central pathological review are needed.

Efficacy and safety of atezolizumab in the treatment of urothelial carcinoma: a systematic review and meta-analysis

BACKGROUND

There is still controversy regarding the safety and efficacy of atezolizumab for the treatment of urothelial carcinoma (UC). This research aimed to extensively investigate the effectiveness and safety of atezolizumab as a therapy for UC.

METHODS

A thorough literature review was conducted using databases including PubMed, Embase, the Cochrane Library, and Web of Science. The search included studies published from the inception of each database until May 24, 2024. The primary outcomes, progression-free survival (PFS) and overall survival (OS), were calculated using hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs).

RESULTS

Ten randomized controlled trials (RCTs) totaling 4,148 participants were included in our analysis. Compared to UC patients who received a placebo, either alone or in combination with chemotherapy medications, aggregated data showed that patients with UC who received atezolizumab had significantly longer OS(HR = 0.88, 95% CI [0.83, 0.94], p < 0.0001). Three RCTs also provided data on PFS, showing that patients who received atezolizumab, either in addition to or instead of chemotherapy, had significantly longer PFS than those who received placebo with or without chemotherapy (HR = 0.85, 95% CI [0.76, 0.95], p = 0.004).

CONCLUSIONS

Atezolizumab has demonstrated significant improvements in OS and PFS among patients with UC, offering crucial insights for decision-making in UC immunotherapy.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/#recordDetails , identifier [CRD42024556757].

Lines of Therapy for Locally Advanced/Metastatic Urothelial Carcinoma: The New Paradigm

Urothelial carcinoma (UC) is the most common malignancy of the urinary tract, with urothelial bladder cancer accounting for approximately 90% of cases. Metastatic UC (mUC) is a particularly aggressive subset that presents significant treatment challenges, especially in patients who are often older than 70 years and have multiple comorbidities. For several decades, cisplatin-based chemotherapy has been the standard first-line treatment for locally advanced (LA) mUC. However, its utility has been limited as many patients are ineligible owing to their health status, and overall survival rates remain suboptimal. Recent advancements, including antibody-drug conjugates and immunotherapies, have begun to reshape the treatment landscape for LA/mUC. The combination of enfortumab vedotin and pembrolizumab has shown promising clinical outcomes. The approval of multiple novel drugs and combination therapies not only provides new opportunities for patient care but also creates the need for physicians to adapt to this evolving therapeutic paradigm. This review explores the latest clinical data on the management of LA/mUC and offers insights into sequencing therapies for patients with LA/mUC.

Pattern and risk factors of local recurrence and intravesical recurrence after segmental ureterectomy for upper tract urothelial carcinoma

OBJECTIVE

To investigate the pattern and risk factors of local recurrence and intravesical recurrence of ureteral upper tract urothelial carcinoma (UTUC) following segmental ureterectomy (SU).

METHODS

From February 2012 to August 2021, a retrospective analysis was conducted on patients following SU. Univariate and multivariate Cox regression analysis were used to evaluate the risk factors. Kaplan-Meier curves were employed to illustrate survival outcomes.

RESULTS

Among 88 patients, 50 (57%) were male, with a median age of 71 (IQR: 62-77) years. The procedures of ureteral reconstruction included ureteral reimplantation in 77 (88%) cases, ureteroureteral anastomosis in 9 (10 %) cases, Boari flap ureteroplasty with psoas hitch in 1 (1%) case, and cutaneous ureterostomy in 1 (1%) case. The median follow-up time was 44.5 months. The 3-year rate of local recurrence, lymph node metastasis, ipsilateral upper urinary tract recurrence and intravesical recurrence was 31.6%, 19.0%, 22.2% and 35.7%, respectively. G3 (HR = 3.355, 95% CI 1.375-8.184, P = 0.008), and lymphatic vascular infiltration (HR = 3.127, 95% CI 1.043-9.373, P = 0.042) were independent risk factors for local recurrence. G3 (HR = 3.782, 95% CI 1.036-13.812, P = 0.044) was an independent risk factor for lymph node metastasis. Sarcomatoid differentiation (HR = 3.943, 95% CI 1.087-14.308, P = 0.037) was an independent risk factor for ipsilateral upper urinary tract recurrence. Previous or concurrent bladder cancer (HR = 3.280, 95% CI 1.667-6.453, P = 0.001) and sarcomatoid differentiation (HR = 4.442, 95% CI 1.317-14.989, P = 0.016) were independent risk factor for intravesical recurrence. The most common regions for bladder recurrence were posterior wall (21%), same lateral wall (16%) and trigon (16%).

CONCLUSION

SU is a feasible treatment for selected UTUC patients, yet it is associated with a considerable risk of local and intravesical recurrence. Careful monitoring and active adjuvant therapy are essential to minimize the recurrence rate for patients with risk factors.

Response to Systemic Therapies in Patient-Derived Cell Lines from Primary and Recurrent Adult Granulosa Cell Tumors

In patients with the rare adult-type granulosa cell tumor (aGCT), surgery is the primary treatment for both primary and recurrent disease. In cases of inoperable disease, systematic therapy is administered, but variable response rates and drug resistance complicate predicting the most effective therapy. Drug screen testing on patient-derived cell lines may offer a solution. In a national prospective study on aGCT, fresh tissue was cultured into 2D cell lines, testing 27 clinical and experimental drugs. Dose-response curves and synergy were calculated using GraphPad Prism and CompuSyn software. We established 34 patient-derived cell lines from tissue of 20 patients with aGCT. Of these, seven patients had a primary diagnosis of aGCT and 13 patients had recurrent disease. In eight patients, multiple tumor locations were cultured. On each cell line, 10 monotherapies and 17 combinations of drugs were tested. Carboplatin/gemcitabine showed efficacy and synergy in almost all patient-derived cell lines. Synergy could not be detected in the regular carboplatin/paclitaxel and carboplatin/etoposide combinations. Experimental combinations alpelisib/fulvestrant and alpelisib/gemcitabine showed efficacy of more than 75%. Drug screens on patient-derived tumor cell lines reflect the reality of the variable response of systemic therapy in patients with aGCT. In future research, this technique may be used to personalize the systemic treatment of patients with aGCT in a clinical study. The good response to carboplatin/gemcitabine in our patient-derived cell lines can then be confirmed in a clinical setting.

Multiparametric MR Urography: State of the Art

MR urography (MRU) is an imaging technique that provides comprehensive evaluation of the kidneys, pelvicalyceal system, ureters, and urinary bladder. Although CT urography (CTU) remains the first-line imaging modality for the urinary tract, incremental improvements in MRU have allowed simultaneous imaging of the kidneys, collecting system, and urinary bladder with superior contrast resolution and tissue characterization, equivalent visualization of the upper tracts, and similar specificity for detection of noncalculous diseases of the collecting system compared with that of CTU. MRU has evolved into an alternative to CTU in the broader patient population and a first-line examination in specific patient populations for which CTU is less preferred. This subgroup includes pediatric patients, pregnant patients, patients needing recurring studies, and patients with poor renal function or severe allergies to iodinated contrast material. The most common techniques encompassing a conventional MRU examination include static-fluid T2-weighted imaging and gadolinium-enhanced urothelial and excretory phase imaging. The addition of dynamic contrast-enhanced MRI and diffusion-weighted imaging results in multiparametric MRU that increases diagnostic accuracy. Newer techniques, such as parallel imaging, compressed sensing, radial k-space sampling, and deep learning-based image reconstruction, can shorten examination times and improve image quality and patient compliance. Successful MRU interpretation relies on technique optimization, knowledge of various urinary tract pathologic conditions, and familiarity with different sequences, potential interpretive pitfalls, and artifacts. ©RSNA, 2025 Supplemental material is available for this article.

Application of raman spectroscopy in the non-invasive diagnosis of urological diseases via urine

OBJECTIVES

The objective of this review is to provide a comprehensive overview of the utilization of Raman spectroscopy in urinary system diseases, highlighting its potential in non-invasive diagnostic methodologies for early diagnosis and prognostic assessment of urinary ailments.

METHODS

We searched PubMed, Web of Science, and Google Scholar using 'raman,' 'bladder,' 'kidney,' 'prostate,' 'cancer,' 'infection,' 'stone or urinary calculi,' and 'urine or urinary,' along with 'AND' and 'OR' to refine our search. We excluded irrelevant articles and screened potential ones based on titles and abstracts before assessing the full texts for relevance and quality.

FINDINGS

The findings indicate that RS can furnish data on biomolecules in urine, which is significant for non-invasive diagnostic approaches. It has shown potential within non-invasive diagnostic methodologies and is expected to play a pivotal role in the early diagnosis and prognostic assessment of urinary system diseases, such as malignancies, urinary tract infections, kidney diseases, urolithiasis, and other urinary conditions.

CONCLUSIONS

Raman spectroscopy has demonstrated significant potential in providing precise and rapid diagnostic approaches for clinical use in the context of urinary system diseases. Its ability to analyze biomolecules non-invasively positions it as an increasingly important tool in the early diagnosis and prognostic assessment of these conditions.

5α-reductase inhibitors with or without alpha-blockers and risk of incident upper tract urothelial carcinoma in men with benign prostatic hyperplasia: Analysis of US insurance claims data

BACKGROUND

Increasing data suggests that androgen receptor signaling may play an important role in the carcinogenesis of urothelial cancers. While the chemoprotective effect of 5-alpha reductase inhibitors (5-ARi) on bladder cancer risk in men with Benign Prostatic Hyperplasia (BPH) has been explored with conflicting results, the evidence regarding 5-ARi treatment, and the risk of incident Upper Tract Urothelial Carcinoma (UTUC) development is lacking. Therefore, our objective was to investigate the impact of the 5-ARi administration on the incidence of new UTUC cases using a large US database.

METHODS

The MerativeTM Marketscan® database was used to identify men ≥ 50 years old with a diagnosis of BPH and an active 5-ARi prescription between 2007 and 2021 and were subsequently matched with paired controls. A multivariable Cox regression model was implemented to ascertain the association of 5-ARi and/or alpha-blocker (α-B) medications on the incidence of UTUC. Additional subgroup analyses were conducted based on exposure risk (with a 2-year threshold) to investigate the relationship between 5-ARi and UTUC over time.

RESULTS

Overall, n=1,103,743 men BPH without prescriptions for BPH, n=31,142 men on 5-ARi, and n=160,049 using 5-ARi + α-B were identified. Over the follow-up period, a total of n=4,761 patients were diagnosed with UTUC. After matching, UTUC incidence ranged from 0.36% to 0.41% in men without active BPH therapy vs. 0.30% and 0.52% for the 5-ARi and 5-ARi + α-B groups, respectively. In multivariable analysis, the chemoprotective effect on UTUC risk was not observed for either 5-ARi monotherapy (adjusted hazard ratio [aHR]: 0.91, 95% CI: 0.58-1.44) or 5-ARi + α-B combination (aHR: 1.02, 95% CI: 0.87-1.19). This remained true for both short-term (≤ 2 years) and long-term (> 2 years) follow-up periods.

CONCLUSIONS

The use of 5-ARi for BPH, whether used alone or in combination with α-B, is not associated with incident UTUC.

Hematuria in the ER patient: optimizing detection of upper tract urothelial cancer - A pictorial essay

Upper tract urothelial carcinoma (UTUC) is a rare and challenging subset of the more frequently encountered urothelial carcinomas (UCs), comprising roughly 5-7% of all UCs and less than 10% of all renal tumors. Hematuria is a common presenting symptom in the emergency setting, often prompting imaging to rule out serious etiologies, with UTUC especially posing as a diagnostic challenge. These UTUC lesions of the kidney and ureter are often small, mimicking other pathologies, and are more aggressive than typical UC of the bladder, emphasizing the importance of timely and accurate diagnosis. Multidetector computed tomography urography (CTU) is the standard imaging modality for diagnosis, tumor staging, and surgical planning. Various postprocessing techniques like multiplanar reconstructions, maximal intensity projection (MIP) images, and 3D volumetric rendering technique (VRT) are crucial for accurate detection. In addition, 3D cinematic rendering (CR) is a novel technique that employs advanced illumination models, producing images with realistic shadows and increased surface detail, outperforming traditional VRT. We will review the distinctive imaging features between UTUC and infiltrating mimicking lesions on CTU in patients who presented with hematuria, in conjunction with advanced postprocessing techniques, ultimately improving diagnostic confidence and preoperative planning in the emergency context.

Intravesical Instillation of Chemotherapy Before Radical Surgery for Upper Urinary Tract Urothelial Carcinoma: The REBACARE Trial

BACKGROUND AND OBJECTIVE

Intravesical instillation of chemotherapy (IIC) after radical surgery for upper urinary tract urothelial carcinoma (UTUC) reduces the risk of intravesical recurrence (IVR). However, compliance is low because of possible extravesical leakage after bladder cuff excision. The aim of this study was to evaluate the efficacy of preoperative IIC in reducing the risk of IVR.

METHODS

In this prospective, single-arm, multi-institutional, phase 2 clinical trial, 190 chemonaïve patients with primary UTUC without prior or concurrent bladder cancer received a single intravesical instillation of mitomycin C for 1-2 hr within 3 h before surgery. The primary endpoint was the 2-yr histologically confirmed IVR rate, with a target reduction of >40% (from 33.2% according to literature data to <20%). A historical cohort of 247 patients with UTUC who did not receive perioperative IIC served as the reference. Secondary endpoints included compliance, toxicity, and IVR-free survival, which was analyzed via multivariable Cox regression and stratified by previous diagnostic ureteroscopy (d-URS).

KEY FINDINGS AND LIMITATIONS

The 2-yr IVR rate was 24% (95% confidence interval [CI] 18-31%) on intention-to-treat analysis and 23% (95% CI 13-32%) on per-protocol analysis. Multivariable analysis revealed that d-URS was associated with higher IVR risk. In the REBACARE cohort, patients without d-URS had threefold lower IVR risk (hazard ratio 0.33, 95% CI 0.12-0.87) in comparison to the reference cohort. Compliance with preoperative instillation was 96% and no grade >2 toxicity occurred.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Preoperative IIC with mitomycin C was feasible and well tolerated and significantly reduced IVR risk for patients without d-URS. These findings suggest that preoperative IIC is a viable strategy for this subset of UTUC patients and that d-URS should be performed judiciously.

The correlation between discrepancies in clinical and pathological T stages and overall survival in upper urinary tract urothelial carcinoma: Analysis of the hospital-based cancer registry data in Japan

OBJECTIVE

Our study assessed the correlation between discrepancies in clinical and pathological T stages and overall survival (OS) in patients with upper urinary tract urothelial carcinoma (UTUC), including renal pelvis (UCP) and ureter (UCU) carcinoma, treated with radical surgery.

METHODS

We utilized data from the Japanese Hospital-Based Cancer Registry (HBCR) to identify UTUC cases (n = 2376), consisting of UCP cases (n = 1196) and UCU cases (n = 1180), diagnosed with cTa-3N0M0 between 2012 and 2013. All cases were histologically confirmed and treated solely with radical surgery, excluding any chemotherapy or radiotherapy. We investigated the correlation between stage classification discrepancies and OS.

RESULTS

Among UCP and UCU patients, cT2N0M0 had the highest discrepancy rates between clinical and pathological stages (68% and 51%), while cT3N0M0 had the lowest (21% and 20%). Among UCP and UCU patients with cTa/is/1N0M0, those with up-staging showed significantly worse OS compared to same-staging (HR 1.7 and 2.5, p = 0.001 and <0.001, respectively). In UCU patients with cT2N0M0, the 5-year OS rates were 41.9% for up-staging, 63.7% for same-staging, and 76.4% for down-staging, with significantly worse survival in the up-staged group. Among UCP and UCU patients with cT3N0M0, the 5-year OS rates were 29.3% and 7.7% for those with up-staging, 53.7% and 30.6% for those with same staging, and 79.6% and 65.4% for those with down-staging.

CONCLUSION

Using a large real-world cohort, we found stage discrepancies to be a significant independent prognostic factor in non-metastatic UTUC patients. Treatment should be carefully selected, considering T-staging discrepancies and prognosis.

Drug classes associated with the development of fulminant type 1 diabetes: a retrospective analysis using the FDA adverse event reporting system database

BACKGROUND

Fulminant type 1 diabetes mellitus (FT1DM) is a severe subtype of type 1 diabetes characterized by rapid onset, metabolic disturbances, and irreversible insulin secretion failure. Recent studies have suggested associations between FT1DM and certain medications, warranting further investigation.

OBJECTIVES

This study aims to identify drugs associated with an increased risk of FT1DM using the FDA Adverse Event Reporting System (FAERS) database, evaluate reporting patterns, and provide actionable insights to reduce FT1DM occurrence and improve medication safety.

METHODS

A retrospective analysis of FAERS data from 2013 to 2023 was conducted. Drug names were standardized using text mining tools, and safety signals were evaluated using reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS).

RESULTS

A total of 706 FT1DM cases were identified, predominantly in older individuals and males. Nineteen drugs were implicated, including immune checkpoint inhibitors (nivolumab, ipilimumab, pembrolizumab, avelumab, durvalumab, atezolizumab), lenvatinib, eribulin, psychiatric drugs (atomoxetine, carbamazepine, lamotrigine), anti-infectives (sulfamethoxazole, trimethoprim, amoxicillin), and metabolic modulators (dapagliflozin, sitagliptin, hydrochlorothiazide, allopurinol).

CONCLUSION

This study highlights drugs potentially triggering FT1DM and emphasizes the need for pharmacovigilance and glucose monitoring in patients treated with these medications.

Preoperative Computed Tomography-Based Prediction and Patterns of Lymph Node Metastasis in Renal Pelvis and Ureteral Urothelial Carcinomas

Background/Objectives: The accurate preoperative prediction of lymph node (LN) metastasis is essential to optimizing surgical management in renal pelvis urothelial carcinoma (RPUC) and ureteral urothelial carcinoma (UUC). This study evaluates the predictive value of preoperative computed tomography (CT) findings in detecting LN metastasis and determining primary metastatic LN location based on the tumor site. Methods: This retrospective study included 48 RPUC and 97 UUC patients who underwent surgery with lymph node dissection (LND) between 2005 and 2023. Preoperative CT images were assessed for tumor size, location, multifocality, peritumoral fat infiltration, hydronephrosis grade, LN status, and metastatic LN location. Logistic regression and receiver operating characteristic (ROC) curve analyses identified predictive factors for LN metastasis, while Pearson's chi-square and Fisher's exact tests determined the association between locations of LN metastasis and primary tumor sites after categorizing UUC into upper and lower UUC. Results: In RPUC, 13 of 48 patients had LN metastasis, with tumor size and peritumoral fat infiltration emerging as significant predictors (p < 0.05). In UUC, 39 of 97 patients had LN metastasis, with tumor size and hydronephrosis grade being significant predictors (p < 0.001). An optimal tumor size threshold of 4 cm was identified for predicting LN metastasis in UUC, and 4.4 cm for RPUC. Additionally, a hydronephrosis grade of 3 or higher was found to be a strong predictor in UUC. ROC analysis showed high accuracy, yielding an AUC of 0.907 in RPUC and 0.904 in UUC. Cross-validation supported the robustness of these findings. Primary LN metastatic sites were predominantly ipsilateral hilar nodes in RPUC and ipsilateral pelvic nodes in lower UUC (p < 0.001). Conclusions: Preoperative CT imaging provides a reliable, noninvasive tool for predicting LN metastasis in RPUC and UUC. Identifying key imaging-based predictors can facilitate risk stratification and surgical decision-making, particularly regarding the necessity and extent of LND.

To explore the risk factors of lymphovascular invasion in patients with upper tract urothelial carcinoma and construct a prediction model

Background and objective

To explore the risk factors and construct a prediction model of the lymphovascular invasion (LVI) in patients with upper tract urothelial carcinoma (UTUC).

Methods

Clinical data of 143 UTUC patients treated in our hospital during Jan. 2010 and Dec. 2022 were retrospectively analyzed. The patients were divided into LVI positive group and LVI negative group according to the postoperative lymphovascular conditions. Kaplan-Meier method was used to evaluate the overall survival (OS) and cancer-specific survival (CSS) of the two groups, and the survival curve was drawn. The correlation between LVI and inclusion indexes was analyzed using univariate and ultivariate. A prediction model was established and receiver operating characteristic (ROC) curve was drawn to analyze the diagnostic value.

Results

The median survival time of LVI positive patients was 78 months (95%CI 44.47-111.53), lower than the 90months (95%CI 72.77-107.23) for LVI negative patients, and the 5-year OS of LVI positive patients was 53.0%, lower than that of LVI negative patients (79.6%). The difference was statistically significant (P=0.005). The 5-year CSS of LVI positive patients was 57.0%, lower than that of LVI negative patients (85.7%, P=0.009). The results of univariate analysis showed that there were statistically significant differences between the two groups (P < 0.05) in exfoliation cytology (P=0.044), hydronephrosis (P=0.015), preoperative fibrinogen level (P=0.003), lymph node status (P=0.014), pathological stage (P=0.001) and grade (P=0.047). Multivariate Logistic regression analysis showed that hydronephrosis (P=0.022), pathological stage (P < 0.001), lymph node status (P=0.025) and fibrinogen level (P=0.019) were independent factors influencing the occurrence of lymphovascular invasion, and the combination of four indexes above was better than any single index. the ROC curve showed that the area under the curve (AUC) of postoperative LVI was the largest when combined with the four predictors, and the AUC was 0.833 (95%CI 0.759-0.907). When the Youden index was 0.594, the sensitivity was 81.1%, and the specificity was 78.3%.

Conclusion

Lymphovascular invasion is related to hydronephrosis, pathological stage, lymph node condition and fibrinogen level. Patients with preoperative hydronephrosis, high pathological stage, lymph node metastasis and high fibrinogen level were at higher risk of lymphovascular invasion.

The Diagnostic Accuracy of the Paris System for Reporting Upper Urinary Tract Cytology: The Atypical Urothelial Cell Conundrum

BACKGROUND

The diagnosis of upper urinary tract urothelial carcinoma (UTUC) in cytological specimens is challenging, particularly the designation of atypical urothelial cells (AUC). The application of the Paris System for Reporting Urinary Cytology (TPS) has improved the performance of lower tract urothelial carcinoma specimens but has shown variable results in upper tract specimens, which are frequently instrumented.

METHODS

This retrospective study analysed upper tract selective cytology samples from January to December 2023. Samples were classified under TPS 2.0 categories. Histological specimens were used where available as the gold standard to calculate statistical metrics including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Out of 122 samples, 12.2% were considered non-diagnostic or insufficient, with 13.1% designated as Non-high-grade urothelial carcinoma (N-HGUC), 53.3% as atypical urothelial cells (AUC) and 21.3% as positive/suspicious for HGUC. Histopathological correlation was available for 48.7% of cases. The risk of malignancy was: NHGUC (0%), AUC (47%) and HGUC (77.7%). The highest PPV was for HGUC (78%), with a diagnostic accuracy of 81.3% and specificity of 88%. In contrast, AUC had a PPV of 47% in instrumented and non-instrumented samples, rising to 58% in combination with the HGUC category.

CONCLUSION

TPS 2.0 is an effective tool with excellent diagnostic accuracy for HGUC and in excluding malignancies in the N-HGUC category, but in our hands, the high rates of the AUC category, together with the low PPV, remain a major challenge and an obstacle to the correct stratification of patients with UTUC.

Development and validation of a predictive model for postoperative metastasis of upper tract urothelial carcinoma after radical nephroureterectomy and analysis of risk factors for different metastatic sites: a multicenter study

PURPOSE

To develop a prediction model for assessing the risk of postoperative metastasis in upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU) and to analyze independent risk factors for metastasis at different sites.

METHODS

We retrospectively analyzed data from 555 UTUC patients who underwent RNU at 3 medical centers between January 2012 and August 2023. Patients were randomly divided into a training cohort (n = 388) and a validation cohort (n = 167) at a 7:3 ratio. Univariate and multivariate Cox regression analyses were performed in the training cohort to identify postoperative metastasis risk factors. A nomogram was developed based on these factors and validated. In addition, independent risk factors for metastasis at different sites were analyzed.

RESULTS

Among the 555 patients, 122 (22.0%) developed postoperative metastasis. Middle and lower ureteral tumors, T stage ≥ T3, high-grade tumors, lymphovascular invasion (LVI), and a prognostic nutritional index (PNI) < 48.75 were associated with poorer metastasis-free survival (MFS). The nomogram achieved C-indexes of 0.816 and 0.812 in the training and validation cohorts. Age < 65 years was a risk factor for lymph node metastasis, tumor size and necrosis predicted liver metastasis, and a higher preoperative platelet-to-lymphocyte ratio (PLR) was associated with bone metastasis. Median overall survival (OS) for lymph node, lung, liver, multiple sites, bone, and brain metastasis were 14, 10, 6, 5.5, 5, and 4.5 months, respectively.

CONCLUSION

The prediction model developed effectively assesses postoperative metastasis risk in UTUC patients' aids in guiding individualized treatment. The risk factors for different metastasis sites are generally similar, with slight variations, which may offer new directions for future research on site-specific therapeutic strategies.

Geriatric Nutritional Risk Index as a prognostic marker for predicting survival outcomes in patients with UTUC after radical nephroureterectomy

The purpose of this study was to determine the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in patients with upper tract urothelial carcinoma (UTUC) after radical nephrectomy (RNU). A retrospective study of UTUC patients was conducted at West China Hospital between May 2016 and June 2019. The optimal cut-off point for GNRI was determined using the X-Tile procedure. Univariate and multivariate analyses were performed to identify predictors, and two- and four-year cancer-specific survival (CSS) prediction nomograms were created based on the results of the multivariate analyses. Furthermore, time-dependent ROC curve, calibration curve and decision curve analyses were conducted. A total of 219 patients with UTUC following RNU were identified and subsequently divided into three groups based on the critical values of GNRI (91.2, 98.8). GNRI was identified as a significant risk factor for CSS, with patients exhibiting higher GNRI demonstrating elevated CSS (hazard ratio = 0.58; 95% confidence interval, 0.32-0.92; P = 0.037). Furthermore, the GNRI-based nomogram demonstrated high predictive capacity for CSS, with areas under the curve of 0.810 and 0.842 for 2- and 4-year CSS, respectively. Preoperative GNRI is an independent predictor for CSS in UTUC patients who underwent RNU and should be considered as a promising personalized tool for clinical decision-making.

Long term survival in elderly patients with resectable upper tract urothelial carcinoma: analysis of hospital-based cancer registry data in Japan

BACKGROUND

To clarify the long-term prognoses of elderly upper tract urothelial carcinoma (UTUC) patients after surgery.

METHODS

We used a hospital-based cancer registry data in Japan to extract patients with pT1-3N0M0 UTUC diagnosed in 2009 who underwent surgery, and classified them by age group (≤ 64, 65-74, ≥ 75 years old). We estimated the 10-year overall survival (OS) by a Kaplan-Meier analysis. For cancer survival estimation, we calculated the 10-year net survival (NS) by Pohar-Preme method using the Japanese life tables.

RESULTS

A total of 1139 UTUC patients (564 renal pelvic cancer [RPC] and 575 ureteral cancer [UrC]) were identified. The 10-year OS rates for elderly RPC patients (≥ 75 years old) were significantly worse than for younger patients (≤ 64 years old) in pT1 (43.1% vs. 80.1%) and pT2-3 (34.2% vs. 67.3%) stages. In contrast, the 10-year NS rates were comparable between elderly and younger RPC groups in pT1 (93.3% vs. 87.0%) and T2-3 (77.4% vs. 73.7%) stages. While the 10-year NS and OS rates of patients with pT1 UrC had similar trends as RPC patients, the NS and OS rates of elderly patients with pT2-3 UrC were significantly worse than younger patients.

CONCLUSIONS

Among resectable UTUC, except for pT2-3 UrC patients, estimated cancer survival rates for elderly patients were similar to younger patients. These findings may be useful in shared decision making by informing discussions about treatment strategies with elderly patients and their families.

The impact of post-nephroureterectomy surgically induced chronic kidney disease on survival outcomes

OBJECTIVE

To investigate the prevalence, predictors and impact of surgically induced chronic kidney disease (CKD-S) on survival outcomes in patients with upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU).

METHODS

Utilising the ROBUUST 2.0 registry, a multicentre retrospective analysis was conducted in patients with UTUC undergoing RNU between 2006 and 2022 who did not have baseline chronic kidney disease (CKD) stages 3-5. We calculated the prevalence of postoperative CKD-S3a (estimated glomerular filtration rate [eGFR] 59-45 mL/min/1.73 m2) and CKD-S3b (eGFR <45 mL/min/1.73 m2) as measured by the Chronic Kidney Disease Epidemiology Collaboration 2021 equation. The analytical cohort was stratified by postoperative CKD stage [no CKD-S [eGFR ≥60 mL/min/1.73 m2]; CKD-S3a [eGFR 59-45 mL/min/1.73 m2] and CKD-S3b [eGFR <45 mL/min/1.73 m2]). The primary outcome was all-cause mortality (ACM). Predictors for development of CKD-S3a/3b and ACM/cancer-specific mortality (CSM) were analysed using logistic and Cox regression, respectively. Kaplan-Meier analysis was used to analyse overall survival (OS) and cancer-specific survival (CSS) among postoperative CKD groups.

RESULTS

We analysed 1862 patients; 34.7% (646) and 39.6% (738), respectively, developed CKD-S3a and CKD-S3b. Predictors of CKD-S3b included increasing age (odds ratio [OR] 1.03, P = 0.029), decreasing preoperative eGFR (OR 1.06, P < 0.001) and receipt of neoadjuvant (OR 2.07, P = 0.006) and adjuvant chemotherapy (OR 1.41, P = 0.012). Worsened ACM was associated with CKD-S3b (hazard ratio 1.42, P = 0.032), but not CKD-S3a (P = 0.766). Development of CKD-S3a (P = 0.812) and CKD-S3b (P = 0.316) were not associated with CSM. The 5-year OS rate was significantly worse in CKD-S3b (no-CKD 71%, CKD-S3a 70%, CKD-S3b 59%; P = 0.017). No differences between CKD-S groups were noted for 5-year CSS (no-CKD 78%, CKD-S3a 77%, CKD-S3b 82%; P = 0.44).

CONCLUSIONS

A significant proportion of UTUC patients undergoing RNU developed CKD-S. Development of CKD-S3b was associated with worse ACM. Increasing age, preoperative eGFR, and chemotherapy were associated with developing CKD-S3b. Our findings call for further exploration and refinement of nephron-preserving surgical strategies and non-nephrotoxic systemic therapy to improve survival outcomes in UTUC.

Sarcomatoid renal pelvis carcinoma: A case report

Sarcomatoid carcinoma is a malignant tumor of epithelial origin, some of the cells of which are differentiated in a sarcomatoid direction and are highly invasive. Sarcomatoid renal pelvis carcinoma (SRPC) is very rare. This article reports on an elderly woman with SRPC and discusses the clinical and pathological features and prognosis of SRPC in the hope of providing a reference for the diagnosis and treatment of this disease.

Updates on Urothelial Carcinoma of the Upper Urinary Tract with a Focus on Molecular Findings

Urothelial carcinoma (UC) of the upper urinary tract (UUT) is rare, constituting 5% to 10% of UCs, with a higher prevalence in males and older adults. It encompasses various subtypes and, unlike UC of the bladder, often presents as invasive disease. Molecular studies reveal frequent FGFR3 and TP53 mutations, guiding therapeutic strategies. Lynch Syndrome (LS), a hereditary condition, significantly contributes to UUT UC, especially in young patients. Current treatments emphasize platinum-based chemotherapy post-surgery, though immunotherapy shows promise, especially in LS cases. Further molecular insights are crucial for improving diagnosis and treatment.

Individualizing first-line treatment for advanced urothelial carcinoma: A favorable dilemma for patients and physicians

The treatment landscape for patients with advanced urothelial carcinoma (UC) has evolved rapidly in recent years. In current guidelines, combination treatment with enfortumab vedotin plus pembrolizumab is the first-line (1L) standard of care, and other recommended 1L treatment options are platinum-based chemotherapy followed by avelumab as switch-maintenance treatment in patients without progression, or combination treatment with nivolumab, cisplatin, and gemcitabine for cisplatin-eligible patients only. Individual patients differ in terms of their health status, disease characteristics, expected toxicities, and treatment preferences; thus, a "one-size-fits-all" approach to treatment is unlikely to be optimal. The availability of several treatment options creates the potential for individualized treatment. In this review, we discuss factors that may be considered when selecting 1L treatment for patients with advanced UC, including efficacy and safety data from phase 3 trials and real-world studies, quality of life, patient priorities for treatment, patient and disease characteristics, treatment sequencing, biomarkers, and treatment access and cost. Patients and physicians should discuss the benefit-risk balance of all available 1L options to enable shared decision-making. Longer follow-up from clinical trials and additional real-world studies are needed to further inform treatment selection.

Adjuvant immunotherapy in high-risk muscle invasive urothelial carcinoma: A systematic review and meta-analysis of randomized clinical trials

Despite surgical resection, many patients with muscle invasive urothelial carcinoma (MIUC) experience recurrence. Adjuvant immune checkpoint inhibition (ICI) following radical resection in patients with MIUC demonstrates disparate outcomes among phase III randomized controlled trials (RCTs). Our objective was to synthesize available data regarding the disease-free survival (DFS) benefit of adjuvant ICIs for patients with MIUC and evaluate the overall safety profile of ICIs in this setting. The protocol was registered with PROSPERO, CRD42022352587. We searched MEDLINE, Embase, CENTRAL, and relevant conference proceedings from inception up to January 29, 2024. Only phase III RCTs comparing adjuvant ICI versus placebo/observation were selected. Study screening and selection, along with data extraction was performed in duplicate according to a predefined registered protocol. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used. Quality assessment was performed using the Cochrane risk-of-bias (RoB 2) tool for randomized trials. The primary and secondary endpoints were DFS and serious adverse events, respectively. All outcomes were analyzed using random-effects meta-analysis owing to inter-study heterogeneity. Sensitivity and subgroup analyses were performed to identify potential sources of heterogeneity. A priori defined subgroups of interest included positive program death-ligand 1 (PD-L1) expression, previous use of neoadjuvant chemotherapy (NAC), primary tumor origin, pathologic lymph node status, and baseline Eastern Cooperative Oncology Group performance status. Pooled results across the 3 RCTs (2,220 patients) demonstrated significantly improved DFS for patients treated with ICI in the intention-to-treat cohorts (HR 0.76, 95% CI 0.65-0.90). There was considerable clinical and statistical heterogeneity (I2 = 44%) due to differences in inclusion criteria and interventions. Overall, there was a low risk of bias among the RCTs. Regarding subgroup analyses, there was significant benefit among patients with negative PD-L1 expression (HR 0.76, 95% CI 0.64-0.90), those who received prior NAC (HR 0.69, 95% CI 0.52-0.91), and patients with lower tract (HR 0.71, 95% CI 0.55-0.92) but not upper tract disease (HR 1.21, 95% CI 0.87-1.68). This pooled analysis of DFS and safety provides support for ICI utilization in the setting of high-risk resected MIUC.

Single-Cell RNA Sequencing Reveals the Tumor Heterogeneity and Immunosuppressive Microenvironment in Urothelial Carcinoma

Urothelial carcinoma (UC) can arise from either the lower urinary tract or the upper tract; they represent different disease entities and require different clinical treatment strategies. A full understanding of the cellular characteristics in UC may guide the development of novel therapies. Here, we performed single-cell transcriptome analysis from four patients with UC of the bladder (UCB), five patients with UC of the ureter (UCU), and four patients with UC of the renal pelvis (UCRP) to develop a comprehensive cell atlas of UC. We found the rare epithelial cell subtype EP9 with epithelial-to-mesenchymal transition (EMT) and cancer stem cell (CSC) features, and specifically expressed SOX6, which was associated with poor prognosis. We also found that ACKR1+ endothelial cells and inflammatory cancer-associated fibroblasts (iCAFs) were more enriched in UCU, which may promote pathogenesis. While ESM1+ endothelial cells may more actively participate in UCB and UCRP tumorigenesis by promoting angiogenesis. Additionally, CD8 + effector T cells were more enriched in UCU and UCRP patients, while Tregs were mainly enriched in UCB tumors. C1QC+ macrophages and LAMP3+ dendritic cells were more enriched in UCB, which is closely related to the formation of the heterogeneous immunosuppressive microenvironment. Furthermore, we found strong interactions between iCAFs, EP9, and Endo_ESM1, and different degrees of activation of the FGF-FGFR3 axis and immune checkpoint pathway were observed in different UC subtypes. Our study elucidated the cellular heterogeneity and the components of the microenvironment in UC arising from the upper and lower urinary tracts and provided novel therapeutic targets.

The role of intravesical chemotherapy following nephroureterectomy in upper tract urothelial carcinoma: A systematic review and meta-analysis

INTRODUCTION

Intravesical recurrence of upper tract urothelial carcinoma after radical nephroureterectomy occurs in 22% to 47%. Intravesical chemotherapy is still underused due to concerns about its efficacy and safety. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of intravesical chemotherapy regimens in reducing the risk of intravesical recurrence following radical nephroureterectomy.

MATERIALS AND METHODS

A literature search was conducted using PubMed/Medline, Embase, and Web of Science databases to identify reports published until March 2024. The PRISMA guidelines were followed to identify eligible studies. The outcomes measured were intravesical recurrence rates and complications in patients treated with different intravesical instillation chemotherapy and timing after radical nephroureterectomy. Sub-analyses were performed on randomized controlled trials and studies involving patients with no history of bladder cancer.

RESULTS

Eighteen studies met our inclusion criteria, and data from 2,483 patients were reviewed. Intravesical chemotherapy significantly reduced the risk of intravesical recurrence at 12 months (OR = 0.46; 95% CI: 0.33-0.65; P < 0.001;) and at 24 months (OR = 0.41, 95% CI: 0.28-0.61; P < 0.001). Notably, no association was found when confronting intra and postoperative instillations (OR = 0.66; 95% CI: 0.34-1.28; P = 0.2), nor single vs. multiple instillation (OR = 1.37; 95% CI: 0.75-2.50; P = 0.3). The pooled rate for minor and major complications was 9% and 0.9%, respectively.

CONCLUSION

This study demonstrates that intravesical chemotherapy significantly reduces intravesical recurrence rates after radical nephroureterectomy at 12 and 24 months. Additionally, it underscores the favorable safety profile of intravesical chemotherapy, with a low incidence of major complications. The ideal instillation scheme and chemotherapy agent should be further defined.

Mixed Neuroendocrine Carcinoma and Urothelial Carcinoma of the Upper Urinary Tract: A Case Report and Literature Review

We describe a rare case of high-grade divergent urothelial carcinoma (UC) of the renal pelvis with neuroendocrine differentiation, specifically a small cell carcinoma (SCC) component. A 70-year-old male who presented with frank hematuria underwent a thorough clinical workup including computed tomography (CT) scan, which showed a large, contrast-enhancing obstructive right renal mass. The mass, when analyzed microscopically, showed two distinct components: high-grade urothelial carcinoma and SCC. Immunohistochemistry analysis confirmed primary dual morphological subtypes and ruled out a metastatic source. Mixed SCC and UC of the renal pelvis are extremely rare diagnoses, and staging of these tumors is difficult, highlighting the importance of integrated diagnostic approaches for an accurate characterization of complex renal tumors.

Risk-adapted scoring model to identify candidates benefiting from adjuvant chemotherapy after radical nephroureterectomy for localized upper urinary tract urothelial carcinoma: A multicenter study

PURPOSE

Adjuvant chemotherapy (AC) is recommended for muscle-invasive or lymph node-positive upper urinary tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). However, disease recurrences are frequently observed in pT1 disease, and AC may increase the risk of overtreatment in pT2 UTUC patients. This study aimed to validate a risk-adapted scoring model for selecting UTUC patients with ≤pT2 disease who would benefit from AC.

MATERIALS AND METHODS

We retrospectively analyzed 443 ≤pT2 UTUC patients who underwent RNU. A risk-adapted scoring model was applied, categorizing patients into low- or high-risk groups. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were analyzed according to risk group.

RESULTS

Overall, 355 patients (80.1%) and 88 patients (19.9%) were categorized into the low- and high-risk groups, respectively, with the latter having higher pathological stages, concurrent carcinoma in situ, and synchronous bladder tumors. Disease recurrence occurred in 45 patients (10.2%), among whom 19 (5.4%) and 26 (29.5%) belonged to the low- and high-risk groups, respectively (p<0.001). High-risk patients had significantly shorter RFS (64.3% vs. 93.6% at 60 months; hazard ratio [HR] 13.66; p<0.001) and worse CSS (80.7% vs. 91.5% at 60 months; HR 4.25; p=0.002). Multivariate analysis confirmed that pT2 stage and the high-risk group were independent predictors of recurrence and cancer-specific death (p<0.001). Decision curve analysis for RFS showed larger net benefits with our model than with the T stage model.

CONCLUSIONS

The risk-adapted scoring model effectively predicts recurrence and identifies optimal candidates for AC post RNU in non-metastatic UTUC.

Effectiveness and safety of adjuvant treatment of tislelizumab with or without chemotherapy in patients with high-risk upper tract urothelial carcinoma: a retrospective, real-world study

BACKGROUND

Upper tract urothelial carcinoma (UTUC) is a rare subset of urothelial cancers with poor prognosis. No consensus exists on the benefit of adjuvant immunotherapy for patients with UTUCs after nephroureterectomy with curative intent and the existing studies are limited. Herein, this study aimed to evaluate the effectiveness and safety of adjuvant treatment of tislelizumab with or without chemotherapy in patients with high-risk UTUC.

METHODS

A retrospective study was conducted on 63 patients with high-risk UTUC who received tislelizumab with or without gemcitabine-cisplatin (GC) chemotherapy regimen after surgery between January 2020 and December 2022. Data on demographic and clinical characteristics, surgical, outcomes, prognostic factors, and safety were collected and analyzed.

RESULTS

Among the 63 patients with high-risk UTUC, the median age was 66 years (interquartile range 57-72), with 33 (52%) being male. The majority of patients with staged pT3 (44%) and pN0 (78%) disease. Fifty-one patients (81%) received tislelizumab plus GC chemotherapy, and 12 (19%) were treated with tislelizumab monotherapy. After the median follow-up of 26 months (range 1-47), 49 (78%) patients achieved stable disease. The 2-year disease-free survival (DFS) and 2-year overall survival were 78.68% (95% CI: 60.02-87.07%) and 81.40% (95% CI: 68.76-89.31%), respectively. The cycles of GC chemotherapy were independent prognostic factors for survival, with higher DFS (hazard ratio = 0.68, 95% CI, 0.50-0.93; p = 0.016) observed in the subgroup undergoing ≥ 3 cycles versus < 3 cycles of GC chemotherapy. Fifty-eight patients (92%) experienced at least one treatment-related adverse event (TRAE), with grade 3-4 TRAEs occurring in 13%. The most common grade 3-4 TRAEs were decreased white blood cells, thrombocytopenia, and ulcers.

CONCLUSIONS

The study demonstrates promising clinical benefits and a manageable safety profile of the tislelizumab-based adjuvant regimen for patients with high-risk UTUC. This suggests that adjuvant immunotherapy represents a potential therapeutic strategy for this population.

The effectiveness and safety of RC48 alone or in combination with PD-1 inhibitors for locally advanced or metastatic urothelial carcinoma: a multicenter, real-world study

BACKGROUND

RC48 is an antibody-drug conjugate (ADC) specifically targeting HER2. Phase II and III clinical trials have proven its significant anti-tumor effect against locally advanced or metastatic urothelial carcinoma (la/mUC). This study aims to further assess the effectiveness and safety of RC48 for patients with la/mUC and provide insights for further clinical practice.

METHODS

Retrospective analysis for 42 patients with la/mUC who underwent RC48 alone or in combination with PD-1 inhibitors therapy between 18 October 2022 and 1 May 2024 were conducted to assess effectiveness and safety of RC48. Descriptive statistics were used to summarize baseline characteristics, treatment-related adverse events, etc. Cox proportional risk model and the Kaplan-Meier method were applied to analyze patients' survival.

RESULTS

We observed a median progression-free survival (mPFS) of 6.2 months, although median overall survival (mOS) has not been reached so far. An objective response rate (ORR) of 54.8% and a disease control rate (DCR) of 83.3% was also observed. Patients with first-line therapy, second- or later-line therapy and neoadjuvant therapy were observed disease remission with ORRs of 47.7%, 40.0% and 100.0%, respectively. The most common treatment-related adverse events (TRAEs) include hypoesthesia and elevated transaminases which affect over 90.0% of patients and mostly grade 1-2 in severity, and no treatment-related fatalities were found.

CONCLUSIONS

This multicenter, real-world study confirms that RC48 alone or in combination with PD-1 inhibitors exerted a promising effectiveness and manageable safety for first-line, second- and post-line, and neoadjuvant therapy with la/mUC.

The surgical technique and efficacy of a novel pure retroperitoneoscopic extravesical bladder cuff excision without intraoperative repositioning for upper tract urothelial carcinoma

To evaluate the feasibility, effectiveness and therapeutic outcomes of a novel pure retroperitoneoscopic extravesical bladder cuff excision (PREBE) in patients with upper tract urothelial carcinoma (UTUC), a retrospectively comparative study between PREBE and traditional laparoscopic nephroureterectomy (TLNU) was done in a single center. We retrospectively evaluated 72 patients diagnosed with UTUC at our hospital from January 2022 to January 2024. The patients who underwent TLNU (n = 35) and PREBE (n = 37) were consecutively enrolled. The kidney and bladder cuff were retroperitoneoscopically dissected and the bladder was repaired with needle sutures under retroperitoneoscopic in the PREBE group. Demographic, perioperative, and follow-up data were collected and compared between the two groups. Both procedures were performed effectively in 72 patients without converting to open surgery. The PREBE group exhibited shorter mean operative time (P < 0.01), less mean estimated blood loss (EBL) (P < 0.01), shorter median drainage tube removal time, shorter median first postoperative defecation (FPD) time (P < 0.01) and shorter median postoperative hospital stay (P < 0.01). However, there was no statistical difference in postoperative pathological results or in the incidence of intravesical recurrence between the two groups. The mean follow-up time was 13.8 months for the PREBE group and 14.4 months for the TLNU group. The PREBE is a safe and effective treatment for patients with UTUC, avoiding intraoperative patient repositioning while offering better perioperative outcomes to those of traditional techniques.

Comparative Analysis of Long-Term Renal Outcomes in Upper Tract Urothelial Carcinoma: Local Ablation Versus Radical Nephroureterectomy

(1) Background: Upper tract urothelial carcinoma (UTUC) is typically managed through radical nephroureterectomy (RNU) or local ablation (LA). Compared to RNU, LA offers nephron-sparing benefit for select patients but may present increased recurrence risk. This study primarily compares long-term differences between LA and RNU in chronic kidney disease (CKD) progression, estimated glomerular filtration rate (eGFR) decline, all-cause mortality, and need for dialysis. (2) Methods: A retrospective cohort study was conducted using the TriNetX database, examining patients with UTUC treated with RNU (n = 2007) or LA (n = 4172). Propensity score matching balanced both cohorts (n = 1965 per group). Risk ratios and hazard ratios with 95% confidence intervals were calculated over 10 years. (3) Results: At 10 years, LA preserved higher mean eGFR (53.49 vs. 46.72; p < 0.001) and lower mean creatinine (1.56 vs. 1.66; p = 0.017). However, LA held a higher incidence of end-stage renal disease (ESRD) (3.6% vs. 2.2%, p = 0.008) and all-cause mortality (26.7% vs. 23.5%, p = 0.016). There was no significant difference in rates of dialysis (p = 0.79). (4) Conclusions: RNU did not carry an increased risk of ESRD, advanced stages of CKD, need for renal dialysis, or overall mortality compared with LA. LA may delay but not totally prevent renal dysfunction when compared to RNU, and exhibits a more gradual timeline.

Impact of upper tract urothelial carcinoma history on patients with non-muscle invasive bladder cancer undergoing intravesical chemotherapy

This study was designed to evaluate the impact of upper tract urothelial carcinoma (UTUC) history on prognosis in patients with non-muscle-invasive bladder cancer (NMIBC) receiving intravesical chemotherapy. We conducted a single center, retrospective, cohort study of 444 NMIBC patients who received intravesical chemotherapy after transurethral resection of the bladder cancer (TURBT) at Peking University People's Hospital from 2000 to 2015. Patients were divided into UTUC-NMIBC group (with UTUC history) and primary NMIBC group (without UTUC history) by presence of previous UTUC. Demographic, clinical and pathologic factors were analyzed. Kaplan-Meier curves and the log-rank test were used to depict and compare recurrence-free survival (RFS) and progression-free survival (PFS) between the two groups. Multivariable Cox regression models were constructed to determine the variables associated with RFS and PFS. Compared to the primary NMIBC group (n = 410), the UTUC-NMIBC group (n = 34) had an older median age [72.0 (65.0-81.0) vs. 66.0 (58-75) years; P = 0.007], a higher incidence of multiple tumors (52.9% vs. 33.9%; P = 0.026) and a higher recurrence rate (52.9% vs. 30.7%; P = 0.008) and worse RFS (P < 0.001). In multivariate analysis, UTUC history was an independent risk factor for recurrence (hazard ratio = 2.242; P = 0.001), but not for progression. Interestingly, subgroup analysis indicated patients with recent UTUC history (≤ 24 months between UTUC and NMIBC diagnoses) were associated with increased recurrence rates (73.7% vs. 26.7%; P = 0.014). Presence of UTUC history was an independent risk factor for recurrence in patients with NMIBC who received intravesical chemotherapy, especially in those with a shorter interval between UTUC and NMIBC diagnoses.

Risk Factors Predictive of Contralateral Recurrence of Upper Tract Urothelial Carcinoma Include Chronic Kidney Diseases and Postoperative Initiation of Dialysis

BACKGROUND

The objective of the present study was to evaluate the impact of dialysis on patients with upper tract urothelial carcinoma (UTUC) who are undergoing surgical intervention, as well as to identify predictive factors linked to contralateral recurrence.

METHODS

A retrospective review was conducted on patients who underwent radical nephroureterectomy (RNU) for non-metastatic UTUC at our institution from 2000 to 2013. The contralateral recurrence rate was calculated using the Kaplan-Meier method, and multivariate logistic regression analysis was employed to examine the relationship between clinicopathological characteristics and contralateral recurrence.

RESULTS

A total of 593 patients were included in this analysis, of which 31 (5.8%) experienced metachronous recurrence on the contralateral side. Kaplan-Meier analysis indicated a statistically significant reduction in the contralateral recurrence-free survival rate among female patients (p = 0.040), those with a prior history of bladder cancer (p < 0.001), individuals presenting with multiple tumors (p = 0.011), patients with advanced chronic kidney disease (CKD) (p < 0.001), and those requiring postoperative dialysis (p < 0.001). In contrast, preoperative hemodialysis status did not show a significant correlation with contralateral recurrence (p = 0.08). The multivariate analysis identified a history of bladder cancer (hazard ratio (HR), 3.19; 95% confidence interval (CI), 1.2-8.4; p = 0.018), the necessity for new hemodialysis postoperatively (HR, 5.34; 95% CI, 1.3-25.6; p = 0.034), and advanced CKD (HR, 2.52; 95% CI, 1.4-4.9; p = 0.021) as independent risk factors associated with an increased rate of contralateral recurrence.

CONCLUSIONS

In conclusion, advanced CKD, a history of bladder cancer, and the initiation of new dialysis following surgery were identified as independent prognostic indicators for contralateral recurrence in patients with initial unilateral UTUC undergoing RNU. It is recommended that patients exhibiting these three adverse characteristics undergo rigorous monitoring of the contralateral upper urinary tract throughout the follow-up period.

Minimally Invasive One-Docking, Two-Target, and Three-Port Robotic-Assisted Nephroureterectomy: Redefining Surgical Approach

OBJECTIVE

Nephroureterectomy (NU) is a challenging multi-quadrant surgical procedure that involves intra-infra- and retroperitoneal dissection. The introduction of the da Vinci Xi platform has further improved the minimally invasive approach. With the Xi robotic system, single docking for multi-quadrant dissection is now feasible and increasingly popular. Herein, we redefined the surgical technique by optimizing minimal port usage, maximizing template visualization, and utilizing the Xi platform's retargeting system, based on our experience with 15 patients.

METHODS

This single-center cohort study was based on the experience of a single surgeon with 15 patients who underwent robotic radical nephroureterectomy (RRNU) between 2019 and 2024, performed via the one docking, three-port technique. Patient data were retrospectively collected and analyzed from the medical records.

RESULTS

The cohort's median age was 79 years, with male predominance of 80%. The median operative time was 133 min, with 60% of procedures completed within 150 min; longer times (>150 min) were due to additional intraoperative non-robotic procedures. Median blood loss was 100 mL, with two patients requiring intraoperative blood transfusion. Lymph node dissection (LND) in six patients did not significantly affect the overall operative time. The intraoperative and major postoperative complication rates (Clavien-Dindo grade > III) were 13.3%.

CONCLUSIONS

The use of three robotic ports combined with the Xi platform's camera-hop feature is a safe and effective technique for multi-quadrant, minimally invasive procedures, particularly in RRNU. This approach facilitates procedural goals and reduces overall operative time.

Fluorinated chitosan mediated transepithelial delivery of sanguinarine-loaded platinum (IV) prodrug for intravesical instillation therapy of muscle-invasive bladder cancer

Cisplatin-based neoadjuvant chemotherapy is first-line strategy to inhibit progression and metastasis of muscle-invasive bladder cancer (MIBC). However, its clinical efficacy is often limited by drug resistance and severe systemic side effects, highlighting the urgent need for innovative therapeutic approaches. Despite advancements in cisplatin-based regimens, research on intravesical cisplatin delivery systems remains scarce. In this study, we developed an amphiphilic platinum(IV) prodrug micellar platform (Pt (IV)-DI-PEG) capable of efficiently encapsulating sanguinarine (San), which was further coated with fluorinated chitosan (FCS) to construct San@Pt(IV)-DI-PEG@FCS nanoparticles (SPFNPs) for intravesical instillation even targeting MIBC. The resulting SPFNPs demonstrated several advantages: the FCS coating facilitated enhanced trans-epithelial drug delivery by regulating bladder epithelial tight junction proteins, enabling efficient intravesical administration; Second, the glutathione (GSH)-responsive reduction of the Pt(IV) prodrug promoted tumor-targeted release of San and localized accumulation of Pt(II), while simultaneously depleting intracellular GSH. Furthermore, the released San induced reactive oxygen species (ROS) production, oxidative cleavage and inhibit the activation and function of poly (ADP-ribose) polymerase, collectively impairing nucleotide-excision repair and preventing the elimination of Pt-DNA adducts, resulting in persistent DNA damage, cell cycle arrest, and apoptosis in tumor cells. The synergistic effects of San and cisplatin were validated in both orthotopic mouse models and patient-derived orthotopic xenograft, demonstrating robust anti-tumor efficacy. This study underscores the potential of intravesical cisplatin formulations as a promising strategy for MIBC treatment, offering a shift from traditional systemic chemotherapy towards localized, targeted drug delivery systems.

Clinical and molecular analysis of JCPyV and BKPyV infection and associated risk of urothelial carcinoma development in the upper tract

BACKGROUND

Human polyomaviruses (HPyVs), JC polyomavirus (JCPyV) and BK polyomavirus (BKPyV), have been found in upper tract urothelial carcinoma UTUC; however, the association of the viral oncogenic factors and clinical characteristics of UTUC remains unclear. This study aimed to investigate the prevalence of JCPyV and BKPyV in UTUC and their correlation with cancer progression among the southwest Taiwanese population from 2020 to 2022.

METHODS

A total of 72 paraffin-embedded UTUC tissue samples and 41 adjacent tissue samples were collected from 72 patients. Nested polymerase chain reaction and DNA sequencing were used to detect viral DNA and genotypes. Immunohistochemistry was performed using anti- large T (LT) and anti-p53 monoclonal antibodies to detect the expression of viral early LT protein and cellular p53 protein, respectively.

RESULTS

The overall prevalence of JCPyV and BKPyV were higher in UTUC than in adjacent tissue samples (65.3% [47/72] vs. 17.1% [7/41]). JCPyV and BKPyV were detected in 95.7% (45/47) and 4.3% (2/47) of the HPyVs-positive UTUC samples, respectively. JCPyV-TW-3 was the predominant strain of JCPyV infection. In UTUC samples, the LT protein of JCPyV and BKPyV positivity rate was 65.3%, while that of mutant p53 protein was 52.7%. JCPyV infection and LT protein expression increased the odds ratio (OR) of UTUC by 9.13-fold. The OR of UTUC was higher by 10.34-fold in patients with mutant p53 and by 10.37-fold in those with simultaneous LT and mutant p53 expression. The presence of LT protein in UTUC patients may increase the OR of mutant p53 protein expression by 2.93-fold compared to its absence. Women had a 5.19-fold higher superiority of JCPyV infection and LT expression than men. Patients with chronic kidney disease (CKD) had a 3.15-fold higher OR for mutant p53 protein expression than those without it. In the UTUC advanced stages, the OR of virus and LT expression was 3.18-fold higher compared to those who do not require chemotherapy.

CONCLUSIONS

JCPyV infection is highly prevalent in UTUC, and the presence of CKD concurrent with high expressions of LT and mutant p53 proteins in patients may be a useful indicator for chemotherapy and poor prognosis.

Clinical outcomes of nephroureterectomy with bladder cuff excision or radical cystectomy for distal ureteral carcinoma invaded muscle of the ureteral orifice

PURPOSE

To present the clinical outcomes of nephroureterectomy with bladder cuff excision (NU-BCE) or radical cystectomy (NU-RC) when distal ureteral carcinoma invaded muscle of the ureteral orifice using inverse probability of treatment weighting (IPTW).

METHODS

This multicenter study retrospectively studied the demographics and perioperative outcomes of 59 patients who underwent NU-BCE or NU-RC between 2003 and 2024. Relapse-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were presented using Kaplan-Meier curves. Cox proportional hazard regression to find independent predictors.

RESULTS

Of all patients, the median follow-up time for RFS was 8 months and 18 months for CSS and OS. After IPTW, the median RFS, CSS, and OS for patients who underwent NU-BCE and NU-RC was 9 vs. 27 months (p = 0.037), 18 vs. 40 months (p = 0.027), 18 vs. 30 months (p = 0.371), respectively. The mortality due to progression and complications in NU-BCE and NU-RC patients were 56.4% vs. 20.4% and 2.2% vs. 22.9% (p = 0.016). NU-BCE reduced the median operation time, blood loss, and drainage volume. Apart from NU-RC (HR, 0.18; 95%CI: 0.08-0.44; p < 0.001) (HR, 0.28; 95%CI: 0.1-0.79; p = 0.016) and tumor volume(HR, 1.17; 95%CI: 1.06-1.29; p = 0.002) (HR, 1.21; 95%CI: 1.11-1.31; p < 0.001), which are independent prognostic factors for RFS and CSS, another independent prognostic factor for CSS is the ureteral carcinoma with renal pelvic carcinoma (HR, 4.32; 95%CI: 1.28-14.511; p = 0.018).

CONCLUSIONS

Patients who underwent NU-RC had better RFS and CSS than NU-BCE, but there was little difference in OS due to the higher mortality rate of postoperative complications in the NU-RC.

Oncologic Outcomes of Endoscopic Management of Upper Tract Urothelial Carcinoma: A Systematic Review and Pooled Analysis from the EAU-YAU Urothelial Working Group

BACKGROUND AND OBJECTIVE

Data about the mid- and long-term oncologic outcomes of endoscopic kidney-sparing surgery (eKSS) for upper tract urothelial carcinoma (UTUC) are scarce. Therefore, we aimed to summarize the current evidence on the oncologic outcomes of eKSS for UTUC.

METHODS

A literature search was conducted to identify reports published until May 2024. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The outcomes were the following: recurrence-free (RFS), intravesical recurrence-free (IV-RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival.

KEY FINDINGS AND LIMITATIONS

We found 56 studies (n = 52 retrospective) that met our inclusion criteria (n = 2862 patients). The 1-, 2-, 5-, and 10-yr OS rates were 96%, 87%, 80%, and 42%, respectively. The 1-, 2-, 5-, and 10-yr CSS rates were 97%, 89%, 82%, and 69%, respectively. RFS rates at 1, 2, and 5 yr were 69%, 55%, and 45%, respectively. IV-RFS rates at 1, 2, and 5 yr were 80%, 65%, and 64%, respectively. PFS rates at 2 and 5 yr were 75% and 69%, respectively. In low-grade UTUC, OS rates at 2 and 5 yr were 93% and 77%, respectively. The 2- and 5-yr CSS rates were 98% and 88%, respectively. At 2 yr, RFS, IV-RFS, and PFS were 52%, 54%, and 94%, respectively. For high-grade UTUC, only three studies reported data on 2-yr RFS, which was 34%. The main limitation is the heterogeneity found across the studies.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Local recurrence, bladder recurrence, and progression of UTUC occur mainly within 2 yr after eKSS. After 5-yr follow-up, OS and CSS drop, while the risk of local recurrence is non-negligible.

Segmental Resection with Ureteral Reimplantation vs Radical Nephroureterectomy with Bladder Cuff Removal for Urothelial Carcinoma of Distal Ureter: A Propensity Score Matching Study in a Large Chinese Center

Purpose: We aim to compare the clinical outcomes of radical nephroureterectomy with bladder cuff removal (RNU) and segmental resection with ureteral reimplantation (RR) in Chinese patients with distal ureteral urothelial carcinoma. Materials and Methods: A retrospective analysis of medical records was performed for 922 patients found to have distal ureteral cancer, defined as below the level of the iliac vessels, with 747 patients who underwent RNU and 175 who underwent RR included in the final analysis. The primary endpoints included clinical outcomes and changes in the estimated glomerular filtration rate (eGFR). Survival analysis was conducted using the Kaplan-Meier method, and propensity score matching (PSM) was utilized to mitigate selection bias between the two surgical approaches. Results: After PSM, the Kaplan-Meier survival curves demonstrated significant associations between surgical approach and both local recurrence-free survival (LRFS) and bladder recurrence-free survival (BRFS), but no significant differences were found in cancer-specific survival (CSS) and overall survival (OS). There were no significant differences in metastasis-free survival and contralateral recurrence-free survival between the two groups. Multivariate Cox regression analysis identified RR as an independent predictor of poorer outcomes for LRFS and BRFS. In addition, a significant increase in eGFR was observed following RR, whereas a significant decrease was noted after RNU. Conclusion: RR is associated with equivalent CSS and OS compared with RNU, even in the context of high-risk distal ureteral cancer, and results in improved postoperative eGFR, whereas the potential of RR to increase the risk of local tumor recurrence and intravesical recurrence requires clinical consideration.

A pretreatment nomogram to predict muscle-invasiveness in high-risk upper tract urothelial carcinoma (ROBUUST 2.0 collaborative group)

BACKGROUND

The ability to predict muscle invasion in the final pathology of upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU) potentially influences the selection of the most appropriate treatment modality. The present study aims to develop a model predicting muscle-invasive status in high-risk UTUC.

METHODS

The ROBUUST (RObotic surgery for Upper tract Urothelial cancer - UTUC - STudy) 2.0 dataset is an international, multicenter registry of patients undergoing curative surgery for UTUC between 2015 and 2022. Data about high-risk patients, classified according to EAU and NCCN prognostic stratification criteria, who underwent RNU were retrieved. The primary outcome was the identification of muscle-invasiveness. Two multivariable models, differing in the inclusion of biopsy-related data, were fitted with pT stage results at final pathology. Their predictive ability was calculated using the area under the receiver operating characteristic curve and decision curve analysis (DCA). A nomogram was developed using the model demonstrating the highest area under the curve (AUC) and clinical net benefit.

RESULTS

In the overall cohort, 1558 patients met the inclusion criteria, with 934 patients having ≥pT2 disease. Patients in the ≥pT2 cohort had significantly worse oncological outcomes in terms of metastases, all-cause, and cancer-specific deaths (all P<0.001). The biopsy-related model had the highest AUC (74%) and the highest net benefit in DCA. The DCA showed an improvement in the clinical risk prediction of muscle-invasiveness, and a reduction in the number of upfront or unnecessary RNU, at every ≥pT2 probability threshold.

CONCLUSIONS

The proposed prognostic model is a valuable tool for estimating the risk of muscle-invasiveness in high-risk UTUC patients, owing to its optimal predictive ability and user-friendly design.

Phospholipase C Beta 2 as a Key Regulator of Tumor Progression and Epithelial-Mesenchymal Transition via PI3K/AKT Signaling in Renal Cell Carcinoma

Background: Renal cell carcinoma (RCC) represents the most common form of invasive kidney cancer in adults. Among the components critical to cellular regulation is Phospholipase C Beta 2 (PLCB2), a member of the phospholipase C enzyme family. This enzyme plays a vital role in managing key cellular functions such as growth, differentiation, migration, and survival. Despite its significant importance, the specific expression patterns and molecular mechanisms of PLCB2 in the progression of RCC are not well understood. Methods: This investigation employed a combination of bioinformatics analyses, scRNA-seq, functional assays, transcriptome sequencing, real-time quantitative PCR (RT-PCR), immunofluorescence, rescue experiments, and Western blotting to explore the regulatory function of PLCB2 in driving the epithelial-mesenchymal transition (EMT) in RCC through the PI3K/AKT signaling pathway. Results:PLCB2 expression is significantly elevated in RCC samples, and this increase is inversely correlated with patient prognosis. The knockdown of PLCB2 in RCC cell lines leads to a marked reduction in cell proliferation, invasion, migration, and EMT. Transcriptome sequencing further revealed that PLCB2 is significantly associated with the PI3K/AKT pathway. Notably, the PI3K activator 740Y-P was able to reverse the reductions in migration, invasion, and EMT caused by the PLCB2 knockdown. Conclusions: Our findings underscore the pivotal role of PLCB2 in regulating RCC invasion and metastasis by modulating the EMT via the PI3K/AKT signaling pathway. This highlights PLCB2 not only as a key prognostic biomarker, but also as a promising therapeutic target in the treatment of advanced-stage RCC, offering new avenues for more effective interventions.

The Gender-Biased Differential Effect of KDM6A Mutation on Immune Therapy in Urothelial Carcinoma: A Public Database Study

Background/Objectives: It is said that genes that escape from X chromosome inactivation (XCI) contribute to gender differences. We analyzed the prognostic role of these genes and identified a gender-biased difference in prognosis according to KDM6A mutation in the immune therapy cohort (IMvigor 210). We also investigate the gender-biased differential effect of KDM6A mutation in several public databases of urothelial carcinoma (UC). Methods: We used AACR GENIE, The Cancer Genome Atlas, International Cancer Genome Consortium, several public databases related to immune therapy, chemotherapy, and BCG treatment. We studied the gender-biased prognostic role of KDM6A mutation in several cohorts and the association between KDM6A mutation and immune-related fractions according to gender. Results: The expression of KDM6A was higher in females than in males in several cohorts. Mutation of KDM6A was observed in about 20-25% of the patients. The rate of KDM6A mutation was higher in females than in males in several cohorts. Kaplan-Meier analysis revealed a gender-biased difference in prognosis between patients with KDM6A mutations and those with the wild-type KDM6A in several cohorts, including the immune therapy cohort. The rate of immune-inflamed type was higher in males than in females in the patients with KDM6A mutation in the IMvigor 210 and UC-GENOME studies. Single-sample Gene Set Enrichment Analysis showed that CD8+ cells and type 1 IFN response fractions and APC co-inhibition fraction were higher in the male than female patients with KDM6A mutation. Similar findings were observed in other immune-related studies (UC-GENOME). Conclusions: The effect of KDM6A mutation on immune therapy varied according to gender, and the status of KDM6A mutation may be a promising biomarker in immune therapy in UC.