Impact of previous, simultaneous or intravesical recurrence bladder cancer on prognosis of upper tract urothelial carcinoma after nephroureterectomy: a large population-based study

Background

Currently, the impact of previous, simultaneous, or subsequent bladder cancer on the prognosis of upper urinary tract urothelial carcinoma (UTUC) is controversial. We aimed to investigate the impact of previous, simultaneous or intravesical recurrence (IVR) bladder cancer on the prognosis of UTUC based on a large population-based cohort from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

A total of 8,431 UTUC patients diagnosed from 2004 to 2018 met the inclusion criteria were identified based on the SEER database. We evaluated the impact of bladder cancer on the prognosis of UTUC by Kaplan-Meier method and propensity score matching (PSM).

Results

In all, 6,831 patients only had UTUC (UTUC-only), 880 patients with previous or simultaneous bladder cancer (UTUC-Bca), 720 patients with IVR (UTUC-IVR). After adjusting baseline covariates that varied significantly among groups, we found UTUC-Bca cohort, regardless of tumor grade and stage, had poorer prognosis than UTUC-only cohort. In general, we demonstrated IVR had no significant impact on the prognosis of UTUC compared to PSM matched patients without IVR. However, subgroup analysis revealed that UTUC patients with subsequent MIBC recurrence or shorter interval (<20 months) between UTUC and IVR had worse prognosis compared with UTUC-only cohort.

Conclusions

UTUC patients with previous or simultaneous bladder cancer, IVR with MIBC, and shorter interval between UTUC and IVR were significant predictor for worse prognosis. Thus, more stringent postoperative surveillance and active treatment strategies should be considered for UTUC patients with those risk factors.

Risk factor analysis of intravesical recurrence after retroperitoneoscopic nephroureterectomy for upper tract urothelial carcinoma

Background

One of the major concerns of patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy is intravesical recurrence (IVR). The purpose of the present study was to investigate the predictive risk factors for IVR after retroperitoneoscopic nephroureterectomy (RNU) for UTUC.

Methods

Clinicopathological and surgical information were collected from the medical records of 73 patients treated with RNU for non-metastatic UTUC, without a history of or concomitant bladder cancer. The association between IVR after RNU and clinicopathological and surgery-related factors, including preoperative urine cytology and pneumoretroperitoneum time, was analyzed using the Fisher exact test.

Results

During the median follow-up time of 39.1 months, 18 (24.7%) patients had subsequent IVR after RNU. The 1- and 3-year IVR-free survival rates were 85.9% and 76.5%, respectively. The Fisher exact test revealed that prolonged pneumoretroperitoneum time of ≥ 210 min was a risk factor for IVR in 1 year after RNU (p = 0.0358) and positive urine cytology was a risk factor for IVR in 3 years after RNU (p = 0.0352).

Conclusions

In UTUC, the occurrences of IVR in 1 and 3 years after RNU are highly probable when the pneumoretroperitoneum time is prolonged (≥ 210 min) and in patients with positive urine cytology, respectively. Strict follow-up after RNU is more probable recommended for these patients.

Predictive Value of Preoperative Positive Urine Cytology for Development of Bladder Cancer After Nephroureterectomy in Patients With Upper Urinary Tract Urothelial Carcinoma: A Prognostic Nomogram Based on a Retrospective Multicenter Cohort Study and Systematic Meta-Analysis

Background

Upper urinary tract urothelial carcinoma (UUT-UC) is a rare and severe urinary malignancy. Several studies have explored the relationship between preoperative urine cytology and intravesical recurrence (IVR) in patients with UUT-UC. However, the results of these studies are controversial or even contradictory, and investigations with UUT-UC patients in northeast China are rare.

Methods

We first estimated the prognostic significance of preoperative urine cytology in the outcomes of intravesical recurrence in 231 UUT-UC patients (training cohort = 142, validation cohort = 89) after radical nephroureterectomy (RNU) by the nomogram model. Subsequently, we quantitatively combined our results with the published data after searching several databases to assess whether preoperative positive urine cytology was associated with poor intravesical recurrence-free survival and a high risk of tumor malignant biological behavior.

Results

Firstly, the multicenter retrospective cohort study demonstrated that preoperative positive urine cytology correlated with poor intravesical recurrence-free survival and can serve as significant independent predictors of IVR by Kaplan-Meier curves and Cox regression analysis. The construction of the nomogram demonstrated that predictive efficacy and accuracy were significantly improved when preoperative urine cytology was combined. Meanwhile, meta-analysis showed that preoperative positive urine cytology was associated with a 49% increased risk of IVR. In the subgroup analysis by region, study type, and sample size, the pooled hazard ratios (HRs) were statistically significant for the Japan subgroup (HR 1.32), China subgroup (HR 1.88), cohort study subgroup (HR 1.45), and the single-arm study subgroup (HR 1.63).

Conclusions

Preoperative urine cytology was validated as a potential predictor of intravesical recurrence in patients with UUT-UC after RNU, although these results need to be generalized with caution. Large, prospective trials are required to further confirm its significance in prognosis and tumor malignant biological behavior.

Preoperative positive voided urine cytology predicts poor clinical outcomes in patients with upper tract urothelial carcinoma undergoing nephroureterectomy

BACKGROUND

Performance of urinary cytology is recommended as the part of a standard diagnostic workup and base surveillance regimens in upper tract urothelial carcinoma (UTUC). However, the effect of positive voided urine cytology (VUC) on UTUC prognosis, compared with negative VUC, has not been fully demonstrated. This study aimed to evaluate the impact of preoperative VUC on predicting intravesical recurrence, disease recurrence, and mortality in patients with UTUC who underwent nephroureterectomy (RNU).

METHODS

Clinicopathological information was collected from 315 UTUC patients treated with RNU. The association between VUC and oncological outcomes was analyzed using the Kaplan-Meier method with log-rank test and Cox proportional hazards regression models. Multiple logistic regression analysis was performed to identify the influence of VUC on tumor grade.

RESULTS

Preoperative positive VUC, presenting in 101 patients (32%), was significantly associated with tumor multifocality (P = 0.017) and higher tumor grade (P = 0.010). On multivariable Cox regression analyses, preoperative positive VUC was an independent prognostic factor of intravesical recurrence-free survival (RFS) (hazard ratio [HR] = 2.21, 95% confidence interval [CI] 1.06-4.64; P = 0.035), RFS (HR = 1.80, 95% CI 1.08-2.99; P = 0.023), and cancer-specific survival (CSS) (HR = 1.87, 95% CI 1.10-3.18; P = 0.020), but not overall survival (HR = 1.32, 95% CI 0.80-2.18; P = 0.28). Logistic regression analysis revealed that VUC was related to high tumor grade in UTUC (odds ratio = 2.23, 95%CI 1.15-4.52).

CONCLUSION

Preoperative positive VUC significantly increases the risk of intravesical recurrence in UTUC patients undergoing RNU. In addition, positive VUC is an adverse predictor of RFS and CSS, which might be due to the association between positive VUC and high tumor grade.

Tumor Multifocality is a Significant Risk Factor of Urinary Bladder Recurrence after Nephroureterectomy in Patients with Upper Tract Urothelial Carcinoma: A Single-Institutional Study

The purpose of this study was to identify the significant risk factors of urinary bladder recurrence (UBR) after nephroureterectomy (NUx) in patients with upper tract urothelial carcinoma (UTUC). A total of 550 patients diagnosed with UTUC between January 2001 and December 2015 were included in this retrospective study. The median age of our patients was 68 (range 24–93) and the median follow-up time after NUx was 40.3 months (range 8–191). The most important censored point of this study was the first episode of UBR. Of the 550 patients, UBR occurred in 164 patients (29.8%). One hundred and forty-two (86.6%) patients with UBR were identified within two years after NUx for UTUC, with the median time interval between NUx and UBR being 8.4 months (range 3–59.8). Through univariate analysis, the positive surgical margin (p = 0.049) and tumor multifocality (p = 0.024) were both significant prognostic factors for UBR-free survival after NUx in patients with UTUC. However, only tumor multifocality (p = 0.037) remained a significant prognostic factor by multivariate analysis. In conclusion, tumor multifocality is a significant risk factor of UBR after nephroureterectomy in patients with upper tract urothelial carcinoma.

Intravesical irrigation might prevent bladder recurrence in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVES

To examine the effectiveness of intravesical irrigation with physiological saline solution or distilled water for the prevention of bladder recurrence in patients undergoing laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma.

METHODS

This retrospective study involved 109 upper urinary tract urothelial carcinoma patients who underwent laparoscopic nephroureterectomy, and were evaluated at Chiba University Hospital and Yokohama Rosai Hospital between 2001 and 2018. We investigated the outcomes and analyzed various clinical factors including with or without intravesical irrigation related to bladder carcinoma recurrence after surgery. Physiological saline solution or distilled water was used for irrigation, which was carried out only during surgery.

RESULTS

The median follow-up period after surgery was 26.1 months. Bladder recurrence was confirmed within 2 years for 45 of the 109 patients in the present study. Irrigation was carried out for 48 cases (distilled water, 26 patients; physiological saline solution, 22 patients). Tumor grade (G1-2 vs G3; P = 0.05) and intravesical irrigation (yes vs no; P = 0.0058) were related to bladder recurrence on univariate analyses. On multivariate analyses, intravesical irrigation was the independent factor involved in the prevention of bladder recurrence (P = 0.0051). Comparison between the irrigation and non-irrigation groups showed that bladder recurrence rates were significantly lower in the irrigation group (irrigation group vs non-irrigation group: 25.0% vs 52.5%, P = 0.0066). There was no significant difference in the recurrence rate between the two solutions used for irrigation.

CONCLUSIONS

Intravesical irrigation during surgery of upper urinary tract urothelial carcinoma might decrease postoperative bladder recurrence rates.

Association between demographic factors and prognosis in urothelial carcinoma of the upper urinary tract: a systematic review and meta-analysis

We aimed to assess the prognostic significance of demographic factors, including age, sex, performance status, smoking status, obesity, and race in upper urinary tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy through a systematic review and meta-analysis. We conducted PubMed search for all articles published until December 2014 according to Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Survival outcomes of interest were intravesical recurrence (IVR) free survival, progression free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). Seventy-nine studies, including numbers of subjects ranging from 24 to 9899, met the inclusion criteria. Advanced age was significantly associated with worse PFS [hazard ratio (HR) 1.01] and OS (HR 1.05). The significant predictors of CSS were age (HR 1.02) and performance status (HR 1.35). Female gender (HR 0.81) and smoking (HR 1.38) were the significant predictors only for IVR free survival. No significant associations with survival outcomes were observed in obesity and race. Our study reveals that age is one of the most important demographic predictor of survival in UTUC. Also, male gender, poor performance status, and smoking are also significantly related to worse survival outcomes. However, large well-designed prospective studies are required to investigate the precise prognostic significance of demographics.

Dialysis Increases the Risk of Bladder Recurrence in Patients with Upper Tract Urothelial Cancer: A Population-Based Study

BACKGROUND

The relation of dialysis to tumor recurrence in patients with upper tract urothelial cancer (UTUC) is unknown; however, a limited number of small-scale studies suggest that patients with renal diseases prior to UTUC are more likely to exhibit bladder recurrence. We performed a population-based analysis to determine the effect of dialysis on bladder recurrence for patients with UTUC.

METHODS

This retrospective cohort study included patients diagnosed with UTUC (2002-2007) from the Taiwan National Cancer Registry and divided them into two groups-dialysis and non-dialysis groups. These patients were followed up until bladder recurrence, death, or the end of 2010. Competing risk analyses adjusting covariates and death were applied to determine the relation of dialysis and bladder recurrence.

RESULTS

Of the 5141 eligible patients, 548 (10.7%) were undergoing dialysis. The cumulative bladder recurrence was significantly higher in the dialysis group than in the non-dialysis group (29% vs. 21%, modified log-rank p < 0.001). In the multivariable analysis, the dialysis group exhibited a 64% increased bladder recurrence risk (cause-specific hazard ratio 1.64, 95% confidence interval 1.34-2.01, p < 0.001), which was confirmed using stratification and propensity score weighting methods. The other prognostic factors for bladder recurrence were sex, diabetes, cardiac disorder, Charlson Comorbidity Index, and tumor grade.

CONCLUSIONS

Despite unknown reasons, approximately one-tenth of patients with UTUC have experienced dialysis treatment. Patients undergoing dialysis have a higher risk of bladder recurrence. Various treatment and screening strategies should be developed for dialysis and non-dialysis patients.

Evidenced-based clinical practice guideline for upper tract urothelial carcinoma (summary--Japanese Urological Association, 2014 edition)

Upper tract urothelial carcinoma is more rare than bladder cancer, although they are both categorized as urothelial carcinoma. Because of the low incidence, little clinical evidence is available regarding the treatment of the former. However, recently such evidence has slowly begun to accumulate. The guideline presented herein was compiled for the purpose of ensuring proper diagnosis and treatment by physicians involved in the treatment of upper tract urothelial carcinoma. We carefully selected 16 clinical questions essential for daily clinical practice and grouped them into four major categories: epidemiology, diagnosis, surgery and systemic chemotherapy/other matters. Related literature was searched using PubMed and Japan Medical Abstracts Society databases for articles published between 1987 and 2013. If the judgment was made on the basis of insufficient or inadequate evidence, the grade of recommendation was determined on the basis of committee discussions and resultant consensus statements. Here, we present a short English version of the original guideline, and overview its key clinical issues.

Transitional cell carcinoma of the ureteric stump: a systematic review of the literature

OBJECTIVE

To present a review of the literature using evidence-based criteria for diagnosis and treatment of malignant growths in the ureteric remnant following nephrectomy for non-malignant disease.

METHODS

A database search using the key search words was performed, producing a total of 16 articles published between 1952 and 2009. The Oxford Centre for Evidence-Based Medicine classification was used. Statistical significance was tested by Pearson correlation. Demographic data, reason for nephrectomy, symptoms, time to diagnosis since initial nephrectomy, imaging modality and treatment option chosen, as well as histology and overall survival were reviewed.

RESULTS

Analysis was possible for 33 out of 63 cases reported in the literature. There was a male predominance (82%). Visible, painless haematuria was the presenting symptom in 72% of cases. Open ureterectomy was performed in the majority of patients (85%), while none had laparoscopic surgery. Transitional cell carcinoma was found in 66% of cases. Mean follow-up was 2.7 years. Metastases were detected in 36% and correlated significantly with cancer-specific mortality (95% CI: p < 0.001). Tumour stage, grade and cell type did not correlate significantly with mortality.

CONCLUSION

Gross, painless haematuria is a feature highly suggestive of neoplastic change. Diagnosis often involves multimodality imaging and endoscopy. Complete ureterectomy with removal of bladder cuff, previously resected endoscopically, is the treatment of choice. Metastases at diagnosis and follow-up carry a worse prognosis.

Predictive factors for bladder recurrence after radical nephroureterectomy for upper urinary tract urothelial carcinoma

INTRODUCTION

To identify predictive factors for developing subsequent bladder urothelial carcinoma (UC) in patients undergoing radical nephroureterectomy for the treatment of upper urinary tract UC (UUT-UC).

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 78 patients with clinically localized UUT-UC who had undergone operation at our institution between June 1994 and December 2009. Univariate and multivariate analyses were carried out to determine the predictive factors.

RESULTS

Out of a total of 78 patients, 14 (17.9%) developed bladder UC after radical nephroureterectomy at a median interval of 10 months (range: 3-46). Of these 14 patients, 11 (78.6%) experienced bladder recurrence within the first 2 years of follow-up. All 14 patients (100%) had non-muscle-invasive bladder UC and 10 patients (71.4%) had high-grade tumors. The univariate analysis identified preoperative voided urine cytology, tumor configuration, and adjuvant systemic chemotherapy as significant predictive factors for bladder recurrence, whereas the multivariate analysis indicated that only preoperative voided urine cytology was an independent predictive factor.

CONCLUSIONS

Positive preoperative voided urine cytology is an independent predictor for bladder recurrence after radical nephroureterectomy for UUT-UC. Therefore, closer surveillance of the bladder is necessary, especially in patients with positive preoperative urine cytology.

Oncologic outcomes obtained after neoadjuvant and adjuvant chemotherapy for the treatment of urothelial carcinomas of the upper urinary tract: a review

INTRODUCTION

Nephroureterectomy with excision of a bladder cuff is the gold standard in the treatment of upper urinary tract carcinomas (UTUC). But especially for patients suffering from advanced tumor stages, life expectancy has not improved over the years with local recurrence or distant metastases being the main reasons for treatment failure. Chemotherapy in an adjuvant or neoadjuvant setting seems therefore to be a promising approach.

METHODS

The literature of the last 20 years was searched using Medline. Articles were chosen by using the given abstracts. Only articles written in English and not older than 20 years were considered.

RESULTS

Most information concerning chemotherapy of urothelial carcinomas is gained from studies comprising patients suffering from lower urinary tract carcinomas. The combination of methotrexate, adriamycin, vinblastine and cisplatin as well as the combination of gemcitabine and cisplatin are the most used chemotherapy regimens in advanced UCC and have shown beneficial results. The summarized data of studies for UTUC contained no level one information. Down staging effects as well as prolongation of survival have been shown for some patients treated with neoadjuvant chemotherapy, but because of the small study groups and the retrospective design, no definite conclusions can be drawn from these results. In addition, there exists an uncertainty for preoperative staging. Results for adjuvant chemotherapy are lacking.

CONCLUSION

No definite recommendations for peri-operative chemotherapy in UTUC can be derived from the current literature. Current therapy is largely based on extrapolation from the bladder cancer literature. Prospective studies dedicated to UTUC are needed.