Robot-assisted nephroureterectomy: surgical and mid-term oncological outcomes in over 1100 patients (ROBUUST 2.0 collaborative group)

OBJECTIVE

To analyse surgical, functional, and mid-term oncological outcomes of robot-assisted nephroureterectomy (RANU) in a contemporary large multi-institutional setting.

PATIENTS AND METHODS

Data were retrieved from the ROBotic surgery for Upper tract Urothelial cancer STtudy (ROBUUST) 2.0 database, an international, multicentre registry encompassing data of patients with upper urinary tract urothelial carcinoma undergoing curative surgery between 2015 and 2022. The analysis included all consecutive patients undergoing RANU except those with missing data in predictors. Detailed surgical, pathological, and postoperative functional data were recorded and analysed. Oncological time-to-event outcomes were: recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Survival analysis was performed using the Kaplan-Meier method, with a 3-year cut-off. A multivariable Cox proportional hazard model was built to evaluate predictors of each oncological outcome.

RESULTS

A total of 1118 patients underwent RANU during the study period. The postoperative complications rate was 14.1%; the positive surgical margin rate was 4.7%. A postoperative median (interquartile range) estimated glomerular filtration rate decrease of -13.1 (-27.5 to 0) mL/min/1.73 m2 from baseline was observed. The 3-year RFS was 59% and the 3-year MFS was 76%, with a 3-year OS and CSS of 76% and 88%, respectively. Significant predictors of worse oncological outcomes were bladder-cuff excision, high-grade tumour, pathological T stage ≥3, and nodal involvement.

CONCLUSIONS

The present study contributes to the growing body of evidence supporting the increasing adoption of RANU. The procedure consistently offers low surgical morbidity and can provide favourable mid-term oncological outcomes, mirroring those of open NU, even in non-organ-confined disease.

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

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

Upper Tract Urothelial Carcinoma (UTUC) Diagnosis and Risk Stratification: A Comprehensive Review

Diagnosis and risk stratification are cornerstones of therapeutic decisions in the management of patients with upper tract urothelial carcinoma (UTUC). Diagnostic modalities provide data that can be integrated, to provide nomograms and stratification tools to predict survival and adverse outcomes. This study reviews cytology, ureterorenoscopy and the novel tools and techniques used with it (including photodynamic diagnosis, narrow-band imaging, optical coherence tomography, and confocal laser endomicroscopy), and biopsy. Imaging modalities and novel biomarkers are discussed in another article. Patient- and tumor-related prognostic factors, their association with survival indices, and their roles in different scores and predictive tools are discussed. Patient-related factors include age, sex, ethnicity, tobacco consumption, surgical delay, sarcopenia, nutritional status, and several blood-based markers. Tumor-related prognosticators comprise stage, grade, presentation, location, multifocality, size, lymphovascular invasion, surgical margins, lymph node status, mutational landscape, architecture, histologic variants, and tumor-stroma ratio. The accuracy and validation of pre-operative predictive tools, which incorporate various prognosticators to predict the risk of muscle-invasive or non-organ confined disease, and help to decide on the surgery type (radical nephroureterectomy, or kidney-sparing procedures) are also investigated. Post-operative nomograms, which help decide on adjuvant chemotherapy and plan follow-up are explored. Finally, a revision of the current stratification of UTUC patients is endorsed.

Perirenal fat stranding as a predictor of disease progression after radical nephroureterectomy for renal pelvic urothelial carcinoma: a retrospective study

BACKGROUND

To investigate the impact of Perirenal fat stranding (PRFS) on progression after radical nephroureterectomy (RNU) for renal pelvic urothelial carcinoma (RPUC) without hydronephrosis and to reveal the pathological findings of PRFS.

METHODS

Clinicopathological data, including computed tomography (CT) findings of the ipsilateral PRFS, were collected from the medical records of 56 patients treated with RNU for RPUC without hydronephrosis between 2011 and 2021 at our institution. PRFS on CT was classified as either low or high PRFS. The impact of PRFS on progression-free survival (PFS) after RNU was analyzed using the Kaplan-Meier method and log-rank test. In addition, specimens including sufficient perirenal fat from patients with low and with high PRFS were pathologically analyzed. Immunohistochemical analysis of CD68, CD163, CD3, and CD20 was also performed.

RESULTS

Of the 56 patients, 31(55.4%) and 25 (44.6%) patients were classified as having low and high PRFS, respectively. Within a median follow-up of 40.6 months postoperatively, 11 (19.6%) patients showed disease progression. The Kaplan-Meier method and log-rank test revealed that patients with high PRFS had significantly lower PFS rates than those with low PRFS (3-year PFS 69.8% vs 93.3%; p = 0.0393). Pathological analysis revealed that high PRFS specimens (n = 3 patients) contained more fibrous strictures in perirenal fat than low PRFS specimens (n = 3 patients). In addition, M2 macrophages (CD163 +) infiltrating fibrous tissue in perirenal area were observed in all patients with high PRFS group.

CONCLUSIONS

PRFS of RPUC without hydronephrosis consists of collagenous fibers with M2 macrophages. The presence of ipsilateral high PRFS might be a preoperative risk factor for progression after RNU for RPUC patients without hydronephrosis. Prospective studies with large cohorts are required in the future.

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

CONTEXT

The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial carcinoma (UTUC) has updated the guidelines to aid clinicians in evidence-based management of UTUC.

OBJECTIVE

To provide an overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in these guidelines are based on a review of the literature via a systematic search of the PubMed, Ovid, EMBASE, and Cochrane databases. Data were searched using the following keywords: urinary tract cancer, urothelial carcinomas, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, (neo)adjuvant treatment, instillation, recurrence, risk factors, metastatic, immunotherapy, and survival. The results were assessed by a panel of experts.

EVIDENCE SYNTHESIS

Even though data are accruing, for many areas there is still insufficient high-level evidence to provide strong recommendations. Patient stratification on the basis of histology and clinical examination (including imaging) and assessment of patients at risk of Lynch syndrome will aid management. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk UTUC and two functional kidneys. In particular, for patients with high-risk or metastatic UTUC, new treatment options have become available. In high-risk UTUC, platinum-based chemotherapy after radical nephroureterectomy, and adjuvant nivolumab for unfit or patients who decline chemotherapy, are options. For metastatic disease, gemcitabine/carboplatin chemotherapy is recommended as first-line treatment for cisplatin-ineligible patients. Patients with PD-1/PD-L1-positive tumours should be offered a checkpoint inhibitor (pembrolizumab or atezolizumab).

CONCLUSIONS

These guidelines contain information on the management of individual patients according to the current best evidence. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen according to the risk stratification of these tumours.

PATIENT SUMMARY

Cancer of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, timely and appropriate diagnosis is most important. A number of known risk factors exist.

Comparison between robot-assisted versus open nephroureterectomy for upper tract urothelial carcinoma: outcomes from a pooled analysis

The present study aimed to compare the efficacy and safety between robot-assisted nephroureterectomy (RANU) and open nephroureterectomy (ONU) for the treatment of upper tract urothelial carcinoma (UTUC). We systematically searched four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) to locate pertinent studies published in English up to January 2023. The primary outcomes evaluated included perioperative results, complications, and oncologic outcomes. Statistical analyses and calculations were performed using Review Manager 5.4. The study was registered with PROSPERO (ID: CRD42022383035). In total, eight comparative trials, including 37,984 patients were enrolled. Compared to ONU, RANU was associated with a significantly shorter length of stay (weighted mean difference [WMD] - 1.63 days, 95% confidence interval [CI] - 2.90, - 0.35; p = 0.01), less blood loss (WMD - 107.04 mL, 95% CI - 204.97, - 9.11; p = 0.03), less major complication(OR 0.78, 95% CI 0.70, 0.88; p < 0.0001), and lower positive surgical margin (PSM) (OR 0.33, 95% CI 0.12, 0.92; p = 0.03). However, no statistically significant differences were observed between the two groups in operative time, transfusion rates, rate of lymph node dissection, lymph node yield, overall complications, overall survival, cancer-specific survival, recurrence-free survival, and progression-free survival. RANU has superior advantages compared to ONU in terms of length of hospital stay, blood loss, postoperative complications, and PSM, while providing comparable oncologic outcomes in patients with UTUC.

The lowest level of tumor involvement is a significant prognostic factor for upper tract urothelial carcinoma after radical nephroureterectomy: A large retrospective cohort study

Purpose

To evaluate the prognostic impact of the lowest level of tumor location for upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

Materials and methods

Data were collected from patients with UTUC treated with RNU (01/2005- 06/2020) at a single center in Taiwan. Patients were stratified by the lowest level of tumor location into three groups: renal pelvis only (RPO), above upper ureter (AUU), and below upper ureter (BUU). We compared characteristics between groups and examined the association of the lowest level of tumor involvement with intravesical recurrence (IVR), systemic metastasis (SM), and cancer-specific mortality (CSM).

Results

Overall, 1239 patients (542 RPO, 260 AUU, 437 BUU) were enrolled. Concurrent bladder cancer, multifocality, tumor architecture, lymphovascular invasion, carcinoma in situ, and variant histology were significantly different across different tumor locations. BUU had worse five-year intravesical recurrence (IVR), systemic metastasis (SM) and cancer-specific mortality (CSM) (p &lt; 0.001, p = 0.056 and p = 0.13, respectively). In multivariable models, the lowest level of tumor involvement was an independent predictor of IVR (AUU hazard ratio (HR) = 1.52, p = 0.007; BUU HR = 1.75, p &lt; 0.001), but only BUU was an independent predictor of SM (HR = 1.61, p = &lt; 0.001) and CSM (HR = 1.51, p = 0.008).

Conclusion

The lowest level of tumor involvement in UTUC, especially BUU, was associated with a higher risk of IVR, SM and CSM. Assessment of the lowest level of tumor involvement after RNU may help identify patients who require more intensive follow-up.

Ex Vivo Near-Infrared Molecular Imaging of Human Upper Urinary Tract Urothelial Carcinoma With a CD47-Based Targeted Tracer

Objective

The low detection rate of early and small tumors remains a clinical problem that urgently needs to be solved in the accurate diagnosis and treatment of upper urinary tract urothelial carcinoma (UTUC). The objective of this study is to evaluate the feasibility of CD47 as a target for optical molecular imaging of human UTUC and conduct preliminary ex vivo imaging experiments.

Methods

We firstly analyzed the genome-wide mRNA expression data from Gene Expression Omnibus (GEO). Paraffin-embedded tissue specimens comprising UTUC and normal urothelium were collected. All tissue specimens were used for immunohistochemistry to compare CD47 protein expression in normal and cancer tissue. Meanwhile, 12 patients undergoing radical nephroureterectomy were prospectively included in ex vivo imaging experiments. Freshly isolated upper urinary tract specimens were incubated with anti-CD47-Alexa Fluor 790 and then imaged under white light and near-infrared (NIR) light. Standard histopathologic evaluation was performed, and findings were correlated with CD47-targeted NIR molecular imaging.

Results

The GEO data revealed that CD47 mRNA expression was higher in UTUC specimens than that in paracancer normal tissue. In immunohistochemical analysis, the CD47 protein expression level was higher in both non-muscle-invasive and muscle-invasive (stage ≥T2) UTUCs than that in normal uroepithelium, and the localization of CD47 protein was the tumor cell membrane. In the ex vivo imaging experiments, all patients were pathologically diagnosed with UTUC, and no adverse effects of anti-CD47-Alexa Fluor 790 on the histological structure of the tumor and normal uroepithelium were observed. In the NIR grayscale images, the mean fluorescence intensity of the tumor tissue was significantly higher than that of the adjacent normal background tissue, which greatly improved the visualization of the tumor.

Conclusions

CD47-targeted NIR molecular imaging could be a feasible and powerful strategy for the accurate diagnosis of UTUC. Larger-scale randomized trials are needed.

MicroRNA Signatures in the Upper Urinary Tract Urothelial Carcinoma Scenario: Ready for the Game Changer?

Upper urinary tract urothelial carcinoma (UTUC) represents a minor subgroup of malignancies arising in the urothelium of the renal pelvis or ureter. The estimated annual incidence is around 2 cases per 100,000 people, with a mean age at diagnosis of 73 years. UTUC is more frequently diagnosed in an invasive or metastatic stage. However, even though the incidence of UTUC is not high, UTUC tends to be aggressive and rapidly progressing with a poor prognosis in some patients. A significant challenge in UTUC is ensuring accurate and timely diagnosis, which is complicated by the non-specific nature of symptoms seen at the onset of disease. Moreover, there is a lack of biomarkers capable of identifying the early presence of the malignancy and guide-tailored medical treatment. However, the growing understanding of the molecular biology underlying UTUC has led to the discovery of promising new biomarkers. Among these biomarkers, there is a class of small non-coding RNA biomarkers known as microRNAs (miRNAs) that are particularly promising. In this review, we will analyze the main characteristics of UTUC and focus on microRNAs as possible novel tools that could enter clinical practice in order to optimize the current diagnostic and prognostic algorithm.

The Impact of Primary Tumor Location on Long-Term Oncological Outcomes in Patients with Upper Tract Urothelial Carcinoma Treated with Radical Nephroureterectomy: A Systematic Review and Meta-Analysis

Background: Upper tract urothelial carcinoma (UTUC) accounts for up to 10% of all urothelial neoplasms. Currently, various tumor-related factors are proposed to be of importance in UTUC prognostic models; however, the association of the primary UTUC location with oncological outcomes remains controversial. Thus, we sought to perform a systematic review and meta-analysis of the latest available evidence and assess the impact of primary tumor location on long-term oncological outcomes in patients with UTUC undergoing radical nephroureterectomy. Materials and Methods: A computerized systematic literature search was conducted in October 2021 through the PubMed, Web of Science, Scopus, and Cochrane Library databases. The primary endpoint was cancer-specific survival (CSS), and the secondary endpoints were overall survival (OS) and disease-free survival (DFS). Effect measures for the analyzed outcomes were reported hazard ratios (HRs) and 95% confidence intervals (CIs). Results: Among the total number of 16,836 UTUC in 17 included studies, 10,537 (62.6%) were renal pelvic tumors (RPTs), and 6299 (37.4%) were ureteral tumors (UTs). Pooled results indicated that patients with UT had significantly worse CSS (HR: 1.37, p < 0.001), OS (HR: 1.26, p = 0.003, and DFS (HR: 1.51, p < 0.001) compared to patients with RPT. Based on performed subgroup analyses, we identified different definitions of primary tumor location and geographical region as potential sources of heterogeneity. Conclusions: Ureteral location of UTUC is associated with significantly worse long-term oncological outcomes. Our results support the need for close follow-up and the consideration of perioperative chemotherapy in patients with UTUC located in the ureter. However, further prospective studies are needed to draw final conclusions.

Robot-assisted versus open radical nephroureterectomy for urothelial carcinoma of the upper urinary tract: A retrospective cohort study across ten years

PURPOSE

Radical nephroureterectomy is the gold standard of treatment for high-risk non-metastatic urothelial carcinoma of the upper urinary tract. However, the optimal surgical approach remains a controversial debate. This study compared the perioperative and oncological outcomes of open and robot-assisted radical nephroureterectomies.

METHODS

131 consecutive radical nephroureterectomies (66 robot-assisted nephroureterectomies vs. 65 open nephroureterectomies) for urothelial carcinoma of the upper urinary tract at a single tertiary referral center were included from 2009 to 2019. The perioperative and oncological outcomes were compared between both surgical approaches, including logistic regression analysis, propensity score matching, Kaplan Meier analyses, and Cox regression models.

RESULTS

Overall, robot-assisted surgery had less blood loss (150 ml vs. 250, p = 0.004) and less positive surgical margins (1.5% vs. 15.4%, p = 0.004) at a comparable operating time (robotic 188min vs. 178). Any grade complications were more frequent after open surgery (40.9% vs. 63.1%, p = 0.011), and the length of stay was shorter after robotic nephroureterectomy (9 days vs. 12, p < 0.001). These differences remained significant in the propensity score matched analysis, except for the complication rates, which were still lower for the robotic approach, but no longer significant. At a median follow-up of 30.9 months (range 1.4-129.5), neither the progression-free survival (PFS, 2-year: robotic 66.7% vs. open 55.3%), nor the overall survival differed significantly (OS, 2-year: robotic 76.2% vs. open 68.4%). In the Cox regression, the surgical approach did not impact the PFS or OS. Lymph node metastases (HR 3.32, p = 0.008) had the strongest impact on the PFS besides patient age (HR 1.51 per 10 years, p = 0.025) and prior cystectomy (HR 2.42, p = 0.026) in the multivariate analysis.

CONCLUSIONS

Robot-assisted radical nephroureterectomy had significant perioperative advantages at comparable oncological outcomes compared to open surgery for the treatment of urothelial carcinoma of the upper urinary tract at a high volume center, experienced in robotic surgery.

Pretreatment elevated fibrinogen level predicts worse oncologic outcomes in upper tract urothelial carcinoma

This study aimed to further validate the prognostic role of fibrinogen in upper tract urothelial carcinoma (UTUC) in a large Chinese cohort. A total of 703 patients who underwent radical nephroureterectomy were retrospectively identified. Fibrinogen levels of ≥4.025 g l⁻¹ were defined as elevated. Logistic regression analysis was performed to determine the association between fibrinogen and adverse pathological features. Kaplan–Meier analysis and Cox regression models were used to assess the associations of fibrinogen with cancer-specific survival (CSS), disease recurrence-free survival (RFS), and overall survival (OS). Harrell c-index and decision curve analysis were used to assess the clinical utility of multivariate models. The median follow-up duration was 42 (range: 1–168) months. Logistic regression analysis revealed that elevated fibrinogen was associated with higher tumor stage and grade, lymph node involvement, lymphovascular invasion, sessile carcinoma, concomitant variant histology, and positive surgical margins (all P < 0.05). Multivariate Cox regression analysis demonstrated that elevated fibrinogen was independently associated with decreased CSS (hazard ratio [HR]: 2.33; P < 0.001), RFS (HR: 2.09; P < 0.001), and OS (HR: 2.09; P < 0.001). The predictive accuracies of the multivariate models were improved by 3.2%, 2.0%, and 2.8% for CSS, RFS, and OS, respectively, when fibrinogen was added. Decision curve analysis showed an added benefit for CSS prediction when fibrinogen was added to the model. Preoperative fibrinogen may be a strong independent predictor of worse oncologic outcomes in UTUC; therefore, it may be valuable to apply this marker to the current risk stratification in UTUC.

The Prognostic Value of Body Mass Index in Patients With Urothelial Carcinoma After Surgery: A Systematic Review and Meta-Analysis

Background:

The clinical evidence of body mass index (BMI) for survival has increased in urothelial carcinoma (UC). This study aimed to investigate the prognostic value of BMI on the oncologic outcomes of patients with UC after surgery.

Methods:

The systematic review and meta-analysis was performed using Pubmed, Embase and Cochrane Library. We collected hazard ratio (HR) and 95% confidence interval (CI) on cancer specific survival (CSS), overall survival (OS) and recurrence-free survival (RFS) from the studies including upper tract urothelial carcinoma (UTUC) and urothelial carcinoma of bladder (UCB).

Results:

A total of 13 studies comprising over 12,200 patients were enrolled in the quantitative synthesis. Compared with normal weight, overweight was associated with better CSS (HR = 0.87, 95% CI: 0.79-0.95) and RFS (HR = 0.86, 95% CI: 0.78-0.96). Meanwhile, we found that obese patients had worse CSS (HR = 1.14, 95%CI: 1.03-1.26), OS (HR = 1.31, 95% CI: 1.19-1.44) and RFS (HR = 1.24, 95% CI: 1.12-1.37). We observed that underweight was associated with inferior CSS (HR = 1.87, 95% CI: 1.54-2.26) in UTUC patients.

Conclusions:

Overweight was a protective factor for patients with UC after surgery, while obesity and underweight predicted unfavorable survival. Individual BMI may be considered for prognostication after surgeries and patient stratification for clinical trials.

Association between lymphovascular invasion and oncological outcome in node-negative upper tract urothelial carcinoma with different stage

OBJECTIVES

To evaluate the prognostic impact of lymphovascular invasion (LVI) on node-negative upper tract urothelial carcinoma (UTUC) in patients treated with radical nephroureterectomy (RNU).

MATERIALS AND METHODS

A retrospective study was performed in single tertiary referral center of middle Taiwan between 2001 and 2015. Seven hundred and twenty-eight patients were diagnosed of UTUC and underwent RNU with ipsilateral bladder cuff excision including 303 and 195 patients with N0 and Nx status respectively. LVI status was assessed as a prognostic factor for cancer-specific (CSS) and overall survival (OS) using univariate and multivariate Cox regression analysis.

RESULTS

LVI was observed in 82 patients (16.5%). LVI presentation associated with smoking status, advanced tumor stage, high tumor grade, positive surgical margin, and consequence lung/liver/bone metastasis. In the multivariate analysis, LVI was failed to predict CSS, OS, and disease-free survival (DFS) (hazard ratio [HR] [95% confidence interval [CI]: 1.07 [0.55-2.09], 1.05 [0.62-1.79], 1.15 [0.69-1.92], in CSS, OS, DFS, respectively). In the subgroup analysis of pT1-2 disease, the CSS, OS, and DFS were associated with LVI status (HR [95% CI]: 2.29 [0.44-11.84], 3.17 [1.16-8.67], 2.66 [1.04-6.79], in CSS, OS, DFS, respectively). In contrast, there was no difference in pT3 disease.

CONCLUSION

In conclusion, LVI status was not associated with survival outcomes of node-negative UTUC in our study. The subgroup analysis showed different prognostic impacts of LVI status in node-negative UTUC with T1-2 and T3 stage. Further evidence to clarify the prognostic effect is needed to make LVI became a practical factor in clinical decision-making.

Oncologic outcomes of radical nephroureterectomy (RNU)

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

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update

CONTEXT

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

OBJECTIVE

To provide an overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC.

CONCLUSIONS

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

PATIENT SUMMARY

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.

Nomograms to predict overall and cancer-specific survival in patients with upper tract urothelial carcinoma: a large population-based study

Background

To develop and validate survival nomograms for predicting the overall survival (OS) and cancer-specific survival (CSS) in upper tract urothelial carcinoma (UTUC) patients.

Method

Patients diagnosed with UTUC from 2010 to 2015 in the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively enrolled. Clinical characteristics and survival outcomes were respectively collected from the included patients. Then, eligible patients were divided into the training cohort and the validation cohort. Additionally, survival nomograms were developed based on the results of multivariate Cox analysis in the training cohort. Furthermore, Kaplan-Meier (KM) survival curves were generated to assess the actual effect of each variable. Lastly, the nomograms were validated using the concordance index (C-index), the area under the receiver operating characteristic (ROC) curve and calibration curves.

Results

Totally, 3,556 patients were included, with 2,492 in the training cohort and 1,064 in the validation cohort. No significant differences were detected in comparisons in clinical characteristics between two cohorts. Based on the results of uni- and multivariate Cox regression analysis, seven factors (age, TNM stage, use of surgery/radiation and marital status) for OS and six factors (age, TNM stage and use of surgery/radiation) for CSS were selected to develop the survival nomograms. The C-index for OS and CSS was 0.763 and 0.793 in the training cohort, and 0.759 and 0.784 in the validation cohort. Additionally, the 3- and 5-year AUCs for OS were 0.808 and 0.780 in the training cohort, and 0.785 and 0.778 in the validation group. As for CSS, it was 0.833 and 0.803 in the training cohort, and 0.815 and 0.810 in the validation cohort. Lastly, the calibration curves indicated a good consistency between the actual survival and the predictive survival.

Conclusions

It was the first time to conduct survival models for UTUC patients with predictive performance. It might be valuable of clinical application and further exploration with more studies in the future.

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

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

Single-docking robotic-assisted nephroureterectomy and extravesical bladder cuff excision without intraoperative repositioning: The technique and oncological outcomes

BACKGROUND

/Objective: Currently there are few report of oncologic outcomes following robotic-assisted radical nephroureterectomy (RRNU) based on long-term follow-up. To evaluate the therapeutic effect of RRNU for upper tract urothelial carcinoma (UTUC), a technique of single-docking RRNU was described and its oncological outcomes was evaluated.

PATIENTS AND METHODS

The data of 29 patients underwent RRNU for UTUC of Ta-T3 from July 2013 to June 2016 was analyzed. The data of 131 patients of UTUC underwent laparoscopic radical nephroureterectomy (LRNU) over the same period was analyzed as control. Kaplan-Meier analysis and Cox regression were used for prognosis evaluation.

RESULTS

The median follow-up time was 40.5 and 40.4 months in RRNU cohort and LRNU cohort. No difference in 5-year intravesical recurrence-free survival (IVRFS) (88.0% vs. 85.5%, p = 0.611) or distant metastasis-free survival (93.1% vs.96.7%, p = 0.323) between RRNU cohort and LRNU cohort. The 5-year retroperitoneal recurrence-free survival and cancer-specific survival (CS) were lower in RRNU cohort than in LRNU cohort (77.3% vs. 87.7%, and 71.2% v.s. 84.7%, respectively).

CONCLUSION

The single-docking RRNU is an effective treatment for UTUC, avoiding the re-docking of patient-side cart or the intraoperative reposition of patient, and bringing equivalent 5-year IVRFS compared to LRNU. However, the lower 5-year retroperitoneal recurrence-free survival and CS in RRNU cohort warned the concern of higher chance of local tumor spillage during RRNU. The noninferiority of RRNU to LRNU still needed the confirmation of large sample sized, prospective randomized controlled study.

New endoscopic procedure for bladder wall closure: results from the porcine model

Upper urinary tract urothelial carcinomas are usually managed by radical nephroureterectomy (RNU), often followed by intravesical chemotherapy to minimize recurrence. Open surgery is the gold standard procedure for RNU, but it associates with high morbidity, and it has been increasingly replaced by minimally invasive strategies, such as laparoscopy and endoscopy. Although effective, endoscopic ureteral excision leaves the bladder unsutured, increasing the risk of tumor spillage, and precluding the immediate administration of intravesical chemotherapy. Here we describe a new method to close the bladder wall after ureteral excision, using barbed sutures via the endoscopic access. Our results in 8 female pigs demonstrate that this method is effective to close the bladder wall. The procedure was completed in a median time of 24 min, and no adverse events were registered in the follow-up or at the three-week necropsy. This technique improves a previous approach described by our group because the device is more flexible and allows to tie the knots inside the bladder. Barbed sutures have been used in the clinical practice for other types of surgeries, and therefore this method can further be adapted to human patients with no safety concerns. Its use may allow to administer intravesical chemotherapy, which reduces tumor recurrence and improves patient outcomes.

Impact of AIB1 expression on the prognosis of upper tract urothelial carcinoma after radical nephroureterectomy

BACKGROUND

Amplified in breast cancer 1 (AIB1) is a candidate oncogene in human breast cancer, which has been identified to be amplified and overexpressed in several types of other human cancers. Abnormalities of AIB1 and its clinical/prognostic significance, however, in upper tract urothelial carcinoma (UTUC) remain unclear.

OBJECTIVE

To explore what role AIB1 plays in upper tract urothelial carcinoma.

METHODS

The expression of AIB1 was analyzed using immunohistochemical staining in 133 UTUC patients. Overall, cancer specific and recurrence-free survival rates (OS, CSS, and RFS) were estimated using the Kaplan-Meier method. Multivariable COX regression models containing relevant clinicopathological variables addressed the prediction of postoperative outcome.

RESULTS

High AIB1 expression was observed to be associated with increased hazard ratios for 5-year CSS (80.6% vs. 55.8%, p= 0.008) and OS (78.1% vs. 54.8%, p= 0.006). Multivariable analysis revealed that elevated AIB1 expression was an independent prognostic predictor of OS, CSS and RFS. Additionally, pT, pN and hydronephrosis were independently associated with oncologic outcome of UTUC. Three proposed nomograms were proposed to provide an individualized risk estimate of postoperative outcome in patients with UTUC.

CONCLUSIONS

AIB1 can be used as an independent molecular marker for the prognosis of clinical outcomes of UTUC.

Prognostic Value of Lymphovascular Invasion in Node-Negative Upper Urinary Tract Urothelial Carcinoma Patients Undergoing Radical Nephroureterectomy

PURPOSE

This study aimed to evaluate the prognostic impact of lymphovascular invasion (LVI) in patients treated with radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

We collected data from 180 patients who were treated with RNU from 2005 to 2013 at our institution. The Kaplan-Meier method with log-rank test and Cox proportional hazards regression models were used for univariate and multivariate analyses.

RESULTS

LVI was present in 28 patients (15.6%), which was associated with higher pathological tumor stage (p<0.001), tumor necrosis (p=0.012), lymph node metastasis (p=0.017) and multifocality (p=0.012). On multivariate analysis, LVI was an independent prognostic factor of recurrence-free survival [RFS: hazard ratio (HR)=2.954; 95% confidence interval (CI)=1.539-5.671; p=0.001] and cancer-specific survival (CSS: HR=3.530; 95% CI=1.701-7.325; p=0.001) in all patients. In patients with node-negative UTUC, LVI was also a significant predictor of RFS (HR=3.732; 95% CI 1.866-7.464; p<0.001) and CSS (HR=3.825; 95% CI=1.777-8.234; p=0.001).

CONCLUSION

LVI status was an independent predictor in patients with UTUC who underwent RNU. The estimate of LVI could help physicians identify high-risk patients and make a better medication regimen of adjuvant chemotherapy.

Effects of Variant Histology on the Oncologic Outcomes of Patients With Upper Urinary Tract Carcinoma After Radical Nephroureterectomy: A Propensity Score-Matched Analysis

PURPOSE

To determine the prognostic effect of upper tract urothelial carcinoma (UTUC) with variant histology (VH) after radical nephroureterectomy (RNU).

PATIENTS AND METHODS

The data of 1173 patients who received RNU for UTUC without neoadjuvant chemotherapy in 11 institutions between 2002 and 2016 were retrospectively reviewed. A matched propensity score analysis was performed. Clinicopathologic variables, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were compared between patients with pure UTUC and patients with UTUC and VH. Univariate and multivariate Cox proportional regression models were used to determine the independent variables associated with oncologic outcomes.

RESULTS

UTUC with VH was observed in 93 patients (7.9%). After propensity score matching, UTUC with VH showed no difference in clinicopathologic features compared to pure UTUC; however, it was associated with shorter RFS, CSS, and OS (log rank, P = .011, P = .002, P = .006, respectively). Additionally, the multivariate analysis revealed that VH was independently associated with a poor RFS [hazard ratio (HR) = 1.92; 95% confidence interval (CI), 1.27-2.89; P = .002], CSS (HR = 4.47; 95% CI, 1.99-10.1; P = .001), and OS (HR = 3.00; 95% CI, 1.55-5.78; P = .001). However, the Kaplan-Meier method revealed that differences in RFS, CSS, and OS were not significant in patients who received adjuvant chemotherapy (log rank, P = .562, P = .060, P = .153, respectively).

CONCLUSION

UTUC with VH was independently associated with poor oncologic outcomes in patients with UTUC after RNU. Although patients with UTUC and VH had a poor prognosis compared to patients with pure UTUC, adjuvant chemotherapy would be helpful in improving the survival rates of these patients.

Is preoperative serum lactate dehydrogenase useful in predicting the outcomes of patients with upper tract urothelial carcinoma?

Background

Lactate dehydrogenase (LDH) has been proved to be associated with clinical outcomes in various carcinomas; however, limited evidence was available in upper urinary tract urothelial carcinoma (UTUC). Thus, the aim of this study was to evaluate the prognostic impact of LDH in UTUC.

Patients and methods

A cohort of 668 patients WERE retrospectively included between 2003 and 2016. Kaplan‐Meier method and Cox proportional hazards regression models were used to evaluate the association of LDH with overall survival (OS), cancer‐specific survival (CSS), disease recurrence‐free survival (RFS), and metastasis‐free survival (MFS). The cutoff level of LDH was set at 220 U/L for the upper limit of normal.

Results

Kaplan‐Meier plots showed the group with elevated LDH had significant poor OS (P = 0.003), CSS (P = 0.005), and RFS (P = 0.005), but not MFS (P = 0.099). However, multivariate Cox analysis suggested that LDH was not an independent predictor for CSS (HR 1.50, 95%CI: 0.87‐2.59), OS (HR 1.56, 95%CI: 0.94‐2.58), RFS (HR 1.33, 95%CI: 0.83‐2.12), or MFS (HR 1.16, 95%CI: 0.79‐1.71). Albumin, globulin, and HBDH were also not related to survival outcomes of UTUC patients in multivariate analysis, while higher alkaline phosphatase was associated with worse CSS and OS, and higher white blood cells contributed to poor CSS and RFS. In subgroup analysis, results found higher LDH was associated with poor OS in patients with localized disease (pT ≤ 2) (HR 4.03, 95%CI: 1.37‐11.88).

Conclusion

The preoperative LDH was not an independent prognostic factor for patients with UTUC, while elevated LDH was proved to be correlated with worse OS in patients with localized disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prognostic impact of tumor infiltrating lymphocytes on patients with metastatic urothelial carcinoma receiving platinum based chemotherapy

The impact of tumor infiltrating lymphocytes (TILs) on survival was confirmed in various cancer types. Our study aims to investigate the prognostic role of TILs on survival in patients with metastatic urothelial carcinoma (mUC) receiving platinum based chemotherapy. Patients who were diagnosed to have pathologically proved mUC between 1997 and 2016 and received palliative chemotherapy with platinum based regimen were recruited into our study. Kaplan-Meier curves and Cox regression analysis were constructed for overall survival (OS). A total of 259 mUC patients were enrolled into our study with median age 63 years and median follow-up visit 13.5 months. Of these patients, 179 (69%) had intense TILs and 80 (31%) had non-intense TILs. The median OS were 15.7 vs. 6.7 months (P = < 0.001) for patients with intense TILs and non-intense TILs, respectively. Subgroup analysis showed that TILs was both prognostically significant no matter for urothelial carcinoma of bladder and upper tract urothelial carcinoma. Multivariate analysis showed that TILs were strongly prognostic factors related to OS. Our study suggested mUC patients with intense TILs were independently associated with survival. Based on our study, TILs is clinically useful for outcomes anticipation and risk stratification, as well as patients counseling.

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update

CONTEXT

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

OBJECTIVE

To provide an overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; ureteroscopy; nephroureterectomy; adjuvant treatment; instillation; recurrence; risk factors; and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing number of retrospective articles in UTUC. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification, as well as for radical and conservative treatment; prognostic factors are also discussed. A single postoperative dose of intravesical mitomycin after radical nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumours and two functional kidneys.

CONCLUSIONS

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

PATIENT SUMMARY

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis; appropriate diagnosis and management is most important. We present recommendations based on current evidence for optimal management.

Can lymphovascular invasion replace the prognostic value of lymph node involvement in patients with upper tract urothelial carcinoma after radical nephroureterectomy?

INTRODUCTION

This study aimed to evaluate whether lymphovascular invasion (LVI) can replace lymph node (LN) involvement as a prognostic marker in patients who do not undergo lymph node dissection (LND) during surgery in patients with upper tract urothelial carcinoma (UTUC).

METHODS

A total of 505 patients who underwent radical nephroureterectomy (RNU) were recruited from four academic centres and divided into four groups: node negative (N0, Group 1); node positive (N+, Group 2); no LND without LVI (NxLVI-, Group 3); and no LND with LVI (NxLVI+, Group 4).

RESULTS

Patients in Group 2 had larger tumours, a higher incidence of left-sided involvement, more aggressive T stage and grade, and a higher positive surgical margin rate than patients in other groups. Pathological features (T stage and grade) were poorer in Group 4 than in Groups 1 and 3. Compared to other groups, Group 2 had the worst prognostic outcomes regarding locoregional/distant metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). LVI and LN status in Group 4 was not associated with MFS in multivariate analysis. Among Nx diseases, LVI was not an independent predictor of MFS or CCS. The small number of cases in Groups 2 and 4 is a major limitation of this study.

CONCLUSIONS

Clinical outcomes according to LVI did not correlate with those outcomes predicted by LN involvement in patients with UTUC. Therefore, LVI may not be used as a substitute for nodal status in patients who do not undergo LND at the time of surgery.

Predictive models and prognostic factors for upper tract urothelial carcinoma: a comprehensive review of the literature

In the context of customized patient care for upper tract urothelial carcinoma (UTUC), decision-making could be facilitated by risk assessment and prediction tools. The aim of this study was to provide a critical overview of existing predictive models and to review emerging promising prognostic factors for UTUC. A literature search of articles published in English from January 2000 to June 2016 was performed using PubMed. Studies on risk group stratification models and predictive tools in UTUC were selected, together with studies on predictive factors and biomarkers associated with advanced-stage UTUC and oncological outcomes after surgery. Various predictive tools have been described for advanced-stage UTUC assessment, disease recurrence and cancer-specific survival (CSS). Most of these models are based on well-established prognostic factors such as tumor stage, grade and lymph node (LN) metastasis, but some also integrate newly described prognostic factors and biomarkers. These new prediction tools seem to reach a high level of accuracy, but they lack external validation and decision-making analysis. The combinations of patient-, pathology- and surgery-related factors together with novel biomarkers have led to promising predictive tools for oncological outcomes in UTUC. However, external validation of these predictive models is a prerequisite before their introduction into daily practice. New models predicting response to therapy are urgently needed to allow accurate and safe individualized management in this heterogeneous disease.

Prognostic model to predict survival in patients with metastatic upper tract urothelial carcinoma treated with cisplatin-based chemotherapy

OBJECTIVES

To create a novel prognostic model to predict survival in metastatic upper tract urothelial carcinoma patients treated with cisplatin-based chemotherapy.

METHODS

After institutional review board approval, patients who had metastatic upper tract urothelial carcinoma and were treated with cisplatin based chemotherapy from 2000 to 2012 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Significantly predictive factors were identified by multivariate Cox regress analyses. Kaplan-Meier curves were plotted to estimate overall survival. Several prognostic models were validated by using our cohort, and Harrell's c-index was calculated to evaluate their predicting performances.

RESULTS

The present study consisted of 136 patients with a median age of 62 years and a median follow-up visit of 13.6 months. Multivariate analyses showed that renal function, performance status, liver metastasis and number of metastatic sites was independently related to survival. Based on these four variables, we constructed a prognostic model "renal function, performance status, liver metastasis, number of metastatic sites" with significantly different survival (P < 0.001). C-index results were renal function, performance status, liver metastasis, number of metastatic sites model 0.80 (0.69-0.90), Bajorin model 0.72 (0.61-0.83), Taguchi model 0.77 (0.67-0.87) and Tanaka model 0.78 (0.69-0.88). Our renal function, performance status, liver metastasis, number of metastatic sites prognostic model achieved the highest c-index in this study.

CONCLUSIONS

Our renal function, performance status, liver metastasis, number of metastatic sites prognostic model could be useful for providing prognostic information on survival in patients with metastatic upper tract urothelial carcinoma.

[Elective organ and function preservation in ureter and renal pelvis tumors]

With the technical innovations of smaller, flexible ureteroscopes, color-filtered imaging, and endoscopic laser technology, organ-preserving treatment for upper urinary tract transitional cell carcinoma has become feasible. While in the past, radical nephroureterectomy was the sole gold standard approach for the treatment of upper urinary tract tumors, the endoscopic approach is no longer restricted to only patients with the imperative indication of kidney preservation. Initial clinical results have demonstrated oncologic efficacy of endoscopic management or segmental ureteral resection. However, careful preoperative risk-assessment and close endoscopic follow-up are mandatory.

Prognostic factors of recurrent disease in upper urinary tract urothelial cancer after radical nephroureterectomy: Subanalysis of the multi-institutional national database of the Japanese Urological Association

OBJECTIVES

To explore predictive factors of disease recurrence after radical nephroureterectomy in patients with upper urinary tract urothelial cancer.

METHODS

A multi-institutional national database promoted by the Japanese Urological Association including 293 institutions and 1172 patients was used for the present study. Patient with non-metastatic upper urinary tract urothelial cancer who underwent primary radical nephroureterectomy with curative intent were analyzed. Univariate analysis using the Kaplan-Meier method and multivariate Cox regression models with stepwise selection was used to evaluate time to recurrence after surgery.

RESULTS

The median duration of follow up was 55.8 months, and disease recurred in 325 (27.7%) patients at a median of 11.4 months after radical nephroureterectomy. According to a Cox proportional hazards model, the Union International Contre le Cancer 2002 pathological stage of the primary tumor, lymph node status, presence of lymphatic and/or vascular invasion, infiltrative growth pattern, and age were independent predictors (P < 0.05) of recurrence-free survival.

CONCLUSIONS

Despite several limitations, our analysis suggests that pathological tumor stage, lymph node status, lymphovascular invasion, infiltrative growth pattern and age represent important prognostic variables after radical nephroureterectomy in Japanese patients with upper urinary tract urothelial cancer. This information could be potentially used to select patients for adjuvant systemic therapy.

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma: 2015 Update

CONTEXT

The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial cell carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

OBJECTIVE

To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using these keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Due to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing interest in UTUC. The 2009 TNM classification is recommended. Recommendations are given for diagnosis and risk stratification as well as radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Recommendations are also provided for patient follow-up after different therapeutic strategies.

CONCLUSIONS

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

PATIENT SUMMARY

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.

Clinical significance of prognosis using the neutrophil-lymphocyte ratio and erythrocyte sedimentation rate in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVES

To evaluate the clinical significance of preoperative erythrocyte sedimentation rate (ESR) and neutrophil-lymphocyte ratio (NLR) as prognostic factors in patients undergoing radical nephroureterectomy for upper tract urothelial carcinoma (UTUC).

PATIENTS AND METHODS

A total of 410 patients were retrospectively reviewed. An elevated NLR was defined as ≥2.5 and a normal ESR was considered to be in the range of 0-22 mm/h in men and 0-27 mm/h in women. Patients were divided into three groups: those with ESR and NLR in the normal range (group 0, n = 168), those with either elevated ESR or elevated NLR (group I, n = 169), and those with both elevated ESR and elevated NLR (group II, n = 73).

RESULTS

The median patient age was 64 years and the median follow-up duration was 40.2 months. In all, 35.6 and 41.2% of patients had elevated NLRs and ESRs, respectively. Group II was associated with advanced tumour status in terms of size, grade, stage, lymph node and margin status (P < 0.05). Preoperative ESR (hazard ratio [HR] 1.784, 95% confidence interval [CI] 1.173-2.712), NLR (HR 1.704, 95% CI 1.136-2.556), and prognostic grouping (HR 2.285, 95% CI 1.397-3.737 for group I; HR 2.962, 95% CI 1.719-5.102 for group II) were independent predictors of progression-free survival (PFS) in the multivariate model (P < 0.05). Prognostic grouping was also an independent prognostic factor for cancer-specific survival (CSS) and overall survival (OS). Time-dependent area under the receiver-operating characteristic curves showed that NLR plus ESR had a greater diagnostic value than NLR alone regarding oncological outcomes (P < 0.05).

CONCLUSIONS

Prognostic grouping using ESR and NLR was identified as an independent prognostic marker in patients with UTUC. The addition of ESR improved the prognostic value of NLR alone in predicting oncological outcomes. The combination of preoperative ESR and NLR might be a new prediction tool in patients with UTUC after radical nephroureterectomy.