Factors Predicting Oncological Outcomes of Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma in Taiwan

BackgroundTaiwan is one of the endemic regions where upper tract urothelial carcinoma (UTUC) accounts for approximately a third of all urothelial tumors. Owing to its high prevalence, extensive experience has been accumulated in minimally invasive radical nephroureterectomy (RNU). Although a variety of predictive factors have been explored in numerous studies, most of them were on a single-center or limited institutional basis and data from a domestic cohort are lacking.ObjectiveThis study aims to identify significant predicting factors of oncological outcomes, including overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and intravesical recurrence-free survival (IVRFS), following RNU for UTUC in Taiwan.MethodsA multicenter registry database, Taiwan UTUC Collaboration Group, was utilized to analyze oncological outcomes of 3,333 patients undergoing RNU from 1988 to 2021 among various hospitals in Taiwan. Clinicopathological parameters were recorded according to the principles established by consensus meetings. The Kaplan-Meier estimator was utilized to estimate the survival rates, and the curves were compared using the stratified log-rank test. Univariate and multivariate analyses were performed with the Cox proportional hazard model to explore potential predicting factors.ResultsWith a median follow-up of 41.8 months in 1,808 patients with complete information, the 5-year IVRFS, DFS, CSS, and OS probabilities were 66%, 72%, 81%, and 70%, respectively. In total, 482 patients experienced intravesical recurrence, 307 died of UTUC, and 583 died of any cause. Gender predominance was female (57%). A total of 1,531 patients (84.7%) had high-grade tumors; preoperative hydronephrosis presented in 1,094 patients (60.5%). Synchronous bladder UC was identified in 292 patients (16.2%). Minimally invasive procedures accounted for 78.8% of all surgeries, including 768 hand-assisted laparoscopic (42.5%) and 494 laparoscopic (27.3%) approaches. Synchronous bladder UC was the dominant adverse predicting factor for all survival outcomes. Other independent predicting factors for OS, CSS, and DFS included age ≧70, presence of preoperative hydronephrosis, positive surgical margin, LVI, pathological T and N staging, and laparoscopic RNU.ConclusionSynchronous UC of the urinary bladder is an independent adverse prognostic factor for survival in UTUC. The presence of preoperative hydronephrosis was also corroborated as a disadvantageous prognostic factor. Our multivariate analysis suggested that laparoscopic RNU might provide better oncological control.

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Oncological outcomes of patients who achieved surgical quality during minimally invasive radical nephroureterectomy for upper tract urothelial carcinoma: a multicenter retrospective analysis (ROBUUST collaborative group)

European Urology Open Science ◽

10.1016/s2666-1683(21)00822-3 ◽

2021 ◽

Vol 32 ◽

pp. S64

Author(s):

A. Veccia ◽

U. Carbonara ◽

R. Tellini ◽

R. Meherazin ◽

D. Eun ◽

...

Keyword(s):

Minimally Invasive ◽

Urothelial Carcinoma ◽

Retrospective Analysis ◽

Upper Tract Urothelial Carcinoma ◽

Collaborative Group ◽

Radical Nephroureterectomy ◽

Surgical Quality ◽

Upper Tract ◽

Oncological Outcomes

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The Impact of Diagnostic Ureteroscopy Prior to Radical Nephroureterectomy on Oncological Outcomes in Patients with Upper Tract Urothelial Carcinoma: A Comprehensive Systematic Review and Meta-analysis

10.20944/preprints202107.0387.v1 ◽

2021 ◽

Author(s):

Łukasz Nowak ◽

Wojciech Krajewski ◽

Joanna Chorbińska ◽

Paweł Kiełb ◽

Michał Sut ◽

...

Keyword(s):

Systematic Review ◽

Urothelial Carcinoma ◽

Meta Analysis ◽

Upper Tract Urothelial Carcinoma ◽

Cochrane Library ◽

Radical Nephroureterectomy ◽

Free Survival ◽

Upper Tract ◽

Oncological Outcomes ◽

The Impact

Background: The incidence of intravesical recurrence (IVR) following radical nephroureterectomy (RNU) is reported in up to 50% of patients with upper tract urothelial carcinoma (UTUC). It was suggested that preoperative diagnostic ureteroscopy (URS) could increase the IVR rate after RNU, however, the available data are often conflicting. Thus, in this systematic review and meta-analysis we sought to synthesize that available data for the impact of pre-RNU URS for UTUC on IVR and other oncological outcomes; Materials and methods: A systematic literature search of the PubMed, Embase and Cochrane Library databases was performed in June 2020. Cumulative analyses of hazard ratios (HRs) and their corresponding 95% confidence intervals (CI) were conducted. The primary endpoint was intravesical recurrence-free survival (IVRFS), with the secondary endpoints being cancer-specific survival (CSS), overall survival (OS), and metastasis-free survival (MFS); Results: Among a total of 5489 patients included in the sixteen selected papers, 2387 (43.4%) underwent diagnostic URS before RNU and 3102 (56.6%) did not. Pre-RNU diagnostic URS was significantly associated with worse IVRFS after RNU (HR=1.44, 95% CI: 1.29-1.61, p&lt;0.001) than RNU alone. However, subgroup analysis including patients without biopsy during URS revealed no significant impact of diagnostic URS on IVRFS (HR=1.28, 95% CI: 0.90-1.80, p=0.16). The results of other analyses showed no significant differences in CSS (HR=0.94, p=0.63), OS (HR: 0.94, p=0.56), and MFS (HR: 0.91, p=0.37) between patients who underwent URS before RNU and those who did not. Conclusions: The results of this meta-analysis confirm that diagnostic URS prior to RNU is significantly associated with worse IVRFS, albeit with no concurrent impact on the other long-term survival outcomes. Our results indicate that URS has a negative impact on IVRFS only when combined with endoscopic biopsy. Future studies are warranted to assess the role of immediate postoperative intravesical chemotherapy in patients undergoing biopsy during URS for suspected UTUC.

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Bilateral Nephroureterectomy Versus Unilateral Nephroureterectomy for Treating De Novo Upper Tract Urothelial Carcinoma After Renal Transplantation: A Comparison of Surgical and Oncological outcomes

Clinical Medicine Insights Oncology ◽

10.1177/11795549211035541 ◽

2021 ◽

Vol 15 ◽

pp. 117955492110355

Author(s):

Qiming Zhang ◽

Runzhuo Ma ◽

Youzhao Li ◽

Min Lu ◽

Hongxian Zhang ◽

...

Keyword(s):

Renal Transplantation ◽

Urothelial Carcinoma ◽

De Novo ◽

Upper Tract Urothelial Carcinoma ◽

Perioperative Outcomes ◽

Categorical Variables ◽

Radical Nephroureterectomy ◽

Free Survival ◽

Upper Tract ◽

Oncological Outcomes

Background: There is currently no consensus on the optimal management of de novo unilateral upper tract urothelial carcinoma (UTUC) in renal transplant recipients. We aimed to compare the surgical and oncological outcomes of simultaneous bilateral radical nephroureterectomy (SBRNU) and unilateral radical nephroureterectomy (URNU) to determine the appropriate surgical method. Methods: Patients who developed de novo UTUC after renal transplantation and underwent surgical treatment at our center were included in the study. Outcomes were compared between the SBRNU group (underwent bilateral RNU within 3 months) and the URNU group using the Mann–Whitney U-test for continuous variables, Pearson’s chi-square test for categorical variables, and the log-rank test for survival data. Results: A total of 48 patients were identified, including 21 and 27 patients in the SBRNU and URNU groups, respectively. Comparison of perioperative data showed that the SBRNU group had a significantly longer operative time ( P < .001) and hospital stay ( P = .040) than the URNU group but no statistically significant difference in the blood loss ( P = .171) and morbidity rate ( P = .798). After a median follow-up of 65 months, the SBRNU group had a significantly longer disease-free survival ( P = .009), longer cancer-specific survival ( P = .032), marginally longer overall survival ( P = .066), and similar intravesical recurrence-free survival ( P = .274) than the URNU group. Conclusions: Our data suggest that SBRNU contributes to improved survival without significantly compromising the perioperative outcomes compared with URNU. SBRNU can be considered a feasible option for de novo UTUC after renal transplantation in specialized centers. Prospective studies should be conducted to further explore the best treatment options for this group of patients.

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The Impact of Diagnostic Ureteroscopy Prior to Radical Nephroureterectomy on Oncological Outcomes in Patients with Upper Tract Urothelial Carcinoma: A Comprehensive Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10184197 ◽

2021 ◽

Vol 10 (18) ◽

pp. 4197

Author(s):

Łukasz Nowak ◽

Wojciech Krajewski ◽

Joanna Chorbińska ◽

Paweł Kiełb ◽

Michał Sut ◽

...

Keyword(s):

Systematic Review ◽

Urothelial Carcinoma ◽

Meta Analysis ◽

Upper Tract Urothelial Carcinoma ◽

Cochrane Library ◽

Radical Nephroureterectomy ◽

Free Survival ◽

Upper Tract ◽

Oncological Outcomes ◽

The Impact

Background: The incidence of intravesical recurrence (IVR) following radical nephroureterectomy (RNU) is reported in up to 50% of patients with upper tract urothelial carcinoma (UTUC). It was suggested that preoperative diagnostic ureteroscopy (URS) could increase the IVR rate after RNU. However, the available data are often conflicting. Thus, in this systematic review and meta-analysis we sought to synthesize available data for the impact of pre-RNU URS for UTUC on IVR and other oncological outcomes. Materials and methods: A systematic literature search of the PubMed, Embase, and Cochrane Library databases was performed in June 2021. Cumulative analyses of hazard ratios (HRs) and their corresponding 95% confidence intervals (CI) were conducted. The primary endpoint was intravesical recurrence-free survival (IVRFS), with the secondary endpoints being cancer-specific survival (CSS), overall survival (OS), and metastasis-free survival (MFS). Results: Among a total of 5489 patients included in the sixteen selected papers, 2387 (43.4%) underwent diagnostic URS before RNU and 3102 (56.6%) did not. Pre-RNU diagnostic URS was significantly associated with worse IVRFS after RNU (HR = 1.44, 95% CI: 1.29–1.61, p < 0.001) than RNU alone. However, subgroup analysis including patients without biopsy during URS revealed no significant impact of diagnostic URS on IVRFS (HR = 1.28, 95% CI: 0.90–1.80, p = 0.16). The results of other analyses showed no significant differences in CSS (HR = 0.94, p = 0.63), OS (HR: 0.94, p = 0.56), and MFS (HR: 0.91, p = 0.37) between patients who underwent URS before RNU and those who did not. Conclusions: The results of this meta-analysis confirm that diagnostic URS prior to RNU is significantly associated with worse IVRFS, albeit with no concurrent impact on the other long-term survival outcomes. Our results indicate that URS has a negative impact on IVRFS only when combined with endoscopic biopsy. Future studies are warranted to assess the role of immediate postoperative intravesical chemotherapy in patients undergoing biopsy during URS for suspected UTUC.

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Oncological outcomes of laparoscopic versus open nephroureterectomy for the treatment of upper tract urothelial carcinoma: an updated meta-analysis

World Journal of Surgical Oncology ◽

10.1186/s12957-021-02236-z ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Radosław Piszczek ◽

Łukasz Nowak ◽

Wojciech Krajewski ◽

Joanna Chorbińska ◽

Sławomir Poletajew ◽

...

Keyword(s):

Urothelial Carcinoma ◽

Meta Analysis ◽

Locally Advanced ◽

Upper Tract Urothelial Carcinoma ◽

Current Evidence ◽

Recurrence Free Survival ◽

Radical Nephroureterectomy ◽

Free Survival ◽

Upper Tract ◽

Oncological Outcomes

Abstract Background During the past two decades, laparoscopic radical nephroureterectomy (LRNU) has been proposed as an alternative technique to open radical nephroureterectomy (ORNU) and has become increasingly accepted for the treatment of patients with upper tract urothelial carcinoma (UTUC). Nevertheless, the oncologic efficacy of LRNU remains controversial, especially for the treatment of locally advanced (T3/T4 and/or N+) UTUC. In this meta-analysis, we aimed to cumulatively compare the oncological outcomes of LRNU versus ORNU. Materials and methods The present meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A search was conducted of three electronic databases, namely, Medline, Embase, and Cochrane Library. Outcome measurements of cancer-specific survival (CSS), overall survival (OS), intravesical recurrence-free survival (IVRFS), and recurrence-free survival (RFS), including hazard ratios (HRs) and 95% confidence intervals (CIs), were extracted and pooled. Results Eighteen articles published from 2007 to 2020 were included in the final quantitative analysis. One study was a randomized controlled trial (RCT), and the remaining articles had a retrospective design. Among a total of 10,730 participants in the selected papers, 5959 (55.5%) and 4771 (44.5%) underwent ORNU and LRNU, respectively. The results of pooled analyses revealed no significant differences in CSS (HR 0.84, 95% CI 0.60–1.19, p = 0.33), OS (HR 0.84, 95% CI 0.62–1.13, p = 0.25), IVRFS (HR 1.08, 95% CI 0.85–1.39, p = 0.52), and RFS (HR 1.09, 95% CI 0.94–1.25, p = 0.26) between LRNU and ORNU groups. Furthermore, the results of subgroup analyses for pT3/T4 and pTany N+ populations did not confirm any statistically significant differences between LRNU and ORNU in terms of any survival parameter. Conclusions Our present meta-analysis of current evidence suggests that LRNU and ORNU have comparable oncological outcomes in patients with UTUC, even in those with locally advanced disease. Further multicenter RCTs with large sample sizes and uniform data regarding specific surgical procedures, such as bladder cuff excision, are required to establish definitive conclusions.

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Developing a nomogram for predicting intravesical recurrence after radical nephroureterectomy: a retrospective cohort study of mainland Chinese patients

Japanese Journal of Clinical Oncology ◽

10.1093/jjco/hyab017 ◽

2021 ◽

Author(s):

Shicong Lai ◽

Xingbo Long ◽

Pengjie Wu ◽

Jianyong Liu ◽

Samuel Seery ◽

...

Keyword(s):

Urothelial Carcinoma ◽

Cox Regression ◽

Upper Tract Urothelial Carcinoma ◽

Chinese Patients ◽

Clinicopathological Parameters ◽

Radical Nephroureterectomy ◽

Ki 67 ◽

Data Set ◽

Mainland Chinese ◽

Upper Tract

Abstract Objective To evaluate the role of Ki-67 in predicting subsequent intravesical recurrence following radical nephroureterectomy and to develop a predictive nomogram for upper tract urothelial carcinoma patients. Methods This retrospective analysis involved 489 upper tract urothelial carcinoma patients who underwent radical nephroureterectomy with bladder cuff excision. The data set was randomly split into a training cohort of 293 patients and a validation cohort of 196 patients. Immunohistochemical analysis was used to assess the immunoreactivity of the biomarker Ki-67 in the tumor tissues. A multivariable Cox regression model was utilized to identify independent intravesical recurrence predictors after radical nephroureterectomy before constructing a nomographic model. Predictive accuracy was quantified using time-dependent receiver operating characteristic curve. Decision curve analysis was performed to evaluate the clinical benefit of models. Results With a median follow-up of 54 months, intravesical recurrence developed in 28.2% of this sample (n = 137). Tumor location, multifocality, pathological T stage, surgical approach, bladder cancer history and Ki-67 expression levels were independently associated with intravesical recurrence (all P < 0.05). The full model, which intercalated Ki-67 with traditional clinicopathological parameters, outperformed both the basic model and Xylinas’ model in terms of discriminative capacity (all P < 0.05). Decision-making analysis suggests that the more comprehensive model can also improve patients’ net benefit. Conclusions This new model, which intercalates the Ki-67 biomarker with traditional clinicopathological factors, appears to be more sensitive than nomograms previously tested across mainland Chinese populations. The findings suggest that Ki-67 could be useful for determining risk-stratified surveillance protocols following radical nephroureterectomy and in generating an individualized strategy based around intravesical recurrence predictions.

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