Ten‐year survival outcomes after radical nephroureterectomy with a risk‐stratified approach using prior diagnostic ureteroscopy: a single‐institution observational retrospective cohort study

Abstract

To evaluate the long-term oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU) and the impact of diagnostic ureteroscopy (URS) on survival outcomes. Materials and MethodsA retrospective analysis of all consecutive patients undergoing RNU for suspected UTUC at a UK tertiary referral centre from a prospectively maintained database was conducted. The primary outcome measures were 5-and 10-year cancerspecific survival (CSS). The secondary outcomes were: overall survival (OS), recurrence-free survival (RFS), impact of prior diagnostic URS on OS, CSS and intravesical RFS (intravesical-RFS), and predictors of intravesical recurrence. Statistical analysis was performed in R using the 'survminer' and 'survival' packages. The Kaplan-Meier method was used to calculate survival functions and these were expressed in graphical form. Uni-/multivariate survival analyses were performed using the Cox proportional hazard regression model. Statistical significance in this study was set at P < 0.05. ResultsA total of 422 patients underwent RNU with confirmed UTUC. The median (interquartile range) follow-up of patients with confirmed UTUC was 9.2 (5.6-12.7) years. The 5-and 10-year CSS rates were 70.5% (95% confidence interval [CI] 65.9-74.9) and 67.1% (95% CI 62.4-71.6), respectively. OS (HR 1.04 [95% CI 0.78-1.38]; P = 0.46) and CSS (HR 0.96 [95% CI 0.68-1.34]; P = 0.81) were similar in the diagnostic URS and the direct RNU cohorts. intravesical RFS was superior for the direct RNU cohort ; P = 0.008). In multivariate analysis, prior URS, T2 stage, proximal ureter tumour and bladder cancer history were predictors of metachronous bladder recurrence. ConclusionThis single-centre retrospective cohort study reports the long-term oncological outcomes of RNU with a median follow-up of 9.2 years, serving as a reference standard in counselling patients undergoing RNU. Stage and grade of the RNU specimen were the only two studied factors that appeared to adversely impact long-term CSS and OS. Our results suggest that the risk of intravesical recurrence is increased nearly twofold in patients who have undergone diagnostic URS prior to RNU. Prior URS, however, does not appear to adversely impact long-term CSS and OS. The authors suggest that a risk-stratified approach be adopted, wherein diagnostic URS is offered only in equivocal cases.

Ureteroscopy and tailored treatment of upper tract urothelial cancer: recent advances and unmet needs

“…Finally, in the Newcastle series, very few cases (<4%) were performed using a robotic approach, and in most (67%) cases an endoscopic technique was used to manage the bladder cuff [1]. In recent years, the role of robot‐assisted surgery has expanded significantly.…”

“…Veeratterapillay et al. [1] reported a detailed analysis of >400 UTUC cases managed with radical nephroureterectomy (RNU) during a 15‐year period at the Freeman Hospital (Newcastle upon Tyne, UK), and some key findings from their report are ‘food for thought’.…”

Do all patients require ureteroscopy prior to nephroureterectomy?

“…In this month’s BJUI , Veeratterapillay et al. [1] report on 10‐year survival following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), specifically looking at the impact of diagnostic ureteroscopy on outcomes. One of the key findings highlighted is the impact of diagnostic ureteroscopy prior to RNU.…”

“…By omitting ureteroscopy in unequivocal cases Veeratterapillay et al. [1] demonstrate the median time to RNU from diagnosis was significantly shortened (49 vs 78 days, P < 0.001). In our series, we found RNU was performed 21 days earlier if ureteroscopy was not undertaken [4].…”

“…What was not addressed by Veetatterapillay et al. [1] but would certainly be of interest in this context is to use the findings of ODMIT‐C and extend them to a study of the impact of intravesical chemotherapy at the time of ureteroscopy to reduce bladder seeding [2].…”