The diagnostic ureteroscopy before radical nephroureterectomy in upper urinary tract urothelial carcinoma is not associated with higher intravesical recurrence

Abstract

BackgroundTo clarify if diagnostic ureteroscopy (URS) before radical nephroureterectomy for patients with upper tract urothelial carcinoma (UTUC) will increase the risk of intravesical recurrence.MethodsFrom retrospective review of cohort at our institution, 502 patients with UTUC who underwent radical nephroureterectomy with bladder cuff excision were enrolled from 1990 to 2013. Cox proportional hazards model was used to analyze the overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and intravesical recurrence-free survival (IVRFS). The log-rank test was used for comparing survival curves. All potential risk factors were included in the multivariate Cox proportional hazards model to recognize independent predictors. From NHI database, we included patients of UTUC without bladder cancer history using population-based database in Taiwan from 1996 to 2013. In total, 3079 URS and 2634 non-URS patients with UTUC were identified. Univariate and multivariate Cox proportional hazards regressions were performed to measure the risk of IVRFS and all-cause mortality.ResultsFrom our database, the comparison of clinicopathological characteristics in UTUC patients between with URS biopsy group (URS+) (n = 206, 41%) and without URS biopsy group (URS−) (n = 296, 59%) was insignificantly different excluding surgical method. URS biopsy is not associated with worse OS (p = 0.720), DFS (p = 0.294), MFS (p = 0.808), and IVRFS (p = 0.560) by multivariate analysis. Only bladder cancer history is an independent significant factor to predict IVR (p < 0.001). The same result from NHI database, URS before radical surgery will not increase the risk of IVRFS [adjusted HR 1.136, 95% CI 1.00–1.30; P = 0.059] and OS [adjusted HR 0.919, 95% CI 0.82–1.04; P = 0.164].ConclusionsPreoperative URS manipulation is not associated with higher risk of IVRFS even in patients without bladder cancer history. Diagnostic URS is feasible to compensate the insufficient information of image in patients with UTUC.

Endoscopic management versus radical nephroureterectomy for localized upper tract urothelial carcinoma in a high endemic region

“…In addition, after multivariate analysis with adjustment for confounding factors, prior history of bladder UC and concurrent bladder UC were independent risks for intravesical recurrence for all UTUC. A large cohort study focusing on the impact of diagnostic ureteroscopy after RNU also found that bladder UC was the main risk for intravesical recurrence but not diagnostic urteroscopy 23 . To date, the pathophysiology or mechanism of lower tract seeding of urothelial cancer still remains unclear and most of the published evidences that favored diagnostic ureteroscopy as a risk factor were biased due to not excluding cases with prior bladder UC 23 .…”

“…A large cohort study focusing on the impact of diagnostic ureteroscopy after RNU also found that bladder UC was the main risk for intravesical recurrence but not diagnostic urteroscopy 23 . To date, the pathophysiology or mechanism of lower tract seeding of urothelial cancer still remains unclear and most of the published evidences that favored diagnostic ureteroscopy as a risk factor were biased due to not excluding cases with prior bladder UC 23 . In brief, it is still controversial as to whether diagnostic ureteroscopy is a major reason increasing the risk of intravesical recurrence, and a well designed randomized trial is mandatory to answer this unsolved issue.…”

The Effect of Diagnostic Ureterorenoscopy on Intravesical Recurrence in Patients Undergoing Nephroureterectomy for Primary Upper Tract Urinary Carcinoma

“…They concluded that URS is not an independent risk factor for IVR. In another cohort study, the authors found that URS prior to RNU was not associated with a higher risk of IRFS even in patients without a history of bladder cancer [26]. Yoo et al [27] investigated whether biopsy during URS for UTUC before RNU affected IVR.…”

Impact of diagnostic ureteroscopy before radical nephroureterectomy on intravesical recurrence in patients with upper tract urothelial cancer

“…In one study of 502 patients, of whom 206 underwent preoperative URS (Pre-U) and 296 did not (Non-U), Pre-U did not increase the risk for IVR (HR, 1. 136; 95% confidence interval [CI], 1.00-1.30; p=0.059) [3]. Another meta-analysis showed that Pre-U before RNU did not negatively affect overall survival, recurrencefree survival, cancer-specific survival, or metastasis-specific survival [4].…”