Study Type – Therapy (case series)
Level of Evidence 4
What's known on the subject? and What does the study add?
Upper urinary tract urothelial carcinomas (UTUC) have historically been treated with radical, extirpative surgery, primarily nephroureterectomy with bladder-cuff excision. In general, there has been growing interest in renal preservation, as evidenced by the broadening application of nephron-sparing surgery for renal parenchymal tumours. Beyond imperative reasons such as tumour in a solitary kidney, bilateral disease, or comorbidities preventing radical surgery, there is a growing role for endoscopic management of upper tract tumours. The aim has been to obtain similar oncological results to those of extirpative surgery, while preserving long-term renal function. Properly selecting patients for these therapies, designing specific treatments based on a complex presentation, and general information with regard to outcomes and risks for patient counselling have been based historically on results from relatively small series without long-term follow-up.
This study reflects all patients with UTUC treated by a single tertiary referral surgeon, accrued prospectively over 15 years using the same surgical techniques and treatment algorithms throughout the entire study period, with 10-year survival data. The consecutively accrued nature and size of the study groups, uniformity in treatments, statistical review and long-term follow-up provide baseline oncological data that could help frame future study.
- • To present long-term oncological outcomes of all patients treated surgically for upper urinary tract urothelial carcinoma (UTUC) over a 15-year period.
PATIENTS AND METHODS
- • All patients (N= 160) treated from January 1996 to August 2011 were prospectively studied and placed into three distinct groups after initial diagnostic ureteroscopy (URS): Group 1: low grade lesions treated with URS (n= 66); Group 2: high grade lesions palliatively treated with URS (n= 16); and Group 3: extirpative surgery (nephroureterectomy [NU]; n= 80).
- • Statistical analysis was performed using Kaplan–Meier methodology to calculate overall (OS), cancer-specific (CSS) and metastasis-free survival (MFS).
- • The median patient age at presentation was 73 years, and the mean (range) follow-up time was 38.2 (1–185) months. At initial diagnostic URS, 71 (44.4%) patients presented with high grade and 89 (55.6%) patients presented with low grade disease.
- • The 2-, 5- and 10-year CSS rates were 98, 87 and 81% for patients with low grade disease, and 97, 87 and 78% for patients treated with URS (Group 1), not significantly different from those patients with low grade disease treated with NU (Group 3), (P= 0.54).
- • Of the patients treated with URS for low grade disease, 10 (15.2%) progressed to high grade disease at a mean time of 38.5 months.
- • Patients with high grade disease treated with NU had a 2-, 5-, and 10-year CSS of 70, 53 and 38%, with a MFS of 55, 45 and 35%.
- • Median survival of patients with high grade disease treated with palliative URS was 29.2 months with a 2-year OS of 54%.
- • On multivariate analysis only high grade lesion on initial presentation was found to be a significant factor (P < 0.001; hazard ratio = 7.27).
- • Grade is the most significant predictor of OS and CSS in those with UTUC, regardless of treatment method.
- • Ureteroscopic and extirpative therapy are acceptable options for those with low grade disease showing excellent long-term CSS.
- • Extirpative therapy was found to result in relatively poor long-term CSS in patients with high grade disease, underscoring the need for adjuvant or neoadjuvant therapies.