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Keywords:

  • endoscopic management;
  • percutaneous resection;
  • upper tract urothelial carcinoma;
  • ureteroscopy

Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

Endoscopic management of small, low-grade, non-invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long-term survival outcomes of endoscopically-managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow-up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease-specific survival outcomes.

The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long-term follow-up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade-stratified analysis of different outcomes, including upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and disease-specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low-grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres.

OBJECTIVE

  • • 
    To report the long-term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20-year period.

PATIENTS AND METHODS

  • • 
    Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment.
  • • 
    Outcomes were obtained via retrospective analysis of notes, electronic records and registry data.
  • • 
    Survival outcomes, including overall survival (OS), UTUC-specific survival (disease-specific survival; DSS), upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and progression-free survival, were estimated using Kaplan–Meier methods and grade-stratified differences were analyzed using the log-rank test.

RESULTS

  • • 
    Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years.
  • • 
    All patients underwent ureteroscopy and biopsy-confirmation of pathology was obtained in 81% (n= 59) of the patients. In total, 14% (n= 10) of the patients underwent percutaneous resection.
  • • 
    Median (range; mean) follow-up was 54 (1–223; 62.8) months.
  • • 
    Upper tract recurrence occurred in 68% (n= 50). Eventually, 19% (n= 14) of the patients proceeded to nephroureterectomy.
  • • 
    The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months.

CONCLUSIONS

  • • 
    The present study represents one of the largest reported series of endoscopically-managed UTUC, with high pathological verification and long-term follow-up.
  • • 
    Upper-tract recurrence is common, which mandates regular ureteroscopic surveillance.
  • • 
    However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.