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Upper-tract urothelial carcinoma (UTUC) is a relatively rare tumour that accounts for ≈5% of all urothelial carcinomas [1,2]. UTUC can occur in either the renal collecting system or the ureter, and occasionally in both. Because ureteric tumours are generally not reported separately, their exact incidence remains unclear. Pathological stage, lymph node metastasis and tumour grade have been established as prognostic factors for UTUC [3–6], but there have been few studies to date assessing location within the ureter as a prognostic factor .
For invasive, non-metastatic UTUC, radical nephroureterectomy (NU) with bladder cuff removal is the standard treatment . Partial ureterectomy is usually reserved for low grade, non-invasive tumours too large for endoscopic ablative management, or for isolated high grade tumours where nephron-sparing was imperative [9,10]. Endoscopic management was originally offered only in patients with imperative indications for nephron-sparing [11–13]. With new data supporting the importance of nephron-sparing whenever possible, endoscopic management is becoming more relevant , but there are limited data comparing surgical approaches to radical NU, partial ureterectomy and endoscopic resection (ENDO) with regard to oncological outcomes.
The aim of the present study was to assess the impact of tumour location within the ureter and the impact of surgical approach on recurrence-free survival (RFS) and cancer-specific survival (CSS) with regard to ureteric tumours in a contemporary cohort of patients treated at a single tertiary referral centre.
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Investigators have failed to agree on the prognostic value of tumour location in UTUC. Some have reported that ureteric UTUC is associated with an adverse prognosis [17–19], while others state the opposite . Recently, two large multicentre multivariate analyses identified no significant prognostic difference with respect to the location of UTUC [5,20]. To our knowledge, only one study to date examined the prognostic significance of tumour location within the ureter . That study, including 127 ureteric tumour cases, reported that distal ureteric tumours have a better prognosis than more proximally located tumours . In the present series, there were no significant differences in either RFS or CSS with respect to ureteric tumour location. To date, the largest population-based study on the prognostic significance of tumour location for patients with UTUC showed that, when adjusted for stage, tumour location did not affect oncological outcomes . Thus, we agree that for ureteric tumours, tumour location is not an independent predictor of oncological outcome .
Although NU represents the treatment of choice for patients with UTUC, partial ureterectomy and ENDO may be performed in selected patients [9,10,14]. A large population-based study of 2299 patients with UTUC treated with NU or partial ureterectomy did not find that surgery type affected the cancer-specific mortality-free rates . To our knowledge, the largest series ever published with exclusively ureteric tumours , which included145 cases, agreed with this conclusion.
A comparative study  including 97 patients with UTUC, with a median follow-up of 45.8 months, found that the ENDO group had more superficial tumours (81.5%), similar to the 90% in the present study. They also discovered that the ENDO group had a significantly shorter time to recurrence compared with the NU group (median time: 12 vs 19 months), which is similar to the present study with a median time to delayed NU or partial ureterectomy of 13 months. They also found that for low grade tumours, there were no differences in the 5-year CSS and disease-free survival between the NU and ENDO groups. This finding was supported not only by the present study, but also by the only other two comparative studies, each with longer follow-up in survivors (medians of 54 and 76.9 months, respectively) [24,25]. To our knowledge, while there are no large series of patients who underwent NU after failed ENDO, some authors [24,26,27] have suggested no significant impact on survival when NU is delayed. Furthermore, Pak et al. convincingly described the considerable cost savings of ENDO over NU when the latter leads to end-stage or even chronic renal disease.
So although staging analysis has not been performed in the present study owing to small sample size, we agree that, when technically feasible and in select patients, ENDO is an acceptable alternative to more radical surgery for low grade, non-invasive ureteric tumours, admittedly at the cost of frequent re-treatments and close standard surveillance [25,29].
The present study has some limitations. It represents a non-randomized, retrospective analysis of a database from a single tertiary referral centre, which allows inherent selection bias to influence our results in various potential directions. Owing to relatively small sample size, it lacks staging evaluation. Given the low incidence rate of ureteric tumours, multicentre studies are needed to generalize the findings. Despite these limitations, the present study benefits from a centralized pathological review and standard, consistent follow-up practices. Moreover, clinical and pathological characteristics were similar among each study group, avoiding some selection bias.
In conclusion, the present results did not find prognostic significance of tumour location or surgical approach for outcomes in patients with ureteric tumours. Although NU is standard treatment for invasive ureteric tumours, partial ureterectomy and ENDO can safely be performed in select patients. Despite the risk of a shorter time to recurrence, ENDO can be recommended in low grade, non-invasive ureteric tumours but only with close, thorough surveillance practices.