RESUMEN
Patients with end stage renal disease (ESRD) are at high risk of developing upper tract urothelial carcinoma (UTUC). Due to high recurrence rate of UTUC in contralateral kidney and ureter, and high risk of complications related to surgery and anesthesia, whether it's necessary to remove both kineys and ureters at one time remains in debate. We utilized Taiwanese UTUC Registry Database to valuate the difference of oncological outcomes and perioperative complications between patients with ESRD with unilateral and bilateral UTUC receiving surgical resection. Patients with ESRD and UTUC were divided into three groups, unilateral UTUC, previous history of unilateral UTUC with metachronous contralateral UTUC, and concurrent bilatetral UTUC. Oncological outcomes, perioperative complications, and length of hospital stays were investiaged. We found that there is no diffence of oncological outcomes including overall survival, cancer specific survival, disease free survival and bladder recurrence free survival between these three groups. Complication rate and length of hospital stay are similar. Adverse oncological features such as advanced tumor stage, lymph node involvement, lymphovascular invasion, and positive surgical margin would negatively affect oncological outcomes.
Asunto(s)
Fallo Renal Crónico , Nefroureterectomía , Complicaciones Posoperatorias , Humanos , Nefroureterectomía/métodos , Masculino , Femenino , Fallo Renal Crónico/cirugía , Fallo Renal Crónico/complicaciones , Anciano , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Resultado del Tratamiento , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/complicaciones , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/complicaciones , Tiempo de Internación , Taiwán/epidemiología , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/complicaciones , Recurrencia Local de Neoplasia/epidemiologíaRESUMEN
OBJECTIVES: We sought to determine whether bladder cuff excision and its technique influence outcomes after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS AND MATERIALS: A multicenter, international, retrospective analysis using the ROBotic surgery for Upper tract Urothelial cancer Study (ROBUUST) 2.0 registry identified 1,718 patients undergoing RNU for UTUC between 2015 and 2023 at 17 centers across the United States, Europe, and Asia. Data was gathered on (1) whether bladder cuff excision was performed and (2) what technique was used, including formal excision or other techniques (pluck technique, stripping/intussusception technique) and outcomes. Multivariate and survival analyses were performed to compare the groups. RESULTS: Most patients (90%, 1,540/1,718) underwent formal bladder cuff excision in accordance with EAU and AUA guidelines. Only 4% (68/1,718) underwent resection using other techniques, and 6% (110/1,718) did not have a bladder cuff excised. Median follow up for the cohort was 24 months (IQR 9-44). When comparing formal bladder cuff excision to other excision techniques, there were no differences in oncologic or survival outcomes including bladder recurrence-free survival (BRFS), recurrence-free survival (RFS), metastasis-free survival (MFS), overall survival (OS), or cancer-specific survival (CSS). However, excision of any kind conferred a decreased risk of bladder-specific recurrence compared to no excision. There was no difference in RFS, MFS, OS, or CSS when comparing bladder cuff excision, other techniques, and no excision. CONCLUSIONS: Bladder cuff excision improves recurrence-free survival, particularly when considering bladder recurrence. This benefit is conferred regardless of technique, as long as the intramural ureter and ureteral orifice are excised. However, the benefit of bladder cuff excision on metastasis-free, overall, and cancer-specific survival is unclear.
Asunto(s)
Carcinoma de Células Transicionales , Nefroureterectomía , Sistema de Registros , Vejiga Urinaria , Humanos , Masculino , Femenino , Nefroureterectomía/métodos , Anciano , Estudios Retrospectivos , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Vejiga Urinaria/cirugía , Vejiga Urinaria/patología , Persona de Mediana Edad , Resultado del Tratamiento , Neoplasias Renales/cirugía , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias de la Vejiga Urinaria/cirugía , Neoplasias de la Vejiga Urinaria/mortalidad , Neoplasias de la Vejiga Urinaria/patologíaRESUMEN
BACKGROUND: The effectiveness of laparoscopic nephroureterectomy (LNU) vs open nephroureterectomy (ONU) for upper tract urothelial carcinoma (UTUC) is unclear. METHODS: We conducted a meta-analysis of studies based on propensity score-matched cohorts to compare the surgical and oncological outcomes of LNU and ONU in UTUC patients. A literature search was conducted on PubMed, Embase, and Cochrane Library until July 12, 2023. The Newcastle-Ottawa Scale was utilized to assess the quality of eligible studies. Measurements of surgical and oncological outcomes were extracted and pooled including mean difference (MD), risk ratio (RR), hazard ratios (HR), and 95% confidence intervals (CI). RESULTS: Five high-quality retrospective studies were included, totaling 6422 patients; 2080 (32.4%) underwent LNU, and 4342 (67.6%) underwent ONU. With respect to surgical outcomes, patients in the LNU group experienced less estimated blood loss and had shorter hospital stay than those in the ONU group, but there was no significant difference in complication rates and operation time. In regard to oncological outcomes, there were no significant differences between the LNU and ONU groups in 3-year overall survival (OS) and cancer-specific survival (CSS). However, 3-year intravesical recurrence free survival (IVRFS) was worse in the LNU group compared to the ONU group. CONCLUSION: LNU was associated with less estimated blood loss and shorter hospital stays than ONU, but there were no differences in OS and CSS between the surgical modalities. Nonetheless, LNU might result in poorer IVRFS than ONU.
Asunto(s)
Laparoscopía , Nefroureterectomía , Puntaje de Propensión , Humanos , Nefroureterectomía/métodos , Laparoscopía/métodos , Laparoscopía/estadística & datos numéricos , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Urológicas/cirugía , Neoplasias Urológicas/mortalidad , Neoplasias Renales/cirugía , Neoplasias Renales/mortalidad , MasculinoRESUMEN
OBJECTIVE: Disease recurrence, particularly intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), is common. We investigated whether violations of onco-surgical principles before or during RNU, collectively referred to as surgical violation (SV), were associated with survival outcomes. Material and methods: Data from a consecutive series of patients who underwent RNU for UTUC 2001-2012 at Skåne University Hospital Lund/Malmö were collected. Preoperative insertion of a nephrostomy tube, opening the urinary tract during surgery or refraining from excising the distal ureter were considered as SVs. Survival outcomes in patients with and without SV (IVR-free [IVRFS], disease-specific [DSS] and overall survival [OS]) were assessed using multivariate Cox regression analyses (adjusted for tumour stage group, prior or concomitant bladder cancer, comorbidity and preoperative urinary cytology). RESULTS: Of 150 patients, 47 (31%) were subjected to at least one SV. Overall, SV was not associated with IVRFS (HR 0.81, 95% CI 0.4-1.6) but with worse DSS (HR 1.9, 95% CI 1.03-3.7) and OS (HR 1.9, 95% CI 1.2-3) in multivariable analysis. Additional analyses with a broader definition of SV including also preoperative instrumentation of the upper urinary tract (ureteroscopy and/or double J stenting) showed similar outcomes for DSS (HR 2.1, 95% CI 1.1-4.3). CONCLUSION: Worse survival outcomes, despite no difference in IVR, for patients that were subjected to the violation of sound onco-surgical principles before or during RNU for UTUC strengthen the notion that adhering to such principles is a cornerstone in upper tract urothelial cancer surgery.
Asunto(s)
Carcinoma de Células Transicionales , Neoplasias Renales , Nefroureterectomía , Neoplasias Ureterales , Humanos , Nefroureterectomía/métodos , Femenino , Masculino , Anciano , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Neoplasias Renales/cirugía , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Persona de Mediana Edad , Tasa de Supervivencia , Estudios Retrospectivos , Recurrencia Local de Neoplasia/epidemiología , Anciano de 80 o más Años , Uréter/cirugíaRESUMEN
BACKGROUND: The role of kidney-sparing surgery in patients with high-risk upper urinary tract urothelial carcinoma is controversial. The present study aimed to assess oncological and functional outcomes of robot-assisted distal ureterectomy in patients with high-risk distal ureteral tumors. METHODS: The ROBUUST 2.0 multicenter international (2015-2022) dataset was used for this retrospective cohort analysis. High-risk patients with distal ureteral tumors were divided based on type of surgery: robot-assisted distal ureterectomy or robot-assisted nephroureterectomy. A survival analysis was performed for local recurrence-free survival, distant metastasis-free survival, and overall survival. After adjusting for clinical features of the high-risk prognostic group, Cox proportional hazard model was plotted to evaluate significant predictors of time-to-event outcomes. RESULTS: Overall, 477 patients were retrieved, of which 58 received robot-assisted distal ureterectomy and 419 robot-assisted nephroureterectomy, respectively, with a mean (±SD) follow-up of 29.6 months (±2.6). The two groups were comparable in terms of baseline features. At survival analysis, no significant difference was observed in terms of recurrence-free survival (P=0.6), metastasis-free survival (P=0.5) and overall survival (P=0.7) between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy. At Cox regression analysis, type of surgery was never a significant predictor of worse oncological outcomes. At last follow-up patients undergoing robot-assisted distal ureterectomy had significantly better postoperative renal function. CONCLUSIONS: Comparable outcomes in terms of recurrence-free survival, metastasis-free survival, and overall survival between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy patients, and better postoperative renal function preservation in the former group were observed. Kidney-sparing surgery should be considered as a potential option for selected patients with high-risk distal ureteral UTUC.
Asunto(s)
Carcinoma de Células Transicionales , Nefroureterectomía , Procedimientos Quirúrgicos Robotizados , Uréter , Neoplasias Ureterales , Humanos , Estudios Retrospectivos , Masculino , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Femenino , Anciano , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Persona de Mediana Edad , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Uréter/cirugía , Nefroureterectomía/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: Localized Upper Urinary Tract Urothelial Carcinoma (UTUC) is an uncommon cancer typically detected at an advanced stage. Currently, radical nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for high-risk UTUC. This meta-analysis aims to evaluate the 5-year overall and cancer-specific survival and bladder recurrence rates in studies comparing endoscopic kidney-sparing surgeries (E-KSS) with RNU in localized UTUC. EVIDENCE ACQUISITION: We performed a literature search on 20th April 2023 through PubMed, Web of Science, and Scopus. The PICOS model was used for study inclusion: P: adult patients with localized UTUC; I: E-KSS. C: RNU; O: primary: overall survival (OS); secondary: cancer-specific survival (CSS), bladder recurrence rate, and metastasis-free survival (MFS). S: retrospective, prospective, and randomized studies. EVIDENCE SYNTHESIS: Overall, 11 studies involving 2284 patients were eligible for this meta-analysis, 737 in the E-KSS group and 1547 in the RNU group. E-KSS showed a similar overall 5-year OS between E-KSS and RNU, and for low-grade tumors, while 5-year OS favored RNU for high-grade tumors (RR 1.84, 95% CI 1.26-2.69, p = 0.002). No difference emerged for 5-year CSS between the two groups, even when the results were stratified for low- and high grade tumors. Bladder recurrence rate and 5-year MFS were also similar between the two groups. CONCLUSIONS: Our review showed that E-KSS is a viable option for patients with localized UTUC with non-inferior oncological outcomes as compared with RNU, except for 5-year OS in high-grade tumors which favoured RNU.
Asunto(s)
Carcinoma de Células Transicionales , Neoplasias Renales , Nefroureterectomía , Neoplasias Ureterales , Humanos , Nefroureterectomía/métodos , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/mortalidad , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/mortalidad , Ureteroscopía/métodosRESUMEN
BACKGROUND: Diagnostic ureteroscopy (URS) with or without biopsy remains a subject of contention in the management of upper tract urothelial carcinoma (UTUC), with varying recommendations across different guidelines. The study aims to analyse the decision-making and prognostic role of diagnostic ureteroscopy (URS) in high-risk UTUC patients undergoing curative surgery. MATERIALS AND METHODS: In this retrospective multi-institutional analysis of high-risk UTUC patients from the ROBUUST dataset, a comparison between patients who received or not preoperative URS and biopsy before curative surgery was carried out. Logistic regression analysis evaluated differences between patients receiving URS and its impact on treatment strategy. Survival analysis included 5-year recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS). After adjusting for high-risk prognostic group features, Cox proportional hazard model estimated significant predictors of time-to-event outcomes. RESULTS: Overall, 1,912 patients were included, 1,035 with preoperative URS and biopsy and 877 without. Median follow-up: 24 months. Robot-assisted radical nephroureterectomy was the most common procedure (55.1%), in both subgroups. The 5-year OS (Pâ¯=â¯0.04) and CSS (P < 0.001) were significantly higher for patients undergoing URS. The 5-year RFS (Pâ¯=â¯0.6), and MFS (Pâ¯=â¯0.3) were comparable between the 2 groups. Preoperative URS and biopsy were neither a significant predictor of worse oncological outcomes nor of a specific treatment modality. CONCLUSIONS: The advantage in terms of OS and CSS in patients undergoing preoperative URS could derive from a better selection of candidates for curative treatment. The treatment strategy is likely more influenced by tumor features than by URS findings.
Asunto(s)
Carcinoma de Células Transicionales , Neoplasias Ureterales , Ureteroscopía , Humanos , Ureteroscopía/métodos , Masculino , Femenino , Estudios Retrospectivos , Pronóstico , Anciano , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/diagnóstico , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/patología , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/diagnóstico , Persona de Mediana Edad , Toma de Decisiones Clínicas , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/mortalidad , Neoplasias Renales/diagnósticoRESUMEN
Introduction and Objective: Kidney-sparing surgery (KSS) for upper tract urothelial cancer (UTUC) has gained increasing interest recently. However, there is limited contemporary data regarding the role of KSS in ureteral urothelial carcinoma. Therefore, we investigated the survival outcomes of ureteral urothelial carcinoma after KSS from a large, prospective international UTUC registry. Methods: The Clinical Research Office of the Endourology Society-Urothelial Carcinomas of the Upper Tract (CROES-UTUC) Registry included patients with UTUC who received KSS or radical nephroureterectomy (RNU) between 2014 and 2019. In this study, we included patients with ureteral UTUC only. Study outcomes included overall survival (OS), cancer-specific survival (CSS), upper tract recurrence-free survival (RFS), intravesical RFS, progression-free survival (PFS), and metastasis-free survival (MFS). Propensity score matching (PSM) was performed to balance the tumor features' differences between groups. Results: Of the 391 patients with ureteral UTUC, 309 (79.0%) received RNU and 82 (21.0%) received KSS by ureteroscopy with laser ablation (n = 28) or segmental resection (n = 54). After PSM, there were no differences in OS (p = 0.525), CSS (p = 0.487), upper tract RFS (p = 0.147), intravesical RFS (p = 0.989), PFS (p = 0.617), and MFS (p = 0.336) between KSS and RNU. There were no significant differences between ureteroscopic ablation and segmental resection in OS, CSS, intravesical RFS, PFS, and MFS with RNU. Proximal ureteral UTUC had worse OS and CSS outcomes than other tumor locations following segmental resection. Conclusions: In patients with ureteral UTUC, no significant differences in long-term survival outcomes were observed between KSS and RNU. Proximal ureteral UTUC had worse survival outcomes over other tumor locations following segmental resection.
Asunto(s)
Nefroureterectomía , Tratamientos Conservadores del Órgano , Neoplasias Ureterales , Humanos , Nefroureterectomía/métodos , Masculino , Femenino , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/patología , Neoplasias Ureterales/mortalidad , Anciano , Resultado del Tratamiento , Persona de Mediana Edad , Tratamientos Conservadores del Órgano/métodos , Riñón/cirugía , Riñón/patología , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/patología , Estudios Prospectivos , Anciano de 80 o más Años , Uréter/cirugía , Uréter/patologíaRESUMEN
BACKGROUND: It is unknown whether the stage of the primary may influence the survival (OS) of metastatic upper tract urothelial carcinoma (mUTUC) patients treated with nephroureterectomy (NU) and systemic therapy (ST). We tested this hypothesis within a large-scale North American cohort. METHODS: Within Surveillance Epidemiology and End Results database 2000-2020, all mUTUC patients treated with ST+NU or with ST alone were identified. Kaplan-Maier plots depicted OS. Multivariable Cox regression (MCR) models tested for differences between ST+NU and ST alone predicting overall mortality (OM). All analyses were performed in localized (T1-T2) and then repeated in locally advanced (T3-T4) patients. RESULTS: Of all 728 mUTUC patients, 187 (26%) harbored T1-T2 vs 541 (74%) harbored T3-T4. In T1-T2 patients, the median OS was 20 months in ST+NU vs 10 months in ST alone. Moreover, in MCR analyses that also relied on 3 months' landmark analyses, the combination of ST+NU independently predicted lower OM (HR 0.37, p < 0.001). Conversely, in T3-T4 patients, the median OS was 12 in ST+NU vs 10 months in ST alone. Moreover, in MCR analyses that also relied on 3 months' landmark analyses, the combination of ST+NU was not independently associated with lower OM (HR 0.85, p = 0.1). CONCLUSIONS: In mUTUC patients, treated with ST, NU drastically improved survival in T1-T2 patients, even after strict methodological adjustments (multivariable and landmark analyses). However, this survival benefit did not apply to patients with locally more advanced disease (T3-T4).
Asunto(s)
Carcinoma de Células Transicionales , Neoplasias Renales , Nefroureterectomía , Neoplasias Ureterales , Humanos , Femenino , Masculino , Anciano , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Neoplasias Ureterales/terapia , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/secundario , Neoplasias Renales/patología , Neoplasias Renales/cirugía , Neoplasias Renales/mortalidad , Neoplasias Renales/terapia , Tasa de Supervivencia , Persona de Mediana Edad , Estudios Retrospectivos , Terapia Combinada , Estadificación de Neoplasias , Anciano de 80 o más AñosRESUMEN
BACKGROUND: The effect of radical nephroureterectomy (RNUx) on postoperative renal function in patients diagnosed with upper tract urothelial carcinoma (UTUC) has not been thoroughly explored. METHODS: We conducted a retrospective analysis including 785 patients who underwent RNUx for UTUC. We assessed the preoperative and postoperative estimated glomerular filtration rates (eGFRs) and factors related to the decline in eGFR. Additionally, we examined the effect of comorbidities (diabetes or hypertension) on the postoperative eGFR at 1 year. Cox proportional hazard models were employed to investigate the clinical effect of RNUx on oncological outcomes, including non-urothelial tract recurrence-free survival (NUTRFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS: The median preoperative and postoperative eGFR levels were 54.7 and 40.6 ml/min/1.73 m2 respectively. The proportions of patients with preoperative and postoperative eGFR ≥60 mL/min/1.73 m2 were 35.9% and 5.1%, respectively. The median decline in the eGFR after surgery was 26.8%. Patients with preoperative eGFR <60 ml/min/1.73 m2 demonstrated significantly lower odds of a postoperative decline in eGFR of 25% or more. The effect of comorbidities on postoperative eGFR at 1 year was significant (Pâ¯=â¯0.048). The 3-year NUTRFS, CSS, and OS rates were 72.9%, 85.2%, and 81.5%, respectively. Preoperative chronic kidney disease was an independent factor associated with inferior NUTRFS, CSS, and OS. CONCLUSION: Different degrees of impairment of renal function occur among UTUC patients. Only 5.1% of patients retain a postoperative eGFR ≥60 ml/min/1.73 m2. Preoperative renal impairment was linked to reduced odds of postoperative eGFR decrease and associated with survival. In addition, the presence of comorbidities had a significant effect on the decline in eGFR. These findings emphasize the importance of developing evidence-based perioperative treatment strategies for UTUC patients with impaired renal function.
Asunto(s)
Carcinoma de Células Transicionales , Tasa de Filtración Glomerular , Nefroureterectomía , Humanos , Nefroureterectomía/métodos , Estudios Retrospectivos , Masculino , Femenino , Anciano , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Persona de Mediana Edad , Neoplasias Renales/cirugía , Neoplasias Renales/fisiopatología , Resultado del Tratamiento , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/complicaciones , Riñón/fisiopatología , Riñón/cirugía , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Bone metastasis (BM) carries a poor prognosis for patients with upper-tract urothelial carcinoma (UTUC). This study aims to identify survival predictors and develop a prognostic nomogram for overall survival (OS) in UTUC patients with BM. METHODS: The Surveillance, Epidemiology, and End Results database was used to select patients with UTUC between 2010 and 2019. The chi-square test was used to assess the baseline differences between the groups. Kaplan-Meier analysis was employed to assess OS. Univariate and multivariate analyses were conducted to identify prognostic factors for nomogram establishment. An independent cohort was used for external validation of the nomogram. The discrimination and calibration of the nomogram were evaluated using concordance index (C-index), area under receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA). All statistical analyses were performed using SPSS 23.0 and R software 4.2.2. RESULTS: The mean OS for UTUC patients with BM was 10 months (95% CI: 8.17 to 11.84), with 6-month OS, 1-year OS, and 3-year OS rates of 41%, 21%, and 3%, respectively. Multi-organ metastases (HR = 2.21, 95% CI: 1.66 to 2.95, P < 0.001), surgery (HR = 0.72, 95% CI: 0.56 to 0.91, P = 0.007), and chemotherapy (HR = 0.37, 95% CI: 0.3 to 0.46, P < 0.001) were identified as independent prognostic factors. The C-index was 0.725 for the training cohort and 0.854 for the validation cohort, and all AUC values were > 0.679. The calibration curve and DCA curve showed the accuracy and practicality of the nomogram. CONCLUSIONS: The OS of UTUC patients with BM was poor. Multi-organ metastases was a risk factor for OS, while surgery and chemotherapy were protective factors. Our nomogram was developed and validated to assist clinicians in evaluating the OS of UTUC patients with BM.
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Neoplasias Óseas , Carcinoma de Células Transicionales , Nomogramas , Neoplasias Ureterales , Humanos , Neoplasias Óseas/secundario , Neoplasias Óseas/mortalidad , Masculino , Femenino , Anciano , Persona de Mediana Edad , Carcinoma de Células Transicionales/secundario , Carcinoma de Células Transicionales/mortalidad , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Neoplasias Ureterales/secundario , Tasa de Supervivencia , Neoplasias Renales/patología , Neoplasias Renales/mortalidad , Pronóstico , Estudios Retrospectivos , Programa de VERF , Anciano de 80 o más AñosRESUMEN
INTRODUCTION: Upper tract urothelial carcinoma (UTUC) is a rare disease accounting only for 5%-10% of urothelial carcinoma (UC). For localized high-risk disease, radical nephroureterectomy (RNU) is the standard of care. While minimally invasive (MIS) RNU has not been shown to decisively improve overall survival (OS) compared to open surgery, MIS RNU has been associated with reduced hospital length of stay (LOS), blood transfusion requirements and improved recovery, which are important considerations when treating older patients. The purpose of this study is to examine trends in surgical approach selection and outcomes of open vs. MIS RNU in patients aged ≥80 years. METHODS: Using the National Cancer Database (NCDB), patients aged ≥80 years who underwent open or MIS (either robotic or laparoscopic) RNU were identified from 2010 to 2019. Demographic, patient-related, and disease-specific factors associated with either open or MIS RNU were assessed using multivariate logistic regression models. Survival analysis was conducted using Kaplan-Meier plots and Cox-proportional hazard regression. Inverse probability of treatment weighting (IPTW) was utilized to adjust for confounding variables. Survival analysis was also conducted on the IPTW adjusted cohort using Kaplan-Meier plots and Cox-proportional hazard regression. RESULTS: 5,687 patients were identified, with 1,431 (25.2%) and 4,256 (74.8%) patients undergoing open and MIS RNU respectively. The proportion of RNU performed robotically has increased from 12.5% in 2010 to 50.4% in 2019. MIS was associated with a shorter hospital LOS (4.7 days versus 5.9 days, SMD 23.7%). Multivariate analysis revealed that MIS was associated with a significant reduction in 90-day mortality (OR: 0.571; 95%CI: 0.34-0.96, Pâ¯=â¯0.033) and improved median OS (53.8 months [95%CI: 50.9-56.9] vs 42.35 months [95%CI: 38.6-46.8], P < 0.001) compared to open surgery. IPTW-adjusted survival analysis revealed improved median OS with MIS when compared to open surgery, with a survival benefit of 46.1 months (95%CI: 40.2-52.4 months) versus 37.7 months (95%CI: 32.6-46.5 months, Pâ¯=â¯0.0034) respectively. IPTW-adjusted cox proportional hazard analysis demonstrated that MIS was significantly associated with reduced mortality (HR 0.76, 95%CI: 0.66-0.87, P < 0.001). CONCLUSION: In octogenarians undergoing RNU, MIS is associated with improved median OS and 90-day mortality.
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Procedimientos Quirúrgicos Mínimamente Invasivos , Nefroureterectomía , Puntaje de Propensión , Humanos , Femenino , Masculino , Nefroureterectomía/métodos , Anciano de 80 o más Años , Resultado del Tratamiento , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Análisis de Supervivencia , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/mortalidad , Neoplasias Renales/cirugía , Neoplasias Renales/mortalidad , Tasa de Supervivencia , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidadRESUMEN
PURPOSE: The study aimed to investigate the impact of adjuvant chemotherapy on time to recurrence (TTR) and overall survival (OS) in patients with histologic variants of upper tract urothelial carcinoma (VUTUC) following radical nephroureterectomy (RNU). MATERIALS AND METHODS: A retrospective review of 131 VUTUC patients' medical records, from a pool of 368 non-metastatic localized or locally advanced UTUC cases, treated at a single tertiary referral center between January 2011 and January 2021. The intervention was adjuvant chemotherapy administration post-RNU. TTR and OS were evaluated using Kaplan-Meier and Cox proportional hazard regression, covariates adjusted for age, postoperative GFR, history of neoadjuvant chemotherapy, T and N stage with stabilized inverse probability of treatment weighting (sIPTW). RESULTS: The application of adjuvant chemotherapy showed a significant extension in TTR (P = .01), but no substantial impact on OS (P = .19) after sIPTW adjustment for covariates. Multivariate analysis revealed adjuvant chemotherapy, tumor size, and lymphovascular invasion as significant prognostic factors for TTR. In contrast, only tumor size and perineural invasion were significant for OS. Adjuvant chemotherapy reduced the progression risk in certain VUTUC subtypes (squamous or glandular/micropapillary), but not in sarcomatoid variants. CONCLUSIONS: Adjuvant chemotherapy appears to improve TTR, albeit without a significant effect on OS, in nonmetastatic localized and locally advanced VUTUC patients post-RNU. While beneficial to some VUTUC subtypes, it did not yield significant advantages for sarcomatoid variants. Despite adjustments for known confounders, the study's findings may be subject to potential selection bias and unmeasured confounding factors.
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Quimioradioterapia Adyuvante , Nefroureterectomía , Neoplasias Ureterales , Neoplasias Urológicas , Quimioradioterapia Adyuvante/métodos , Tasa de Supervivencia , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/patología , Neoplasias Ureterales/cirugía , Neoplasias Urológicas/mortalidad , Neoplasias Urológicas/patología , Neoplasias Urológicas/cirugía , Neoplasias Urológicas/terapia , Recurrencia Local de Neoplasia , Pronóstico , Estudios Retrospectivos , Resultado del Tratamiento , Humanos , Masculino , Femenino , Anciano , Estimación de Kaplan-Meier , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/cirugía , Antibióticos AntineoplásicosAsunto(s)
Carcinoma de Células Transicionales , Invasividad Neoplásica , Humanos , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Metástasis Linfática , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/mortalidad , Neoplasias Urológicas/patología , Neoplasias Urológicas/cirugía , Neoplasias Urológicas/mortalidad , Neoplasias Ureterales/patología , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Tasa de SupervivenciaRESUMEN
INTRODUCTION: The objective of this study was to determine effects of adjuvant chemotherapy (AC) on survival outcomes compared to surgery alone without AC for upper tract urothelial carcinoma (UTUC) patients with variant histology (VH). METHODS: We conducted a systematic review and meta-analysis of studies investigating AC for UTUC in Medline, Embase, the Cochrane Library up to January 2023. Population, intervention, comparator, and outcome were UTUC patients with VH, radical nephroureterectomy with AC, radical nephroureterectomy only, and oncological survival, respectively. RESULTS: Four retrospective studies were included. Regarding overall survival (OS), the pooled hazard ratio was 0.61 (95% confidence interval: 0.42-0.87; p = 0.007) across two studies. Regarding cancer-specific survival (CSS), the pooled hazard ratio was 0.46 (95% confidence interval: 0.25-0.84; p = 0.01) across three studies. All included studies had a high quality based on the Newcastle-Ottawa Scale. Certainty of evidence for OS was low. Certainty of evidence for CSS was moderate due to a strong association (hazard ratio <0.5). Publication bias was not significant for any studies. CONCLUSION: In UTUC patients with VH, administration of AC after surgery might have better survival outcomes than surgery alone. Our study provides evidence for decision-making of clinicians who treat UTUC patients with VH.
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Carcinoma de Células Transicionales , Neoplasias Renales , Nefroureterectomía , Neoplasias Ureterales , Humanos , Quimioterapia Adyuvante , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/tratamiento farmacológico , Neoplasias Ureterales/patología , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/tratamiento farmacológico , Carcinoma de Células Transicionales/patología , Neoplasias Renales/cirugía , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Neoplasias Renales/tratamiento farmacológico , Resultado del Tratamiento , Tasa de SupervivenciaRESUMEN
BACKGROUND: To examine the recent trends in incidence, incidence-based mortality, survival, and treatment of upper tract urothelial carcinoma (UTUC) from 2004 to 2019 and investigate whether patients would benefit from adjuvant chemotherapy. METHODS: Within the Surveillance, Epidemiology, and End Results (SEER) database, we identified 18,422 patients diagnosed with UTUC from 2004 to 2019. Joinpoint regression analyses were used to test the trends in annual percentage change (APC) for statistical significance. RESULTS: From 2004 to 2019, the incidence of all UTUC decreased from 1.46 to 1.27 per 100,000 person-years [APC: -1.11, P<0.001]. In subgroup analysis, the incidence decreased for localized, regional and stage I-II, but increased for distant. Over the study period, changes in trend for 5-year cancer specific survival [APC: -0.21, P=0.676] and 5-year overall survival [APC: 0.18, P=0.751] of all UTUC were not significant. The 5-year cancer specific survival and 5-year overall survival for regional and stage III cancer improved significantly from 2004 to 2014. Since 2004, rates of treatment with nephroureterectomy combined with chemotherapy increased significantly [APC: 7.38, P<0.001], while rates of treatment with nephroureterectomy alone decreased significantly [APC: -1.89, P<0.001]. CONCLUSION: The overall incidence of UTUC is reduced, with a significant reduction in the incidence of early stage UTUC but an increase in the incidence of late stage UTUC. No significant change in IBM was observed over the study period. No significant improvement in survival for early stage UTUC. Significant improvements in regional and stage III survival were observed with active adjuvant chemotherapy. There is also an excess of combination therapy. LEVEL OF EVIDENCE: 8.
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Carcinoma de Células Transicionales , Neoplasias Renales , Neoplasias Ureterales , Humanos , Incidencia , Masculino , Femenino , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/terapia , Carcinoma de Células Transicionales/epidemiología , Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/tratamiento farmacológico , Anciano , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/terapia , Neoplasias Ureterales/epidemiología , Neoplasias Ureterales/patología , Tasa de Supervivencia , Neoplasias Renales/mortalidad , Neoplasias Renales/terapia , Neoplasias Renales/epidemiología , Persona de Mediana Edad , Estados Unidos/epidemiología , Programa de VERF , Quimioterapia Adyuvante , Estadificación de Neoplasias , Anciano de 80 o más AñosRESUMEN
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.POUT was a phase III, randomized, open-label trial, including 261 patients with muscle-invasive or lymph node-positive, nonmetastatic upper tract urothelial cancer (UTUC) randomly assigned after radical nephroureterectomy to platinum-based chemotherapy (132) or surveillance (129). Primary outcome analysis demonstrated that chemotherapy improved disease-free survival (DFS). At that time, the planned secondary outcome analysis of overall survival (OS) was immature. By February 2022, 50 and 67 DFS events had occurred in the chemotherapy and surveillance groups, respectively, at a median follow-up of 65 months. The 5-year DFS was 62% versus 45%, univariable hazard ratio (HR), 0.55 (95% CI, 0.38 to 0.80, P = .001). The restricted mean survival time (RMST) was 18 months longer (95% CI, 6 to 30) in the chemotherapy arm. There were 46 and 60 deaths in the chemotherapy and control arms, respectively. The 5-year OS was 66% versus 57%, with univariable HR, 0.68 (95% CI, 0.46 to 1.00, P = .049) and RMST difference 11 months (95% CI, 1 to 21). Treatment effects were consistent across chemotherapy regimens (carboplatin or cisplatin) and disease stage. Toxicities were similar to those previously reported, and there were no clinically relevant differences in quality of life between arms. In summary, although OS was not the primary outcome measure, the updated results add further support for the use of adjuvant chemotherapy in patients with UTUC, suggesting long-term benefits.
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Nefroureterectomía , Humanos , Nefroureterectomía/métodos , Quimioterapia Adyuvante , Femenino , Supervivencia sin Enfermedad , Masculino , Anciano , Persona de Mediana Edad , Carcinoma de Células Transicionales/tratamiento farmacológico , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/cirugía , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Urológicas/tratamiento farmacológico , Neoplasias Urológicas/mortalidad , Neoplasias Urológicas/cirugía , Neoplasias Urológicas/patología , Neoplasias Ureterales/tratamiento farmacológico , Neoplasias Ureterales/mortalidad , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/patología , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/mortalidad , Neoplasias Renales/cirugía , Neoplasias Renales/patologíaRESUMEN
PURPOSE: The aim of this retrospective study was to evaluate the efficacy of adjuvant cisplatin-based chemotherapy in patients with locally advanced upper tract urothelial carcinoma (UTUC), administered following radical nephroureterectomy. MATERIALS AND METHODS: Patients with UTUC, arising from renal pelvis or ureter, staged pT3/T4 or N+ were treated with adjuvant chemotherapy following surgery. The chemotherapy consisted of gemcitabine 1,000 mg/m2 on days 1 and 8, cisplatin 70 mg/m2 on day 1. Treatment was repeated every 3 weeks for up to 4 cycles. Endpoints included disease-free survival (DFS), metastasis-free survival (MFS), and safety. RESULTS: Among 89 eligible patients, 85 (95.5%) completed at least 3 cycles of adjuvant chemotherapy. Chemotherapy was well tolerated, the main toxicities being mild-to-moderate gastrointestinal toxic effects and pruritus. With a median follow-up of 37 months, median DFS was 30 months (95% confidence interval, 22 to 39), and the median MFS was not reached. The 3-year DFS and MFS were 44% and 56%, respectively. Multivariate analyses revealed that the main factor associated with DFS and MFS was the lymph node involvement, whereas age, T category, grade, or the primary site of UTUC were not significantly associated with DFS or MFS. CONCLUSION: Adjuvant cisplatin-based chemotherapy after radical surgery of pT3/T4 or N+ UTUC was feasible and may demonstrate benefits in DFS and MFS. Whether novel agents added to the chemotherapy regimen, as a concurrent combination or maintenance, impacts on survival or reduces the development of metastases remains to be studied.
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Cisplatino , Humanos , Masculino , Femenino , Quimioterapia Adyuvante/métodos , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Cisplatino/administración & dosificación , Cisplatino/uso terapéutico , Cisplatino/efectos adversos , Gemcitabina , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Nefroureterectomía/métodos , Desoxicitidina/análogos & derivados , Desoxicitidina/administración & dosificación , Desoxicitidina/uso terapéutico , Anciano de 80 o más Años , Carcinoma de Células Transicionales/tratamiento farmacológico , Carcinoma de Células Transicionales/patología , Carcinoma de Células Transicionales/mortalidad , Resultado del Tratamiento , Adulto , Neoplasias Urológicas/tratamiento farmacológico , Neoplasias Urológicas/patología , Neoplasias Urológicas/mortalidad , Neoplasias Ureterales/tratamiento farmacológico , Neoplasias Ureterales/patología , Neoplasias Ureterales/mortalidad , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/patología , Neoplasias Renales/mortalidad , Neoplasias Renales/cirugíaRESUMEN
OBJECTIVES: To assess the prognostic ability of lymphovascular invasion (LVI) in upper tract urothelial carcinoma (UTUC) as a predictor of overall survival (OS) using a large North American cohort. PATIENTS AND METHODS: Our cohort included 5940 patients with clinical M0 UTUC who underwent a radical nephroureterectomy (RNU), between 2010 and 2016, within the National Cancer Database. The main variable of interest was LVI status, and its interaction with pathological nodal (pN) status. Kaplan-Meier curves were used to depict the OS also stratifying patients on LVI status. Cox regression analysis tested the impact of LVI status on OS after accounting for the available covariates. RESULTS: The median (interquartile range [IQR]) age at diagnosis was 71 (63-78) years and most patients had pathological T1 stage disease (48.6%). Nodal status was pN0, pN1 and pNx in 45.8%, 6.3% and 47.9%, respectively. Overall, 22.1% had LVI. The median (IQR) follow-up time was 32.6 (16.0-53.3) months. At the 5-year postoperative follow-up, the estimated OS rate was 28% in patients with LVI vs 66% in those without LVI (P < 0.001). When patients were stratified based on nodal status those rates were 32% vs 68% in pN0 patients (P < 0.001), 23% vs 30% in pN1 patients (P = 0.8), and 28% vs 65% in pNx patients (P < 0.001). On multivariable analysis, the presence of LVI was associated with less favourable OS (hazard ratio 1.79, 95% confidence interval 1.60-1.99; P < 0.001). CONCLUSION: Our study assessed the impact of LVI on OS in patients with UTUC in a large North American nationwide cohort. Our series, as the largest to date, indicate that LVI is associated with less favourable survival outcomes in patients with UTUC after RNU, and this variable could be used in counselling patients about their prognosis and might be a useful tool for future trials to risk-stratify patients.
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Carcinoma de Células Transicionales , Neoplasias Renales , Metástasis Linfática , Invasividad Neoplásica , Nefroureterectomía , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Carcinoma de Células Transicionales/cirugía , Carcinoma de Células Transicionales/mortalidad , Carcinoma de Células Transicionales/patología , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/mortalidad , Neoplasias Ureterales/patología , Neoplasias Ureterales/cirugía , Neoplasias Ureterales/mortalidad , Pronóstico , Tasa de Supervivencia , Vasos Linfáticos/patología , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The aim of this study was to investigate whether diagnostic ureteroscopy (URS) biopsy is unfavourable for bladder tumour recurrence in upper urinary tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: We performed a retrospective analysis of 195 patients diagnosed with UTUC, who were divided into a diagnostic URS group (URS+) and a nondiagnostic URS group (URS-) according to whether diagnostic ureteroscopic biopsy was performed. A Cox regression model was used to analyse the risk factors for intravesical recurrence (IVR)-free survival (IRFS) and overall survival (OS) in UTUC after radical nephroureterectomy (RNU). Kaplan-Meier analysis was used to estimate the influence of factors on the incidence of IVR and the cumulative survival rate of UTUC. RESULTS: Patients with a maximum tumour diameter of less than 3.1 cm, low-stage tumours, and ureteral tumours were more likely to undergo diagnostic URS before radical surgery. Multivariate Cox regression analysis showed that tumour pathological stage and diagnostic ureteroscopic biopsy can be used as predictors of IVR after RNU (p = 0.019, 0.033). Kaplan-Meier survival analysis found that diagnostic ureteroscopic biopsy was a high-risk factor for IRFS (p = 0.034). Subcomponent analysis showed that pTa/Tis/T1, pT2, pT3/pT4 stage, and diagnostic ureteroscopic biopsy with pTa/Tis/T1 stage were unfavourable for IVR (p = 0.047). CONCLUSION: Diagnostic ureteroscopic biopsy before RNU should be carefully selected for patients with atypical preoperative UTUC. We believe that intravesical chemotherapy drug perfusion can be used after surgery to prevent IVR if biopsy is unavoidable, but this still requires further prospective studies.