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Nephroureterectomy vs. segmental ureterectomy of clinically localized, high-grade, urothelial carcinoma of the ureter: Practice patterns and outcomes

  • Javier A Piraino 1,
  • Zachary A Snow 1,
  • Daniel C Edwards 1,
  • Shaun Hager 1,
  • Brian H McGreen 1,
  • Gregory J Diorio 1
1 Main Line Health, Department of Urology, Wynnewood, PA, USA

Publication: Urologic Oncology: Seminars and Original Investigations, Volume 38, Issue 11, November 2020

Background

Nephroureterectomy (NU) remains the gold-standard for upper-tract urothelial carcinoma (UTUC). However, nephron-sparing management (NSM), specifically segmental ureterectomy (SU) for urothelial tumors distal to the renal pelvis may offer decreased risk of renal insufficiency and equivalent cancer control.

Objectives

To identify patient-specific and facility-related factors that are associated with the selection of SU vs. NU for patients with clinically localized, high-grade, ureteral UTUC.

Design, setting, participants

We searched the National Cancer Database between 2004 and 2015 for patients with high-grade, clinically localized, primary ureteral UTUC managed by either NU or SU.

Outcome measurements and statistical analysis

Univariate and multivariate analysis was performed to assess patient, disease-specific, facility and treatment-related factors associated with SU vs. NU. Since surgical approach was only indexed after 2010, separate multivariable logistic regressions were performed including and excluding surgical approach in order to capture patients treated between 2004 and 2009. Survival analysis utilized Kaplan-Meier methods and Cox proportional hazards regression.

Results and limitations

Multivariate analysis including surgical approach demonstrated that among other factors, higher clinical stage (P = 0.034), larger tumor size (P < 0.001), the addition of neoadjuvant chemotherapy (P = 0.002), and the utilization of minimally invasive surgery (P < 0.05) decreased the likelihood of patients receiving SU. In this same cohort, institutions with larger facility volumes (P = 0.038) and performing intraoperative lymph node dissection (P < 0.001) were associated with a higher probability of SU. Excluding surgical approach, once again more advanced clinical stage (P = 0.005), larger tumor size (P < 0.001), and neoadjuvant chemotherapy (P = 0.003) decreased the probability of patients receiving SU, while increasing age (P = 0.049) and intraoperative lymph node dissection (P < 0.001) were more closely associated with SU compared to NU. No differences were noted in pathological T stage (P > 0.05), 30-day readmission (P = 0.7), 30-day mortality (P = 0.09), and 90-day mortality (P = 0.157) on multivariate analysis between SU and NU. Additionally, no significant differences were seen in median overall survival between patients receiving SU or NU (53 vs. 50 months; P = 0.143).

Conclusions

Comparable outcomes suggest segmental ureterectomy for high-grade ureteral UTUC is appropriate in well-selected patients. Practice patterns appear consistent with guideline recommendations (decreased tumor size and lower clinical stage favor SU), but treatment disparities may exist based on a multitude of patient, pathologic- and facility-related factors. Improved dissemination of knowledge regarding practice patterns and outcomes of SU for UTUC of the ureter has the potential to improve delivery of NSM in appropriate patients.

Expert's summary

By Dr. Francesco Soria

UTUC is a rare entity, representing around 5% of all urothelial cancers. The standard treatment is generally represented by RNU with bladder cuff excision, eventually accompanied by perioperative chemotherapy. During the last decades kidney-sparing surgery (KSS) has been advocated with the aim to preserve the renal function without compromising long-term oncological outcomes in suitable patients. Based on international guidelines, KSS (mainly performed with an endoscopic approach with laser ablation of the lesion) is indicated for low-risk patients such as those with low grade, <2cm, unifocal tumor. However, several retrospective series have demonstrated the safety and efficacy of segmental ureterectomy even in patients with high-risk disease, especially in case of tumor in the distal ureter. However, these studies were generally limited by their single-center nature and by their small sample size.

In this original article, Piraino er al. aimed to overcome these limitations by investigating the National Cancer Database. No difference was found in terms of perioperative morbidity, pathological and long-term oncological outcomes, thereby demonstrating that SU represents a feasible and safe procedure in well selected patients. In the absence of randomized controlled trials comparing RNU to SU, almost impossible to run due to the rarity of the disease, these results reinforce the role of SU in the treatment of ureteral UTUC. 


Expert's comment

In this retrospective, population-based study, the authors evaluated factors associated with different surgical procedures for ureteral cancer. Patients with primary high-grade, clinically localized, ureteral upper tract urothelial carcinoma (UTUC) managed with either segmental ureterectomy (SU) or radical nephroureterectomy (RNU) between 2004 and 2015 were included in the analysis. Overall, 6690 patients treated with RNU were compared to 2289 who underwent SU. Practice patterns revealed that the choice of SU was generally favored decreased tumor size and lower clinical stage, in accordance with international guidelines. No difference was noted in terms of pathological tumor stage, readmission, mortality and overall survival.