Radical Nephrouretectomy Research Articles

Prognostic significance of multifocal upper tumors with presence of high inflammation status in upper tract urothelial carcinoma following radical nephrouretectomy

Prognostic significance of multifocal upper tumors with presence of high inflammation status in upper tract urothelial carcinoma following radical nephrouretectomy

Total Intracorporeal Versus Open Bladder Cuffing in Robotic Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

To evaluate a single institution experience of total intracorporeal bladder cuffing and distal ureterectomy (DUBC) in robotic radical nephrouretectomy (RNU) for upper tract urothelial carcinoma (UTUC). One hundred sixty-eight patients treated for UTUC with robotic RNU at our institution from May 2009 to October 2019 were retrospectively analyzed. Ninety-two patients underwent total intracorporeal DUBC after robotic dock repositioning, whereas 76 patients underwent open methods via Gibson incision. Perioperative outcomes including operation time, estimated blood loss (EBL), transfusion rates, use of painkillers, Visual analogue scale (VAS) pain scores, and complication rates were compared, as well as pathological and oncological outcomes. Uni- and multi-variate Cox regression models were performed for survival analysis. There were no significant differences in baseline patient characteristics between the 2 groups. Patients who underwent intracorporeal bladder cuffing had less EBL (169.8 ± 150.4 vs 214.6 ± 157.0, P = .091) and decreased pain at 1 week (VAS score 1.18 ± 1.1 vs 2.2 ± 1.1, P = .017). Pathological outcomes were not significantly different, and oncological outcomes including local and intravesical recurrence, cancer-specific and overall mortality were comparable to patients who received extracorporeal bladder cuffing. Intracorporeal bladder cuffing was not associated with increased risk of progression on univariate analysis (HR 0.600, 95% CI, 0.314-1.147; P = .122). Based on our experience, intracorporeal DUBC can be a safe and oncologically non-inferior alternative method to RNU, with benefits of decreased EBL and postoperative pain. Future prospective trials are necessary to further validate our results.

Pre‑existing renal insufficiency synchronous with high preoperative neutrophil‑to‑lymphocyte ratio as a risk factor of intravesical recurrence in patients with pure upper tract urothelial carcinoma after radical nephroureterectomy.

The present study aimed to evaluate the influence of pre-treatment neutrophil-to-lymphocyte ratio (NLR) on bladder recurrence in patients with impaired renal function following radical nephrouretectomy (RNU) to treat pure upper tract urothelial carcinoma (UTUC). Retrospective data of 362 patients with pure UTUC who underwent RNU between 2008 and 2019 were analyzed. Kaplan-Meier analyses were performed to evaluate the association of preoperative NLR and estimation of the glomerular filtration rate (eGFR) with intravesical recurrence-free survival (IVRF). Furthermore, multivariate analyses were conducted to determine independent factors for predicting IVRF. In the retrospective cohort study of 362 patients, 103 patients (28%) had intravesical recurrence in a median follow-up of 50.1 months; among those, 85 (83%) developed bladder recurrence within two years after RNU. The Kaplan-Meier analysis indicated that patients exhibiting lower eGFR and higher NLR showed significantly poor IVRF rates (P=0.044). The simultaneous presence of eGFR <45 and NLR >3.8 was an independent factor for the shorter IVRF time in multivariate analysis with Cox's proportional hazards model. Most intravesical recurrences occurred within two years after RNU, particularly in pre-existing poor eGFR patients with preoperative high NLR. Moreover, pre-existing moderate to severe CKD synchronous with pre-operative NLR >3.8 was demonstrated as an independent factor for subsequent bladder recurrence in patients with pure UTUC following RNU. Therefore, such high-risk patients ought to be provided with close bladder monitoring during the follow-up.

Trends in management and outcomes in patients with upper tract urothelial carcinoma following radical nephrouretectomy at Memorial Sloan Kettering Cancer Center.

469 Background: Although there have been changes in the treatment paradigm of patients with upper tract urothelial carcinoma (UTUC) over the past 2 decades, there is limited data on the particular management strategies and associated outcomes. We evaluated surgical trends, perioperative management, and oncologic outcomes of patients who underwent radical nephroureterectomy (RNU) for UTUC at Memorial Sloan Kettering Cancer Center over a 24-year period. Methods: Between 1995 and 2018, we identified 760 patients with UTUC who underwent RNU. 15 had multiple RNU and we kept only the first procedure for analysis. Generalized additive models were fitted to examine the association between date of surgery and continuous while generalized additive models with a logit link were used to estimate categorical variables. As surgical approach was defined using three different categories (open, laparoscopic and robotic) a generalized additive multinomial model was used. Generalized additive cox proportional hazards models were used to estimate the association between surgery date and estimate 2-year cancer-specific survival. Results: The use of pre-operative diagnostic endoscopic biopsies also increased from 12% to 72% which coincides with an increased proportion high grade disease on final pathology from 55% to 91%. The rate of open RNU declined from 100% to 54% with a coinciding rise in the utilization of minimally invasive approaches. Laparoscopy peaked in 2008 and then was subsequently replaced by the robotic approach. Mean lymph node yield increased over the study interval with more retroperitoneal lymph node dissections performed. Utilization of neoadjuvant chemotherapy also increased over time with a current rate of 31%, coinciding with an increase in pT0 rate from only 2% to 9%.The 2-year cancer specific survival probability has improved from 76% to 87% over the study period. Conclusions: Several changes in treatment patterns for patients with UTUC over the past 2 decades appear to correspond with an improvement of oncologic outcomes. How these changes directly relate to each other requires further investigation.

Risk factors of renal function after radical nephroureterectomy for upper tract urothelial carcinoma

Objective To investigate the risk factors which can lead to chronic kidney disease (CKD) after radical nephroureterectomy and guide adjuvant chemotherapy for the patients with upper tract urothelial carcinoma (UTUC). Methods 239 patients with UTUC, who were treated at our hospital from October 2010 to February 2015 was analyzed retrospectively. Serum creatinine levels were measured preoperatively and 1 month (range: 21days to 35 days) after radical nephroureterectomy. 129 males and 110 females patients were enrolled. Ages were from 41 to 94, and mean age was 66 years. All patients underwent radical surgery. The pathological stages included Ta/T1/T2/T3/T4, and grades included G1/G2/G3. We calculated GFR using Chronic Kidney Disease Epidemiology Collaboration(CKD-EPI) equations in consideration of age, sex, and serum creatinine level. The new-onset CKD after RNU was defined as when the calculated CKD-EPI GFR decreased to less than 60 ml/(min·1.73 m2). These patients were divided into 2 groups which depended on whether they got CKD after RNU. Cohorts were stratified by gender, age, smoking, BMI, hypertension, diabetes mellitus(DM), tumor location, tumor size, multifocality, pathologic stage, grade, hydronephrosis and preoperative CKD-EPI GFR. The chi-square test was used to examine the relationship among the various cohorts and the CKD after RNU. The Kaplan-Meier method was adopted to identify the relationship between Overall survival (OS). Cancer-specific survival (CSS) and CKD. Univariate and multivariate analyses were performed to study the relationship between clinical factors and CKD after RNU using the Cox proportional hazards regression model and chi-square test. Results In our study, the median follow-up time was 41.3(range from 2-82) months for 239 patients. Median CKD-EPI GFR for all patients before and after surgery was 71.4(65.2-108.7)ml/(min·1.73 m2) and 54.7(37.6-93.8)ml/(min·1.73 m2), meanwhile 105 cases became new-onset CKD. There was no significant difference in overall or cancer specific survival between CKD+ and CKD-(P=0.137, P=0.190). However age (HR=1.825, 95%CI 1.203-2.768, P=0.017), hydronephrosis (HR=0.243, 95%CI 0.106-0.613, P=0.034) and preoperative CKD-EPI GFR(HR=0.237, 95%CI 0.109-0.524, P=0.021) were significantly correlative with postoperative new-onset CKD. Conclusion Age, absence of hydronephrosis and preoperative CKD-EPI GFR were independent risk factors predicting new-onset CKD. They can be the predictor of new-onset CKD. Key words: Upper tract urothelial carcinoma; Radical nephrouretectomy; Chronic kidney disease; Glomerular filtration rate(GFR); Risk factors analysis

Preoperative prognostic nutritional index is a significant predictor of survival in patients with localized upper tract urothelial carcinoma after radical nephroureterectomy

BackgroundPatient's nutritional and immunological status have a potentially significant role in survival outcome in patients with malignant tumors. We investigated the prognostic value of preoperative prognostic nutritional index (PNI) in patients with localized upper tract urothelial carcinoma (UTUC) undergoing radical nephrouretectomy (RNU). Patients and methodsA total of 425 patients with nonmetastatic UTUC (Ta-4N0/+M0) who underwent RNU were evaluated. PNI was calculated as 10 × serum albumin concentration (g/dl) + 0.005 × lymphocyte counts (number/mm3). The associations of preoperative PNI level with clinical and pathologic variables were analyzed. ResultsThe optimal cutoff value of PNI for cancer-specific survival (CSS) stratification was determined to be 46.78. Multivariate analysis identified low PNI as an independent prognostic factor for CSS (HR = 1.98, 95% CI: 1.31–2.99, P = 0.001) and overall survival (HR = 1.74, 95% CI: 1.20–2.53, P = 0.004). The estimated c-index of the multivariate model for CSS and overall survival increased from 0.777 and 0.767 to 0.791 and 0.774, respectively, when PNI added, which was higher than hypoalbuminemia (albumin<37.75g/l) or neutrophil-to-lymphocyte ratio >2.955 added. ConclusionsPreoperative PNI was an independent prognostic factor for predicting survival in patients with UTUC undergoing RNU. Preoperative PNI may become a useful biomarker, particularly because of its low associated cost and easy accessibility.

De Ritis Ratio (AST/ALT) as a Significant Prognostic Factor in Patients With Upper Tract Urothelial Cancer Treated With Surgery.

We investigated the clinical prognostic value of preoperative De Ritis ratio (aspartate aminotransferase [AST]/alanine aminotransferase [ALT]) on postsurgical survival outcomes in patients with upper tract urothelial cancer (UTUC). We retrospectively analyzed the data of 623 patients who underwent radical nephrouretectomy for UTUC. Multivariate regression tests were performed to identify possible associations between adverse pathologic events and AST/ALT. The risk of postoperative progression and survival were tested using Kaplan-Meier analyses and Cox proportional hazards models. According to the receiver operator characteristic curve of AST/ALT for cancer-specific mortality, patients with AST/ALT value≥1.5 were regarded as the high AST/ALT group, and the remaining patients formed the low AST/ALT group. In Kaplan-Meier analyses, the high AST/ALT group showed worse progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (all P< .001). Elevated AST/ALT was associated with higher T stage (hazard ratio [HR], 1.577; 95% confidence interval [CI], 1.077-2.311; P= .033) and higher cellular grade (HR, 1.538; 95% CI, 1.034-2.287; P= .041) in multivariate regression tests. In multivariate Cox analyses, high AST/ALT was revealed as an independent predictor of PFS (HR, 2.335; 95% CI, 1.633-3.340; P< .001), CSS (HR, 2.550; 1.689-3.851; P< .001), and overall survival (HR, 2.069; 95% CI, 1.409-3.038; P< .001). Elevated preoperative AST/ALT was a significant predictor of worse postoperative survival in patients surgically treated for UTUC. Further large prospective studies are needed for better understanding of the prognostic value of preoperative AST/ALT.

MP7-07 ENDOSCOPIC MANAGEMENT FOR UPPER TRACT UROTHELIAL CANCER (UTUC) COMPARED TO IMMEDIATE NEPHROURETERECTOMY: SURVIVAL OUTCOMES IN SEER DATABASE AND CANCER CENTER COHORT

INTRODUCTION AND OBJECTIVES: Patients with upper tract urothelial carcinoma (UTUC) may undergo endoscopic procedures for diagnostic and therapeutic intentions prior to definitive surgical management with radical nephrouretectomy (RNU). We assessed for differences in survival based on initial management strategy. METHODS: From 2004 to present, patients undergoing RNU for low grade UTUC from Memorial Sloan-Kettering Cancer Center (MSKCC) had their charts reviewed retrospectively to identify those patients who were initially managed endoscopically with ureteroscopy and tumor ablation. Those less than 66 years of age were excluded to provide an age-matched cohort for combined analysis. Data from Surveillance, Epidemiology and End Results (SEER) from this same time period was obtained and the same selection criteria was used. Survival trends were assessed with Kaplan-Meier analyses. Cox-proportional hazard models were constructed to determine the independent effect of initial management strategy on overall survival (OS) and cancer specific survival (CSS) controlling for age, race, gender, comorbidity, and data source. RESULTS: 838 patients went directly to RNU, and 167 had RNU after initial endoscopic management. We found no difference in OS between the groups (p1⁄40.632) with median follow up of 96 months. The Kaplan-Meier survival analysis for CSS comparing endoscopic management with initial RNU is shown in the figure. Conversely, CSS was significantly worse for those treated with endoscopic management first versus immediate definitive surgery (HR 1.69, 95% CI 1.07-2.69, p1⁄40.025). CONCLUSIONS: In elderly patients with low grade UTUC, there is no difference in overall survival for those that start with endoscopic management of their disease. The observed lower CSS in these patients bears further investigation of the possible contributory selection factors in this patient population.

Impact of an Adjuvant Chemotherapeutic Regimen on the Clinical Outcome in High Risk Patients with Upper Tract Urothelial Carcinoma: A Japanese Multi-Institution Experience

Current guidelines do not yet provide any recommendations for adjuvant chemotherapy in patients with upper tract urothelial carcinoma managed with radical nephroureterectomy. We evaluated whether an adjuvant chemotherapeutic regimen would affect the clinical outcome in patients with high risk upper tract urothelial carcinoma. We identified 873 patients who had undergone radical nephrouretectomy for localized upper tract urothelial carcinoma at 14 Japanese institutions between 1993 and 2011. We assessed whether the type of regimen, such as methotrexate, vinblastine, doxorubicin and cisplatin, and gemcitabine and cisplatin, in an adjuvant setting, could affect the subsequent clinical outcome of patients with upper tract urothelial carcinoma. On multivariate analysis pathological T stage, tumor grade, lymphovascular invasion and lymph node involvement were prognostic factors for recurrence-free survival and cancer specific survival. We defined 229 patients with 3 or more of these factors as the high risk group. In an analysis according to adjuvant regimen, Kaplan-Meier curves showed that the 1 and 2-year recurrence-free survival rates in the methotrexate, vinblastine, doxorubicin and cisplatin treated group were 71.4% and 47.9%, which were significantly higher than in the gemcitabine and cisplatin treated group (48.2% and not reached, p=0.022) or those not treated with adjuvant chemotherapy (53.4% and 39.6%, p=0.039). Similar results were observed in terms of cancer specific survival. Our study showed that pT3-4, tumor grade 3, positive lymphovascular invasion and lymph node involvement were independent risk factors for disease mortality in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy. In the high risk group methotrexate, vinblastine, doxorubicin and cisplatin adjuvant chemotherapy contributed to improve subsequent mortality compared to gemcitabine and cisplatin or no adjuvant chemotherapy.

641 MANAGEMENT OF THE INTRAVESICAL URETER AND BLADDER CUFF DURING RADICAL NEPHROURETERECTOMY: OUTCOMES FROM THE CANADIAN UPPER TRACT COLLABORATION

641 MANAGEMENT OF THE INTRAVESICAL URETER AND BLADDER CUFF DURING RADICAL NEPHROURETERECTOMY: OUTCOMES FROM THE CANADIAN UPPER TRACT COLLABORATION

The Impact of Previous Ureteroscopic Tumor Ablation on Oncologic Outcomes After Radical Nephrouretectomy for Upper Urinary Tract Urothelial Carcinoma

Abstract We investigated whether a history of endoscopic tumor ablation impacts oncologic outcomes after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC). Using a multi-institutional database that contained patients who were treated with RNU, oncologic outcomes were assessed according to history of ureteroscopic tumor ablation. Disease-free survival (DFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier survival analysis. Multivariate Cox regression analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU. The study included 1268 patients, 853 men and 415 women, with a mean age of 67.5 years (range 32-94 y) and 52.8 months median follow-up after RNU. A total of 175 (13%) patients underwent RNU after endoscopic tumor ablation and 1093 (87%) patients underwent RNU without a history of endoscopic ablation. The 5-year DFS and CSS rates were 72% and 77% in those with a history of tumor ablation vs 69% and 73% in those without a history of ablation (P = 0.171 and P = 0.365, respectively). In multivariate Cox regression analysis, history of ablation therapy was not associated with disease recurrence or cancer-specific mortality (hazard ratio [HR]: 0.79, P = 0.185 and HR: 0.7, P = 0.078, respectively). Our collaborative international efforts suggest that in selected patients, endoscopic tumor ablation does not adversely affect the recurrence and survival after subsequent RNU for UTUC. Our data support the continued role of ureteroscopic ablation of UTUC in appropriately selected patients.

MP-5.21: Overexpression of HER-2 is a Prognostic Factor in Upper Tract Urothelial Carcinoma Post-Radical Nephroureterectomy

To investigate the correlation of HER-2 expression and oncological outcomes in patients treated with radical nephrouretectomy for upper tract urothelial carcinoma (UTUC).