Diagnostic Ureterorenoscopy Is Associated with Increased Intravesical Recurrence following Radical Nephroureterectomy in Upper Tract Urothelial Carcinoma

Abstract

Diagnostic ureterorenoscopy is powerful tool to confirm upper tract urothelial cancer (UTUC). However, URS and associated manipulation may be related to the risk of intravesical recurrence (IVR) following radical nephroureterectomy (RNU). We aimed to investigate whether preoperative ureterorenoscopy would increase IVR after RNU in patients with UTUC. We performed a retrospective analysis of 630 patients who had RNU with bladder cuff excision due to UTUC. Diagnostic URS was performed in 282 patients (44.7%). Patients were divided into two groups according to the URS. Survival analysis and multivariate Cox regression model were performed to address risk factors for the IVR. The interval from URS to RNU was measured. During URS, manipulation such as biopsy and resection was determined. The median age was 64 (IQR 56–72) years with follow-up duration of 34.3 (15.7–64.9) months. Median time from URS to RNU was 16 (0–38) days. The IVR developed in 42.5% (n = 268) patients at 8.2 (4.9–14.7) months. The five-year IVR-free survival rate was 42.6 ± 8.0% and 63.6 ± 6.9% in patients with and without preoperative URS, respectively (P < 0.001). In multivariate analysis, previous history of bladder tumour, extravesical excision of distal ureter, multifocal tumour, and URS (HR, 95% CI; 1.558, 1.204–2.016, P = 0.001) were independent predictors for higher IVR. The IVR rate in patients without manipulation during URS was not different to those with manipulation (P = 0.658). The duration from URS to RNU was not associated with IVR (P = 0.799). Diagnostic URS for UTUC increased IVR rate after RNU. However, the lessening of interval from URS to radical surgery or URS without any manipulation could not reduce the IVR rate.

Diagnostic Ureteroscopy Prior to Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma Increased the Risk of Intravesical Recurrence

“…Sankin et al [9] also found the same relationship between time delay and risk for IVR. In contrast, Sung et al [11] revealed that the concurrent and delayed RNU after URS did not make any difference in the incidence of IVR or time to bladder recurrence, making the issue more complicated. In addition, Nison et al [12] reported that the use of diagnostic URS did not alter the risk of CSS, RFS, or MFS as well as muscle-invasive lesions.…”

“…The general descriptions of included studies were summarised in Table 1. Among the included studies, 7 (60%) were from Asian countries [8, 10, 11, 13, 14, 17] and 3 studies were conducted in USA [9, 15, 16] and one in France [12], respectively. A total of 4,057 participants were included in the subsequent meta-analysis, of which 518 patients had a history of TCC in bladder.…”

“…Eight studies [8-11, 13, 14, 17, 24] provided HRs for the URS-related risk of IVR, including 3,340 participants, of which 1,219 had IVR. The reasons to exclude the other 3 studies from quantitative analysis included no HR available [16] and HRs were for URS-related risk of recurrence (both upper tract and IVR) [12, 15].…”

“…Moreover, Sung et al [11] found that in patients who underwent diagnostic URS prior to RNU, any manipulation (biopsy or dilation) did not increase the IVR rate during URS ( p = 0.658). In addition, the IVR rate of the delayed RNU did not differ from that of concurrent RNU group ( p = 0.545).…”

Cytologic persistence of malignant cells after transurethral resection of bladder tumors: Implications for concomitant manipulation of the urinary tract at the time of endoscopic resection

“…Similarly, several studies have demonstrated an association between postsurgical positive cytology and urothelial tumor recurrence for both TURBT and radical nephroureterectomy . Finally, 2 studies examined the inverse principle and demonstrated that ureteroscopy of the upper tract within the setting of high‐grade urothelial carcinoma is associated with intravesical recurrences, with a likely mechanism of high pressure irrigation in the upper tract dislodging high‐grade cells, resulting in lower tract implantation . These observations, taken together, suggest that although the theoretical risk may be low, within the setting of positive cytology, viable tumor cells are likely to be present in the bladder and could result in upper tract implantation, especially within the setting of urothelial trauma.…”