Does preoperative percutaneous nephrostomy insertion worsen upper-tract urothelial cancer oncological outcome? A retrospective single center study

Abstract

Background Physicians doubt percutaneous nephrostomy (PCN) insertion on cancer related hydronephrosis patients causes tumor seeding and worse cancer control. In this article, we attempted to determine if preoperative PCN alters cancer control in upper tract urothelial cancer (UTUC) patients. Methods Retrospective analysis of UTUC patients in a single center from 2005 to 2015. Exclusion criteria included lymph node metastasis, and patients underwent perioperative adjuvant chemotherapy or radiotherapy. There were 664 patients in this analysis, with clinico-pathological data being collected retrospectively for Cox-regression statistical analysis. Outcomes were measured by local recurrence, distant metastasis and cancer-specific death with Kaplan-Meier curves. Results There were respectively 25 and 639 UTUC cancers in the preoperative PCN and non-PCN insertion groups with mean follow-up duration of 37.9 and 48.6 months, respectively. The preoperative PCN group consisted of 17 patients (68%) with tumor located in the ureter, while the PCN-negative group included 236 patients (36%) with tumor located in the ureter being statistically significant. These two groups were comparable in gender, age, follow-up duration, tumor stage, and pathological features of the UTUC. As for the cancer control in the PCN group, 4(16%), 1(4%) and 1(4%) had local recurrence, distant metastasis and cancer-specific death respectively; in the non-PCN group, 101(15.8%), 96(15%) and 72(11.2%) exhibited local recurrence, distant metastasis and cancer-specific death respectively. Statistical analysis showed no difference in oncologic outcomes between these two groups.( p = 0.804, 0.201 and 0.254). Conclusions Preoperative percutaneous nephrostomy on upper-tract urothelial cancer poses little risk on tumor seeding and could be considered as part of treatment strategy if renal function preservation is needed.

Antegrade Instillation of UGN-101 (Mitomycin for Pyelocalyceal Solution) for Low-Grade Upper Tract Urothelial Carcinoma: Initial Clinical Experience

“…21 More directly relevant to the work described here, a retrospective analysis comparing 25 patients with UTUC who underwent nephrostomy placement with 639 who did not, demonstrated similar oncologic outcomes whether or not nephrostomy was placed. 22 Given that patients being treated with UGN-101 have LG UTUC, and with strategic nephrostomy placement (away from a calyx containing tumor), these authors postulate the risk of tract seeding is very low. In those without a tumor-free landing zone for nephrostomy placement, this risk must be balanced with the potential for increased oncologic control from UGN-101 administration as well as the risk of adverse events related to retrograde administration or a greater number of endoscopic ablations.…”

Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma

“… 27,28 In terms of complications, around 17% of cases require blood transfusion, with a 1% risk of emergency RNU or renal artery embolization 96 . In addition, tumor seeding of the nephrostomy tract is a potential risk in 0.75% of patients 12,97 . However, these findings are based on the conventional percutaneous approach using a 30 Fr sheath 94 and not a miniature nephroscope 98 .…”

The role of endoscopic management and adjuvant topical therapy for upper tract urothelial cancer

“…Though percutaneous procedures are inherently more invasive than retrograde endoscopic counterparts, percutaneous biopsies of UTUC have shown minimal risk of tract seeding and intravesical recurrence when compared against retrograde procedures (46,48,49). The process of percutaneous access can provide the additional benefit of facilitating nephrostomy tube placement, which may help treat severe hydronephrosis or impending renal failure for UTUC patients with little seeding risk (49). Conversely, studies of percutaneous resection of UTUC have shown an association of percutaneous resection with recurrence.…”

“…However, data from larger studies that are UTUC-specific is limited. In a 2019 comparison of 25 patients with UTUC and percutaneous nephrostomy placement compared to 639 UTUC patients without nephrostomy, Huang et al found that 20% and 30.8% of patients, respectively, had either local recurrence or distant metastasis, suggesting that percutaneous nephrostomies had little effect on risk of tumor seeding (49). At this time, there remains a scarcity of data with larger populations of UTUC patients who have undergone percutaneous nephrostomy tube placement, and the true effect of percutaneous nephrostomy on seeding risk has yet to be fully characterized.Retrograde endoscopic resection/ablation Endoscopic resection of UTUC may be performed as part of the initial ureteroscopic tumor visualization and biopsy, while both endoscopic resection and ablation can be curative treatments for low-grade disease.…”