Oncologic outcomes and prognostic impact of urothelial recurrences in patients undergoing segmental and total ureterectomy for upper tract urothelial carcinoma

Abstract

Introduction:We evaluated the impact of urothelial recurrences in a cohort of patients undergoing segmental (SU) and total ureterectomy (TU) as an alternative to nephroureterectomy (NU) for upper tract urothelial carcinoma. Methods: Between 1999 and 2012, patients who underwent SU, TU and NU for treatment of upper tract urothelial carcinoma were evaluated. Demographic, surgical, pathologic and oncologic data were collected. Recurrence-free (RFS) and disease-specific survival (DSS) were analyzed using Kaplan-Meier and multivariable Cox methods. Results: A total 141 patients were evaluated, 35 underwent SU, 10 TU and 96 NU. Patients who underwent TU were more likely to have bilateral disease (p < 0.01), solitary kidney (p < 0.01), and multifocal disease (p = 0.01). Organ-confined (p < 0.01) and lowgrade disease (p < 0.01) were more common in the TU and SU groups compared with NU. At a median follow-up of 56.9 months (range: 0.2-181.1) disease relapse occurred in 88 (55.3%) patients. Localized recurrence occurred in 31.1% of SU/TU group compared to 27.1% (p = 0.62) of the NU group. Neither total nor segmental ureterectomy demonstrated significantly worse RFS (p = 0.26 and p = 0.81), CSS (p = 0.96 and p = 0.52) or overall survival (p = 0.59 and p = 0.55) compared with complete NU. Localized urothelial recurrence did not confer increased risk of cancer-specific (p = 0.73) or overall mortality (p = 0.39). The paper's most important limitations include its retrospective nature and its relatively small number of patients. Conclusion:No significant survival differences were demonstrated between surgical approaches for upper tract urothelial cancer. Localized urothelial recurrence after surgical treatment for upper tract urothelial cancer does not affect mortality in this population. TU with ileal-substitution may provide an alternative option for patients with extensive ureteral disease and poor renal function.

Oncologic outcomes comparison of partial ureterectomy and radical nephroureterectomy for urothelial carcinoma

“…The probable reason is that the number of patients involved in our study is not large enough, thus this study may not be powerful enough to show significance [6]. Furthermore, there were some selection biases that RNU group seemed to have more aggressive pathological features compared with PU group, because there was not the standardized indication for PU and surgeon preferred PU for lower stage UTUCs [13, 14]. Selection biases can lead to better survival in PU group compared with RNU group, though the difference was not significant in our analysis.…”

Long-term outcomes of total ureterectomy with ileal-ureteral substitution treatment for ureteral cancer: a single-center experience

“…A total ureterectomy with ileal-ureteral substitution not only provides maximal ureteral excision as wide as in renal autotransplantation, but avoids the devastating vascular complications. According to our review, only a few studies [ 12 , 22 , 23 ] used the total ureterectomy and ileal ureteral-substitution to treat ureteral UC. The present study, which focuses on the outcome of total ureterectomy with ileal-ureteral substitution in treating ureteral UCs, has the largest sample and the longest follow-up.…”

“…However, endoscopic management may carry risks of under-staging, under-grading, or increased risk of recurrence, where SU may not be feasible in multifocal disease or in the case of long segment of tumor involvement [ 8 ]. Both procedures also encounter certain risk of recurrence on the remaining ureter [ 11 , 12 ].…”

“…Ileal-ureteral substitution was designed to bridge a huge ureteral defect, and the safety was showed in some studies [ 19 – 21 ]. However, only small case series and case reports discussed about the combination of total ureterectomy with ileal-ureteral substitution in treating ureteral UC [ 12 , 22 , 23 ]. Besides, these studies did not focus on the long-term functional and oncological outcome specifically for this procedure.…”

Narrative review of nephron-sparing surgical management of upper tract urothelial carcinoma: is there a role for distal ureterectomy, segmental ureterectomy, and partial nephrectomy

“…For more proximally located tumors, segmental ureteral resection with end-to-end uretero-ureterostomy after adequate proximal & distal ureteral mobilization, to allow for tension free anastomosis, can be performed ( 9 , 10 ). TU with ileal segment replacement have also been reported in more widespread/multifocal ureteral involvement ( 11 ). These procedures can be performed with open, laparoscopic or robotic-assisted approaches based on surgeon’s discretion/experience.…”