Preoperative upper tract invasive diagnostic modalities are associated with intravesical recurrence following surgery for upper tract urothelial carcinoma: A population-based study

Abstract

Background Intravesical recurrence (IVR) after surgery for upper tract urothelial carcinoma (UTUC) is a clinical problem. We investigated if preoperative invasive diagnostic modalities (IDM) such as antegrade/retrograde uretero-pyelography and/or selective urine cytology/barbotage, and URS with or without concomitant biopsy are associated with IVR after radical surgery for UTUC. Risk of death from urothelial cancer and all causes was investigated as secondary outcomes. Methods We investigated a population-based cohort of 1038 consecutive patients subjected to radical surgery for UTUC 2015–2019 in Sweden, using the Bladder Cancer Data Base Sweden (BladderBaSe 2.0), comprising all patients in the Swedish National Registry of Urinary Bladder Cancer. Risk estimates of IVR, death from urothelial cancer, and all causes was assessed using multivariable Cox regression models. Results The study included 536 cases with and 502 without preoperative IDM. IDM was associated with increased risk of IVR (HR 1.24, 95% CI 1.03–1.52) and risk of urothelial cancer death (HR 1.56, CI 1.12–2.18), compared to no IDM after a median follow-up of 1.3 yrs. Stratified analysis for tumor location showed that IDM was associated with risk of IVR in ureteric cancer (HR 1.66, 95% CI 1.21–2.28) but not in renal pelvic cancer (HR 1.07, 95% CI 0.81–1.41). Limitations included the observational setting and the lack of variables such as tumour grade, multifocality and preoperative hydronephrosis. Conclusions Worse outcomes for patients subjected to preoperative IDM highlight the need for carefully considering diagnostic decisions for UTUC patients, specifically in tumours located in the ureter.

Violation of onco-surgical principles is associated with survival outcomes in upper tract urothelial carcinomas after radical nephroureterectomy

“…Although invasive diagnostic modalities independently have been associated with IVR in population-based series [9] such association could not be confirmed in the current data even after additional analyses with preoperative instrumentation of the upper urinary tract included as exposure. The lack of information about other known risk factors for IVR such as tumour size, hydronephrosis and tumour multiplicity when performing time-to-event analysis [10] together with limited statistical power in the present study are possible explanations for the lack of association with IVRFS in the current study.…”

“…The rare and heterogenous nature of UTUC constitutes a challenge for the urologist both in planning the diagnostic work-up and in surgical treatment. To improve survival outcomes in patients undergoing RNU, quality of care indicators including a complete removal of the distal ureter with excision of a bladder cuff has been proposed as one of five measures to achieve pentafecta at RNU [14] Despite recommendations in guidelines, proportions without bladder cuff excision up to 30% in patients operated with RNU have been published [9,15] In comparison, in the present study, 15% (22/150) of the patients were operated without bladder cuff excision. However, during later years in the authors' institution, patients subjected to SVs tended to decrease, which might be partly due to increased surgical volumes over time [16].…”

“…Survival estimates were calculated from the time of surgery to the time of event (IVR, death attributed to urothelial carcinoma or allcause death, respectively). Given that preoperative invasive diagnostic modalities have been associated with the current study outcomes [9] additional analyses with a broader definition of SV were performed, including also preoperative instrumentation of the upper urinary tract as exposure.…”

Upper Tract Urothelial Carcinoma (UTUC) Diagnosis and Risk Stratification: A Comprehensive Review

“…Diagnostic URS without biopsy was not associated with worse IVRFS [7]. Table 1 summarizes the studies assessing the association between URS, IVR (intravesical recurrence), and RFS (recurrence-free survival) [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. A study on 143 patients demonstrated a pathological phenotype-specific association between pre-operation URS and oncological outcomes, as the subgroup of patients with non-papillary and ≥pT3 UTUC had poorer overall and progression-free survival [23].…”