Prevention of Recurrent Bladder Tumors after Nephroureterectomy for Primary Upper Urinary Tract Urothelial Carcinoma: An Individualized Selection Strategy Based on Patient Risk Stratification Is Needed

Abstract

Objective: To evaluate the efficacies of different chemotherapy regimens in different risk sub-groups for the prevention of bladder recurrence after radical nephroureterectomy (RNU). Materials and Methods: Between 2004 and 2012, we recruited 685 patients who underwent RNU for upper tract urothelial carcinoma at 4 Chinese institutions. We assessed whether the type of intravesical chemotherapy regimen affected the bladder recurrence rate in patients with different risk levels after RNU. Results: For all patients, the bladder recurrence rate was lower with intravesical chemotherapy than without, but no significant differences were found between the 2 intravesical chemotherapy regimens (single dose or relatively long-term therapy). We used multivariate analysis to define the risk factors for bladder recurrence and stratified patients into low-, intermediate-, and high-risk sub-groups accordingly. The bladder recurrence rate in the low-risk patients was not significantly different between patients with or without intravesical chemotherapy. However, in the intermediate-risk and high-risk patients, the rate was greater in patients without intravesical chemotherapy than in patients with. Furthermore, the rate was not significantly different between the 2 intravesical chemotherapy regimens in the intermediate-risk patients, while the efficacy of the relatively long-term regimen in high-risk patients remains unclear. Conclusions: Our study showed that an individualized strategy based on patient risk stratification is needed.

A Comparison of Different Prophylactic Intravesical Chemotherapy Regimens for Bladder Cancer Recurrence After Nephroureterectomy for Primary Upper Tract Urothelial Carcinomas: A Retrospective 2-center Study

“…Previous investigators have focused on risk factors for the development of bladder recurrence after surgery and have shown that intraluminal seeding should be an important factor leading to implantation metastases, 8,9,21 and it is also the basis for the administration of a single dose of intravesical chemotherapy. However, data from present study suggest that several doses of intravesical chemotherapy following RNU can reduce the incidence of bladder recurrence more effectively (multiple vs single, 13.1% vs 25.4%). Therefore, we surmise that dispersed viable intraluminal cancer cells are not completely mopped up by a single instillation, suggesting why maintenance chemotherapy achieves more apparent benefits in terms of recurrence.…”

“…And Wu et al 10 demonstrated that, in a series of 196 patients, intravesical recurrence was lower in those who received MMC or epirubicin for 6 to 8 times after RNU compared to those who received neither. However, to the best of our knowledge, only a retrospective study has compared the efficacy of single and multiple instillations, but the comparison between multiple instillations and single instillation remains undefined 13 .…”

“…And Wu et al 10 demonstrated that, in a series of 196 patients, intravesical recurrence was lower in those who received MMC or epirubicin for 6 to 8 times after RNU compared to those who received neither. However, to the best of our knowledge, only a retrospective study has compared the efficacy of single and multiple instillations, but the comparison between multiple instillations and single instillation remains undefined 13 . Although previous studies have shown that maintenance chemotherapy has benefits in terms of the prevention of recurrence in the postoperative regimen of bladder cancer, 14,15 it is unclear whether these benefits extend to UTUC because of the differences between these malignancies.…”

The complex relationship between upper urinary tract and bladder cancer: clinical and predictive issues

“…Their results have been biased by intrinsic limitations, namely the retrospective nature and relatively small number of cases in single center studies. Further attempts of risk stratification for IVR have been made, taking into account from time to time the above-mentioned parameters along with additional ones, such as papillary tumor architecture and lymphovascular invasion ( 19 ), and even the impact of different chemotherapy regimens ( 20 ). Current guidelines from the European Association of Urology ( 21 ) suggest a risk stratification based on three categories of predictors of increased risk for IVR namely, (I) patient-specific factors (i.e., male gender, previous BC, smoking and preoperative chronic kidney disease), (II) tumour-specific factors (i.e., positive preoperative urinary cytology, ureteral location, multifocality, invasive pT stage, and necrosis), and (III) treatment-specific factors (i.e., laparoscopic approach, extravesical bladder cuff removal, and positive surgical margins).…”

A húgyhólyag-recidíva jellemzői felső üregrendszeri daganatos betegekben radikális ureteronephrectomia után

“…Mostanáig két elmélet látott napvilágot a felső üregrendszert érintő elváltozást követő gyakori húgyhólyagrecidívát illetően: az első hipotézis szerint ilyenkor üregrendszeren belüli szórás és megtapadás történik, míg a másik szerint a húgyhólyag területe malformatión megy keresztül, és így alakul daganattá a folyamatos carcinogen környezet miatt [10]. Azémar és mtsai a 2011. évi tanulmányuk során a felső üregrendszeri daganatok utáni húgyhólyag-recidívát befolyásoló tényezőket szerették volna meghatározni.…”