Prognostic factors of intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma

Differential Risk Factors for Early Intravesical Recurrence After Radical Nephroureterectomy for Upper Urinary Tract Carcinoma According to the History of Non-Muscle Invasive Bladder Cancer

OBJECTIVES

To evaluate the preoperative risk factors for early intravesical recurrence after radical nephroureterectomy (RNU) in patients with upper urinary tract carcinoma (UTUC) according to the history of non-muscle invasive bladder cancer (NMIBC).

METHODS

We retrospectively evaluated patients who underwent RNU for UTUC between 2012 and 2022 at 14 hospitals. Early recurrence was defined as intravesical pathologically confirmed recurrence within 1 year after RNU. Patients who received single-dose immediate intravesical instillation (IVI) as prevention for intravesical recurrence were excluded. Using preoperative factors, we examined the risk factors for early intravesical recurrences in patients with and without a history of NMIBC. Death from any cause within 1 year after RNU was regarded as a competitive risk.

RESULTS

We included 504 UTUC patients who were treated with RNU. Among these patients, 126 (25.0%) had a history of NMIBC, whereas 378 (75%) did not. According to multivariate analysis, the presence of macrohematuria, positive cytology in self-voided urine, and performing diagnostic ureteroscopy prior to RNU were risk factors in patients without a history of NMIBC. On the other hand, an NMIBC diagnosis within 1 year prior to RNU and an extravesical approach for bladder cuff management were risk factors in RNU-treated patients with a history of NMIBC.

CONCLUSIONS

Early intravesical recurrence risk factors differ between UTUC patients with and without a history of NMIBC. Different stratification may be needed to predict intravesical recurrence risk in these two types of UTUC patients.

Emerging strategies: conservative management of upper tract urothelial carcinoma

PURPOSE OF REVIEW

Upper tract urothelial carcinoma (UTUC) is a rare yet aggressive malignancy, representing 5-10% of urothelial cancers. While radical nephroureterectomy (RNU) has traditionally offered excellent oncological control, it compromises renal function. Recent advancements have shifted the paradigm toward kidney-sparing strategies in select cases. This review highlights innovations in UTUC diagnosis and conservative management, focusing on emerging imaging techniques, noninvasive biomarkers, and minimally invasive treatments.

RECENT FINDINGS

Advances in multiparametric MRI and radiomics have improved diagnostic accuracy and risk stratification. Moreover, noninvasive biomarkers - including circulating tumor DNA, microRNAs, and urinary methylation assays - provide promising tools for early detection and surveillance. Kidney-sparing approaches such as endoscopic laser ablation and segmental ureterectomy have demonstrated comparable oncologic outcomes in low-risk patients. Moreover, topical therapies, including intracavitary treatments like UGN-101, offer a promising minimally invasive option.

SUMMARY

The conservative management of UTUC is evolving, driven by advancements in imaging, molecular diagnostics, and minimally invasive treatments. While kidney-sparing approaches are increasingly utilized in low-risk patients, further prospective studies are needed to validate their efficacy.

Gold standard nephroureterectomy, chemoprophylaxis and surveillance in upper tract urothelial carcinoma

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence on surgical management, strategies to reduce tumor recurrence, and surveillance regimens in patients diagnosed with upper tract urothelial carcinoma (UTUC) and elected for radical treatment.

RECENT FINDINGS

Minimally invasive surgery is gaining momentum in the surgical management of UTUC. Chemoprophylaxis is still the gold standard to reduce intravesical recurrence after radical nephroureterectomy (RNU). Novel surveillance strategies have been proposed to adapt follow-up regimens to patients' characteristics.

SUMMARY

Minimally invasive surgery has been associated with comparable oncological outcomes to the open approach while improving postoperative morbidity. In these cases, bladder cuff excision (BCE) is mostly performed by an extravesical approach, that demonstrates a noninferiority compared to the intravesical one in terms of oncological outcomes. Although lymphadenectomy is recommended in patients with high-risk tumors, its benefits are still unclear. Currently, there is a lack of recent prospective trials on chemoprophylaxis to reduce intravesical recurrence post RNU, making single-dose postoperative chemotherapy instillation the standard treatment. Although novel risk stratification models were released by international urological guidelines, their validity is mainly nonevidence-based. Risk-adapted follow-up strategies incorporating cystoscopy and cross-sectional imaging accounting for individual patient factors should be implemented.