Clinical implications of intravesical recurrence after radical nephroureterectomy for upper urinary 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.

The long-term impact of single intraoperative instillation of pirarubicin after radical nephroureterectomy on local and systemic cancer control: a prospective, multicenter, randomized trial

PURPOSE

Although the preventive effect against intravesical recurrence (IVR) has been established for single instillation of chemotherapy during or after radical surgery of upper urinary tract urothelial carcinoma (UTUC), there has been no research on the long-term outcome. This study aims to investigate the IVR and long-term survival outcome of a single intraoperative instillation of pirarubicin during radical nephroureterectomy (RNU).

METHODS

In this prospective, multicenter, randomized trial, 97 patients undergoing RNU between August 2012 and January 2019 were randomly assigned either to receive a single intraoperative pirarubicin instillation or to serve as the controls.

RESULTS

A total of 80 patients were analyzed, including 42 in the pirarubicin group and 38 in the control group. The median follow-up period was 58.5 months and 62 months in the pirarubicin and the control groups, respectively. In patients who did not experience IVR, the median follow-up period was 59 months and 61 months in the pirarubicin and the control groups, respectively. There was no significant difference in OS between the two groups, although the IVR rate was significantly lower in pirarubicin group (p = 0.044). Multivariable analyses revealed that the pirarubicin instillation was the only independent factor for IVR.

CONCLUSIONS

The present trial demonstrated that a single intraoperative instillation of pirarubicin resulted in a significant and long-term reduction of IVR, although there was no significant difference in OS.

Ideal cystoscopic interval after nephroureterectomy in patients with upper tract urothelial carcinoma

PURPOSE

The purpose of this study was to clarify the appropriate cystoscopic interval after nephroureterectomy (NU) for upper tract urothelial carcinoma (UTUC) using a hypothetical model.

METHODS

A total of 155 patients who underwent NU in 15 years were retrospectively evaluated. Three hypothetical models for surveillance intervals were created: 3 (model 1), 6 (model 2) and 12 months (model 3). We superimposed these models on the actual surveillance of each patient and analyzed the observed timing of recurrence. The time from recurrence to scheduled cystoscopy (timeRCS) was defined as the time from recurrence to estimated cystoscopy. The gap risk ratio was calculated based on the average of timeRCS for model 1 at 0-1 year after surgery.

RESULTS

The median follow-up was 20.5 months. Intravesical recurrence was observed in 63 patients (40.6%). The 3-year intravesical recurrence-free survival rate in patients without a history of bladder cancer before NU was significantly higher than in those with a history of bladder cancer (61% vs. 42%, P = 0.034). The medians of timeRCS for models 1, 2, and 3 were 1.9, 2.9, and 8.4 months, respectively. The gap risk ratios for model 1 at 1-3 years, model 2 at 2-3 years for patients with a history of bladder cancer, and model 2 at 1-3 years for patients without a history of bladder cancer were less than 1.0.

CONCLUSION

Model analysis shows that the cystoscopic follow-up interval can be extended depending on the presence or absence of a history of bladder cancer and the time after NU.

Differential effect of surgical technique on intravesical recurrence after radical nephroureterectomy in patients with upper tract urothelial cancer: a systematic review and Meta-analysis

CONTEXT

Radical nephroureterectomy (RNU) with bladder cuff resection is the standard treatment in patients with high-risk upper tract urothelial cancer (UTUC). However, it is unclear which specific surgical technique may lead to improve oncological outcomes in term of intravesical recurrence (IVR) in patients with UTUC.

OBJECTIVE

To evaluate the efficacy of surgical techniques and approaches of RNU in reducing IVR in UTUC patients.

EVIDENCE ACQUISITION

Three databases were queried in January 2024 for studies analyzing UTUC patients who underwent RNU. The primary outcome of interest was the rate of IVR among various types of surgical techniques and approaches of RNU.

EVIDENCE SYNTHESIS

Thirty-one studies, comprising 1 randomized controlled trial and 1 prospective study, were included for a systematic review and meta-analysis. The rate of IVR was significantly lower in RNU patients who had an early ligation (EL) of the ureter compared to those who did not (HR: 0.64, 95% CI: 0.44-0.94, p = 0.02). Laparoscopic RNU significantly increased the IVR compared to open RNU (HR: 1.28, 95% CI: 1.06-1.54, p < 0.001). Intravesical bladder cuff removal significantly reduced the IVR compared to both extravesical and transurethral bladder cuff removal (HR: 0.65, 95% CI: 0.51-0.83, p = 0.02 and HR: 1.64, 95% CI: 1.15-2.34, p = 0.006, respectively).

CONCLUSIONS

EL of the affected upper tract system, ureteral management, open RNU, and intravesical bladder cuff removal seem to yield the lowest IVR rate in patients with UTUC. Well-designed prospective studies are needed to conclusively elucidate the optimal surgical technique in the setting of single post-operative intravesical chemotherapy.

Single Early Intravesical Instillation of Epirubicin for Preventing Bladder Recurrence after Nephroureterectomy in Upper Urinary Tract Urothelial Carcinoma

PURPOSE

We aimed to assess the effectiveness of early single intravesical administration of epirubicin in preventing intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma.

MATERIALS AND METHODS

Patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy between November 2018 and May 2022 were retrospectively reviewed. Intravesical epirubicin was administered within 48 hours if no evidence of leakage was observed. Epirubicin (50 mg) in 50 mL normal saline solution was introduced into the bladder via a catheter and maintained for 60 minutes. The severity of adverse events was graded using the Clavien-Dindo classification. We compared intravesical recurrence rate between the two groups. Multivariate analyses were performed to identify the independent predictors of bladder recurrence following radical nephroureterectomy.

RESULTS

Epirubicin (n=55) and control (n=116) groups were included in the analysis. No grade 1 or higher bladder symptoms have been reported. A statistically significant difference in the intravesical recurrence rate was observed between the two groups (11.8% at 1 year in the epirubicin group vs. 28.4% at 1 year in the control group; log-rank p=0.039). In multivariate analysis, epirubicin instillation (hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.20 to 0.93; p=0.033) and adjuvant chemotherapy (HR, 0.29; 95% CI, 0.13 to 0.65; p=0.003) were independently predictive of a reduced incidence of bladder recurrence.

CONCLUSION

This retrospective review revealed that a single immediate intravesical instillation of epirubicin is safe and can reduce the incidence of intravesical recurrence after radical nephroureterectomy. However, further prospective trials are required to confirm these findings.

Effect of subsequent bladder cancer on survival in upper tract urothelial carcinoma patients post-radical nephroureterectomy: a systematic review and meta-analysis

BACKGROUND

Radical nephroureterectomy (RNU) is the primary treatment strategy for upper tract urothelial carcinoma (UTUC). However, the intravesical recurrence occurs in 20-50% of all patients. The specific effect of subsequent bladder cancer (SBCa) on survival remains unclear. Therefore, we investigated the effect of SBCa following RNU in patients with UTUC.

METHODS

PubMed, EMBASE, and Cochrane Library were exhaustively searched for studies comparing oncological outcomes between SBCa and without SBCa. Standard cumulative analyses using hazard ratios (HR) with 95% confidence intervals (CI) were performed using Review Manager (version 5.3).

RESULTS

Five studies involving 2057 patients were selected according to the predefined eligibility criteria. Meta-analysis of cancer-specific survival (CSS) and overall survival (OS) revealed no significant differences between the SBCa and non-SBCa groups. However, subgroup analysis of pT0-3N0M0 patients suggested that people with SBCa had worse CSS (HR = 5.13, 95%CI 2.39-10.98, p < 0.0001) and OS (HR = 4.00, 95%CI 2.19-7.31, p < 0.00001).

CONCLUSIONS

SBCa appears to be associated with worse OS in patients with early stage UTUC. However, caution must be taken before recommendations are made because this interpretation is based on very few clinical studies and a small sample size. Research sharing more detailed surgical site descriptions, as well as enhanced outcome data collection and improved reporting, is required to further investigate these nuances.

Intravesical Therapy for Upper Urinary Tract Urothelial Carcinoma: A Comprehensive Review

Upper tract urothelial carcinoma (UTUC) poses unique challenges in diagnosis and treatment. This comprehensive review focuses on prophylactic intravesical therapy for UTUC, summarizing key aspects of intravesical therapy in various clinical scenarios, including concurrent with or following radical nephroureterectomy, kidney-sparing surgery, ureteroscopy-guided biopsy. The incidence of intravesical recurrence in UTUC after surgical treatment is significant, necessitating effective preventive measures. Intravesical therapy plays a vital role in reducing the risk of bladder recurrence following UTUC surgery. Tailoring timing, drug selection, dosage, and frequency is vital in optimizing treatment outcomes and reducing intravesical recurrence risk in UTUC. This review provides a comprehensive summary of the history, clinical trials, guideline recommendations, and clinical applications of intravesical therapy for UTUC. It also discusses the future directions based on current clinical needs and ongoing trials. Future directions entail optimizing dosage, treatment duration, and drug selection, as well as exploring novel agents and combination therapies. Intravesical therapy holds tremendous potential in improving outcomes for UTUC patients and reducing the risk of bladder recurrence. Although advancements have been made in UTUC treatment research, further refinements are necessary to enhance efficacy and safety.

Comparable survival benefits of partial ureterectomy to radical nephroureterectomy in non-metastatic ureter carcinoma: a population-matched study

PURPOSE

We aim to compare the long-term oncologic outcomes, including overall survival (OS), cancer-specific survival (CSS), and bladder cancer recurrence (BCR) among patients with ureter carcinoma who received nephroureterectomy (RNU) or partial ureterectomy (PU).

METHODS

We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results database between 2004 and 2015 of patients with ureter carcinoma who underwent RNU or PU. Propensity score matching (PSM) was applied to balance the baseline data. The Kaplan-Meier method with subgroup analysis was conducted to verify the effect of the two surgery types. Fine-Gray competing risk regression estimated the cumulative incidence of BCR.

RESULTS

A total of 2509 patients were involved; 665 (26.5%) patients underwent PU, and 1844 (73.5%) patients underwent RNU. Patients who underwent PU experienced a similar OS and CSS compared with those who underwent RNU in both PSM cohorts (HR [hazard ratio], 1.07 (0.93-1.23); P = 0.37; HR, 1.10 (0.91-1.31); P = 0.32, respectively), adjust model (HR, 0.99 (0.88-1.11); P = 0.87; HR, 1.05 (0.90-1.20); P = 0.55, respectively), and the subgroup analysis. For BCR, the patients who underwent PU were associated with a similar risk of developing BCR compared with those that received RNU, according to the univariate competing risk model (P = 0.47), adjust model (HR, 1.00 (0.73-1.37); P = 1), and subgroup analysis.

CONCLUSION

RNU did not confer a distinct survival advantage compared with PU, which supports the role of PU in treating patients with ureter carcinomas.

A 6-month maintenance schedule of mitomycin C after radical nephroureterectomy for upper tract urothelial carcinoma for the prevention of intravesical recurrence: a retrospective, single center study

PURPOSE

To show the effect of a 6-month (4 times weekly followed by 5 times monthly) maintenance mitomycin C regimen on the prevention of intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

METHODS

A total of 119 patients undergoing a RNU between 2007 and 2021 in a single center hospital were retrospectively reviewed. A total of 66 patients were eligible for further analysis. 27 patients received no post-operative MMC (median follow-up: 110 months) and 39 patients received a 6-month (4 times weekly, 5 times monthly) maintenance regimen of MMC (median follow up: 48 months). The primary outcome was the 1-, 2- and 5-year bladder recurrence free survival (BRFS).

RESULTS

There was a significant difference (p = 0.001) in BRFS between the two groups. The 1-, 2, and 5-year BRFS for the MMC- group was 67%, 63% and 43%, respectively. The 1-, 2- and 5-year BRFS for the MMC + group was 95%, 86% and 86%, respectively. Univariate analysis showed no other potential prognostic factors that had a significant effect on the BRFS.

CONCLUSION

A 6-month maintenance schedule of MMC is effective at significantly reducing the risk of IVR after RNU for UTUC. We could not find any other significant prognostic factors to predict IVR.

Presence of secondary bladder cancer following radical nephroureterectomy for upper tract urothelial carcinoma: characteristics, risk factors, and predictive value

BACKGROUND

To assess the characteristics, predictive risk factors, and prognostic effect of secondary bladder cancer (SBCa) following radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC).

METHODS

Using the Surveillance, Epidemiology, and End Results database, the authors analyzed clinicopathologic characteristics and survival data from 472 UTUC patients with SBCa after RNU, between 2004 and 2017. Cox's proportional hazard regression model was implemented to identify independent predictors associated with post-recurrence outcomes. The threshold for statistical significance was p < 0.05.

RESULTS

In total, 200 Ta-3N0M0 localized UTUC patients with complete data were finally included. With a median follow-up of 71.0 months (interquartile ranges [IQR] 36.0 -103.8 months), 52.5% (n = 105) had died, with 30.5% (n = 61) dying of UTUC. The median time interval from UTUC to SBCa was 13.5 months (IQR 6.0-40.8 months). According to multivariable Cox regression analysis, patients with SBCa located at multiple sites, advanced SBCa stage, higher SBCa grade, elderly age and a shorter recurrence time, encountered worse cancer-specific survival (CSS), all p < 0.05.

CONCLUSION

For primary UTUC patients with SBCa after radical surgery, advanced age, multiple SBCa sites, shorter recurrence time, higher SBCa stage, and grade proved to be significant independent prognostic factors of CSS. We ought to pay more attention to SBCa prevention as well as to earlier signs which may increase the likelihood of early detection. Having the ability to manage what may be seen as the superficial SBCa signs may enable us to improve survival but further research is required.

Assessment of Therapeutic Benefit and Option Strategy on Intravesical Instillation for Preventing Bladder Cancer Recurrence after Radical Nephroureterectomy in Patients with Upper Urinary Tract Urothelial Carcinoma

Objective

Upper urinary tract urothelial carcinoma (UUT-UC) is a very aggressive disease, characterized by 22%–50% of patients suffering from subsequent bladder recurrence after radical nephroureterectomy (RNU). Although the therapy of intravesical instillation is reported to be effective in preventing bladder recurrence, no study had been reported in Northeast China. The findings relating to the clinical effectiveness of intravesical instillation after RNU are somewhat controversial, and the best efficacy and least adverse effects of instillation drugs have not been widely accepted. Here, we aimed at evaluating the efficacy of intravesical instillation for the prevention intravesical recurrence systematically.

Methods

In this retrospective cohort study, from October 2006 to September 2017, 158 UUT-UC patients underwent RNU were divided into 4 groups: epirubicin (EPB) instillation group, hydroxycamptothecin (HCPT) instillation group, bacillus Calmette–Guerin (BCG) instillation group, and noninstillation group. Cox univariate and multivariate analyses were employed to identify the risk factors for intravesical recurrence-free survival (IVRFS). The nomogram model was also applied to predict patient outcomes. Subsequently, to evaluate the clinical significance of intravesical instillation comprehensively, several databases including PubMed, Ovid, and Embase were searched and data from published studies with our results were combined by direct meta-analysis. Moreover, a network meta-analysis comparing instillation therapies was conducted to evaluate the clinical efficacy of different instillation drugs.

Results

In our retrospective cohort study, the Kaplan–Meier survival curve demonstrated noninstillation groups were associated with worsened IVRFS. Meanwhile, multivariate analysis indicated that intravesical instillation was independent protective factors for IVRFS (hazard ratio [HR] = 0.731). Moreover, calibration plots, receiver operating characteristic (ROC) curves, area under the curve (AUC) values, and the C-index showed the priority of nomogram's predictive accuracy. Next, direct meta-analysis including 19 studies showed that intravesical instillation could prevent the recurrence of bladder cancer with a pooled risk ratio (RR) estimate of 0.53. Subgroup analysis by study type, year of intravesical recurrence, first instillation time, and instillation times also confirmed the robustness of the results. Moreover, intraoperative instillation was associated with a decrease in the risk of bladder recurrence compared with postoperative instillation. Then, a network meta-analysis including 7 studies indicated that pirarubicin (THP) (surface under the cumulative ranking curve [SUCRA] = 89.2%) is the most effective therapy to reduce the risk of bladder recurrence, followed by BCG (SUCRA = 83.5%), mitomycin C (MMC) (SUCRA = 53.6%), EPB (SUCRA = 52.6%), and HCPT (SUCRA = 5.1%) after the analysis of the value ranking.

Conclusions

A maintenance schedule of intravesical instillation prevents the recurrence of bladder cancer after RNU in UUT-UC patients effectively. Large, prospective trials are needed to further confirm its value. Compared with other chemotherapy regimens, THP may be a promising drug with favorable efficacy to prevent bladder recurrence. As included studies had moderate risk of bias, the results of network meta-analysis should be applied with caution.

Impact of previous, simultaneous or intravesical recurrence bladder cancer on prognosis of upper tract urothelial carcinoma after nephroureterectomy: a large population-based study

Background

Currently, the impact of previous, simultaneous, or subsequent bladder cancer on the prognosis of upper urinary tract urothelial carcinoma (UTUC) is controversial. We aimed to investigate the impact of previous, simultaneous or intravesical recurrence (IVR) bladder cancer on the prognosis of UTUC based on a large population-based cohort from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

A total of 8,431 UTUC patients diagnosed from 2004 to 2018 met the inclusion criteria were identified based on the SEER database. We evaluated the impact of bladder cancer on the prognosis of UTUC by Kaplan-Meier method and propensity score matching (PSM).

Results

In all, 6,831 patients only had UTUC (UTUC-only), 880 patients with previous or simultaneous bladder cancer (UTUC-Bca), 720 patients with IVR (UTUC-IVR). After adjusting baseline covariates that varied significantly among groups, we found UTUC-Bca cohort, regardless of tumor grade and stage, had poorer prognosis than UTUC-only cohort. In general, we demonstrated IVR had no significant impact on the prognosis of UTUC compared to PSM matched patients without IVR. However, subgroup analysis revealed that UTUC patients with subsequent MIBC recurrence or shorter interval (<20 months) between UTUC and IVR had worse prognosis compared with UTUC-only cohort.

Conclusions

UTUC patients with previous or simultaneous bladder cancer, IVR with MIBC, and shorter interval between UTUC and IVR were significant predictor for worse prognosis. Thus, more stringent postoperative surveillance and active treatment strategies should be considered for UTUC patients with those risk factors.

Is bladder preservation safe? The oncology outcomes of patients after 2-sided radical nephroureterectomies due to bilateral upper urinary tract urothelial carcinomas

PURPOSE

The prognosis of patients undergoing 2-sided radical nephroureterectomies (RNUs) with a residual bladder due to bilateral upper tract urothelial carcinoma (UTUC) is poorly understood. This study was aimed toward surveying the oncology outcomes and prognostic factors that may help in shared decision-making related to bladder preservation in patients preparing to receive 2-sided RNUs.

METHODS

Patients with synchronous or metachronous bilateral UTUC who received bilateral RNUs with a residual bladder in our hospital were retrospectively reviewed. Clinical and pathological data were analyzed for potential variables affecting the oncology outcomes.

RESULTS

A total of 50 patients were included. The average age at completion of the 2-sided RNU was 62.7 ± 12.4 years, with a mean follow-up of 88.4 ± 59.3 months after the 2-sided RNUs. The medium overall survival was 13.4 ± 1.8 years. Twenty-six patients (52%) had cancer recurrence in the residual bladder, but only 2 (8%) of the recurrences were muscle invasive. The highest UTUC stage was the only predictive factor for cancer-specific survival (CSS) rather than intravesical recurrence. The 5 year CSS rates in patients with the highest UTUC stage ≦ pT2 and ≧ pT3 were 90% and 51%, respectively (p = 0.007).

CONCLUSIONS

Risk of cancer recurrence in the residual bladder is high, but does not affect survival outcomes. The highest UTUC stage plays a significant role in cancer-specific survival. With a careful patient surveillance, bladder preservation may be reasonable in patients with bilateral UTUC preparing for 2-sided RNUs.

Conditional Intravesical Recurrence-Free Survival Rate After Radical Nephroureterectomy With Bladder Cuff Excision for Upper Tract Urothelial Carcinoma

Background

To evaluate the conditional intravesical recurrence (IVR)–free (IVRF) survival rate in patients with upper tract urothelial carcinoma (UTUC) who had no history of bladder cancer and no concomitant bladder cancer. Hence, we aimed to analyze a relatively large number of patients with UTUC who underwent radical nephroureterectomy with bladder cuff excision (RNUx).

Methods

We retrospectively analyzed the data of 1,095 patients with UTUC who underwent RNUx. Their baseline characteristics, bladder tumor history, and UTUC features were analyzed to evaluate oncological outcomes. To determine the factors affecting IVR, surgical modality, use of preoperative ureteroscopy, TNM stage, and pathological outcomes were evaluated. Multivariable Cox regression analyses were performed to evaluate the factors affecting IVR. Conditional IVRF survival rate was analyzed using Kaplan–Meier curves.

Results

Among the 1,095 patients, 462 patients developed IVR, and the mean time to the development of IVR was 13.08 ± 0.84 months after RNUx. A total of 30.74% of patients with IVR and 15.32% of those without IVR had a history of bladder cancer (p < 0.001). Multivariable analysis showed that a history of bladder cancer, multifocal tumors, use of preoperative ureteroscopy, extravesical bladder cuffing method, lymph node involvement, positive surgical margins, and use of adjuvant chemotherapy were determined to be risk factors for IVR. The conditional IVRF rate was 74.0% at 12 months after RNUx, 87.1% at 24 months after RNUx, 93.6% at 36 months after RNUx, and 97.3% at 60 months after RNUx. The median IVRF survival period was 133.00 months for all patients. In patients with IVRF at 24 months after RNUx, only ureteroscopy was an independent risk factor for IVR [hazard ratio (HR) 1.945, p = 0.040]. In patients with IVRF at ≥36 months, there was no significant factor affecting IVR.

Conclusions

Active IVR assessment is required until 36 months after RNUx. In addition, patient education and regular screening tests, such as urine analysis and cytology, are required for patients with IVRF for ≥36 months.

UroVysion® predicts intravesical recurrence after radical nephroureterectomy for urothelial carcinoma of the upper urinary tract: a prospective study

BACKGROUND

Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UCUUT) is common. One of the mechanisms driving this is the implantation of cancer cells from the UCUUT at the RNUs. Therefore, their detection after RNU can assist in predicting IVR. This study aimed to examine the utility of UroVysion^® as a tool for predicting bladder recurrence after RNU for UCUUT.

METHODS

We prospectively enrolled 65 patients who received RNU for high-grade UCUUT between October 2013 and April 2017.

RESULTS

Of the 65 patients, 54 (83.1%) who had both bladder urine samples available immediately after RNU (0 postoperative days: POD) and 5 days after RNU (5POD) were selected. We performed UroVysion^® and cytology. Twenty-two patients showed IVR with 32 foci. UroVysion^® results at 0POD (26 patients, 48.1%) and/or 5POD (31 patients, 57.4%) were positive in 42 (77.8%) patients. The sensitivity, specificity, positive predictive value, and negative predictive value of UroVysion^® for included cases were measured for both 0POD and 5POD samples; they were determined to be 95.5% (21/22), 34.4% (11/32), 50.0% (21/42), and 91.7% (11/12), respectively. For cytology, these values were 75.0% (15/20), 52.9% (18/34), 48.4% (15/31), and 78.3% (18/23), respectively. Forty-two (64.6%) patients who were UroVysion^®-positive demonstrated IVR. The IVR rate between the group positive for either 0POD or 5POD and that negative for both significantly differed for both UroVysion^® (p = 0.019) and cytology (p = 0.046).

CONCLUSION

Multiple urine tests using UroVysion^® after RNU could be a useful predictor for IVR.

Preoperative Monocyte-to-lymphocyte Ratio Predicts for Intravesical Recurrence in Patients With Urothelial Carcinoma of the Upper Urinary Tract After Radical Nephroureterectomy Without a History of Bladder Cancer

BACKGROUND

This study aimed to investigate the preoperative monocyte-to-lymphocyte ratio (MLR) as a biomarker for intravesical recurrence (IVR) in upper urinary tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU) for the first time.

PATIENTS AND METHODS

This study involved the clinical data of 255 patients with UTUC without a history of bladder cancer who had undergone RNU from March 2004 to February 2019 at an academic institution. The associations between MLR and IVR were assessed with Kaplan-Meier method and Cox regression analysis.

RESULTS

The median follow-up was 43.93 months. Of the 255 patients, 37 developed IVR during the follow-up period. Kaplan-Meier analysis revealed that patients with high MLR (> 0.22) had poor IVR-free survival (P = .001); this prognostic value was in accordance with patients with high grade and more advanced stage UTUC. Cox regression preoperative models showed that ureteral tumor site (hazard ratio [HR], 2.784; P = .005), surgical approach (HR, 2.745; P = .008), and high MLR (HR, 4.085; P < .001) were an independent risk factor for IVR. These factors were used as a signature to establish a prognostic risk model, which revealed significant differences among the 3 subgroups of patients with low, intermediate, and high risk (P < .001).

CONCLUSION

Ureteral tumor site, surgical approach, and preoperative MLR are significant predictors for IVR in patients with UTUC after RNU. MLR may become a useful biomarker to predict IVR in patients with UTUC after RNU.

Risk factors and oncological outcome for intravesical recurrence in organ-confined upper urinary tract urothelial carcinoma patients after radical nephroureterectomy: A propensity score-matched case control study

PURPOSE

Radical nephroureterectomy (RNU) is the primary treatment strategy for upper urinary tract urothelial carcinoma (UTUC); however, the prognosis is poor and recurrences are common. The risk factors for intravesical recurrence (IVR) remain inconsistent and unclear. Thus, we have identified the risk factors for IVR in patients with organ-confined UTUC.

METHODS

We retrospectively studied 229 patients with UTUC who underwent RNU combined with bladder cuff resection at our center between 1 January 2010 and 31 December 2015. After propensity score-matching, 204 patients were included in our study. Patient demographics, co-morbidities, and peri-operative data were recorded. Univariate and multivariate Cox proportional hazard regression were used to estimate the hazard ratio and 95% confidence intervals. Overall (OS) and cancer-specific survival (CSS) were measured using the Kaplan-Meier curve with a log-rank test. A p-value <0.05 was considered statistically significant.

RESULTS

Of the 229 patients, 42 (18.3%) had IVR after 40 months (range, 24-56 months) follow-up. In the matched group, the independent risk factors for IVR were tumor diameter (HR = 2.690, p = 0.038) and tumor stage (T3 vs. T1, HR = 3.363, p = 0.019; T2 vs. T1, HR = 2.835, p = 0.022). OS and CSS were poor in patients with IVR than patients without IVR (p < 0.0001).

CONCLUSIONS

In this propensity score-matched case-control study, tumor diameter and tumor stage were shown to be independent risk factors for IVR in patients with organ-confined UTUC. Moreover, patients with IVR had poor prognosis than patients without IVR. Thus, more active postoperative surveillance and treatment strategies should be adopted for these patients, which may help improve treatment outcomes.

Development and validation of a prognostic nomogram for patients with intravesical recurrence after radical nephroureterectomy for non-metastatic upper tract urothelial carcinoma

PURPOSE

To develop and validate a prognostic nomogram for patients with intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for non-metastatic upper tract urothelial carcinoma (UTUC).

METHODS

The clinical data of 468 patients registered in the surveillance, epidemiology and end results database between 2010 and 2015 were retrospectively analyzed. Multivariate analysis using the Cox proportional hazard model was used to determine independent prognostic factors for the development of a nomogram to predict the 1-, 3-, and 5-year probability of individual cancer-specific survival (CSS). Moreover, the nomogram was internally validated using receiver operating characteristic curves and calibration plots.

RESULTS

Age at IVR > 80 years, UTUC stage ≥ T3, bladder cancer (BC) stage T1, and muscle-invasive BC (stage ≥ T2) were identified as independent risk factors for CSS in patients with IVR after RNU, whereas a time interval of > 24 months between UTUC and BC was an independent protective factor. The 1-, 3-, and 5-year predictive accuracies of our nomogram were 0.74, 0.70, and 0.71, respectively. Additionally, 1-, 3-, and 5-year calibration curves demonstrated perfect agreement between the nomogram-predicted and the actual CSS.

CONCLUSIONS

This study developed and internally validated the first nomogram to date to predict individual prognosis in patients with IVR after RUN for UTUC. This nomogram can be used for patient counseling and for designing clinical trials.

Single Versus Maintenance Intravesical Chemotherapy for the Prevention of Bladder Recurrence after Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Randomized Clinical Trial

INTRODUCTION

The objective of this study was to determine the efficiency of 1-year maintenance intravesical chemotherapy (MIC) in reducing bladder recurrence (BR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma compared with single intravesical instillation (SIC).

PATIENTS AND METHODS

Between January 2015 and May 2017, patients who underwent RNU were randomized to receive SIC (epirubicin 50 mg) or MIC (once weekly for 6 weeks plus once monthly for 1 year). The primary outcome was the rate of histologically proven BR. The secondary outcomes included chemotherapy-related toxicities and disease-specific survival (DSS). Thirty-five patients in each arm were required to achieve a power of 80%.

RESULTS

A total of 38 (SIC) and 36 (MIC) patients were analyzed. In SIC, BR developed in 5 (13.2%) over a median follow-up of 3 months (range, 3-6 months) compared with 9 (25%) patients over 12 months (range, 3-28 months) in MIC (P = .08). The 6- and 12-month BR-free survivals were the same (86.8%) in SIC versus 88.9% and 83.3% in MIC, respectively (P = .2). Lymphovascular invasion was significantly associated with BR (P = .04). Post-RNU intravesical chemotherapy regimens did not alter DSS. Blood transfusion and advanced tumor stage were independent predictors for DSS. No significant medication toxicity was reported.

CONCLUSIONS

Following RNU, MIC did not change the natural course of BR beyond a single instillation apart from potentially delaying its occurrence. Lymphovascular invasion and blood transfusion were associated with worse BR and DSS outcomes, respectively.

Intravesical irrigation might prevent bladder recurrence in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVES

To examine the effectiveness of intravesical irrigation with physiological saline solution or distilled water for the prevention of bladder recurrence in patients undergoing laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma.

METHODS

This retrospective study involved 109 upper urinary tract urothelial carcinoma patients who underwent laparoscopic nephroureterectomy, and were evaluated at Chiba University Hospital and Yokohama Rosai Hospital between 2001 and 2018. We investigated the outcomes and analyzed various clinical factors including with or without intravesical irrigation related to bladder carcinoma recurrence after surgery. Physiological saline solution or distilled water was used for irrigation, which was carried out only during surgery.

RESULTS

The median follow-up period after surgery was 26.1 months. Bladder recurrence was confirmed within 2 years for 45 of the 109 patients in the present study. Irrigation was carried out for 48 cases (distilled water, 26 patients; physiological saline solution, 22 patients). Tumor grade (G1-2 vs G3; P = 0.05) and intravesical irrigation (yes vs no; P = 0.0058) were related to bladder recurrence on univariate analyses. On multivariate analyses, intravesical irrigation was the independent factor involved in the prevention of bladder recurrence (P = 0.0051). Comparison between the irrigation and non-irrigation groups showed that bladder recurrence rates were significantly lower in the irrigation group (irrigation group vs non-irrigation group: 25.0% vs 52.5%, P = 0.0066). There was no significant difference in the recurrence rate between the two solutions used for irrigation.

CONCLUSIONS

Intravesical irrigation during surgery of upper urinary tract urothelial carcinoma might decrease postoperative bladder recurrence rates.

Risk factors for bladder cancer recurrence survival in patients with upper-tract urothelial carcinoma

PURPOSE

The aim of this work was to investigate the predictive factors for bladder cancer recurrence survival (BCRS) in patients with upper-tract urothelial carcinoma (UTUC).

METHODS

We selected patients with UTUC who underwent segmental ureterectomy (Su) or nephroureterectomy (Nu) from 2004 to 2013 from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with a history of intravesical therapy for bladder cancer and bladder cancer prior to the diagnosis of UTUC were excluded. We used Kaplan-Meier analysis, log-rank tests, and Cox proportional hazards model to compare overall survival, cancer-specific survival, and BCRS.

RESULTS

In a cohort of 1,454 patients, 169 (11.6%) had low-grade tumors and 1,285 (88.4%) had high-grade tumors; 239 (16.4%) underwent Su and 1,215 (83.6%) underwent Nu. We found that T4 grade (hazard ratio [HR] = 6.216; 95% confidence interval [CI], 3.197-12.087) and ureteral tumors (HR = 1.764; 95% CI, 1.173-2.652) were predictors of shorter BCRS, whereas Nu (HR = 0.608; 95% CI, 0.388-0.953) predicted longer BCRS. Five-year BCRS rates were low-grade tumors: 94.1%, high-grade tumors: 85.4% (p = 0.038); plus Su: 82.9%, and Nu: 87.6% (p = 0.016).

CONCLUSIONS

Use of Su should be more selective for high-grade tumors, as it correlates with shorter BCRS. Tumors located in the ureter are associated with shorter BCRS than those located in the renal pelvis.

Predictive value of gene methylation for second recurrence following surgical treatment of first bladder recurrence of a primary upper-tract urothelial carcinoma

The clinical relevance of aberrant DNA promoter methylation is being increasingly recognized in urothelial carcinoma. The present study was conducted to explore the methylation status of patients with upper-tract urothelial carcinoma (UTUC) who experienced bladder recurrence, and to evaluate the predictive value of gene methylation for second bladder recurrence and tumor progression. A total of 85 patients with primary UTUC, who experienced bladder recurrence after radical nephroureterectomy, were enrolled between January 2001 and December 2013. Using methylation-sensitive polymerase chain reaction, the promoter methylation statuses of 10 genes were analyzed in the bladder tumor specimens. Among the patient group, 32 patients experienced second bladder recurrence, and bladder progression was detected in 16. With the exception of BRCA1, the methylation rate of the majority of genes tended to gradually increase to varying extents with the number of recurrences; a smaller proportion of primary tumors exhibited gene methylation when compared with the first recurrent tumors and second recurrent tumors. Univariate and multivariate Cox regression analyses revealed that unmethylated GDF15 [hazard ratio (HR)=0.36; 95% confidence interval (CI), 0.14-0.92] and methylated VIM (HR=2.91; 95% CI, 1.11-7.61) in the first recurrent bladder tumor, as well as male gender (HR=2.28; 95% CI, 1.06-4.87), first recurrence interval <8 months (HR=2.34; 95% CI, 1.15-4.78) and primary UTUC tumor size ≥5 cm (HR=3.48; 95% CI, 1.43-8.45) were independent risk factors for a second bladder recurrence after surgery for the first bladder recurrence; the Harrell's concordance index (c-index) for the related nomogram was 0.71 (95% CI: 0.61-0.81). Furthermore, methylated CDH1 (HR=2.91; 95% CI, 1.08-7.77) and VIM (HR=4.91; 95% CI, 1.11-21.7) in the first recurrent bladder tumor, male gender (HR=3.6; 95% CI, 1.1-11.73), and primary tumor stage T2-T4 (HR=4.57; 95% CI, 1.22-17.13), multifocality (HR=3.64; 95% CI, 1.19-11.16) and size ≥5 cm (HR=3.1; 95% CI, 1.91-10.54) for the primary UTUC were considered to be predictors of tumor progression; the c-index for the nomogram was 0.88 (95% CI, 0.69-0.92). The present findings demonstrated that promoter methylation of cancer-related genes was frequently observed in patients with urothelial carcinoma, and that the gene methylation rate of certain genes tended to gradually increase with the number of bladder recurrences. This may be used as a predictive factor for a second bladder recurrence and tumor progression after the surgical treatment of the first bladder recurrence.

Outcomes of subsequent non-muscle-invasive bladder cancer treated with intravesical Bacillus Calmette-Guérin after radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVES

To describe the clinicopathological characteristics and prognosis of subsequent non-muscle-invasive bladder cancer (NMIBC) after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC), and particularly its response to intravesical Bacillus Calmette-Guérin (BCG).

PATIENTS AND METHODS

An observational study was conducted in 1463 patients with UTUC who had undergone RNU and in 1555 patients with primary NMIBC. Of the 1463 patients with UTUC, 256 (17%) subsequently developed NMIBC (UTUC-NMIBC group) and were available for the analysis. The clinicopathological background and outcomes, including intravesical recurrence-free survival and bladder progression-free survival, were compared between the patients with UTUC-NMIBC and the patients with primary NMIBC treated with intravesical BCG. Propensity score matching was performed to adjust for the potential differences in the backgrounds of the two groups. To validate the utility of the CUETO scoring model in the UTUC-NMIBC group, risk scores were calculated and compared with the published probabilities for recurrence and progression.

RESULTS

Compared with the unadjusted primary NMIBC group (n = 352), the UTUC-NMIBC group (n = 75) were found to have a worse prognosis for intravesical recurrence and progression, before propensity score matching. After propensity score matching for potential confounding factors, however, a worse prognosis was observed only for intravesical recurrence. The validation test of the CUETO scoring model for the UTUC-NMIBC group showed a significant difference in the rate of intravesical recurrence and progression for the 0-4 and 5-6 score groups between the UTUC-NMIBC group and the CUETO risk table reference data.

CONCLUSION

Compared with the primary NMIBC group, the UTUC-NMIBC group had a worse prognosis after intravesical BCG, especially with regard to intravesical recurrence. This suggests that patients with UTUC-NMIBC are inherently poor responders to BCG exposure. An optimal treatment strategy and risk scoring model to select patients for adjuvant intravesical BCG, chemotherapy or immediate radical cystectomy should be established.