Neoadjuvant systemic therapy in patients undergoing nephroureterectomy for urothelial cancer: a multidisciplinary systematic review and critical analysis

Efficacy and safety of dose-dense gemcitabine and cisplatin as neoadjuvant chemotherapy for high-grade upper tract urothelial carcinoma (cT2-3N0M0)

PURPOSE

Neoadjuvant chemotherapy for upper tract urothelial carcinoma has shown favorable results. However, few studies have been conducted on dose-dense regimens that have demonstrated superior efficacy in bladder cancer. We aimed to retrospectively evaluate the efficacy and safety of dose-dense gemcitabine and cisplatin as neoadjuvant chemotherapy for upper tract urothelial carcinoma.

MATERIALS AND METHODS

Ninety-five patients who underwent radical nephroureterectomy for high-grade upper tract urothelial carcinoma (cT2-3N0M0) with dose-dense gemcitabine and cisplatin (n = 33) or without neoadjuvant chemotherapy (n = 62, Control) were included. Propensity score matching was performed based on the patient and tumor demographics. Efficacy was evaluated by the pathological response rate defined as pathological downstaging to ≤ pT1N0 and complete response (pT0N0). Progression-free survival, cancer-specific survival, and overall survival were estimated. All adverse events and postoperative complications were assessed.

RESULTS

Thirty-one matched patients were included in each cohort after adjusting for baseline propensity score matching. The pathological downstaging to ≤ pT1N0 rate of the neoadjuvant chemotherapy group was significantly higher than the Control group. The complete response rate was 6.5% in the neoadjuvant chemotherapy group; pT0N0 was not observed in the Control group. The 2-year progression-free survival and cancer-specific survival rates were significantly better in the neoadjuvant chemotherapy group. Of the 33 patients who received neoadjuvant chemotherapy, 7 severe adverse events (grade 3 or higher) were observed in 6 patients.

CONCLUSIONS

Dose-dense gemcitabine and cisplatin showed a favorable pathological response and oncological outcome with good tolerability.

Challenges in diagnosing and managing sarcomatoid urothelial carcinoma of the renal pelvis: a case report

Sarcomatoid urothelial carcinoma of the renal pelvis is an extremely rare malignant tumor with a high risk of recurrence and metastasis and a poor prognosis. This case reports a 61-year-old male patient with renal pelvic sarcomatoid urothelial carcinoma who developed extensive lymph node metastasis 26 days after posterior laparoscopic radical nephrectomy for renal carcinoma, and the patient died on the 45th postoperative day, with the cause of death being advanced malignancy of the tumor. This case highlights the rapid progression of sarcomatoid urothelial carcinoma, and sarcomatoid variants should be identified as early as possible, with active multidisciplinary adjuvant therapy and closer follow-up when feasible. Retrospective analysis of this patient's treatment regimen and admission provides lessons for recognizing and aggressively managing this rare and fatal variant of urothelial carcinoma.

A pretreatment nomogram to predict muscle-invasiveness in high-risk upper tract urothelial carcinoma (ROBUUST 2.0 collaborative group)

BACKGROUND

The ability to predict muscle invasion in the final pathology of upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU) potentially influences the selection of the most appropriate treatment modality. The present study aims to develop a model predicting muscle-invasive status in high-risk UTUC.

METHODS

The ROBUUST (RObotic surgery for Upper tract Urothelial cancer - UTUC - STudy) 2.0 dataset is an international, multicenter registry of patients undergoing curative surgery for UTUC between 2015 and 2022. Data about high-risk patients, classified according to EAU and NCCN prognostic stratification criteria, who underwent RNU were retrieved. The primary outcome was the identification of muscle-invasiveness. Two multivariable models, differing in the inclusion of biopsy-related data, were fitted with pT stage results at final pathology. Their predictive ability was calculated using the area under the receiver operating characteristic curve and decision curve analysis (DCA). A nomogram was developed using the model demonstrating the highest area under the curve (AUC) and clinical net benefit.

RESULTS

In the overall cohort, 1558 patients met the inclusion criteria, with 934 patients having ≥pT2 disease. Patients in the ≥pT2 cohort had significantly worse oncological outcomes in terms of metastases, all-cause, and cancer-specific deaths (all P<0.001). The biopsy-related model had the highest AUC (74%) and the highest net benefit in DCA. The DCA showed an improvement in the clinical risk prediction of muscle-invasiveness, and a reduction in the number of upfront or unnecessary RNU, at every ≥pT2 probability threshold.

CONCLUSIONS

The proposed prognostic model is a valuable tool for estimating the risk of muscle-invasiveness in high-risk UTUC patients, owing to its optimal predictive ability and user-friendly design.

If not now, then when? The need for new evidence in the robotic management of upper tract urothelial carcinoma

Current guidelines recommend radical nephroureterectomy with bladder cuff excision as the standard surgical treatment for high-risk upper tract urothelial carcinoma (UTUC). While large evidence is available regarding open and laparoscopic nephroureterectomy, data focusing on robotic nephroureterectomy (RNU) in UTUC are mostly limited with mixed results, especially in locally advanced disease. In light of the recent introduction of new robotic platforms, it is of utmost importance to further investigate oncologic outcomes associated with RNU. Moreover, stronger data exploring different operative settings (i.e. robotic arms and trocars placement) for the new robotic systems are eagerly warranted. To give an answer to such open clinical questions, the Junior ERUS/Young Academic Urologist Working Group on Robot-assisted Surgery designed a multicentric project involving different high-volume centers across the world. The aim of the study will be exploring surgical and oncologic outcomes of RNU, specifically focusing on several clinical unmet needs, such as best operative setting for new robotic platforms, lymph node dissection (LDN) template and robotic bladder cuff management.

Increased Apolipoprotein A1 Expression Correlates with Tumor-Associated Neutrophils and T Lymphocytes in Upper Tract Urothelial Carcinoma

An increased neutrophil-to-lymphocyte ratio (NLR) is a poor prognostic biomarker in various types of cancer, because it reflects the inhibition of lymphocytes in the circulation and tumors. In urologic cancers, upper tract urothelial carcinoma (UTUC) is known for its aggressive features and lack of T cell infiltration; however, the association between neutrophils and suppressed T lymphocytes in UTUC is largely unknown. In this study, we examined the relationship between UTUC-derived factors and tumor-associated neutrophils or T lymphocytes. The culture supernatant from UTUC tumor tissue modulated neutrophils to inhibit T cell proliferation. Among the dominant factors secreted by UTUC tumor tissue, apolipoprotein A1 (Apo-A1) exhibited a positive correlation with NLR. Moreover, tumor-infiltrating neutrophils were inversely correlated with tumor-infiltrating T cells. Elevated Apo-A1 levels in UTUC were also inversely associated with the population of tumor-infiltrating T cells. Our findings indicate that elevated Apo-A1 expression in UTUC correlates with tumor-associated neutrophils and T cells. This suggests a potential immunomodulatory effect on neutrophils and T cells within the tumor microenvironment, which may represent therapeutic targets for UTUC treatment.

Atypical presentations of UTUC: a case report of three patients

Background

Upper tract urothelial carcinoma (UTUC) is a rare clinical condition primarily characterized by symptoms such as gross or microscopic hematuria, flank pain, and renal colic. Although computed tomography urography (CTU) is currently the most accurate imaging modality for diagnosis, atypical presentations and physical examination findings can sometimes obscure lesions, posing diagnostic challenges.

Case presentation

In this report, three patients exhibited atypical symptoms, sharing a common complaint of flank pain. Notably, the first patient, who had recently undergone laparoscopic right duplex nephrectomy, presented with microscopic hematuria, whereas the other two did not show any gross or microscopic hematuria. Computed tomography urography revealed hydronephrosis and infection without significant renal pelvic space-occupying lesions, with persistently elevated white blood cell (WBC) counts, but no fever. These atypical clinical presentations confounded clinicians, delaying the diagnosis of upper tract urothelial carcinoma until postoperative pathological examination for the first two patients and resulting in advanced-stage diagnosis for the third patient. Postoperative pathology confirmed high-grade invasive upper tract urothelial carcinoma in all three patients.

Conclusion

Upper tract urothelial carcinoma can manifest atypically without hematuria and may be challenging to visualize on computed tomography urography, potentially leading to misdiagnosis. Therefore, clinicians should maintain a high level of suspicion for malignant tumors when patients exhibit hydronephrosis, infection on imaging, and persistently elevated white blood cell counts without fever, even in the absence of typical signs of upper urothelial carcinoma on computed tomography urography.

Perioperative and oncological outcomes of distal ureter management during nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis

INTRODUCTION

The best approach of the bladder cuff (i.e., transvesical, extravesical, endoscopic) during radical nephroureterectomy (RNU) remains an unsolved question. The aim of this review is to compare the oncological and perioperative outcomes among three different approaches of the distal ureter during RNU.

EVIDENCE ACQUISITION

A literature search was conducted through June 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The primary outcome was bladder recurrence-free survival and secondary outcomes included: perioperative outcomes, metastasis-free survival, and cancer-specific survival.

EVIDENCE SYNTHESIS

A total of 19 non-randomized studies comprising 6581 patients met our inclusion criteria. The risk of bladder recurrence, metastasis and cancer-related death did not differ significantly between each approach (all P>0.05). In subgroup analysis excluding patients with history of bladder cancer, the risk of bladder recurrence remained similar between each approach (all P>0.05). There was no significant difference in terms of operative time, estimated blood loss, length of hospital stay, and postoperative complications between each approach (all P>0.05). The main limitation is the retrospective design of 18/19 included studies.

CONCLUSIONS

The present systematic review and meta-analysis highlights the lack of high-level evidence on distal ureter management during RNU. On the basis of the available data, the present review supports the equivalence of different techniques of bladder cuff excision during RNU. The extravesical approach seems non-inferior to the transvesical approach in terms of oncological and perioperative outcomes.

Urinary MicroRNAs as Biomarkers of Urological Cancers: A Systematic Review

MicroRNAs (miRNAs) are emerging as biomarkers for the detection and prognosis of cancers due to their inherent stability and resilience. To summarize the evidence regarding the role of urinary miRNAs (umiRNAs) in the detection, prognosis, and therapy of genitourinary cancers, we performed a systematic review of the most important scientific databases using the following keywords: (urinary miRNA) AND (prostate cancer); (urinary miRNA) AND (bladder cancer); (urinary miRNA) AND (renal cancer); (urinary miRNA) AND (testicular cancer); (urinary miRNA) AND (urothelial cancer). Of all, 1364 articles were screened. Only original studies in the English language on human specimens were considered for inclusion in our systematic review. Thus, a convenient sample of 60 original articles was identified. UmiRNAs are up- or downregulated in prostate cancer and may serve as potential non-invasive molecular biomarkers. Several umiRNAs have been identified as diagnostic biomarkers of urothelial carcinoma and bladder cancer (BC), allowing us to discriminate malignant from nonmalignant forms of hematuria. UmiRNAs could serve as therapeutic targets or recurrence markers of non-muscle-invasive BC and could predict the aggressivity and prognosis of muscle-invasive BC. In renal cell carcinoma, miRNAs have been identified as predictors of tumor detection, aggressiveness, and progression to metastasis. UmiRNAs could play an important role in the diagnosis, prognosis, and therapy of urological cancers.

Perioperative and oncologic outcomes of transperitoneal versus retroperitoneal laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and pooled analysis of comparative outcomes

BACKGROUND

The debate on whether to choose a transperitoneal (TP) or retroperitoneal (RP) approach for treating upper urinary tract urothelial carcinoma (UTUC) with laparoscopic surgery has been drawing attention. This study aimed to systematically review and meta-analyze the existing evidence regarding oncologic and perioperative outcomes of transperitoneal laparoscopic radical nephroureterectomy (TLNU) and retroperitoneal laparoscopic radical nephroureterectomy (RLNU) in managing UTUC.

METHODS

A comprehensive literature search was conducted using PubMed, Scopus, Embase, and Google Scholar for identifying randomized controlled trials (RCTs) and observational studies that evaluated the outcomes of TLNU and RLNU for UTUC. Continuous variables were represented by weighted mean difference (WMD) and standard mean difference (SMD), while binary variables were represented by odds ratio (OR), with 95% confidence intervals (CIs). The quality was assessed using the Newcastle-Ottawa scale. A sensitivity analysis was performed to evaluate the robustness of the estimates.

RESULT

Six observational studies were incorporated into this meta-analysis. The overall TLNU was associated with significantly shorter operating time (WMD - 19.85; 95% CI - 38.03 to - 1.68; P = 0.03); longer recovery time of intestinal function (SMD 0.46; 95% CI 0.08 to 0.84; P = 0.02). However, the terms of estimated blood loss (WMD - 5.72; 95% CI - 19.6 to - 8.15; P = 0.42); length of stay (WMD - 0.35; 95% CI - 1.61 to 0.91; P = 0.59), visual analog pain scale (WMD - 0.38; 95% CI - 0.99 to 0.84; P = 0.22); drainage duration (WMD - 0.22; 95% CI - 0.61 to 0.17; P = 0.26); overall complication rates (OR 1.24; 95% CI 0.58 to 2.63; P = 0.58); local recurrence rate (OR 0.6; 95% CI 0.3 to 1.21; P = 0.16); distant metastasis (OR 0.94; 95% CI 0.04 to 20.77; P = 0.97); 1-year overall survival (OS) (OR 0.45; 95% CI 0.1 to 2.01; P = 0.3) showed no difference between TLNU and RLUN.

CONCLUSION

TLNU provides similar surgical outcomes and oncologic results compared to RLUN; however, TLNU has a shorter procedure time and prolonged intestinal function recovery time. Due to the heterogeneity among the studies, randomized clinical trials with follow-ups in the long term are required to obtain more definite results.

TRIAL REGISTRATION

www.crd.york.ac.uk/prospero/ , identifier CRD42023388554.

Correlation between the timing of diagnostic ureteroscopy for upper tract urothelial cancer and intravesical recurrence after radical nephroureterectomy

Objective

We aimed to evaluate the effect of the timing of diagnostic ureteroscopy (URS) on intravesical recurrence (IVR) following radical nephroureterectomy (RNU).

Patients and methods

The clinical data of 220 patients with upper tract urothelial carcinoma (UTUC) treated with RNU at our center from June 2010 to December 2020 were retrospectively analyzed. According to the timing of the URS, all patients were divided into three groups: the no URS group, the 1-session group (diagnostic URS immediately followed by RNU), and the 2-session group (RNU after diagnostic URS). Additionally, we analyzed IVR-free survival (IVRFS) using the Kaplan-Meier and Cox proportional regression methods.

Results

The median follow-up period of these 220 patents was 41 (range: 2-143) months. Among them, 58 patients developed IVR following RNU. Kaplan-Meier curve displayed a significantly higher IVR rate in both treatment groups than in the no-URS group (p=0.025). In the subgroup of patients with renal pelvis cancer, the incidence of IVR was significantly higher in both treatment groups than in the group without URS (p=0.006). In univariate Cox proportional regression analysis, the two treatment groups were risk factors for IVR compared to the no-URS group [p=0.027, hazard ratio (HR): 1.93, 95% confidence interval (CI): 1.08-3.46]. The two-stage group (p=0.032, HR: 1.98, 95% CI: 1.08-3.65), positive urine pathology (p<0.001, HR: 8.12, 95% CI: 3.63-18.15), adjuvant chemotherapy (p<0.001, HR: 0.20, 95% CI: 0.10-0.38), and positive margin (p<0.0001, HR: 7.50, 95% CI: 2.44-23.08) were all identified as independent predictors in the multivariate.

Conclusion

This study revealed that delayed RNU following diagnostic URS may increase the risk of postoperative IVR in patients with UTUC, preoperatively positive uropathology, and positive surgical margin were risk factors for IVR after RNU, while early postoperative chemotherapy may effectively prevent IVR. Delay of RUN after URS could increase the risk of IVR.